Wis. ForwardHealth Online Handbook, Hospice, Topic #15737

Claims for services that are prescribed, referred, or ordered must include the Type 1 NPI (National Provider Identifier) of the

Medicaid-enrolled provider who prescribed, referred, or ordered the service. ForwardHealth will deny claims if they do not

include a Medicaid-enrolled provider's NPI or if they are submitted with the NPI of a provider who is not enrolled with Wisconsin

Medicaid. (However, providers should not include the NPI of a provider who prescribes, refers, or orders services on claims for

services that are not prescribed, referred, or ordered, as those claims will also deny if the provider is not enrolled in Medicaid.)

Note: Claims submitted for ESRD (end-stage renal disease) services do not require referring provider information; however,

prescribing and ordering provider information will still be required on claims.

Contacting Prescribing/Referring/Ordering Provider After a Claim Denial

If a claim is denied for prescribed, referred, or ordered services because the prescribing/referring/ordering provider was not

Medicaid-enrolled, the rendering provider should contact the prescribing/referring/ordering provider and:

• Communicate that the prescribing/referring/ordering provider is must be enrolled in Wisconsin Medicaid.

• Inform the prescribing/referring/ordering provider of the limited enrollment available for prescribing/referring/ordering

providers.

Time (In Minutes) Unit(s) Billed

1–30 .5

31–44 .5

45–60 1.0

61–74 1.0

75–90 1.5

91–104 1.5

105–120 2.0

121–134 2.0

• Resubmit the claim once the prescribing/referring/ordering provider has enrolled in Wisconsin Medicaid.

Exception for Prescribed, Referred, or Ordered Services Prior to a

Member's Medicaid Enrollment

Providers may submit claims for prescribed, referred, or ordered services by a non-Medicaid-enrolled provider if the member

was not yet enrolled in Wisconsin Medicaid at the time the prescription, referral, or order was written (and the member has since

enrolled in Wisconsin Medicaid). However, once the prescription, referral, or order expires, the prescribing/referring/ordering

provider is required to enroll in Wisconsin Medicaid if they continue to prescribe, refer, or order services for the member.

The procedures for submitting claims for this exception depend on the type of claim submitted:

• Institutional, professional, and dental claims for this exception must be sent to the following address:

ForwardHealth

P.R.O. Exception Requests

Ste 50

313 Blettner Blvd

Madison WI 53784

A copy of the prescription, referral, or order must be included with the claim.

• Pharmacy and compound claims for this exception do not require any special handling. These claims include a prescription

date, so they can be processed to bypass the prescriber Medicaid enrollment requirement in situations where the provider

prescribed services before the member was enrolled in Wisconsin Medicaid.