Wis. Admin. Code Department of Health Services § DHS 154.04 - Patient certification
(1) APPLICATION. To apply for assistance in
paying for the costs of treatment of adult cystic fibrosis, a patient shall
complete a form available from a cystic fibrosis treatment center, and shall
submit the completed form either to the center or directly to the department.
When an application form is submitted to a cystic fibrosis treatment center,
the center shall forward the application form to the department within 14 days
from the date of receipt.
(2)
NOTIFICATION OF APPLICANT. The department shall certify a patient as eligible
for reimbursement for part of the medical costs of treatment of cystic fibrosis
if all requirements under s.
DHS
154.03 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 shall 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 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, participant liability, the types of medical services
required for proper care 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 office
of administrative hearings so that it is received there within 30 days after
the date of the notice of denial, revocation or nonrenewal of
certification.
Notes
The mailing address of the Division of Hearings and Appeals is P.O. Box 7875, Madison, Wisconsin 53707.
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