Register January 2014 No. 697
Chapter DHS 106
PROVIDER RIGHTS AND RESPONSIBILITIES
General requirements for provision of services.
Manner of preparing and submitting claims for reimbursement.
Payment of claims for reimbursement.
Voluntary termination of program participation.
Involuntary termination or suspension from program participation.
Involuntary termination and alternative sanctions for home care providers.
Effects of suspension or involuntary termination.
Departmental discretion to pursue monetary recovery.
Withholding payment of claims.
Pre-payment review of claims.
Procedure, pleadings and practice.
Discretionary waivers and variances.
Ch. DHS 106 Note
Chapter HSS 106 was renumbered Chapter HFS 106 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 106 was renumbered to chapter DHS 106 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636
In addition to provisions of chs. DHS 105
relating to individual provider types and the manner by which specified services are to be provided and paid for under medical assistance (MA), the participation of all providers certified under ch. DHS 105
to provide or claim reimbursement for services under the program shall be subject to the conditions set forth in this chapter.
DHS 106.01 History
Cr. Register, December, 1979, No. 288
, eff. 2-1-80; am. Register, February, 1986, No. 362
, eff. 3-1-86; corrections made under s. 13.92 (4) (b) 7.
, Stats., Register December 2008 No. 636
General requirements for provision of services.
Providers shall comply with the following general conditions for participation as providers in the MA program:
(2) Covered services.
A provider shall be reimbursed only for covered services specified in ch. DHS 107
(3) Recipient eligible on date of service.
A provider shall be reimbursed for a service only if the recipient of the service was eligible to receive MA benefits on the date the service was provided.
(4) Compliance with state and federal requirements.
A provider shall be reimbursed only if the provider complies with applicable state and federal procedural requirements relating to the delivery of the service.
(5) Appropriate and medically necessary services.
A provider shall be reimbursed only for services that are appropriate and medically necessary for the condition of the recipient.
(6) Provision of non-covered services.
If a provider determines that, to assure quality health care to a recipient, it is necessary to provide a non-covered service, nothing in this chapter shall preclude the provider from furnishing the service, if before rendering the service the provider advises the recipient that the service is not covered under the program and that, if provided, the recipient is responsible for payment.
(7) Services to recipients with a primary provider.
A provider other than the designated primary provider may not claim reimbursement for a service to an individual whose freedom to choose a provider has been restricted under s. DHS 104.03
as indicated on the recipient's MA identification card unless the service was rendered pursuant to a written referral from the recipient's designated primary provider or the service was rendered in an emergency. If rendered in an emergency, the provider seeking reimbursement shall submit to the fiscal agent a written description of the nature of the emergency along with the service claim.
(8) Refusal to provide MA services.
A provider is not required to provide services to a recipient if the recipient refuses or fails to present a currently valid MA identification card. If a recipient fails, refuses or is unable to produce a currently valid identification card, the provider may contact the fiscal agent to confirm the current eligibility of the recipient. The department shall require its fiscal agent to install and maintain adequate toll-free telephone service to enable providers to verify the eligibility of recipients to receive benefits under the program.
(9) Medical and financial recordkeeping and documentation. DHS 106.02(9)(a)(a) Preparation and maintenance.
A provider shall prepare and maintain truthful, accurate, complete, legible and concise documentation and medical and financial records specified under this subsection, s. DHS 105.02 (6)
, the relevant provisions of s. DHS 105.02 (7)
, other relevant sections in chs. DHS 105
and the relevant sections of ch. DHS 107
that relate to documentation and medical and financial recordkeeping for specific services rendered to a recipient by a certified provider. In addition to the documentation and recordkeeping requirements specified in pars. (b)
, the provider's documentation, unless otherwise specifically contained in the recipient's medical record, shall include:
The identity of the person who provided the service to the recipient;
An accurate, complete and legible description of each service provided;
(b) Medical record content.
A provider shall include in a recipient's medical record the following written documentation, as applicable:
Date, department or office of the provider, as applicable, and provider name and profession;
Disposition, recommendations and instructions given to the recipient, including any prescriptions and plans of care or treatment provided; and
Prescriptions, plans of care and any other treatment plans for the recipient received from any other provider.
(c) Financial records.
A provider shall maintain the following financial records in written or electronic form:
Payroll ledgers, canceled checks, bank deposit slips and any other accounting records prepared by the provider;
Billings to MA, medicare, a third party insurer or the recipient for all services provided to the recipient;
Evidence of the provider's usual and customary charges to recipients and to persons or payers who are not recipients;
The provider's appointment books for patient appointments and the provider's schedules for patient supervision, if applicable;
Billing claims forms for either manual or electronic billing for all health services provided to the recipient;
Records showing all persons, corporations, partnerships and entities with an ownership or controlling interest in the provider, as defined in 42 CFR 455.101
Employee records for those persons currently employed by the provider or who have been employed by the provider at any time within the previous 5 years. Employee records shall include employee name, salary, job qualifications, position description, job title, dates of employment and the employee's current home address or the last known address of any former employee.
The provider shall maintain documentation of all information received or known by the provider of the recipient's eligibility for services under MA, medicare or any other health care plan, including but not limited to an indemnity health insurance plan, a health maintenance organization, a preferred provider organization, a health insuring organization or other third party payer of health care.