Wisconsin Administrative Code
Department of Health Services
DHS 101-109 - Medical Assistance
Chapter DHS 106 - Provider Rights And Responsibilities
Section DHS 106.04 - Payment of claims for reimbursement

Universal Citation: WI Admin Code ยง DHS 106.04

Current through February 26, 2024

(1) TIMELINESS.

(a) Timeliness of payment. The department shall reimburse a provider for a properly provided covered service according to the provider payment schedule entitled "terms of provider reimbursement," found in the appropriate MA provider handbook distributed by the department. The department shall issue payment on claims for covered services, properly completed and submitted by the provider, in a timely manner. Payment shall be issued on at least 95% of these claims within 30 days of claim receipt, on at least 99% of these claims within 90 days of claim receipt, and on 100% of these claims within 180 days of receipt. The department may not consider the amount of the claim in processing claims under this subsection.

(b) Exceptions. The department may exceed claims payment limits under par. (a) for any of the following reasons:
1. If a claim for payment under medicare has been filed in a timely manner, the department may pay a MA claim relating to the same services within 6 months after the department or the provider receives notice of the disposition of the medicare claims;

2. The department may make payments at any time in accordance with a court order, or to carry out hearing decisions or department corrective actions taken to resolve a dispute; or

3. The department may issue payments in accordance with waiver provisions if it has obtained a waiver from the federal health care financing administration under 42 CFR 447.45(e).

(1m) PAYMENT MECHANISM.

(a) Definitions. In this subsection:
1. "Automated claims processing system" means the computerized system operated by the department's fiscal agent for paying the claims of providers.

2. "Manual partial payment" means a method of paying claims other than through the automated claims processing system.

(b) Automated claims processing. Except as provided in par. (c), payment of provider claims for reimbursement for services provided to recipients shall be made through the department's automated claims processing system.

(c) Manual partial payment. The department may pay up to 75% of the reimbursable amount of a provider's claim in advance of payments made through the automated claims processing system if all the following conditions exist:
1. The provider requests a manual partial payment and is informed that the payment will be automatically recouped when the provider's claims are later processed through the automated claims processing system;

2. A provider's claims for services provided have been pending in the automated claims processing system for more than 30 days, or the provider provides services to MA recipients representing more than 50% of the provider's income and payment for these services has been significantly delayed beyond the claims processing time historically experienced by the provider;

3. The delay in payment under subd. 2. is due to no fault of the provider;

4. Further delay in payment will have a financial impact on the provider which is likely to adversely affect or disrupt the level of care otherwise provided to recipients; and

5. The provider has submitted documentation of covered services, including the provider name and MA billing number, the recipient's name and MA number, the date or dates of services provided, type and quantity of services provided as appropriate and any other information pertinent to payment for covered services.

(d) Recoupment of manual partial payments. Manual partial payments shall be automatically recouped when the provider's claims are processed through the automated claims system.

(e) Cash advances prohibited. In no case may the department or its fiscal agent make advance payment for services not yet provided. No payment may be made unless covered services have been provided and a claim or document under par. (c) 5. for these services has been submitted to the department.

(2) COST SHARING.

(a) General policy. Pursuant to s. 49.45(18), Stats., the department shall establish copayment rates and deductible amounts for medical services covered under MA. Recipients shall provide the copayment amount or coinsurance to the provider or pay for medical services up to the deductible amount, as appropriate, except that the services and recipients listed in s. DHS 104.01(12) (a) are exempt from cost-sharing requirements. Providers are not entitled to reimbursement from MA for the copayment, coinsurance or deductible amounts for which a recipient is liable.

(b) Liability for refunding erroneous copayment. In the event that medical services are covered by a third party and the recipient makes a copayment to the provider, the department is not responsible for refunding the copayment amount to the recipient.

(3) NON-LIABILITY OF RECIPIENTS. A provider shall accept payments made by the department in accordance with sub. (1) as payment in full for services provided a recipient. A provider may not attempt to impose a charge for an individual procedure or for overhead which is included in the reimbursement for services provided nor may the provider attempt to impose an unauthorized charge or receive payment from a recipient, relative or other person for services provided, or impose direct charges upon a recipient in lieu of obtaining payment under the program, except under any of the following conditions:

(a) A service desired, needed or requested by a recipient is not covered under the program or a prior authorization request is denied and the recipient is advised of this fact before receiving the service;

(b) An applicant is determined to be eligible retroactively under s. 49.46(1) (b), Stats., and a provider has billed the applicant directly for services rendered during the retroactive period, in which case the provider shall, upon notification of the recipient's retroactive eligibility, submit claims under this section for covered services provided during the retroactive period. Upon receipt of payment from the program for the services, the provider shall reimburse in full the recipient or other person who has made prior payment to the provider. A provider shall not be required to reimburse the recipient or other person in excess of the amount reimbursed by the program; or

(c) A recipient in a nursing home chooses a private room in the nursing home and the provisions of s. DHS 107.09(4) (k) are met.

(4) RELEASE OF BILLING INFORMATION BY PROVIDERS.

(a) Restrictions. A provider may not release information to a recipient or to a recipient's attorney relating to charges which have been billed or which will be billed to MA for the cost of care of a recipient without notifying the department, unless any real or potential third-party payer liability has been assigned to the provider.

(b) Provider liability. If a provider releases information relating to the cost of care of a recipient or beneficiary contrary to par. (a), and the recipient or beneficiary receives payment from a liable third-party payer, the provider shall repay to the department any MA benefit payment it has received for the charges in question. The provider may then assert a claim against the recipient or beneficiary for the amount of the MA benefit repaid to the department.

Note: See the Wisconsin Medical Assistance Provider Handbook for specific information on procedures to be followed in the release of billing information.

(5) RETURN OF OVERPAYMENT.

(a) Except as provided in par. (b), if a provider receives a payment under the MA program to which the provider is not entitled or in an amount greater than that to which the provider is entitled, the provider shall return to the department the amount of the overpayment, including but not limited to erroneous, excess, duplicative and improper payments, regardless of cause, within 30 days after the date of the overpayment in the case of a duplicative payment from MA, medicare or other health care payer and within 30 days after the date of discovery in the case of all other overpayments.

(b) In lieu of returning the overpayment, a provider may notify the department in writing within 30 days after the date of the overpayment or its discovery, as applicable, of the nature, source and amount of the overpayment and request that the overpayment be deducted from future amounts owed the provider by the MA program.

(c) The department shall honor the request under par. (b) if the provider is actively participating in the program, is not currently under investigation for fraud or MA program abuse, is not subject to an intermediate sanction under s. DHS 106.08, and is claiming and receiving MA reimbursement in amounts sufficient to reasonably ensure full recovery of the overpayment within a limited period of time. Any limited recovery period shall be consistent with the applicable federally required time period for the department's repayment of the federal financial participation associated with the overpayment as stated in 42 CFR 433.300-322.

(d) If the department denies the provider's request under par. (b) to have the overpayment deducted from future amounts paid, the provider shall return to the department the full amount of the overpayment within 30 days after receipt of the department's written denial.

(6) GOOD FAITH PAYMENT. A claim denied for recipient eligibility reasons may qualify for a good faith payment if the service provided was provided in good faith to a recipient with an MA identification card which the provider saw on the date of service and which was apparently valid for the date of service.

Disclaimer: These regulations may not be the most recent version. Wisconsin may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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