DHS 107.07(5)(5) Unusual circumstances. In certain unusual circumstances the department may request that a non-covered service be performed, including but not limited to diagnostic casts, in order to substantiate a prior authorization request. In these cases the service shall be reimbursed.

DHS 107.07 HistoryHistory: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (1) (c) 10. and (2) (c) 9. e. and f., cr. (2) (c) 9. g. and (3) (8), r. and recr. (4) (q), Register, February, 1988, No. 386, eff. 3-1-88; r. and recr. (1) (g) and (4) (j), renum. (2) (c) 9. to 12. and (4) (k) to (t) to be (2) (c) 10. to 13. and (4) (m) to (v), cr. (2) (c) 9., (4) (k) and (L), Register, December, 1989, No. 408, eff. 1-1-90; correction in (4) (j) made under s. 13.93 (2m) (b) 7., Stats., Register, December, 1989, No. 408; CR 05-033: r. and recr. (1), (3) and (4) cr. (1m), (2) (a) 5. to 7. and (4m), am. (2) (a) (intro.) and 1. to 4. and (2) (b), r. (2) (c) Register August 2006 No. 608, eff. 9-1-06; emerg. r. (1) (k) and (2) (a) 5., am. (2) (a) (intro.), (3) (intro.), (a) 3., (4) (intro.), (j) and (4m) eff. 4-30-07; CR 07-041: r. (1) (i), (k) and (2) (a) 5., am. (2) (a) (intro.), (3) (intro.), (a) 3., (4) (intro.), (j) and (4m) Register December 2007 No. 624, eff. 1-1-08; corrections in (1m) (intro.) and (4m) (intro.) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 22-043: r. (4) (b), am. (4) (c), r. (4) (k) 1. Register May 2023 No. 809, eff. 6-1-23.

DHS 107.08(1)(a)(a) Inpatient services. Covered hospital inpatient services are those medically necessary services which require an inpatient stay ordinarily furnished by a hospital for the care and treatment of inpatients, and which are provided under the direction of a physician or dentist in an institution certified under s. DHS 105.07 or 105.21.

DHS 107.08(1)(b)(b) Outpatient services. Covered hospital outpatient services are those medically necessary preventive, diagnostic, rehabilitative or palliative items or services provided by a hospital certified under s. DHS 105.07 or 105.21 and performed by or under the direction of a physician or dentist for a recipient who is not a hospital inpatient.

DHS 107.08(2)(d)(d) Hospitalization for any other medical service noted in s. DHS 107.06 (2), 107.10 (2), 107.16 (2), 107.17 (2), 107.18 (2), 107.19 (2), 107.20 (2) or 107.24 (3). The admitting physician shall either obtain the prior authorization directly or ensure that prior authorization has been obtained by the attending physician or dentist.

DHS 107.08(3)(a)2.2. A recipient’s attending physician shall determine if private room accommodations are medically necessary. Charges for private room accommodations shall be denied unless the private room is medically necessary and prescribed by the recipient’s attending physician. When a private room is not medically necessary, neither MA nor the recipient may be held responsible for the cost of the private room charge. If, however, a recipient requests a private room and the hospital informs the recipient at the time of admission of the cost differential, and if the recipient understands and agrees to pay the differential, then the recipient may be charged for the differential.