MedicaidPrior AuthHigh impact
Prior Authorization Process Improvements: Removing Spell of Illness and Revising Limits for Therapy ServicesFebruary 9, 2026: This Update has been revised since its original publication. Audiologists will now receive the ForwardHealth Update, two ForwardHealth Online Handbook topics were added to the Quick Links section, and information about Individualized Education Plan (IEP) submissions was added. Revised information appears in red text on pages 1 and 2.
Wisconsin Medicaid (ForwardHealth)·WI · Physical Therapy, Occupational Therapy, Speech Therapy·Prior Authorization
Effective date
Jan 1, 2026
We identified it
Sep 29, 2026
Summary
Effective January 1, 2026, ForwardHealth (Wisconsin Medicaid/BadgerCare Plus) eliminates the Spell of Illness (SOI) policy for physical therapy, occupational therapy, and speech-language pathology services. Members now receive up to 35 medically necessary visits per discipline per calendar year before prior authorization is required (changed from a lifetime limit). Providers must use new process types (111, 112, 113) and the revised PA/TA form (F-11008, 12/2025); outdated forms will be rejected.
Action Required
By December 31, 2025: (1) Billing team must update prior authorization submission processes to use process types 111, 112, and 113 instead of process types 114, 115, and 116 for PT, OT, and SLP services. (2) Obtain and implement the revised Prior Authorization/Therapy Attachment form (F-11008, 12/2025) in all billing systems and workflows; discard the obsolete PA/SOIA form (F-11039). (3) Update internal documentation and billing guidelines to reflect the 35-visit-per-calendar-year threshold instead of the lifetime limit. (4) Train billing staff that IEPs are no longer required for school-aged children outpatient PA requests (though coordination of care documentation in Element 10 must still be submitted for subsequent requests). (5) Ensure that all PA requests for outpatient therapy include both the PA/RF (F-11018) and the updated PA/TA form (F-11008, 12/2025). Effective January 1, 2026: (6) Reject or correct any submitted PA requests using outdated forms or process types 114, 115, 116, or the PA/SOIA form to prevent claim denials. Consequence: PA requests submitted with outdated forms or process types will be returned by ForwardHealth and must be resubmitted, delaying authorization and potentially blocking claim payment.