Coverage and Prior Authorizations
BadgerCare Plus Coverage and Prior Authorization Requirements
Before rendering care, providers must verify whether a code is covered under the member’s BadgerCare Plus plan and whether prior authorization (PA) is required. Reviewing these details in advance helps prevent claim denials and ensures compliance with Wisconsin Medicaid requirements.
Coverage under BadgerCare Plus may include service limitations, frequency limits or exclusions.
How to Verify Coverage and Prior Authorization
Before submitting an authorization request:
- Determine Coverage
Refer to the ForwardHealth Max Fee Schedule to confirm whether a CPT/HCPCS code is covered under BadgerCare Plus. - Determine Prior Authorization Requirements
Refer to the most current CCHP BadgerCare Plus Prior Authorization List to determine whether a covered code requires prior authorization.
Important:
- Some CPT codes do not require prior authorization. However, all inpatient admissions, including those associated with inpatient-only CPT codes, require authorization to be submitted within three (3) business days of admission.
- If a code appears on the ForwardHealth Max Fee Schedule but does not appear on the most current Prior Authorization List prior authorization is not required.
Submit Authorizations
Steps for submitting in-network and out-of-network authorizations.
In-Network Providers
In-network providers must submit inpatient admission notifications and prior authorization requests online through the GuidingCare Authorization Portal.
The GuidingCare Authorization Portal gives CCHP network providers the online capability to:
- Submit authorization requests quickly and securely.
- Receive a reference number, an approval or review notification immediately.
- Submit concurrent review information for inpatient admissions.
Out-of-Network Providers
Out-of-network providers must complete the Out-of-Network (OON) Provider Authorization Request Form .
Fax completed form to 414-266-4726.
Contact us
For questions or assistance with authorization requests contact the CCHP Clinical Services Department.
877-227-1142, option 2
Affirmative Statement
Chorus Community Health Plans (CCHP) is committed to ensuring members receive appropriate, high-quality care when they need it. We use an authorization process as part of our Utilization Management (UM) program to support this goal. UM decisions are based only on medical appropriateness of care and services, and existence of coverage under the member's benefit plan. CCHP does not reward any individual for issuing denials of coverage. Financial incentives for UM decision-makers do not encourage decisions that result in underutilization of medically necessary services.