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General requirements for provision of services – Wis. Admin. Code DHS §106-02

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A provider providing medical assistance may only be reimbursed for covered services as long as the recipient was eligible for medical assistance when the treatment was administered.  Reimbursement for medical services must be for medically necessary services. 

Providers participating in Medicaid or other state medical assistance programs must maintain accurate documentation and medical and financial records.  The provider must also document the following:

  • Recipient’s name;
  • Person who provided services to the recipient;
  • A complete description of the services provided;
  • The purpose of the services;
  • The quantity and level of services provided;
  • Date of service;
  • Location of the services;
  • Relevant financial records;

As noted above, the provider must also maintain medical records for the recipients of medical assistance.  The medical record must include the following:

  • Date, department, and name of the provider;
  • Chief medical complaint;
  • Clinical findings;
  • Diagnosis;
  • Tests ordered;
  • Therapies or other treatments ordered;
  • Disposition and instructions given to the recipient;
  • Prescriptions or plans of care for the recipient;

The provider must also maintain financial records, as noted above.  The financial record must be maintained either in written or electronic form and must include the following:

  • Payroll checks or other accounting records prepared by the provider;
  • Medicare, insurance or third party billing;
  • Evidence of the provider’s usual charges;
  • Provider’s appointment books;
  • Billing claims forms;
  • Records of anyone with an ownership interest;
  • Employee records;

The provider must also retain all claims information, cost information submitted to Medicaid.  The provider must retain all records for at least 5 years, except that rural health clinics must retain records for at least 6 years from the date payment was received for a medical service.  The retention period does not end even if the provider no longer participates in Medicaid. 

A provider must grant an employee of the Department of Health Services access to medical records, if requested.

Current as of June 2015