DHS 107.08(3)(c)2.2. If a hospital is certified and reimbursed as a type of provider other than a hospital, the hospital is subject to all coverage and reimbursement requirements for that type of provider.
DHS 107.08(3)(c)3.3. On any given calendar day a patient in a hospital shall be considered either an inpatient or an outpatient, but not both. Emergency room services shall be considered outpatient services unless the patient is admitted as an inpatient and counted on the midnight census. Patients who are same day admission and discharge patients and who die before the midnight census shall be considered inpatients.
DHS 107.08(3)(c)4.4. All covered services provided during an inpatient stay, except professional services which are separately billed, shall be considered hospital inpatient services.
DHS 107.08(4)(4)Non-covered services.
DHS 107.08(4)(a)(a) The following services are not covered hospital services:
DHS 107.08(4)(a)1.1. Unnecessary or inappropriate inpatient admissions or portions of a stay;
DHS 107.08(4)(a)2.2. Hospitalizations or portions of hospitalizations disallowed by the PRO;
DHS 107.08(4)(a)3.3. Hospitalizations either for or resulting in surgeries which the department views as experimental due to questionable or unproven medical effectiveness;
DHS 107.08(4)(a)4.4. Inpatient services and outpatient services for the same patient on the same date of service unless the patient is admitted to a hospital other than the facility providing the outpatient care;
DHS 107.08(4)(a)5.5. Hospital admissions on Friday or Saturday, except for emergencies, accident or accident care and obstetrical cases, unless the hospital can demonstrate to the satisfaction of the department that the hospital provides all of its services 7 days a week; and
DHS 107.08(4)(a)6.6. Hospital laboratory, diagnostic, radiology and imaging tests not ordered by a physician, except in emergencies;
DHS 107.08(4)(b)(b) Neither MA nor the recipient may be held responsible for charges or services identified in par. (a) as non-covered, except that a recipient may be billed for charges under par. (a) 3. or 5., if the recipient was notified in writing in advance of the hospital stay that the service was not a covered service.
DHS 107.08(4)(c)(c) If hospital services for a patient are no longer medically necessary and an appropriate alternative care setting is available but the patient refuses discharge, the patient may be billed for continued services if he or she receives written notification prior to the time medically unnecessary services are provided.
DHS 107.08(4)(d)(d) The following professional services are not covered as part of a hospital inpatient claim but shall be billed by an appropriately certified MA provider;
DHS 107.08(4)(d)1.1. Services of physicians, including pathologists, radiologists and the professional-billed component of laboratory and radiology or imaging services, except that services by physician intern and residents services are included as hospital services;
DHS 107.08(4)(d)2.2. Services of psychiatrists and psychologists, except when performing group therapy and medication management, including services provided to a hospital inpatient when billed by a hospital, clinic or other mental health or AODA provider;
DHS 107.08(4)(d)3.3. Services of podiatrists;
DHS 107.08(4)(d)4.4. Services of physician assistants;
DHS 107.08(4)(d)5.5. Services of nurse midwives, nurse practitioners and independent nurses when functioning as independent providers;
DHS 107.08(4)(d)6.6. Services of certified registered nurse anesthetists;
DHS 107.08(4)(d)7.7. Services of anesthesia assistants;
DHS 107.08(4)(d)8.8. Services of chiropractors;
DHS 107.08(4)(d)9.9. Services of dentists;
DHS 107.08(4)(d)10.10. Services of optometrists;
DHS 107.08(4)(d)11.11. Services of hearing aid dealers [instrument specialist];
DHS 107.08(4)(d)12.12. Services of audiologists;
DHS 107.08(4)(d)13.13. Any of the following provided on the date of discharge for home use:
DHS 107.08(4)(d)13.a.a. Drugs;
DHS 107.08(4)(d)13.b.b. Durable medical equipment; or