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.
Claims shall be submitted in accordance with the claims submission requirements, claim form instructions and coding information provided by the department or its fiscal agent.
Every claim submitted shall be signed by the provider or the provider's authorized representative, certifying to the truthfulness, accuracy and completeness of the claim.
A claim shall be submitted within 12 months after the date that services for which the claim is made are provided, except that a claim may be submitted later if the department is notified within that 12 month period that the sole reason for late submission concerns another funding source and the claim is submitted within 180 days after obtaining a decision on reimbursement from the other funding source.
A claim may not be submitted until after the patient has taken delivery of the blood products and supplies.
The department shall establish allowable costs for blood products and supplies as a basis for reimbursing providers.
Reimbursement may not be made for any cost of blood supplies and equipment payable under any other state or federal program or any grant or contract.
Before submitting a claim to the hemophilia home care program, a provider shall seek payment for services provided to a participant from medicare, medical assistance or another health care plan if the participant is eligible for services under medicare, medical assistance or the other health care plan.
When benefits from medicare, medical assistance or another health care plan or other third party payer have been paid, in whole or in part to the provider, the amount of the payment from all other payers shall be indicated on or with the bill to the hemophilia home care program. The amount of the medicare, medical assistance, other health care plan or other third party payer reimbursement shall reduce the amount of the claim for hemophilia home care program payment.
If a provider receives a payment under the program to which the provider is not entitled or in an amount greater than that to which the provider is entitled, the provider shall promptly return the amount of the erroneous or excess payment to the department.
A provider may request a hearing to review a decision to deny payment or the level of payment. A request for a hearing shall be filed with the department's office of administrative hearings within 90 days after the date of the payment or decision to deny payment. A request for a hearing is considered filed upon its receipt by the office of administrative hearings. All appeals shall include written documentation and any information deemed necessary by the department. Hearings shall be conducted in accordance with subch. III of ch. 227
DHS 153.06 Note
Note: The mailing address of the Office of Administrative Hearings is P.O. Box 7875, Madison, Wisconsin 53707.
The department shall use common methods employed by managed care programs and the medical assistance program to contain costs, including prior authorization and other limitations regarding health care utilization and reimbursement.
DHS 153.06 History
Cr. Register, December, 1994, No. 468
, eff. 1-1-95; CR 04-051
: cr. (3) (g) Register November 2004 No. 587
, eff. 12-1-04.
A participant's liability to contribute toward the cost of treatment shall be calculated in accordance with subs. (2)
. If there are 2 or more participants in the same family, the family's liability shall be limited to the liability of one member of the family.
(2) Income deductible.
A participant whose estimated total family income in the current year is at or above 200% of the federal poverty guidelines shall obligate or expend the following percentage of that income to pay the cost of medical treatment for the condition before the hemophilia home care program will provide assistance in paying for the cost of treatment:
When total family income is from 200% to 250% of the federal poverty guidelines, 0.50% of that income.
When total family income is more than 250% but not more than 275% of the federal poverty guidelines, 0.75% of that income.
When total family income is more than 275%, but not more than 300% of the federal poverty guidelines, 1.0% of that income.
When total family income is more than 300% but not more than 325% of the federal poverty guidelines, 1.25% of that income.
When total family income is more than 325% but not more than 350% of the federal poverty guidelines, 2.0% of that income.
When total family income is more than 350% but not more than 375% of the federal poverty guidelines, 2.75% of that income.
When total family income is more than 375% but not more than 400% of the federal poverty guidelines, 3.5% of that income.
When total family income is more than 400% of the federal poverty guidelines, 4.5% of that income.
A participant shall pay a coinsurance amount to cover part of the cost of blood products and home care supplies.
A participant's coinsurance amount shall be determined at the time the patient is certified for eligibility and annually thereafter.
The amount of a participant's coinsurance shall be related to family size and to family income rounded to the nearest whole dollar, in accordance with the schedule in Table 153.07.
The amount that a patient pays in coinsurance annually may not exceed the following applicable percentage of the family's income, rounded to the nearest whole dollar:
(4) Participant copayment.
When a pharmacy directly bills the hemophilia home care program for a prescription received by a program participant, the participant is responsible for a $7.50 copayment amount for each generic drug and a $15.00 copayment amount for each brand name drug.
An heir or beneficiary of the estate of a participant or a participant's surviving spouse may apply to the department for a waiver of an estate claim filed by the department pursuant to s. 49.682
, Stats. The criteria for granting waivers in s. DHS 108.02 (12) (b)
shall apply to applications under this subsection. All of the procedures and rights in s. DHS 108.02 (12) (b)
shall apply to this subsection.
"Beneficiary" means any person nominated in a will to receive an interest in property other than in a fiduciary capacity;
"Decedent" means a deceased participant or the deceased surviving spouse of a participant who received benefits that are subject to recovery under s. 49.682
"Heir" means any person who is entitled under the statutes of intestate succession, ch. 852, Stats.
, to an interest in property of a decedent;
"Waiver applicant" means a beneficiary or heir of a decedent who requests the department to waive an estate claim filed by the department pursuant to s. 49.682
The department may make adjustments to and settle estate claims filed under s. 49.682
, Stats., to obtain the fullest amount practicable.
Patient Coinsurance Liability for the Direct Cost of Treatment
- See PDF for table
DHS 153.07 Note
Note: To illustrate how a patient's coinsurance liability is calculated, assume that the family has 2 members and an annual income of $38,000, and that a bill has been received for treatment in the amount of $600. The patient would be liable for 16% of that bill, or $96.
DHS 153.07 History
Cr. Register, December, 1994, No. 468
, eff. 1-1-95; emerg. cr. (5), eff. 11-1-95; cr. (5), Register, April, 1996, No. 484
, eff. 5-1-96; CR 02-070
: am. (4) Register October 2002 No. 562
, eff. 11-1-02; CR 04-051
: am. (2) and (4), cr. (2) (f) to (h) Register November 2004 No. 587
, eff. 12-1-04; corrections in (5) (a) and (b) (intro.) made under s. 13.92 (4) (b) 7.
, Stats., Register January 2009 No. 637
Standards for comprehensive treatment centers. DHS 153.08(1)(1)
A comprehensive hemophilia treatment center shall comply with the standards in this section.
A comprehensive hemophilia treatment center shall have the following staff:
The physician director shall be a physician licensed in Wisconsin and certified by the American board of internal medicine or American board of pediatrics or equivalent certifying body, with specialized training in hematology.
The responsibilities of the physician director shall include organizing and coordinating the administrative functions of the comprehensive hemophilia treatment center; delegating duties and establishing a formal means of accountability for those involved in patient care; participating in the development, negotiation and implementation of agreements into which the center may enter; maintaining records and submitting any required reports to the department; providing medical supervision; and developing written home care training policies and procedures and supervising their implementation.
The center shall have a multidisciplinary staff which shall include a hematologist, internist, pediatrician, orthopedic surgeon, oral surgeon or dentist, radiologist, physical therapist, registered nurse, social worker and financial counselor.
The multidisciplinary staff and the physician director shall develop patient maintenance programs and shall provide services, including the training of patients in home care, access to the necessary psychosocial evaluations and referrals and assistance in securing reimbursement.
(c) Specialists available.
The center shall arrange for the availability of a nutritionist, psychiatrist or psychologist, and an educational, vocational or rehabilitation counselor, as needed.
A comprehensive hemophilia treatment center shall be approved under ss. 50.32
, Stats., and ch. DHS 124
, and shall meet all of the requirements of s. 1861 (e) of the Social Security Act of 1935, as amended, including having an agreement to participate in the federal Medicare program.
A comprehensive hemophilia treatment center shall provide all of the following:
Training in home care self-infusion techniques for hemophilia patients and their parents or guardians. This training shall include instructing the patient and whoever assists the patient in how to use the products, equipment and supplies necessary for home care treatment;
A written maintenance program for each home care hemophilia patient. The maintenance program shall be reviewed by the multidisciplinary staff every 6 months and shall accompany the patient in inter-facility transfer;
Blood products and home care supplies, including plasma factor concentrate, cryoprecipitate and fresh frozen plasma. Blood products and supplies may be provided directly or under agreement;
Emergency medical services 24-hours a day and 7 days a week for home care patients who need medical services; and
Services of a laboratory certified under 42 CFR 493
capable of testing for plasma factor deficiency and for the presence of inhibitors to one or more clotting factors. Laboratory services may be provided directly or under agreement.
DHS 153.08 Note
The department of health services regulates laboratories testing human specimens under agreement with the federal department of health and human services for compliance with 42 CFR 493
(5) Availability of a grievance mechanism for patients.
A center shall have a written grievance procedure and shall provide a copy to each patient. A patient shall be permitted to file a grievance.
All comprehensive hemophilia treatment centers and other providers shall maintain the following records:
Agreements with persons or organizations for payment which may be made, directly or indirectly, by the hemophilia home care program;
Billings and records which are the subject of the billings, as are necessary to disclose fully the nature and extent of the billings; and
Any and all prescriptions necessary to disclose the nature and extent of blood products and supplies provided and billed for under the program.
DHS 153.08 History
Cr. Register, December, 1994, No. 468
, eff. 1-1-95; corrections in (3) made under s. 13.92 (4) (b) 7.
, Stats., Register January 2009 No. 637
; correction in (4) (e) made under s. 13.92 (4) (b) 7.
, Stats., Register July 2011 No. 667