Wis. ForwardHealth Online Handbook, Hospice, Topic #659

If a response is not received within 120 days, the amount originally paid by BadgerCare Plus or Wisconsin Medicaid will be

withheld from future payments. This is not a final action. To receive payment after the original payment has been withheld,

providers are required to submit the required documentation to the appropriate address as indicated in the following tables. For

DOS (dates of service) that are within claims submission deadlines, providers should refer to the first table. For DOS that are

beyond claims submission deadlines, providers should refer to the second table.

Within Claims Submission Deadlines

Scenario Documentation Requirement Submission Address

The provider discovers through the EVS

(Enrollment Verification System) that

ForwardHealth has removed or end-dated the other health insurance

coverage from the member's file.

A claim according to normal claims submission

procedures (do not use the provider-based

billing summary).

ForwardHealth

Claims and Adjustments

313 Blettner Blvd

Madison WI 53784

The provider discovers that the

member's other coverage information

(that is, enrollment dates) reported by

the EVS is invalid.

• A Commercial Other Coverage

Discrepancy Report (F-01159

(04/2017)) form or Medicare Other

Coverage Discrepancy Report (F-02074

(04/2018)) form.

• A claim according to normal claims

submission procedures after verifying that

the member's other coverage information

has been updated by using the EVS (do

not use the provider-based billing

summary).

Send the Commercial Other

Coverage Discrepancy Report form

or Medicare Other Coverage

Discrepancy Report form to the

address indicated on the form.

Send the claim to the following

address:

ForwardHealth

Claims and Adjustments

313 Blettner Blvd

Madison WI 53784

The other health insurance source

reimburses or partially reimburses the

provider-based billing claim.

• A claim according to normal claims

submission procedures (do not use the

provider-based billing summary).

• The appropriate other insurance indicator

on the claim or complete and submit the

Explanation of Medical Benefits form, as

applicable.

ForwardHealth

Claims and Adjustments

313 Blettner Blvd

Madison WI 53784

• The amount received from the other

health insurance source on the claim or

complete and submit the Explanation of

Medical Benefits form, as applicable.

The other health insurance source denies

the provider-based billing claim.

• A claim according to normal claims

submission procedures (do not use the

provider-based billing summary).

• The appropriate other insurance indicator

or Medicare disclaimer code on the claim

or complete and submit the Explanation of

Medical Benefits form, as applicable.

ForwardHealth

Claims and Adjustments

313 Blettner Blvd

Madison WI 53784

The commercial health insurance carrier

does not respond to an initial and

follow-up provider-based billing claim.

• A claim according to normal claims

submission procedures (do not use the

provider-based billing summary).

• The appropriate other insurance indicator

on the claim or complete and submit the

Explanation of Medical Benefits form, as

applicable.

ForwardHealth

Claims and Adjustments

313 Blettner Blvd

Madison WI 53784

Beyond Claims Submission Deadlines

Scenario Documentation Requirement Submission Address

The provider discovers through

the EVS that ForwardHealth has

removed or end-dated the other

health insurance coverage from

the member's file.

• A claim (do not use the provider-based billing

summary).

• A Timely Filing Appeals Request (F-13047

(08/2015)) form according to normal timely filing

appeals procedures.

ForwardHealth

Timely Filing

Ste 50

313 Blettner Blvd

Madison WI 53784

The provider discovers that the

member's other coverage

information (that is, enrollment

dates) reported by the EVS is

invalid.

• A Commercial Other Coverage Discrepancy

Report form or Medicare Other Coverage

Discrepancy Report form.

• After using the EVS to verify that the member's

other coverage information has been updated,

include both of the following:

» A claim (do not use the provider-based

billing summary.)

Send the Commercial Other

Coverage Discrepancy Report form

or Medicare Other Coverage

Discrepancy Report form to the

address indicated on the form.

Send the timely filing appeals

request to the following address:

» A Timely Filing Appeals Request form

according to normal timely filing appeals

procedures.

ForwardHealth

Timely Filing

Ste 50

313 Blettner Blvd

Madison WI 53784

The commercial health insurance

carrier reimburses or partially

reimburses the provider-based

billing claim.

• A claim (do not use the provider-based billing

summary).

• Indicate the amount received from the commercial

health insurance on the claim or complete and

submit the Explanation of Medical Benefits form,

as applicable.

• A Timely Filing Appeals Request form according

to normal timely filing appeals procedures.

ForwardHealth

Timely Filing

Ste 50

313 Blettner Blvd

Madison WI 53784

The other health insurance source

denies the provider-based billing

claim.

• A claim.

• The appropriate other insurance indicator or

Medicare disclaimer code on the claim or

complete and submit the Explanation of Medical

Benefits form, as applicable.

• A Timely Filing Appeals Request form according

to normal timely filing appeals procedures.

• The Provider-Based Billing Summary.

• Documentation of the denial, including any of the

following:

» Remittance information from the other

health insurance source.

» A written statement from the other health

insurance source identifying the reason for

denial.

» A letter from the other health insurance

source indicating a policy termination date

that proves that the other health insurance

source paid the member.

» A copy of the insurance card or other

documentation from the other health

insurance source that indicates that the

policy provides limited coverage such as

pharmacy, dental, or Medicare

supplemental coverage only.

ForwardHealth

Timely Filing

Ste 50

313 Blettner Blvd

Madison WI 53784