DHS 154.035(1)(1)The patient dies.
DHS 154.035(2)(2)The patient moves out of the state of Wisconsin.
DHS 154.035 HistoryHistory: CR 04-051: cr. Register November 2004 No. 587, eff. 12-1-04.
DHS 154.037DHS 154.037Retroactive eligibility. Retroactive eligibility is not available under the adult cystic fibrosis program. Patients who are found to be eligible under s. DHS 154.03 become eligible for benefits on the date the application was received.
DHS 154.037 HistoryHistory: CR 04-051: cr. Register November 2004 No. 587, eff. 12-1-04.
DHS 154.04DHS 154.04Patient certification.
DHS 154.04(1)(1)Application. To apply for assistance in paying for the costs of treatment of adult cystic fibrosis, a patient shall complete a form available from a cystic fibrosis treatment center, and shall submit the completed form either to the center or directly to the department. When an application form is submitted to a cystic fibrosis treatment center, the center shall forward the application form to the department within 14 days from the date of receipt.
DHS 154.04(2)(2)Notification of applicant. The department shall certify a patient as eligible for reimbursement for part of the medical costs of treatment of cystic fibrosis if all requirements under s. DHS 154.03 are met. The department shall notify the patient, in writing, of its decision within 60 days after the department receives an application for assistance. If the application is denied, the notice shall include the reason for denial with information that the patient may request a hearing under sub. (7) on that decision.
DHS 154.04(3)(3)Recertification. Certification is for one year. To be recertified, a participant shall complete, sign and submit to the department a financial statement form received from the department. The participant shall provide to the department full, truthful and correct information necessary for the department to determine eligibility and liability.
DHS 154.04(4)(4)Revocation or nonrenewal of certification. The department shall revoke or not renew a participant’s certification if the department finds that the participant is no longer eligible for the program. The department shall send written notice of revocation or nonrenewal to the participant, stating the reason for it and with information that the participant may request a hearing under sub. (7) on that decision.
DHS 154.04(5)(5)Participant responsibility to provide information.
DHS 154.04(5)(a)(a) A participant shall inform the department within 30 days of any change in address, other source of health care coverage or family size, or any change in income of more than 10%.
DHS 154.04(5)(b)(b) The department may verify or audit a participant’s total family income. The department may redetermine a participant’s estimated total family income for the current year based on change in the family’s financial circumstances.
DHS 154.04(6)(6)Confidentiality of patient information. All personally identifiable information provided by or on behalf of a patient to the department shall remain confidential and may not be used for any purpose other than to determine program eligibility, participant liability, the types of medical services required for proper care and the payment of claims. Statistical analyses of program data may not reveal patient identity.
DHS 154.04(7)(7)Appeal. A patient denied assistance under sub. (2) or a participant whose certification is revoked or not renewed under sub. (4) may request a hearing on that decision under ss. 227.44 to 227.50, Stats., by the department of administration’s division of hearings and appeals. The request for a hearing shall be in writing and shall be sent to the office of administrative hearings so that it is received there within 30 days after the date of the notice of denial, revocation or nonrenewal of certification.
DHS 154.04 NoteNote: The mailing address of the Division of Hearings and Appeals is P.O. Box 7875, Madison, Wisconsin 53707.
DHS 154.04 HistoryHistory: Cr. Register, December, 1994, No. 468, eff. 1-1-95.
DHS 154.05DHS 154.05Provider approval.
DHS 154.05(1)(1)Cystic fibrosis treatment centers.
DHS 154.05(1)(a)(a) Condition. To be reimbursed by the program for medical care provided to program participants, a cystic fibrosis treatment center shall be certified by the national cystic fibrosis foundation and, except as provided in par. (b), shall be located in Wisconsin.
DHS 154.05(1)(b)(b) Border state treatment centers. The department may approve a treatment center in a state bordering on Wisconsin as a cystic fibrosis treatment center if the center is within 100 miles of the Wisconsin border, has a practice that includes providing services to Wisconsin residents and is certified by the national cystic fibrosis foundation. A border state cystic fibrosis treatment center is subject to the same requirements and contractual agreements as cystic fibrosis treatment centers located in Wisconsin.
DHS 154.05(1)(c)(c) Availability of a grievance mechanism for program participants. A cystic fibrosis treatment center shall have a written grievance procedure and shall provide a copy to each program participant. The cystic fibrosis treatment center may not discriminate against or take other retaliatory measures against a participant because the participant filed a grievance.
DHS 154.05(2)(2)Other providers.
DHS 154.05(2)(a)(a) A hospital or physician located in Wisconsin shall be deemed approved for reimbursement for treatment rendered to a program participant upon the department’s receipt of a valid claim for services rendered.
DHS 154.05(2)(b)(b) A pharmacy or a provider of home health care supplies shall be deemed approved for reimbursement for treatment-related services provided to a program participant upon the department’s receipt of a valid claim for services rendered.
DHS 154.05 HistoryHistory: Cr. Register, December, 1994, No. 468, eff. 1-1-95.
DHS 154.06DHS 154.06Provider reimbursement.
DHS 154.06(1)(1)Claim forms.
DHS 154.06(1)(a)(a) A provider shall use claim forms furnished or prescribed by the department or its fiscal agent, except that a provider may submit claims by electronic media or electronic submission if the provider or billing service is approved by the department for electronic claims submission.