Wis. Admin. Code Department of Health Services § DHS 153.04 - Patient certification

(1) APPLICATION. To apply for assistance in paying for the costs of blood products and supplies used in the home care of hemophilia, a patient shall complete a form available from a comprehensive hemophilia treatment center, and shall submit the completed form either to the center or directly to the department. The completed form shall include a signed certification by the physician director of the center that the patient has successfully participated in a home care program, and that the physician director will review the patient's maintenance program every 6 months and, on request of the department, will verify that the patient is complying with the program.
(2) NOTIFICATION OF APPLICANT. The department shall certify a patient as eligible for reimbursement for part of the costs of blood products and supplies used in the home treatment of hemophilia if all requirements under s. DHS 153.03 are met. The department shall notify the patient, in writing, of its decision within 60 days after the department receives an application for assistance. If the application is denied, the notice shall include the reason for denial with information that the patient may request a hearing under sub. (7) on that decision.
(3) RECERTIFICATION. Certification is for one year. To be recertified, a participant shall complete, sign and submit to the department a financial statement form received from the department. The participant shall provide to the department full, truthful and correct information necessary for the department to determine eligibility and liability.
(4) REVOCATION OR NONRENEWAL OF CERTIFICATION. The department may revoke or not renew a participant's certification if the department finds that the participant is no longer eligible for the program. The department shall send written notice of revocation or nonrenewal to the participant, stating the reason for it and with information that the participant may request a hearing under sub. (7) on that decision.
(5) PARTICIPANT RESPONSIBILITY TO PROVIDE INFORMATION.
(a) A participant shall inform the department within 30 days of any change in address, other source of health care coverage or family size, or any change in income of more than 10%.
(b) The department may verify or audit a participant's total family income. The department may redetermine a participant's estimated total family income for the current year based on a change in the family's financial circumstances.
(6) CONFIDENTIALITY OF PATIENT INFORMATION. All personally identifiable information provided by or on behalf of a patient to the department shall remain confidential and may not be used for any purpose other than to determine program eligibility, patient liability and the payment of claims. Statistical analyses of program data may not reveal patient identity.
(7) APPEAL. A patient denied assistance under sub. (2) or a participant whose certification is revoked or not renewed under sub. (4) may request a hearing on that decision under ss. 227.44 to 227.50, Stats., by the department of administration's division of hearings and appeals. The request for a hearing shall be in writing and shall be sent to the division of hearings and appeals so that it is received there within 30 days after the date of the notice of denial, revocation or nonrenewal of certification.

Notes

Wis. Admin. Code Department of Health Services § DHS 153.04
Cr. Register, December, 1994, No. 468, eff. 1-1-95.

The mailing address of the Division of Hearings and Appeals is P.O. Box 7875, Madison, Wisconsin 53707.

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