Chapter DHS 105

PROVIDER CERTIFICATION

DHS 105.01   Introduction.

DHS 105.02   Requirements for maintaining certification.

DHS 105.03   Participation by non-certified persons.

DHS 105.04   Supervision of provider assistants.

DHS 105.05   Physicians and assistants.

DHS 105.055   Nurse anesthetists and anesthesiologist assistants.

DHS 105.06   Dentists and dental hygienists.

DHS 105.07   General hospitals.

DHS 105.075   Rehabilitation hospitals.

DHS 105.08   Skilled nursing facilities.

DHS 105.09   Medicare bed requirement.

DHS 105.10   SNFs and ICFs with deficiencies.

DHS 105.11   Intermediate care facilities.

DHS 105.12   ICFs for individuals with intellectual disabilities or individuals with related conditions.

DHS 105.14   Adult day care centers.

DHS 105.15   Pharmacies.

DHS 105.16   Home health agencies.

DHS 105.17   Personal care providers.

DHS 105.19   Nurses in independent practice.

DHS 105.20   Nurse practitioners.

DHS 105.201   Nurse-midwives.

DHS 105.21   Hospital IMDS.

DHS 105.22   Psychotherapy providers.

DHS 105.23   Alcohol and other drug abuse (AODA) treatment providers.

DHS 105.24   Mental health day treatment or day hospital service providers.

DHS 105.25   Alcohol and other drug abuse (AODA) day treatment providers.

DHS 105.255   Community support programs.

DHS 105.257   Community-based psychosocial service programs.

DHS 105.26   Chiropractors.

DHS 105.265   Podiatrists.

DHS 105.27   Physical therapists and assistants.

DHS 105.28   Occupational therapists and assistants.

DHS 105.29   Speech and hearing clinics.

DHS 105.30   Speech pathologists.

DHS 105.31   Audiologists.

DHS 105.32   Optometrists.

DHS 105.33   Opticians.

DHS 105.34   Rehabilitation agencies.

DHS 105.35   Rural health clinics.

DHS 105.36   Family planning clinics or agencies.

DHS 105.37   Early and periodic screening, diagnosis and treatment (EPSDT) providers.

DHS 105.38   Ambulance providers.

DHS 105.39   Specialized medical vehicle providers.

DHS 105.40   Durable medical equipment and medical supply vendors.

DHS 105.41   Certification of hearing instrument specialists.

DHS 105.42   Physician office laboratories.

DHS 105.43   Hospital and independent clinical laboratories.

DHS 105.44   Portable x-ray providers.

DHS 105.45   Dialysis facilities.

DHS 105.46   Blood banks.

DHS 105.47   Health maintenance organizations and prepaid health plans.

DHS 105.48   Out-of-state providers.

DHS 105.49   Ambulatory surgical centers.

DHS 105.50   Hospices.

DHS 105.51   Case management agency providers.

DHS 105.52   Prenatal care coordination providers.

DHS 105.53   School-based service providers.

DHS 105.54   Qualified complex rehabilitation technology suppliers.

Ch. DHS 105 Note Note: Chapter HSS 105 as it existed on February 28, 1986 was repealed and a new chapter HSS 105 was created effective March 1, 1986. Chapter HSS 105 was renumbered Chapter HFS 105 under s. 13.93 (2m) (b) 1., Stats., and corrections made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, January, 1997, No. 493. Chapter HFS 105 was renumbered to chapter DHS 105 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 105.01 DHS 105.01 Introduction.

DHS 105.01(1) (1) Purpose. This chapter identifies the terms and conditions under which providers of health care services are certified for participation in the medical assistance program (MA).

DHS 105.01(2) (2) Definitions. In this chapter:

DHS 105.01(2)(a) (a) “Group billing provider” means an entity which provides or arranges for the provision of medical services by more than one certified provider.

DHS 105.01(2)(b) (b) “Provider assistant” means a provider such as a physical therapist assistant whose services must be provided under the supervision of a certified or licensed professional provider, and who, while required to be certified, is not eligible for direct reimbursement from MA.

DHS 105.01(3) (3) General conditions for participation. In order to be certified by the department to provide specified services for a reasonable period of time as specified by the department, a provider shall truthfully, accurately, completely and in a timely manner do all of the following:

DHS 105.01(3)(a) (a) Affirm in writing that, with respect to each service for which certification is sought, the provider and each person employed by the provider for the purpose of providing the service holds all licenses or similar entitlements as specified in chs. DHS 101 to 108 and required by federal or state statute, regulation or rule for the provision of the service;

DHS 105.01(3)(b) (b) Affirm in writing that neither the provider, nor any person in whom the provider has a controlling interest, nor any person having a controlling interest in the provider, has, since the inception of the medicare, medicaid, or title 20 services program, been convicted of a crime related to, or been terminated from, a federal-assisted or state-assisted medical program;

DHS 105.01(3)(c) (c) Disclose in writing to the department all instances in which the provider, any person in whom the provider has a controlling interest, or any person having a controlling interest in the provider has been sanctioned by a federal-assisted or state-assisted medical program, since the inception of medicare, medicaid or the title 20 services program;

DHS 105.01(3)(d) (d) Furnish the following information to the department, in writing:

DHS 105.01(3)(d)1. 1. The names and addresses of all vendors of drugs, medical supplies or transportation, or other providers in which it has a controlling interest or ownership;

DHS 105.01(3)(d)2. 2. The names and addresses of all persons who have a controlling interest in the provider; and

DHS 105.01(3)(d)3. 3. Whether any of the persons named in compliance with subd. 1. or 2., is related to another as spouse, parent, child or sibling;

DHS 105.01(3)(e) (e) Execute a provider agreement with the department; and

DHS 105.01(3)(f) (f)

DHS 105.01(3)(f)1. 1. Accept and consent to the use, based on a methodology determined by the investigating or auditing agency, of statistical sampling and extrapolation as the means to determine amounts owed by the provider to MA as the result of an investigation or audit conducted by the department, the department of justice medicaid fraud control unit, the federal department of health and human services, the federal bureau of investigation, or an authorized agent of any of these.

DHS 105.01(3)(f)2. 2. The sampling and extrapolation methodologies, if any, used in the investigation or audit shall be generally consistent, as applicable, with the guidelines on audit sampling issued by the statistical sampling subcommittee of the American institute of certified public accountants. Extrapolation, when performed, shall apply to the same period of time upon which the sampling is derived.

DHS 105.01(3)(f)3. 3. The department and the other investigative agencies shall retain the right to use alternative means to determine, consistent with applicable and generally accepted auditing practices, amounts owed as the result of an investigation or audit.

DHS 105.01(3)(f)4. 4. Nothing in this paragraph shall be construed to limit the right of a provider to appeal a department recovery action brought under s. DHS 108.02 (9).

DHS 105.01(4) (4) Providers required to be certified. The following types of providers are required to be certified by the department in order to participate in the MA program:

DHS 105.01(4)(a) (a) Institutional providers;

DHS 105.01(4)(b) (b) Non-institutional providers;

DHS 105.01(4)(c) (c) Provider assistants;

DHS 105.01(4)(d) (d) Group billing providers; and

DHS 105.01(4)(e) (e) Providers performing professional services for hospital inpatients under s. DHS 107.08 (4) (d). Hospitals which provide the setting for the performance of professional services to its inpatients shall ensure that the providers of those services are appropriately certified under this chapter.

DHS 105.01(5) (5) Persons not required to be individually certified. The following persons are not required to be individually certified by the department in order to participate in the MA program:

DHS 105.01(5)(a) (a) Technicians or support staff for a provider, including:

DHS 105.01(5)(a)1. 1. Dental hygienists, except as provided under sub. (5m);