Wis. ForwardHealth Online Handbook, Hospice, Topic #547

All providers who bill the

service codes that are part of

this criteria are subject to

review, regardless of their

compliance rates.

claims submitted during the

three-month period may not

drop more than 10% of the

provider's volume of submitted

claims prior to pre-payment

review.

Submission Deadline

ForwardHealth recommends that providers submit claims at least on a monthly basis. Billing on a monthly basis allows the

maximum time available for filing and refiling before the mandatory submission deadline.

With few exceptions, state and federal laws require that providers submit correctly completed claims before the submission

deadline.

Providers are responsible for resolving claims. Members are not responsible for resolving claims. To resolve claims before the

submission deadline, ForwardHealth encourages providers to use all available resources.

Claims

To receive reimbursement, claims and adjustment requests must be received within 365 days of the DOS (date of service). This

deadline applies to claims, corrected claims, and adjustments to claims.

Crossover Claims

To receive reimbursement for services that are allowed by Medicare, claims and adjustment requests for coinsurance, copay, and

deductible must be received within 365 days of the DOS or within 90 days of the Medicare processing date, whichever is later.

This deadline applies to all claims, corrected claims, and adjustments to claims. Providers should submit these claims through

normal processing channels (not timely filing).

Exceptions to the Submission Deadline

State and federal laws provide eight exceptions to the submission deadline. According to federal regulations and Wis. Admin.

Code DHS 106.03, ForwardHealth may consider exceptions to the submission deadline only in the following circumstances:

• Change in a nursing home resident's LOC (level of care) or liability amount

• Decision made by a court order, fair hearing, or the Wisconsin DHS (Department of Health Services)

• Denial due to discrepancy between the member's enrollment information in ForwardHealth interChange and the member's

actual enrollment

• Reconsideration or recoupment

• Retroactive enrollment for persons on GR (General Relief)

• Medicare denial occurs after ForwardHealth's submission deadline

• Refund request from an other health insurance source

• Retroactive member enrollment

ForwardHealth has no authority to approve any other exceptions to the submission deadline.

Claims or adjustment requests that meet one of the exceptions to the submission deadline may be submitted to Timely Filing.