Wis. ForwardHealth Online Handbook, Hospice, Topic #663

For each provider-based billing claim, the provider is required to send a claim to the appropriate other health insurance source.

The provider should add all information required by the other health insurance source to the claim. The providers should also

attach additional documentation (for example, Medicare's remittance information) if required by the other health insurance source.

documentation from the other health

insurance source that indicates the

policy provides limited coverage such

as pharmacy, dental, or Medicare

supplemental coverage.

» A copy of the Explanation of Medical

Benefits form, as applicable.

• 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 other health insurance source fails

to respond to the initial and follow-up

provider-based billing claim.

• The Provider-Based Billing Summary.

• Indication that no response was received by

the other health insurance source.

• Indication of the dates that the initial and

follow-up provider-based billing claims

were submitted to the other health insurance

source.

ForwardHealth

Provider-Based Billing

PO Box 6220

Madison WI 53716-0220

Fax 608-221-4567