New Coverage for Peer Recovery Support Services

REQUIREMENTS: By March 31, 2026, the billing team must: (1) Ensure all PRS provider agencies are enrolled with Wisconsin Medicaid as eligible provider types (Overdose Treatment Provider Agencies certified under DHS 72, or Community Support Programs, Hospitals, IOPs, Narcotic Treatment Services, Outpatient Mental Health/Substance Abuse, Residential SUD Treatment, or Substance Abuse Day Treatment providers); (2) Configure billing system to identify the competent mental health professional (not the PRC) as the rendering provider on all PRS claims; (3) Establish documentation requirements ensuring all PRS claims include: supervisory visit documentation (1 hour per 30 hours face-to-face services under sole supervision, or 1 hour per 60 hours under co-supervision model), proof of PRC training (40 hours specific training + 24 hours supervised experience + 8 hours annual continuing education), and member plan of care authorization; (4) Update encounter forms and billing workflows to capture PRS service hours and link them to a documented member plan of care; (5) Train clinical and billing staff that PRS services are non-clinical complements that do not duplicate or replace clinical treatment or case management; (6) Implement medical necessity review process per Wisconsin Admin Code § DHS 101.03(96m) to avoid claim denials and recoupment; (7) Communicate to all treatment providers, qualified prescribers, and supervising clinicians the 520-hour annual member limit. Failure to comply will result in claim denials, recoupment, and potential payment integrity audits.