Section 106.11. Pre-payment review of claims.

 

(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.

History: Cr. Register, December, 1979, No. 288 , eff. 2-1-80; am. Register, February, 1986, No. 362 , eff. 3-1-86; renum. from HSS 106.09, Register, February, 1993, No. 446 , eff. 3-1-93.