Wis. ForwardHealth Online Handbook, Hospice, Topic #387

Extraordinary claims are BadgerCare Plus or Medicaid claims for a BadgerCare Plus/Medicaid SSI HMO or Children's Specialty

Managed Care PIHP (Prepaid Inpatient Health Plan) enrollee that have been denied by an HMO/PIHP but may be paid as fee-for-service claims.

These are some examples of extraordinary claims situations:

• The enrollee was not enrolled in an HMO/PIHP at the time they were admitted to an inpatient hospital, but then they

enrolled in an HMO/PIHP during the hospital stay. In this case, all claims related to the stay (including professional claims)

should be submitted to fee for service. For the professional claims associated with the inpatient hospital stay, the provider is

required to include the date of admittance and date of discharge in Item Number 18 of the paper 1500 Health Insurance

Claim Form ((02/12)).

• The claims are for orthodontia/prosthodontia services that began before HMO/PIHP coverage. The provider must include

a record with the claim indicating when the bands were placed.

Submitting Extraordinary Claims

When submitting an extraordinary claim, providers must include:

• A legible copy of the completed claim form in accordance with billing guidelines.

• A letter detailing the problem, any claim denials, and any steps taken to correct the situation.

• A copy of the Explanation of Medical Benefits form as applicable.

Submit extraordinary claims to:

ForwardHealth

Extraordinary Claims

313 Blettner Blvd

Madison WI 53784