Prior Authorization Process Improvements: Therapies Dual Treatment, Modifiers for Disposable Medical Supplies and Durable Medical Equipment

BILLING TEAM ACTIONS REQUIRED: The source document does not state an explicit effective date for these changes, only an October 2026 publication date. Check with ForwardHealth directly (800-947-9627) or the Prior Authorization Process Improvements page at https://www.forwardhealth.wi.gov/ to confirm when these changes take effect and whether they are already in effect as of the analysis date (2026-10-27). Once effective date is confirmed, implement the following: 1. DUAL THERAPY TREATMENT (Physical Therapy Process Type 111, Occupational Therapy Process Type 112, Speech-Language Therapy Process Type 113): - Billing team and providers must submit SEPARATE prior authorization requests for each therapy provider when dual treatment occurs (member receiving same discipline from two or more providers). - Update intake and verification workflows to identify dual treatment scenarios and document each provider's separate plan of care. - When submitting the second PA request, providers will receive a ForwardHealth Portal message asking to confirm dual treatment. Answer this prompt accurately to avoid denial. - CONSEQUENCE: Second PA requests without dual treatment confirmation will be denied as duplicates. If dual treatment is legitimate and medically necessary, ensure providers respond to the Portal prompt and maintain documentation of separate plans of care on the PA/Therapy Attachment (PA/TA) Form F-11008 (12/2025). - Note: This differs from care collaboration (which spans multiple service areas). Dual treatment occurs within one service area. 2. DMS AND DME PRIOR AUTHORIZATION MODIFIERS: - Billing team must ensure all DMS (Disposable Medical Supplies) and DME (Durable Medical Equipment) prior authorization requests include required modifiers when using NOC (not otherwise classified) or NOS (not otherwise specified) codes. - Locate correct modifiers in: ForwardHealth Online Handbook Modifiers topic #2021 (DMS) and Modifiers topic #1735 (DME), or in the DMS and DME Indices. - Update billing software to require modifier entry on all DMS/DME PA submissions. - CONSEQUENCE: ForwardHealth will DENY prior authorization requests for DMS and DME that do not include required modifiers. 3. DOCUMENTATION: - Verify compliance with Wisconsin documentation retention requirements (Wis. Admin. Code § DHS 106.02(9)) per Wisconsin Statute § 49.45(3)(f). Maintain all records for verification of claims. - CONSEQUENCE: Failure to produce documentation may result in claim denial, recoupment of paid claims, intermediate sanctions, or Medicaid program termination. 4. MANAGED CARE IMPLEMENTATION: - If your practice serves BadgerCare Plus managed care members, contact the applicable MCO directly for implementation details, as MCOs must provide at least the same benefits as fee-for-service but may have additional requirements.