• Certification
  • Obtaining Certification Packets
    • Introduction
    • Certification for Multiple Services
    • Certification for Multiple Locations
  • Completing Certification Materials
    • Introduction
    • Provider Agreement
    • Terms of Reimbursement
  • Effective Date of Medicaid Certification
    • Introduction
    • Earliest Effective Date
    • Group Certification Effective Dates
    • Request for Change of Effective Date
    • Medicare Enrollment
  • Materials for New Providers
  • Provider Numbers
    • Introduction
    • Billing Performing Provider Number
    • Nonbilling Performing Provider Number
    • Group Billing Numbers
  • Provider Type and Specialty Changes
  • Recertification
    • Introduction
    • Active Recertification
    • Automatic Recertification
  • Reinstating Certification
  • Border-Status Certification
  • Noncertified In-State Providers
  • Out-of-State Providers
  • Out-of-State Youth Program
  • Ending Participation in Wisconsin Medicaid
• Ongoing Responsibilities
  • Introduction
  • Keeping Information Current
    • Introduction
    • Changes in Address or Status
    • Notify the Bureau of Quality Assurance of Changes
  • Change in Ownership
    • Introduction
    • Repayment Following Change in Ownership
  • Documentation Requirements
    • Introduction
    • Reviews and Audits
  • Safeguarding Recipient Confidentiality
  • Release of Billing Information to Government Agencies
  • Records Requests
    • Introduction
    • Requests for Billing Information or Medical Claim Records
    • For More Information
  • Recipient Discrimination Prohibited
  • Accommodating Recipients with Disabilities
  • Allowing Recipient Access to Records
  • Monitoring Contracted Staff
• Provider Rights
  • Introduction
  • Limiting the Number of Recipients
  • Ending Participation in Wisconsin Medicaid
    • Introduction
    • Additional Requirements for Certain Providers
  • Requesting Discretionary Waivers and Variances of Wisconsin Administrative Code Rules
    • Introduction
    • Requirements for a Discretionary Waiver or Variance
    • Application for a Discretionary Waiver or Variance
  • Hearing Requests
• Provider Sanctions
  • Witholding Payments
  • Intermediate Sanctions
  • Involuntary Termination
  • Sanctions for Collecting Payment from Recipients
• Appendix
  • Appendix 1 — Provider Change of Address or Status Completion Instructions
  • Appendix 2 — Provider Change of Address or Status
  • Appendix 3 — Documentation Requirements
  • Appendix 4 — Civil Rights Compliance (Nondiscrimination)
• PDF

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Certification and Ongoing Responsibilities

Provider Sanctions

Withholding Payments

The Department of Health and Family Services (DHFS) may withhold full or partial Medicaid provider payments without prior notification if, as the result of any review or audit, the DHFS finds reliable evidence of fraud or willful misrepresentation.

“Reliable evidence” of fraud or willful misrepresentation includes, but is not limited to, the filing of criminal charges by a prosecuting attorney against the provider or one of the provider’s agents or employees.

The DHFS is required to send the provider a written notice within five days of taking this action. The notice will generally set forth the allegations without necessarily disclosing specific information about the investigation.

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