We assist families with the Prior Authorization process, ensuring your child receives the full scope of benefits they are entitled to under Wisconsin Medicaid.
Waivers & Programs Navigation
We serve as your clinical advocates in a complex system, managing the Prior Authorization paperwork and state requirements so you can focus on being a parent, not a case manager.
Waivers & Programs Navigation:
In Wisconsin, accessing comprehensive home care often means navigating two distinct systems: the Children’s Long-Term Support (CLTS) Waiver and the federal HealthCheck (EPSDT) benefit. B&Y Health Care specializes in the administrative burden of these programs. We don’t just provide staff; we actively manage the Prior Authorization (PA) process, ensuring that the State of Wisconsin has the robust clinical documentation needed to approve your child’s hours based on medical necessity, rather than arbitrary budget caps.
Key Points for Wisconsin Families:
The HealthCheck Mandate:
- Under the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) rule—known as “HealthCheck” in Wisconsin—children under 21 are entitled to all medically necessary services. We ensure that your child’s Private Duty Nursing (PDN) is billed correctly through this entitlement, preserving your limited CLTS Waiver budget for other needs like respite or home modifications.
Prior Authorization (PA) Mastery:
- Getting approval for 8+ hours of daily nursing requires precise clinical evidence. Our intake team prepares the specific “ForwardHealth” documentation (including the Plan of Care and Physician Orders) that proves your child’s condition meets the state’s strict “Skilled Nursing” criteria.
Denial & Appeal Support:
- If your requested hours are denied or reduced by the state, B&Y Health Care assists families in gathering the additional clinical data required to appeal the decision. We help you demonstrate why a reduction in care would be unsafe.
The Funding Mix:
- We help families understand which card pays for what. We coordinate directly with your County Waiver Agency (CWA) to clarify which services use your “ForwardHealth Card” (State Plan) and which ones come from your “CLTS Waiver Budget,” ensuring no funding stream is left untapped.
Case Management Liaison:
- We act as the primary clinical contact for your county Service Coordinator. By keeping your coordinator informed of medical changes, we ensure your Individual Service Plan (ISP) remains up-to-date without you having to make constant phone calls.
“Did You Know?”
Did You Know? “Medical Necessity” Trumps Budget Caps.Unlike the CLTS Waiver or Family Care, the EPSDT benefit for children has no financial cap. If a physician certifies that a service is “medically necessary” to correct or ameliorate a condition, Wisconsin Medicaid must cover it. This is why we prioritize billing nursing through EPSDT—it ensures your child gets the care they need, regardless of cost.
Confused by a Denial or Waitlist?
You don’t have to accept “no” for an answer when it comes to medically necessary care. Contact B&Y Health Care today for a Benefits Review, and let us help you understand what your child is truly entitled to.
Homegrown Health, Heartfelt Healing
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