DHS 107.23(3)(a)4.
4. Services of more than the 2 attendants required under s.
256.15 (4), Stats., are covered only if the recipient's condition requires the physical presence of more than 2 attendants for purposes of restraint or lifting. Medical personnel not employed by the ambulance provider who care for the recipient in transit shall bill the program separately.
DHS 107.23(3)(a)5.a.a. If a recipient is pronounced dead by a legally authorized person after an ambulance is requested but before the ambulance arrives at the pick-up site, emergency service only to the point of pick-up is covered.
DHS 107.23(3)(a)5.b.
b. If ambulance service is provided to a recipient who is pronounced dead enroute to a hospital or dead on arrival at the hospital by a legally authorized person, the entire ambulance service is covered.
DHS 107.23(3)(a)6.
6. Ambulance reimbursement shall include payment for additional services provided by an ambulance provider such as for drugs used in transit or for starting intravenous solutions, EKG monitoring for infection control, charges for reusable devices and equipment, charges for sterilization of a vehicle including after carrying a recipient with a contagious disease, and additional charges for services provided at night or on weekends, or on holidays. Separate payments for these charges shall not be made.
DHS 107.23(3)(a)7.
7. Non-emergency transfers by ambulance that are for the convenience of the recipient or the recipient's family are reimbursed only when the attending physician documents that the participation of the family in the recipient's care is medically necessary and the recipient would suffer hardship if the transfer were not made by ambulance.
DHS 107.23(3)(b)1.1. Transportation by SMV shall be covered only if the purpose of the trip is to receive an MA-covered service. Documentation of the name and address of the service provider shall be kept by the SMV provider. Any order received by the transportation provider by telephone shall be repeated in the form of written documentation within 10 working days of the telephone order or prior to the submission of the claim, whichever comes first.
DHS 107.23(3)(b)2.
2. Charges for waiting time are covered charges. Waiting time is allowable only when a to-and-return trip is being billed. Waiting time may only be charged for one recipient when the transportation provider or driver waits for more than one recipient at one location in close proximity to where the MA-covered services are provided and no other trips are made by the vehicle or driver while the service is provided to the recipient. In this subdivision, “waiting time" means time when the transportation provider is waiting for the recipient to receive MA covered services and return to the vehicle.
DHS 107.23(3)(b)3.
3. Services of a second SMV transportation attendant are covered only if the recipient's condition requires the physical presence of another person for purposes of restraint or lifting. The transportation provider shall obtain a statement of the appropriateness of the second attendant from the physician, physician assistant, nurse midwife or nurse practitioner attesting to the need for the service and shall retain that statement.
DHS 107.23(3)(b)5.
5. A trip to a sheltered workshop or other nonmedical facility is covered only when the recipient is receiving an MA-covered service there on the dates of transportation and the medical services are of the level, intensity or extent consistent with the medical need defined in the recipient's plan of care.
DHS 107.23(3)(b)6.
6. Trips to school for MA-covered services shall be covered only if the recipient is receiving services on the day of the trip under the Individuals with Disabilities Education Act,
20 USC 33, and the MA-covered services are identified in the recipient's individual education plan and are delivered at the school.
DHS 107.23(3)(b)7.
7. Unloaded mileage as defined in sub.
(1) (c) 5. is not reimbursed if there is any other passenger in the vehicle whether or not that passenger is an MA recipient.
DHS 107.23(3)(b)8.
8. When 2 or more recipients are being carried at the same time, the department may adjust the rates.
DHS 107.23(3)(b)9.
9. Additional charges for services at night or on weekends or holidays are not covered charges.
DHS 107.23(3)(b)10.
10. A recipient confined to a cot or stretcher may only be transported in an SMV if the vehicle is equipped with restraints which secure the cot or stretcher to the side and the floor of the vehicle. The recipient shall be medically stable and no monitoring or administration of non-emergency medical services or procedures may be done by SMV personnel.
DHS 107.23(3)(c)1.1. Non-emergency transportation of a recipient by common carrier is subject to approval by the county or tribal agency or its designee before departure. The reimbursement shall be no more than an amount set by the department and shall be less per mile than the rates paid by the department for SMV purposes. Reimbursement for urgent transportation is subject to retroactive approval by the county or tribal agency or its designee.
DHS 107.23(3)(c)2.
2. The county or tribal agency or its designee shall reimburse the recipient or the vendor for transportation service only if the service is not provided directly by the county or tribal agency or its designee.
DHS 107.23(3)(c)3.
3. Transportation provided by a county or tribal agency or its designee shall involve the least costly means of transportation which the recipient is capable of using and which is reasonably available at the time the service is required. Reimbursement to the recipient shall be limited to mileage to the nearest MA provider who can provide the service if the recipient has reasonable access to health care of adequate quality from that provider. Reimbursement shall be made in the most cost-effective manner possible and only after sources for free transportation such as family and friends have been exhausted.
DHS 107.23(3)(c)4.
4. The county or tribal agency or its designee may require documentation by the service provider that an MA-covered service was received at the specific location.
DHS 107.23(3)(c)5.
5. No provider may be reimbursed more for transportation provided for an MA recipient than the provider's usual and customary charge. In this subdivision, “usual and customary charge" means the amount the provider charges or advertises as a charge for transportation except to county or tribal agencies or non-profit agencies.
DHS 107.23(4)
(4)
Non-covered services. The following transportation services and charges related to transportation services are non-covered services:
DHS 107.23(4)(a)
(a) Emergency transportation of a recipient who is pronounced dead by a legally authorized person before the ambulance is called;
DHS 107.23(4)(d)
(d) Charges for excess mileage resulting from the use of indirect routes to and from destinations;
DHS 107.23(4)(g)
(g) SMV transport of an ambulatory recipient, except an ambulatory recipient under sub.
(1) (c) 1., to a methadone clinic or physician's clinic solely to obtain methadone or related services such as drug counseling or urinalysis;
DHS 107.23(4)(h)
(h) Transportation by SMV to a pharmacy to have a prescription filled or refilled or to pick up medication or disposable medical supplies;
DHS 107.23(4)(i)
(i) Transportation by SMV provided solely to compel a recipient to attend therapy, counseling or any other MA-covered appointment; and
DHS 107.23(4)(j)
(j) Transportation to any location where no MA-covered service was provided either at the destination or pick-up point.
DHS 107.23 Note
Note: For more information on non-covered services, see s.
DHS 107.03.
DHS 107.23 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; am. (1) (c) and (4) (5),
Register, February, 1988, No. 386, eff. 3-1-88; r. and recr.,
Register, November, 1994, No. 467, eff. 12-1-94; correction in (3) (a) 4. made under s.
13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636.
DHS 107.24
DHS 107.24 Durable medical equipment and medical supplies. DHS 107.24(1)(a)
(a) “Medical supplies” means disposable, consumable, expendable or nondurable medically necessary supplies which have a very limited life expectancy. Examples are plastic bed pans, catheters, electric pads, hypodermic needles, syringes, continence pads and oxygen administration circuits.
DHS 107.24(1)(b)
(b) “Qualified health care professional” means any of the following:
DHS 107.24(2)(a)1.1. Durable medical equipment (DME) and medical supplies, excluding complex rehabilitation technology identified in subd.
2., are covered services only when prescribed by a physician and when provided by a certified physician, clinic, hospital outpatient department, nursing home, pharmacy, home health agency, therapist, orthotist, prosthetist, hearing instrument specialist or medical equipment vendor.
DHS 107.24(2)(a)2.
2. Complex rehabilitation manual wheelchairs, power wheelchairs, and other seating components identified in the Wisconsin DME and medical supplies indices are covered services only when prescribed by a physician and when provided by a qualified complex rehabilitation technology supplier.
DHS 107.24(2)(b)
(b) Items covered. Covered services are limited to items contained in the Wisconsin durable medical equipment (DME) and medical supplies indices. Items prescribed by a physician which are not contained in one of these indices or in the listing of non-covered services in sub.
(5) require submittal of a DME additional request. Should the item be deemed covered, a prior authorization request may be required.
DHS 107.24(2)(c)
(c) Categories of durable medical equipment. The following are categories of durable medical equipment covered by MA:
DHS 107.24(2)(c)1.
1. Occupational therapy assistive or adaptive equipment. This is medical equipment used to assist a person with a disability to adapt to the environment or achieve independence in performing daily personal functions. Examples are adaptive hygiene equipment, adaptive positioning equipment and adaptive eating utensils.
DHS 107.24(2)(c)2.
2. Orthopedic or corrective shoes. These are any shoes attached to a brace for prosthesis; mismatched shoes involving a difference of a full size or more; or shoes that are modified to take into account discrepancy in limb length or a rigid foot deformation. Arch supports are not considered a brace. Examples of orthopedic or corrective shoes are supinator and pronator shoes, surgical shoes for braces, and custom-molded shoes.
DHS 107.24(2)(c)3.
3. Orthoses. These are devices which limit or assist motion of any segment of the human body. They are designed to stabilize a weakened part or correct a structural problem. Examples are arm braces and leg braces.
DHS 107.24(2)(c)4.
4. Other home health care durable medical equipment. This is medical equipment used to increase the independence of a person with a disability or modify certain disabling conditions. Examples are patient lifts, hospital beds and traction equipment.
DHS 107.24(2)(c)5.
5. Oxygen therapy equipment. This is medical equipment used for the administration of oxygen or medical formulas or to assist with respiratory functions. Examples are a nebulizer, a respirator and a liquid oxygen system.
DHS 107.24(2)(c)6.
6. Physical therapy splinting or adaptive equipment. This is medical equipment used to assist a person with a disability to achieve independence in performing daily activities. Examples are splints and positioning equipment.
DHS 107.24(2)(c)7.
7. Prostheses. These are devices which replace all or part of a body organ to prevent or correct a physical disability or malfunction. Examples are artificial arms, artificial legs and hearing aids.
DHS 107.24(2)(c)8.
8. Wheelchairs. These are chairs mounted on wheels usually specially designed to accommodate individual disabilities and provide mobility. Examples are a standard weight wheelchair, a lightweight wheelchair and an electrically-powered wheelchair.
DHS 107.24(2)(c)9.
9. Complex rehabilitation technology. These are items identified in the Wisconsin DME and medical supplies indices which are updated to comply with s.
49.45 (9r) (a) 2., Stats.
DHS 107.24(2)(d)
(d) Categories of medical supplies. Only approved items within the following generic categories of medical supplies are covered:
DHS 107.24(3)
(3)
Services requiring prior authorization. All of the following services require prior authorization:
DHS 107.24(3)(a)
(a) Purchase of all items indicated as requiring prior authorization in the Wisconsin DME and medical supplies indices, published periodically and distributed to appropriate providers by the department.
DHS 107.24(3)(b)
(b) Repair or modification of an item which exceeds the department-established maximum reimbursement without prior authorization. Reimbursement parameters are published periodically in the DME and medical supplies provider handbook.
DHS 107.24(3)(c)
(c) Purchase, rental, repair or modification of any item not contained in the current DME and medical supplies indices.
DHS 107.24(3)(d)
(d) Purchase of items in excess of department-established frequencies or dollar limits outlined in the current Wisconsin DME and medical supplies indices.
DHS 107.24(3)(e)
(e) The second and succeeding months of rental use, with the exception that all hearing aid or other assistive listening device rentals require prior authorization.
DHS 107.24(3)(f)
(f) Purchase of any item which is not covered by Medicare, part b, when prescribed for a recipient who is also eligible for Medicare.
DHS 107.24(3)(g)
(g) Any item required by a recipient in a nursing home which meets the requirements of sub.
(4) (c).
DHS 107.24(3)(h)
(h) Purchase or rental of a hearing aid or other assistive listening device in any of the following circumstances:
DHS 107.24(3)(h)1.
1. A request for prior authorization of a hearing aid or other ALD shall be reviewed only if the request consists of an otological report from the recipient's physician and an audiological report from an audiologist or hearing instrument specialist, is on forms designated by the department and contains all information requested by the department. A hearing instrument specialist may perform an audiological evaluation and a hearing aid evaluation to be included in the audiological report if these evaluations are prescribed by a physician who determines all of the following:
DHS 107.24(3)(h)1.c.
c. The recipient has no special need which would necessitate either the diagnostic tools of an audiologist or a comprehensive evaluation requiring the expertise of an audiologist.
DHS 107.24(3)(h)2.
2. After a new or replacement hearing aid or other ALD has been worn for a 30-day trial period, the recipient shall obtain a performance check from a certified audiologist, a certified hearing instrument specialist or at a certified speech and hearing center. The department shall provide reimbursement for the cost of the hearing aid or other ALD after the performance check has shown the hearing aid or ALD to be satisfactory, or 45 days has elapsed with no response from the recipient.
DHS 107.24(3)(h)3.
3. Special modifications other than those listed in the MA speech and hearing provider handbook shall require prior authorization.
DHS 107.24(3)(h)4.
4. Provision of services in excess of the life expectancies of equipment enumerated in the MA speech and hearing provider handbook require prior authorization, except for hearing aid or other ALD batteries and repair services.
DHS 107.24(3)(i)
(i) A request for prior authorization of complex rehabilitation manual wheelchairs, complex rehabilitation power wheelchairs, and other complex rehabilitation seating components shall be reviewed only if the request consists of all of the following:
DHS 107.24(3)(i)1.
1. Documentation of a complex rehabilitative technology clinical evaluation performed by a qualified health care professional that includes all of the following:
DHS 107.24(3)(i)1.a.
a. A detailed description of the qualified health care professional's assessment as outlined in the provider handbook including identification of the specific complex rehabilitation technology items requested.
