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. DHS 109.52(11)(a)(a) Voluntary termination. Any SeniorCare provider may terminate participation in the SeniorCare program and the medical assistance program. A SeniorCare provider electing to terminate program participation shall, at least 30 days before the termination date, notify the department in writing of that decision, the reasons for termination and the effective date of termination from the program. DHS 109.52(11)(b)(b) Reimbursement. A SeniorCare provider may not claim reimbursement for prescription drugs provided to participants on or after the effective date specified in the termination notice. If the SeniorCare provider’s notice of termination fails to specify an effective date, the department shall terminate the SeniorCare provider’s certification to provide and claim reimbursement for services under the program on the date on which the department receives notice of termination. DHS 109.52(13)(13) Effects of suspension or involuntary termination. The provisions of s. DHS 106.07 apply to the SeniorCare program. DHS 109.52 HistoryHistory: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; corrections in (2) (a), (5) (d), (12) and (13) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; correction in (2) (a) made under s. 13.92 (4) (b) 7., Stats., Register July 2011 No. 667; CR 22-046: am. (8) (d), (11) (b) Register June 2023 No. 810, eff. 7-1-23. DHS 109.53DHS 109.53 Department recovery of overpayments from SeniorCare providers. DHS 109.53(1)(1) Recoupment methods. If the department finds that a SeniorCare provider has received an overpayment, including but not limited to erroneous, excess, duplicative and improper payments under the program, regardless of cause, the department may recover the amount of the overpayment by any of the following methods, at its discretion: DHS 109.53(1)(a)(a) Offsetting or making an appropriate adjustment against other amounts owed the SeniorCare provider for covered services. DHS 109.53(1)(b)(b) Offsetting or crediting against amounts the department determines are owed the SeniorCare provider for subsequent services provided under the program if both of the following conditions are met: DHS 109.53(1)(b)1.1. The amount owed the SeniorCare provider at the time of the department’s finding is insufficient to recover in whole the amount of the overpayment. DHS 109.53(1)(b)2.2. The SeniorCare provider is claiming and receiving SeniorCare reimbursement in amounts sufficient to reasonably ensure full recovery of the overpayment within a reasonable period of time. DHS 109.53(1)(c)(c) Requiring the SeniorCare provider to pay directly to the department the amount of the overpayment. DHS 109.53(2)(2) Written notice. No recovery by offset, adjustment or demand for payment may be made by the department under sub. (1), except as provided under sub. (3), unless the department gives the SeniorCare provider prior written notice of the department’s intention to recover the amount determined to have been overpaid. The notice shall set forth the amount of the intended recovery, the method of the intended recovery, identify the claim or claims in question or other basis for recovery, summarize the basis for the department’s finding that the SeniorCare provider has received amounts to which the SeniorCare provider is not entitled or in excess of that to which the SeniorCare provider is entitled, and inform the SeniorCare provider of a right to appeal the intended action under sub. (5). The SeniorCare provider shall make payment due the department within 30 days after the date of service of the notice of intent to recover. The department shall send final notices of intent to recover by certified mail. DHS 109.53(3)(3) Exception. The department is not required to provide written notice under sub. (2) when the overpayment was made as a result of a computer processing or clerical error, for a recoupment of a manual partial payment, or when the SeniorCare provider requested or authorized the recovery to be made. In any of these cases, the department shall provide written notice of any payment adjustments made on the next remittance issued the SeniorCare provider. The notice shall specify the amount of the adjustment made and the claim that was the subject of the adjustment. DHS 109.53(4)(4) Withholding of payment involving fraud or willful misrepresentation.