DHS 109.52(3)(d)(d) Furnish the following information to the department in writing: DHS 109.52(3)(d)1.1. The names and addresses of all vendors of drugs, medical supplies or transportation, or other providers in which the SeniorCare provider has a controlling interest or ownership. DHS 109.52(3)(d)2.2. The names and addresses of all persons who have a controlling interest in the SeniorCare provider. DHS 109.52(3)(d)3.3. Whether any of the persons named in compliance with subd. 1. or 2., is related to another named in subd. 1. or 2. DHS 109.52(3)(e)(e) Execute a SeniorCare provider agreement with the department. DHS 109.52(4)(4) Notification of certification decision. Within 60 days after the department receives a complete application for certification, including evidence of licensure or Medicare certification, or both, if required, the department shall either approve the application and issue the certification, or deny the application. If the application for certification is denied, the department shall give the applicant reasons, in writing, for the denial. DHS 109.52(5)(a)(a) Compliance with requirements. A SeniorCare provider shall maintain compliance with the requirements in this subsection in order to maintain SeniorCare certification. DHS 109.52(5)(b)(b) Change in provider status. A SeniorCare provider shall report to the department in writing any change in licensure, certification, group affiliation, corporate name or ownership by the time of the effective date of the change. The department may require the SeniorCare provider to complete a new provider application and a new provider agreement when a change in status occurs. A SeniorCare provider shall immediately notify the department of any change of address but the department shall not require the completion of a new provider application or a new provider agreement for a change of address. DHS 109.52(5)(c)(c) Change in ownership. If the ownership of a certified SeniorCare provider changes, the provider agreement shall automatically terminate. DHS 109.52(5)(d)(d) Program compliance. A SeniorCare provider may lose SeniorCare certification for any of the reasons listed in sub. (12) or in s. DHS 106.06. DHS 109.52(6)(6) Response to inquiries. A SeniorCare provider shall respond as directed to inquiries by the department regarding the validity of provider information maintained by the department. DHS 109.52(7)(7) Maintenance of records. A SeniorCare provider shall prepare and maintain whatever records are necessary to fully disclose the nature and extent of services provided by the SeniorCare provider under the program, including those enumerated in sub. (8). Each SeniorCare provider shall maintain all required records for at least a period of 5 years from the date the department pays for the services rendered, unless otherwise stated in this chapter. If a SeniorCare provider’s participation in the program terminates for any reason, all related records shall remain subject to the conditions enumerated in this subsection and sub. (8). DHS 109.52(8)(8) Records to be maintained. SeniorCare providers shall retain all of the following records: DHS 109.52(8)(a)(a) Contracts or agreements with persons or organizations for the furnishing of SeniorCare items or services, payment for which may be made in whole or in part, directly or indirectly, by the department. DHS 109.52(8)(b)(b) Billings and records of services or supplies which are the subject of the billings that are necessary to fully disclose the nature and extent of the SeniorCare services or supplies. DHS 109.52(8)(c)(c) All policies and regulations adopted by the SeniorCare provider’s governing body. DHS 109.52(8)(d)(d) Prescriptions that support SeniorCare billings, including records of SeniorCare covered vaccines and vaccine administration. DHS 109.52(8)(g)(g) Receipts for costs associated with SeniorCare services billed. DHS 109.52(9)(9) Provider agreement duration. The provider agreement shall, unless terminated, remain in full force and effect for a maximum of one year from the date the department accepts a SeniorCare provider into the program. In the absence of a notice of termination by the SeniorCare provider or department, the agreement shall automatically renew and extend for a period of one year. DHS 109.52(10)(a)(a) Reimbursement for emergency services. If a person in Wisconsin or in another state who is not certified as a SeniorCare provider by the department in this state provides emergency services to a Wisconsin participant, that person may not be reimbursed for those services unless the drugs are covered under this chapter and all of the following conditions are met: DHS 109.52(10)(a)1.1. The person submits to the department a provider data form and a claim for reimbursement of emergency services on forms prescribed by the department. DHS 109.52(10)(a)2.2. The person submits to the department a statement in writing on a form prescribed by the department explaining the nature of the emergency, if known, including a description of the participant’s condition, cause of emergency, diagnosis and extent of injuries, the drugs that were provided and when, and the reason that the participant could not receive drugs from a certified SeniorCare provider. DHS 109.52(10)(a)3.3. The person possesses all licenses and other entitlements required under state and federal statutes, rules and regulations, and is qualified to provide all services for which a claim is submitted. DHS 109.52(10)(b)(b) Reimbursement prohibited for non-emergency services. The department may not reimburse non-emergency services provided by a non-certified person unless the department receives prior authorization as provided in s. DHS 109.32 (2). DHS 109.52(10)(c)(c) Reimbursement determination. Based upon the signed statement and the claim for reimbursement, the department shall determine whether the services are reimbursable.