Wisconsin Administrative Code

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…

DHS 107.067 Pharmacist services. (1) COVERED SERVICES. Pharmacist services covered by the MA program are any medically necessary services that are covered under this chapter, provided to a recipient, and delivered by a licensed pharmacist when one of the following apply: (a) The …

DHS 107.08 Hospital services. (1) COVERED SER(a) Inpatient services. Covered hospital inpatient services are those medically necessary services which require an inpatient stay ordinarily furnished by a hospital for the care and treatment of inpatients, and which are provided unde…

DHS 107.09 Nursing home services. (1) DEFINITION. In this section, “active treatment” means an ongoing, organized effort to help each resident attain his or her developmental capacity through the resident’s regular participation, in accordance with an individualized plan, in a pr…

DHS 107.10 Drugs. (1) COVERED SERVICES. Drugs and drug products covered by MA include legend and non-legend drugs and supplies listed in the Wisconsin medicaid drug index which are prescribed by any of the following: (a) A physician licensed under s. 448.04, Stats. (b) A dentist …

DHS 107.11 Home health services. (1) DEFINITIONS. In this section: (a) “Community-based residential facility” has the meaning prescribed in s. 50.01 (1g), Stats. (b) “Home health aide services” means medically oriented tasks, assistance with activities of daily living and inciden…

DHS 107.112 Personal care services. (1) COVERED SERVICES. (a) Personal care services are medically oriented activities related to assisting a recipient with activities of daily living necessary to maintain the recipient in his or her place of residence in the community. These ser…

DHS 107.113 Respiratory care for ventilator-assisted recipients. (1) COVERED SERVICES. (a) Services, medical supplies and equipment necessary to provide life support for a recipient who has been hospitalized for at least 30 consecutive days for his or her respiratory condition an…

DHS 107.12 Private duty nursing services. (1) COVERED SERVICES. (a) Private duty nursing is skilled nursing care available for recipients with medical conditions requiring more continuous skilled care than can be provided on a part-time, intermittent basis. Only a recipient who r…

DHS 107.121 Nurse-midwife services. (1) COVERED Covered services provided by a certified nurse-midwife may include the care of mothers and their babies throughout the maternity cycle, including pregnancy, labor, normal childbirth and the immediate postpartum period, provided that…

DHS 107.122 Independent nurse practitioner services. (1) COVERED SERVICES. Services provided by a nurse practitioner, including a clinical nurse specialist, which are covered by the MA program are those medical services delegated by a prescribing provider by a written protocol de…

DHS 107.13 Mental health services. (1) INPATIENT CARE IN A HOSPITAL IMD. (a) Covered services. Inpatient hospital mental health and AODA care shall be covered when prescribed by a physician and when provided within a hospital institution for mental disease (IMD) which is certifie…

DHS 107.14 Podiatry services. (1) COVERED SER(a) Podiatry services covered by medical assistance are those medically necessary services for the diagnosis and treatment of the feet and ankles, within the limitations described in this section, when provided by a certified podiatris…

DHS 107.15 Chiropractic services. (1) DEFINITION. In this section, “spell of illness” means a condition characterized by the onset of a spinal subluxation.“Subluxation” means the alteration of the normal dynamics, anatomical or physiological relationships of contiguous articular …

DHS 107.16 Physical therapy. (1) COVERED SERVICES. (a) General. Covered physical therapy services are those medically necessary modalities, procedures and evaluations enumerated in pars. (b) to (d), when prescribed by a prescribing provider and performed by a qualified physical t…

DHS 107.17 Occupational therapy. (1) COVERED SERVICES. Covered occupational therapy services are the following medically necessary services when prescribed by a prescribing provider, in accordance with s. 49.46 (2) (a) 4. or (2) (b) 6., Stats., and performed by a certified occupa…

DHS 107.18 Speech and language pathology services. (1) COVERED SERVICES. (a) General. Covered speech and language pathology services are those medically necessary diagnostic, screening, preventive or corrective speech and language pathology services prescribed by a prescribing pr…

DHS 107.19 Audiology services. (1) COVERED SERVICES. Covered audiology services are those medically necessary diagnostic, screening, preventive or corrective audiology services the chapter was last published. DHS 107.19 WISCONSIN ADMINISTRATIVE CODE prescribed by a prescribing pr…

DHS 107.20 Vision care services. (1) COVERED SERCovered vision care services are eyeglasses and those medically necessary services provided by licensed optometrists within the scope of practice of the profession of optometry as defined in s. 449.01, Stats., who are certified unde…

DHS 107.21 Family planning services. (1) COVERED (a) General. Covered family planning services are the services included in this subsection when prescribed by a prescribing provider and provided to a recipient, including initial physical exam and health history, annual office vis…

DHS 107.22 Early and periodic screening, diagnosis and treatment (EPSDT) services. (1) COVERED SERVICES. Early and periodic screening and diagnosis to ascertain physical and mental defects, and the provision of treatment as provided in sub. (4) to correct or ameliorate the defect…

DHS 107.23 Transportation. (1) COVERED SERVICES. (a) Purpose. Transportation by ambulance, specialized medical vehicle (SMV) or county-approved or tribe-approved common carrier as defined under par. (d) 1., is a covered service when provided to a recipient in accordance with this…

DHS 107.24 Durable medical equipment and medical supplies. (1) DEFINITION. In this section: (a) “DME” means durable medical equipment. (b) “Medical supplies” means disposable, consumable, expendable or nondurable medically necessary supplies which have a very limited life expecta…

DHS 107.26 Dialysis services. Dialysis services are covered services when provided by facilities certified pursuant to s. DHS 105.45.

DHS 107.27 Blood. The provision of blood is a covered service when provided to a recipient by a physician certified pursuant to s. DHS 105.05, a blood bank certified pursuant to s. DHS 105.46 or a hospital certified pursuant to s. DHS 105.07.

DHS 107.28 Health maintenance organization and prepaid health plan services. (1) COVERED SERVICES. (a) HMOs. 1. Except as provided in subd. 2., all health maintenance organizations (HMOs) that contract with the department shall provide to enrollees all MA services that are covere…

DHS 107.29 Rural health clinic services. Covered rural health clinic services are the following: (1) Services furnished by a physician within the scope of practice of the profession under state law, if the physician performs the services in the clinic or the services are furnishe…

DHS 107.30 Ambulatory surgical center services. (1) COVERED SERVICES. Covered ambulatory surgical center (ASC) services are those medically necessary services identified in this section which are provided by or under the supervision of a certified physician in a certified ambulat…

DHS 107.31 Hospice care services. (1) DEFINI(a) “Attending physician” means a physician who is a doctor of medicine or osteopathy certified under s. DHS 105.05 and identified by the recipient as having the most significant role TIONS. the chapter was last published. 51 DEPARTMENT…

DHS 107.33 Ambulatory prenatal services for recipients with presumptive eligibility. (1) COVERED SERVICES. Ambulatory prenatal care services are covered services. These services include treatment of conditions or complications that are caused by, exist or are exacerbated by a pre…

DHS 107.34 Prenatal care coordination services. (1) COVERED SERVICES. (a) General. 1. Prenatal care coordination services covered by MA are services described in this section that are provided by an agency certified under s. DHS 105.52 or by a qualified person under contract with…

DHS 107.345 Child care coordination services. (1) COVERED SERVICES. (a) Definitions. In this section: 1. “Care coordinator” means an individual who meets the criteria under s. DHS 105.525 (3). 2. “Employee of the child care coordination provider” means a qualified professional or…

DHS 107.36 School-based services. (1) COVERED SERVICES. (a) General. 1. School-based services covered by the MA program are services described in this section that are provided by a school district or CESA. 2. The school district or CESA shall ensure that individuals who deliver …

DHS 108.01 Safeguarded information. (1) Except for purposes directly related to direct program administration, the department may not use or disclose any information concerning past or present applicants and recipients of MA. (2) In this section, Xdirect program administrationY m…

DHS 108.02 Department rights and responsibilities. (1) DIFFERENT BENEFITS FOR DIFFERENT GROUPS. The department may offer MA benefits to the categorically needy which are different from the benefits offered to the medically needy, subject to ss. 49.46 (2) (a) and 49.47 (6) (a), St…

DHS 108.03 County responsibilities. (1) DETERMINATION OF ELIGIBILITY. Agencies shall be responsible for determination of eligibility for MA. These determinations shall comply with standards for eligibility found in ss. 49.46 (1), 49.47 (4), and 49.665 (4), Stats., and ch. DHS 103…

DHS 109.01 Authority and purpose.

DHS 109.02 Applicability.