Covered and Noncovered Services
Covered Services
Recipient Payment for Covered Services
Under state and federal laws, a Medicaid-certified provider may not collect payment from a recipient, or authorized person acting on behalf of the recipient, for Medicaid-covered services even if the services are covered but do not meet program requirements. Denial of a claim by Wisconsin Medicaid does not necessarily render a Medicaid recipient liable. However, a covered service for which PA was denied is treated as a noncovered service. (If a recipient chooses to receive an originally requested service instead of the service approved on a modified PA request, it is also treated as a noncovered service.) If a recipient requests a covered service for which PA was denied (or modified), the provider may collect payment from the recipient if certain conditions are met. Refer to the Collecting Payment from Recipients chapter of this section for more information.
If a provider collects payment from a recipient, or authorized person acting on behalf of the recipient, for a Medicaid-covered service, the provider may be subject to program sanctions including termination of Medicaid certification. Providers should refer to the Certification and Ongoing Responsibilities section of this handbook for more information about provider sanctions.
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