Section DHS 109.51 - Provider responsibility(1) AUDIT AND PROGRAM MONITORING.(a) Providers shall comply with the audit and program monitoring conditions under s. DHS 105.01 (3) (f) 1. to 3.(b) Nothing in this subsection shall be construed to limit the right of a provider to appeal a department recovery action brought under s. DHS 109.53 (4).(2) CONFIDENTIALITY OF MEDICAL INFORMATION. Information about participants shall be confidential in accordance with ss. 146.81 to 146.83, Stats. No privilege exists under the SeniorCare program regarding communications or disclosures of information requested by appropriate federal or state agencies or an authorized agent of such agencies concerning the extent or kind of services provided participants under the program. The disclosure by a SeniorCare provider of these communications or medical records, made in good faith under the requirements of this program, shall not create any civil liability or provide any basis for criminal actions for unprofessional conduct.(3) PROVIDER RESPONSIBILITY. At the request of a person authorized by the department and on presentation of that person's credentials, a SeniorCare provider shall permit access to any requested records, whether in written, electronic, or micrographic form. Access for purposes of this subsection shall include the opportunity to inspect, review, audit and reproduce the records.(4) RECORD RETENTION. Termination of a SeniorCare provider's program participation does not end the SeniorCare provider's responsibility to retain and provide access to records unless an alternative arrangement for retention, maintenance and access has been established by the SeniorCare provider and approved in writing by the department.(5) SUBMISSION OF CLAIMS. A SeniorCare provider shall submit all claims for prescription drugs purchased by a participant during spend-down and deductible periods.(6) THIRD PARTY LIABILITY. A SeniorCare provider shall seek reimbursement from any third party insurer legally liable to contribute in whole or in part to the cost of prescription drugs prior to billing the SeniorCare program.(7) REFUNDS TO PARTICIPANTS. A SeniorCare provider shall fully refund participant payments for drugs subsequently covered by SeniorCare. If either the deductible or copayment retroactively applies, the provider shall fully refund the participant the excess amount that the participant paid. The excess is the difference between the actual amount the participant paid and the amount the participant is responsible for under SeniorCare.(8) LIMITATIONS ON COPAYMENTS AND DEDUCTIBLES. (a) As a condition of participation by a SeniorCare provider in the program under s. 49.45, 49.46, or 49.47, Stats., the SeniorCare provider may not charge an eligible participant who presents a valid prescription order and a SeniorCare identification an amount for a prescription drug under the order that exceeds the following: 1. For a deductible benefit, as specified in s. DHS 109.13 (3), the program payment rate.2. For a prescription benefit, the copayment amount, as applicable, that is specified in s. DHS 109.13 (2) (b). No dispensing fee may be charged to a person under this paragraph.3. For persons receiving spend-down services, as specified in s. DHS 109.13 (4), the retail price.(b) The department shall calculate and transmit amounts that may be used in calculating charges under par. (a) to SeniorCare providers.Wis. Admin. Code Department of Health Services DHS 109.51
CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; correction in (1) (a) made under s. 13.92(4) (b) 7, Stats., Register December 2008 No. 636.Amended by, CR 22-046: am. (5) Register June 2023 No. 810, eff. 7/1/2023