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;
DHS 107.02(3)(e)9. 9. The limitations imposed by pertinent federal or state statutes, rules, regulations or interpretations, including medicare, or private insurance guidelines;
DHS 107.02(3)(e)10. 10. The need to ensure that there is closer professional scrutiny for care which is of unacceptable quality;
DHS 107.02(3)(e)11. 11. The flagrant or continuing disregard of established state and federal policies, standards, fees or procedures; and
DHS 107.02(3)(e)12. 12. The professional acceptability of unproven or experimental care, as determined by consultants to the department.
DHS 107.02(3)(f) (f) Professional consultants. The department or its fiscal agent may use the services of qualified professional consultants in determining whether requests for prior authorization meet the criteria in par. (e).
DHS 107.02(3)(g) (g) Authorization not transferable. Prior authorization, once granted, may not be transferred to another recipient or to another provider. In certain cases the department may allow multiple services to be divided among non-billing providers certified under one billing provider. For example, prior authorization for 15 visits for occupational therapy may be performed by more than one therapist working for the billing provider for whom prior authorization was granted. In emergency circumstances the service may be provided by a different provider.
DHS 107.02(3)(h) (h) Medical opinion reports. Medical evaluations and written medical opinions used in establishing a claim in a tort action against a third party may be covered services if they are prior-authorized. Prior authorization shall be issued only where:
DHS 107.02(3)(h)1. 1. A recipient has sustained personal injuries requiring medical or other health care services as a result of injury, damage or a wrongful act caused by another person;
DHS 107.02(3)(h)2. 2. Services for these injuries are covered under the MA program;
DHS 107.02(3)(h)3. 3. The recipient or the recipient's representative has initiated or will initiate a claim or tort action against the negligent third party, joining the department in the action as provided under s. 49.89, Stats.; and
DHS 107.02(3)(h)4. 4. The recipient or the recipient's representative agrees in writing to reimburse the program in whole for all payments made for the prior-authorized services from the proceeds of any judgment, award, determination or settlement on the recipient's claim or action.
DHS 107.02(3)(i) (i) Significance of prior authorization approval.
DHS 107.02(3)(i)1.1. Approval or modification by the department or its fiscal agent of a prior authorization request, including any subsequent amendments, extensions, renewals, or reconsideration requests:
DHS 107.02(3)(i)1.a. a. Shall not relieve the provider of responsibility to meet all requirements of federal and state statutes and regulations, provider handbooks and provider bulletins;
DHS 107.02(3)(i)1.b. b. Shall not constitute a guarantee or promise of payment, in whole or in part, with respect to any claim submitted under the prior authorization; and
DHS 107.02(3)(i)1.c. c. Shall not be construed to constitute, in whole or in part, a discretionary waiver or variance under s. DHS 106.13.
DHS 107.02(3)(i)2. 2. Subject to the applicable terms of reimbursement issued by the department, covered services provided consistent with a prior authorization, as approved or modified by the department or its fiscal agent, are reimbursable provided:
DHS 107.02(3)(i)2.a. a. The provider's approved or modified prior authorization request and supporting information, including all subsequent amendments, renewals and reconsideration requests, is truthful and accurate;
DHS 107.02(3)(i)2.b. b. The provider's approved or modified prior authorization request and supporting information, including all subsequent amendments, extensions, renewals and reconsideration requests, completely and accurately reveals all facts pertinent to the recipient's case and to the review process and criteria provided under s. DHS 107.02 (3);
DHS 107.02(3)(i)2.c. c. The provider complies with all requirements of applicable state and federal statutes, the terms and conditions of the applicable provider agreement pursuant to s. 49.45 (2) (a) 9., Stats., all applicable requirements of chs. DHS 101 to 108, including but not limited to the requirements of ss. DHS 106.02, 106.03, 107.02, and 107.03, and all applicable prior authorization procedural instructions issued by the department under s. DHS 108.02 (4);
DHS 107.02(3)(i)2.d. d. The recipient is MA eligible on the date of service; and
DHS 107.02(3)(i)2.e. e. The provider is MA certified and qualified to provide the service on the date of the service.
DHS 107.02(4) (4)Cost-sharing.
DHS 107.02(4)(a) (a) General policy. The department shall establish cost-sharing provisions for MA recipients, pursuant to s. 49.45 (18), Stats. Cost-sharing requirements for providers are described under s. DHS 106.04 (2), and services and recipients exempted from cost-sharing requirements are listed under s. DHS 104.01 (12) (a).
DHS 107.02(4)(b) (b) Notification of applicable services and rates. All services for which cost-sharing is applicable shall be identified by the department to all recipients and providers prior to enforcement of the provisions.
DHS 107.02(4)(d) (d) Limitation on copayments for prescription drugs. Providers may not collect copayments in excess of $5 a month from a recipient for prescription drugs if the recipient uses one pharmacy or pharmacist as his or her sole provider of prescription drugs.
DHS 107.02 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; r. and recr. (1) and am. (14) (c) 12. and 13., Register, February, 1988, No. 386, eff. 3-1-88; cr. (4) (c) 14., Register, April, 1988, No. 388, eff. 7-1-88; r. and recr. (4) (c), Register, December, 1988, No. 396, eff. 1-1-89; emerg. am. (4) (a), r. (4) (c), eff. 1-1-90; am. (4) (a) r. (4) (c), Register, September, 1990, No. 417, eff. 10-1-90; am. (2) (b), r. (2) (c), renum. (2) (d) and (e) to be (2) (c) and (d), cr. (2m), Register, September, 1991, No. 429, eff. 10-1-91; emerg. cr. (3) (i), eff. 7-1-92; am. (2) (c) and (d), cr. (2) (e) to (j) and (3) (i), Register, February, 1993, No. 446, eff. 3-1-93; r. (2m) (a) 17., Register, November, 1994, No. 467, eff. 12-1-94; am. (2) (a), Register, January, 1997, No. 493, eff. 2-1-97; correction in (4) (a) made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520; correction in (3) (h) 3. made under s. 13.93 (2m) (b) 7., Stats., Register, October, 2000, No. 538; CR 03-033: am. (2m) (a) 10. and (c) Register December 2003 No. 576, eff. 1-1-04; corrections in (2) (e) to (j), (3) (d) (intro.), (i) 1. c., 2. c., and (4) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 14-066: r. (2m) (a) 7. Register August 2015 No. 716, eff. 9-1-15.
DHS 107.03 DHS 107.03Services not covered. The following services are not covered services under MA:
DHS 107.03(1) (1)Charges for telephone calls;
DHS 107.03(2) (2)Charges for missed appointments;
DHS 107.03(3) (3)Sales tax on items for resale;
DHS 107.03(4) (4)Services provided by a particular provider that are considered experimental in nature;
DHS 107.03(5) (5)Procedures considered by the department to be obsolete, inaccurate, unreliable, ineffectual, unnecessary, imprudent or superfluous;
DHS 107.03(6) (6)Personal comfort items, such as radios, television sets and telephones, which do not contribute meaningfully to the treatment of an illness;
DHS 107.03(7) (7)Alcoholic beverages, even if prescribed for remedial or therapeutic reasons;
DHS 107.03(8) (8)Autopsies;
DHS 107.03(9) (9)Any service requiring prior authorization for which prior authorization is denied, or for which prior authorization was not obtained prior to the provision of the service except in emergency circumstances;
DHS 107.03(10) (10)Services subject to review and approval pursuant to s. 150.21, Stats., but which have not yet received approval;
DHS 107.03(11) (11)Psychiatric examinations and evaluations ordered by a court following a person's conviction of a crime, pursuant to s. 972.15, Stats.;
DHS 107.03(12) (12)Consultations between or among providers, except as specified in s. DHS 107.06 (4) (e);
DHS 107.03(13) (13)Medical services for adult inmates of the correctional institutions listed in s. 302.01, Stats.;
DHS 107.03(14) (14)Medical services for a child placed in a detention facility;
DHS 107.03(15) (15)Expenditures for any service to an individual who is an inmate of a public institution or for any service to a person 21 to 64 years of age who is a resident of an institution for mental diseases (IMD), unless the person is 21 years of age, was a resident of the IMD immediately prior to turning 21 and has been continuously a resident since then, except that expenditures for a service to an individual on convalescent leave from an IMD may be reimbursed by MA.
DHS 107.03(16) (16)Services provided to recipients when outside the United States, except Canada or Mexico;
DHS 107.03(17) (17)Separate charges for the time involved in completing necessary forms, claims or reports;
DHS 107.03(18) (18)Services provided by a hospital or professional services provided to a hospital inpatient are not covered services unless billed separately as hospital services under s. DHS 107.08 or 107.13 (1) or as professional services under the appropriate provider type. No recipient may be billed for these services as non-covered;
DHS 107.03(19) (19)Services, drugs and items that are provided for the purpose of enhancing the prospects of fertility in males or females, including but not limited to the following:
DHS 107.03(19)(a) (a) Artificial insemination, including but not limited to intra-cervical and intra-uterine insemination;
DHS 107.03(19)(b) (b) Infertility counseling;
DHS 107.03(19)(c) (c) Infertility testing, including but not limited to tubal patency, semen analysis or sperm evaluation;
DHS 107.03(19)(d) (d) Reversal of female sterilization, including but not limited to tubouterine implantation, tubotubal anastomoses or fimbrioplasty;
DHS 107.03(19)(e) (e) Fertility-enhancing drugs used for the treatment of infertility;
DHS 107.03(19)(f) (f) Reversal of vasectomies;
DHS 107.03(19)(g) (g) Office visits, consultations and other encounters to enhance the prospects of fertility; and
DHS 107.03(19)(h) (h) Other fertility-enhancing services and items;
DHS 107.03(20) (20)Surrogate parenting and related services, including but not limited to artificial insemination and subsequent obstetrical care;
DHS 107.03(21) (21)Ear lobe repair;
DHS 107.03(22) (22)Tattoo removal;
DHS 107.03(23) (23)Drugs, including hormone therapy, associated with transsexual surgery or medically unnecessary alteration of sexual anatomy or characteristics;
DHS 107.03(24) (24)Transsexual surgery;
DHS 107.03(25) (25)Impotence devices and services, including but not limited to penile prostheses and external devices and to insertion surgery and other related services; and
DHS 107.03(26) (26)Testicular prosthesis.
DHS 107.03 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; emerg. r. and recr. (15), eff. 8-1-88; r. and recr. (15), Register, December, 1988, No. 396, eff. 1-1-89; emerg. am. (15), eff. 6-1-89; am. (15), Register, February, 1990, No. 410, eff. 3-1-90; am. (10), (12), (16) and (17), cr. (18), Register, September, 1991, No. 429, eff. 10-1-91; am. (17) and (18), cr. (19) to (26), Register, January, 1997, No. 493, eff. 2-1-97; correction in (13) made under s. 13.93 (2m) (b) 7., Stats., Register, October, 2000, No. 538.
DHS 107.035 DHS 107.035Definition and identification of experimental services.
DHS 107.035(1)(1)Definition. “Experimental in nature," as used in s. DHS 107.03 (4) and this section, means a service, procedure or treatment provided by a particular provider which the department has determined under sub. (2) not to be a proven and effective treatment for the condition for which it is intended or used.
DHS 107.035(2) (2)Departmental review. In assessing whether a service provided by a particular provider is experimental in nature, the department shall consider whether the service is a proven and effective treatment for the condition which it is intended or used, as evidenced by:
DHS 107.035(2)(a) (a) The current and historical judgment of the medical community as evidenced by medical research, studies, journals or treatises;
DHS 107.035(2)(b) (b) The extent to which medicare and private health insurers recognize and provide coverage for the service;
DHS 107.035(2)(c) (c) The current judgment of experts and specialists in the medical specialty area or areas in which the service is applicable or used; and
DHS 107.035(2)(d) (d) The judgment of the MA medical audit committee of the state medical society of Wisconsin or the judgment of any other committee which may be under contract with the department to perform health care services review within the meaning of s. 146.37, Stats.
DHS 107.035(3) (3)Exclusion of coverage. If on the basis of its review the department determines that a particular service provided by a particular provider is experimental in nature and should therefore be denied MA coverage in whole or in part, the department shall send written notice to physicians or other affected certified providers who have requested reimbursement for the provision of the experimental service. The notice shall identify the service, the basis for its exclusion from MA coverage and the specific circumstances, if any, under which coverage will or may be provided.
DHS 107.035(4) (4)Review of exclusion from coverage. At least once a year following a determination under sub. (3), the department shall reassess services previously designated as experimental to ascertain whether the services have advanced through the research and experimental stage to become established as proven and effective means of treatment for the particular condition or conditions for which they are designed. If the department concludes that a service should no longer be considered experimental, written notice of that determination shall be given to the affected providers. That notice shall identify the extent to which MA coverage will be recognized.
DHS 107.035 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.
DHS 107.04 DHS 107.04Coverage of out-of-state services. All non-emergency out-of-state services require prior authorization, except where the provider has been granted border status pursuant to s. DHS 105.48.
DHS 107.04 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520.
DHS 107.05 DHS 107.05Coverage of emergency services provided by a person not a certified provider. Emergency services necessary to prevent the death or serious impairment of the health of a recipient shall be covered services even if provided by a person not a certified provider. A person who is not a certified provider shall submit documentation to the department to justify provision of emergency services, according to the procedures outlined in s. DHS 105.03. The appropriate consultant to the department shall determine whether a service was an emergency service.
DHS 107.05 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 107.06 DHS 107.06Physician services.
DHS 107.06(1)(1)Covered services. Physician services covered by the MA program are, except as otherwise limited in this chapter, any medically necessary diagnostic, preventive, therapeutic, rehabilitative or palliative services provided in a physician's office, in a hospital, in a nursing home, in a recipient's residence or elsewhere, and performed by or under the direct, on-premises supervision of a physician within the scope of the practice of medicine and surgery as defined in s. 448.01 (9), Stats. These services shall be in conformity with generally accepted good medical practice.
DHS 107.06(2) (2)Services requiring prior authorization. The following physician services require prior authorization in order to be covered under the MA program:
DHS 107.06(2)(a) (a) All covered physician services if provided out-of-state under non-emergency circumstances by a provider who does not have border status. Transportation to and from these services shall also require prior authorization, which shall be obtained by the transportation provider;
DHS 107.06(2)(b) (b) All medical, surgical, or psychiatric services aimed specifically at weight control or reduction, and procedures to reverse the result of these services;
DHS 107.06(2)(c) (c) Surgical or other medical procedures of questionable medical necessity but deemed advisable in order to correct conditions that may reasonably be assumed to significantly interfere with a recipient's personal or social adjustment or employability, an example of which is cosmetic surgery;
DHS 107.06(2)(d) (d) Prescriptions for those drugs listed in s. DHS 107.10 (2);
DHS 107.06(2)(e) (e) Ligation of internal mammary arteries, unilateral or bilateral;
DHS 107.06(2)(f) (f) Omentopexy for establishing collateral circulation in portal obstruction;
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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.