DHS 107.21   Family planning services.
DHS 107.22   Early and periodic screening, diagnosis and treatment (EPSDT) services.
DHS 107.23   Transportation.
DHS 107.24   Durable medical equipment and medical supplies.
DHS 107.25   Diagnostic testing services.
DHS 107.26   Dialysis services.
DHS 107.27   Blood.
DHS 107.28   Health maintenance organization and prepaid health plan services.
DHS 107.29   Rural health clinic services.
DHS 107.30   Ambulatory surgical center services.
DHS 107.31   Hospice care services.
DHS 107.32   Case management services.
DHS 107.33   Ambulatory prenatal services for recipients with presumptive eligibility.
DHS 107.34   Prenatal care coordination services.
DHS 107.36   School-based services.
Ch. DHS 107 Note Note: Chapter HSS 107 as it existed on February 28, 1986 was repealed and a new chapter HSS 107 was created effective March 1, 1986. Chapter HSS 107 was renumbered Chapter HFS 107 under s. 13.93 (2m) (b) 1., Stats., and corrections made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, January, 1997, No. 493. Chapter HFS 107 was renumbered to chapter DHS 107 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 107.01 DHS 107.01General statement of coverage.
DHS 107.01(1) (1) The department shall reimburse providers for medically necessary and appropriate health care services listed in ss. 49.46 (2) and 49.47 (6) (a), Stats., when provided to currently eligible medical assistance recipients, including emergency services provided by persons or institutions not currently certified. The department shall also reimburse providers certified to provide case management services as defined in s. DHS 107.32 to eligible recipients.
DHS 107.01(2) (2) Services provided by a student during a practicum are reimbursable under the following conditions:
DHS 107.01(2)(a) (a) The services meet the requirements of this chapter;
DHS 107.01(2)(b) (b) Reimbursement for the services is not reflected in prospective payments to the hospital, skilled nursing facility or intermediate care facility at which the student is providing the services;
DHS 107.01(2)(c) (c) The student does not bill and is not reimbursed directly for his or her services;
DHS 107.01(2)(d) (d) The student provides services under the direct, immediate on-premises supervision of a certified provider; and
DHS 107.01(2)(e) (e) The supervisor documents in writing all services provided by the student.
DHS 107.01 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (1), Register, February, 1988, No. 386, eff. 3-1-88.
DHS 107.02 DHS 107.02General limitations.
DHS 107.02(1) (1)Payment.
DHS 107.02(1)(a)(a) The department shall reject payment for claims which fail to meet program requirements. However, claims rejected for this reason may be eligible for reimbursement if, upon resubmission, all program requirements are met.
DHS 107.02(1)(b) (b) Medical assistance shall pay the deductible and coinsurance amounts for services provided under this chapter which are not paid by medicare under 42 USC 1395 to 1395zz, and shall pay the monthly premiums under 42 USC 1395v. Payment of the coinsurance amount for a service under medicare part B, 42 USC 1395j to 1395w, may not exceed the allowable charge for this service under MA minus the medicare payment, effective for dates of service on or after July 1, 1988.
DHS 107.02(2) (2)Non-reimbursable services. The department may reject payment for a service which ordinarily would be covered if the service fails to meet program requirements. Non-reimbursable services include:
DHS 107.02(2)(a) (a) Services which fail to comply with program policies or state and federal statutes, rules and regulations, for instance, sterilizations performed without following proper informed consent procedures, or controlled substances prescribed or dispensed illegally;
DHS 107.02(2)(b) (b) Services which the department, the PRO review process or the department fiscal agent's professional consultants determine to be medically unnecessary, inappropriate, in excess of accepted standards of reasonableness or less costly alternative services, or of excessive frequency or duration;
DHS 107.02(2)(c) (c) Non-emergency services provided by a person who is not a certified provider;
DHS 107.02(2)(d) (d) Services provided to recipients who were not eligible on the date of the service, except as provided under a prepaid health plan or HMO;
DHS 107.02(2)(e) (e) Services for which records or other documentation were not prepared or maintained, as required under s. DHS 106.02 (9);
DHS 107.02(2)(f) (f) Services provided by a provider who fails or refuses to prepare or maintain records or other documentation as required under s. DHS 106.02 (9);
DHS 107.02(2)(g) (g) Services provided by a provider who fails or refuses to provide access to records as required under s. DHS 106.02 (9) (e) 4.;
DHS 107.02(2)(h) (h) Services for which the provider failed to meet any or all of the requirements of s. DHS 106.03, including but not limited to the requirements regarding timely submission of claims;
DHS 107.02(2)(i) (i) Services provided inconsistent with an intermediate sanction or sanctions imposed by the department under s. DHS 106.08; and
DHS 107.02(2)(j) (j) Services provided by a provider who fails or refuses to meet and maintain any of the certification requirements under ch. DHS 105 applicable to that provider.
DHS 107.02(2m) (2m)Services requiring a physician's order or prescription.
DHS 107.02(2m)(a)(a) The following services require a physician's order or prescription to be covered under MA:
DHS 107.02(2m)(a)1. 1. Skilled nursing services provided in a nursing home;
DHS 107.02(2m)(a)2. 2. Intermediate care services provided in a nursing home;
DHS 107.02(2m)(a)3. 3. Home health care services;
DHS 107.02(2m)(a)4. 4. Independent nursing services;
DHS 107.02(2m)(a)5. 5. Respiratory care services for ventilator-dependent recipients;
DHS 107.02(2m)(a)6. 6. Physical and occupational therapy services;
DHS 107.02(2m)(a)8. 8. Speech pathology and audiology services;
DHS 107.02(2m)(a)9. 9. Medical supplies and equipment, including rental of durable equipment, but not hearing aid batteries, hearing aid accessories or repairs;
DHS 107.02(2m)(a)10. 10. Drugs, except when prescribed by a nurse practitioner under s. DHS 107.122, a podiatrist under s. DHS 107.14 or an advanced practice nurse prescriber under s. DHS 107.10;
DHS 107.02(2m)(a)11. 11. Prosthetic devices;
DHS 107.02(2m)(a)12. 12. Laboratory, diagnostic, radiology and imaging test services;
DHS 107.02(2m)(a)13. 13. Inpatient hospital services;
DHS 107.02(2m)(a)14. 14. Outpatient hospital services;
DHS 107.02(2m)(a)15. 15. Inpatient hospital IMD services;
DHS 107.02(2m)(a)16. 16. Hearing aids;
DHS 107.02(2m)(a)18. 18. Hospital private room accommodations;
DHS 107.02(2m)(a)19. 19. Personal care services; and
DHS 107.02(2m)(a)20. 20. Hospice services.
DHS 107.02(2m)(b) (b) Except as otherwise provided in federal or state statutes, regulations or rules, a prescription or order shall be in writing or be given orally and later be reduced to writing by the provider filling the prescription or order, and shall include the date of the prescription or order, the name and address of the prescriber, the prescriber's MA provider number, the name and address of the recipient, the recipient's MA eligibility number, an evaluation of the service to be provided, the estimated length of time required, the brand of drug or drug product equivalent medically required and the prescriber's signature. For hospital patients and nursing home patients, orders shall be entered into the medical and nursing charts and shall include the information required by this paragraph. Services prescribed or ordered shall be provided within one year of the date of the prescription.
DHS 107.02(2m)(c) (c) A prescription for specialized transportation services shall include an explanation of the reason the recipient is unable to travel in a private automobile, or a taxicab, bus or other common carrier. A prescription for a recipient not declared legally blind or not determined to be indefinitely disabled, as defined under s. DHS 107.23 (1) (c) shall specify the length of time for which the recipient shall require the specialized transportation, which may not exceed 90 days.
DHS 107.02(3) (3)Prior authorization.
DHS 107.02(3)(a)(a) Procedures for prior authorization. The department may require prior authorization for covered services. In addition to services designated for prior authorization under each service category in this chapter, the department may require prior authorization for any other covered service for any reason listed in par. (b). The department shall notify in writing all affected providers of any additional services for which it has decided to require prior authorization. The department or its fiscal agent shall act on 95% of requests for prior authorization within 10 working days and on 100% of requests for prior authorization within 20 working days from the receipt of all information necessary to make the determination. The department or its fiscal agent shall make a reasonable attempt to obtain from the provider the information necessary for timely prior authorization decisions. When prior authorization decisions are delayed due to the department's need to seek further information from the provider, the recipient shall be notified by the provider of the reason for the delay.
DHS 107.02(3)(b) (b) Reasons for prior authorization. Reasons for prior authorization are:
DHS 107.02(3)(b)1. 1. To safeguard against unnecessary or inappropriate care and services;
DHS 107.02(3)(b)2. 2. To safeguard against excess payments;
DHS 107.02(3)(b)3. 3. To assess the quality and timeliness of services;
DHS 107.02(3)(b)4. 4. To determine if less expensive alternative care, services or supplies are usable;
DHS 107.02(3)(b)5. 5. To promote the most effective and appropriate use of available services and facilities; and
DHS 107.02(3)(b)6. 6. To curtail misutilization practices of providers and recipients.
DHS 107.02(3)(c) (c) Penalty for non-compliance. If prior authorization is not requested and obtained before a service requiring prior authorization is provided, reimbursement shall not be made except in extraordinary circumstances such as emergency cases where the department has given verbal authorization for a service.
DHS 107.02(3)(d) (d) Required information. A request for prior authorization submitted to the department or its fiscal agent shall, unless otherwise specified in chs. DHS 101 to 108, identify at a minimum:
DHS 107.02(3)(d)1. 1. The name, address and MA number of the recipient for whom the service or item is requested;
DHS 107.02(3)(d)2. 2. The name and provider number of the provider who will perform the service requested;
DHS 107.02(3)(d)3. 3. The person or provider requesting prior authorization;
DHS 107.02(3)(d)4. 4. The attending physician's or dentist's diagnosis including, where applicable, the degree of impairment;
DHS 107.02(3)(d)5. 5. A description of the service being requested, including the procedure code, the amount of time involved, and dollar amount where appropriate; and
DHS 107.02(3)(d)6. 6. Justification for the provision of the service.
DHS 107.02(3)(e) (e) Departmental review criteria. In determining whether to approve or disapprove a request for prior authorization, the department shall consider:
DHS 107.02(3)(e)1. 1. The medical necessity of the service;
DHS 107.02(3)(e)2. 2. The appropriateness of the service;
DHS 107.02(3)(e)3. 3. The cost of the service;
DHS 107.02(3)(e)4. 4. The frequency of furnishing the service;
DHS 107.02(3)(e)5. 5. The quality and timeliness of the service;
DHS 107.02(3)(e)6. 6. The extent to which less expensive alternative services are available;
DHS 107.02(3)(e)7. 7. The effective and appropriate use of available services;
DHS 107.02(3)(e)8. 8. The misutilization practices of providers and recipients;
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.