Provider Enrollment and Ongoing Responsibilities : Documentation

1099 Miscellaneous Forms

ForwardHealth generates the 1099 Miscellaneous form in January of each year for earnings greater than $600.00, per IRS regulations. One 1099 Miscellaneous form per financial payer and per tax identification number is generated, regardless of how many provider IDs or NPIs share the same tax identification number. For example, a provider who conducts business with both Medicaid and WCDP will receive separate 1099 Miscellaneous forms for each program.

The 1099 Miscellaneous forms are sent to the address designated as the "1099 mailing address."

Availability of Records to Authorized Personnel

The Wisconsin DHS has the right to inspect, review, audit, and reproduce provider records pursuant to Wis. Admin. Code § DHS 106.02(9)(e). The DHS periodically requests provider records for compliance audits to match information against ForwardHealth's information on paid claims, PA requests, and enrollment. These records include, but are not limited to, medical/clinical and financial documents. Providers are obligated to ensure that the records are released to an authorized DHS staff member(s).

Wisconsin Medicaid reimburses providers $0.06 per page for the cost of reproducing records requested by the DHS to conduct a compliance audit. A letter of request for records from the DHS will be sent to a provider when records are required.

Reimbursement is not made for other reproduction costs included in the provider agreement between the DHS and a provider, such as reproduction costs for submitting PA requests and claims.

Also, state-contracted MCOs, including HMOs and SSI HMOs, are not reimbursed for the reproduction costs covered in their contract with the DHS.

The reproduction of records requested by the PRO under contract with the DHS is reimbursed at a rate established by the PRO.

Certification of Need for Specialized Medical Vehicle Transportation Form

All SMV trips require a completed Certification of Need for Specialized Medical Vehicle Transportation form, including nursing home and hospital discharge trips. The Certification of Need for Specialized Medical Vehicle Transportation form is used to verify that, in the judgment of a medical professional, the member being transported by SMV truly requires SMV transportation and cannot safely travel by common carrier.

It is the member's responsibility to provide the SMV provider with a copy of the Certification of Need for Specialized Medical Vehicle Transportation form.

Form Completion and Maintenance

In order for Wisconsin Medicaid to reimburse SMV providers for services, the providers are required to maintain a completed Certification of Need for Specialized Medical Vehicle Transportation form in their records for each member transported. A completed Certification of Need for Specialized Medical Vehicle Transportation form is required to be in the member's file within 14 working days after the date it is signed and before any claim is submitted (Wis. Admin. Code §§ DHS 107.23[1][c]2. and 3.).

The form requires a signature from one of the following medical care providers:

• Nurse midwife
• Nurse practitioner
• Physician assistant
• Physician

The medical care provider may approve SMV transportation by telephone. In cases of telephone approval, Wis. Admin. Code § DHS 107.23(3)(b)1., requires that the SMV provider obtain a completed Certification of Need for Specialized Medical Vehicle Transportation form by whichever of the following deadlines comes first:

• Within 10 working days of the medical provider's telephone approval for SMV service
• Prior to submitting a claim for the SMV service

Confidentiality and Proper Disposal of Records

ForwardHealth supports member rights regarding the confidentiality of health care and other related records, including an applicant or member's billing information or medical claim records. An applicant or member has a right to have this information safeguarded, and the provider is obligated to protect that right. Use or disclosure of any information concerning an applicant or member (including an applicant or member's billing information or medical claim records) for any purpose not connected with program administration is prohibited unless authorized by the applicant or member (program administration includes contacts with third-party payers that are necessary for pursuing third-party payment and the release of information as ordered by the court).

Federal HIPAA Privacy and Security regulations establish requirements regarding the confidentiality and proper disposal of health care and related records containing PHI. These requirements apply to all providers (who are considered "covered entities") and their business associates who create, retain, and dispose of such records.

For providers and their business partners who are not subject to HIPAA, Wisconsin confidentiality laws have similar requirements pertaining to proper disposal of health care and related records.

HIPAA Privacy and Security Regulations

Definition of Protected Health Information

As defined in the HIPAA privacy and security regulations, PHI is protected health information (including demographic information) that:

• Is created, received, maintained, or transmitted in any form or media.
• Relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the payment for the provision of health care to an individual.
• Identifies the individual or provides a reasonable basis to believe that it can be used to identify the individual.

A member's name combined with their member identification number or Social Security number is an example of PHI.

Requirements Regarding "Unsecured" Protected Health Information

Title XIII of the American Recovery and Reinvestment Act of 2009 (also known as the HITECH Act) included a provision that significantly expanded the scope, penalties, and compliance challenges of HIPAA. This provision imposes new requirements on covered entities and their business associates to notify patients, the federal government, and the media of breaches of "unsecured" PHI (refer to 45 C.F.R. Parts 160 and 164 and § 13402 of the HITECH Act).

Unsecured PHI is PHI that has not been rendered unusable, unreadable, or indecipherable to unauthorized individuals through the use of physical destruction approved by the U.S. HHS. According to HHS, destruction is the only acceptable method for rendering PHI unusable, unreadable, or indecipherable.

As defined by federal law, unsecured PHI includes information in any medium, not just electronic data.

Actions Required for Proper Disposal of Records

To secure PHI, providers and their business associates are required to use one of the following destruction methods approved by the HHS:

• Paper, film, labels, or other hard copy media should be shredded or destroyed such that the PHI cannot be read or otherwise reconstructed.
• Electronic media should be cleared, purged, or destroyed such that the PHI cannot be retrieved according to National Institute of Standards and Technology Special Publication 800-88, Guidelines for Media Sanitization, which can be found on the NIST website.

For more information regarding securing PHI, providers may refer to Health Information Privacy on the HHS website.

Wisconsin Confidentiality Laws

Wis. Stat. § 134.97 requires providers and their business partners who are not subject to HIPAA regulations to comply with Wisconsin confidentiality laws pertaining to the disposal of health care and related records containing PHI.

Wis. Stat. § 146.836 specifies that the requirements apply to "all patient health care records, including those on which written, drawn, printed, spoken, visual, electromagnetic or digital information is recorded or preserved, regardless of physical form or characteristics." Paper and electronic records are subject to Wisconsin confidentiality laws.

"Personally Identifiable Data" Protected

According to Wis. Stat. § 134.97(1)(e), the types of records protected are those containing "personally identifiable data."

As defined by the law, personally identifiable data is information about an individual's medical condition that is not considered to be public knowledge. This may include account numbers, customer numbers, and account balances.

Actions Required for Proper Disposal of Records

Health care and related records containing personally identifiable data must be disposed of in such a manner that no unauthorized person can access the personal information. For the period of time between a record's disposal and its destruction, providers and their business partners are required to take actions that they reasonably believe will ensure that no unauthorized person will have access to the personally identifiable data contained in the record.

Businesses Affected

Wis. Stat.§§ 134.97 and 134.98, governing the proper disposal of health care and related records, apply to medical businesses as well as financial institutions and tax preparation businesses. For the purposes of these requirements, a medical business is any for-profit or nonprofit organization or enterprise that possesses information — other than personnel records — relating to a person's physical or mental health, medical history, or medical treatment. Medical businesses include sole proprietorships, partnerships, firms, business trusts, joint ventures, syndicates, corporations, limited liability companies, or associates.

Continuing Responsibilities for All Providers After Ending Participation

Ending participation in a ForwardHealth program does not end a provider's responsibility to protect the confidentiality of health care and related records containing PHI.

Providers who no longer participate in a ForwardHealth program are responsible for ensuring that they and their business associates/partners continue to comply with all federal and state laws regarding protecting the confidentiality of members' PHI. Once record retention requirements expire, records must be disposed of in such a manner that they cannot be reconstructed — according to federal and state regulations — in order to avoid penalties.

All ForwardHealth providers and their business associates/partners who cease practice or go out of business should ensure that they have policies and procedures in place to protect all health care and related records from any unauthorized disclosure and use.

Penalties for Violations

Any covered entity provider or provider's business associate who violates federal HIPAA regulations regarding the confidentiality and proper disposal of health care and related records may be subject to criminal and/or civil penalties, including any or all of the following:

• Fines up to $1.5 million per calendar year
• Jail time
• Federal HHS Office of Civil Rights enforcement actions

For entities not subject to HIPAA, Wis. Stat. § 34.97(4) imposes penalties for violations of confidentiality laws. Any provider or provider's business partner who violates Wisconsin confidentiality laws may be subject to fines up to $1,000 per incident or occurrence.

For more specific information on the penalties for violations related to members' health care records, providers should refer to § 13410(d) of the HITECH Act, which amends 42 USC § 1320d-5, and Wis. Stat. §§ 134.97(3), (4) and 146.84.

Financial Records

According to Wis. Admin. Code § DHS 106.02(9)(c), a provider is required to maintain certain financial records in written or electronic form.

Maintaining Required Information

SMV providers are required to maintain the following information:

• Necessity for SMV transportation
• Trip information
• Vehicle information
• Driver information
• Company name and/or address

Wisconsin Medicaid may recoup payment if providers fail to maintain adequate records to support each claim.

Necessity for Specialized Medical Vehicle Transportation

To document the necessity for SMV transportation, providers are required to maintain a copy of the member's Certification of Need for Specialized Medical Vehicle Transportation form. The form must be completely filled out and signed by a nurse midwife, nurse practitioner, physician, or physician assistant.

Trip Information

Providers are required to maintain documentation of every transport, including the following:

• DOS
• Driver's name
• Name and member identification number of each member carried
• VIN
• A statement from the member's nurse midwife, nurse practitioner, physician, or physician assistant about the appropriateness of the additional attendant, cot, or stretcher (if additional attendant, cot, or stretcher are needed)
• Names of additional attendants (if additional attendants are used)
• Beginning and ending times for waiting time and total amount of waiting time (if waiting time occurs)
• Full odometer readings (to the tenth of a mile) from the beginning and end of the trip
• Pick-up and drop-off addresses and times
• The type of facility to which the member is transported or the reason for the trip

Vehicle Information

Providers are required to maintain the following vehicle information:

• Documentation showing that an assigned driver or mechanic has inspected each vehicle at least every seven days to ensure proper functioning of the vehicle (Wis. Admin. Code § DHS 105.39[2][b]). The Weekly Driver's Vehicle Inspection Report form may be used to document this information.
• A current list of certified vehicles used to transport members in accordance with Wis. Admin. Code § DHS 105.39. The list must include the following information about each vehicle:
  • VIN
  • License plate number
  • Registration expiration date
  • Year, make, and model
  • Whether or not the vehicle has a wheelchair ramp
  • Whether or not the vehicle has a wheelchair lift
  • Whether or not the vehicle has a cot or stretcher

The demographic maintenance tool must be used to maintain vehicle information.

• Proof of insurance for each vehicle. It is the provider's responsibility to report and document changes in vehicle insurance carrier or coverage.

Driver Information

Providers are required to maintain a current list of all drivers in accordance with Wis. Admin. Code § DHS 105.39. The list must include the following information for each driver:

• Name
• Driver's license number
• Driver's license expiration date
• License type
• License restrictions or violations (if any)
• Date of first aid training (drivers are required to take refresher training in first aid at least every three years)
• Date of CPR training taken through the American Red Cross or the American Heart Association (drivers are required to renew their CPR certification at least every two years)
• Date of training for the use of lifts, ramps, and restraint devices
• Date of training for the care of passengers in seizure

Providers are required to make driver training documentation (e.g., copies of CPR and first aid course completion cards) available to ForwardHealth upon request. A copy of the driver's CPR completion card or digital certificate from the American Red Cross or the American Heart Association must be submitted to ForwardHealth every time CPR certification is renewed.

The demographic maintenance tool must be used to maintain driver information.

Company Name and/or Address

Providers are required to report a change in company name and/or address using the demographic maintenance tool.

Medical Records

A dated clinician's signature must be included in all medical notes. According to Wis. Admin. Code § DHS 106.02(9)(b), a provider is required to include certain written documentation in a member's medical record.

Member Access to Records

Providers are required to allow members access to their health care records, including those related to ForwardHealth services, maintained by a provider in accordance with Wisconsin Statutes, excluding billing statements.

Fees for Health Care Records

Per Wis. Stat. § 146.83, providers may charge a fee for providing one set of copies of health care records to members who are enrolled in Wisconsin Medicaid or BadgerCare Plus programs on the date of the records request. This applies regardless of the member's enrollment status on the DOS contained within the health care records.

Per Wis. Stat. § 146.81(4), health care records are all records related to the health of a patient prepared by, or under the supervision of, a health care provider.

Providers are limited to charging members enrolled in state-funded health care programs 25 percent of the applicable fees for providing one set of copies of the member's health care records.

Note: A provider may charge members 100 percent of the applicable fees for providing a second or additional set of copies of the member's health care records.

The Wisconsin DHS adjusts the amounts a provider may charge for providing copies of a member's health care records yearly per Wis. Stat. § 146.83(3f)(c).

Policy Requirements for Use of Electronic Signatures on Electronic Health Records

For ForwardHealth policy areas where a signature is required, electronic signatures are acceptable as long as the signature meets the requirements. When ForwardHealth policy specifically states that a handwritten signature is required, an electronic signature will not be accepted. When ForwardHealth policy specifically states that a written signature is required, an electronic signature will be accepted.

Reimbursement for services paid to providers who do not meet all electronic signature requirements may be subject to recoupment.

Electronic Signature Definition

An electronic signature, as stated in Wis. Stats. § 137.11(8), is "an electronic sound, symbol, or process attached to or logically associated with a record and executed or adopted by a person with the intent to sign the record."

Some examples include:

• Typed name (performer may type their complete name)
• Number (performer may type a number unique to them)
• Initials (performer may type initials unique to them)

All examples above must also meet all of the electronic signature requirements.

Benefits of Using Electronic Signatures

The use of electronic signatures will allow providers to:

• Save time by streamlining the document signing process.
• Reduce the costs of postage and mailing materials.
• Maintain the integrity of the data submitted.
• Increase security to aid in non-repudiation.

Electronic Signature Requirements

By following the general electronic signature requirements below, the use of electronic signatures provides a secure alternative to written signatures. These requirements align with HIPAA Privacy Rule guidelines.

General Requirements

When using an electronic signature, all of the following requirements must be met:

• The electronic signature must be under the sole control of the rendering provider. Only the rendering provider or designee has the authority to use the rendering provider's electronic signature. Providers are required to maintain documentation that shows the electronic signature that belongs to each rendering provider if a numbering or initial system is used (e.g., what number is assigned to a specific rendering provider). This documentation must be kept confidential.
• The provider is required to have current policies and procedures regarding the use of electronic signatures. The Wisconsin DHS recommends the provider conduct an annual review of policies and procedures with those using electronic signatures to promote ongoing compliance and to address any changes in the policies and procedures.
• The provider is required to conduct or review a security risk analysis in accordance with the requirements under 45 CFR s. 164.308(a)(1).
• The provider is required to implement security updates as necessary and correct identified security deficiencies as part of its risk management process.
• The provider is required to establish administrative, technical, and physical safeguards in compliance with the HIPAA Security Rule.

Electronic Health Record Signature Requirements

An EHR that utilizes electronic signatures must meet the following requirements:

• The certification and standard criteria defined in the Health Information Technology Initial Set of Standards, Implementation Specifications, Certification Criteria for Electronic Health Record Technology Final Rule (45 CFR Part 170) and any revisions including, but not limited to, the following:
  • Assign a unique name and/or number for identifying, tracking user identity, and establishing controls that permit only authorized users to access electronic health information.
  • Record actions related to electronic health information according to the standard set forth in 45 CFR s. 170.210.
  • Enable a user to generate an audit log for a specific time period. The audit log must also have the ability to sort entries according to any of the elements specified in the standard 45 CFR s. 170.210.
  • Verify that a person or entity seeking access to electronic health information is the one claimed and is authorized to access such information.
  • Record the date, time, patient identification, and user identification when electronic health information is created, modified, accessed, or deleted. An indication of which action(s) occurred and by whom must also be recorded.
  • Use a hashing algorithm with a security strength equal to or greater than SHA-1 as specified by the NIST in FIPS PUB 180-3 (October 2008) to verify that electronic health information has not been altered. (Providers unsure whether or not they meet this guideline should contact their IT and/or security/privacy analyst.)
• Ensure the EHR provides:
  • Nonrepudiation — assurance that the signer cannot deny signing the document in the future
  • User authentication — verification of the signer's identity at the time the signature was generated
  • Integrity of electronically signed documents — retention of data so that each record can be authenticated and attributed to the signer
  • Message integrity — certainty that the document has not been altered since it was signed
  • Capability to convert electronic documents to paper copy — the paper copy must indicate the name of the individual who electronically signed the form as well as the date electronically signed
• Ensure electronically signed records created by the EHR have the same back-up and record retention requirements as paper records.

Preparation and Maintenance of Records

All providers who receive payment from Wisconsin Medicaid, including state-contracted MCOs, are required to maintain records that fully document the basis of charges upon which all claims for payment are made, according to Wis. Admin. Code § DHS 106.02(9)(a). This required maintenance of records is typically required by any third-party insurance company and is not unique to ForwardHealth.

Record Retention

Providers are required to retain documentation, including medical and financial records, for a period of not less than five years from the date of payment, except RHCs, which are required to retain records for a minimum of six years from the date of payment.

According to Wis. Admin. Code § DHS 106.02(9)(d), providers are required to retain all evidence of billing information.

Ending participation as a provider does not end a provider's responsibility to retain and provide access to fully maintained records unless an alternative arrangement of record retention and maintenance has been established.

Maintaining Confidentiality of Records

Ending participation in a ForwardHealth program does not end a provider's responsibility to protect the confidentiality of health care and related records containing PHI.

Providers who no longer participate in a ForwardHealth program are responsible for ensuring that they and their business associates/partners continue to comply with all federal and state laws regarding protecting the confidentiality of members' PHI. Once record retention requirements expire, records must be disposed of in such a manner that they cannot be reconstructed — according to federal and state regulations — in order to avoid penalties. For more information on the proper disposal of records, refer to Confidentiality and Proper Disposal of Records.

All ForwardHealth providers and their business associates/partners who cease practice or go out of business should ensure that they have policies and procedures in place to protect all health care and related records from any unauthorized disclosure and use.

Reviews and Audits

The Wisconsin DHS periodically reviews provider records. DHS has the right to inspect, review, audit, and photocopy the records. Providers are required to permit access to any requested record(s), whether in written, electronic, or micrographic form.

Records Requests

Requests for billing or medical claim information regarding services reimbursed by Wisconsin Medicaid may come from a variety of individuals including attorneys, insurance adjusters, and members. Providers are required to notify ForwardHealth when releasing billing information or medical claim records relating to charges for covered services except in the following instances:

• When the member is a dual eligible (i.e., member is eligible for both Medicare and Wisconsin Medicaid or BadgerCare Plus) and is requesting materials pursuant to Medicare regulations.
• When the provider is attempting to exhaust all existing health insurance sources prior to submitting claims to ForwardHealth.

Request From a Member or Authorized Person

If the request for a member's billing information or medical claim records is from a member or authorized person acting on behalf of a member, the provider is required to do the following:

1. Send a copy of the requested billing information or medical claim records to the requestor.
2. Send a letter containing the following information to ForwardHealth:
   • Member's name
   • Member's ForwardHealth identification number or SSN, if available
   • Member's DOB
   • DOS
   • Entity requesting the records, including name, address, and telephone number

   The letter must be sent to the following address:

   Wisconsin Casualty Recovery — HMS
   Ste 100
   5615 Highpoint Dr
   Irving TX 75038-9984

Request From an Attorney, Insurance Company, or Power of Attorney

1. Obtain a release signed by the member or authorized representative.
2. Furnish the requested material to the requester, marked "BILLED TO FORWARDHEALTH" or "TO BE BILLED TO FORWARDHEALTH," with a copy of the release signed by the member or authorized representative. Approval from ForwardHealth is not necessary.
3. Send a copy of the material furnished to the requestor, along with a copy of their original request and medical authorization release to:

Wisconsin Casualty Recovery — HMS
Ste 100
5615 Highpoint Dr
Irving TX 75038-9984

Request for Information About a Member Enrolled in a State-Contracted Managed Care Organization

1. Obtain a release signed by the member or authorized representative.
2. Send a copy of the letter requesting the information, along with the release signed by the member or authorized representative, directly to the MCO.

The MCO makes most benefit payments and is entitled to any recovery that may be available.

Request for a Statement From a Dual Eligible

If the request is for an itemized statement from a dual eligible, pursuant to HR 2015 (Balanced Budget Act of 1997) § 4311, a dual eligible has the right to request and receive an itemized statement from their Medicare-enrolled health care provider. The Act requires the provider to furnish the requested information to the member. The Act does not require the provider to notify ForwardHealth.

Release of Billing Information to Government Agencies

Providers are permitted to release member information without informed consent when a written request is made by Wisconsin DHS or the federal HHS to perform any function related to program administration, such as auditing, program monitoring, and evaluation.

Providers are authorized under Wisconsin Medicaid confidentiality regulations to report suspected misuse or abuse of program benefits to the DHS, as well as to provide copies of the corresponding patient health care records.

Specialized Medical Vehicle Provider's Vehicle(s) Insurance Documentation Requirements

Insurance Documentation Requirements

As part of the enrollment process, new SMV providers are required to submit the insurance documentation detailed in the Specialized Medical Vehicle Insurance Documentation Checklist form. Currently enrolled SMV providers are required to submit complete insurance documentation immediately when there has been a change in their insurance carrier/agency or when a new replacement insurance policy (excluding a renewal for the same policy) has been issued. SMV providers are required to submit the following information to Wisconsin Medicaid for approval:

• Copy of the current vehicle's/vehicles' commercial insurance policy (certificates of insurance are not acceptable)
• Letter of receipt of payment from the insurance company

It is the responsibility of the provider, not the insurance agency, to ensure that Wisconsin Medicaid receives the complete insurance documentation by the due date. Providers should give their insurance representative a copy of the checklist so that the representative is familiar with the specific requirements. To avoid delays in approval by Wisconsin Medicaid, providers should review the insurance documentation for accuracy before submitting it.

Providers may submit insurance information by uploading it through the demographic maintenance tool or mailing it to the following address:

Wisconsin Medicaid
Provider Enrollment
313 Blettner Blvd
Madison WI 53784

Note: Providers are required to keep all vehicle information on file with Wisconsin Medicaid current. Vehicle information must be updated using the demographic maintenance tool.

Temporary Enrollment Requirements

Wisconsin Medicaid grants temporary enrollment to SMV providers who submit an insurance binder that documents all of the information required in Section I of the checklist. Temporary enrollment is granted to new providers or to currently enrolled providers who change their insurance carrier/agency or obtain a new replacement policy. Temporary enrollment is limited to a maximum of 60 days from the effective date on the binder or the specified binder expiration date, whichever comes first. Wisconsin Medicaid determines the length of a new or reenrolled provider's temporary enrollment by the initial enrollment or reenrollment effective date. For example, if the initial enrollment or reenrollment date assigned was May 15, and the insurance binder was valid May 1 to June 30, Wisconsin Medicaid would approve the temporary enrollment from May 15 to June 30, or for 46 days.

SMV providers are required to submit a copy of their final insurance policy that documents all of the information in Section I of the checklist. Wisconsin Medicaid must receive the policy before the temporary enrollment ends, or Wisconsin Medicaid will cancel the provider number. The provider number will remain canceled until Wisconsin Medicaid receives the documentation; this causes a lapse in enrollment. The date that Wisconsin Medicaid receives the acceptable insurance documentation is the date of the SMV provider's reenrollment. Wisconsin Medicaid will not pay claims with DOS during the period of lapsed enrollment. SMV providers are responsible for ensuring that Wisconsin Medicaid receives a copy of the actual acceptable policy before their temporary enrollment expires to avoid a lapse in enrollment.

Changes in Coverage

Wisconsin Medicaid prohibits SMV providers from transporting Medicaid members in any vehicle not covered under the terms of the commercial insurance policy on file with Wisconsin Medicaid. Substitution of vehicles is not allowed. Before using any vehicle that is not on file with Wisconsin Medicaid, providers are required to submit a copy of the amended insurance policy or changed endorsement with the VIN of each additional vehicle to Wisconsin Medicaid for approval.

Additionally, providers are required to update the vehicle information on file with Wisconsin Medicaid, if applicable, using the demographic maintenance tool.

Cancellation

When Wisconsin Medicaid receives a cancellation notice from an SMV provider's insurance carrier/agency, Wisconsin Medicaid sends a sanction notice to the provider. The sanction notice states that the provider's number will be canceled in 20 days if Wisconsin Medicaid does not receive notice of reinstatement of insurance without a lapse from the same carrier/agency (for the same policy) or complete documentation of insurance from the provider. The provider number remains canceled until Wisconsin Medicaid receives the documentation; this causes a lapse in enrollment. The date on which Wisconsin Medicaid receives the acceptable insurance documentation is the date the SMV provider is reenrolled. That date is then the assigned reenrollment date. Wisconsin Medicaid will not reimburse claims with DOS during the period of lapsed enrollment.

Specialized Medical Vehicle Insurance Documentation Checklist

All new and reinstated SMV providers are required to submit the completed insurance documentation detailed in the Specialized Medical Vehicle Insurance Documentation Checklist. Currently enrolled SMV providers who change their insurance carrier/agency or obtain a new replacement policy are required to submit the information immediately to Wisconsin Medicaid. Additionally, providers are required to update the vehicle information on file with Wisconsin Medicaid, if applicable, using the demographic maintenance tool. All of the policy items in section I of the Checklist must be contained in the policy (and binder if submitted first). All items of the letter of receipt in Section II of the Checklist must be included in the letter of receipt of payment.

Specialized Medical Vehicle Transportation Trip Ticket/ Medical Care Verification Form

Providers are required to complete a Specialized Medical Vehicle Transportation Trip Ticket/Medical Care Verification form for each transport. Completing the medical care verification section on the form is optional. Where odometer readings are requested on the form, providers are required to use the actual full odometer reading including tenths of a mile. No other mileage calculations such as tripometers, grid maps, or city block calculations, for example, will be accepted.

Providers may develop their own form. If providers choose to develop their own form, it must contain the same information as the Wisconsin Medicaid form.

Weekly Driver's Vehicle Inspection Report

The information on the Weekly Driver's Vehicle Inspection Report form is mandatory, in accordance with Wis. Admin. Code § DHS 105.39. Providers may develop their own form to document vehicle information, as long as it contains all the information on the ForwardHealth version.

If providers plan to use their own version of this form, it must be reviewed and approved prior to use. Submit the alternate version of the form to the following address:

Wisconsin Medicaid
Provider Enrollment
313 Blettner Blvd
Madison WI 53784

ForwardHealth will notify the provider in a letter that the form is received and approved. An effective date for the alternate version of the form will be included in the letter.