Wis. ForwardHealth Online Handbook, Hospice, Topic #280

Retroactive enrollment occurs when an individual has applied for BadgerCare Plus or Medicaid and enrollment is granted with an

effective date prior to the date the enrollment determination was made. A member's enrollment may be backdated to allow

retroactive coverage for medical bills incurred prior to the date of application.

The retroactive enrollment period may be backdated up to three months prior to the month of application if all enrollment

requirements were met during the period. Enrollment may be backdated more than three months if there were delays in

determining enrollment or if court orders, fair hearings, or appeals were involved.

Reimbursing Members in Cases of Retroactive Enrollment

When a member receives retroactive enrollment, he or she has the right to request the return of payments made to a Medicaid-enrolled provider for a covered service during the period of retroactive enrollment, according to Wis. Admin. Code § DHS

104.01(11). A Medicaid-enrolled provider is required to submit claims to ForwardHealth for covered services provided to a

member during periods of retroactive enrollment. Medicaid cannot directly refund the member.

If a service(s) that requires PA (prior authorization) was performed during the member's period of retroactive enrollment, the

provider is required to submit a PA request and receive approval from ForwardHealth before submitting a claim.

If a provider receives reimbursement from Medicaid for services provided to a retroactively enrolled member and the member has

paid for the service, the provider is required to reimburse the member or authorized person acting on behalf of the member (for

example, local General Relief agency) the full amount that the member paid for the service.

If a claim cannot be filed within 365 days of the DOS (date of service) due to a delay in the determination of a member's

retroactive enrollment, the provider is required to submit the claim to Timely Filing within 180 days of the date the retroactive

enrollment is entered into Wisconsin's EVS (Enrollment Verification System) (if the services provided during the period of

retroactive enrollment were covered).