Chapter DHS 106

Register August 2010 No. 656

Chapter DHS 106

PROVIDER RIGHTS AND RESPONSIBILITIES

DHS 106.01   Introduction.

DHS 106.02   General requirements for provision of services.

DHS 106.03   Manner of preparing and submitting claims for reimbursement.

DHS 106.04   Payment of claims for reimbursement.

DHS 106.05   Voluntary termination of program participation.

DHS 106.06   Involuntary termination or suspension from program participation.

DHS 106.065   Involuntary termination and alternative sanctions for home care providers.

DHS 106.07   Effects of suspension or involuntary termination.

DHS 106.08   Intermediate sanctions.

DHS 106.09   Departmental discretion to pursue monetary recovery.

DHS 106.10   Withholding payment of claims.

DHS 106.11   Pre-payment review of claims.

DHS 106.12   Procedure, pleadings and practice.

DHS 106.13   Discretionary waivers and variances.

Ch. DHS 106 Note Note: Chapter HSS 106 was renumbered Chapter HFS 106 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 106 was renumbered to chapter DHS 106 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 106.01 DHS 106.01 Introduction. In addition to provisions of chs. DHS 105 and 107 relating to individual provider types and the manner by which specified services are to be provided and paid for under medical assistance (MA), the participation of all providers certified under ch. DHS 105 to provide or claim reimbursement for services under the program shall be subject to the conditions set forth in this chapter.

DHS 106.01 History History: Cr. Register, December, 1979, No. 288, eff. 2-1-80; am. Register, February, 1986, No. 362, eff. 3-1-86; corrections made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 106.02 DHS 106.02 General requirements for provision of services. Providers shall comply with the following general conditions for participation as providers in the MA program:

DHS 106.02(1) (1) Certification. A provider shall be certified under ch. DHS 105.

DHS 106.02(2) (2) Covered services. A provider shall be reimbursed only for covered services specified in ch. DHS 107.

DHS 106.02(3) (3) Recipient eligible on date of service. A provider shall be reimbursed for a service only if the recipient of the service was eligible to receive MA benefits on the date the service was provided.

DHS 106.02(4) (4) Compliance with state and federal requirements. A provider shall be reimbursed only if the provider complies with applicable state and federal procedural requirements relating to the delivery of the service.

DHS 106.02(5) (5) Appropriate and medically necessary services. A provider shall be reimbursed only for services that are appropriate and medically necessary for the condition of the recipient.

DHS 106.02(6) (6) Provision of non-covered services. If a provider determines that, to assure quality health care to a recipient, it is necessary to provide a non-covered service, nothing in this chapter shall preclude the provider from furnishing the service, if before rendering the service the provider advises the recipient that the service is not covered under the program and that, if provided, the recipient is responsible for payment.

DHS 106.02(7) (7) Services to recipients with a primary provider. A provider other than the designated primary provider may not claim reimbursement for a service to an individual whose freedom to choose a provider has been restricted under s. DHS 104.03 or 104.05 as indicated on the recipient’s MA identification card unless the service was rendered pursuant to a written referral from the recipient’s designated primary provider or the service was rendered in an emergency. If rendered in an emergency, the provider seeking reimbursement shall submit to the fiscal agent a written description of the nature of the emergency along with the service claim.

DHS 106.02(8) (8) Refusal to provide MA services. A provider is not required to provide services to a recipient if the recipient refuses or fails to present a currently valid MA identification card. If a recipient fails, refuses or is unable to produce a currently valid identification card, the provider may contact the fiscal agent to confirm the current eligibility of the recipient. The department shall require its fiscal agent to install and maintain adequate toll-free telephone service to enable providers to verify the eligibility of recipients to receive benefits under the program.

DHS 106.02(9) (9) Medical and financial recordkeeping and documentation.

DHS 106.02(9)(a) (a) Preparation and maintenance. A provider shall prepare and maintain truthful, accurate, complete, legible and concise documentation and medical and financial records specified under this subsection, s. DHS 105.02 (6), the relevant provisions of s. DHS 105.02 (7), other relevant sections in chs. DHS 105 and 106 and the relevant sections of ch. DHS 107 that relate to documentation and medical and financial recordkeeping for specific services rendered to a recipient by a certified provider. In addition to the documentation and recordkeeping requirements specified in pars. (b) to (d), the provider’s documentation, unless otherwise specifically contained in the recipient’s medical record, shall include:

DHS 106.02(9)(a)1. 1. The full name of the recipient;

DHS 106.02(9)(a)2. 2. The identity of the person who provided the service to the recipient;

DHS 106.02(9)(a)3. 3. An accurate, complete and legible description of each service provided;

DHS 106.02(9)(a)4. 4. The purpose of and need for the services;

DHS 106.02(9)(a)5. 5. The quantity, level and supply of service provided;

DHS 106.02(9)(a)6. 6. The date of service;

DHS 106.02(9)(a)7. 7. The place where the service was provided; and

DHS 106.02(9)(a)8. 8. The pertinent financial records.

DHS 106.02(9)(b) (b) Medical record content. A provider shall include in a recipient’s medical record all of the following written documentation, as applicable:

DHS 106.02(9)(b)1. 1. Date, department or office of the provider, as applicable, and provider name and profession.

DHS 106.02(9)(b)2. 2. Chief medical complaint or purpose of the service or services.

DHS 106.02(9)(b)3. 3. Clinical findings.

DHS 106.02(9)(b)4. 4. Diagnosis or medical impression.

DHS 106.02(9)(b)5. 5. Studies ordered, such as laboratory or x-ray studies.

DHS 106.02(9)(b)6. 6. Therapies or other treatments administered.

DHS 106.02(9)(b)7. 7. Disposition, recommendations and instructions given to the recipient, including any prescriptions and plans of care or treatment provided.

DHS 106.02(9)(b)8. 8. Prescriptions, plans of care and any other treatment plans for the recipient received from any other provider.

DHS 106.02(9)(b)9. 9. Delivery mode of the services provided, when provided via telehealth as established under s. DHS 107.02 (5), including all of the following:

DHS 106.02(9)(b)9.a. a. Whether provided via audio-visual telehealth, via audio-only telehealth, or via telehealth externally acquired images.

DHS 106.02(9)(b)9.b. b. Whether provided synchronously or asynchronously.

DHS 106.02(9)(c) (c) Financial records. A provider shall maintain the following financial records in written or electronic form:

DHS 106.02(9)(c)1. 1. Payroll ledgers, canceled checks, bank deposit slips and any other accounting records prepared by the provider;

DHS 106.02(9)(c)2. 2. Billings to MA, medicare, a third party insurer or the recipient for all services provided to the recipient;

DHS 106.02(9)(c)3. 3. Evidence of the provider’s usual and customary charges to recipients and to persons or payers who are not recipients;

DHS 106.02(9)(c)4. 4. The provider’s appointment books for patient appointments and the provider’s schedules for patient supervision, if applicable;

DHS 106.02(9)(c)5. 5. Billing claims forms for either manual or electronic billing for all health services provided to the recipient;

DHS 106.02(9)(c)6. 6. Records showing all persons, corporations, partnerships and entities with an ownership or controlling interest in the provider, as defined in 42 CFR 455.101; and