102.423 Health service fee schedule.
953 words·~4 min read·
/wi/chapter-102/102-423-5A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
102.423 Health service fee schedule.
(1)Definitions. In this section:
(a)“Eligible hospital” has the meaning given under s. 50.38
(1).
(b)“Items or services” means hospital facility services that are “items and services,” as defined under 45 CFR 180.20 .
(2)Applicability.
(a)Subject to par.
(b), this section shall apply to a fee for an item or service only if all of the following apply:
1. The fee is for an item or service that was provided by an eligible hospital.
2. The fee is for an item or service for which the eligible hospital may receive hospital inpatient or hospital outpatient reimbursement from the Medical Assistance program under subch. IV of ch. 49 .
3. The fee was paid within the applicable period under par.
(c).
1.
a. If a notice from the department of health services under s. 50.38
(a)1. is published by the legislative reference bureau in the Wisconsin Administrative Register indicating that either s. 50.38
(a)1. a. or b. applies, then this section shall not apply from the day the notice is published until subd. 2. applies.
b. Except as provided in subd. 1. a. , if a notice from the department of health services under s. 50.38
(a)1. is published by the legislative reference bureau in the Wisconsin Administrative Register indicating that either s. 50.38
(a)1. c. or d. applies, then this section shall not apply beginning on the first day of the calendar year following the calendar year in which the notice is published until subd. 2. applies.
2.
a. Notwithstanding subd. 1. , if a notice from the department of health services under s. 50.38
(b)1. is published by the legislative reference bureau in the Wisconsin Administrative Register indicating that either s. 50.38
(b)1. a. or b. applies, then this section applies from the day the notice is published.
b. Notwithstanding subd. 1. and except as provided in subd. 2. a. , if a notice from the department of health services under s. 50.38
(b)1. is published by the legislative reference bureau in the Wisconsin Administrative Register indicating that either s. 50.38
(b)1. c. or d. applies, then this section applies beginning on the first day of the calendar year following the calendar year in which the notice is published.
1. In order for this section to apply to a fee, an insurer or self-insured employer must remit payment for the fee to the eligible hospital within the period specified in subd. 2. , which shall begin to run on the day after whichever of the following dates is latest:
a. The date the eligible hospital electronically sends to the insurer or self-insured employer the medical records to substantiate the submitted hospital bill or, if such records are sent by mail, the 3rd day after the date the records are postmarked.
b. The date the eligible hospital electronically sends the bill described in subd. 1. a. or, if the bill is sent by mail, the 3rd day after the date the bill is postmarked.
2.
a. If the aggregate amount billed is equal to or greater than $65,000, the period within which an insurer or self-insured employer must remit payment shall be 90 calendar days after the date determined under subd. 1.
b. If the aggregate amount billed is less than $65,000, the period within which an insurer or self-insured employer must remit payment shall be 60 calendar days after the date determined under subd. 1.
3. An insurer or self-insured employer may request that an eligible hospital send additional medical records to the insurer or self-insured employer that the insurer or self-insured employer reasonably believes are necessary to substantiate the claim. The eligible hospital shall provide the requested records to the extent practicable or within 10 days after the request is received, but a request under this subdivision by an insurer or self-insured employer shall not operate to extend the period specified under subd. 2. a. or b.
4.
a. An insurer or self-insured employer may submit a request to the department for an extension to the period specified in subd. 2. if the insurer or self-insured employer has not yet determined whether an injury is compensable under this chapter. The department may, pursuant to rules promulgated under subd. 4. e. , authorize such an extension if the department determines that the insurer or self-insured employer has not yet determined compensability despite its good faith effort to do so.
A single extension granted by the department shall not exceed 30 calendar days. There is no limit to the number of extensions that an insurer or self-insured employer may request or that the department may grant under this subdivision, but an insurer or self-insured employer may not request another extension after a denial.
b. If the department denies a request for extension under this subdivision, the insurer or self-insured employer shall, notwithstanding subds. 1. and 2. , have 14 calendar days after the denial to remit payment for the fee to the eligible hospital. If the insurer or self-insured employer remits payment for the fee to the eligible hospital within that 14-day period, then this section applies to that fee.
c. A request by an insurer or self-insured employer for an extension under this subdivision or a denial by the department of a request for extension under this subdivision shall not be used as evidence of bad faith by the insurer or self-insured employer.
d. Any information provided by an insurer or self-insured employer pursuant to this subdivision shall not be used as evidence of bad faith by the insurer or self-insured employer.