Wisconsin Legislature: DHS 107.30(1)(a)

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2. Provides for prompt resolution of the grievance; and

3. Assures the participation of individuals with authority to require corrective action;

(d) Provide for an internal quality assurance system that:

1. Is consistent with the utilization control requirements established by the department and set forth in the contract;

2. Provides for review by appropriate health professionals of the process followed in providing health services;

3. Provides for systematic data collection of performance and patient results;

4. Provides for interpretation of this data to the practitioners; and

5. Provides for making needed changes;

(e) Provide that the organization submit marketing plans, procedures and materials to the department for approval before using the plans;

(f) Provide that the HMO advise enrolled recipients about the proper use of health care services and the contributions recipients can make to the maintenance of their own health;

(g) Provide for development of a medical record-keeping system that:

1. Collects all pertinent information relating to the medical management of each enrolled recipient; and

2. Makes that information readily available to member health care professionals;

(h) Provide that HMO-enrolled recipients may be excluded from specific MA requirements, including but not limited to copayments, prior authorization requirements, and the second surgical opinion program; and

(i) Provide that if a recipient who is a member of an HMO or other prepaid plan seeks medical services from a certified provider who is not participating in that plan without a referral from a provider in that plan, or in circumstances other than emergency circumstances as defined in 42 CFR 434.30, the recipient shall be liable for the entire amount charged for the service.

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; cr. (1) (c), Register, October, 2000, No. 538, eff. 11-1-00; correction in (1) (c) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 107.29 Rural health clinic services. Covered rural health clinic services are the following:

(1) Services furnished by a physician within the scope of practice of the profession under state law, if the physician performs the services in the clinic or the services are furnished away from the clinic and the physician has an agreement with the clinic providing that the physician will be paid by it for these services;

(2) Services furnished by a physician assistant or nurse practitioner if the services are furnished in accordance with the requirements specified in s. DHS 105.35;

(3) Services and supplies that are furnished incidental to professional services furnished by a physician, physician assistant or nurse practitioner;

(4) Part-time or intermittent visiting nurse care and related medical supplies, other than drugs and biologicals, if:

(a) The clinic is located in an area in which there is a shortage of home health agencies;

(b) The services are furnished by a registered nurse or licensed practical nurse employed by or otherwise compensated for the services by the clinic;

(c) The services are furnished under a written plan of treatment that is established and reviewed at least every 60 days by a supervising physician of the clinic, or that is established by a physician, physician assistant or nurse practitioner and reviewed and approved at least every 60 days by a supervising physician of the clinic; and

(d) The services are furnished to a homebound recipient. In this paragraph, “homebound recipient” means, for purposes of visiting nurse care, a recipient who is permanently or temporarily confined to a place of residence, other than a hospital or skilled nursing facility, because of a medical or health condition. The person may be considered homebound if the person leaves the place of residence infrequently; and

(5) Other ambulatory services furnished by a rural health clinic. In this subsection, “other ambulatory services” means ambulatory services other than the services in subs. (1), (2), and (3) that are otherwise included in the written plan of treatment and meet specific state plan requirements for furnishing those services. Other ambulatory services furnished by a rural health clinic are not subject to the physician supervision requirements under s. DHS 105.35.

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; corrections in (2) and (5) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 107.30 Ambulatory surgical center services.

(1) Covered services. Covered ambulatory surgical center (ASC) services are those medically necessary services identified in this section which are provided by or under the supervision of a certified physician in a certified ambulatory surgical center. The physician shall demonstrate that the recipient requires general or local anesthesia, and a postanesthesia observation time, and that the services could not be performed safely in an office setting. These services shall be performed in conformance with generally-accepted medical practice. Covered ambulatory surgical center services shall be limited to the following procedures:

(a) Surgical procedures:

1. Adenoidectomy or tonsillectomy;

2. Arthroscopy;

3. Breast biopsy;

4. Bronchoscopy;

5. Carpal tunnel;

6. Cervix biopsy or conization;

7. Circumcision;

8. Dilation and curettage;

9. Esophago-gastroduodenoscopy;

10. Ganglion resection;

11. Hernia repair;

12. Hernia — umbilical;

13. Hydrocele resection;

14. Laparoscopy, peritoneoscopy or other sterilization methods;

15. Pilonidal cystectomy;

16. Procto-colonoscopy;

17. Tympanoplasty;

18. Vasectomy;

19. Vulvar cystectomy; and

20. Any other surgical procedure that the department determines shall be covered and that the department publishes notice of in the MA provider handbook; and

(b) Laboratory procedures. The following laboratory procedures are covered but only when performed in conjunction with a covered surgical procedure under par. (a):

1. Complete blood count (CBC);

2. Hemoglobin;

3. Hematocrit;

4. Urinalysis;

5. Blood sugar;

6. Lee white coagulant; and

7. Bleeding time.

(2) Services requiring prior authorization. Any surgical procedure under s. DHS 107.06 (2) requires prior authorization.

Note: For more information on prior authorization, see s. DHS 107.02 (3).

(3) Other limitations.

(a) A sterilization is a covered service only if the procedures specified in s. DHS 107.06 (3) are followed.

1. Nursing, technician, and related services;

2. Use of ambulatory surgical center facilities;

3. Drugs, biologicals, surgical dressings, supplies, splints, casts and appliances, and equipment directly related to the provision of a surgical procedure;

4. Diagnostic or therapeutic services or items directly related to the provision of a surgical procedure;

5. Administrative, recordkeeping and housekeeping items and services; and

6. Materials for anesthesia.

(4) Non-covered services.

(a) Ambulatory surgical center services and items for which payment may be made under other provisions of this chapter are not covered services. These include:

1. Physician services;

2. Laboratory services;

3. X-ray and other diagnostic procedures, except those directly related to performance of the surgical procedure;

4. Prosthetic devices;

5. Ambulance services;

6. Leg, arm, back and neck braces;

7. Artificial limbs; and

8. Durable medical equipment for use in the recipient’s home.

Note: For more information on non-covered services, see s. DHS 107.03.

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction in (3) (b) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 20-039: r. (3) (b) Register October 2021 No. 790, eff. 11-1-21.

DHS 107.31 Hospice care services.

(1) Definitions.

(a) “Attending physician” means a physician who is a doctor of medicine or osteopathy certified under s. DHS 105.05 and identified by the recipient as having the most significant role in the determination and delivery of his or her medical care at the time the recipient elects to receive hospice care.

(b) “Bereavement counseling” means counseling services provided to the recipient’s family following the recipient’s death.

(d) “Interdisciplinary group” means a group of persons designated by a hospice to provide or supervise care and services and made up of at least a physician, a registered nurse, a medical worker and a pastoral counselor or other counselor, all of whom are employees of the hospice.

(e) “Medical director” means a physician who is an employee of the hospice and is responsible for the medical component of the hospice’s patient care program.

(f) “Respite care” means services provided by a residential facility that is an alternate place for a terminally ill recipient to stay to temporarily relieve persons caring for the recipient in the recipient’s home or caregiver’s home from that care.