Ch. DHS 105 NoteNote: Chapter HSS 105 as it existed on February 28, 1986 was repealed and a new chapter HSS 105 was created effective March 1, 1986. Chapter HSS 105 was renumbered Chapter HFS 105 under s. 13.93 (2m) (b) 1., Stats., and corrections made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, January, 1997, No. 493. Chapter HFS 105 was renumbered to chapter DHS 105 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636. DHS 105.01(1)(1) Purpose. This chapter identifies the terms and conditions under which providers of health care services are certified for participation in the medical assistance program (MA). DHS 105.01(2)(a)(a) “Group billing provider” means an entity which provides or arranges for the provision of medical services by more than one certified provider. DHS 105.01(2)(b)(b) “Provider assistant” means a provider such as a physical therapist assistant whose services must be provided under the supervision of a certified or licensed professional provider, and who, while required to be certified, is not eligible for direct reimbursement from MA. DHS 105.01(3)(3) General conditions for participation. In order to be certified by the department to provide specified services for a reasonable period of time as specified by the department, a provider shall truthfully, accurately, completely and in a timely manner do all of the following: DHS 105.01(3)(a)(a) Affirm in writing that, with respect to each service for which certification is sought, the provider and each person employed by the provider for the purpose of providing the service holds all licenses or similar entitlements as specified in chs. DHS 101 to 108 and required by federal or state statute, regulation or rule for the provision of the service; DHS 105.01(3)(b)(b) Affirm in writing that neither the provider, nor any person in whom the provider has a controlling interest, nor any person having a controlling interest in the provider, has, since the inception of the medicare, medicaid, or title 20 services program, been convicted of a crime related to, or been terminated from, a federal-assisted or state-assisted medical program; DHS 105.01(3)(c)(c) Disclose in writing to the department all instances in which the provider, any person in whom the provider has a controlling interest, or any person having a controlling interest in the provider has been sanctioned by a federal-assisted or state-assisted medical program, since the inception of medicare, medicaid or the title 20 services program; DHS 105.01(3)(d)(d) Furnish the following information to the department, in writing: DHS 105.01(3)(d)1.1. The names and addresses of all vendors of drugs, medical supplies or transportation, or other providers in which it has a controlling interest or ownership; DHS 105.01(3)(d)2.2. The names and addresses of all persons who have a controlling interest in the provider; and DHS 105.01(3)(d)3.3. Whether any of the persons named in compliance with subd. 1. or 2., is related to another as spouse, parent, child or sibling; DHS 105.01(3)(f)1.1. Accept and consent to the use, based on a methodology determined by the investigating or auditing agency, of statistical sampling and extrapolation as the means to determine amounts owed by the provider to MA as the result of an investigation or audit conducted by the department, the department of justice medicaid fraud control unit, the federal department of health and human services, the federal bureau of investigation, or an authorized agent of any of these. DHS 105.01(3)(f)2.2. The sampling and extrapolation methodologies, if any, used in the investigation or audit shall be generally consistent, as applicable, with the guidelines on audit sampling issued by the statistical sampling subcommittee of the American institute of certified public accountants. Extrapolation, when performed, shall apply to the same period of time upon which the sampling is derived. DHS 105.01(3)(f)3.3. The department and the other investigative agencies shall retain the right to use alternative means to determine, consistent with applicable and generally accepted auditing practices, amounts owed as the result of an investigation or audit. DHS 105.01(3)(f)4.4. Nothing in this paragraph shall be construed to limit the right of a provider to appeal a department recovery action brought under s. DHS 108.02 (9). DHS 105.01(4)(4) Providers required to be certified. The following types of providers are required to be certified by the department in order to participate in the MA program: DHS 105.01(4)(e)(e) Providers performing professional services for hospital inpatients under s. DHS 107.08 (4) (d). Hospitals which provide the setting for the performance of professional services to its inpatients shall ensure that the providers of those services are appropriately certified under this chapter. DHS 105.01(5)(5) Persons not required to be individually certified. The following persons are not required to be individually certified by the department in order to participate in the MA program: DHS 105.01(5)(a)3.3. Hospital and nursing home administrators, clinic managers, and administrative and billing staff; DHS 105.01(5)(a)11.11. All other persons whose cost of service is built into the charge submitted by the provider, including housekeeping and maintenance staff; and DHS 105.01(5)(b)(b) Except for providers required to be separately certified under sub. (4) (b) to (e), providers employed by or under contract to certified institutional providers, including but not limited to physicians, therapists, nurses and provider assistants. These providers shall meet certification standards applicable to their respective provider type. DHS 105.01(5m)(5m) Optional Certification. A dental hygienist licensed under s. 447.04 (2), Stats., may opt to be individually certified by the department for MA reimbursement for dental hygiene services. DHS 105.01(6)(6) Notification of certification decision. Except as provided in s. DHS 105.17 (5), within 60 days after receipt by the department or its fiscal agent of a complete application for certification, including evidence of licensure or medicare certification, or both, if required, the department shall either approve the application and issue the certification or deny the application. If the application for certification is denied, the department shall give the applicant reasons, in writing, for the denial. DHS 105.01 HistoryHistory: Cr. Register, February, 1986, No. 362, eff. 3-1-86; r. (2) (b) and (c), (5) (a) 6., renum. (2) (d) and (5) (a) 7. to 12. to be (2) (b) and (5) (a) 6. to 11., Register, February, 1988, No. 386, eff. 3-1-88; am. (4) (c) and (d) and (5) (b), cr. (4) (e), Register, September, 1991, No. 429, eff. 10-1-91; emerg. am. (3) (d) 3. and (e), cr. (3) (f), eff. 7-1-92; am. (3) (d) 3. and (e), cr. (3) (f), Register, February, 1993, No. 446, eff. 3-1-93; CR 03-033: am. (3) (intro.) Register December 2003 No. 576, eff. 1-1-04; CR 05-033: am. (5) (a) 1., cr. (5m) Register August 2006 No. 608, eff. 9-1-06; corrections in (3) (a), (f) 4. and (4) (e) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 09-107: am. (6) Register August 2010 No. 656, eff. 9-1-10. DHS 105.02DHS 105.02 Requirements for maintaining certification. Providers shall comply with the requirements in this section in order to maintain MA certification. DHS 105.02(1)(1) Change in provider status. Providers shall report to the department in writing any change in licensure, certification, group affiliation, corporate name or ownership by the time of the effective date of the change. The department may require the provider to complete a new provider application and a new provider agreement when a change in status occurs. A provider shall immediately notify the department of any change of address but the department may not require the completion of a new provider application or a new provider agreement for a change of address. DHS 105.02(2)(a)(a) Non-nursing home provider. In the event of a change in the ownership of a certified provider, except a nursing home, the provider agreement shall automatically terminate, except that the provider shall continue to maintain records required by subs. (4), (6) and (7) unless an alternative method of providing for maintenance of these records has been established in writing and approved by the department. DHS 105.02(2)(b)(b) Nursing home provider. In the event of a change in the ownership of a nursing home, the provider agreement shall automatically be assigned to the new owner. DHS 105.02(3)(3) Response to inquiries. A provider shall respond as directed to inquiries by the department regarding the validity of information in the provider file maintained by the department or its fiscal agent. DHS 105.02(4)(4) Maintenance of records. Providers shall prepare and maintain whatever records are necessary to fully disclose the nature and extent of services provided by the provider under the program. Records to be maintained are those enumerated in subs. (6) and (7). All records shall be retained by providers for a period of not less than 5 years from the date of payment by the department for the services rendered, unless otherwise stated in chs. DHS 101 to 108. In the event a provider’s participation in the program is terminated for any reason, all MA-related records shall remain subject to the conditions enumerated in this subsection and sub. (2). DHS 105.02(5)(5) Participation in surveys. Providers shall participate in surveys conducted for research and MA policy purposes by the department or its designated contractors. Participation involves accurate completion of the survey questionnaire and return of the completed survey form to the department or to the designated contractor within the specified time period. DHS 105.02(6)(6) Records to be maintained by all providers. All providers shall maintain the following records: DHS 105.02(6)(a)(a) Contracts or agreements with persons or organizations for the furnishing of items or services, payment for which may be made in whole or in part, directly or indirectly, by MA; DHS 105.02(6)(b)(b) MA billings and records of services or supplies which are the subject of the billings, that are necessary to fully disclose the nature and extent of the services or supplies; and DHS 105.02(6)(c)(c) Any and all prescriptions necessary to disclose the nature and extent of services provided and billed under the program. DHS 105.02(7)(a)(a) Specific types of providers. The following records shall be maintained by hospitals, skilled nursing facilities (SNFs), intermediate care facilities (ICFs) and home health agencies, except that home health agencies are not required to maintain records listed in subds. 5., 11. and 14., and SNFs, ICFs and home health agencies are not required to maintain records listed in subd. 4.: DHS 105.02(7)(a)9.9. Cash receipt and receivable ledgers, and supporting receipts and billings; DHS 105.02(7)(a)10.10. Accounts payable, operating expense ledgers and cash disbursement ledgers, with supporting purchase orders, invoices, or checks; DHS 105.02(7)(a)11.11. Records, by department, of the use of support services such as dietary, laundry, plant and equipment, and housekeeping; DHS 105.02(7)(a)14.14. Ledger identifying dates and amounts of all deposits to and withdrawals from MA resident trust fund accounts, including documentation of the amount, date, and purpose of the withdrawal when withdrawal is made by anyone other than the resident. When the resident chooses to retain control of the funds, that decision shall be documented in writing and retained in the resident’s records. Once that decision is made and documented, the facility is relieved of responsibility to document expenditures under this subsection; and DHS 105.02(7)(b)(b) Prescribed service providers. The following records shall be kept by pharmacies and other providers of services requiring a prescription: DHS 105.02(7)(b)3.3. Purchase invoices and receipts for medical supplies and equipment billed to MA; and DHS 105.02(8)(8) Provider agreement duration. The provider agreement shall, unless terminated, remain in full force and effect for a maximum of one year from the date the provider is accepted into the program. In the absence of a notice of termination by either party, the agreement shall automatically be renewed and extended for a period of one year. DHS 105.03DHS 105.03 Participation by non-certified persons. DHS 105.03(1)(1) Reimbursement for emergency services. If a resident of Wisconsin or of another state who is not certified by MA in this state provides emergency services to a Wisconsin recipient, that person shall not be reimbursed for those services by MA unless the services are covered services under ch. DHS 107 and: DHS 105.03(1)(a)(a) The person submits to the fiscal agent a provider data form and a claim for reimbursement of emergency services on forms prescribed by the department; DHS 105.03(1)(b)(b) The person submits to the department a statement in writing on a form prescribed by the department explaining the nature of the emergency, including a description of the recipient’s condition, cause of emergency, if known, diagnosis and extent of injuries, the services which were provided and when, and the reason that the recipient could not receive services from a certified provider; and DHS 105.03(1)(c)(c) The person possesses all licenses and other entitlements required under state and federal statutes, rules and regulations, and is qualified to provide all services for which a claim is submitted. DHS 105.03(2)(2) Reimbursement prohibited for non-emergency services. No non-emergency services provided by a non-certified person may be reimbursed by MA. DHS 105.03(3)(3) Reimbursement determination. Based upon the signed statement and the claim for reimbursement, the department’s professional consultants shall determine whether the services are reimbursable.
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Chs. DHS 101-109; Medical Assistance
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