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Provider responsibility – Wis. Admin. Code DHS §109-51

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Senior care provider responsibilities

This law sets forth the responsibilities for certified Senior Care providers.  The law states that providers must comply with all program monitoring rules and conditions, but allows providers to appeal any DHS action withholding payment to the provider due to fraud or misrepresentation by the provider.


The law states that providers are required to maintain the confidentiality of any information about participants, but the providers are allowed to disclose information when requested by appropriate federal or state agencies with respect to the services provided by the program to its participants.  Providers are further required to give persons authorized by the department of health services access to requested records.  A provider's responsibility to maintain and provide access to these records does not end when the provider ceases participation in the program.


The law further sets forth requirements for the providers with respect to submission of claims for drugs purchased by a participant, reimbursement from third party insurers, refunding participant payment for drugs covered by Senior Care, and limitations on copayments and deductibles.

Current as of June 2015