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. DHS 106.03 HistoryHistory: 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 106.04DHS 106.04 Payment of claims for reimbursement. 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)(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)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)(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(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 NoteNote: 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)(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. DHS 106.04(5)(d)(d) If the department denies the provider’s request under par. (b) to have the overpayment deducted from future amounts paid, the provider shall return to the department the full amount of the overpayment within 30 days after receipt of the department’s written denial. DHS 106.04(6)(6) Good faith payment. A claim denied for recipient eligibility reasons may qualify for a good faith payment if the service provided was provided in good faith to a recipient with an MA identification card which the provider saw on the date of service and which was apparently valid for the date of service. DHS 106.04 HistoryHistory: Cr. Register, December, 1979, No. 288, eff. 2-1-80; am. Register, February, 1986, No. 362, eff. 3-1-86; r. (2) (b) 10. and 11., cr. (7) (f), Register, February, 1988, No. 386, eff. 3-1-88; renum. (2) (b) 5. to 9. to be 6. to 10. and am. 9. and 10., cr. (2) (b) 5., 11. and 12., Register, December, 1988, No. 396, eff. 1-1-89; emerg. am. (2) (a), r. (2) (b) to (e), renum. (2) (f) to be (2) (b), eff. 1-1-90; am. (2) (a), r. (2) (b) to (e), renum. (2) (f) to be (2) (b), Register, September, 1990, No. 417, eff. 10-1-90; emerg. cr. (1m), eff. 11-1-90; cr. (1m), Register, May, 1991, No. 425, eff. 6-1-91; am. (3) (intro.), Register, September, 1991, No. 429, eff. 10-1-91; emerg. am. (1m) (c) 1., renum. (1m) (d), (5) and (9) to be (1m) (e), (4) and (6) and am. (4), cr. (1m) (d), r. (4), (7) and (8), r. and recr. (6), eff. 7-1-92; am. (1m) (c) 1., renum. (1m) (d) and (9) to be (1m) (e) and (6), cr. (1m) (d), r. and recr. (5), r. (6) to (8), Register, February, 1993, No. 446, eff. 3-1-93; correction in (3) (b) made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520; corrections in (2) (a) and (3) (c) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636. DHS 106.05DHS 106.05 Voluntary termination of program participation. DHS 106.05(1)(a)(a) Termination notice. Any provider other than a skilled nursing facility or intermediate care facility may at any time terminate participation in the program. A provider electing to terminate program participation shall at least 30 days before the termination date notify the department in writing of that decision and of the effective date of termination from the program. DHS 106.05(1)(b)(b) Reimbursement. A provider may not claim reimbursement for services provided recipients on or after the effective date specified in the termination notice. If the provider’s notice of termination fails to specify an effective date, the provider’s certification to provide and claim reimbursement for services under the program shall be terminated on the date on which notice of termination is received by the department. DHS 106.05(2)(2) Skilled nursing and intermediate care facilities. DHS 106.05(2)(a)(a) Termination notice. A provider certified under ch. DHS 105 as a skilled nursing facility or intermediate care facility may terminate participation in the program upon advance written notice to the department and to the facility’s resident recipients or their legal guardians in accordance with s. 50.03 (14) (e), Stats. The notice shall specify the effective date of the facility’s termination of program participation. DHS 106.05(2)(b)(b) Reimbursement. A skilled nursing facility or intermediate care facility electing to terminate program participation may claim and receive reimbursement for services for a period of not more than 30 days beginning on the effective termination date. Services furnished during the 30-day period shall be reimbursable provided that: DHS 106.05(2)(b)1.1. The recipient was not admitted to the facility after the date on which written notice of program termination was given the department; and DHS 106.05(2)(b)2.2. The facility demonstrates to the satisfaction of the department that it has made reasonable efforts to facilitate the orderly transfer of affected resident recipients to another appropriate facility. DHS 106.05(3)(3) Record retention. Voluntary termination of a provider’s program participation under this section does not end the provider’s responsibility to retain and provide access to records as required under s. DHS 106.02 (9) unless an alternative arrangement for retention, maintenance and access has been established by the provider and approved in writing by the department. DHS 106.05 HistoryHistory: Cr. Register, December, 1979, No. 288, eff. 2-1-80; am. Register, February, 1986, No. 362, eff. 3-1-86; correction in (2) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636. DHS 106.06DHS 106.06 Involuntary termination or suspension from program participation. The department may suspend or terminate the certification of any person, partnership, corporation, association, agency, institution or other entity participating as a health care provider under the program, if the suspension or termination will not deny recipients access to MA services and if after reasonable notice and opportunity for a hearing the department finds that any of the following occurred: DHS 106.06(1)(1) Non-compliance with MA requirements. The provider has repeatedly and knowingly failed or refused to comply with federal or state statutes, rules or regulations applicable to the delivery of, or billing for, services under the program; DHS 106.06(2)(2) Refusal to comply with provider agreement. The provider has repeatedly and knowingly failed or refused to comply with the terms and conditions of its provider agreement; DHS 106.06(3)(a)(a) The provider has prescribed, provided, or claimed reimbursement for services under the program which were: DHS 106.06(3)(b)(b) Findings precipitating action by the department under this subsection shall be based on the written findings of a peer review committee established by the department or a PRO under contract to the department to review and evaluate health care services provided under the program. The findings shall be presumptive evidence that the provider has engaged in improper activities under this subsection. DHS 106.06(4)(4) Suspension or revocation. The licensure, certification, authorization or other official entitlement required as a prerequisite to the provider’s certification to participate in the program has been suspended, restricted, terminated, expired or revoked; DHS 106.06(4m)(4m) In the case of a freestanding personal care agency as defined in s. DHS 105.17 (1) (a), the freestanding personal care agency has violated one or more of the applicable requirements of ch. DHS 105 in a manner or to a degree that may endanger or threaten the health or safety of clients, has not paid the fee, or has failed to provide information requested by the department in connection with certification; DHS 106.06(5)(5) Public health in jeopardy. A provider’s licensure, certification, authorization or other official entitlement has been suspended, terminated, expired or revoked under state or federal law following a determination that the health, safety or welfare of the public is in jeopardy; DHS 106.06(6)(a)(a) The provider is excluded or terminated from the medicare program or otherwise sanctioned by the medicare program because of fraud or abuse of the medicare program under 42 CFR 420.101 or 474.10. DHS 106.06(6)(c)(c) The provider is a party convicted of a crime, ineligible to participate in the medicare program and the health care financing administration directs the department to suspend the provider; DHS 106.06(7)(7) Service during period of noncertification. The provider has provided a service to a recipient during a period in which provider’s licensure, certification, authorization, or other entitlement to provide the service was terminated, suspended, expired or revoked; DHS 106.06(8)(8) Criminal conviction. The provider has been convicted of a criminal offense related to providing or claiming reimbursement for services under medicare or under this or any other state’s MA program. In this subsection, “convicted” means that a judgment of conviction has been entered by a federal, state or local court, irrespective of whether an appeal from that judgment is pending; DHS 106.06(9)(9) False statements. The provider knowingly made or caused to be made a false statement or misrepresentation of material fact in connection with provider’s application for certification or recertification; DHS 106.06(10)(10) Failure to report status change. The provider has concealed, failed or refused to disclose any material change in licensure, certification, authorization, or ownership which, if known to the department, would have precluded the provider from being certified;
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Chs. DHS 101-109; Medical Assistance
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