Wis. Admin. Code Department of Health Services DHS 104.03 - Primary provider
(1) REQUIRED DESIGNATION.
(a)
Required when program is
abused. If the department discovers that a recipient is abusing the
program, including abuse under s.
DHS
104.02(5), the department may require
the recipient to designate, in any or all categories of health care provider, a
primary health care provider of the recipient's choice, except when free choice
is limited under s.
DHS
104.035.
(b)
Selection of provider.
The department shall allow a recipient to choose a primary provider from the
department's current list of certified providers, except when free choice is
limited under s.
DHS
104.035. The recipient's choice shall become effective
only with the concurrence of the designated primary provider. The type of
service and identification number of the primary provider shall be endorsed on
the recipient's MA card.
(c)
Failure to cooperate. If the recipient fails to designate a
primary provider after receiving a formal request from the department, the
department shall designate a primary provider for the recipient in the
proximity of the recipient's residence.
(2) REFERRAL TO OTHER PROVIDERS. A primary
provider may, within the scope of the provider's practice, make referrals to
other providers of medical services for which reimbursement will be made if the
referral can be documented as medically necessary and the services are covered
by MA. This documentation shall be made by the primary provider in the
recipient's medical record.
(3)
ALTERNATIVE PRIMARY PROVIDER. The department may allow the designation of an
alternate primary provider. When approval is given by the department to select
an alternate primary provider, the recipient may designate an alternate primary
provider in the same manner a primary provider is designated.
(4) EXCEPTION. The limitations imposed in
this section do not apply in the case of an emergency. Emergency health care
provided by any provider to a recipient restricted under this section shall be
eligible for reimbursement if the claim for reimbursement is accompanied by a
full explanation of the emergency circumstances.
Notes
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