Wisconsin Administrative Code

DHS 105.29 Speech and hearing clinics. For MA certification, speech and hearing clinics shall be currently accredited by the American speech and hearing association (ASHA) pursuant to the guidelines for “accreditation of professional ser- 26 vices programs in speech pathology and…

DHS 105.30 Speech pathologists. For MA certification, speech pathologists shall: (1) Possess a current certification of clinical competence from the American speech and hearing association; (2) Have completed the educational requirements and work experience necessary for such a c…

DHS 105.31 Audiologists. For MA certification, audiologists shall: (1) Possess a certificate of clinical competence from the American speech and hearing association (ASHA); (2) Have completed the educational requirements and work experience necessary for the certificate; or (3) H…

DHS 105.32 Optometrists. For MA certification, optometrists shall be licensed and registered pursuant to ss. 449.04 and 449.06, Stats. Note: For covered vision care services, see s. DHS 107.20. History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.

DHS 105.33 Opticians. For MA certification, opticians shall practice as described in s. 449.01 (2), Stats. Note: For covered vision care services, see s. DHS 107.20. History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.

DHS 105.34 Rehabilitation agencies. For MA certification on or after January 1, 1988, a rehabilitation agency providing outpatient physical therapy, or speech and language pathology form, or occupational therapy shall be certified to participate in medicare as an outpatient rehab…

DHS 105.35 Rural health clinics. For MA certification, a rural health clinic shall be: (1) Certified to participate in medicare; (2) Licensed as required under all other local and state laws; and (3) Staffed with persons who are licensed, certified form or registered in accordanc…

DHS 105.36 Family planning clinics or agencies. For MA certification, family planning clinics or agencies shall meet the following conditions: (1) GENERAL. In order to qualify for MA reimbursement, family planning clinics shall certify to the department that: (a) An MA card has b…

DHS 105.37 Early and periodic screening, diagnosis and treatment (EPSDT) providers. (1) EPSDT HEALTH ASSESSMENT AND EVALUATION SERVICES. (a) Eligible providers. The following providers are eligible for certification as providers of EPSDT health assessment and evaluation services:…

DHS 105.38 Ambulance providers. (1) For MA certification, ambulance service providers shall be licensed pursuant to s. 256.15, Stats., and ch. DHS 110, and shall meet ambulance inspection standards of the Wisconsin department of transportation under s. 341.085, Stats., and ch. Tr…

DHS 105.39 Specialized medical vehicle providers. (1) For MA certification, a specialized medical vehicle provider shall meet the requirements of this section and shall sign the affidavit required under sub. (6) stipulating that the provider is in compliance with the requirements…

DHS 105.40 Durable medical equipment and medical supply vendors. (1) Except as provided in sub. (2), vendors of durable medical equipment and medical supplies shall be eligible to participate in the MA program. (2) Orthotists and prosthetists who develop and fit appliances for re…

DHS 105.41 Certification of hearing instrument specialists. For MA certification, hearing instrument specialists shall be licensed pursuant to ss. 459.01 to 459.14, Stats. Note: For covered hearing aids and supplies, see s. DHS 107.24.

DHS 105.42 Physician office laboratories. (1) REFor MA certification, physician office laboratories, except as noted in sub. (2), shall be licensed pursuant to 42 CFR 493 (CLIA). QUIREMENTS. (2) EXCEPTION. Physician office laboratories servicing no more than 2 physicians, chiropr…

DHS 105.43 Hospital and independent clinical laboratories. For MA certification, a clinical laboratory that is a hospital laboratory or an independent laboratory shall be licensed pursuant to 42 CFR 493 (CLIA). In addition, the laboratory shall be certified to participate in medi…

DHS 105.44 Portable x-ray providers. For MA certification, a portable x-ray provider shall be directed by a physician or group of physicians, registered pursuant to s. 254.35, Stats., and ch. DHS 157, certified to participate in medicare, and shall meet the requirements of 42 CFR…

DHS 105.45 Dialysis facilities. For MA certification, dialysis facilities shall meet the requirements enumerated in ss. DHS 152.05 and 152.08, and shall be certified to participate in medicare. Note: For covered dialysis services, see s. DHS 107.26. History: Cr. Register, Februar…

DHS 105.46 Blood banks. For MA certification, blood banks shall be licensed or registered with the U.S. food and drug administration and shall be approved pursuant to 42 CFR 493 (CLIA). Note: For covered blood services, see s. DHS 107.27. History: Cr. Register, February, 1986, No…

DHS 105.47 Health maintenance organizations and prepaid health plans. (1) CONTRACTS AND LICENSING. Except as provided in sub. (3), for MA certification, a health maintenance organization or prepaid health plan shall enter into a written contract with the department to provide ser…

DHS 105.48 Out-of-state providers. (1) When a provider in a state that borders on Wisconsin documents to the department’s satisfaction that it is common practice for recipients in a particular area of Wisconsin to go for medical services to the provider’s locality in the neighbor…

DHS 105.49 Ambulatory surgical centers. For MA certification, an ambulatory surgical center shall be certified to participate in medicare as an ambulatory surgical center under 42 CFR 416.39. Note: For covered ambulatory surgical center services, see s. DHS 107.30. History: Cr. R…

DHS 105.50 Hospices. For MA certification, a hospice shall be certified to participate in medicare as a hospice under 42 CFR 418.50 to 418.100. History: Cr. Register, February, 1988, No. 386, eff. 3-1-88.

DHS 105.51 Case management agency providers. (1) AGENCY. For MA certification, a provider of case management services shall be an agency with state statutory authority to operate one or more community human service programs. A case management agency may be a county or Indian trib…

DHS 105.52 Prenatal care coordination providers. (1) AGENCY. For MA certification, an agency that provides prenatal care coordination services under s. DHS 107.34 (1) may be any of the following: (a) A community-based health organization. (b) A community-based social services age…

DHS 105.525 Child care coordination providers. (1) PREREQUISITES. For MA certification, an agency that provides child care coordination services under s. DHS 107.345 (1) shall: (a) Be an agency under s. DHS 105.52 (1) (a) to (d) or (f) to (o) that is certified to provide prenatal…

DHS 105.529 Crisis urgent care and observation facilities. For MA certification as a crisis urgent care and observation facility under s. 49.45 (41a), Stats., a provider agency shall be certified to operate under ch. DHS 31. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: …

DHS 105.53 School-based service providers. (1) ELIGIBLE PROVIDERS. For MA certification, a school-based service provider shall be either a school district under ch. 120, Stats., or a cooperative educational service agency (CESA) under ch. 116, Stats. (1m) DEFINITION. In this sect…

DHS 105.54 Qualified complex rehabilitation technology suppliers. (1) CERTIFICATION. For MA certification, the chapter was last published. DHS 105.54 WISCONSIN ADMINISTRATIVE CODE complex rehabilitation technology suppliers shall do all of the following: (a) Be accredited by a de…

DHS 106.01 Introduction. In addition to provisions of chs. DHS 105 and 107 relating to individual provider types and the manner by which specified services are to be provided and paid for under medical assistance (MA), the participation of all providers certified under ch. DHS 10…

DHS 106.02 General requirements for provision of services. Providers shall comply with the following general conditions for participation as providers in the MA program: (1) CERTIFICATION. A provider shall be certified under ch. DHS 105. (2) COVERED SERVICES. A provider shall be …

DHS 106.03 Manner of preparing and submitting claims for reimbursement. (1) FORMAT. (a) In this subsection, Xbilling serviceY means a provider or an entity under contract to a provider which provides electronic media billing or electronic billing transmission for one or more prov…

DHS 106.04 Payment of claims for reimbursement. (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 Xterms of provider reimbursement,Y found in the appropr…

DHS 106.05 Voluntary termination of program participation. (1) PROVIDERS OTHER THAN NURSING HOMES. (a) Termination notice. Any provider other than a skilled nursing facility or intermediate care facility may at any time terminate participation in the program. A provider electing …

DHS 106.06 Involuntary termination or suspension from program participation. The department may suspend or terminate the certification of any person, partnership, corporation, association, agency, institution or other entity participating as a health care provider under the progr…

DHS 106.065 Involuntary termination and alternative sanctions for home care providers. (1) TERMINATION. (a) The department may terminate a home care provider[s certification to participate in the MA program for failure to comply with the requirements of s. DHS 105.19, 107.11, 107…

DHS 106.07 Effects of suspension or involuntary termination. (1) LENGTH OF SUSPENSION OR INVOLUNTARY TERMINATION. In determining the period for which a party identified in this chapter is to be disqualified from participation in the program, the department shall consider the foll…

DHS 106.08 Intermediate sanctions. (1) To enforce compliance with MA program requirements, the department may impose on a provider for a violation listed under sub. (2) one or more of the sanctions under sub. (3) unless the requirements of s. DHS 106.065 apply. Any sanction impos…

DHS 106.09 Departmental discretion to pursue monetary recovery. (1) Nothing in this chapter shall preclude the department from pursuing monetary recovery from a provider at the same time action is initiated to impose sanctions provided for under this chapter. (2) The department m…

DHS 106.10 Withholding payment of claims. (1) Suspension or termination from participation shall preclude a provider from submitting any claims for payment, either personally or through claims submitted by any clinic, group, corporation or other association for any health care pr…

DHS 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…

DHS 106.12 Procedure, pleadings and practice. (1) SCOPE. The provisions of this section shall govern the following administrative actions by the department: (a) Decertification or suspension of a provider from the medical assistance program pursuant to s. 49.45 (2) (a) 12., Stats…

DHS 106.13 Discretionary waivers and variances. A provider or recipient may apply for and the department shall consider applications for a discretionary waiver or variance of any rule in chs. DHS 102 to 105, 107 and 108, excluding ss. DHS 107.02 (1) (b), (2) (e) to (j) and (3) (a…

DHS 107.01 General statement of coverage. (1) The department shall reimburse providers for medically necessary and appropriate health care services listed in ss. 49.46 (2) and 49.47 (6) (a), Stats., when provided to currently eligible medical assistance recipients, including emer…

DHS 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. DHS 107.16 …

DHS 107.03 Services not covered. The following services are not covered services under MA: (1) Service charges for telephone calls; (2) Charges for missed appointments; (3) Sales tax on items for resale; (4) Services provided by a particular provider that are considered experimen…

DHS 107.035 Definition and identification of experimental services. (1) DEFINITION. “Experimental in nature,” as used in s. DHS 107.03 (4) and this section, means a service, procedure or treatment provided by a particular provider which the department has determined under sub. (2…

DHS 107.04 Coverage of out-of-state services. All non-emergency out-of-state services require prior authorization, except where the provider has been granted border status pursuant to s. DHS 105.48. History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made unde…

DHS 107.05 Coverage of emergency services provided by a person not a certified provider. Emergency services necessary to prevent the death or serious impairment of the health of a recipient shall be covered services even if provided by a person not a certified provider. A person …

DHS 107.06 Physician services. (1) COVERED SERPhysician services covered by the MA program are, except as otherwise limited in this chapter, any medically necessary diagnostic, preventive, therapeutic, rehabilitative or palliative services provided in a physician’s office, in a h…

DHS 107.065 Anesthesiology services. (1) COVAnesthesiology services covered by the MA program are any medically necessary medical services applied to a recipient to induce the loss of sensation of pain associated with surgery, dental procedures or radiological services. These ser…