DHS 106.02 NoteNote: Dental hygienists are encouraged to work with dentists, when available, to assist in these programs.
DHS 106.02(12)(a)2.2. An MA certified dental hygienist and any entity who employs or contracts with a MA certified dental hygienist under s. 447.06 (2) (a) 2., 3., and 5., Stats., or that uses the volunteer services of an MA certified dental hygienist shall maintain written documentation of all of the following: DHS 106.02(12)(a)2.b.b. Any referral of a patient who has a condition that cannot be treated within the dental hygienist scope of practice as defined under s. 447.03, Stats., to a private dental practice; a federally qualified health center that provide dental services; a rural dental health clinic; a college or university that provides dental diagnostic and clinical services; or any other dental entity that employs, contracts with, or is under the supervision of a licensed dentist. DHS 106.02(12)(a)2.c.c. Consultation with a licensed dentist in a private dental practice; a federally qualified health center that provide dental services; a rural dental health clinic; a college or university that provides dental diagnostic and clinical services; or any other entity that employs, contracts with, or is under the supervision of a licensed dentist. DHS 106.02(12)(b)(b) Compliance with this subsection is subject to audit by the department and the legislature. DHS 106.02 HistoryHistory: Cr. Register, December, 1979, No. 288, eff. 2-1-80; am. Register, February, 1986, No. 362, eff. 3-1-86; emerg. r. and recr. (9), eff. 7-1-92; r. and recr. (9), cr. (11), Register, February, 1993, No. 446, eff. 3-1-93; correction made in (10) under s. 13.93 (2m) (b) 7., Stats., Register, June, 1994, No. 462; CR 05-033: cr. (12) Register August 2006 No. 608, eff. 9-1-06; corrections in (1), (2), (7), (9) (e) 3., 5., (f), (g) and (11) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 20-068: am. (10) Register December 2021 No. 792, eff. 1-1-22; CR 22-043: am. (9) (b) (intro.), 1. to 7., cr. (9) (b) 9. Register May 2023 No. 809, eff. 6-1-23. DHS 106.03DHS 106.03 Manner of preparing and submitting claims for reimbursement. DHS 106.03(1)(a)(a) In this subsection, “billing service” means a provider or an entity under contract to a provider which provides electronic media billing or electronic billing transmission for one or more providers. DHS 106.03(1)(b)(b) A provider shall use claim forms prescribed or furnished by the department, except that a provider may submit claims by electronic media or electronic transmission if the provider or billing service is approved by the department for electronic claims submission. A billing service shall be approved in writing by the department based on the billing service’s ability to consistently meet format and content specifications required for the applicable provider type. The department shall, upon request, provide a written format and the content specifications required for electronic media or electronic transmission billings and shall advise the provider or billing service of procedures required to obtain department approval of electronic billing. DHS 106.03(1)(c)(c) Upon the department’s approval of the provider or the provider’s billing service to submit claims through electronic media or electronic transmission billing, the provider shall sign an agreement to comply with the format, content and procedural requirements of the department. DHS 106.03(1)(d)(d) The department may at its discretion revoke its approval and rescind the agreement for electronic media or electronically transmitted claims submission at any time if the provider or billing service fails to fully comply with all of the department’s instructions for submission of electronic media or electronically transmitted claims, or repeatedly submits duplicate, inaccurate or incomplete claims. The department may at its discretion revoke its approval and rescind the agreement under par. (c) when the provider’s claims repeatedly fail to provide correct and complete information necessary for timely and accurate claims processing and payment in accordance with billing instructions provided by the department or its fiscal agent. DHS 106.03(2)(a)(a) In the preparation of claims, the provider shall use, as applicable, diagnosis, place of service, type of service, procedure codes and other information specified by the department under s. DHS 108.02 (4) for identifying services billed on the claim. The department shall inform affected providers of the name and source of the designated diagnosis and procedure codes. DHS 106.03(2)(b)(b) Claims shall be submitted in accordance with the claims submission requirements, claim forms instructions and coding information provided by the department. DHS 106.03(2)(c)(c) Whether submitted directly by the provider, by the provider’s billing service or by another agent of the provider, the truthfulness, completeness, timeliness and accuracy of any claim are the sole responsibility of the provider. DHS 106.03(2)(d)(d) Every claim submitted shall be signed by the provider or by the provider’s authorized agent, certifying to the accuracy and completeness of the claim and that services billed on the claim are consistent with the requirements of chs. DHS 101 to 108 and the department’s instructions issued under s. DHS 108.02 (4). For claims submitted by electronic media or electronic transmission, the provider agreement under sub. (1) (c) substitutes for the signature required by this paragraph for each claims submission. DHS 106.03(2m)(2m) EVV requirements for claim reimbursement. Claims for services that require EVV shall have associated EVV records for applicable services. Claims that require EVV that are not matched to an EVV record may be denied. DHS 106.03(3)(a)(a) A claim may not be submitted to MA until the recipient has received the service which is the subject of the claim and the requirements of sub. (7) have been met. A claim may not be submitted by a nursing home for a recipient who is a nursing home resident until the day following the last date of service in the month for which reimbursement is claimed. A claim may not be submitted by a hospital for a recipient who is a hospital inpatient until the day following the last date of service for which reimbursement is claimed. DHS 106.03(3)(b)1.1. To be considered for payment, a correct and complete claim or adjustment shall be received by the department’s fiscal agent within 365 days after the date of the service except as provided in subd. 4. and par. (c). The department fiscal agent’s response to any claim or adjustment received more than 365 days after the date of service shall constitute final department action with respect to payment of the claim or adjustment in question. DHS 106.03(3)(b)2.2. The provider is responsible for providing complete and timely follow-up to each claim submission to verify that correct and accurate payment was made, and to seek resolution of any disputed claims. 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)(c) The sole exceptions to the 365 day billing deadline are as follows: