“Automated claims processing system" means the computerized system operated by the department's fiscal agent for paying the claims of providers.
“Manual partial payment" means a method of paying claims other than through the automated claims processing system.
(b) Automated claims processing.
Except as provided in par. (c)
, payment of provider claims for reimbursement for services provided to recipients shall be made through the department's automated claims processing system.
(c) Manual partial payment.
The department may pay up to 75% of the reimbursable amount of a provider's claim in advance of payments made through the automated claims processing system if all the following conditions exist:
The provider requests a manual partial payment and is informed that the payment will be automatically recouped when the provider's claims are later processed through the automated claims processing system;
A provider's claims for services provided have been pending in the automated claims processing system for more than 30 days, or the provider provides services to MA recipients representing more than 50% of the provider's income and payment for these services has been significantly delayed beyond the claims processing time historically experienced by the provider;
Further delay in payment will have a financial impact on the provider which is likely to adversely affect or disrupt the level of care otherwise provided to recipients; and
The provider has submitted documentation of covered services, including the provider name and MA billing number, the recipient's name and MA number, the date or dates of services provided, type and quantity of services provided as appropriate and any other information pertinent to payment for covered services.
(d) Recoupment of manual partial payments.
Manual partial payments shall be automatically recouped when the provider's claims are processed through the automated claims system.
(e) Cash advances prohibited.
In no case may the department or its fiscal agent make advance payment for services not yet provided. No payment may be made unless covered services have been provided and a claim or document under par. (c) 5.
for these services has been submitted to the department.
(a) General policy.
Pursuant to s. 49.45 (18)
, Stats., the department shall establish copayment rates and deductible amounts for medical services covered under MA. Recipients shall provide the copayment amount or coinsurance to the provider or pay for medical services up to the deductible amount, as appropriate, except that the services and recipients listed in s. DHS 104.01 (12) (a)
are exempt from cost-sharing requirements. Providers are not entitled to reimbursement from MA for the copayment, coinsurance or deductible amounts for which a recipient is liable.
(b) Liability for refunding erroneous copayment.
In the event that medical services are covered by a third party and the recipient makes a copayment to the provider, the department is not responsible for refunding the copayment amount to the recipient.
(3) Non-liability of recipients.
A provider shall accept payments made by the department in accordance with sub. (1)
as payment in full for services provided a recipient. A provider may not attempt to impose a charge for an individual procedure or for overhead which is included in the reimbursement for services provided nor may the provider attempt to impose an unauthorized charge or receive payment from a recipient, relative or other person for services provided, or impose direct charges upon a recipient in lieu of obtaining payment under the program, except under any of the following conditions:
A service desired, needed or requested by a recipient is not covered under the program or a prior authorization request is denied and the recipient is advised of this fact before receiving the service;
An applicant is determined to be eligible retroactively under s. 49.46 (1) (b)
, Stats., and a provider has billed the applicant directly for services rendered during the retroactive period, in which case the provider shall, upon notification of the recipient's retroactive eligibility, submit claims under this section for covered services provided during the retroactive period. Upon receipt of payment from the program for the services, the provider shall reimburse in full the recipient or other person who has made prior payment to the provider. A provider shall not be required to reimburse the recipient or other person in excess of the amount reimbursed by the program; or
DHS 106.04(4)(a)(a) Restrictions.
A provider may not release information to a recipient or to a recipient's attorney relating to charges which have been billed or which will be billed to MA for the cost of care of a recipient without notifying the department, unless any real or potential third-party payer liability has been assigned to the provider.
(b) Provider liability.
If a provider releases information relating to the cost of care of a recipient or beneficiary contrary to par. (a)
, and the recipient or beneficiary receives payment from a liable third-party payer, the provider shall repay to the department any MA benefit payment it has received for the charges in question. The provider may then assert a claim against the recipient or beneficiary for the amount of the MA benefit repaid to the department.
DHS 106.04 Note
Note: See the Wisconsin Medical Assistance Provider Handbook for specific information on procedures to be followed in the release of billing information.
Except as provided in par. (b)
, if a provider receives a payment under the MA program to which the provider is not entitled or in an amount greater than that to which the provider is entitled, the provider shall return to the department the amount of the overpayment, including but not limited to erroneous, excess, duplicative and improper payments, regardless of cause, within 30 days after the date of the overpayment in the case of a duplicative payment from MA, medicare or other health care payer and within 30 days after the date of discovery in the case of all other overpayments.
In lieu of returning the overpayment, a provider may notify the department in writing within 30 days after the date of the overpayment or its discovery, as applicable, of the nature, source and amount of the overpayment and request that the overpayment be deducted from future amounts owed the provider by the MA program.
The department shall honor the request under par. (b)
if the provider is actively participating in the program, is not currently under investigation for fraud or MA program abuse, is not subject to an intermediate sanction under s. DHS 106.08
, and is claiming and receiving MA reimbursement in amounts sufficient to reasonably ensure full recovery of the overpayment within a limited period of time. Any limited recovery period shall be consistent with the applicable federally required time period for the department's repayment of the federal financial participation associated with the overpayment as stated in 42 CFR 433.300
If the department denies the provider's request under par. (b)
to have the overpayment deducted from future amounts paid, the provider shall return to the department the full amount of the overpayment within 30 days after receipt of the department's written denial.
(6) Good faith payment.
A claim denied for recipient eligibility reasons may qualify for a good faith payment if the service provided was provided in good faith to a recipient with an MA identification card which the provider saw on the date of service and which was apparently valid for the date of service.
DHS 106.04 History
Cr. Register, December, 1979, No. 288
, eff. 2-1-80; am. Register, February, 1986, No. 362
, eff. 3-1-86; r. (2) (b) 10. and 11., cr. (7) (f), Register, February, 1988, No. 386
, eff. 3-1-88; renum. (2) (b) 5. to 9. to be 6. to 10. and am. 9. and 10., cr. (2) (b) 5., 11. and 12., Register, December, 1988, No. 396
, eff. 1-1-89; emerg. am. (2) (a), r. (2) (b) to (e), renum. (2) (f) to be (2) (b), eff. 1-1-90; am. (2) (a), r. (2) (b) to (e), renum. (2) (f) to be (2) (b), Register, September, 1990, No. 417
, eff. 10-1-90; emerg. cr. (1m), eff. 11-1-90; cr. (1m), Register, May, 1991, No. 425
, eff. 6-1-91; am. (3) (intro.), Register, September, 1991, No. 429
, eff. 10-1-91; emerg. am. (1m) (c) 1., renum. (1m) (d), (5) and (9) to be (1m) (e), (4) and (6) and am. (4), cr. (1m) (d), r. (4), (7) and (8), r. and recr. (6), eff. 7-1-92; am. (1m) (c) 1., renum. (1m) (d) and (9) to be (1m) (e) and (6), cr. (1m) (d), r. and recr. (5), r. (6) to (8), Register, February, 1993, No. 446
, eff. 3-1-93; correction in (3) (b) made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520
; corrections in (2) (a) and (3) (c) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636
DHS 106.05 Voluntary termination of program participation. DHS 106.05(1)(a)
(a) Termination notice.
Any provider other than a skilled nursing facility or intermediate care facility may at any time terminate participation in the program. A provider electing to terminate program participation shall at least 30 days before the termination date notify the department in writing of that decision and of the effective date of termination from the program.
A provider may not claim reimbursement for services provided recipients on or after the effective date specified in the termination notice. If the provider's notice of termination fails to specify an effective date, the provider's certification to provide and claim reimbursement for services under the program shall be terminated on the date on which notice of termination is received by the department.
(2) Skilled nursing and intermediate care facilities. DHS 106.05(2)(a)(a) Termination notice.
A provider certified under ch. DHS 105
as a skilled nursing facility or intermediate care facility may terminate participation in the program upon advance written notice to the department and to the facility's resident recipients or their legal guardians in accordance with s. 50.03 (14) (e)
, Stats. The notice shall specify the effective date of the facility's termination of program participation.
A skilled nursing facility or intermediate care facility electing to terminate program participation may claim and receive reimbursement for services for a period of not more than 30 days beginning on the effective termination date. Services furnished during the 30-day period shall be reimbursable provided that:
The recipient was not admitted to the facility after the date on which written notice of program termination was given the department; and
The facility demonstrates to the satisfaction of the department that it has made reasonable efforts to facilitate the orderly transfer of affected resident recipients to another appropriate facility.
(3) Record retention.
Voluntary termination of a provider's program participation under this section does not end the provider's responsibility to retain and provide access to records as required under s. DHS 106.02 (9)
unless an alternative arrangement for retention, maintenance and access has been established by the provider and approved in writing by the department.
DHS 106.05 History
Cr. Register, December, 1979, No. 288
, eff. 2-1-80; am. Register, February, 1986, No. 362
, eff. 3-1-86;
correction in (2) (a) made under s. 13.92 (4) (b) 7.
, Stats., Register December 2008 No. 636
DHS 106.06 Involuntary termination or suspension from program participation.
The department may suspend or terminate the certification of any person, partnership, corporation, association, agency, institution or other entity participating as a health care provider under the program, if the suspension or termination will not deny recipients access to MA services and if after reasonable notice and opportunity for a hearing the department finds that any of the following occurred:
(1) Non-compliance with MA requirements.
The provider has repeatedly and knowingly failed or refused to comply with federal or state statutes, rules or regulations applicable to the delivery of, or billing for, services under the program;
(2) Refusal to comply with provider agreement.
The provider has repeatedly and knowingly failed or refused to comply with the terms and conditions of its provider agreement;
The provider has prescribed, provided, or claimed reimbursement for services under the program which were:
Findings precipitating action by the department under this subsection shall be based on the written findings of a peer review committee established by the department or a PRO under contract to the department to review and evaluate health care services provided under the program. The findings shall be presumptive evidence that the provider has engaged in improper activities under this subsection.
(4) Suspension or revocation.
The licensure, certification, authorization or other official entitlement required as a prerequisite to the provider's certification to participate in the program has been suspended, restricted, terminated, expired or revoked;
In the case of a freestanding personal care agency as defined in s. DHS 105.17 (1) (a)
, the freestanding personal care agency has violated one or more of the applicable requirements of ch. DHS 105
in a manner or to a degree that may endanger or threaten the health or safety of clients, has not paid the fee, or has failed to provide information requested by the department in connection with certification;
(5) Public health in jeopardy.
A provider's licensure, certification, authorization or other official entitlement has been suspended, terminated, expired or revoked under state or federal law following a determination that the health, safety or welfare of the public is in jeopardy;
The provider is excluded or terminated from the medicare program or otherwise sanctioned by the medicare program because of fraud or abuse of the medicare program under 42 CFR 420.101
The provider is a party convicted of a crime, ineligible to participate in the medicare program and the health care financing administration directs the department to suspend the provider;
(7) Service during period of noncertification.
The provider has provided a service to a recipient during a period in which provider's licensure, certification, authorization, or other entitlement to provide the service was terminated, suspended, expired or revoked;
(8) Criminal conviction.
The provider has been convicted of a criminal offense related to providing or claiming reimbursement for services under medicare or under this or any other state's MA program. In this subsection, “convicted" means that a judgment of conviction has been entered by a federal, state or local court, irrespective of whether an appeal from that judgment is pending;
(9) False statements.
The provider knowingly made or caused to be made a false statement or misrepresentation of material fact in connection with provider's application for certification or recertification;
(10) Failure to report status change.
The provider has concealed, failed or refused to disclose any material change in licensure, certification, authorization, or ownership which, if known to the department, would have precluded the provider from being certified;
(11) Concealment of outside controlling interests.
The provider at the time of application for certification under ch. DHS 105
or after receiving that certification knowingly misrepresented, concealed or failed to disclose to the department full and complete information as to the identity of each person holding an ownership or controlling interest in the provider;
(12) Concealment of provider's controlling interests.
The provider at the time of application for certification under ch. DHS 105
or after receiving that certification knowingly misrepresented, concealed or failed to disclose to the department an ownership or controlling interest the provider held in a corporation, partnership, sole proprietorship or other entity certified under the program;
(13) False statements concerning the nature and scope of services.
The provider made or caused to be made false statements or misrepresentation of material facts in records required under s. DHS 105.02 (4)
and maintained by the provider for purposes of identifying the nature and scope of services provided under the program;
(14) False statements concerning the costs of services.
The provider has knowingly made or caused to be made false statements or has misrepresented material facts in connection with the provider's usual and customary charges submitted to the department as a claim for reimbursement;
(15) False statements concerning cost reports.
The provider has knowingly made or caused to be made false statements or misrepresentation of material facts in cost reports relating to the provider's costs, expenditures or usual and customary charges submitted to the department for the purpose of establishing reimbursement rates under the program;
(16) Failure to keep records.
The provider has failed or refused to prepare, maintain or make available for inspection, audit or copy by persons authorized by the department, records necessary to fully disclose the nature, scope and need of services provided recipients;
(17) False statement on claim.
The provider has knowingly made or caused to be made a false statement or misrepresentation of a material fact in a claim;
(18) Obstruction of investigation.
The provider has intentionally by act of omission or commission obstructed an investigation or audit being conducted by authorized departmental personnel pursuant to s. 49.45 (3) (g)
(19) Payment for referral.
The provider has offered or paid to another person, or solicited or received from another person, any remuneration in cash or in kind in consideration for a referral of a recipient for the purpose of procuring the opportunity to provide covered services to the recipient, payment for which may be made in whole or in part under the program;
(20) Failure to request copayments.
The provider has failed to request from recipients the required copayment, deductible or coinsurance amount applicable to the service provided to recipients after having received a written statement from the department noting the provider's repeated failure to request required copayments, deductible or coinsurance amounts and indicating the intent to impose a sanction if the provider continues to fail to make these requests;
DHS 106.06 Note
See s. 49.45 (18)
, Stats., and s. DHS 106.04 (2)
for requirements on copayments, deductibles and coinsurance amounts.
(21) Charging recipient.
The provider has, in addition to claiming reimbursement for services provided a recipient, imposed a charge on the recipient for the services or has attempted to obtain payment from the recipient in lieu of claiming reimbursement through the program contrary to provisions of s. DHS 106.04 (3)
(22) Racial or ethnic discrimination.
The provider has refused to provide or has denied services to recipients on the basis of the recipient's race, color or national origin in violation of the Civil Rights Act of 1964, as amended, 42 USC 200d
, et. Seq., and the implementing regulations. 45 CFR Part 80
(23) Disability discrimination.
The provider has refused to provide or has denied services to a recipient with a disability solely on the basis of disability, thereby violating section 504 of the Rehabilitation Act of 1973, as amended, 29 USC 794
(24) Funds mismanagement.
A provider providing skilled nursing or intermediate care services has failed to or has refused to establish and maintain an accounting system which ensures full and complete accounting of the personal funds of residents who are recipients, or has engaged in, caused, or condoned serious mismanagement or misappropriation of the funds;
DHS 106.06 Note
See s. DHS 107.09 (4) (i)
for requirements concerning accounting for the personal funds of nursing home residents.
(25) Refusal to repay erroneous payments.
The provider has failed to repay or has refused to repay amounts that have been determined to be owed the department either under s. DHS 106.04 (5)
or pursuant to a judgment of a court of competent jurisdiction, as a result of erroneous or improper payments made to the provider under the program;
(26) Faulty submission of claims, failure to heed MA billing standards, or submission of inaccurate billing information.
The provider has created substantial extraordinary processing costs by submitting MA claims for services that the provider knows, or should have known, are not reimbursable by MA, MA claims which fail to provide correct or complete information necessary for timely and accurate claims processing and payment in accordance with proper billing instructions published by the department or the fiscal agent, or MA claims which include procedure codes or procedure descriptions that are inconsistent with the nature, level or amount of health care provided to the recipient, and, in addition, the provider has failed to reimburse the department for extraordinary processing costs attributable to these practices;
(28) Other termination reasons.
The provider, a person with management responsibility for the provider, an officer or person owning directly or indirectly 5% or more of the shares or other evidences of ownership of a corporate provider, a partner in a partnership which is a provider, or the owner of a sole proprietorship which is a provider, was:
Terminated from participation in the program within the preceding 5 years;
A person with management responsibility for a provider previously terminated under this section, or a person who was employed by a previously terminated provider at the time during which the act or acts occurred which served as the basis for the termination of the provider's program anticipation and knowingly caused, concealed, performed or condoned those acts;
An officer of or person owning, either directly or indirectly, 5% of the stock or other evidences of ownership in a corporate provider previously terminated at the time during which the act or acts occurred which served as the basis for the termination;
An owner of a sole proprietorship or a partner in a partnership that was terminated as a provider under this section, and the person was the owner or a partner at the time during which the act or acts occurred which served as the basis for the termination;
Convicted of a criminal offense related to the provision of services or claiming of reimbursement for services under medicare or under this or any other state's medical assistance program. In this subsection, “convicted" means that a judgment of conviction has been entered by a federal, state or local court, irrespective of whether an appeal from the judgment is pending;
Excluded, terminated, suspended or otherwise sanctioned by medicare or by this or any other state's medical assistance program; or
Barred from participation in medicare by the federal department of health and human services, and the secretary of the federal department of health and human services has directed the department to exclude the individual or entity from participating in the MA program under the authority of section 1128 or 1128A of the social security act of 1935, as amended.
(29) Billing for services of a non-certified provider.
The provider submitted claims for services provided by an individual whose MA certification had been terminated or suspended, and the submitting provider had knowledge of the individual's termination or suspension; or
(30) Business transfer liability.
The provider has failed to comply with the requirements of s. 49.45 (21)
, Stats., regarding liability for repayment of overpayments in cases of business transfer.