Wis. ForwardHealth Online Handbook, Hospice, Topic #662

Within 120 days of the date on the Provider-Based Billing Summary, the Provider-Based Billing Unit must receive documentation

verifying that one of the following occurred:

• 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.

• The provider verifies that the member's other coverage information reported by ForwardHealth is invalid.

• The other health insurance source reimbursed or partially reimbursed the provider-based billing claim.

• The other health insurance source denied the provider-based billing claim.

• The other health insurance source failed to respond to an initial and follow-up provider-based billing claim.

When responding to ForwardHealth within 120 days, providers are required to submit the required documentation to the

appropriate address as indicated in the following table. If the provider's response to ForwardHealth does not include all of the

required documentation, the information will be returned to the provider. The provider is required to send the complete

information within the original 120-day limit.

• The DOS, other health insurance source, billed

amount, and procedure code indicated on the

documentation must match the information on the

Provider-Based Billing Summary.

The commercial health insurance

carrier does not respond to an

initial and follow-up provider-based billing claim.

• A claim (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.

• A Timely Filing Appeals Request form according

to normal timely filing appeals procedures.

ForwardHealth

Timely Filing

Ste 50

313 Blettner Blvd

Madison WI 53784

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.

• The Provider-Based Billing Summary.

• Indication that the EVS no longer reports

the member's other coverage.

ForwardHealth

Provider-Based Billing

PO Box 6220

Madison WI 53716-0220

Fax 608-221-4567

The provider discovers that the

member's other coverage information

(enrollment dates) reported by the

EVS is invalid.

• The Provider-Based Billing Summary.

• One of the following:

» The name of the person with whom

the provider spoke and the member's

correct other coverage information.

ForwardHealth

Provider-Based Billing

PO Box 6220

Madison WI 53716-0220

Fax 608-221-4567

» A printed page from an enrollment

website containing the member's

correct other coverage information.

The other health insurance source

reimburses or partially reimburses the

provider-based billing claim.

• The Provider-Based Billing Summary.

• A copy of the remittance information

received from the other health insurance

source.

• The DOS (date of service), other health

insurance source, billed amount, and

procedure code indicated on the other

insurer's remittance information must match

the information on the Provider-Based

Billing Summary.

• A copy of the Explanation of Medical

Benefits form, as applicable.

Note: In this situation, ForwardHealth will initiate

an adjustment if the amount of the other health

insurance payment does not exceed the allowed

amount (even though an adjustment request should

not be submitted). However, providers (except

nursing home and hospital providers) may issue a

cash refund. Providers who choose this option

should include a refund check but should not use

the Claim Refund form.

ForwardHealth

Provider-Based Billing

PO Box 6220

Madison WI 53716-0220

Fax 608-221-4567

The other health insurance source

denies the provider-based billing

claim.

• The Provider-Based Billing Summary.

• Documentation of the denial, including any

of the following:

» Remittance information from the

other health insurance source.

» A letter from the other health

insurance source indicating a policy

termination date that precedes the

DOS.

» Documentation indicating that the

other health insurance source paid the

member.

» A copy of the insurance card or other

ForwardHealth

Provider-Based Billing

PO Box 6220

Madison WI 53716-0220

Fax 608-221-4567