Wisconsin Administrative Code
Department of Health Services
DHS 101-109 - Medical Assistance
Chapter DHS 104 - Recipient Rights And Duties
Section DHS 104.03 - Primary provider

Universal Citation: WI Admin Code ยง DHS 104.03

Current through February 26, 2024

(1) REQUIRED DESIGNATION.

(a) Required when program is abused. If the department discovers that a recipient is abusing the program, including abuse under s. DHS 104.02(5), the department may require the recipient to designate, in any or all categories of health care provider, a primary health care provider of the recipient's choice, except when free choice is limited under s. DHS 104.035.

(b) Selection of provider. The department shall allow a recipient to choose a primary provider from the department's current list of certified providers, except when free choice is limited under s. DHS 104.035. The recipient's choice shall become effective only with the concurrence of the designated primary provider. The type of service and identification number of the primary provider shall be endorsed on the recipient's MA card.

(c) Failure to cooperate. If the recipient fails to designate a primary provider after receiving a formal request from the department, the department shall designate a primary provider for the recipient in the proximity of the recipient's residence.

(2) REFERRAL TO OTHER PROVIDERS. A primary provider may, within the scope of the provider's practice, make referrals to other providers of medical services for which reimbursement will be made if the referral can be documented as medically necessary and the services are covered by MA. This documentation shall be made by the primary provider in the recipient's medical record.

(3) ALTERNATIVE PRIMARY PROVIDER. The department may allow the designation of an alternate primary provider. When approval is given by the department to select an alternate primary provider, the recipient may designate an alternate primary provider in the same manner a primary provider is designated.

(4) EXCEPTION. The limitations imposed in this section do not apply in the case of an emergency. Emergency health care provided by any provider to a recipient restricted under this section shall be eligible for reimbursement if the claim for reimbursement is accompanied by a full explanation of the emergency circumstances.

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