Wis. ForwardHealth Online Handbook, Hospice, Topic #246

Applicants and members have the right to appeal certain decisions relating to BadgerCare Plus, Medicaid, or HDAP (Wisconsin

HIV Drug Assistance Program) enrollment. An applicant, a member, or authorized person acting on behalf of the applicant or

member, or former member may file the appeal with the DHA (Division of Hearings and Appeals).

Pursuant to Wis. Admin. Code § HA 3.03, an applicant, member, or former member may appeal any adverse action or decision

by an agency or department that affects their benefits. Examples of decisions that may be appealed include, but are not limited to,

the following:

• Individual was denied the right to apply.

• Application for BadgerCare Plus, HDAP, or Wisconsin Medicaid was denied.

• Application for BadgerCare Plus, HDAP, or Wisconsin Medicaid was not acted upon promptly.

• Enrollment was unfairly discontinued, terminated, suspended, or reduced.

In the case when enrollment is cancelled or terminated, the date the member, or authorized person acting on behalf of the member,

files an appeal with the DHA determines what continuing coverage, if any, the member will receive until the hearing decision is

made. The following scenarios describe the coverage allowed for a member who files an appeal:

• If a member files an appeal before his or her enrollment ends, coverage will continue pending the hearing decision.

• If a member files an appeal within 45 days after his or her enrollment ends, a hearing is allowed but coverage is not

reinstated.

If the member files an appeal more than 45 days after his or her enrollment ends, a hearing is not allowed. Members may file an

appeal by submitting a Request for Fair Hearing (DHA-28 (08/09)) form.

Claims for Appeal Reversals

Claim Denial Due to Termination of BadgerCare Plus or Wisconsin Medicaid Enrollment

If a claim is denied due to termination of BadgerCare Plus or Wisconsin Medicaid enrollment, a hearing decision that reverses that

determination will allow the claim to be resubmitted and paid. The provider is required to obtain a copy of the appeal decision

from the member, attach the copy to the previously denied claim, and submit both to ForwardHealth at the following address:

ForwardHealth

Specialized Research

Ste 50

313 Blettner Blvd

Madison WI 53784

If a provider has not yet submitted a claim, the provider is required to submit a copy of the hearing decision along with a paper

claim to Specialized Research.

As a reminder, claims submission deadlines still apply even to those claims with hearing decisions.

Claim Denial Due to Termination of HDAP Enrollment

If a claim is denied due to termination of HDAP enrollment, a hearing decision that reverses that determination will allow the claim

to be resubmitted and paid. The provider is required to obtain a copy of the appeal decision from the member, attach the copy to

the previously denied claim, and submit both to ForwardHealth at the following address:

ForwardHealth

HDAP Claims and Adjustments

PO Box 8758

Madison WI 53708

If a provider has not yet submitted a claim, the provider is required to submit a copy of the hearing decision along with a paper

claim to HDAP Claims and Adjustments.

As a reminder, claims submission deadlines still apply even to those claims with hearing decisions.