DHS 107.08 Note
For more information on prior authorization, see s. DHS 107.02 (3)
DHS 107.08(3)(a)(a) Inpatient limitations.
The following limitations apply to hospital inpatient services:
Inpatient admission for non-therapeutic sterilization is a covered service only if the procedures specified in s. DHS 107.06 (3)
are followed; and
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.
(b) Outpatient limitations.
The following limitations apply to hospital outpatient services:
For services provided by a hospital on an outpatient basis, the same requirements shall apply to the hospital as apply to MA-certified non-hospital providers performing the same services;
Outpatient services performed outside the hospital facility may not be reimbursed as hospital outpatient services; and
All covered outpatient services provided during a calendar day shall be included as one outpatient visit.
If a hospital is certified and reimbursed as a type of provider other than a hospital, the hospital is subject to all coverage and reimbursement requirements for that type of provider.
On any given calendar day a patient in a hospital shall be considered either an inpatient or an outpatient, but not both. Emergency room services shall be considered outpatient services unless the patient is admitted as an inpatient and counted on the midnight census. Patients who are same day admission and discharge patients and who die before the midnight census shall be considered inpatients.
All covered services provided during an inpatient stay, except professional services which are separately billed, shall be considered hospital inpatient services.
Unnecessary or inappropriate inpatient admissions or portions of a stay;
Hospitalizations or portions of hospitalizations disallowed by the PRO;
Hospitalizations either for or resulting in surgeries which the department views as experimental due to questionable or unproven medical effectiveness;
Inpatient services and outpatient services for the same patient on the same date of service unless the patient is admitted to a hospital other than the facility providing the outpatient care;
Hospital admissions on Friday or Saturday, except for emergencies, accident or accident care and obstetrical cases, unless the hospital can demonstrate to the satisfaction of the department that the hospital provides all of its services 7 days a week; and
Hospital laboratory, diagnostic, radiology and imaging tests not ordered by a physician, except in emergencies;
Neither MA nor the recipient may be held responsible for charges or services identified in par. (a)
as non-covered, except that a recipient may be billed for charges under par. (a) 3.
, if the recipient was notified in writing in advance of the hospital stay that the service was not a covered service.
If hospital services for a patient are no longer medically necessary and an appropriate alternative care setting is available but the patient refuses discharge, the patient may be billed for continued services if he or she receives written notification prior to the time medically unnecessary services are provided.
The following professional services are not covered as part of a hospital inpatient claim but shall be billed by an appropriately certified MA provider;
Services of physicians, including pathologists, radiologists and the professional-billed component of laboratory and radiology or imaging services, except that services by physician intern and residents services are included as hospital services;
Services of psychiatrists and psychologists, except when performing group therapy and medication management, including services provided to a hospital inpatient when billed by a hospital, clinic or other mental health or AODA provider;
Services of nurse midwives, nurse practitioners and independent nurses when functioning as independent providers;
Professional services provided to hospital inpatients are not covered hospital inpatient services but are rather professional services and subject to the requirements in this chapter that apply to the services provided by the particular provider type.
Neither a hospital nor a provider performing professional services to hospital inpatients may impose an unauthorized charge on recipients for services covered under this chapter.
DHS 107.08 Note
For more information on non-covered services, see s. DHS 107.03
DHS 107.08 History
Cr. Register, February, 1986, No. 362
, eff. 3-1-86; am. (4) (e) and (f), cr. (4) (g), Register, February, 1988, No. 388
, eff. 3-1-88; correction in (3) (g) made under s. 13.93 (2m) (b) 7., Stats., Register, June, 1990, No. 414
; emerg. renum. (4) to be (4) (a) and am. (4) (a) (intro.) 1., 2., 4., 6. and 7., cr. (4) (b) to (f) eff. 1-1-91; r. and recr. Register, September, 1991, No. 429
, eff. 10-1-91; correction in (2) (d) made under s. 13.93 (2m) (b) 7., Register August 2006 No. 608
; corrections in (1) and (3) (c) 1., made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636
In this section, "active treatment" means an ongoing, organized effort to help each resident attain his or her developmental capacity through the resident's regular participation, in accordance with an individualized plan, in a program of activities designed to enable the resident to attain the optimal physical, intellectual, social and vocational levels of functioning of which he or she is capable.
(2) Covered services.
Covered nursing home services are medically necessary services provided by a certified nursing home to an inpatient and prescribed by a physician in a written plan of care. The costs of all routine, day-to-day health care services and materials provided to recipients by a nursing home shall be reimbursed within the daily rate determined for MA in accordance with s. 49.45 (6m)
, Stats. These services are the following:
Special care services, including activity therapy, recreation, social services and religious services;
Supportive services, including dietary, housekeeping, maintenance, institutional laundry and personal laundry services, but excluding personal dry cleaning services;
Physical plant, including depreciation, insurance and interest on plant;
Personal comfort items, medical supplies and special care supplies. These are items reasonably associated with normal and routine nursing home services which are listed in the nursing home payment formula. If a recipient specifically requests a brand name which the nursing home does not routinely supply and for which there is no equivalent or close substitute included in the daily rate, the recipient, after having been informed in advance that the equivalent or close substitute is not available without charge, will be expected to pay for that brand item at cost out of personal funds; and
Indirect services provided by independent providers of service.
DHS 107.09 Note
Note: Copies of the Nursing Home Payment Formula may be obtained from Records Custodian, Division of Health Care Access and Accountability, P.O. Box 309, Madison, Wisconsin 53701.
DHS 107.09 Note
Note: Examples of indirect services provided by independent providers of services are services performed by a pharmacist reviewing prescription services for a facility and services performed by an occupational therapist developing an activity program for a facility.
(3) Services requiring prior authorization.
The rental or purchase of a specialized wheelchair for a recipient in a nursing home, regardless of the purchase or rental cost, requires prior authorization from the department.
DHS 107.09 Note
For more information on prior authorization, see s. DHS 107.02 (3)
Treatment costs which are both extraordinary and unique to individual recipients in nursing homes shall be reimbursed separately as ancillary costs, subject to any modifications made under sub. (2) (b)
. The following items are not included in calculating the daily nursing home rate but may be reimbursed separately:
Oxygen in liters, tanks, or hours, including tank rentals and monthly rental fees for concentrators;
Tracheostomy and ventilatory supplies and related equipment, subject to guidelines and limitations published by the department in the provider handbook;
Transportation of a recipient to obtain health treatment or care if the treatment or care is prescribed by a physician as medically necessary and is performed at a physician's office, clinic, or other recognized medical treatment center, if the transportation service is provided by the nursing home, in its controlled equipment and by its staff, or by common carrier such as bus or taxi, and if the transportation service was provided prior to July 1, 1986. Transportation shall not be reimbursed as an ancillary service on or after July 1, 1986; and
Direct services provided by independent providers of service only if the nursing home can demonstrate to the department that to pay for the service in question as an add-on adjustment to the nursing home's daily rate is equal in cost or less costly than to reimburse the independent service provider through a separate billing. The nursing home may receive an ancillary add-on adjustment to its daily rate in accordance with s. 49.45 (6m) (b)
, Stats. The independent service provider may not claim direct reimbursement if the nursing home receives an ancillary add-on adjustment to its daily rate for the service.
The costs of services and materials identified in subd. 1.
which are provided to recipients shall be reimbursed in the following manner:
Claims shall be submitted under the nursing home's provider number, and shall appear on the same claim form used for claiming reimbursement at the daily nursing home rate;
The items identified in subd. 1.
shall have been prescribed in writing by the attending physician, or the physician's entry in the medical records or nursing charts shall make the need for the items obvious;
The amounts billed shall reflect the fact that the nursing home has taken advantage of the benefits associated with quantity purchasing and other outside funding sources;
Reimbursement for questionable materials and services shall be decided by the department;
Claims for transportation shall show the name and address of any treatment center to which the patient recipient was transported, and the total number of miles to and from the treatment center; and
The amount charged for transportation may not include the cost of the facility's staff time, and shall be for an actual mileage amount.
(b) Independent providers of service.
Whenever an ancillary cost is incurred under this subsection by an independent provider of service, reimbursement may be claimed only by the independent provider on its provider number. The procedures followed shall be in accordance with program requirements for that provider specialty type.
(c) Services covered in a Christian Science sanatorium.
Services covered in a Christian Science sanatorium shall be services ordinarily received by inpatients of a Christian Science sanatorium, but only to the extent that these services are the Christian Science equivalent of services which constitute inpatient services furnished by a hospital or skilled nursing facility.
Wheelchairs shall be provided by skilled nursing and intermediate care facilities in sufficient quantity to meet the health needs of patients who are recipients. Nursing homes which specialize in providing rehabilitative services and treatment for the developmentally or physically disabled, or both, shall provide the special equipment, including commodes, elevated toilet seats, grab bars, wheelchairs adapted to the recipient's disability, and other adaptive prosthetics, orthotics and equipment necessary for the provision of these services. The facility shall provide replacement wheelchairs for recipients who have changing wheelchair needs.
(e) Determination of services as skilled.
In determining whether a nursing service is skilled, the following criteria shall be applied:
Where the inherent complexity of a service prescribed for a patient is such that it can be safely and effectively performed only by or under the direct supervision of technical or professional personnel, the service shall constitute a skilled service;