No changes for My Choice Medicare, Family Care, and Family Care Partnership.
Authorizations
Authorization processes, secondary coverage, and non-covered services information can be found here. All authorization-related forms are in the resource library below. For other important information about programs, claims, and much more search our full Provider Resource Library; you may use the search feature to find resources by program, find a specific document or use the “Document Types” filter to limit to category-specific documents.
Commonly referenced documents
Hospice Prior Authorization Request Form
April 22, 2022 | pdf (641.21 KB) | Authorization Request Form, Authorizations
How to Obtain a Copy of Your Explanation of Benefits (EOB)
November 2, 2020 | pdf (177.72 KB) | Claims Information
Hypertension Prevention and Wellness Practice Guideline
August 9, 2024 | pdf (251.27 KB) | Practice Guidelines
Influenza Prevention and Wellness Practice Guideline
August 9, 2024 | pdf (272.42 KB) | Practice Guidelines
Inpatient Admission Prior Authorization Request Form
April 22, 2022 | pdf (223.98 KB) | Authorization Request Form, Authorizations
MCW Family Care – Authorization for Release of PHI (ROI) AUTH001
January 25, 2021 | pdf (111.14 KB) | Compliance & Privacy
Used by Family Care to obtain to release information to another or to authorize another entity to release information to MCW Family Care.
MCW Health Plan – Authorization for Family Non-Medical Release of Information (ROI) AUTH005
January 25, 2021 | pdf (109.82 KB) | Compliance & Privacy
Used by the Health Plan to capture family, friends, or others that the member chooses to allow the sharing of information between the health plan and these individuals.
MCW Health Plan – Authorization for General Release of Information – prefilled (ROI) AUTH003
January 25, 2021 | pdf (193.35 KB) | Compliance & Privacy
Same as AUTH002 but prefilled with My Choice Wisconsin Health Plan information as the receiver of the PHI from another entity. AUTH002: Used by the Health Plan (Partnership, SSI, Dual Advantage, BadgerCare Plus) to obtain authorization to release information to another entity/provider or for another entity/provider to release information to the MCW Health Plan.
MCW Health Plan – Authorization for General Release of Information (ROI) AUTH002
January 25, 2021 | pdf (106.37 KB) | Compliance & Privacy
Used by the Health Plan (Partnership, SSI, Dual Advantage, BadgerCare Plus) to obtain authorization to release information to another entity/provider or for another entity/provider to release information to the MCW Health Plan.
MCW Health Plan – Authorization for Multi-Provider Release of Information (ROI) AUTH004
January 25, 2021 | pdf (104.56 KB) | Compliance & Privacy
Used by the Health Plan (typically with a new member) to capture multiple providers/entities on one release; authorizes the listed providers/entities to release information to MCW Health Plan.
Medicaid Home Health Services Prior Authorization Resource
April 22, 2022 | pdf (181.87 KB) | Authorizations, Prior Authorization Resource
Medicaid Hospice Prior Authorization Resource
April 22, 2022 | pdf (155.09 KB) | Authorizations, Prior Authorization Resource
Medicaid Skilled Nursing Facility (SNF) Prior Authorization Resource
April 22, 2022 | pdf (174.57 KB) | Authorizations, Prior Authorization Resource
Medicaid SSI Personal Care Worker Prior Authorization Request Form
April 22, 2022 | pdf (217.05 KB) | Authorizations
Medicare Diabetes Prevention Program Prior Authorization Resource
April 22, 2022 | pdf (206.08 KB) | Authorizations, Prior Authorization Resource
Medicare Home Health Services Prior Authorization Resource
April 22, 2022 | pdf (185.14 KB) | Authorizations, Prior Authorization Resource
Medicare Hospice Prior Authorization Resource
April 22, 2022 | pdf (229.01 KB) | Authorizations, Prior Authorization Resource
Medicare Skilled Nursing Facility (SNF) Prior Authorization Resource
April 12, 2022 | pdf (276.39 KB) | Authorizations, Prior Authorization Resource
Medline Order Form
October 18, 2020 | pdf (297.63 KB) |
Use this form to order Medline disposable medical supplies.
MIDAS Provider Portal User Guide for EVV Services
May 17, 2021 | pdf (790.74 KB) | Claims Information
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