Section DHS 109.61 - Participant duties(1) NOT TO SEEK DUPLICATION OF SERVICES. A participant may not seek the same or similar covered drugs from more than one SeniorCare provider.(2) PRIOR IDENTIFICATION OF ELIGIBILITY. Except in emergencies that preclude prior identification, the participant shall, before receiving prescription drugs, inform the SeniorCare provider that the participant is receiving benefits under SeniorCare and shall present to the SeniorCare provider a current valid SeniorCare identification card.(3) REVIEW OF BENEFITS NOTICE. Participants shall review the explanation of benefits (EOB) notice sent to them by the department and shall report to the department any payments made for drugs not actually provided.(4) INFORMATIONAL COOPERATION WITH SENIORCARE PROVIDERS. Participants shall give SeniorCare providers full, correct and truthful information requested by SeniorCare providers and necessary for the submission of correct and complete claims for SeniorCare reimbursement, including information about all of the following: (a) The participant's eligibility status, accurate name, address and SeniorCare identification number.(b) The participant's use of the SeniorCare card.(c) The participant's use of SeniorCare benefits.(d) The participant's coverage under other insurance programs.(5) NOT TO ABUSE OR MISUSE THE SENIORCARE CARD OR BENEFITS. If a participant abuses or misuses the SeniorCare card or SeniorCare benefits in any manner, the department may terminate benefits or limit access to benefits under s. DHS 109.31 (4). For purposes of this subsection, "abuses or misuses" includes any of the following actions: (a) Altering or duplicating the SeniorCare card in any manner.(b) Permitting the use of the SeniorCare card by any unauthorized individual for the purpose of obtaining health care through SeniorCare.(c) Using a SeniorCare card that belongs to a person not authorized under that card.(d) Using the SeniorCare card to obtain any covered service for another individual.(e) Duplicating or altering prescriptions.(f) Knowingly misrepresenting material facts as to medical symptoms for the purpose of obtaining any covered service.(g) Knowingly furnishing incorrect eligibility status or other information to a SeniorCare provider.(h) Knowingly furnishing false information to a SeniorCare provider in connection with health care previously rendered to the participant and for which SeniorCare has been billed.(i) Knowingly obtaining health care in excess of established program limitations, or knowingly obtaining health care that is clearly not medically necessary.(j) Otherwise obtaining health care by false pretenses.Wis. Admin. Code Department of Health Services DHS 109.61
CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.Amended by, CR 22-046: am. (2) Register June 2023 No. 810, eff. 7/1/2023