ForwardHealth says it will backdate behavioral treatment approvals, after eight providers reported 400 pending prior authorizations and 20 children on hold.
Key Takeaways
- Wisconsin ABA providers report children losing access. Eight provider organizations report 20 children with services on hold and 400 prior authorization requests awaiting a determination. Providers say they cannot continue treatment without an active authorization because ForwardHealth will not reimburse services started before approval and bars billing families when a request is denied.
- ForwardHealth adopted part of the federal prior authorization overhaul. On August 17 the agency stopped returning incomplete requests for correction and capped backdating at 14 calendar days, counting the submission date as the first. It did not adopt the seven calendar day decision timeline that CMS-0057-F attaches to the same set of reforms.
- The department places federal compliance a year after the rule took effect. ForwardHealth’s prior authorization FAQ and a September 14 message to providers both put the seven day requirement at January 1, 2027, while the regulation at 42 CFR 440.230(e) applies it beginning January 1, 2026. The department’s own 2025 metrics, covering every Medicaid fee-for-service request rather than ABA alone, report a mean decision time of 3.1 days measured from receipt of a complete request.
- ForwardHealth has offered interim relief ahead of a September 17 meeting. In a September 14 message to the two provider associations, the department said it has been granting one-time extraordinary backdating to the originally requested start date and will continue that approach for requests submitted on and after August 17 until further notice. Providers must ask for it in writing and meet criteria set out in the Online Handbook.
A child in Wisconsin stopped receiving applied behavior analysis services in early September. Their authorization expired on August 31, and the renewal their provider filed with ForwardHealth is still pending. Under state Medicaid rules, no one can be reimbursed for treating them until that renewal clears. Victoria Oliversen, President-Elect of the Wisconsin Association for Behavior Analysis, told Acuity in an interview that paused cases like this one often involve children being treated for severe challenging behavior, children who are sent home from school over that behavior, who are unsafe at home, and who need a consistent and adequately staffed setting for the treatment to reduce it.
That child is one of 20 whose services have been placed on hold across eight ABA provider organizations, according to figures compiled by Dr. Rebecca Thompson, President of the Wisconsin Autism Providers Association, and provided to Acuity. Those same organizations report 400 prior authorization requests awaiting determination: 242 submitted since August 17, when ForwardHealth changed how it processes them, and 158 submitted before. The figures are self-reported by organizations of varying size, and Acuity has not independently verified them. Of 249 requests submitted since August 17, seven had received a determination as of September 10. Three were approved, and four were denied.
Providers described a narrow set of options in a series of interviews with Acuity. ForwardHealth’s prior authorization request form states that it will not pay for services initiated before approval or after an authorization expires. The agency’s Online Handbook separately provides that when a request is denied after a service has been rendered, the provider cannot require payment from the member. A provider who keeps treating a child whose authorization has lapsed is betting payroll on an approval it cannot see coming, a position ABA operators have faced in other states when payers and public agencies fall behind on processing.
On September 14, the department told the associations it would keep backdating those approvals. In a message reviewed by Acuity, ForwardHealth’s Service Authorization Team wrote that for behavioral treatment requests it has been granting one-time extraordinary backdating to the originally requested start date when a provider resubmits with the missing documentation, and that it will continue doing so for requests submitted on and after August 17 “until further notice.” The message set conditions on that relief, did not define the window for resubmitting, and did not say how long determinations are taking. Providers will take the question back to the department at a workgroup meeting on September 17.
What ForwardHealth Changed in the Prior Authorization Process on August 17
Wisconsin administers ABA as a carved-out Behavioral Treatment Benefit. Prior authorization and claims processing run directly through ForwardHealth, the state’s fee-for-service Medicaid program, with no managed care organization in between. Every Medicaid ABA authorization in the state passes through the same office, a structure that differs sharply from states where the same codes carry different authorization requirements depending on the funding pathway.
Since spring, the Department of Health Services has been rolling out changes in phases to comply with CMS-0057-F, the federal Interoperability and Prior Authorization Final Rule. ForwardHealth Update 2026-09 announced the first tranche in April: portal-only submission, a revised request form, a universal backdating policy, and the elimination of the “Returned, Provider Review” status. Those changes were scheduled for July 13, then postponed. Update 2026-19 moved them to August 17.
The returned status mattered. Under the previous process, a request missing a document came back to the provider with a note explaining what was needed. An archived version of the Online Handbook published through November 30, 2025 states plainly that a return for more information is not a denial. ForwardHealth held such requests for 30 days, and providers could ask for extensions. Outright denials were uncommon. That pathway is gone. An incomplete request now receives an “Incomplete, PA Denied” status and the provider starts over.
The second change was backdating. ForwardHealth now allows a start date up to 14 calendar days before a request is received, counting the day of receipt as the first day. A request filed on September 14 can reach back to September 1, and no further.
What did not change was the clock. The Online Handbook states that ForwardHealth will decide a request within 20 working days of receiving all the necessary information, language that also appears in the archived November 2025 edition.
Providers say they were told to expect otherwise. The summary of the department’s February 19 Behavioral Treatment Audit Workgroup meeting records DHS telling providers that standard prior authorizations would need to be adjudicated within seven days and urgent requests within 72 hours. The associations’ September letter states that providers understood the seven-day timeline would take effect alongside the new process.
Melissa Roberts, Director of Client Services at Sonnenberg Consultants, LLC and a board certified behavior analyst, has supervised the company’s ForwardHealth prior authorization submissions since Wisconsin moved behavioral treatment out of the county waiver program in 2016. She handles authorizations for roughly 75 clients across nine payer portals, and told Acuity that the pairing of the two timelines is the problem. “They’ve got 20 business days to get back to you,” she said, “but you can only go back 14 calendar days.”
Roberts said she has already run into it. A request with an August 2 start date was returned before August 17, and when she resubmitted afterward, the portal would not let her go back further than August 6. The system required her to affirm that she was choosing to change the start date. She has since written to ForwardHealth asking that the original date be honored and does not yet know whether it will be. That request is the mechanism the department would later tell providers it intends to grant.
Oliversen described the result as a partial implementation. “You moved the goalpost, but didn’t give the tools to implement it practically,” she said.
Providers may file up to eight weeks before an authorization expires. If a request filed in advance is denied at or near the 20-working-day mark, the replacement can only reach back 14 calendar days. For a renewal covering care meant to begin September 1, the window to cure a denial closes in mid-September, roughly when the determination itself comes due. “We have room for exactly one error,” Oliversen said.
The Federal Prior Authorization Deadline Appears in Two Places
CMS-0057-F requires impacted payers, including state Medicaid fee-for-service programs, to decide standard prior authorization requests within seven calendar days and expedited requests within 72 hours. The regulation at 42 CFR 440.230(e)(1) applies that requirement beginning January 1, 2026. The agency may grant an extension of up to 14 calendar days when it needs additional information from the provider.
ForwardHealth’s own guidance places the date elsewhere. Its FAQ on interoperability and prior authorization, created in October 2025 and last revised on September 3, 2026, states that the agency is updating requirements in phases “to meet the CMS Final Rule compliance by January 1, 2027.” The department restated that position on September 14, writing that it must be compliant with a seven-day turnaround by January 1, 2027.
Wisconsin’s administrative code sets a separate benchmark. Wis. Admin. Code § DHS 107.02(3)(a) requires the department to act on 95 percent of prior authorization requests within 10 working days and on 100 percent within 20.
In a joint letter sent to DHS on September 3 and shared with Acuity, the Wisconsin Autism Providers Association and the Wisconsin Association for Behavior Analysis wrote that providers “have been given conflicting information about the PA process and timeline” and asked the department to delay the no-returns process until determinations can be made within seven days. The letter placed the federal requirement at January 1, 2027, consistent with the department’s FAQ.
Wisconsin’s Own Prior Authorization Metrics Report a 3.1-Day Average
In other materials the department uses the earlier standard. Its Prior Authorization Metrics report for 2025, published to satisfy the same federal rule, labels its standard request category “response due to provider within 7 calendar days.” The department’s Prior Authorization Data page carries the same definition and lists Behavioral Treatment among the services requiring prior authorization. The report covers every Medicaid fee-for-service prior authorization request the state received and is not broken out by service, so it does not describe Behavioral Treatment on its own.
Within that program-wide picture, reported performance sits well inside the seven-day window. Across 165,012 standard requests in 2025, the department approved 90.2 percent, denied 4.0 percent, and partially denied 5.9 percent. Mean decision time was 3.1 days, and median was 1.0 day. The report also shows the review extension was used zero times.
Those numbers sit far from what providers describe. The distance turns on what the clock measures. The department’s data page states that response time runs from receipt of a complete prior authorization request, and cites DHS 107.02(3)(a), under which a complete request is one that includes the clinical documentation necessary to make a determination. Under the returns process that ended in August, a request sent back for more information was not yet complete, so the published figure captured the final stage of a review rather than the total time a provider waited.
The expedited figures are smaller and slower. Wisconsin received 10 urgent requests across all of 2025, and the mean decision time was 6.3 days against a 72-hour standard.
ABA Prior Authorization Delays Predate the August Change
Providers told Acuity the wait is not new. Roberts said the 20-working-day standard has been in the Handbook for as long as she can remember and simply never mattered while returns existed. Reviewing her own records, she said determinations ran roughly 14 to 16 business days early in 2026 and 18 to 20 by February.
Oliversen said providers across the state are seeing the same pattern. “It’s been consistently 20 business days, at least a month’s wait prior to August 17,” she said. “Many organizations are reporting waits longer than 20 business days.”
The association figures reflect that history. Of the 400 requests pending, 158 were submitted before August 17 and remain undetermined, some of them for more than a month.
What changed, in the providers’ account, was not the speed but the consequence of the delay. Under the old process, a slow determination often ended in a return, and the eventual approval could be backdated to the originally requested start date. Roberts said she has had requests go through two or three returns and still be paid from the original date, in some cases backdated two to three months. Rather than pause services, she said, Sonnenberg reduced the hours it delivered while waiting. Now a slow determination can end in a denial, and the remedy carries a 14-day ceiling.
“We get radio silence from ForwardHealth,” Oliversen said. “We’re just in a waiting game.”
Denials, Member Notice, and Medicaid Appeal Rights
Under the previous process, ForwardHealth rarely denied Behavioral Treatment requests outright, according to both associations, and the 2025 metrics put the program-wide denial rate at 4.0 percent. Roberts said she is nearly certain Sonnenberg had received no denial from ForwardHealth for any client before August 17, though it had received many approvals with modifications, most often for shorter authorization periods or fewer hours than clinically recommended. Since August 17 she has had two requests denied, one because a clinician signature was missing from a form and one on medical necessity. Under the old process, she said, both would have been returns she could correct.
A shift may be appearing in the aggregate figures as well: of the seven determinations issued on post-August 17 submissions, four were denials. Seven decisions is far too small a sample to establish a rate, and the department has not published figures for the period. Roberts said four of her clients were approved at 21 business days, past the outer limit the state’s administrative code sets for all requests.
Denials carry procedural consequences. The Online Handbook states that when a request is denied, the member receives a Notice of Appeal Rights explaining the reason and the right to a fair hearing, and that only the member or an authorized representative may appeal. The federal rule at 42 CFR 440.230(e)(2) requires states to provide notice of a prior authorization decision along with fair hearing rights, including advance notice. Whether an “Incomplete, PA Denied” determination triggers that notice, and how many have been issued for Behavioral Treatment since August 17, were among the questions Acuity put to the department.
The appeal route exists but is not quick. Roberts said Sonnenberg once appealed an authorization granted for fewer hours than clinically recommended and had the decision reversed, recovering payment for hours already delivered. The process took several steps and included a conference call with a judge. Roberts said the appeal was decided in late 2023 or early 2024, and that she confirmed the details with the analyst who handled it. Disputes over stalled ABA payment have moved into litigation in other states, and state agencies have suspended provider payments while questions were resolved.
Prior Authorization Delays Reach ABA Staffing and Access
Oliversen told Acuity the consequences reach past the children directly affected. ABA is delivered one-to-one, so each paused case idles at least one behavior technician. Inconsistent hours are among the most commonly cited reasons technicians leave the field, she said, and September is when caseloads shuffle as children return to school. Operators elsewhere have rebuilt their clinical models around scheduling stability as a retention strategy, and the broader direct care workforce has been losing staff faster than it can replace them.
“They too need routine,” she said of behavior technician staff. Some providers can redeploy technicians to clients with active authorizations, but doing so requires additional administrative planning and cross-training costs. Most providers, she said, simply cancel the hours.
She also described a widening gap between payers. Commercial plans typically return authorization decisions in one to two weeks, she said, so families with private coverage see little disruption. In Milwaukee, she said, families whose primary coverage is ForwardHealth already face longer waits for services, because fewer providers in that market accept ForwardHealth as primary.
Her broader concern is that the delays push providers away from Medicaid altogether. “The risk is this makes it harder for providers to keep taking ForwardHealth as primary, and the families who lose access are the ones with the fewest options,” Oliversen said. At least one ABA provider has closed a state operation and cited credentialing, authorization, and collection delays among the reasons. She said the 20 children identified across eight organizations are likely an undercount, since no one has tabulated paused services statewide, and that she expects the number to rise substantially if determinations do not move faster. That projection has not been independently assessed.
Roberts described a separate effect on new patients. DHS has said it plans real-time review for certain initial requests for children under six by the end of 2026. Roberts said she held a new client’s paperwork expecting that capability on August 17, found it was not yet available, and said the child has not started services.
What Happens Next for Wisconsin ABA Providers
Pam Lano, Section Manager of the Behavioral Health Policy Section in the department’s Bureau of Benefits Policy, wrote to the associations on September 8 that their inquiry had been directed to the prior authorization team in the Bureau of Clinical Policy and Pharmacy, that the team was investigating, and that it would attend the Behavioral Treatment Audit Workgroup meeting on September 17.
Providers had asked for a resolution before that date. The associations wrote that every additional day adds families to the count.
The department answered on September 14. Its Service Authorization Team confirmed that ForwardHealth no longer returns requests and requires a complete and accurate submission, and that an incomplete request is denied and must be refiled. It then described an accommodation. For behavioral treatment requests, ForwardHealth has been granting one-time extraordinary backdating to the requested start date when a provider resubmits with the missing documentation within a specific timeframe and meets the extraordinary circumstances criteria in Handbook Topic #439. To prevent disruption for members and families, the message said, the department will continue that approach for requests submitted on and after August 17 until further notice.
Topic #439 sets conditions. A provider must request backdating in writing on the request itself, include clinical justification for beginning services before authorization was granted, and explain why the request arrived more than 14 calendar days after the requested start date. The examples of extraordinary circumstances published in the Handbook are a court order or hearing decision, retroactive member enrollment, and a provider operating under a correction plan. Agency processing time is not among them. The message did not define the specific timeframe for resubmission.
Thompson told Acuity she believes allowing backdating addresses the underlying problem, and that she had shared the message with the WAPA board.
The department has not responded to Acuity directly. The Wisconsin Department of Health Services did not answer questions submitted on September 8 and September 9. Those questions asked how the department reconciles the 20-working-day standard in its Online Handbook with the seven calendar day requirement in federal regulation, how many Behavioral Treatment requests it has received and adjudicated since August 17 and how long those decisions have taken, whether an “Incomplete, PA Denied” determination generates member notice and fair hearing rights, and whether any interim guidance would reach providers before the September 17 meeting. Acuity asked for a response by September 10.
At least one avenue appears to have gone unused. ForwardHealth’s FAQ describes an urgent request pathway carrying the 72-hour standard, available where a standard timeline could jeopardize a member’s health or ability to regain maximum function. A request submitted as urgent that does not meet the criteria is processed as a standard request. Neither association raised the pathway in its correspondence with the department.
Roberts, asked what would resolve the immediate problem, pointed to a single assurance. If ForwardHealth committed to backdating approvals to the originally requested start date, she said, she would be willing to keep running the hours while determinations are pending.
The department has said its next set of prior authorization changes is planned for December.
