Family planning services.
Early and periodic screening, diagnosis and treatment (EPSDT) services.
Durable medical equipment and medical supplies.
Diagnostic testing services.
Health maintenance organization and prepaid health plan services.
Rural health clinic services.
Ambulatory surgical center services.
Hospice care services.
Case management services.
Ambulatory prenatal services for recipients with presumptive eligibility.
Prenatal care coordination services.
Ch. DHS 107 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Chapter HSS 107 as it existed on February 28, 1986 was repealed and a new chapter HSS 107 was created effective March 1, 1986.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 General statement of coverage. DHS 107.01(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.
Services provided by a student during a practicum are reimbursable under the following conditions:
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;
The student does not bill and is not reimbursed directly for his or her services;
The student provides services under the direct, immediate on-premises supervision of a certified provider; and
The supervisor documents in writing all services provided by the student.
DHS 107.01 History
Cr. Register, February, 1986, No. 362
, eff. 3-1-86; am. (1), Register, February, 1988, No. 386
, eff. 3-1-88.
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.
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
, 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
, 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.
(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:
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;
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;
Non-emergency services provided by a person who is not a certified provider;
Services provided to recipients who were not eligible on the date of the service, except as provided under a prepaid health plan or HMO;
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)
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;
Services provided inconsistent with an intermediate sanction or sanctions imposed by the department under s. DHS 106.08
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.
(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:
Medical supplies and equipment, including rental of durable equipment, but not hearing aid batteries, hearing aid accessories or repairs;
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.
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)(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.
(b) Reasons for prior authorization.
Reasons for prior authorization are:
To safeguard against unnecessary or inappropriate care and services;
To determine if less expensive alternative care, services or supplies are usable;
To promote the most effective and appropriate use of available services and facilities; and
(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.
(d) Required information.
A request for prior authorization submitted to the department or its fiscal agent shall, unless otherwise specified in chs. DHS 101
, identify at a minimum:
The name, address and MA number of the recipient for whom the service or item is requested;
The name and provider number of the provider who will perform the service requested;
The attending physician's or dentist's diagnosis including, where applicable, the degree of impairment;
A description of the service being requested, including the procedure code, the amount of time involved, and dollar amount where appropriate; and
(e) Departmental review criteria.
In determining whether to approve or disapprove a request for prior authorization, the department shall consider:
The extent to which less expensive alternative services are available;