Section 152.06. Provider reimbursement.

 

(1)   Claim forms.

(a) A provider shall use claim forms furnished or prescribed by the department or its fiscal agent, 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.

(b) Claims shall be submitted in accordance with the claims submission requirements, claim form instruction and coding information provided by the department or its fiscal agent.

(c) Every claim submitted shall be signed by the provider or the provider's authorized representative, certifying to the truthfulness, accuracy and completeness of the claim.

(2)   Timeliness.

(a) A claim shall be submitted within 24 months after the date that dialysis or transplant services were provided, except that a claim may be submitted later if the department is notified within that 24 month period that the sole reason for late submission concerns another funding source and the claim is submitted within 180 days after obtaining a decision on reimbursement from the other funding source.

(b) A claim may not be submitted until after the patient has received the dialysis or transplant services.

(3)   Payment.

(a) The department shall establish allowable charges for CRD services as a basis for reimbursing providers.

(b) Reimbursement may not be made for any portion of the cost of medical care which is payable under any other state or federal program, grant, contract or agreement.

(c) Before submitting a claim to the CRD program, a provider shall seek payment for services provided to a certified patient from medicare, medical assistance or another health care plan if the certified patient is eligible for services under medicare, medical assistance or the other health care plan.

(d) When benefits from medicare, medical assistance or another health care plan or other third party payer have been paid, in whole or in part to the provider, the amount of the payment from all other payers shall be indicated on or with the bill to the CRD program. The amount of the medicare, medical assistance, other health care plan or other third party payer reimbursement shall reduce the amount of the claim for CRD program payment.

(e) If a provider receives a payment under the program to which the provider is not entitled or in an amount greater than that to which the provider is entitled, the provider shall promptly return the amount of the erroneous or excess payment to the department.

(f) A provider may request a hearing to review a decision to deny payment or the level of payment. A request for a hearing shall be filed with the department's office of administrative hearings within 90 days after the date of the payment or decision to deny payment. A request for a hearing is considered filed upon its receipt by the office of administrative hearings. All appeals shall include written documentation and any information deemed necessary by the department. Hearings shall be conducted in accordance with subch. III of ch. 227 , Stats.

(g) A provider shall accept the amount paid under this section for the service as payment in full and may not bill the patient for any amount by which the charge for the service exceeds the amount paid for the service under this section.

(h) The department shall use common methods employed by managed care programs and the medical assistance program to contain costs, including prior authorization and other limitations regarding health care utilization and reimbursement.

Cr. Register, June, 1988, No. 390 , eff. 7-1-88; cr. (8), r. and recr. Table, Register, May, 1992, No. 437 , eff. 6-1-92; emerg. r. and recr. Table cr. (6) (d), eff. 9-1-93; r. and recr. Register, December, 1994, No. 468 , eff. 1-1-95; CR 04-051 : cr. (3) (g) and (h) Register November 2004 No. 587 , eff. 12-1-04.

Note

The mailing address of the Office of Administrative Hearings is P.O. Box 7875, Madison, Wisconsin 53707. Microsoft Windows NT 6.1.7601 Service Pack 1