Wis. ForwardHealth Online Handbook, Hospice, Topic #385

ForwardHealth will not review appeals that were not first made to the BadgerCare Plus/Medicaid SSI HMO or Children's

Specialty Managed Care PIHP (Prepaid Inpatient Health Plan). If a provider sends an appeal directly to ForwardHealth without

first filing it with the HMO/PIHP, the appeal will be returned to the provider., and the payment denial or reduction will be upheld.

The provider has 60 calendar days to file an appeal with ForwardHealth after the HMO/PIHP either does not respond in writing

within 45 calendar days, or if the provider is dissatisfied with the HMO/PIHP response.

Appeals will only be reviewed for enrollees who were eligible for and who were enrolled in an HMO/PIHP on the DOS (date of

service) in question.

Once all pertinent information is received, ForwardHealth has 45 calendar days to make a final decision. The provider and the

HMO/PIHP will be notified by ForwardHealth of the final decision. If the decision is in the provider's favor, the HMO/PIHP is

required to pay the provider within 45 calendar days of the final decision. The decision is final, and all parties are required to abide

by the decision.

Providers are required to submit an appeal to ForwardHealth through the Provider Appeals portal.

How to Begin Using the Provider Appeals Portal

Providers who contract with a BadgerCare Plus/Medicaid SSI HMO or Children's Specialty Managed Care PIHP and who need

to appeal a claim decision will be required to register and set up a Provider Appeals portal account. Note: This portal account is

separate from a provider's secure ForwardHealth Portal account.

To register for a Provider Appeals portal account, providers and HMOs/PIHPs can access the Provider Appeals portal.

Providers are required to complete and submit the registration form, available by clicking either the HMO Registration or Provider

Registration button (as applicable) on the Provider Appeals portal home page. Examples of information required to complete the

registration process include the following:

• The provider's Medicaid ID or both their NPI (National Provider Identifier) and taxonomy code

• Provider ZIP+4 code

• DOS for the appeal

• Contact information (name, email, phone number) for the person registering

Once ForwardHealth receives and processes the registration form, an account login ID and associated PIN (provider

identification number) will be created. Providers will receive an email message with their Provider Appeals portal login ID and will

receive their PIN information in a mailed letter.

Note: Third party administrators and out-of-state providers must call the EDI (Electronic Data Interchange) Helpdesk at 866-

417-4979 or send an email to vedswiedi@wisconsin.gov to begin registration.

More information on registering for and using the Provider Appeals portal and additional portal resources, including the Provider

Appeals Portal User Guide, is available.

Portal Functionality

Providers can use the ForwardHealth appeals process through the Provider Appeals portal after exhausting the HMO/PIHP

payment dispute process. Providers are required to use the Provider Appeals portal to:

• Submit an appeal to ForwardHealth for a BadgerCare Plus/Medicaid SSI HMO or Children's Specialty Managed Care

PIHP claim payment denial or reduced payment.

• Submit documentation.

• Check the status of an appeal.

• Respond to requests for additional information.

• View decision notices.

For assistance regarding submission of an appeal through the ForwardHealth Portal, providers can call the ForwardHealth

Managed Care Unit at 800-760-0001, option 1.

Required Documentation

When submitting an appeal to ForwardHealth through the Provider Appeals portal, the following documentation must be

submitted/attached in required fields:

• The original claim submitted to the HMO/PIHP and all corrected claims submitted to the HMO/PIHP

• All of the HMO's/PIHP's payment denial remittances showing the dates of denial and reason codes with descriptions of the

exact reasons for the claim denial

• The provider's written appeal to the HMO/PIHP

• The HMO's/PIHP's response to the appeal

• Relevant medical documentation for appeals regarding coding issues or emergency determination that supports the appeal

(Providers should only submit relevant documentation that supports the appeal. Large medical records submitted with no

indication of where supporting information is found will not be reviewed.)

• Any contract language that supports the provider's appeal with the exact language that supports overturning the payment

denial indicated (Contract language submitted with no indication of where supporting information is found will not be

reviewed, and the denial will be upheld.)

• Any other documentation that supports the appeal (for example, commercial insurance Explanation of Benefits/Explanation

of Payment to support Wisconsin Medicaid as the payer of last resort)

Only relevant documentation should be included.

Appeal Decisions

A decision to uphold the HMO's/PIHP's original payment denial or to overturn the denial will be made based on the

documentation submitted to ForwardHealth for review. Failure to submit the required documentation or submitting incomplete,

insufficient, or illegible documentation may lead to the original denial being upheld. The decision to overturn an HMO's/PIHP's

denial must be clearly supported by the documentation.

If the HMO/PIHP subsequently overturns their original denial and reprocesses and pays the claim for which an appeal has been

submitted, providers must contact the ForwardHealth Managed Care Unit at 800-760-0001, option 1, and request that the

appeal be withdrawn.

To check on the status of an appeal submitted to ForwardHealth, providers can:

• Access the Provider Appeals portal.

• Call the ForwardHealth Managed Care Unit at 800-760-0001, option 1.