Wis. ForwardHealth Online Handbook, Hospice, Topic #4942

Providers are encouraged to report discrepancies to ForwardHealth by submitting the Commercial Other Coverage Discrepancy

Report (F-01159 (04/2017)) form or Medicare Other Coverage Discrepancy Report (F-02074 (04/2018)) form. Providers are

asked to complete the form in the following situations:

• The provider is aware of other coverage information that is not indicated by Wisconsin's EVS (Enrollment Verification

System).

• The provider received other coverage information that contradicts the information indicated by the EVS.

• A claim is denied because the EVS indicates commercial managed care coverage but the coverage is not available to the

member (for example, the member does not live in the plan's service area).

Providers should not use the Commercial Other Coverage Discrepancy Report form or Medicare Other Coverage Discrepancy

Report form to update any information regarding a member's coverage in a state-contracted MCO (managed care organization).

When reporting discrepancies, providers should include photocopies of current insurance cards and any available documentation,

such as remittance information and benefit coverage dates or denials.