DHS 107.07(4)(L)
(L) Professional visits, other than for the oral evaluation of a nursing home resident, or hospital calls as noted in sub.
(1) (j) 4. DHS 107.07(4m)
(4m) Non-covered services; dental hygienists. The following services are not covered by MA whether or not the service is performed by a person under the supervision of a dentist or physician or by a dental hygienist who is individually certified under ch.
DHS 105:
DHS 107.07(4m)(b)
(b) Oral hygiene instruction or training in preventive dental care as a separate procedure, including tooth brushing technique, flossing or use of special oral hygiene aids, tobacco cessation counseling, or nutritional counseling.
DHS 107.07(5)
(5) Unusual circumstances. In certain unusual circumstances the department may request that a non-covered service be performed, including but not limited to diagnostic casts, in order to substantiate a prior authorization request. In these cases the service shall be reimbursed.
DHS 107.07 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; am. (1) (c) 10. and (2) (c) 9. e. and f., cr. (2) (c) 9. g. and (3) (8), r. and recr. (4) (q),
Register, February, 1988, No. 386, eff. 3-1-88; r. and recr. (1) (g) and (4) (j), renum. (2) (c) 9. to 12. and (4) (k) to (t) to be (2) (c) 10. to 13. and (4) (m) to (v), cr. (2) (c) 9., (4) (k) and (L),
Register, December, 1989, No. 408, eff. 1-1-90; correction in (4) (j) made under s. 13.93 (2m) (b) 7., Stats.,
Register, December, 1989, No. 408;
CR 05-033: r. and recr. (1), (3) and (4) cr. (1m), (2) (a) 5. to 7. and (4m), am. (2) (a) (intro.) and 1. to 4. and (2) (b), r. (2) (c)
Register August 2006 No. 608, eff. 9-1-06; emerg. r. (1) (k) and (2) (a) 5., am. (2) (a) (intro.), (3) (intro.), (a) 3., (4) (intro.), (j) and (4m) eff. 4-30-07;
CR 07-041: r. (1) (i), (k) and (2) (a) 5., am. (2) (a) (intro.), (3) (intro.), (a) 3., (4) (intro.), (j) and (4m)
Register December 2007 No. 624, eff. 1-1-08; corrections in (1m) (intro.) and (4m) (intro.) made under s. 13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636;
CR 22-043: r. (4) (b), am. (4) (c), r. (4) (k) 1.
Register May 2023 No. 809, eff. 6-1-23.
DHS 107.08(1)(a)(a) Inpatient services. Covered hospital inpatient services are those medically necessary services which require an inpatient stay ordinarily furnished by a hospital for the care and treatment of inpatients, and which are provided under the direction of a physician or dentist in an institution certified under s.
DHS 105.07 or
105.21.
DHS 107.08(1)(b)
(b) Outpatient services. Covered hospital outpatient services are those medically necessary preventive, diagnostic, rehabilitative or palliative items or services provided by a hospital certified under s.
DHS 105.07 or
105.21 and performed by or under the direction of a physician or dentist for a recipient who is not a hospital inpatient.
DHS 107.08(2)
(2) Services requiring prior authorization. The following covered services require prior authorization:
DHS 107.08(2)(a)
(a) Covered hospital services if provided out-of-state under non-emergency circumstances by non-border status providers;
DHS 107.08 Note
Note: For more information on prior authorization, see s.
DHS 107.02 (3).
DHS 107.08(3)(a)
(a) Inpatient limitations. The following limitations apply to hospital inpatient services:
DHS 107.08(3)(a)1.
1. Inpatient admission for non-therapeutic sterilization is a covered service only if the procedures specified in s.
DHS 107.06 (3) are followed; and
DHS 107.08(3)(a)2.
2. A recipient's attending physician shall determine if private room accommodations are medically necessary. Charges for private room accommodations shall be denied unless the private room is medically necessary and prescribed by the recipient's attending physician. When a private room is not medically necessary, neither MA nor the recipient may be held responsible for the cost of the private room charge. If, however, a recipient requests a private room and the hospital informs the recipient at the time of admission of the cost differential, and if the recipient understands and agrees to pay the differential, then the recipient may be charged for the differential.
DHS 107.08(3)(b)
(b) Outpatient limitations. The following limitations apply to hospital outpatient services:
DHS 107.08(3)(b)1.
1. For services provided by a hospital on an outpatient basis, the same requirements shall apply to the hospital as apply to MA-certified non-hospital providers performing the same services;
DHS 107.08(3)(b)2.
2. Outpatient services performed outside the hospital facility may not be reimbursed as hospital outpatient services; and
DHS 107.08(3)(b)3.
3. All covered outpatient services provided during a calendar day shall be included as one outpatient visit.
DHS 107.08(3)(c)2.
2. If a hospital is certified and reimbursed as a type of provider other than a hospital, the hospital is subject to all coverage and reimbursement requirements for that type of provider.
DHS 107.08(3)(c)3.
3. On any given calendar day a patient in a hospital shall be considered either an inpatient or an outpatient, but not both. Emergency room services shall be considered outpatient services unless the patient is admitted as an inpatient and counted on the midnight census. Patients who are same day admission and discharge patients and who die before the midnight census shall be considered inpatients.
DHS 107.08(3)(c)4.
4. All covered services provided during an inpatient stay, except professional services which are separately billed, shall be considered hospital inpatient services.
DHS 107.08(4)(a)1.
1. Unnecessary or inappropriate inpatient admissions or portions of a stay;
DHS 107.08(4)(a)2.
2. Hospitalizations or portions of hospitalizations disallowed by the PRO;
DHS 107.08(4)(a)3.
3. Hospitalizations either for or resulting in surgeries which the department views as experimental due to questionable or unproven medical effectiveness;
DHS 107.08(4)(a)4.
4. Inpatient services and outpatient services for the same patient on the same date of service unless the patient is admitted to a hospital other than the facility providing the outpatient care;
DHS 107.08(4)(a)5.
5. Hospital admissions on Friday or Saturday, except for emergencies, accident or accident care and obstetrical cases, unless the hospital can demonstrate to the satisfaction of the department that the hospital provides all of its services 7 days a week; and
DHS 107.08(4)(a)6.
6. Hospital laboratory, diagnostic, radiology and imaging tests not ordered by a physician, except in emergencies;
DHS 107.08(4)(b)
(b) Neither MA nor the recipient may be held responsible for charges or services identified in par.
(a) as non-covered, except that a recipient may be billed for charges under par.
(a) 3. or
5., if the recipient was notified in writing in advance of the hospital stay that the service was not a covered service.
DHS 107.08(4)(c)
(c) If hospital services for a patient are no longer medically necessary and an appropriate alternative care setting is available but the patient refuses discharge, the patient may be billed for continued services if he or she receives written notification prior to the time medically unnecessary services are provided.
DHS 107.08(4)(d)
(d) The following professional services are not covered as part of a hospital inpatient claim but shall be billed by an appropriately certified MA provider;
DHS 107.08(4)(d)1.
1. Services of physicians, including pathologists, radiologists and the professional-billed component of laboratory and radiology or imaging services, except that services by physician intern and residents services are included as hospital services;
DHS 107.08(4)(d)2.
2. Services of psychiatrists and psychologists, except when performing group therapy and medication management, including services provided to a hospital inpatient when billed by a hospital, clinic or other mental health or AODA provider;
DHS 107.08(4)(d)5.
5. Services of nurse midwives, nurse practitioners and independent nurses when functioning as independent providers;
DHS 107.08(4)(e)
(e) Professional services provided to hospital inpatients are not covered hospital inpatient services but are rather professional services and subject to the requirements in this chapter that apply to the services provided by the particular provider type.
DHS 107.08(4)(f)
(f) Neither a hospital nor a provider performing professional services to hospital inpatients may impose an unauthorized charge on recipients for services covered under this chapter.
DHS 107.08 Note
Note: For more information on non-covered services, see s.
DHS 107.03.
DHS 107.08 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; am. (4) (e) and (f), cr. (4) (g),
Register, February, 1988, No. 388, eff. 3-1-88; correction in (3) (g) made under s. 13.93 (2m) (b) 7., Stats.,
Register, June, 1990, No. 414; emerg. renum. (4) to be (4) (a) and am. (4) (a) (intro.) 1., 2., 4., 6. and 7., cr. (4) (b) to (f) eff. 1-1-91; r. and recr.
Register, September, 1991, No. 429, eff. 10-1-91; correction in (2) (d) made under s. 13.93 (2m) (b) 7.,
Register August 2006 No. 608; corrections in (1) and (3) (c) 1., made under s. 13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636.
DHS 107.09(1)(1)
Definition. In this section, “active treatment" means an ongoing, organized effort to help each resident attain his or her developmental capacity through the resident's regular participation, in accordance with an individualized plan, in a program of activities designed to enable the resident to attain the optimal physical, intellectual, social and vocational levels of functioning of which he or she is capable.
DHS 107.09(2)
(2) Covered services. Covered nursing home services are medically necessary services provided by a certified nursing home to an inpatient and prescribed by a physician in a written plan of care. The costs of all routine, day-to-day health care services and materials provided to recipients by a nursing home shall be reimbursed within the daily rate determined for MA in accordance with s.
49.45 (6m), Stats. These services are the following:
