Wisconsin Medicaid Billing Guide
Top Eligible Payers
ForwardHealth (Wisconsin Medicaid FFS), UHC, Anthem BCBS, Chorus Community Plan
CPA Required
Yes – Certain Services
CPA Required Cases
Prescriptive services
Eligible Population
1,400,000
Eligible for Service
Service Eligibility
1,400,000
Enacted Date
06/01/2022
Insurance Mandate
Yes
Last edited time
June 4, 2024 9:52 PM
Rules
Reimbursement mandated within scope of practice
Legislative Link
Line of Business
Medicaid
Table of Contents
Introduction
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.
Summary of pharmacist billing in Wisconsin
- Pharmacists must be reimbursement for services delivered within the scope of practice.
- Pharmacists can provider and bill services to over 1.4 million eligible medicaid beneficiaries, both those managed by the state and managed care organizations.
- In order to bill for services, provider enrollment is required to establish contracts with patients covered under ForwardHealth or a Managed Medicaid plan
- Collaborative Practice Agreements (CPA) are required only under certain circumstances, such as for prescribing new therapy, discontinuation or alteration of medication dose or frequency
- Pharmacists may begin billing for services to ForwardHealth members starting July 2024.
In the sections below, you’ll find a host of resources to help support your journey towards billing for patient care services
Scope of Practice
Pharmacist can request payment for any services that performed within their scope of practice, as well as services delegated by a collaborating provided specified within an active collaborative practice agreement (CPA). It should be noted, billed services must extend beyond what is necessary in the course of medication dispensing process and covered by your professional dispensing fee (order interpretation, DUR review, offering medication counseling).
Example | OBRA 90 requires pharmacist to offer counseling on new prescriptions. If a pharmacist provides education and resources exceeding what would be required to ensure patient understanding and safe medication use, the services may be separately billable.
- Medication History / Reconciliation
- Provision of disease state education and resources
- Monitoring response to medication therapy
- Monitoring chronic disease state progression as it relates to medication therapy
- Diet and exercise counseling associated with managing chronic disease states
- Preventative care services (e.g. smoking cessation, vaccination status assessment)
- Development of medication compliance regimen (e.g. setting up medication synchronization, medication packaging, or pill-boxes)
- Point of care testing (HbA1c, BP, influenza, COVID-19, etc.)
- Point of care device set up and training (CGM, HbA1c, ambulatory BP cuff, etc.)
- Aiding in therapeutic drug selections
- Administering prescribed drug products and devices under 450.035 (1r), including vaccines
Please see the bookmarked page below linking to the Wisconsin Statute authorizing pharmacy practice. This includes a complete list of activities that included under pharmacist scope in the state.
https://docs.legis.wisconsin.gov/statutes/statutes/450/01/16Provider Enrollment
Complete ForwardHealth Provider Enrollment Application
Managed Care Enrollment Links
- United Healthcare (UHC) | Join our network – Medical providers
- Anthem Blue Cross and Blue Shield | Getting Started | Anthem.com
- Chorus Community Health Plans | CCHP Get Credentialed | Chorus Community Health Plans
Billing Guidance
As pharmacists, we’re accustomed to billing for drug products through the pharmacy benefit. An NDC is adjudicated through the pharmacy management system and hits the pharmacy switch, which is loaded with a robust network of PBM data and ultimately returns medication coverage details. When billing for clinical services, providers submit claims through the medical benefit, which leverages a clearinghouse (very similar to the switch), to do the very same.
Pharmacist Reimbursement Rates - Wisconsin Medicaid
An example of the staple CPT codes and associated reimbursement rates is included below. These are a category of billing codes referred to as “Evaluation & Management”. More simply put, these are the same codes a primary care doctor would use to bill an annual physical. ForwardHealth has confirmed these codes can also be leveraged by pharmacists in the course of your patient care for any number of services, many of which are listed in the Scope of Practice section above.
New Patient – Evaluation & Management (Care coordination & counseling)
- 99202 (~15 min): $47.35; $189.40 / hr
- 99203 (~30 min): $72.62; $145.24 / hr
- 99204 (~45 min): $110.94; $147.92 / hr
- 99205 (~60 min): $146.41; $146.41 / hr
Established Patient – Evaluation & Management (Care coordination & counseling)
- 99211 (~5 min): $15.61; $183.96 / hr
- 99212 (~10 min): $37.79; $222.15 / hr
- 99213 (~20 min): $60.42; $177.39 / hr
- 99214 (~30 min): $85.58; $171.16 / hr
- 99215 (~40): $119.97; $179.96 / hr