DHS 106.03(3)(b)3.3. To ensure that submissions are correct and there is appropriate follow-up of all claims, providers shall follow the claims preparation and submission instructions in provider handbooks and bulletins issued by the department.

DHS 106.03(3)(b)4.4. If a claim was originally denied or incorrectly paid because of an error on the recipient eligibility file, an incorrect HMO designation, an incorrect nursing home level of care authorization or nursing home patient liability amount, the department may pay a correct and complete claim or adjustment only if the original claim was received by the department’s fiscal agent within 365 days after the date of service and the resubmission or adjustment is received by the department’s fiscal agent within 455 days after the date of service.

DHS 106.03(3)(b)5.5. If a provider contests the propriety of the amount of payment received from the department for services claimed, the provider shall notify the fiscal agent of its concerns, requesting reconsideration and payment adjustment. All submissions of claims payment adjustments shall be made within 365 days from the date of service, except as provided in subd. 4. and par. (c). The fiscal agent shall, within 45 days of receipt of the request, respond in writing and advise what, if any, payment adjustment will be made. The fiscal agent’s response shall identify the basis for approval or denial of the payment adjustment requested by the provider. This action shall constitute final departmental action with respect to payment of the claim in question.

DHS 106.03(3)(c)1.1. If a claim was initially processed or paid and the department subsequently initiates an adjustment to increase a rate or payment or to correct an initial processing error of the department’s fiscal agent, the department may pay a correct and complete claim or adjustment only if the provider submits a request for an adjustment or claim and that request or claim is received by the department’s fiscal agent within 90 days after the adjustment initiated by the department;

DHS 106.03(3)(c)2.2.

DHS 106.03(3)(c)2.a.a. If a claim for payment under medicare has been filed with medicare within 365 days after the date of service, the department may pay a claim relating to the same service only if a correct and complete claim is received by the fiscal agent within 90 days after the disposition of the medicare claim;

DHS 106.03(3)(c)2.b.b. If medicare or private health insurance reconsiders its initial payment and requests recoupment of a previous payment, the department may pay a correct and complete request for an adjustment which is received within 90 days after the notice of recoupment;

DHS 106.03(3)(c)3.3. If a claim for payment cannot be filed in a timely manner due to a delay in the determination of a recipient’s retroactive eligibility under s. 49.46 (1) (b), Stats., the department may pay a correct and complete claim only if the claim is received by the fiscal agent within 180 days after mailing of the backdated MA identification card to the recipient; and

DHS 106.03(3)(c)4.4. The department may make a payment at any time in accordance with a court order or to carry out a hearing decision or department-initiated corrective action taken to resolve a dispute. To request payment the provider shall submit a correct and complete claim to the department’s fiscal agent within 90 days after mailing of a notice by the department or the court of the court order, hearing decision or corrective action to the provider or recipient.

DHS 106.03(4)(4) Health care services requiring prior authorization. No payment may be made on a claim for service requiring prior authorization if written prior authorization was not requested and received by the provider prior to the date of service delivery, except that claims that would ordinarily be rejected due to lack of the provider’s timely receipt of prior authorization may be paid under the following circumstances:

DHS 106.03(4)(a)(a) Where the provider’s initial request for prior authorization was denied and the denial was either rescinded in writing by the department or overruled by an administrative or judicial order;

DHS 106.03(4)(b)(b) Where the service requiring prior authorization was provided before the recipient became eligible, and the provider applies to and receives from the department retroactive authorization for the service; or

DHS 106.03(4)(c)(c) Where time is of the essence in providing a service which requires prior authorization, and verbal authorization is obtained by the provider from the department’s medical consultant or designee. To ensure payment on claims for verbally-authorized services, the provider shall retain records which show the time and date of the authorization and the identity of the individual who gave the authorization, and shall follow-up with a written authorization request form attaching documentation pertinent to the verbal authorization.

DHS 106.03(5)(a)(a) Eligible providers. Payment for a service shall be made directly to the provider furnishing the service or to the provider organization which provides or arranges for the availability of the service on a prepayment basis, except that payment may be made:

DHS 106.03(5)(a)1.1. To the employer of an individual provider if the provider is required as a condition of employment to turn over fees derived from the service to the employer or to a facility; or

DHS 106.03(5)(a)2.2. To a facility if a service was provided in a hospital, clinic or other facility, and there exists a contractual agreement between the individual provider and the facility, under which the facility prepares and submits the claim for reimbursement for the service provided by the individual provider.

DHS 106.03(5)(b)(b) Facility contracting with providers. An employer or facility submitting claims for services provided by a provider in its employ or under contract as provided in par. (a) shall apply for and receive certification from the department to submit claims and receive payment on behalf of the provider performing the services. Any claim submitted by an employer or facility so authorized shall identify the provider number of the individual provider who actually provided the service or item that is the subject of the claim.

DHS 106.03(5)(br)(br) Providers of professional services to hospital inpatients. Notwithstanding pars. (a) and (b), in the case of a provider performing professional services to hospital inpatients, payment shall be made directly to the provider or to the hospital if it is separately certified to be reimbursed for the same professional services.

DHS 106.03(5)(c)(c) Prohibited payments. No payment which under par. (a) (intro.) is made directly to an individual provider or provider organization may be made to anyone else under a reassignment or power of attorney except to an employer or facility under par. (a) 1. or 2., but nothing in this paragraph shall be construed:

DHS 106.03(5)(c)1.1. To prevent making the payment in accordance with an assignment from the person or institution providing the service if the service is made to a governmental agency or entity or is established by or pursuant to the order of a court of competent jurisdiction; or

DHS 106.03(5)(c)2.2. To preclude an agent of the provider from receiving any payment if the agent does so pursuant to an agency agreement under which the compensation to be paid to the agent for services in connection with the billing or collection of payments due the person or institution under the program is unrelated, directly or indirectly, to the amount of payments or the claims for them, and is not dependent upon the actual collection of the payment.

DHS 106.03(6)(6) Assignment of medicare part B benefits. A provider providing a covered service to a dual entitlee shall accept assignment of the recipient’s part B medicare benefits if the service provided is, in whole or in part, reimbursable under medicare part B coverage. All services provided to dual entitlees which are reimbursable under medicare part B shall be billed to medicare. In this subsection,“dual entitlee” means an MA recipient who is also eligible to receive part B benefits under medicare.

DHS 106.03(7)(a)1.1. “Health care plan” means a plan or policy which provides coverage of health services, regardless of the nature and extent of coverage or reimbursement, including an indemnity health insurance plan, a health maintenance organization, a health insuring organization, a preferred provider organization or any other third party payer of health care.

DHS 106.03(7)(a)2.2. “Properly seek payment” means taking the following actions:

DHS 106.03(7)(a)2.a.a. When required by the payer as a condition for payment for the particular service, the provider shall request prior authorization or pre-certification from medicare or the other health care plan, except in the case of emergency services. This includes following the preparation and submission requirements of the payer and ensuring that the information provided to the payer is truthful, timely, complete and accurate. Prior authorization or pre-certification means a process and procedures established by medicare or the other health care plan which involve requiring the review or approval by the payer or its agent prior to the provision of a service in order for the service to be considered for payment;