Therapy Protocol

The therapy provider will fax the CCCW Therapy Cover Sheet and the member’s Plan of Care to CCCW at (866) 672-6648 or email This email address is being protected from spambots. You need JavaScript enabled to view it.

The CCCW Therapy Cover Sheet includes the following:

  • Provider Name
  • Member name (Last, First and MI)
  • Date of Birth
  • Type of therapy (including need for evaluation)
  • Frequency and length of each service
  • Start and End dates of each service
  • Payer sources (including who is primary)
  • Section for IDT response to request

NOTE: Therapy Evaluations or Therapy Evaluations and treatment done at the same visit do NOT need prior authorization but should be included on the Therapy Cover sheet.


CCCW Member Authorization Deptartment staff will forward the fax to the appropriate IDT (Health & Wellness Coordinator & Community Resource Coordinator) and Member Support Coordination Manager. 


Within 24 hours of receiving the Therapy Cover sheet and Plan of Care, the IDT will contact the Therapy Provider as outline below: 

a. Fax the completed Therapy Cover sheet indicating Authorization
OR 
b. Fax the completed Therapy Cover sheet indicating Denial
OR
c. Phone the Therapy Provider to request additional information

  1.  Within 72 hours of receiving this additional information the IDT will contact the Therapy Provider as outlined below to either:
    1. Fax the completed Therapy Cover sheet indicating Authorization
      OR
    2. Fax the completed Therapy Cover sheet indicating Denial


    *For questions/follow-up related to faxed Therapy Cover Sheet please contact the member’s IDT
    *For questions related to filing a claim please call CCCW Member Authorization Deptartment at (715) 204-1738 or email This email address is being protected from spambots. You need JavaScript enabled to view it.

    NOTE: Effective 10/01/09 Therapy claims should be mailed to CCCW (NOT to WPS, see below).

    Community Care Connections of Wisconsin
    3349 Church Street, Suite 1
    Stevens Point, WI 54481


    Therapy Fax Coversheet