Chapter DHS 106

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) (3) Timeliness of submission.

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) (b)

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. 2.

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) (7) Medicare and other health care plans.

DHS 106.03(7)(a) (a) In this subsection:

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. 2. “Properly seek payment” means taking the following actions:

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.

DHS 106.03 History History: Cr. Register, December, 1979, No. 288, eff. 2-1-80; am. Register, February, 1986, No. 362, eff. 3-1-86; renum. (3) to be (3) (a), cr. (3) (b), Register, February, 1988, No. 386, eff. 3-1-88; emerg. am. (3) (a), eff. 11-1-90; emerg. cr. (5) (br), eff. 1-1-91; am. (3) (a), Register, May, 1991, No. 425, eff. 6-1-91; cr. (5) (br), Register, September, 1991, No. 429, eff. 10-1-91; emerg. r. and recr. (1) to (3) and (7), cr. (8), eff. 7-1-92; r. and recr. (1) to (3) and (7), cr. (8), Register, February, 1993, No. 446, eff. 3-1-93; corrections in (2) (a), (d), (7) (c), (d), (e) and (i) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; republished to reinsert inadvertently deleted text in (2) (c) Register January 2014 No. 697; EmR2306: emerg. cr. (2m), eff. 5-1-23; CR 23-045: cr. (2m) Register January 2024 No. 817, eff. 2-1-24.

DHS 106.04 DHS 106.04 Payment of claims for reimbursement.

DHS 106.04(1) (1) Timeliness.

DHS 106.04(1)(a) (a) Timeliness of payment. The department shall reimburse a provider for a properly provided covered service according to the provider payment schedule entitled “terms of provider reimbursement,” found in the appropriate MA provider handbook distributed by the department. The department shall issue payment on claims for covered services, properly completed and submitted by the provider, in a timely manner. Payment shall be issued on at least 95% of these claims within 30 days of claim receipt, on at least 99% of these claims within 90 days of claim receipt, and on 100% of these claims within 180 days of receipt. The department may not consider the amount of the claim in processing claims under this subsection.

DHS 106.04(1)(b) (b) Exceptions. The department may exceed claims payment limits under par. (a) for any of the following reasons:

DHS 106.04(1)(b)1. 1. If a claim for payment under medicare has been filed in a timely manner, the department may pay a MA claim relating to the same services within 6 months after the department or the provider receives notice of the disposition of the medicare claims;

DHS 106.04(1)(b)2. 2. The department may make payments at any time in accordance with a court order, or to carry out hearing decisions or department corrective actions taken to resolve a dispute; or

DHS 106.04(1)(b)3. 3. The department may issue payments in accordance with waiver provisions if it has obtained a waiver from the federal health care financing administration under 42 CFR 447.45 (e).

DHS 106.04(1m) (1m) Payment mechanism.

DHS 106.04(1m)(a) (a) Definitions. In this subsection:

DHS 106.04(1m)(a)1. 1. “Automated claims processing system” means the computerized system operated by the department’s fiscal agent for paying the claims of providers.

DHS 106.04(1m)(a)2. 2. “Manual partial payment” means a method of paying claims other than through the automated claims processing system.

DHS 106.04(1m)(b) (b) Automated claims processing. Except as provided in par. (c), payment of provider claims for reimbursement for services provided to recipients shall be made through the department’s automated claims processing system.

DHS 106.04(1m)(c) (c) Manual partial payment. The department may pay up to 75% of the reimbursable amount of a provider’s claim in advance of payments made through the automated claims processing system if all the following conditions exist:

DHS 106.04(1m)(c)1. 1. The provider requests a manual partial payment and is informed that the payment will be automatically recouped when the provider’s claims are later processed through the automated claims processing system;

DHS 106.04(1m)(c)2. 2. A provider’s claims for services provided have been pending in the automated claims processing system for more than 30 days, or the provider provides services to MA recipients representing more than 50% of the provider’s income and payment for these services has been significantly delayed beyond the claims processing time historically experienced by the provider;

DHS 106.04(1m)(c)3. 3. The delay in payment under subd. 2. is due to no fault of the provider;

DHS 106.04(1m)(c)4. 4. Further delay in payment will have a financial impact on the provider which is likely to adversely affect or disrupt the level of care otherwise provided to recipients; and

DHS 106.04(1m)(c)5. 5. The provider has submitted documentation of covered services, including the provider name and MA billing number, the recipient’s name and MA number, the date or dates of services provided, type and quantity of services provided as appropriate and any other information pertinent to payment for covered services.

DHS 106.04(1m)(d) (d) Recoupment of manual partial payments. Manual partial payments shall be automatically recouped when the provider’s claims are processed through the automated claims system.

DHS 106.04(1m)(e) (e) Cash advances prohibited. In no case may the department or its fiscal agent make advance payment for services not yet provided. No payment may be made unless covered services have been provided and a claim or document under par. (c) 5. for these services has been submitted to the department.

DHS 106.04(2) (2) Cost sharing.

DHS 106.04(2)(a) (a) General policy. Pursuant to s. 49.45 (18), Stats., the department shall establish copayment rates and deductible amounts for medical services covered under MA. Recipients shall provide the copayment amount or coinsurance to the provider or pay for medical services up to the deductible amount, as appropriate, except that the services and recipients listed in s. DHS 104.01 (12) (a) are exempt from cost-sharing requirements. Providers are not entitled to reimbursement from MA for the copayment, coinsurance or deductible amounts for which a recipient is liable.

DHS 106.04(2)(b) (b) Liability for refunding erroneous copayment. In the event that medical services are covered by a third party and the recipient makes a copayment to the provider, the department is not responsible for refunding the copayment amount to the recipient.

DHS 106.04(3) (3) Non-liability of recipients. A provider shall accept payments made by the department in accordance with sub. (1) as payment in full for services provided a recipient. A provider may not attempt to impose a charge for an individual procedure or for overhead which is included in the reimbursement for services provided nor may the provider attempt to impose an unauthorized charge or receive payment from a recipient, relative or other person for services provided, or impose direct charges upon a recipient in lieu of obtaining payment under the program, except under any of the following conditions:

DHS 106.04(3)(a) (a) A service desired, needed or requested by a recipient is not covered under the program or a prior authorization request is denied and the recipient is advised of this fact before receiving the service;

DHS 106.04(3)(b) (b) An applicant is determined to be eligible retroactively under s. 49.46 (1) (b), Stats., and a provider has billed the applicant directly for services rendered during the retroactive period, in which case the provider shall, upon notification of the recipient’s retroactive eligibility, submit claims under this section for covered services provided during the retroactive period. Upon receipt of payment from the program for the services, the provider shall reimburse in full the recipient or other person who has made prior payment to the provider. A provider shall not be required to reimburse the recipient or other person in excess of the amount reimbursed by the program; or

DHS 106.04(3)(c) (c) A recipient in a nursing home chooses a private room in the nursing home and the provisions of s. DHS 107.09 (4) (k) are met.

DHS 106.04(4) (4) Release of billing information by providers.

DHS 106.04(4)(a) (a) Restrictions. A provider may not release information to a recipient or to a recipient’s attorney relating to charges which have been billed or which will be billed to MA for the cost of care of a recipient without notifying the department, unless any real or potential third-party payer liability has been assigned to the provider.

DHS 106.04(4)(b) (b) Provider liability. If a provider releases information relating to the cost of care of a recipient or beneficiary contrary to par. (a), and the recipient or beneficiary receives payment from a liable third-party payer, the provider shall repay to the department any MA benefit payment it has received for the charges in question. The provider may then assert a claim against the recipient or beneficiary for the amount of the MA benefit repaid to the department.

DHS 106.04 Note Note: See the Wisconsin Medical Assistance Provider Handbook for specific information on procedures to be followed in the release of billing information.

DHS 106.04(5) (5) Return of overpayment.

DHS 106.04(5)(a) (a) Except as provided in par. (b), if a provider receives a payment under the MA program to which the provider is not entitled or in an amount greater than that to which the provider is entitled, the provider shall return to the department the amount of the overpayment, including but not limited to erroneous, excess, duplicative and improper payments, regardless of cause, within 30 days after the date of the overpayment in the case of a duplicative payment from MA, medicare or other health care payer and within 30 days after the date of discovery in the case of all other overpayments.

DHS 106.04(5)(b) (b) In lieu of returning the overpayment, a provider may notify the department in writing within 30 days after the date of the overpayment or its discovery, as applicable, of the nature, source and amount of the overpayment and request that the overpayment be deducted from future amounts owed the provider by the MA program.

DHS 106.04(5)(c) (c) The department shall honor the request under par. (b) if the provider is actively participating in the program, is not currently under investigation for fraud or MA program abuse, is not subject to an intermediate sanction under s. DHS 106.08, and is claiming and receiving MA reimbursement in amounts sufficient to reasonably ensure full recovery of the overpayment within a limited period of time. Any limited recovery period shall be consistent with the applicable federally required time period for the department’s repayment of the federal financial participation associated with the overpayment as stated in 42 CFR 433.300-322.