Participation by non-certified persons

Participation by non-certified persons.

(1) Reimbursement for emergency services. If a resident of Wisconsin or of another state who is not certified by MA in this state provides emergency services to a Wisconsin recipient, that person shall not be reimbursed for those services by MA unless the services are covered services under ch. DHS 107 and:

(a) The person submits to the fiscal agent a provider data form and a claim for reimbursement of emergency services on forms prescribed by the department;

(b) The person submits to the department a statement in writing on a form prescribed by the department explaining the nature of the emergency, including a description of the recipient’s condition, cause of emergency, if known, diagnosis and extent of injuries, the services which were provided and when, and the reason that the recipient could not receive services from a certified provider; and

(c) 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.

(2) Reimbursement prohibited for non-emergency services. No non-emergency services provided by a non-certified person may be reimbursed by MA.

(3) Reimbursement determination. Based upon the signed statement and the claim for reimbursement, the department’s professional consultants shall determine whether the services are reimbursable.