Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 106 - Provider Rights And Responsibilities › Section DHS 106.02 - General requirements for provision of services

Current through June 24, 2024
Providers shall comply with the following general conditions
				  for participation as providers in the MA program:
(1) CERTIFICATION. A provider shall be
				certified under ch. DHS 105.
(2)
				COVERED SERVICES. A provider shall be reimbursed only for covered services
				specified in ch. DHS 107.
(3)
				RECIPIENT ELIGIBLE ON DATE OF SERVICE. A provider shall be reimbursed for a
				service only if the recipient of the service was eligible to receive MA
				benefits on the date the service was provided.
(4) COMPLIANCE WITH STATE AND FEDERAL
				REQUIREMENTS. A provider shall be reimbursed only if the provider complies with
				applicable state and federal procedural requirements relating to the delivery
				of the service.
(5) APPROPRIATE AND
				MEDICALLY NECESSARY SERVICES. A provider shall be reimbursed only for services
				that are appropriate and medically necessary for the condition of the
				recipient.
(6) PROVISION OF
				NON-COVERED SERVICES. If a provider determines that, to assure quality health
				care to a recipient, it is necessary to provide a non-covered service, nothing
				in this chapter shall preclude the provider from furnishing the service, if
				before rendering the service the provider advises the recipient that the
				service is not covered under the program and that, if provided, the recipient
				is responsible for payment.
(7)
				SERVICES TO RECIPIENTS WITH A PRIMARY PROVIDER. A provider other than the
				designated primary provider may not claim reimbursement for a service to an
				individual whose freedom to choose a provider has been restricted under s. DHS
				104.03 or 104.05 as indicated on the recipient's MA identification card unless
				the service was rendered pursuant to a written referral from the recipient's
				designated primary provider or the service was rendered in an emergency. If
				rendered in an emergency, the provider seeking reimbursement shall submit to
				the fiscal agent a written description of the nature of the emergency along
				with the service claim.
(8) REFUSAL
				TO PROVIDE MA SERVICES. A provider is not required to provide services to a
				recipient if the recipient refuses or fails to present a currently valid MA
				identification card. If a recipient fails, refuses or is unable to produce a
				currently valid identification card, the provider may contact the fiscal agent
				to confirm the current eligibility of the recipient. The department shall
				require its fiscal agent to install and maintain adequate toll-free telephone
				service to enable providers to verify the eligibility of recipients to receive
				benefits under the program.
(9)
				MEDICAL AND FINANCIAL RECORDKEEPING AND DOCUMENTATION.
(a)
Preparation and
				maintenance.
A provider shall prepare and maintain truthful, accurate,
				complete, legible and concise documentation and medical and financial records
				specified under this subsection, s. DHS 105.02 (6), the relevant provisions of
				s. DHS 105.02 (7), other relevant sections in chs. DHS 105 and 106 and the
				relevant sections of ch. DHS 107 that relate to documentation and medical and
				financial recordkeeping for specific services rendered to a recipient by a
				certified provider. In addition to the documentation and recordkeeping
				requirements specified in pars. (b) to (d), the provider's documentation,
				unless otherwise specifically contained in the recipient's medical record,
				shall include:
1. The full name of the
				recipient;
2. The identity of the
				person who provided the service to the recipient;
3. An accurate, complete and legible
				description of each service provided;
4. The purpose of and need for the
				services;
5. The quantity, level
				and supply of service provided;
6.
				The date of service;
7. The place
				where the service was provided; and
8. The pertinent financial records.