Section 107.02. General limitations.

 

(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.

(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.

(2)   Non-reimbursable services. The department may reject payment for a service which ordinarily would be covered if the service fails to meet program requirements. Non-reimbursable services include:

(a) Services which fail to comply with program policies or state and federal statutes, rules and regulations, for instance, sterilizations performed without following proper informed consent procedures, or controlled substances prescribed or dispensed illegally;

(b) Services which the department, the PRO review process or the department fiscal agent's professional consultants determine to be medically unnecessary, inappropriate, in excess of accepted standards of reasonableness or less costly alternative services, or of excessive frequency or duration;

(c) Non-emergency services provided by a person who is not a certified provider;

(d) Services provided to recipients who were not eligible on the date of the service, except as provided under a prepaid health plan or HMO;

(e) Services for which records or other documentation were not prepared or maintained, as required under s. DHS 106.02 (9) ;

(f) Services provided by a provider who fails or refuses to prepare or maintain records or other documentation as required under s. DHS 106.02 (9) ;

(g) Services provided by a provider who fails or refuses to provide access to records as required under s. DHS 106.02 (9) (e) 4. ;

(h) Services for which the provider failed to meet any or all of the requirements of s. DHS 106.03 , including but not limited to the requirements regarding timely submission of claims;

(i) Services provided inconsistent with an intermediate sanction or sanctions imposed by the department under s. DHS 106.08 ; and

(j) Services provided by a provider who fails or refuses to meet and maintain any of the certification requirements under ch. DHS 105 applicable to that provider.

(2m)   Services requiring a physician's order or prescription.

(a) The following services require a physician's order or prescription to be covered under MA:

1. Skilled nursing services provided in a nursing home;

2. Intermediate care services provided in a nursing home;

3. Home health care services;

4. Independent nursing services;

5. Respiratory care services for ventilator-dependent recipients;

6. Physical and occupational therapy services;

8. Speech pathology and audiology services;

9. Medical supplies and equipment, including rental of durable equipment, but not hearing aid batteries, hearing aid accessories or repairs;

10. Drugs, except when prescribed by a nurse practitioner under s. DHS 107.122 , a podiatrist under s. DHS 107.14 or an advanced practice nurse prescriber under s. DHS 107.10 ;

11. Prosthetic devices;

12. Laboratory, diagnostic, radiology and imaging test services;

13. Inpatient hospital services;

14. Outpatient hospital services;

15. Inpatient hospital IMD services;

16. Hearing aids;

18. Hospital private room accommodations;

19. Personal care services; and

20. Hospice services.

(b) Except as otherwise provided in federal or state statutes, regulations or rules, a prescription or order shall be in writing or be given orally and later be reduced to writing by the provider filling the prescription or order, and shall include the date of the prescription or order, the name and address of the prescriber, the prescriber's MA provider number, the name and address of the recipient, the recipient's MA eligibility number, an evaluation of the service to be provided, the estimated length of time required, the brand of drug or drug product equivalent medically required and the prescriber's signature. For hospital patients and nursing home patients, orders shall be entered into the medical and nursing charts and shall include the information required by this paragraph. Services prescribed or ordered shall be provided within one year of the date of the prescription.

(c) A prescription for specialized transportation services shall include an explanation of the reason the recipient is unable to travel in a private automobile, or a taxicab, bus or other common carrier. A prescription for a recipient not declared legally blind or not determined to be indefinitely disabled, as defined under s. DHS 107.23 (1) (c) shall specify the length of time for which the recipient shall require the specialized transportation, which may not exceed 90 days.

(3)   Prior authorization.

(a) Procedures for prior authorization. The department may require prior authorization for covered services. In addition to services designated for prior authorization under each service category in this chapter, the department may require prior authorization for any other covered service for any reason listed in par. (b) . The department shall notify in writing all affected providers of any additional services for which it has decided to require prior authorization. The department or its fiscal agent shall act on 95% of requests for prior authorization within 10 working days and on 100% of requests for prior authorization within 20 working days from the receipt of all information necessary to make the determination. The department or its fiscal agent shall make a reasonable attempt to obtain from the provider the information necessary for timely prior authorization decisions. When prior authorization decisions are delayed due to the department's need to seek further information from the provider, the recipient shall be notified by the provider of the reason for the delay.

(b) Reasons for prior authorization. Reasons for prior authorization are:

1. To safeguard against unnecessary or inappropriate care and services;

2. To safeguard against excess payments;

3. To assess the quality and timeliness of services;

4. To determine if less expensive alternative care, services or supplies are usable;

5. To promote the most effective and appropriate use of available services and facilities; and

6. To curtail misutilization practices of providers and recipients.

(c) Penalty for non-compliance. If prior authorization is not requested and obtained before a service requiring prior authorization is provided, reimbursement shall not be made except in extraordinary circumstances such as emergency cases where the department has given verbal authorization for a service.

(d) Required information. A request for prior authorization submitted to the department or its fiscal agent shall, unless otherwise specified in chs. DHS 101 to 108 , identify at a minimum:

1. The name, address and MA number of the recipient for whom the service or item is requested;

2. The name and provider number of the provider who will perform the service requested;

3. The person or provider requesting prior authorization;

4. The attending physician's or dentist's diagnosis including, where applicable, the degree of impairment;

5. A description of the service being requested, including the procedure code, the amount of time involved, and dollar amount where appropriate; and

6. Justification for the provision of the service.

(e) Departmental review criteria. In determining whether to approve or disapprove a request for prior authorization, the department shall consider:

1. The medical necessity of the service;

2. The appropriateness of the service;

3. The cost of the service;

4. The frequency of furnishing the service;

5. The quality and timeliness of the service;

6. The extent to which less expensive alternative services are available;

7. The effective and appropriate use of available services;

8. The misutilization practices of providers and recipients;

9. The limitations imposed by pertinent federal or state statutes, rules, regulations or interpretations, including medicare, or private insurance guidelines;

10. The need to ensure that there is closer professional scrutiny for care which is of unacceptable quality;

11. The flagrant or continuing disregard of established state and federal policies, standards, fees or procedures; and

12. The professional acceptability of unproven or experimental care, as determined by consultants to the department.

(f) Professional consultants. The department or its fiscal agent may use the services of qualified professional consultants in determining whether requests for prior authorization meet the criteria in par. (e) .

(g) Authorization not transferable. Prior authorization, once granted, may not be transferred to another recipient or to another provider. In certain cases the department may allow multiple services to be divided among non-billing providers certified under one billing provider. For example, prior authorization for 15 visits for occupational therapy may be performed by more than one therapist working for the billing provider for whom prior authorization was granted. In emergency circumstances the service may be provided by a different provider.

(h) Medical opinion reports. Medical evaluations and written medical opinions used in establishing a claim in a tort action against a third party may be covered services if they are prior-authorized. Prior authorization shall be issued only where:

1. A recipient has sustained personal injuries requiring medical or other health care services as a result of injury, damage or a wrongful act caused by another person;

2. Services for these injuries are covered under the MA program;

3. The recipient or the recipient's representative has initiated or will initiate a claim or tort action against the negligent third party, joining the department in the action as provided under s. 49.89 , Stats.; and

4. The recipient or the recipient's representative agrees in writing to reimburse the program in whole for all payments made for the prior-authorized services from the proceeds of any judgment, award, determination or settlement on the recipient's claim or action.

(i) Significance of prior authorization approval.

1. Approval or modification by the department or its fiscal agent of a prior authorization request, including any subsequent amendments, extensions, renewals, or reconsideration requests:

a. Shall not relieve the provider of responsibility to meet all requirements of federal and state statutes and regulations, provider handbooks and provider bulletins;

b. Shall not constitute a guarantee or promise of payment, in whole or in part, with respect to any claim submitted under the prior authorization; and

c. Shall not be construed to constitute, in whole or in part, a discretionary waiver or variance under s. DHS 106.13 .

2. Subject to the applicable terms of reimbursement issued by the department, covered services provided consistent with a prior authorization, as approved or modified by the department or its fiscal agent, are reimbursable provided:

a. The provider's approved or modified prior authorization request and supporting information, including all subsequent amendments, renewals and reconsideration requests, is truthful and accurate;

b. The provider's approved or modified prior authorization request and supporting information, including all subsequent amendments, extensions, renewals and reconsideration requests, completely and accurately reveals all facts pertinent to the recipient's case and to the review process and criteria provided under s. DHS 107.02 (3) ;

c. The provider complies with all requirements of applicable state and federal statutes, the terms and conditions of the applicable provider agreement pursuant to s. 49.45 (2) (a) 9. , Stats., all applicable requirements of chs. DHS 101 to 108 , including but not limited to the requirements of ss. DHS 106.02 , 106.03 , 107.02 , and 107.03 , and all applicable prior authorization procedural instructions issued by the department under s. DHS 108.02 (4) ;

d. The recipient is MA eligible on the date of service; and

e. The provider is MA certified and qualified to provide the service on the date of the service.

(4)   Cost-sharing.

(a) General policy. The department shall establish cost-sharing provisions for MA recipients, pursuant to s. 49.45 (18) , Stats. Cost-sharing requirements for providers are described under s. DHS 106.04 (2) , and services and recipients exempted from cost-sharing requirements are listed under s. DHS 104.01 (12) (a) .

(b) Notification of applicable services and rates. All services for which cost-sharing is applicable shall be identified by the department to all recipients and providers prior to enforcement of the provisions.

(d) Limitation on copayments for prescription drugs. Providers may not collect copayments in excess of $5 a month from a recipient for prescription drugs if the recipient uses one pharmacy or pharmacist as his or her sole provider of prescription drugs.

Cr. Register, February, 1986, No. 362 , eff. 3-1-86; r. and recr. (1) and am. (14) (c) 12. and 13., Register, February, 1988, No. 386 , eff. 3-1-88; cr. (4) (c) 14., Register, April, 1988, No. 388 , eff. 7-1-88; r. and recr. (4) (c), Register, December, 1988, No. 396 , eff. 1-1-89; emerg. am. (4) (a), r. (4) (c), eff. 1-1-90; am. (4) (a) r. (4) (c), Register, September, 1990, No. 417 , eff. 10-1-90; am. (2) (b), r. (2) (c), renum. (2) (d) and (e) to be (2) (c) and (d), cr. (2m), Register, September, 1991, No. 429 , eff. 10-1-91; emerg. cr. (3) (i), eff. 7-1-92; am. (2) (c) and (d), cr. (2) (e) to (j) and (3) (i), Register, February, 1993, No. 446 , eff. 3-1-93; r. (2m) (a) 17., Register, November, 1994, No. 467 , eff. 12-1-94; am. (2) (a), Register, January, 1997, No. 493 , eff. 2-1-97; correction in (4) (a) made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520 ; correction in (3) (h) 3. made under s. 13.93 (2m) (b) 7., Stats., Register, October, 2000, No. 538 ; CR 03-033 : am. (2m) (a) 10. and (c) Register December 2003 No. 576 , eff. 1-1-04; corrections in (2) (e) to (j), (3) (d) (intro.), (i) 1. c., 2. c., and (4) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636 ; CR 14-066 : r. (2m) (a) 7. Register August 2015 No. 716 , eff. 9-1-15.