Chapter DHS 107

DHS 107.23(1)(d)2. 2. Transportation of an MA recipient by a common carrier to a Wisconsin provider to receive MA-covered services shall be a covered service if the transportation is authorized by the county or tribal agency or its designated agency. Reimbursement shall be for the charges of the common carrier, for mileage expenses or a contracted amount the county or tribal agency or its designated agency has agreed to pay a common carrier. A county or tribal agency may develop its own transportation system or may enter into contracts with common carriers, individuals, private businesses, SMV providers and other governmental agencies to provide common carrier services. A county or tribe is limited in making this type of arrangement by sub. (3) (c).

DHS 107.23(1)(d)3. 3. Transportation of an MA recipient by a common carrier to an out-of-state provider, excluding a border-status provider, to receive MA-covered services shall be covered if the transportation is authorized by the county or tribal agency or its designated agency. The county or tribal agency or its designated agency may approve a request only if prior authorization has been received for the nonemergency medical services as required under s. DHS 107.04. Reimbursement shall be for the charges of the common carrier, for mileage expenses or a contracted amount the county or tribal agency or its designated agency has agreed to pay the common carrier.

DHS 107.23(1)(d)4. 4. Related travel expenses may be covered when the necessary transportation is other than routine, such as transportation to receive a service that is available only in another county, state or country, and the transportation is prior authorized by the county or tribal agency or its designated agency. These expenses may include the cost of meals and commercial lodging enroute to MA-covered care, while receiving the care and when returning from the care, and the cost of an attendant to accompany the recipient. The necessity for an attendant, except for children under 16 years of age, shall be determined by a physician, physician assistant, nurse midwife or nurse practitioner with that determination documented and submitted to the county or tribal agency. Reimbursement for the cost of an attendant may include the attendant’s transportation, lodging, meals and salary. If the attendant is a relative of the recipient, reimbursed costs are limited to transportation, commercial lodging and meals. Reimbursement for the costs of meals and commercial lodging shall be no greater than the amounts paid by the state to its employees for those expenses. The costs of more than one attendant shall be reimbursed only if the recipient’s condition requires the physical presence of another person. Documentation stating the need for the second attendant shall be from a physician, physician assistant, nurse midwife or nurse practitioner and shall explain the need for the attendant and be maintained by the transportation provider if the provider is not a common carrier. If the provider is a common carrier, the statement of need shall be maintained by the county or tribal agency or its designated agency authorizing the transportation. If the length of attendant care is over 4 weeks in duration, the department shall determine the necessary expenses for the attendant or attendants after the first 4 weeks and at 4-week intervals thereafter. In this subdivision, “attendant” means a person needed by the transportation provider to assist with tasks necessary in transporting the recipient and that cannot be done by the driver or a person traveling with the recipient in order to receive training in the care of the recipient, and “relative” means a parent, grandparent, grandchild, stepparent, spouse, son, daughter, stepson, stepdaughter, brother, sister, half-brother or half-sister, with this relationship either by consanguinity or direct affinity.

DHS 107.23(1)(d)5. 5. If a recipient for emergency reasons beyond that person’s control is unable to obtain the county or tribal agency’s or designee’s authorization for necessary transportation prior to the transportation, such as for a trip to a hospital emergency room on a weekend, the county or tribal agency or its designee may provide retroactive authorization. The county or tribal agency or its designee may require documentation from the medical service provider or the transportation provider, or both, to establish that the transportation was necessary.

DHS 107.23(2) (2) Services requiring prior authorization. The following covered services require prior authorization from the department:

DHS 107.23(2)(a) (a) All non-emergency transportation of a recipient by water ambulance to receive MA-covered services;

DHS 107.23(2)(b) (b) All non-emergency transportation of a recipient by fixed-wing air ambulance to receive MA-covered services;

DHS 107.23(2)(c) (c) All non-emergency transportation of a recipient by helicopter ambulance to receive MA-covered services;

DHS 107.23(2)(d) (d) Trips by ambulance to obtain physical therapy, occupational therapy, speech therapy, audiology services, chiropractic services, psychotherapy, methadone treatment, alcohol abuse treatment, other drug abuse treatment, mental health day treatment or podiatry services;

DHS 107.23(2)(e) (e) Trips by ambulance from nursing homes to dialysis centers; and

DHS 107.23(2)(f) (f) All SMV transportation to receive MA-covered services, except for services to be received out of state for which prior authorization has already been received, that is over 40 miles for a one-way trip in Brown, Dane, Fond du Lac, Kenosha, La Crosse, Manitowoc, Milwaukee, Outagamie, Sheboygan, Racine, Rock and Winnebago counties from a recipient’s residence, and 70 miles for a one-way trip in all other counties from a recipient’s residence.

DHS 107.23 Note Note: For more information on prior authorization, see s. DHS 107.02 (3).

DHS 107.23(3) (3) Limitations.

DHS 107.23(3)(a) (a) Ambulance transportation.

DHS 107.23(3)(a)1. 1. When a hospital-to-hospital or nursing home-to-nursing home non-emergency transfer is made by ambulance, the ambulance provider shall obtain, before the transfer, written certification from the recipient’s physician, physician assistant, nurse midwife or nurse practitioner explaining why the discharging institution was not an appropriate facility for the patient’s condition and the admitting institution is appropriate for that condition. The document shall be signed by the recipient’s physician, physician assistant, nurse midwife or nurse practitioner and shall include details of the recipient’s condition. This document shall be maintained by the ambulance provider.

DHS 107.23(3)(a)2. 2. If a recipient residing at home requires treatment at a nursing home, the transportation provider shall obtain a written statement from the provider who prescribed the treatment indicating that transportation by ambulance is necessary. The statement shall be maintained by the ambulance provider.

DHS 107.23(3)(a)3. 3. For other non-emergency transportation, the ambulance provider shall obtain documentation for the service signed by a physician, physician assistant, nurse midwife, dentist or nurse practitioner. The documentation shall include the recipient’s name, the date of transport, the details about the recipient’s condition that preclude transport by any other means, the specific circumstances requiring that the recipient be transported to the office or clinic to obtain a service, the services performed and an explanation of why the service could not be performed in the hospital, nursing home or recipient’s residence. Documentation of the physician, dentist, physician assistant, nurse midwife or nurse practitioner performing the service shall be signed and dated and shall be maintained by the ambulance provider. Any order received by the transportation provider by telephone shall be repeated in the form of written documentation within 10 working days of the telephone order or prior to the submission of the claim, whichever comes first.

DHS 107.23(3)(a)4. 4. Services of more than the 2 attendants required under s. 256.15 (4), Stats., are covered only if the recipient’s condition requires the physical presence of more than 2 attendants for purposes of restraint or lifting. Medical personnel not employed by the ambulance provider who care for the recipient in transit shall bill the program separately.

DHS 107.23(3)(a)5. 5.

DHS 107.23(3)(a)5.a. a. If a recipient is pronounced dead by a legally authorized person after an ambulance is requested but before the ambulance arrives at the pick-up site, emergency service only to the point of pick-up is covered.

DHS 107.23(3)(a)5.b. b. If ambulance service is provided to a recipient who is pronounced dead enroute to a hospital or dead on arrival at the hospital by a legally authorized person, the entire ambulance service is covered.

DHS 107.23(3)(a)6. 6. Ambulance reimbursement shall include payment for additional services provided by an ambulance provider such as for drugs used in transit or for starting intravenous solutions, EKG monitoring for infection control, charges for reusable devices and equipment, charges for sterilization of a vehicle including after carrying a recipient with a contagious disease, and additional charges for services provided at night or on weekends, or on holidays. Separate payments for these charges shall not be made.

DHS 107.23(3)(a)7. 7. Non-emergency transfers by ambulance that are for the convenience of the recipient or the recipient’s family are reimbursed only when the attending physician documents that the participation of the family in the recipient’s care is medically necessary and the recipient would suffer hardship if the transfer were not made by ambulance.

DHS 107.23(3)(b) (b) SMV transportation.

DHS 107.23(3)(b)1. 1. Transportation by SMV shall be covered only if the purpose of the trip is to receive an MA-covered service. Documentation of the name and address of the service provider shall be kept by the SMV provider. Any order received by the transportation provider by telephone shall be repeated in the form of written documentation within 10 working days of the telephone order or prior to the submission of the claim, whichever comes first.

DHS 107.23(3)(b)2. 2. Charges for waiting time are covered charges. Waiting time is allowable only when a to-and-return trip is being billed. Waiting time may only be charged for one recipient when the transportation provider or driver waits for more than one recipient at one location in close proximity to where the MA-covered services are provided and no other trips are made by the vehicle or driver while the service is provided to the recipient. In this subdivision, “waiting time” means time when the transportation provider is waiting for the recipient to receive MA covered services and return to the vehicle.

DHS 107.23(3)(b)3. 3. Services of a second SMV transportation attendant are covered only if the recipient’s condition requires the physical presence of another person for purposes of restraint or lifting. The transportation provider shall obtain a statement of the appropriateness of the second attendant from the physician, physician assistant, nurse midwife or nurse practitioner attesting to the need for the service and shall retain that statement.

DHS 107.23(3)(b)4. 4. SMV services may only be provided to recipients identified under sub. (1) (c).

DHS 107.23(3)(b)5. 5. A trip to a sheltered workshop or other nonmedical facility is covered only when the recipient is receiving an MA-covered service there on the dates of transportation and the medical services are of the level, intensity or extent consistent with the medical need defined in the recipient’s plan of care.

DHS 107.23(3)(b)6. 6. Trips to school for MA-covered services shall be covered only if the recipient is receiving services on the day of the trip under the Individuals with Disabilities Education Act, 20 USC 33, and the MA-covered services are identified in the recipient’s individual education plan and are delivered at the school.

DHS 107.23(3)(b)7. 7. Unloaded mileage as defined in sub. (1) (c) 5. is not reimbursed if there is any other passenger in the vehicle whether or not that passenger is an MA recipient.

DHS 107.23(3)(b)8. 8. When 2 or more recipients are being carried at the same time, the department may adjust the rates.

DHS 107.23(3)(b)9. 9. Additional charges for services at night or on weekends or holidays are not covered charges.

DHS 107.23(3)(b)10. 10. A recipient confined to a cot or stretcher may only be transported in an SMV if the vehicle is equipped with restraints which secure the cot or stretcher to the side and the floor of the vehicle. The recipient shall be medically stable and no monitoring or administration of non-emergency medical services or procedures may be done by SMV personnel.

DHS 107.23(3)(c) (c) County-approved or tribe-approved transportation.

DHS 107.23(3)(c)1. 1. Non-emergency transportation of a recipient by common carrier is subject to approval by the county or tribal agency or its designee before departure. The reimbursement shall be no more than an amount set by the department and shall be less per mile than the rates paid by the department for SMV purposes. Reimbursement for urgent transportation is subject to retroactive approval by the county or tribal agency or its designee.

DHS 107.23(3)(c)2. 2. The county or tribal agency or its designee shall reimburse the recipient or the vendor for transportation service only if the service is not provided directly by the county or tribal agency or its designee.

DHS 107.23(3)(c)3. 3. Transportation provided by a county or tribal agency or its designee shall involve the least costly means of transportation which the recipient is capable of using and which is reasonably available at the time the service is required. Reimbursement to the recipient shall be limited to mileage to the nearest MA provider who can provide the service if the recipient has reasonable access to health care of adequate quality from that provider. Reimbursement shall be made in the most cost-effective manner possible and only after sources for free transportation such as family and friends have been exhausted.

DHS 107.23(3)(c)4. 4. The county or tribal agency or its designee may require documentation by the service provider that an MA-covered service was received at the specific location.

DHS 107.23(3)(c)5. 5. No provider may be reimbursed more for transportation provided for an MA recipient than the provider’s usual and customary charge. In this subdivision, “usual and customary charge” means the amount the provider charges or advertises as a charge for transportation except to county or tribal agencies or non-profit agencies.

DHS 107.23(4) (4) Non-covered services. The following transportation services and charges related to transportation services are non-covered services:

DHS 107.23(4)(a) (a) Emergency transportation of a recipient who is pronounced dead by a legally authorized person before the ambulance is called;

DHS 107.23(4)(b) (b) Transportation of a recipient’s personal belongings only;

DHS 107.23(4)(c) (c) Transportation of a laboratory specimen only;

DHS 107.23(4)(d) (d) Charges for excess mileage resulting from the use of indirect routes to and from destinations;

DHS 107.23(4)(e) (e) Transport of a recipient’s relatives other than as provided in sub. (1) (d) 4.;

DHS 107.23(4)(f) (f) SMV transport provided by the recipient or a relative, as defined in sub. (1) (d) 4., of the recipient;

DHS 107.23(4)(g) (g) SMV transport of an ambulatory recipient, except an ambulatory recipient under sub. (1) (c) 1., to a methadone clinic or physician’s clinic solely to obtain methadone or related services such as drug counseling or urinalysis;

DHS 107.23(4)(h) (h) Transportation by SMV to a pharmacy to have a prescription filled or refilled or to pick up medication or disposable medical supplies;

DHS 107.23(4)(i) (i) Transportation by SMV provided solely to compel a recipient to attend therapy, counseling or any other MA-covered appointment; and

DHS 107.23(4)(j) (j) Transportation to any location where no MA-covered service was provided either at the destination or pick-up point.

DHS 107.23 Note Note: For more information on non-covered services, see s. DHS 107.03.

DHS 107.23 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (1) (c) and (4) (5), Register, February, 1988, No. 386, eff. 3-1-88; r. and recr., Register, November, 1994, No. 467, eff. 12-1-94; correction in (3) (a) 4. made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 107.24 DHS 107.24 Durable medical equipment and medical supplies.

DHS 107.24(1) (1) Definition. In this section:

DHS 107.24(1)(a) (a) “Medical supplies” means disposable, consumable, expendable or nondurable medically necessary supplies which have a very limited life expectancy. Examples are plastic bed pans, catheters, electric pads, hypodermic needles, syringes, continence pads and oxygen administration circuits.

DHS 107.24(1)(b) (b) “Qualified health care professional” means any of the following:

DHS 107.24(1)(b)1. 1. A physician or physician assistant licensed under subch. II of ch. 448, Stats.

DHS 107.24(1)(b)2. 2. A physical therapist licensed under subch. III of ch. 448, Stats.

DHS 107.24(1)(b)3. 3. An occupational therapist licensed under subch. VII of ch. 448, Stats.

DHS 107.24(1)(b)4. 4. A chiropractor licensed under ch. 446, Stats.

DHS 107.24(2) (2) Covered services.

DHS 107.24(2)(a) (a) Prescription and provision.

DHS 107.24(2)(a)1. 1. Durable medical equipment (DME) and medical supplies, excluding complex rehabilitation technology identified in subd. 2., are covered services only when prescribed by a physician and when provided by a certified physician, clinic, hospital outpatient department, nursing home, pharmacy, home health agency, therapist, orthotist, prosthetist, hearing instrument specialist or medical equipment vendor.

DHS 107.24(2)(a)2. 2. Complex rehabilitation manual wheelchairs, power wheelchairs, and other seating components identified in the Wisconsin DME and medical supplies indices are covered services only when prescribed by a physician and when provided by a qualified complex rehabilitation technology supplier.

DHS 107.24(2)(b) (b) Items covered. Covered services are limited to items contained in the Wisconsin durable medical equipment (DME) and medical supplies indices. Items prescribed by a physician which are not contained in one of these indices or in the listing of non-covered services in sub. (5) require submittal of a DME additional request. Should the item be deemed covered, a prior authorization request may be required.

DHS 107.24(2)(c) (c) Categories of durable medical equipment. The following are categories of durable medical equipment covered by MA:

DHS 107.24(2)(c)1. 1. Occupational therapy assistive or adaptive equipment. This is medical equipment used to assist a person with a disability to adapt to the environment or achieve independence in performing daily personal functions. Examples are adaptive hygiene equipment, adaptive positioning equipment and adaptive eating utensils.

DHS 107.24(2)(c)2. 2. Orthopedic or corrective shoes. These are any shoes attached to a brace for prosthesis; mismatched shoes involving a difference of a full size or more; or shoes that are modified to take into account discrepancy in limb length or a rigid foot deformation. Arch supports are not considered a brace. Examples of orthopedic or corrective shoes are supinator and pronator shoes, surgical shoes for braces, and custom-molded shoes.

DHS 107.24(2)(c)3. 3. Orthoses. These are devices which limit or assist motion of any segment of the human body. They are designed to stabilize a weakened part or correct a structural problem. Examples are arm braces and leg braces.

DHS 107.24(2)(c)4. 4. Other home health care durable medical equipment. This is medical equipment used to increase the independence of a person with a disability or modify certain disabling conditions. Examples are patient lifts, hospital beds and traction equipment.

DHS 107.24(2)(c)5. 5. Oxygen therapy equipment. This is medical equipment used for the administration of oxygen or medical formulas or to assist with respiratory functions. Examples are a nebulizer, a respirator and a liquid oxygen system.

DHS 107.24(2)(c)6. 6. Physical therapy splinting or adaptive equipment. This is medical equipment used to assist a person with a disability to achieve independence in performing daily activities. Examples are splints and positioning equipment.

DHS 107.24(2)(c)7. 7. Prostheses. These are devices which replace all or part of a body organ to prevent or correct a physical disability or malfunction. Examples are artificial arms, artificial legs and hearing aids.

DHS 107.24(2)(c)8. 8. Wheelchairs. These are chairs mounted on wheels usually specially designed to accommodate individual disabilities and provide mobility. Examples are a standard weight wheelchair, a lightweight wheelchair and an electrically-powered wheelchair.

DHS 107.24(2)(c)9. 9. Complex rehabilitation technology. These are items identified in the Wisconsin DME and medical supplies indices which are updated to comply with s. 49.45 (9r) (a) 2., Stats.

DHS 107.24(2)(d) (d) Categories of medical supplies. Only approved items within the following generic categories of medical supplies are covered:

DHS 107.24(2)(d)1. 1. Colostomy, urostomy and ileostomy appliances;

DHS 107.24(2)(d)2. 2. Contraceptive supplies;

DHS 107.24(2)(d)3. 3. Diabetic urine and blood testing supplies;

DHS 107.24(2)(d)4. 4. Dressings;

DHS 107.24(2)(d)5. 5. Gastric feeding sets and supplies;

DHS 107.24(2)(d)6. 6. Hearing aid or other assistive listening devices batteries;

DHS 107.24(2)(d)7. 7. Incontinence supplies, catheters and irrigation apparatus;

DHS 107.24(2)(d)8. 8. Parenteral-administered apparatus; and

DHS 107.24(2)(d)9. 9. Tracheostomy and endotracheal care supplies.

DHS 107.24(3) (3) Services requiring prior authorization. All of the following services require prior authorization:

DHS 107.24(3)(a) (a) Purchase of all items indicated as requiring prior authorization in the Wisconsin DME and medical supplies indices, published periodically and distributed to appropriate providers by the department.

DHS 107.24(3)(b) (b) Repair or modification of an item which exceeds the department-established maximum reimbursement without prior authorization. Reimbursement parameters are published periodically in the DME and medical supplies provider handbook.