Wis. ForwardHealth Online Handbook, Hospice, Topic #384

Children's Specialty Managed Care PIHPs

BadgerCare Plus/Medicaid SSI HMO and Children's Specialty Managed Care PIHP (Prepaid Inpatient Health Plan) contracted

and non-contracted providers are required to first file an appeal directly with the HMO/PIHP after the initial payment denial or

reduction. Providers should refer to their signed contract with the HMO/PIHP or the HMO's/PIHP's website for specific filing

timelines and responsibilities (for example, PA (prior authorization), claim filing timelines, and coordination of benefits

requirements) pertaining to filing a claim reconsideration and/or filing a formal appeal. The provider's signed contract with the

HMO/PIHP may dictate the final decision. Filing a claim reconsideration is not the same as filing a formal appeal.

Appeal documents must reach the HMO/PIHP within the time frame established by the HMO/PIHP. Special care should be

taken to ensure the documents reach the HMO/PIHP by the timely, filing deadline by allowing enough time for U.S. Postal

Service mail handling or by using a verifiable delivery method (for example, secure Portal, fax, certified mail, or secure email).

The HMO/PIHP has 45 calendar days to respond in writing to a formal appeal. The HMO/PIHP decides whether to pay the

claim and sends a letter stating this decision. If the HMO/PIHP does not respond in writing within 45 calendar days or the

provider is dissatisfied with the HMO's/PIHP's response, the provider may submit an appeal to ForwardHealth through the

Provider Appeals portal within 60 calendar days from the end of the 45 calendar day timeline or the date of the HMO/PIHP

response.