DHS 106.03(7)(a)2.c.c. In the case of prior authorization or pre-certification requests, claims or demand bills which are returned or rejected, in whole or in part, by the payer for non-compliance with preparation or submission requirements of medicare or the other health care plan, the provider shall promptly correct and properly resubmit the prior authorization or pre-certification request, claim or demand bill, as applicable to the payer.

DHS 106.03(7)(b)(b) Before submitting a claim to MA for the same services, a provider shall properly seek payment for the services provided to an MA recipient from medicare or, except as provided in par. (g), another health care plan if the recipient is eligible for services under medicare or the other health care plan.

DHS 106.03(7)(c)(c) When benefits from medicare, another health care plan or other third party payer have been paid or are expected to be paid, in whole or in part, to either the provider or the recipient, the provider shall accurately identify the amount of the benefit payment from medicare, other health care plan or other third party payer on or with the bill to MA, consistent with the department’s claims preparation, claims submission, cost avoidance and post-payment recovery instructions under s. DHS 108.02 (4). The amount of the medicare, health care plan or other third party payer reimbursement shall reduce the MA payment amount.

DHS 106.03(7)(d)(d) If medicare or another health care plan makes payment to the recipient or to another person on behalf of the recipient, the provider may bill the payee for the amount of the benefit payment and may take any necessary legal action to collect the amount of the benefit payment from the payee, notwithstanding the provisions set forth in ss. DHS 104.01 (12) and 106.04 (3).

DHS 106.03(7)(e)(e) The provider shall bill medicare or another health care plan for services provided to a recipient in accordance with the claims preparation, claims submission and prior authorization instructions issued by the department under s. DHS 108.02 (4). The provider shall also comply with the instructions issued by the department under s. DHS 108.02 (4) with respect to cost avoidance and post-payment recovery from medicare and other health care plans.

DHS 106.03(7)(f)(f) If, after the provider properly seeks payment, medicare or another provider may submit a claim to MA for the unpaid service, except as provided in par. (k). The provider shall retain all evidence of claims for reimbursement, settlements and denials resulting from claims submitted to medicare and other health care plans.

DHS 106.03(7)(g)(g) If eligibility for a health care plan other than medicare is indicated on the recipient’s MA identification card and billing against that plan is not required by par. (e), the provider may bill either MA or the indicated health care plan, but not both, for the services provided, as follows:

DHS 106.03(7)(g)1.1. If the provider elects to bill the health care plan, the provider shall properly seek payment from the health care plan. A claim may not be submitted to MA until the health care plan pays part of or denies the original claim or 45 days have elapsed with no response from the health care plan; and

DHS 106.03(7)(h)(h) In the event a provider receives a payment first from MA and then from medicare, another health care plan or another third party payer for the same service, the provider shall, within 30 days after receipt of the second and any subsequent payment, refund to MA the MA payment or the payment from medicare, the health care plan or other third party, whichever is less.

DHS 106.03(7)(i)(i) Before billing MA for services provided to any recipient who is also a medicare beneficiary, a medicare-certified provider shall accept medicare assignment and shall properly seek payment from medicare for services covered under the medicare program. In filing claims or demand bills with medicare, a provider shall adhere to the requirements for properly seeking payment as defined under par. (a) 2. and to the instructions issued by the department under s. DHS 108.02 (4) relating to claims preparation, claims submission, prior authorization, cost-avoidance and post-payment recovery.

DHS 106.03(7)(j)(j) If another health care plan, other than medicare, provides coverage for services provided for an MA recipient and the provider has the required billing information, including any applicable assignment of benefits, the provider shall properly seek payment from the health care plan, except as provided in par. (g), and receive a response from that plan prior to billing MA unless 45 days have elapsed with no response from the health care plan, after which the provider may bill MA. This requirement does not apply to a managed health care plan as defined in par. (k).

DHS 106.03(7)(k)(k) A provider authorized to provide services to a recipient under a managed health care plan other than MA, who receives a referral for services from the recipient’s managed health care plan or provides emergency services for a recipient in a managed health care plan, shall properly seek payment from that managed health care plan before billing MA. A provider who does not participate in a managed health care plan, other than MA, that provides coverage to the recipient but who provides services covered by the plan may not bill MA for the services. In this paragraph, “managed health care plan” means a health maintenance organization, preferred provider organization or similarly organized health care plan.

DHS 106.03(8)(8) Personal injury and workers compensation claims. If a provider treats a recipient for injuries or illness sustained in an event for which liability may be contested or during the course of employment, the provider may elect to bill MA for services provided without regard to the possible liability of another party or the employer. The provider may alternatively elect to seek payment by joining in the recipient’s personal injury claim or workers compensation claim, but in no event may the provider seek payment from both MA and a personal injury or workers compensation claim. Once a provider accepts the MA payment for services provided to the recipient, the provider shall not seek or accept payment from the recipient’s personal injury or workers compensation claim.

DHS 106.03 HistoryHistory: Cr. Register, December, 1979, No. 288, eff. 2-1-80; am. Register, February, 1986, No. 362, eff. 3-1-86; renum. (3) to be (3) (a), cr. (3) (b), Register, February, 1988, No. 386, eff. 3-1-88; emerg. am. (3) (a), eff. 11-1-90; emerg. cr. (5) (br), eff. 1-1-91; am. (3) (a), Register, May, 1991, No. 425, eff. 6-1-91; cr. (5) (br), Register, September, 1991, No. 429, eff. 10-1-91; emerg. r. and recr. (1) to (3) and (7), cr. (8), eff. 7-1-92; r. and recr. (1) to (3) and (7), cr. (8), Register, February, 1993, No. 446, eff. 3-1-93; corrections in (2) (a), (d), (7) (c), (d), (e) and (i) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; republished to reinsert inadvertently deleted text in (2) (c) Register January 2014 No. 697; EmR2306: emerg. cr. (2m), eff. 5-1-23; CR 23-045: cr. (2m) Register January 2024 No. 817, eff. 2-1-24.

DHS 106.04(1)(a)(a) Timeliness of payment. The department shall reimburse a provider for a properly provided covered service according to the provider payment schedule entitled “terms of provider reimbursement,” found in the appropriate MA provider handbook distributed by the department. The department shall issue payment on claims for covered services, properly completed and submitted by the provider, in a timely manner. Payment shall be issued on at least 95% of these claims within 30 days of claim receipt, on at least 99% of these claims within 90 days of claim receipt, and on 100% of these claims within 180 days of receipt. The department may not consider the amount of the claim in processing claims under this subsection.

DHS 106.04(1)(b)1.1. If a claim for payment under medicare has been filed in a timely manner, the department may pay a MA claim relating to the same services within 6 months after the department or the provider receives notice of the disposition of the medicare claims;

DHS 106.04(1)(b)2.2. The department may make payments at any time in accordance with a court order, or to carry out hearing decisions or department corrective actions taken to resolve a dispute; or

DHS 106.04(1)(b)3.3. The department may issue payments in accordance with waiver provisions if it has obtained a waiver from the federal health care financing administration under 42 CFR 447.45 (e).

DHS 106.04(1m)(b)(b) Automated claims processing. Except as provided in par. (c), payment of provider claims for reimbursement for services provided to recipients shall be made through the department’s automated claims processing system.

DHS 106.04(1m)(c)(c) Manual partial payment. The department may pay up to 75% of the reimbursable amount of a provider’s claim in advance of payments made through the automated claims processing system if all the following conditions exist:

DHS 106.04(1m)(c)1.1. The provider requests a manual partial payment and is informed that the payment will be automatically recouped when the provider’s claims are later processed through the automated claims processing system;