Section DHS 109.52 - Provider certification(1) GENERAL. This section identifies the terms and conditions under which SeniorCare providers of drugs are certified for participation in the program.(2) PHARMACIES. (a) For SeniorCare certification, pharmacies located in Wisconsin shall meet the requirements for registration and practice under ch. 450, Stats., and chs. Phar 1 to 17. Pharmacies certified to serve patients under the medical assistance program under ch. DHS 105 are required to serve SeniorCare participants.(b) Pharmacies located outside of Wisconsin are exempt from the requirement under par. (a), but shall be registered or licensed by the appropriate agency in the state in which they are located.(3) GENERAL CONDITIONS FOR PARTICIPATION. In order to be certified by the department to dispense drugs under this program, a SeniorCare provider shall do all of the following: (a) Affirm in writing that the SeniorCare provider and each person employed by the SeniorCare provider for the purpose of providing the service holds all licenses or similar entitlements as specified in this chapter and as required by federal or state statute, regulation or rule for the provision of the service.(b) Affirm in writing that neither the SeniorCare provider, nor any person in whom the SeniorCare provider has a controlling interest, nor any person having a controlling interest in the SeniorCare provider, has been convicted of a crime related to, or been terminated from, a federally-assisted or state-assisted medical program.(c) Disclose in writing to the department all instances in which the SeniorCare provider, any person in whom the SeniorCare provider has a controlling interest, or any person having a controlling interest in the SeniorCare provider has been sanctioned by a federally-assisted or state-assisted medical program.(d) Furnish the following information to the department in writing:1. The names and addresses of all vendors of drugs, medical supplies or transportation, or other providers in which the SeniorCare provider has a controlling interest or ownership.2. The names and addresses of all persons who have a controlling interest in the SeniorCare provider.3. Whether any of the persons named in compliance with subd. 1. or 2., is related to another named in subd. 1. or 2.(e) Execute a SeniorCare provider agreement with the department.(4) NOTIFICATION OF CERTIFICATION DECISION. Within 60 days after the department receives a complete application for certification, including evidence of licensure or Medicare certification, or both, if required, the department shall either approve the application and issue the certification, or deny the application. If the application for certification is denied, the department shall give the applicant reasons, in writing, for the denial.(5) REQUIREMENTS FOR MAINTAINING CERTIFICATION. (a)Compliance with requirements. A SeniorCare provider shall maintain compliance with the requirements in this subsection in order to maintain SeniorCare certification.(b)Change in provider status. A SeniorCare provider shall report to the department in writing any change in licensure, certification, group affiliation, corporate name or ownership by the time of the effective date of the change. The department may require the SeniorCare provider to complete a new provider application and a new provider agreement when a change in status occurs. A SeniorCare provider shall immediately notify the department of any change of address but the department shall not require the completion of a new provider application or a new provider agreement for a change of address.(c)Change in ownership. If the ownership of a certified SeniorCare provider changes, the provider agreement shall automatically terminate.(d)Program compliance. A SeniorCare provider may lose SeniorCare certification for any of the reasons listed in sub. (12) or in s. DHS 106.06.(6) RESPONSE TO INQUIRIES. A SeniorCare provider shall respond as directed to inquiries by the department regarding the validity of provider information maintained by the department.(7) MAINTENANCE OF RECORDS. A SeniorCare provider shall prepare and maintain whatever records are necessary to fully disclose the nature and extent of services provided by the SeniorCare provider under the program, including those enumerated in sub. (8). Each SeniorCare provider shall maintain all required records for at least a period of 5 years from the date the department pays for the services rendered, unless otherwise stated in this chapter. If a SeniorCare provider's participation in the program terminates for any reason, all related records shall remain subject to the conditions enumerated in this subsection and sub. (8).(8) RECORDS TO BE MAINTAINED. SeniorCare providers shall retain all of the following records: (a) Contracts or agreements with persons or organizations for the furnishing of SeniorCare items or services, payment for which may be made in whole or in part, directly or indirectly, by the department.(b) Billings and records of services or supplies which are the subject of the billings that are necessary to fully disclose the nature and extent of the SeniorCare services or supplies.(c) All policies and regulations adopted by the SeniorCare provider's governing body.(d) Prescriptions that support SeniorCare billings, including records of SeniorCare covered vaccines and vaccine administration.(e) SeniorCare patient profiles.(f) SeniorCare purchase invoices and receipts.(g) Receipts for costs associated with SeniorCare services billed.(9) PROVIDER AGREEMENT DURATION. The provider agreement shall, unless terminated, remain in full force and effect for a maximum of one year from the date the department accepts a SeniorCare provider into the program. In the absence of a notice of termination by the SeniorCare provider or department, the agreement shall automatically renew and extend for a period of one year.(10) PARTICIPATION BY NON-CERTIFIED PERSONS. (a)Reimbursement for emergency services. If a person in Wisconsin or in another state who is not certified as a SeniorCare provider by the department in this state provides emergency services to a Wisconsin participant, that person may not be reimbursed for those services unless the drugs are covered under this chapter and all of the following conditions are met: 1. The person submits to the department a provider data form and a claim for reimbursement of emergency services on forms prescribed by the department.2. The person submits to the department a statement in writing on a form prescribed by the department explaining the nature of the emergency, if known, including a description of the participant's condition, cause of emergency, diagnosis and extent of injuries, the drugs that were provided and when, and the reason that the participant could not receive drugs from a certified SeniorCare provider.3. The person possesses all licenses and other entitlements required under state and federal statutes, rules and regulations, and is qualified to provide all services for which a claim is submitted.(b)Reimbursement prohibited for non-emergency services. The department may not reimburse non-emergency services provided by a non-certified person unless the department receives prior authorization as provided in s. DHS 109.32 (2).(c)Reimbursement determination. Based upon the signed statement and the claim for reimbursement, the department shall determine whether the services are reimbursable.(11) VOLUNTARY TERMINATION OF PROGRAM PARTICIPATION. (a)Voluntary termination. Any SeniorCare provider may terminate participation in the SeniorCare program and the medical assistance program. A SeniorCare provider electing to terminate program participation shall, at least 30 days before the termination date, notify the department in writing of that decision, the reasons for termination and the effective date of termination from the program.(b)Reimbursement. A SeniorCare provider may not claim reimbursement for prescription drugs provided to participants on or after the effective date specified in the termination notice. If the SeniorCare provider's notice of termination fails to specify an effective date, the department shall terminate the SeniorCare provider's certification to provide and claim reimbursement for services under the program on the date on which the department receives notice of termination.(12) INVOLUNTARY TERMINATION OR SUSPENSION FROM PROGRAM PARTICIPATION. The provisions of s. DHS 106.06 apply to the SeniorCare program, with the exception of s. DHS 106.06 (3), (24) and (30).(13) EFFECTS OF SUSPENSION OR INVOLUNTARY TERMINATION. The provisions of s. DHS 106.07 apply to the SeniorCare program.Wis. Admin. Code Department of Health Services DHS 109.52
CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; corrections in (2) (a), (5) (d), (12) and (13) made under s. 13.92(4) (b) 7, Stats., Register December 2008 No. 636; correction in (2) (a) made under s. 13.92(4) (b) 7, Stats., Register July 2011 No. 667.Amended by, CR 22-046: am. (8) (d), (11) (b) Register June 2023 No. 810, eff. 7/1/2023