reglab/statecodes huggingface dataset:
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 106 - Provider Rights And Responsibilities › Section DHS 106.01 - Introduction

Current through June 24, 2024
In addition to provisions of chs.
				  DHS
				  105 and
				  107 relating to individual
				  provider types and the manner by which specified services are to be provided
				  and paid for under medical assistance (MA), the participation of all providers
				  certified under ch. DHS 105 to provide or claim reimbursement for services
				  under the program shall be subject to the conditions set forth in this
				  chapter.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 106 - Provider Rights And Responsibilities › Section DHS 106.03 - Manner of preparing and submitting claims for reimbursement

Current through June 24, 2024
(1) FORMAT.
(a) In this subsection, "billing service"
				means a provider or an entity under contract to a provider which provides
				electronic media billing or electronic billing transmission for one or more
				providers.
(b) A provider shall use
				claim forms prescribed or furnished by the department, except that a provider
				may submit claims by electronic media or electronic transmission if the
				provider or billing service is approved by the department for electronic claims
				submission. A billing service shall be approved in writing by the department
				based on the billing service's ability to consistently meet format and content
				specifications required for the applicable provider type. The department shall,
				upon request, provide a written format and the content specifications required
				for electronic media or electronic transmission billings and shall advise the
				provider or billing service of procedures required to obtain department
				approval of electronic billing.
(c)
				Upon the department's approval of the provider or the provider's billing
				service to submit claims through electronic media or electronic transmission
				billing, the provider shall sign an agreement to comply with the format,
				content and procedural requirements of the department.
(d) The department may at its discretion
				revoke its approval and rescind the agreement for electronic media or
				electronically transmitted claims submission at any time if the provider or
				billing service fails to fully comply with all of the department's instructions
				for submission of electronic media or electronically transmitted claims, or
				repeatedly submits duplicate, inaccurate or incomplete claims. The department
				may at its discretion revoke its approval and rescind the agreement under par.
				(c) when the provider's claims repeatedly fail to provide correct and complete
				information necessary for timely and accurate claims processing and payment in
				accordance with billing instructions provided by the department or its fiscal
				agent.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 106 - Provider Rights And Responsibilities › Section DHS 106.04 - Payment of claims for reimbursement

Current through June 24, 2024
(1) TIMELINESS.
(a)
Timeliness of payment.
The department shall reimburse a provider for a properly provided covered
				service according to the provider payment schedule entitled "terms of provider
				reimbursement," found in the appropriate MA provider handbook distributed by
				the department. The department shall issue payment on claims for covered
				services, properly completed and submitted by the provider, in a timely manner.
				Payment shall be issued on at least 95% of these claims within 30 days of claim
				receipt, on at least 99% of these claims within 90 days of claim receipt, and
				on 100% of these claims within 180 days of receipt. The department may not
				consider the amount of the claim in processing claims under this
				subsection.
(b)
Exceptions.
The department may exceed claims payment limits
				under par. (a) for any of the following reasons:
1. If a claim for payment under medicare has
				been filed in a timely manner, the department may pay a MA claim relating to
				the same services within 6 months after the department or the provider receives
				notice of the disposition of the medicare claims;
2. The department may make payments at any
				time in accordance with a court order, or to carry out hearing decisions or
				department corrective actions taken to resolve a dispute; or
3. The department may issue payments in
				accordance with waiver provisions if it has obtained a waiver from the federal
				health care financing administration under
				42 CFR
				447.45(e).
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 106 - Provider Rights And Responsibilities › Section DHS 106.05 - Voluntary termination of program participation

Current through June 24, 2024
(1) PROVIDERS OTHER
				THAN NURSING HOMES.
(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.
(b)
Reimbursement.
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.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 106 - Provider Rights And Responsibilities › Section DHS 106.06 - Involuntary termination or suspension from program participation

Current through June 24, 2024
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;
(3) IMPROPER ACTIVITIES.
(a) The provider has prescribed, provided, or
				claimed reimbursement for services under the program which were:
1. Inappropriate;
2. Unnecessary or in excess of the
				recipient's needs;
3. Detrimental
				to the health and safety of the recipient; or
4. Of grossly inferior quality.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 106 - Provider Rights And Responsibilities › Section DHS 106.065 - Involuntary termination and alternative sanctions for home care providers

Current through June 24, 2024
(1) TERMINATION.
(a) The department may terminate a home care
				provider's certification to participate in the MA program for failure to comply
				with the requirements of s.
				DHS
				105.19,
				107.11,
				107.113 or
				107.12, as applicable, or for any of
				the reasons described in s.
				DHS
				106.06 after reasonable notice and opportunity for a
				hearing under s.
				DHS
				106.12(4).
(b) The department shall provide at least 15
				working days advance notice of termination to the provider, except at least 5
				calendar days advance notice to providers is required in situations where the
				recipient's health and safety is in immediate jeopardy.
(c) Any provider terminated under this
				section shall have 30 calendar days from the date of termination of
				certification to make alternative care arrangements for MA recipients under the
				provider's care before the effective date of termination. After the 30-day
				period, MA payment for services provided will cease, except for payments to
				providers terminated in immediate jeopardy situations. In immediate jeopardy
				situations, as determined by the department, the department may make
				alternative care arrangements to preserve continuity of care and for the
				protection of the recipient.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 106 - Provider Rights And Responsibilities › Section DHS 106.07 - Effects of suspension or involuntary termination

Current through June 24, 2024
(1) LENGTH OF
				SUSPENSION OR INVOLUNTARY TERMINATION. In determining the period for which a
				party identified in this chapter is to be disqualified from participation in
				the program, the department shall consider the following factors:
(a) The number and nature of the program
				violations and other related offenses;
(b) The nature and extent of any adverse
				impact on recipients caused by the violations;
(c) The amount of any damages;
(d) Any mitigating circumstances;
				and
(e) Any other pertinent facts
				which have direct bearing on the nature and seriousness of the program
				violations or related offenses.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 106 - Provider Rights And Responsibilities › Section DHS 106.08 - Intermediate sanctions

Current through June 24, 2024
(1) To enforce compliance with MA program
				requirements, the department may impose on a provider for a violation listed
				under sub. (2) one or more of the sanctions under sub. (3) unless the
				requirements of s.
				DHS
				106.065 apply. Any sanction imposed by the department
				pursuant to this section may be appealed by the provider under s.
				DHS
				106.12. Prior to imposing any alternative sanction
				under this section the department shall issue a written notice to the provider
				in accordance with s.
				DHS
				106.12(3). Nothing in this chapter
				shall be construed to compel the department, through a fair hearing or
				otherwise, to impose an intermediate sanction in lieu of suspension or
				termination of certification, a different intermediate sanction, monetary
				recoveries, auditing, withholding of claims or pre-payment review, nor may
				imposition of an intermediate sanction on a provider be construed to limit the
				department's authority under s.
				DHS
				106.06,
				106.065,
				106.07,
				106.10 or
				106.11, under this section, or under
				the applicable provider agreement, concluded pursuant to s.
				49.45(2)
				(a) 9, Stats.
(2) The department may impose an intermediate
				sanction under sub. (3) for any of the following violations of this chapter:
(a) For conduct specified in s.
				DHS
				106.06;
(b) For refusal to grant the department
				access to records under s.
				DHS
				106.02(9) (e);
(c) For conduct resulting in repeated
				recoveries under s.
				DHS
				108.02(9);
(d) For non-compliance with one or more
				certification requirement applicable to the type of provider under ch. DHS
				105;
(e) For interference with
				recipient rights specified under ch. DHS 104; or
(f) For refusal or repeated failure to comply
				with one or more requirement specified under this chapter.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 106 - Provider Rights And Responsibilities › Section DHS 106.09 - Departmental discretion to pursue monetary recovery

Current through June 24, 2024
(1) Nothing in this
				chapter shall preclude the department from pursuing monetary recovery from a
				provider at the same time action is initiated to impose sanctions provided for
				under this chapter.
(2) The
				department may pursue monetary recovery from a provider of case management
				services or community support program services when an audit adjustment or
				disallowance has been attributed to the provider by the federal health care
				financing administration or the department. The provider shall be liable for
				the entire amount. However, no fiscal sanction under this subsection shall be
				taken against a provider unless it is based on a specific policy which was:
(a) In effect during the time period being
				audited; and
(b) Communicated to
				the provider in writing by the department or the federal health care financing
				administration prior to the time period audited.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 106 - Provider Rights And Responsibilities › Section DHS 106.10 - Withholding payment of claims

Current through June 24, 2024
(1) Suspension or
				termination from participation shall preclude a provider from submitting any
				claims for payment, either personally or through claims submitted by any
				clinic, group, corporation or other association for any health care provided
				under MA, except for health care provided prior to the suspension or
				termination.
(2) No clinic, group,
				corporation or other association which is a provider of services may submit any
				claim for payment for any health care provided by an individual provider within
				that organization who has been suspended or terminated from participation in
				MA, except for health care provided prior to the suspension or
				termination.
(3) The department may
				recover any payments made in violation of this subsection. Knowing submission
				of these claims shall be a grounds for administrative sanctions against the
				submitting provider.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 106 - Provider Rights And Responsibilities › Section DHS 106.11 - Pre-payment review of claims

Current through June 24, 2024
(1) HEALTH CARE
				REVIEW COMMITTEES. The department shall establish committees of qualified
				health care professionals to evaluate and review the appropriateness, quality
				and quantity of services furnished recipients.
(2) REFERRAL OF ABERRANT PRACTICES. If the
				department has cause to suspect that a provider is prescribing or providing
				services which are not necessary for recipients, are in excess of the medical
				needs of recipients, or do not conform to applicable professional practice
				standards, the department shall, before issuing payment for the claims, refer
				the claims to the appropriate health care review committee established under
				sub. (1). The committee shall review and evaluate the medical necessity,
				appropriateness and propriety of the services for which payment is claimed. The
				decision to deny or issue the payment for the claims shall take into
				consideration the findings and recommendation of the committee.
(3) WITHDRAWAL OF REVIEW COMMITTEE MEMBERS
				FOR CONFLICT OF INTEREST. No individual member of a health care review
				committee established under sub. (1) may participate in a review and evaluation
				contemplated in sub. (2) if the individual has been directly involved in the
				treatment of recipients who are the subject of the claims under review or if
				the individual is financially or contractually related to the provider under
				review or if the individual is employed by the provider under review.
(4) PROVIDER NOTIFICATION OF
				PREPAYMENT REVIEW. A provider shall be notified by the department of the
				institution of the pre-payment review process under sub. (2). Payment shall be
				issued or denied, following review by a health care review committee, within 60
				days of the date on which the claims were submitted to the fiscal agent by the
				provider.
(5) APPLICATION OF
				SANCTION. If a health care review committee established under sub. (1) finds
				that a provider has delivered services that are inappropriate or not medically
				necessary, the department may require the provider to request and receive from
				the department authorization prior to the delivery of any service under the
				program.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 106 - Provider Rights And Responsibilities › Section DHS 106.12 - Procedure, pleadings and practice

Current through June 24, 2024
(1) SCOPE. The
				provisions of this section shall govern the following administrative actions by
				the department:
(a) Decertification or
				suspension of a provider from the medical assistance program pursuant to s.
				49.45(2)
				(a)12., Stats.;
(b) Imposition of additional sanctions for
				non-compliance with the terms of provider agreements under s.
				49.45(2)
				(a) 9, Stats., or certification criteria
				established under s.
				49.45(2)
				(a)11., Stats., pursuant to s.
				49.45(2)
				(a)13., Stats.; and
(c) Any action or inaction for which due
				process is otherwise required under s.
				227.42,
				Stats.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 106 - Provider Rights And Responsibilities › Section DHS 106.13 - Discretionary waivers and variances

Current through June 24, 2024
A provider or recipient may apply for and the department
				  shall consider applications for a discretionary waiver or variance of any rule
				  in chs.
				  DHS 102 to
				  105,
				  107 and
				  108, excluding ss.
				  DHS 107.02(1) (b), (2) (e) to
				  (j) and (3) (a) and (b) and (d) to (h), to
				  107.03(1) (8) and (10) (18), and
				  107.035. Waivers and variances shall
				  not be available to permit coverage of services that are either expressly
				  identified as non-covered in ch. DHS 107 or are not expressly mentioned in ch.
				  DHS 107. The following requirements and procedures apply to applications under
				  this section:
(1) REQUIREMENTS FOR A
				DISCRETIONARY WAIVER OR VARIANCE. A discretionary wavier or variance may be
				granted only if the department finds all of the following are met:
(a) The waiver or variance will not adversely
				affect the health, safety or welfare of any recipient;
(b) Either:
1. Strict enforcement of a requirement would
				result in unreasonable hardship on the provider or on a recipient; or
2. An alternative to a rule, including a new
				concept, method, procedure or technique, new equipment, new personnel
				qualifications or the implementation of a pilot project is in the interests of
				better care or management;
(c) The waiver or variance is consistent with
				all applicable state and federal statutes and federal regulations;
(d) Consistent with the MA state plan and
				with the federal health care financing administration and other applicable
				federal program requirements, federal financial participation is available for
				all services under the waiver or variance; and
(e) Services relating to the waiver or
				variance are medically necessary.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.01 - General statement of coverage

Current through June 24, 2024
(1) The department
				shall reimburse providers for medically necessary and appropriate health care
				services listed in ss.
				49.46(2) and
				49.47(6) (a),
				Stats., when provided to currently eligible medical assistance recipients,
				including emergency services provided by persons or institutions not currently
				certified. The department shall also reimburse providers certified to provide
				case management services as defined in s. DHS 107.32 to eligible
				recipients.
(2) Services provided
				by a student during a practicum are reimbursable under the following
				conditions:
(a) The services meet the
				requirements of this chapter;
(b)
				Reimbursement for the services is not reflected in prospective payments to the
				hospital, skilled nursing facility or intermediate care facility at which the
				student is providing the services;
(c) The student does not bill and is not
				reimbursed directly for his or her services;
(d) The student provides services under the
				direct, immediate supervision of a certified provider in accordance with their
				profession's regulatory body; and
(e) The supervisor documents in writing all
				services provided by the student.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.02 - General limitations

Current through June 24, 2024
(1) PAYMENT.
(a) The department shall reject payment for
				claims which fail to meet program requirements. However, claims rejected for
				this reason may be eligible for reimbursement if, upon resubmission, all
				program requirements are met.
(am)
				When EVV is required for applicable services, claims shall be submitted in
				accordance with s.
				DHS 106.03
				(2m). Claims that require EVV that are not
				matched to an EVV record may be denied.
(b) Medical assistance shall pay the
				deductible and coinsurance amounts for services provided under this chapter
				which are not paid by medicare under
				42 USC
				1395 to
				1395zz, and shall pay the monthly
				premiums under 42 USC
				1395v. Payment of the coinsurance amount for
				a service under medicare part B,
				42 USC
				1395j to
				1395w, may not exceed the
				allowable charge for this service under MA minus the medicare payment,
				effective for dates of service on or after July 1, 1988.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.035 - Definition and identification of experimental services

Current through June 24, 2024
(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.
(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:
(a) The current and historical judgment of
				the medical community as evidenced by medical research, studies, journals or
				treatises;
(b) The extent to which
				medicare and private health insurers recognize and provide coverage for the
				service;
(c) The current judgment
				of experts and specialists in the medical specialty area or areas in which the
				service is applicable or used; and
(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.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.04 - Coverage of out-of-state services

Current through June 24, 2024
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.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.05 - Coverage of emergency services provided by a person not a certified provider

Current through June 24, 2024
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.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.065 - Anesthesiology services

Current through June 24, 2024
(1) COVERED
				SERVICES. Anesthesiology services covered by the MA program are any medically
				necessary medical services applied to a recipient to induce the loss of
				sensation of pain associated with surgery, dental procedures or radiological
				services. These services are performed by an anesthesiologist certified under
				s.
				DHS
				105.05, or by a nurse anesthetist or an anesthesiology
				assistant certified under s.
				DHS
				105.055. Anesthesiology services shall include
				preoperative, intraoperative and postoperative evaluation and management of
				recipients as appropriate.
(2)
				OTHER LIMITATIONS.
(a) A nurse anesthetist
				shall perform services in the presence of a supervising anesthesiologist or
				performing physician.
(b) An
				anesthesiology assistant shall perform services only in the presence of a
				supervising anesthesiologist.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.07 - Dental services

Current through June 24, 2024
(1) COVERED SERVICES; DENTISTS AND
				PHYSICIANS. Except as provided under subs. (2), (3), (4) and (4m), all of the
				following dental services are covered services when provided by or under the
				supervision of a dentist or physician within the scope of practice of dentistry
				as defined in s. 447.01(8),
				Stats.:
(a) Diagnostic services.
(b) Preventive services.
(c) Restorative services.
(d) Endodontic services.
(e) Periodontic services.
(f) Removable prosthodontic
				services.
(g) Fixed prosthodontic
				services.
(h) Oral and
				maxillofacial surgery services.
(j)
				All of the following other services:
1.
				Unclassified treatment.
2.
				Palliative emergency treatment.
3.
				General anesthesia, intravenous conscious sedation, nitrous oxide, and
				non-intravenous conscious sedation.
4. Hospital calls.
Note:
Orthodontia may be covered under early and
				  periodic screening, diagnosis and treatment (EPSDT) services. Please see s. DHS
				  107.22 (4).
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.08 - Hospital services

Current through June 24, 2024
(1) COVERED SERVICES.
(a)
Inpatient services
.
				Covered hospital inpatient services are those medically necessary services
				which require an inpatient stay ordinarily furnished by a hospital for the care
				and treatment of inpatients, and which are provided under the direction of a
				physician or dentist in an institution certified under s.
				DHS 105.07 or
				105.21.
(b)
Outpatient services
.
				Covered hospital outpatient services are those medically necessary preventive,
				diagnostic, rehabilitative or palliative items or services provided by a
				hospital certified under s.
				DHS 105.07 or
				105.21 and performed by or under the
				direction of a physician or dentist for a recipient who is not a hospital
				inpatient.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.09 - Nursing home services

Current through June 24, 2024
(1) DEFINITION. 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:
(a)
				Routine services and costs, namely:
1.
				Nursing services;
2. Special care
				services, including activity therapy, recreation, social services and religious
				services;
3. Supportive services,
				including dietary, housekeeping, maintenance, institutional laundry and
				personal laundry services, but excluding personal dry cleaning
				services;
4. Administrative and
				other indirect services;
5.
				Physical plant, including depreciation, insurance and interest on
				plant;
6. Property taxes;
				and
7. Transportation services
				provided on or after July 1, 1986;
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.10 - Drugs

Current through June 24, 2024
(1) COVERED SERVICES. Drugs and drug products
				covered by MA include legend and non-legend drugs and supplies listed in the
				Wisconsin medicaid drug index which are prescribed by a physician licensed
				under s.
				448.04,
				Stats., by a dentist licensed under s.
				447.05,
				Stats., by a podiatrist licensed under s.
				448.04,
				Stats., by an optometrist licensed under ch. 449, Stats., by an advanced
				practice nurse prescriber licensed under s.
				441.16,
				Stats., or when a physician delegates the prescribing of drugs to a nurse
				practitioner or to a physician's assistant certified under s.
				448.04,
				Stats., and the requirements under s. N 6.03 for nurse practitioners and under
				s.
				Med
				8.07 for physician assistants are met.
Note:
The Wisconsin medicaid drug index is
				  available from the Division of Health Care Access and Accountability, P.O. Box
				  309, Madison, WI 53701.
Note:
Chapter
				  Med 8 has been
				  repealed.
(2) SERVICES
				REQUIRING PRIOR AUTHORIZATION. The following drugs and supplies require prior
				authorization:
(b) All schedules III and IV
				stimulant drugs;
(c) Medically
				necessary, specially formulated nutritional supplements and replacement
				products, including enteral and parenteral products used for the treatment of
				severe health conditions such as pathologies of the gastrointestinal tract or
				metabolic disorders, as described in the MA provider handbooks and bulletins,
				but not including enteral nutrition products administered through a
				tube.
(d) Drugs the department has
				determined entail substantial cost or utilization problems for the MA program.
				These drugs shall be noted in the Wisconsin medicaid drug index;
(e) Any drug produced by a manufacturer who
				has not entered into a rebate agreement with the federal secretary of health
				and human services, as required by
				42 USC
				1396r-8, if the prescribing provider under
				sub. (1) demonstrates to the department's satisfaction that no other drug sold
				by a manufacturer who complies with
				42 USC
				1396r-8 is medically appropriate and
				cost-effective in treating the recipient's condition;
(f) Drugs identified by the department that
				are sometimes used to enhance the prospects of fertility in males or females,
				when proposed to be used for treatment of a condition not related to fertility;
				and
(g) Drugs identified by the
				department that are sometimes used to treat impotence, when proposed to be used
				for the treatment of a condition not related to impotence.
Note:
For more information on prior
				  authorization, see s.
				  DHS
				  107.02(3).
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.11 - Home health services

Current through June 24, 2024
(1) DEFINITIONS. In this section:
(a) "Community-based residential facility"
				has the meaning prescribed in s.
				50.01 (1g),
				Stats.
(b) "Home health aide
				services" means medically oriented tasks, assistance with activities of daily
				living and incidental household tasks required to facilitate treatment of a
				recipient's medical condition or to maintain the recipient's health.
(c) "Home health visit" or "visit" means a
				period of time of any duration during which home health services are provided
				through personal contact by agency personnel of less than 8 hours a day in the
				recipient's place of residence for the purpose of providing a covered home
				health service. The services are provided by a home health provider employed by
				a home health agency, by a home health provider under contract to a home health
				agency according to the requirements of s.
				DHS
				133.19 or by arrangement with a home health agency. A
				visit begins when the home health provider starts to provide a covered service
				and ends when the service is complete.
(d) "Home health provider" means a person who
				is an RN, LPN, home health aide, physical or occupational therapist, speech
				pathologist, certified physical therapy assistant or certified occupational
				therapy assistant.
(e) "Initial
				visit" means the first home health visit of any duration in a calendar day
				provided by a registered nurse, licensed practical nurse, home health aide,
				physical or occupational therapist or speech and language pathologist for the
				purpose of delivering a covered home health service to a recipient.
(f) "Subsequent visit" means each additional
				visit of any duration following the initial visit in a calendar day provided by
				an RN, LPN or home health aide for the purpose of delivering a covered home
				health service to a recipient.
(g)
				"Unlicensed caregiver" means a home health aide or personal care
				worker.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.112 - Personal care services

Current through June 24, 2024
(1) COVERED
				SERVICES.
(a) Personal care services are
				medically oriented activities related to assisting a recipient with activities
				of daily living necessary to maintain the recipient in his or her place of
				residence in the community. These services shall be provided upon written
				orders of a physician by a provider certified under s.
				DHS
				105.17 and by a personal care worker employed by the
				provider or under contract to the provider who is supervised by a registered
				nurse according to a written plan of care. The personal care worker shall be
				assigned by the supervising registered nurse to specific recipients to do
				specific tasks for those recipients for which the personal care worker has been
				trained. The personal care worker's training for these specific tasks shall be
				assured by the supervising registered nurse. The personal care worker is
				limited to performing only those tasks and services as assigned for each
				recipient and for which he or she has been specifically trained.
(b) Covered personal care services are:
1. Assistance with bathing;
2. Assistance with getting in and out of
				bed;
3. Teeth, mouth, denture and
				hair care;
4. Assistance with
				mobility and ambulation including use of walker, cane or crutches;
5. Changing the recipient's bed and
				laundering the bed linens and the recipient's personal clothing;
6. Skin care excluding wound care;
7. Care of eyeglasses and hearing
				aids;
8. Assistance with dressing
				and undressing;
9. Toileting,
				including use and care of bedpan, urinal, commode or toilet;
10. Light cleaning in essential areas of the
				home used during personal care service activities;
11. Meal preparation, food purchasing and
				meal serving;
12. Simple transfers
				including bed to chair or wheelchair and reverse; and
13. Accompanying the recipient to obtain
				medical diagnosis and treatment.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.121 - Nurse-midwife services

Current through June 24, 2024
(1) COVERED
				SERVICES. Covered services provided by a certified nurse-midwife may include
				the care of mothers and their babies throughout the maternity cycle, including
				pregnancy, labor, normal childbirth and the immediate postpartum period,
				provided that the nurse-midwife services are provided within the limitations
				established in s.
				441.15(2),
				Stats., and ch. N 4.
(2)
				LIMITATION. Coverage for nurse-midwife services for management and care of the
				mother and newborn child shall end after the sixth week of postpartum
				care.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.122 - Independent nurse practitioner services

Current through June 24, 2024
(1) COVERED
				SERVICES. Services provided by a nurse practitioner, including a clinical nurse
				specialist, which are covered by the MA program are those medical services
				delegated by a licensed physician by a written protocol developed with the
				nurse practitioner pursuant to the requirements set forth in s.
				N
				6.03(2) and guidelines set forth by
				the medical examining board and the board of nursing. General nursing
				procedures are covered services when performed by a certified nurse
				practitioner or clinical nurse specialist in accordance with the requirements
				of s.
				N
				6.03(1). These services may include
				those medically necessary diagnostic, preventive, therapeutic, rehabilitative
				or palliative services provided in a medical setting, the recipient's home or
				elsewhere. Specific reimbursable delegated medical acts and nursing services
				are the following:
(a) Under assessment and
				nursing diagnosis:
1. Obtaining a recipient's
				complete health history and recording the findings in a systematic, organized
				manner;
2. Evaluating and analyzing
				a health history critically;
3.
				Performing a complete physical assessment using techniques of observation,
				inspection, auscultation, palpation and percussion, ordering appropriate
				laboratory and diagnostic tests and recording findings in a systematic
				manner;
4. Performing and recording
				a developmental or functional status evaluation and mental status examination
				using standardized procedures; and
5. Identifying and describing behavior
				associated with developmental processes, aging, life style and family
				relationships;
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.14 - Podiatry services

Current through June 24, 2024
(1) COVERED SERVICES.
(a) Podiatry services covered by medical
				assistance are those medically necessary services for the diagnosis and
				treatment of the feet and ankles, within the limitations described in this
				section, when provided by a certified podiatrist.
(b) The following categories of services are
				covered services when performed by a podiatrist:
1. Office visits;
2. Home visits;
3. Nursing home visits;
4. Physical medicine;
5. Surgery;
6. Mycotic conditions and nails;
7. Laboratory;
8. Radiology;
9. Plaster or other cast material used in
				cast procedures and strapping or tape casting for treating fractures,
				dislocations, sprains and open wounds of the ankle, foot and toes;
10. Unna boots; and
11. Drugs and injections.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.15 - Chiropractic services

Current through June 24, 2024
(1) DEFINITION. In this section, "spell of
				illness" means a condition characterized by the onset of a spinal subluxation.
				"Subluxation" means the alteration of the normal dynamics, anatomical or
				physiological relationships of contiguous articular structures. A subluxation
				may have biomechanical, pathophysiological, clinical, radiologic and other
				manifestations.
(2) COVERED
				SERVICES. Chiropractic services covered by MA are manual manipulations of the
				spine used to treat a subluxation. These services shall be performed by a
				chiropractor certified pursuant to s.
				DHS
				105.26.
(3) SERVICES REQUIRING PRIOR AUTHORIZATION.
(a) Requirement.
1. Prior authorization is required for
				services beyond the initial visit and 20 spinal manipulations per spell of
				illness. The prior authorization request shall include a justification of why
				the condition is chronic and why it warrants the scope of service being
				requested.
2. Prior authorization
				is required for spinal supports which have been prescribed by a physician or
				chiropractor if the purchase or rental price of a support is over $75. Rental
				costs under $75 shall be paid for one month without prior approval.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.17 - Occupational therapy

Current through June 24, 2024
(1) COVERED SERVICES. Covered occupational
				therapy services are the following medically necessary services when prescribed
				by a physician and performed by a certified occupational therapist (OT) or by a
				certified occupational therapist assistant (COTA) under the direct, immediate,
				on-premises supervision of a certified occupational therapist or, for services
				under par. (d), by a certified occupational therapist assistant under the
				general supervision of a certified occupational therapist pursuant to the
				requirements of s.
				DHS
				105.28(2):
(a) Motor skills, as follows:
1. Range-of-motion;
2. Gross/fine coordination;
3. Strengthening;
4. Endurance/tolerance; and
5. Balance;
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.19 - Audiology services

Current through June 24, 2024
(1) COVERED SERVICES. Covered audiology
				services are those medically necessary diagnostic, screening, preventive or
				corrective audiology services prescribed by a physician and provided by an
				audiologist certified pursuant to s.
				DHS
				105.31. These services include:
(a) Audiological evaluation;
(b) Hearing aid or other assistive listening
				device evaluation;
(c) Hearing aid
				or other assistive listening device performance check;
(d) Audiological tests;
(e) Audiometric techniques;
(f) Impedance audiometry;
(g) Aural rehabilitation; and
(h) Speech therapy.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.20 - Vision care services

Current through June 24, 2024
(1) COVERED SERVICES. Covered vision care
				services are eyeglasses and those medically necessary services provided by
				licensed optometrists within the scope of practice of the profession of
				optometry as defined in s.
				449.01, Stats., who
				are certified under s.
				DHS
				105.32, and by opticians certified under s.
				DHS
				105.33 and physicians certified under s.
				DHS
				105.05.
(2) SERVICES REQUIRING PRIOR AUTHORIZATION.
				The following covered services require prior authorization by the department:
(a) Vision training, which shall only be
				approved for patients with one or more of the following conditions:
1. Amblyopia;
2. Anopsia;
3. Disorders of accommodation; and
4. Convergence insufficiency;
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.22 - Early and periodic screening, diagnosis and treatment (EPSDT) services

Current through June 24, 2024
(1) COVERED SERVICES. Early and periodic
				screening and diagnosis to ascertain physical and mental defects, and the
				provision of treatment as provided in sub. (4) to correct or ameliorate the
				defects shall be covered services for all recipients under 21 years of age when
				provided by an EPSDT clinic, a physician, a private clinic, an HMO or a
				hospital certified under s.
				DHS
				105.37.
(2) EPSDT HEALTH ASSESSMENT AND EVALUATION
				PACKAGE. The EPSDT health assessment and evaluation package shall include at
				least those procedures and tests required by
				42 CFR
				441.56. The package shall include the
				following:
(a) A comprehensive health and
				developmental history;
(b) A
				comprehensive unclothed physical examination;
(c) A vision test appropriate for the person
				being assessed;
(d) A hearing test
				appropriate for the person being assessed;
(e) Dental assessment and evaluation services
				furnished by direct referral to a dentist for children beginning at 3 years of
				age;
(f) Appropriate immunizations;
				and
(g) Appropriate laboratory
				tests.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.24 - Durable medical equipment and medical supplies

Current through June 24, 2024
(1) DEFINITION. In
				this section:
(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.
(b)
				"Qualified health care professional" means any of the following:
1. A physician or physician assistant
				licensed under subch. II of ch. 448, Stats.
2. A physical therapist licensed under subch.
				III of ch. 448, Stats.
3. An
				occupational therapist licensed under subch. VII of ch. 448, Stats.
4. A chiropractor licensed under ch. 446,
				Stats.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.25 - Diagnostic testing services

Current through June 24, 2024
(1) COVERED
				SERVICES. Professional and technical diagnostic services covered by MA are
				laboratory services provided by a certified physician or under the physician's
				supervision, or prescribed by a physician and provided by an independent
				certified laboratory, and x-ray services prescribed by a physician and provided
				by or under the general supervision of a certified physician.
(2) OTHER LIMITATIONS.
(a) All diagnostic services shall be
				prescribed or ordered by a physician or dentist.
(b) Laboratory tests performed which are
				outside the laboratory's certified areas are not covered.
(c) Portable x-ray services are covered only
				for recipients who reside in nursing homes and only when provided in a nursing
				home.
(d) Reimbursement for
				diagnostic testing services shall be in accordance with limitations set by P.L.
				98-369, Sec. 2303.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.27 - Blood

Current through June 24, 2024
The provision of blood is a covered service when provided to
				  a recipient by a physician certified pursuant to s.
				  DHS
				  105.05, a blood bank certified pursuant to s.
				  DHS
				  105.46 or a hospital certified pursuant to s.
				  DHS
				  105.07.