Wis. ForwardHealth Online Handbook, Hospice, Topic #263

Care Plan

Sometimes a member's enrollment file shows commercial managed care coverage, but the member is unable to receive services

from the managed care plan. Examples of such situations include the following:

• Children enrolled in a commercial managed care plan by a noncustodial parent if the custodial parent refuses to use the

coverage.

• Members enrolled in a commercial managed care plan who reside outside the service area of the managed care plan.

• Members enrolled in a commercial managed care plan who enter a nursing facility that limits the member's access to

managed care providers.

In these situations, Wisconsin Medicaid will reimburse services covered by both BadgerCare Plus or Medicaid and the

commercial managed care plan even though the services are obtained from providers outside the plan.

When submitting claims for these members, providers should do one of the following:

• Indicate the other insurance information on the Explanation of Medical Benefits Form for paper claims.

• Refer to the Wisconsin PES (Provider Electronic Solutions) manual or the appropriate 837 (837 health care claim)

companion guide to determine the appropriate other insurance indicator for electronic claims.