DHS 106.03(4)(c)(c) Where time is of the essence in providing a service which requires prior authorization, and verbal authorization is obtained by the provider from the department’s medical consultant or designee. To ensure payment on claims for verbally-authorized services, the provider shall retain records which show the time and date of the authorization and the identity of the individual who gave the authorization, and shall follow-up with a written authorization request form attaching documentation pertinent to the verbal authorization.

DHS 106.03(5)(a)(a) Eligible providers. Payment for a service shall be made directly to the provider furnishing the service or to the provider organization which provides or arranges for the availability of the service on a prepayment basis, except that payment may be made:

DHS 106.03(5)(a)1.1. To the employer of an individual provider if the provider is required as a condition of employment to turn over fees derived from the service to the employer or to a facility; or

DHS 106.03(5)(a)2.2. To a facility if a service was provided in a hospital, clinic or other facility, and there exists a contractual agreement between the individual provider and the facility, under which the facility prepares and submits the claim for reimbursement for the service provided by the individual provider.

DHS 106.03(5)(b)(b) Facility contracting with providers. An employer or facility submitting claims for services provided by a provider in its employ or under contract as provided in par. (a) shall apply for and receive certification from the department to submit claims and receive payment on behalf of the provider performing the services. Any claim submitted by an employer or facility so authorized shall identify the provider number of the individual provider who actually provided the service or item that is the subject of the claim.

DHS 106.03(5)(br)(br) Providers of professional services to hospital inpatients. Notwithstanding pars. (a) and (b), in the case of a provider performing professional services to hospital inpatients, payment shall be made directly to the provider or to the hospital if it is separately certified to be reimbursed for the same professional services.

DHS 106.03(5)(c)(c) Prohibited payments. No payment which under par. (a) (intro.) is made directly to an individual provider or provider organization may be made to anyone else under a reassignment or power of attorney except to an employer or facility under par. (a) 1. or 2., but nothing in this paragraph shall be construed:

DHS 106.03(5)(c)1.1. To prevent making the payment in accordance with an assignment from the person or institution providing the service if the service is made to a governmental agency or entity or is established by or pursuant to the order of a court of competent jurisdiction; or

DHS 106.03(5)(c)2.2. To preclude an agent of the provider from receiving any payment if the agent does so pursuant to an agency agreement under which the compensation to be paid to the agent for services in connection with the billing or collection of payments due the person or institution under the program is unrelated, directly or indirectly, to the amount of payments or the claims for them, and is not dependent upon the actual collection of the payment.

DHS 106.03(6)(6) Assignment of medicare part B benefits. A provider providing a covered service to a dual entitlee shall accept assignment of the recipient’s part B medicare benefits if the service provided is, in whole or in part, reimbursable under medicare part B coverage. All services provided to dual entitlees which are reimbursable under medicare part B shall be billed to medicare. In this subsection,“dual entitlee” means an MA recipient who is also eligible to receive part B benefits under medicare.

DHS 106.03(7)(a)1.1. “Health care plan” means a plan or policy which provides coverage of health services, regardless of the nature and extent of coverage or reimbursement, including an indemnity health insurance plan, a health maintenance organization, a health insuring organization, a preferred provider organization or any other third party payer of health care.

DHS 106.03(7)(a)2.a.a. When required by the payer as a condition for payment for the particular service, the provider shall request prior authorization or pre-certification from medicare or the other health care plan, except in the case of emergency services. This includes following the preparation and submission requirements of the payer and ensuring that the information provided to the payer is truthful, timely, complete and accurate. Prior authorization or pre-certification means a process and procedures established by medicare or the other health care plan which involve requiring the review or approval by the payer or its agent prior to the provision of a service in order for the service to be considered for payment;

DHS 106.03(7)(a)2.b.b. The provider shall file a truthful, timely, complete and accurate claim or demand bill for the services which complies with the applicable claim preparation and submission requirements of medicare or the other health care plan. This includes providing necessary documentation and pertinent medical information when requested by medicare or the other health care plan as part of pre-payment or post-payment review performed by medicare or the other health care plan; and

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).