Wis. ForwardHealth Online Handbook, Hospice, Topic #18497

An Explanation of Medical Benefits (F-01234 (04/2018)) form must be included for each other payer when other health

insurance (for example, commercial health insurance, Medicare, Medicare Advantage Plans) sources are indicated on a paper

claim or paper adjustment.

Note: ADA (American Dental Association) claims and claim adjustments and compound and noncompound drug claims and claim

adjustments are not subject to the requirements regarding use of the Explanation of Medical Benefits form.

Paper claims or adjustment requests that have other health insurance indicated may be returned to the provider unprocessed or

denied if they are submitted without the Explanation of Medical Benefits form for each other payer. Paper claims or adjustments

submitted with incorrect or incomplete Explanation of Medical Benefits forms will also be returned or denied.

Use of the ForwardHealth Explanation of Medical Benefits form is mandatory; providers are required to use an exact copy.

ForwardHealth will not accept alternate versions (for example, retyped or otherwise reformatted) of the Explanation of Medical

Benefits form.

The Explanation of Medical Benefits form requirement for paper claims and adjustments is intended to help ensure consistency

with electronic claims and adjustments submitted via the ForwardHealth Portal or using an 837 (837 Health Care Claim)

transaction (including those submitted using PES (Provider Electronic Solutions) software or through a clearinghouse or software

vendor).

The Explanation of Medical Benefits form requirement applies to paper claims and paper adjustments submitted to Wisconsin

Medicaid, BadgerCare Plus, SeniorCare, and the WCDP (Wisconsin Chronic Disease Program). Providers are reminded that,

except for a few instances, Wisconsin Medicaid, BadgerCare Plus, SeniorCare, and WCDP are payers of last resort for any

covered service. Therefore, providers are required to make a reasonable effort to exhaust all other existing health insurance

sources before submitting claims to ForwardHealth or to a state-contracted MCO (managed care organization).

Wisconsin Medicaid and BadgerCare Plus are not payers of last resort for members who receive coverage from certain

governmental programs. Providers should ask members if they have coverage from these other government programs.

If a member becomes retroactively enrolled in Wisconsin Medicaid or BadgerCare Plus after the provider has already been

reimbursed by one of these government programs, the provider may be required to submit the claims to ForwardHealth and

refund the payment from the government program.

Ink, Data Alignment, and Quality Standards for Paper Claim Submission

In order for OCR (Optical Character Recognition) software to read paper claim forms accurately, the claim forms must comply

with certain ink standards, as well as other data alignment and quality standards. The Explanation of Medical Benefits form will

also need to comply with these standards.