DHS 106.11(1)(1) Health care review committees. The department shall establish committees of qualified health care professionals to evaluate and review the appropriateness, quality and quantity of services furnished recipients. DHS 106.11(2)(2) Referral of aberrant practices. If the department has cause to suspect that a provider is prescribing or providing services which are not necessary for recipients, are in excess of the medical needs of recipients, or do not conform to applicable professional practice standards, the department shall, before issuing payment for the claims, refer the claims to the appropriate health care review committee established under sub. (1). The committee shall review and evaluate the medical necessity, appropriateness and propriety of the services for which payment is claimed. The decision to deny or issue the payment for the claims shall take into consideration the findings and recommendation of the committee. DHS 106.11(3)(3) Withdrawal of review committee members for conflict of interest. No individual member of a health care review committee established under sub. (1) may participate in a review and evaluation contemplated in sub. (2) if the individual has been directly involved in the treatment of recipients who are the subject of the claims under review or if the individual is financially or contractually related to the provider under review or if the individual is employed by the provider under review. DHS 106.11(4)(4) Provider notification of prepayment review. A provider shall be notified by the department of the institution of the pre-payment review process under sub. (2). Payment shall be issued or denied, following review by a health care review committee, within 60 days of the date on which the claims were submitted to the fiscal agent by the provider. DHS 106.11(5)(5) Application of sanction. If a health care review committee established under sub. (1) finds that a provider has delivered services that are inappropriate or not medically necessary, the department may require the provider to request and receive from the department authorization prior to the delivery of any service under the program. DHS 106.11 HistoryHistory: Cr. Register, December, 1979, No. 288, eff. 2-1-80; am. Register, February, 1986, No. 362, eff. 3-1-86; renum. from HSS 106.09, Register, February, 1993, No. 446, eff. 3-1-93. DHS 106.12DHS 106.12 Procedure, pleadings and practice. DHS 106.12(1)(1) Scope. The provisions of this section shall govern the following administrative actions by the department: DHS 106.12(1)(c)(c) Any action or inaction for which due process is otherwise required under s. 227.42, Stats. DHS 106.12(1m)(1m) Application. The provisions of this section do not apply to either of the following: DHS 106.12(1m)(a)(a) Hearings to contest recoveries by the department of overpayments to providers. Requests for hearings and hearings under these circumstances are governed exclusively by s. DHS 108.02 (9) (e); or DHS 106.12(1m)(b)(b) Contests by providers of the propriety of the amount of payment received from the department, including contests of claim payment denials. The exclusive procedure for these contests is as provided in s. DHS 106.03 (3) (b) 5, except as may be provided under the terms of the applicable provider agreement, pursuant to s. 49.45 (2) (a) 9., Stats. DHS 106.12(2)(2) Due process. The department shall assure due process in implementing any action described in sub. (1) by providing written notice, a fair hearing and written decision pursuant to s. 49.45 (2) (a) 14., Stats., or as otherwise required by law. In addition to any provisions of this section, the procedures implementing a fair hearing and a written decision shall comply with the provisions of ch. 227, Stats. DHS 106.12(3)(3) Written notice. The department shall begin actions described under sub. (1) by serving upon the provider written notice of the intended action or written notice of the action. Notice of intended action described under sub. (1) (a) and (b) shall include the following: DHS 106.12(3)(a)(a) A brief and plain statement specifying the nature of and identifying the statute, regulation or rule giving the department the authority to initiate the action; DHS 106.12(3)(b)(b) A short and plain statement identifying the nature of the transactions, occurrences or events which served as the basis for initiating the action; and DHS 106.12(3)(c)(c) A statement advising the provider of the right to a hearing and the procedure for requesting a hearing. DHS 106.12(4)(4) Request for hearing. A provider desiring to contest a departmental action or inaction under sub. (1) may request a hearing on any matter contested. The request shall be in writing and shall: DHS 106.12(4)(a)(a) Be served upon the department of administration’s division of hearings and appeals unless otherwise directed by the secretary; DHS 106.12(4)(b)(b) For requests for hearings on actions or intended actions by the department, be served within 15 days of the date of service of the department’s notice of intended action or notice of action; DHS 106.12(4)(c)(c) For requests for hearings on inactions by the department, be served within 60 days from the date the provider first became aware of, or should have become aware of with the exercise of reasonable diligence, the cause of the appeal; DHS 106.12(4)(d)(d) Contain a brief and plain statement identifying every matter or issue contested; and DHS 106.12(4)(e)(e) Contain a brief and plain statement of any new matter which the provider believes constitutes a defense or mitigating factor with respect to non-compliance alleged in the notice of action. DHS 106.12 NoteNote: Hearing requests should be sent to the Division of Hearings and Appeals, P.O. Box 7875, Madison, WI 53707.
DHS 106.12(5)(a)(a) Except as provided under par. (b), if no request for a hearing is timely filed, no action described in sub. (1) (a) and (b) may be taken by the department until 15 days after the notice of intended action has been served. Except as provided under par. (b), if a request for a hearing has been timely filed, no action described in sub. (1) (a) or (b) may be taken by the department until the hearing examiner issues a final decision. DHS 106.12(5)(b)(b) Actions described under sub. (1) (a) and (b) may be taken against a provider 15 days after service of the notice of intended action and without a prior hearing when the action is initiated by the department under s. DHS 106.06 (4), (5), (6), (8) or (28). If the provider prevails at the hearing, the provider shall be reinstated retroactive to the date of de-certification or suspension.