Mental Health Counseling Wisconsin Medicaid Managed Care Plan

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MM slash DD slash YYYY
Patient Name*
Medicaid Managed Care Plan Insurance Coverage

Patient has active coverage with this Medicaid plan, and this insurance is the only insurance on file.

90791 - Psychiatric Diagnostic Evaluation
90832 - Individual Psychotherapy 16-37 minutes
90834 - Individual Psychotherapy 38-52 minutes
90837 - Individual Psychotherapy 53 minutes plus
90785 - Interactive Complexity
90846 - Family Therapy without patient 26 minutes plus
90847 - Family Therapy with patient 26 minutes plus
90853 - Group psychotherapy (interpersonal processing)
Is prior authorization required for mental health counseling services?*
When we call on a patient's insurance and verify benefits it is not a guarantee of payment by the insurance company and may vary according to the patient's individual plan when the actual claim is submitted. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member's contract at time of service. The patient responsibility amount provided is an estimate of cost. The patient must understand that their health insurance company may deny payment for the services received. The patient must understand that it is ultimately the patient's responsibility to contact their insurance if they want to know exact benefits.
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