Wisconsin Medicaid Billing Guide
A comprehensive guide for pharmacists to bill and receive reimbursement for clinical services under Wisconsin Medicaid. Learn about 2021 Wisconsin Act 98, provider enrollment, scope of practice, and reimbursement rates.
This in-depth guide includes:
- Overview of 2021 Wisconsin Act 98 and its impact on pharmacist billing
- Complete list of billable services within pharmacist scope of practice
- Step-by-step provider enrollment process for ForwardHealth
- Managed Care Organization (MCO) enrollment links and guidance
- Evaluation & Management CPT codes with Wisconsin Medicaid reimbursement rates
- CPA requirements and when they apply
Strategies for Wisconsin Medicaid Billing Guide
The passage of 2021 Wisconsin Act 98, signed into law in December 2021, grants pharmacists in Wisconsin the status of non-physician providers under Medicaid. This legislation allows pharmacists to bill and be reimbursed for medical services within their scope of practice, significantly enhancing their role in patient care and improving access to healthcare services across the state.
Pharmacists can provide and bill services to over 1.4 million eligible Medicaid beneficiaries, both those managed by the state (ForwardHealth) and managed care organizations like UHC, Anthem BCBS, and Chorus Community Plan. Provider enrollment is required to establish contracts, and pharmacists may begin billing for services to ForwardHealth members starting July 2024.
Billable services include medication history and reconciliation, disease state education, monitoring medication therapy response, diet and exercise counseling, preventative care services, point of care testing, device setup and training, and vaccine administration. These services must extend beyond what is covered by your professional dispensing fee.
Collaborative Practice Agreements (CPAs) are required only for certain prescriptive services, such as prescribing new therapy or altering medication dose or frequency. For most clinical services within your scope of practice, no CPA is needed to bill Wisconsin Medicaid.
Frequently Asked Questions
2021 Wisconsin Act 98, signed into law in December 2021, grants pharmacists in Wisconsin the status of non-physician providers under Medicaid. This means pharmacists can bill and be reimbursed for medical services within their scope of practice, with reimbursement mandated by law.
Over 1.4 million Medicaid beneficiaries in Wisconsin are eligible for pharmacist-provided clinical services. This includes patients covered by ForwardHealth (state Medicaid) and managed care organizations like UHC, Anthem BCBS, and Chorus Community Plan.
CPAs are required only for certain prescriptive services, such as prescribing new therapy, discontinuing medications, or altering dose/frequency. Most clinical services within your scope of practice—like medication therapy management, counseling, and point-of-care testing—do not require a CPA.
Billable services include medication history/reconciliation, disease state education, monitoring medication therapy response, chronic disease monitoring, diet and exercise counseling, preventative care (smoking cessation, vaccination assessment), medication compliance programs, point-of-care testing, device setup and training, and vaccine administration.
First, complete the ForwardHealth provider enrollment training. Then gather required documentation using the enrollment checklist. Submit your application through the ForwardHealth portal. Once enrolled with ForwardHealth, you can also pursue contracts with MCOs like UHC, Anthem, and Chorus to bill their members.
For established patients, rates range from $15.61 (99211, ~5 min) to $119.97 (99215, ~40 min). For new patients, rates range from $47.35 (99202, ~15 min) to $146.41 (99205, ~60 min). These Evaluation & Management codes can be used for care coordination and counseling services.
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