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 105.03
DHS 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.
DHS 105.03 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; correction in (1) (intro.) made under s.
13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636.
DHS 105.04
DHS 105.04 Supervision of provider assistants. Provider assistants shall be supervised. Unless otherwise specified under ss.
DHS 105.05 to
105.49, supervision shall consist of at least intermittent face-to-face contact between the supervisor and the assistant and a regular review of the assistant's work by the supervisor.
DHS 105.04 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86.
DHS 105.05(1)(1)
Physicians. For MA certification, physicians shall be licensed to practice medicine and surgery pursuant to ss.
448.05 and
448.07, Stats., and chs.
Med 1,
2,
3,
4,
5 and
14.
DHS 105.05(2)
(2)
Physician assistants. For MA certification, physician assistants shall be certified and registered pursuant to ss.
448.05 and
448.07, Stats., and chs.
Med 8 and
14.
DHS 105.05 Note
Note: For covered physician services, see s.
DHS 107.06.
DHS 105.05 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86.
DHS 105.055
DHS 105.055 Nurse anesthetists and anesthesiologist assistants. DHS 105.055(1)(1)
Certified registered nurse anesthetist. For MA certification, a nurse anesthetist shall be licensed as a registered nurse pursuant to s.
441.06, Stats., and shall meet one of the following additional requirements:
DHS 105.055(1)(a)
(a) Be certified by either the council on certification of nurse anesthetists or the council on recertification of nurse anesthetists; or
DHS 105.055(1)(b)
(b) Have graduated within the past 18 months from a nurse anesthesia program that meets the standards of the council on accreditation of nurse anesthesia educational programs and be awaiting initial certification.
DHS 105.055(2)
(2)
Anesthesiologist assistant. For MA certification, an anesthesiologist assistant shall meet the following requirements:
DHS 105.055(2)(a)
(a) Have successfully completed a 6 year program for anesthesiologist assistants, 2 years of which consists of specialized academic and clinical training in anesthesia; and
DHS 105.055(2)(b)
(b) Work under the direct supervision of an anesthesiologist who is physically present during provision of services.
DHS 105.055 History
History: Cr.
Register, September, 1991, No. 429, eff. 10-1-91.
DHS 105.06
DHS 105.06 Dentists and dental hygienists. DHS 105.06(2)
(2)
Dental hygienists. For MA certification, dental hygienists shall be licensed pursuant to s.
447.04 (2), Stats.; have 2 years or 3,200 hours of active practice experience as a licensed dental hygienist; and operate within the scope of dental hygiene as defined under ss.
447.01 (3) and
447.06, Stats. Written documentation showing the required experience shall be provided to the department upon application for MA certification.
DHS 105.06 Note
Note: For covered dental services, see s.
DHS 107.07.
DHS 105.06 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats.,
Register, June, 1994, No. 462;
CR 05-033: renum. to be (1), cr. (2)
Register August 2006 No. 608, eff. 9-1-06.
DHS 105.07
DHS 105.07 General hospitals. For MA certification a hospital shall be approved as a general hospital under s.
50.35, Stats., and ch.
DHS 124, shall meet conditions of participation for medicare and shall have a utilization review plan that meets the requirements of
42 CFR 456.101. No facility determined by the department or the federal health care financing administration to be an institution for mental disease (IMD) may be certified as a general hospital under this section. In addition:
DHS 105.07(2)
(2) A hospital providing outpatient alcohol and other drug abuse (AODA) services shall meet the requirements specified in s.
DHS 105.23;
DHS 105.07(3)
(3) A hospital providing mental health day treatment services shall be certified under s.
DHS 105.24;
DHS 105.07(4)
(4) A hospital participating in a PRO review program shall meet the requirements of
42 CFR 456.101 and any additional requirements established under state contract with the PRO; and
DHS 105.07 Note
Note: For certification of a hospital that is an institution for mental disease, see s.
DHS 105.21. For covered hospital services, see s.
DHS 107.08.
DHS 105.07 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; r. and recr. (intro.), am. (1) to (4), cr. (5),
Register, September, 1991, No. 429, eff. 10-1-91; correction in (intro.) made under s.
13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636.
DHS 105.075
DHS 105.075 Rehabilitation hospitals. For MA certification, a rehabilitation hospital shall be approved as a general hospital under s.
50.35, Stats., and ch.
DHS 124, and shall meet the conditions of participation for medicare and shall have a utilization review plan that meets the requirements of
42 CFR 456.101. No facility determined by the department or the federal health care financing administration to be an institution for mental disease (IMD) may be certified as a rehabilitation hospital under this section.
DHS 105.075 Note
Note: For covered hospital services, see s.
DHS 107.08.
DHS 105.08
DHS 105.08 Skilled nursing facilities. For MA certification, skilled nursing facilities shall be licensed pursuant to s.
50.03, Stats., and ch.
DHS 132.
DHS 105.08 Note
Note: For covered nursing home services, see s.
DHS 107.09.
DHS 105.08 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; correction made under s.
13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636.
DHS 105.09(1)(1)
Definition. In this section, “sufficient number of medicare-certified beds" means a supply of beds that accommodates the demand for medicare beds from both the home county and contiguous counties so that no dual eligible recipient is denied access to medicare SNF benefits because of a lack of available beds. In this subsection, “dual eligible recipient" means a person who qualifies for both medical assistance and medicare.
DHS 105.09(2)
(2)
Medicare bed obligation. Each county shall have a sufficient number of skilled nursing beds certified by the medicare program pursuant to ss.
49.45 (6m) (g) and
50.02 (2), Stats. The number of medicare-certified beds required in each county shall be at least 3 beds per 1000 persons 65 years of age and older in the county.
DHS 105.09(3)(a)(a) If a county does not have sufficient medicare-certified beds as determined under sub.
(1), each SNF within that county which does not have one or more medicare-certified beds shall be subject to a fine to be determined by the department of not less than $10 nor more than $100 for each day that the county continues to have an inadequate number of medicare-certified beds.
DHS 105.09(3)(b)
(b) The department may not enforce penalty in par.
(a) if the department has not given the SNF prior notification of criteria specific to its county which shall be used to determine whether or not the county has a sufficient number of medicare-certified beds.
DHS 105.09(3)(c)
(c) If the number of medicare-certified beds in a county is reduced so that the county no longer has a sufficient number of medicare-certified beds under sub.
(1), the department shall notify each SNF in the county of the number of additional medicare-certified beds needed in the county. The department may not enforce the penalty in par.
(a) until 90 days after this notification has been provided.
DHS 105.09(4)(a)(a) In this subsection, a “swing-bed hospital" means a hospital approved by the federal health care financing administration to furnish skilled nursing facility services in the medicare program.
DHS 105.09(4)(b)
(b) A home or portion of a home certified as an ICF-IID is exempt from this section.
DHS 105.09(4)(c)
(c) The department may grant an exemption based on but not limited to:
DHS 105.09(4)(c)1.
1. Availability of a swing-bed hospital operating within a 30 mile radius of the nursing home; or
DHS 105.09(4)(c)2.
2. Availability of an adequate number of medicare-certified beds in a facility within a 30 mile radius of the nursing home.
DHS 105.09(4)(d)
(d) A skilled nursing facility located within a county determined to have an inadequate number of medicare-certified beds and which has less than 100 beds may apply to the department for partial exemption from the requirements of this section. An SNF which applies for partial exemption shall recommend to the department the number of medicare-certified beds that the SNF should have to meet the requirements of this section based on the facility's analysis of the demand for medicare-certified beds in the community. The department shall review all recommendations and issue a determination to each SNF requesting a partial exemption.
