DHS 106.02(9)(c)5.
5. Billing claims forms for either manual or electronic billing for all health services provided to the recipient;
DHS 106.02(9)(c)6.
6. Records showing all persons, corporations, partnerships and entities with an ownership or controlling interest in the provider, as defined in
42 CFR 455.101; and
DHS 106.02(9)(c)7.
7. 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.
DHS 106.02(9)(d)1.1. 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.
DHS 106.02(9)(d)2.
2. The provider shall retain all evidence of claims for reimbursement, claim denials and adjustments, remittance advice, and settlement or demand billings resulting from claims submitted to MA, medicare or other health care plans.
DHS 106.02(9)(d)3.
3. The provider shall retain all evidence of prior authorization requests, cost reports and supplemental cost or medical information submitted to MA, medicare and other third party payers of health care, including the data, information and other documentation necessary to support the truthfulness, accuracy and completeness of the requests, reports and supplemental information.
DHS 106.02(9)(e)1.1. Each provider is solely responsible for the truthfulness, accuracy, timeliness and completeness of claims, cost reports, prior authorization requests and any supplementary information relating to the provider's MA certification or reimbursement for services submitted to MA or to medicare or any other third party payer for claims or requests for MA recipients, whether or not these claims, reports and requests are submitted on paper or in electronic form. This includes but is not limited to the truthfulness, accuracy, timeliness and completeness of the documentation necessary to support each claim, cost report and prior authorization request. The use or consent to use of a service, system or process for the preparation and submission of claims, cost reports or prior authorization requests, whether in electronic form or on paper, does not in any way relieve a provider from sole responsibility for the truthfulness, accuracy, timeliness and completeness of claims, cost reports, prior authorization requests and any supplementary information relating to the provider's MA certification and claims for reimbursement for services submitted to MA or to medicare or any other third party payer in the case of claims, reports or requests for MA recipients. The provider is responsible whether or not the provider is charged for the services, systems or processes and whether or not the department or its fiscal agent consents to the electronic preparation and submission of claims, cost reports, prior authorization requests and any supplementary information relating to the provider's MA certification and claims for reimbursement for services.
DHS 106.02(9)(e)2.
2. All records under pars.
(a) to
(d) shall be retained by a provider for a period of not less than 5 years, except that a rural health clinic provider shall retain the records for not less than 6 years. This period shall begin on the date on which the provider received payment from the program for the service to which the records relate. Termination of a provider's participation does not terminate the provider's responsibility to retain the records unless an alternative arrangement for record retention and maintenance has been established by the provider.
DHS 106.02(9)(e)3.
3. Providers are solely responsible for all costs associated with meeting the responsibilities under the provider agreement required under s.
DHS 105.01 (3) (e) and the preparation and submission of claims, whether in electronic form or on paper, to MA or to medicare or other third party payers in the case of claims for MA recipients, regardless of the means or source of the preparation and submission. This includes but is not limited to claims preparation, acquisition or submission services and services which prepare, acquire or submit claims to payers, including but not limited to MA, on behalf of the provider, whether or not the provider or the provider's membership organization is charged for the preparation or submission of claims, and any other activity required under the provider agreement in accordance with s.
DHS 105.01 (3) (e).
DHS 106.02(9)(e)4.
4. At the request of a person authorized by the department and on presentation of that person's credentials, a provider shall permit access to any requested records, whether in written, electronic, or micrographic form. Access for purposes of this subsection shall include the opportunity to inspect, review, audit and reproduce the records.
DHS 106.02(9)(e)5.
5. Except as otherwise provided under a contract between the department and providers or pre-paid health plans, and except for records requested by the peer review organization under contract with the department, all costs of reproduction by a provider of records under this subsection shall be paid by the department at the per-page rate for record reproduction established by the department under s.
DHS 108.02 (4). Reproduction costs for records requested by the peer review organization shall be paid at the prevailing per-page rate for MA records established by that organization.
DHS 106.02(9)(f)
(f) Condition for reimbursement. Services covered under ch.
DHS 107 are non-reimbursable under the MA program unless the documentation and medical recordkeeping requirements under this section are met.
DHS 106.02(9)(g)
(g) Supporting documentation. The department may refuse to pay claims and may recover previous payments made on claims where the provider fails or refuses to prepare and maintain records or permit authorized department personnel to have access to records required under s.
DHS 105.02 (6) or
(7) and the relevant sections of chs.
DHS 106 and
107 for purposes of disclosing, substantiating or otherwise auditing the provision, nature, scope, quality, appropriateness and necessity of services which are the subject of claims or for purposes of determining provider compliance with MA requirements.
DHS 106.02(10)
(10) Nondiscrimination. Providers shall comply with the Civil Rights Act of 1964,
42 USC 2000d et. seq., and s. 504 of the Rehabilitation Act of 1973, as amended. Accordingly, providers may not exclude, deny or refuse to provide health care services to recipients on the grounds of race, color, gender, age, national origin or disability, nor may they discriminate in their employment practices.
DHS 106.02(11)
(11) Provision of non-reimbursable covered services. A provider may not bill a recipient for covered services which are non-reimbursable under s.
DHS 107.02 (2).
DHS 106.02(12)(a)1.1. At least 20 days before a MA certified dental hygienist performs a service for a dental sealant program conducted by an entity specified under s.
447.06 (2) (a) 2.,
3., and
5., Stats., the dental hygienist shall notify the contract agency for the Wisconsin Seal-A-Smile Dental Sealant program. Upon notification of the dental sealant program dates, the contract agency shall post the program dates on an Internet site. If the dental sealant program is rescheduled, notice may be provided closer to the date of the rescheduled program. If the dental hygienist provides a list of dates of the programs for which the dental hygienist will perform services during the year, the 20 day notice requirement for each event is waived.
DHS 106.02 Note
Note: Dental hygienists are encouraged to work with dentists, when available, to assist in these programs.
DHS 106.02(12)(a)2.
2. An MA certified dental hygienist and any entity who employs or contracts with a MA certified dental hygienist under s.
447.06 (2) (a) 2.,
3., and
5., Stats., or that uses the volunteer services of an MA certified dental hygienist shall maintain written documentation of all of the following:
DHS 106.02(12)(a)2.b.
b. Any referral of a patient who has a condition that cannot be treated within the dental hygienist scope of practice as defined under s.
447.03, Stats., to a private dental practice; a federally qualified health center that provide dental services; a rural dental health clinic; a college or university that provides dental diagnostic and clinical services; or any other dental entity that employs, contracts with, or is under the supervision of a licensed dentist.
DHS 106.02(12)(a)2.c.
c. Consultation with a licensed dentist in a private dental practice; a federally qualified health center that provide dental services; a rural dental health clinic; a college or university that provides dental diagnostic and clinical services; or any other entity that employs, contracts with, or is under the supervision of a licensed dentist.
DHS 106.02(12)(b)
(b) Compliance with this subsection is subject to audit by the department and the legislature.
DHS 106.02 History
History: Cr.
Register, December, 1979, No. 288, eff. 2-1-80; am.
Register, February, 1986, No. 362, eff. 3-1-86; emerg. r. and recr. (9), eff. 7-1-92; r. and recr. (9), cr. (11),
Register, February, 1993, No. 446, eff. 3-1-93; correction made in (10) under s. 13.93 (2m) (b) 7., Stats.,
Register, June, 1994, No. 462;
CR 05-033: cr. (12)
Register August 2006 No. 608, eff. 9-1-06; corrections in (1), (2), (7), (9) (e) 3., 5., (f), (g) and (11) made under s. 13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636;
CR 20-068: am. (10)
Register December 2021 No. 792, eff. 1-1-22;
CR 22-043: am. (9) (b) (intro.), 1. to 7., cr. (9) (b) 9.
Register May 2023 No. 809, eff. 6-1-23.
DHS 106.03
DHS 106.03 Manner of preparing and submitting claims for reimbursement. DHS 106.03(1)(a)(a) In this subsection, “billing service" means a provider or an entity under contract to a provider which provides electronic media billing or electronic billing transmission for one or more providers.
DHS 106.03(1)(b)
(b) A provider shall use claim forms prescribed or furnished by the department, except that a provider may submit claims by electronic media or electronic transmission if the provider or billing service is approved by the department for electronic claims submission. A billing service shall be approved in writing by the department based on the billing service's ability to consistently meet format and content specifications required for the applicable provider type. The department shall, upon request, provide a written format and the content specifications required for electronic media or electronic transmission billings and shall advise the provider or billing service of procedures required to obtain department approval of electronic billing.
DHS 106.03(1)(c)
(c) Upon the department's approval of the provider or the provider's billing service to submit claims through electronic media or electronic transmission billing, the provider shall sign an agreement to comply with the format, content and procedural requirements of the department.
DHS 106.03(1)(d)
(d) The department may at its discretion revoke its approval and rescind the agreement for electronic media or electronically transmitted claims submission at any time if the provider or billing service fails to fully comply with all of the department's instructions for submission of electronic media or electronically transmitted claims, or repeatedly submits duplicate, inaccurate or incomplete claims. The department may at its discretion revoke its approval and rescind the agreement under par.
(c) when the provider's claims repeatedly fail to provide correct and complete information necessary for timely and accurate claims processing and payment in accordance with billing instructions provided by the department or its fiscal agent.
DHS 106.03(2)(a)
(a) In the preparation of claims, the provider shall use, as applicable, diagnosis, place of service, type of service, procedure codes and other information specified by the department under s.
DHS 108.02 (4) for identifying services billed on the claim. The department shall inform affected providers of the name and source of the designated diagnosis and procedure codes.
DHS 106.03(2)(b)
(b) Claims shall be submitted in accordance with the claims submission requirements, claim forms instructions and coding information provided by the department.
DHS 106.03(2)(c)
(c) Whether submitted directly by the provider, by the provider's billing service or by another agent of the provider, the truthfulness, completeness, timeliness and accuracy of any claim are the sole responsibility of the provider.
DHS 106.03(2)(d)
(d) Every claim submitted shall be signed by the provider or by the provider's authorized agent, certifying to the accuracy and completeness of the claim and that services billed on the claim are consistent with the requirements of chs.
DHS 101 to
108 and the department's instructions issued under s.
DHS 108.02 (4). For claims submitted by electronic media or electronic transmission, the provider agreement under sub.
(1) (c) substitutes for the signature required by this paragraph for each claims submission.
DHS 106.03(2m)
(2m)
EVV requirements for claim reimbursement. Claims for services that require EVV shall have associated EVV records for applicable services. Claims that require EVV that are not matched to an EVV record may be denied.
DHS 106.03(3)(a)
(a) A claim may not be submitted to MA until the recipient has received the service which is the subject of the claim and the requirements of sub.
(7) have been met. A claim may not be submitted by a nursing home for a recipient who is a nursing home resident until the day following the last date of service in the month for which reimbursement is claimed. A claim may not be submitted by a hospital for a recipient who is a hospital inpatient until the day following the last date of service for which reimbursement is claimed.
DHS 106.03(3)(b)1.1. To be considered for payment, a correct and complete claim or adjustment shall be received by the department's fiscal agent within 365 days after the date of the service except as provided in subd.
4. and par.
(c). The department fiscal agent's response to any claim or adjustment received more than 365 days after the date of service shall constitute final department action with respect to payment of the claim or adjustment in question.
DHS 106.03(3)(b)2.
2. The provider is responsible for providing complete and timely follow-up to each claim submission to verify that correct and accurate payment was made, and to seek resolution of any disputed claims.
DHS 106.03(3)(b)3.
3. To ensure that submissions are correct and there is appropriate follow-up of all claims, providers shall follow the claims preparation and submission instructions in provider handbooks and bulletins issued by the department.
DHS 106.03(3)(b)4.
4. If a claim was originally denied or incorrectly paid because of an error on the recipient eligibility file, an incorrect HMO designation, an incorrect nursing home level of care authorization or nursing home patient liability amount, the department may pay a correct and complete claim or adjustment only if the original claim was received by the department's fiscal agent within 365 days after the date of service and the resubmission or adjustment is received by the department's fiscal agent within 455 days after the date of service.
DHS 106.03(3)(b)5.
5. If a provider contests the propriety of the amount of payment received from the department for services claimed, the provider shall notify the fiscal agent of its concerns, requesting reconsideration and payment adjustment. All submissions of claims payment adjustments shall be made within 365 days from the date of service, except as provided in subd.
4. and par.
(c). The fiscal agent shall, within 45 days of receipt of the request, respond in writing and advise what, if any, payment adjustment will be made. The fiscal agent's response shall identify the basis for approval or denial of the payment adjustment requested by the provider. This action shall constitute final departmental action with respect to payment of the claim in question.
DHS 106.03(3)(c)
(c) The sole exceptions to the 365 day billing deadline are as follows:
DHS 106.03(3)(c)1.
1. If a claim was initially processed or paid and the department subsequently initiates an adjustment to increase a rate or payment or to correct an initial processing error of the department's fiscal agent, the department may pay a correct and complete claim or adjustment only if the provider submits a request for an adjustment or claim and that request or claim is received by the department's fiscal agent within 90 days after the adjustment initiated by the department;
DHS 106.03(3)(c)2.a.a. If a claim for payment under medicare has been filed with medicare within 365 days after the date of service, the department may pay a claim relating to the same service only if a correct and complete claim is received by the fiscal agent within 90 days after the disposition of the medicare claim;
DHS 106.03(3)(c)2.b.
b. If medicare or private health insurance reconsiders its initial payment and requests recoupment of a previous payment, the department may pay a correct and complete request for an adjustment which is received within 90 days after the notice of recoupment;
DHS 106.03(3)(c)3.
3. If a claim for payment cannot be filed in a timely manner due to a delay in the determination of a recipient's retroactive eligibility under s.
49.46 (1) (b), Stats., the department may pay a correct and complete claim only if the claim is received by the fiscal agent within 180 days after mailing of the backdated MA identification card to the recipient; and
DHS 106.03(3)(c)4.
4. The department may make a payment at any time in accordance with a court order or to carry out a hearing decision or department-initiated corrective action taken to resolve a dispute. To request payment the provider shall submit a correct and complete claim to the department's fiscal agent within 90 days after mailing of a notice by the department or the court of the court order, hearing decision or corrective action to the provider or recipient.
DHS 106.03(4)
(4) Health care services requiring prior authorization. No payment may be made on a claim for service requiring prior authorization if written prior authorization was not requested and received by the provider prior to the date of service delivery, except that claims that would ordinarily be rejected due to lack of the provider's timely receipt of prior authorization may be paid under the following circumstances:
DHS 106.03(4)(a)
(a) Where the provider's initial request for prior authorization was denied and the denial was either rescinded in writing by the department or overruled by an administrative or judicial order;
DHS 106.03(4)(b)
(b) Where the service requiring prior authorization was provided before the recipient became eligible, and the provider applies to and receives from the department retroactive authorization for the service; or
DHS 106.03(4)(c)
(c) Where time is of the essence in providing a service which requires prior authorization, and verbal authorization is obtained by the provider from the department's medical consultant or designee. To ensure payment on claims for verbally-authorized services, the provider shall retain records which show the time and date of the authorization and the identity of the individual who gave the authorization, and shall follow-up with a written authorization request form attaching documentation pertinent to the verbal authorization.
DHS 106.03(5)
(5) Providers eligible to receive payment on claims. DHS 106.03(5)(a)(a) Eligible providers. Payment for a service shall be made directly to the provider furnishing the service or to the provider organization which provides or arranges for the availability of the service on a prepayment basis, except that payment may be made:
DHS 106.03(5)(a)1.
1. To the employer of an individual provider if the provider is required as a condition of employment to turn over fees derived from the service to the employer or to a facility; or
DHS 106.03(5)(a)2.
2. To a facility if a service was provided in a hospital, clinic or other facility, and there exists a contractual agreement between the individual provider and the facility, under which the facility prepares and submits the claim for reimbursement for the service provided by the individual provider.
DHS 106.03(5)(b)
(b) Facility contracting with providers. An employer or facility submitting claims for services provided by a provider in its employ or under contract as provided in par.
(a) shall apply for and receive certification from the department to submit claims and receive payment on behalf of the provider performing the services. Any claim submitted by an employer or facility so authorized shall identify the provider number of the individual provider who actually provided the service or item that is the subject of the claim.
DHS 106.03(5)(br)
(br) Providers of professional services to hospital inpatients. Notwithstanding pars.
(a) and
(b), in the case of a provider performing professional services to hospital inpatients, payment shall be made directly to the provider or to the hospital if it is separately certified to be reimbursed for the same professional services.
DHS 106.03(5)(c)
(c) Prohibited payments. No payment which under par.
(a) (intro.) is made directly to an individual provider or provider organization may be made to anyone else under a reassignment or power of attorney except to an employer or facility under par.
(a) 1. or
2., but nothing in this paragraph shall be construed:
DHS 106.03(5)(c)1.
1. To prevent making the payment in accordance with an assignment from the person or institution providing the service if the service is made to a governmental agency or entity or is established by or pursuant to the order of a court of competent jurisdiction; or
DHS 106.03(5)(c)2.
2. To preclude an agent of the provider from receiving any payment if the agent does so pursuant to an agency agreement under which the compensation to be paid to the agent for services in connection with the billing or collection of payments due the person or institution under the program is unrelated, directly or indirectly, to the amount of payments or the claims for them, and is not dependent upon the actual collection of the payment.
DHS 106.03(6)
(6) Assignment of medicare part B benefits. A provider providing a covered service to a dual entitlee shall accept assignment of the recipient's part B medicare benefits if the service provided is, in whole or in part, reimbursable under medicare part B coverage. All services provided to dual entitlees which are reimbursable under medicare part B shall be billed to medicare. In this subsection,“dual entitlee" means an MA recipient who is also eligible to receive part B benefits under medicare.
DHS 106.03(7)(a)1.
1. “Health care plan" means a plan or policy which provides coverage of health services, regardless of the nature and extent of coverage or reimbursement, including an indemnity health insurance plan, a health maintenance organization, a health insuring organization, a preferred provider organization or any other third party payer of health care.
DHS 106.03(7)(a)2.a.
a. When required by the payer as a condition for payment for the particular service, the provider shall request prior authorization or pre-certification from medicare or the other health care plan, except in the case of emergency services. This includes following the preparation and submission requirements of the payer and ensuring that the information provided to the payer is truthful, timely, complete and accurate. Prior authorization or pre-certification means a process and procedures established by medicare or the other health care plan which involve requiring the review or approval by the payer or its agent prior to the provision of a service in order for the service to be considered for payment;
DHS 106.03(7)(a)2.b.
b. The provider shall file a truthful, timely, complete and accurate claim or demand bill for the services which complies with the applicable claim preparation and submission requirements of medicare or the other health care plan. This includes providing necessary documentation and pertinent medical information when requested by medicare or the other health care plan as part of pre-payment or post-payment review performed by medicare or the other health care plan; and
DHS 106.03(7)(a)2.c.
c. In the case of prior authorization or pre-certification requests, claims or demand bills which are returned or rejected, in whole or in part, by the payer for non-compliance with preparation or submission requirements of medicare or the other health care plan, the provider shall promptly correct and properly resubmit the prior authorization or pre-certification request, claim or demand bill, as applicable to the payer.
DHS 106.03(7)(b)
(b) Before submitting a claim to MA for the same services, a provider shall properly seek payment for the services provided to an MA recipient from medicare or, except as provided in par.
(g), another health care plan if the recipient is eligible for services under medicare or the other health care plan.
DHS 106.03(7)(c)
(c) When benefits from medicare, another health care plan or other third party payer have been paid or are expected to be paid, in whole or in part, to either the provider or the recipient, the provider shall accurately identify the amount of the benefit payment from medicare, other health care plan or other third party payer on or with the bill to MA, consistent with the department's claims preparation, claims submission, cost avoidance and post-payment recovery instructions under s.
DHS 108.02 (4). The amount of the medicare, health care plan or other third party payer reimbursement shall reduce the MA payment amount.
DHS 106.03(7)(d)
(d) If medicare or another health care plan makes payment to the recipient or to another person on behalf of the recipient, the provider may bill the payee for the amount of the benefit payment and may take any necessary legal action to collect the amount of the benefit payment from the payee, notwithstanding the provisions set forth in ss.
DHS 104.01 (12) and
106.04 (3).
DHS 106.03(7)(e)
(e) The provider shall bill medicare or another health care plan for services provided to a recipient in accordance with the claims preparation, claims submission and prior authorization instructions issued by the department under s.
DHS 108.02 (4). The provider shall also comply with the instructions issued by the department under s.
DHS 108.02 (4) with respect to cost avoidance and post-payment recovery from medicare and other health care plans.
DHS 106.03(7)(f)
(f) If, after the provider properly seeks payment, medicare or another provider may submit a claim to MA for the unpaid service, except as provided in par.
(k). The provider shall retain all evidence of claims for reimbursement, settlements and denials resulting from claims submitted to medicare and other health care plans.
DHS 106.03(7)(g)
(g) If eligibility for a health care plan other than medicare is indicated on the recipient's MA identification card and billing against that plan is not required by par.
(e), the provider may bill either MA or the indicated health care plan, but not both, for the services provided, as follows:
DHS 106.03(7)(g)1.
1. If the provider elects to bill the health care plan, the provider shall properly seek payment from the health care plan. A claim may not be submitted to MA until the health care plan pays part of or denies the original claim or 45 days have elapsed with no response from the health care plan; and
DHS 106.03(7)(g)2.
2. If the provider elects to submit a claim to MA, no claim may be submitted to the health care plan.
DHS 106.03(7)(h)
(h) In the event a provider receives a payment first from MA and then from medicare, another health care plan or another third party payer for the same service, the provider shall, within 30 days after receipt of the second and any subsequent payment, refund to MA the MA payment or the payment from medicare, the health care plan or other third party, whichever is less.
DHS 106.03(7)(i)
(i) Before billing MA for services provided to any recipient who is also a medicare beneficiary, a medicare-certified provider shall accept medicare assignment and shall properly seek payment from medicare for services covered under the medicare program. In filing claims or demand bills with medicare, a provider shall adhere to the requirements for properly seeking payment as defined under par.
(a) 2. and to the instructions issued by the department under s.
DHS 108.02 (4) relating to claims preparation, claims submission, prior authorization, cost-avoidance and post-payment recovery.
DHS 106.03(7)(j)
(j) If another health care plan, other than medicare, provides coverage for services provided for an MA recipient and the provider has the required billing information, including any applicable assignment of benefits, the provider shall properly seek payment from the health care plan, except as provided in par.
(g), and receive a response from that plan prior to billing MA unless 45 days have elapsed with no response from the health care plan, after which the provider may bill MA. This requirement does not apply to a managed health care plan as defined in par.
(k).
DHS 106.03(7)(k)
(k) A provider authorized to provide services to a recipient under a managed health care plan other than MA, who receives a referral for services from the recipient's managed health care plan or provides emergency services for a recipient in a managed health care plan, shall properly seek payment from that managed health care plan before billing MA. A provider who does not participate in a managed health care plan, other than MA, that provides coverage to the recipient but who provides services covered by the plan may not bill MA for the services. In this paragraph, “managed health care plan" means a health maintenance organization, preferred provider organization or similarly organized health care plan.
DHS 106.03(8)
(8) Personal injury and workers compensation claims. If a provider treats a recipient for injuries or illness sustained in an event for which liability may be contested or during the course of employment, the provider may elect to bill MA for services provided without regard to the possible liability of another party or the employer. The provider may alternatively elect to seek payment by joining in the recipient's personal injury claim or workers compensation claim, but in no event may the provider seek payment from both MA and a personal injury or workers compensation claim. Once a provider accepts the MA payment for services provided to the recipient, the provider shall not seek or accept payment from the recipient's personal injury or workers compensation claim.
