Wisconsin - Case Management Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

Wisconsin Department of Health Services (DHS) authorizes Case Management under Wis. Admin. Code § DHS 107.32 to assist Medicaid and BadgerCare Plus members in gaining access to medical, social, educational, and vocational services. The service encompasses comprehensive assessment, case plan development, and ongoing monitoring for specific target populations, including children in the Birth to 3 Program and adults in Home and Community-Based Services (HCBS) waivers.

Approval requires enrollment through the ForwardHealth portal under the Targeted Case Management specialty, but access to the state's primary HCBS populations requires securing a contract with a regional Managed Care Organization (MCO) under the Family Care program or winning a competitive state procurement to operate as an IRIS Consultant Agency (ICA).

1. Service Definition and Scope

In Wisconsin, Case Management is defined under Wis. Admin. Code § DHS 107.32(1)(a)1 as services that assist members and their families in gaining access to and coordinating a full array of services. This is not a direct-care provision but a coordination and monitoring function.

The scope includes evaluating the member's needs, developing a written plan, and ensuring the services are delivered and effective. It explicitly covers activities performed by service coordinators in the Birth to 3 Program.

• Assessment: Covered under Wis. Admin. Code § DHS 107.32(1)(b) to identify unmet needs.
• Case Plan Development: Covered under Wis. Admin. Code § DHS 107.32(1)(c) to establish specific goals.
• Ongoing Monitoring: Includes direct observation of the member receiving services from other providers.
• Referral: Providing information and referral to community resources identified in the case plan.
• Advocacy: Client-specific advocacy necessary to assist the member in gaining access to services.
• Birth to 3 Coordination: Arranging for an eligible child's evaluation and developing the Individualized Family Service Plan (IFSP).

2. Regulatory and Oversight Agencies

The Wisconsin Department of Health Services (DHS) is the primary state agency responsible for Medicaid and HCBS waiver oversight. Within DHS, the Division of Medicaid Services (DMS) manages the policy and funding for these programs.

Provider enrollment and claims processing are handled through ForwardHealth, Wisconsin's Medicaid Management Information System (MMIS) and provider portal.

• Wisconsin Department of Health Services (DHS): https://www.dhs.wisconsin.gov
• ForwardHealth Portal: https://www.forwardhealth.wi.gov
• Division of Quality Assurance (DQA): https://www.dhs.wisconsin.gov/dqa/sections.htm
• Family Care Program: https://www.dhs.wisconsin.gov/familycare/index.htm
• IRIS Program: https://www.dhs.wisconsin.gov/iris/index.htm

3. Gatekeeping Prerequisites: Who Can Even Apply

Wisconsin heavily gates HCBS case management through managed care contracting and state procurement processes. While a provider can enroll in ForwardHealth as a Targeted Case Management provider for fee-for-service populations, serving the vast majority of HCBS waiver participants requires structural preconditions.

Providers cannot independently bill for Family Care or IRIS case management without first being selected by the managing entities.

• Family Care MCO Contracting: Providers must secure a network contract with a regional Managed Care Organization (e.g., My Choice Wisconsin, Inclusa); ForwardHealth enrollment alone does not grant access to Family Care members.
• IRIS Consultant Agency (ICA) Procurement: To provide case management in the self-directed IRIS waiver, an agency must win a competitive Request for Proposals (RFP) issued by DHS.
• Target Population Restriction: Fee-for-service Targeted Case Management is limited to specific target groups defined in the ForwardHealth Online Handbook.
• Birth to 3 Program Affiliation: Billing for early intervention case management requires the provider to be enrolled as a Birth to 3 Program or be part of a county department.

4. Licensure and Certification Requirements

Wisconsin does not issue a standalone "Case Management Agency License" through the Division of Quality Assurance (DQA). Instead, agencies are certified through the Medicaid enrollment process by demonstrating compliance with Wis. Admin. Code ch. DHS 105.

Agencies must attest to meeting the structural, policy, and staffing requirements outlined in the administrative code and the specific waiver appendices.

• DQA Facility Licensure: Not required for standalone case management agencies.
• Agency Qualification: Must meet the standards set forth in Wis. Admin. Code § DHS 105.51.
• Provider Agreement: Must electronically sign the DHS provider agreement attesting to compliance with Wis. Admin. Code chs. DHS 101-109.
• Waiver Compliance: Must attest to meeting requirements in the Family Care Waiver or IRIS Waiver documents.

5. Medicaid Provider Enrollment

Agencies must enroll via the ForwardHealth Portal. The system requires providers to select the appropriate billing category and submit documentation verifying their qualifications.

Providers must establish their National Provider Identifier (NPI) and link it to their physical practice locations before applying.

• Enrollment Portal: ForwardHealth Provider Portal (https://www.forwardhealth.wi.gov/WIPortal/Subsystem/Certification/CertificationHomePage.aspx).
• Billing Category: Providers must enroll as a Billing and Rendering provider or a Billing-only provider depending on their structure.
• NPI Requirement: Each practice location must have its own unique NPI obtained via NPPES.
• Application Timeout: The ForwardHealth web page times out after 30 minutes of inactivity.
• Revalidation: Wisconsin Medicaid requires providers to revalidate their enrollment information every three years.

6. Staffing, Training and Background Checks

Case managers performing assessments and case planning must meet strict educational and experiential qualifications defined in Wis. Admin. Code § DHS 105.51(2). The enrolled agency is responsible for verifying these credentials for both direct employees and subcontractors.

Because DHS does not strictly define a "human services-related field," agencies must review transcripts to identify relevant coursework such as human development, long-term care, or psychology.

• Degree Requirement: A degree in a human services-related field.
• Experience Alternative 1: One year of supervised experience combined with the human services degree.
• Experience Alternative 2: Two years of supervised experience working with people in the target population.
• Knowledge Base: Must demonstrate knowledge of the local service delivery system and target group needs.
• Interpreter Qualifications: Sign language interpreters must be licensed under Wis. Stat. § 440.032; foreign language interpreters must be at least 18 years old.

7. Documentation, Policies and Records

Wisconsin Medicaid strictly enforces documentation standards under Wis. Admin. Code § DHS 106.03. Case plans must be highly specific and directly tied to the assessments.

Failure to maintain contemporaneous, detailed records of monitoring activities and case plan updates is a primary cause for payment recoupment.

• Case Plan Contents: Must list goals, outcomes, and specific services directly related to unmet needs identified in the assessment.
• Assessment Limits: For Group A target populations, limited to one assessment or case plan development per member, per calendar year (unless county of residence changes).
• Birth to 3 Records: Must record required information in the IFSP and the child's early intervention record per Wis. Admin. Code ch. DHS 90.
• Medical History: Case managers should request dental history information and note it in the health records review.

8. Billing, Rates and Claims

Reimbursement for Targeted Case Management is processed through ForwardHealth for fee-for-service members, while HCBS waiver case management is billed directly to the contracted MCO.

Wisconsin Medicaid imposes specific frequency limits on how often certain case management activities can be billed.

• Ongoing Monitoring Frequency: Can only be billed once for any given calendar month, unless the member's county of residence changes.
• Provider Limits: Wisconsin Medicaid does not reimburse more than two providers for ongoing monitoring occurring in any month.
• Assessment Limits: More than two assessments or case plans per year for members in target populations A or B are not covered.
• IFSP Participation: Time spent by qualified early intervention providers participating in IFSP development is billable if paid by the enrolled case management provider.

9. Approval Sequence and Timeline

The enrollment process begins with the submission of the application on the ForwardHealth Portal. Providers must complete the application within a strict timeframe once initiated.

Approval is not instantaneous; providers must wait for official written notification before they can begin billing.

• Application Window: Providers have 10 calendar days to complete an application on the ForwardHealth Portal once they begin.
• Notice of Enrollment Decision: Providers must wait for this official notification before providing or billing for services.
• Change in Ownership: ForwardHealth must receive notification within 35 calendar days after the effective date of a change in ownership.
• Effective Date: Providers receive written notification of their new Medicaid enrollment effective date in the mail.

10. Common Denials and Survey Findings

Under Wis. Admin. Code § DHS 107.02(2), BadgerCare Plus and Wisconsin Medicaid actively deny or recoup payments for case management services that fail to meet program requirements.

Audits frequently target missing documentation or failure to verify the qualifications of the individual case managers.

• Missing Records: Recoupment for services for which records or other documentation were not prepared or maintained.
• Regulatory Non-Compliance: Denials for failing to meet any requirements of Wis. Admin. Code § DHS 106.03.
• Unqualified Staff: Billing for assessments performed by staff who do not meet the degree or experience requirements in DHS 105.51(2).
• Frequency Violations: Billing for ongoing monitoring more than once per calendar month without a change in county residence.

11. Key Contacts and Resources

Providers should utilize the ForwardHealth Portal and the specific program pages on the DHS website for the most current handbooks, enrollment criteria, and policy updates.

MCO directories are essential for providers seeking to enter the Family Care network.

• ForwardHealth Provider Portal: https://www.forwardhealth.wi.gov
• ForwardHealth Enrollment Criteria: https://www.forwardhealth.wi.gov/WIPortal/Subsystem/Certification/EnrollmentCriteria.aspx
• Wisconsin DHS Family Care: https://www.dhs.wisconsin.gov/familycare/index.htm
• Wisconsin Administrative Code (DHS 101-109): https://docs.legis.wisconsin.gov/code/admin_code/dhs/101

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