DHS 10.41 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 22-026: am. (2) Register May 2023 No. 809, eff. 6-1-23; EmR2306: emerg. am. (2), eff. 5-1-23; CR 23-045: am. (2) Register January 2024 No. 817, eff. 2-1-24; correction in (2) made under s. 35.17, Stats., Register January 2024 No. 817.

DHS 10.42 DHS 10.42 Certification and contracting.

DHS 10.42(1) (1) No entity may receive payment of funds for the family care benefit as a care management organization unless it is certified by the department as meeting all of the requirements of s. 46.284, Stats., and this chapter and is under contract with the department.

DHS 10.42(2) (2) 

DHS 10.42(2)(a) (a) To obtain and retain certification, an organization shall submit all information and documentation required by the department, in a format prescribed by the department. The department shall review and make a determination on the application within 90 calendar days of receipt of a complete application containing complete and accurate supporting documentation that the organization meets the standards under s. DHS 10.43. The department may conduct any necessary investigation to verify that the information submitted by the organization is accurate. The organization shall consent to disclosure by any third party of information the department determines is necessary to review the application.

DHS 10.42(2)(am) (am) For initial certifications, or when a currently certified organization will provide or arrange for the provision of services to new eligibility groups, the organization shall submit to an onsite readiness review which will assess all of the following:

DHS 10.42(2)(am)1. 1. Operations and administration, including all of the following:

DHS 10.42(2)(am)1.a. a. Administrative staffing and resources.

DHS 10.42(2)(am)1.b. b. Delegation and oversight of entity responsibilities.

DHS 10.42(2)(am)1.c. c. Enrollee and provider communications.

DHS 10.42(2)(am)1.d. d. Grievance and appeals.

DHS 10.42(2)(am)1.e. e. Member services and outreach.

DHS 10.42(2)(am)1.f. f. Provider network management.

DHS 10.42(2)(am)1.g. g. Program integrity compliance.

DHS 10.42(2)(am)2. 2. Service delivery, including all of the following:

DHS 10.42(2)(am)2.a. a. Case management/care coordination/service planning.

DHS 10.42(2)(am)2.b. b. Quality improvement.

DHS 10.42(2)(am)2.c. c. Utilization review.

DHS 10.42(2)(am)3. 3. Financial management, including all of the following:

DHS 10.42(2)(am)3.a. a. Financial reporting and monitoring.

DHS 10.42(2)(am)3.b. b. Financial solvency.

DHS 10.42(2)(am)4. 4. Systems management, including all of the following:

DHS 10.42(2)(am)4.a. a. Claims management.

DHS 10.42(2)(am)4.b. b. Encounter data and enrollment information management.

DHS 10.42(2)(b) (b) If the department denies CMO certification for the organization, the department shall provide written notice to the organization that clearly states the reasons for the denial and describes the manner by which the organization may appeal the department’s decision.

DHS 10.42(3) (3) If an organization applying to operate a CMO meets standards for certification under s. 46.284 (2) and (3), Stats., and s. DHS 10.43, the department shall certify the organization as meeting the requirements. Certification by the department does not bind the department to contracting with the organization to operate a CMO. The department may contract with a certified organization to operate a CMO only if all of the following apply:

DHS 10.42(3)(c) (c) The department has determined that the organization’s services are needed to provide sufficient access to the family care benefit for eligible individuals.

DHS 10.42(3)(d) (d) Before January 1, 2003, the organization is a county or a family care district, unless the governing body of a tribe or band or the Great Lakes inter–tribal council, inc., elects to operate a care management organization within the area and is certified under sub. (2).

DHS 10.42(3)(e) (e) After December 31, 2002, and before January 1, 2004, the organization is a county or a family care district unless any of the following applies: