Wis. ForwardHealth Online Handbook, Hospice, Topic #669

Providers are required to exhaust Medicare coverage before submitting claims to ForwardHealth. This is accomplished by

following these instructions. Providers are required to prepare complete and accurate documentation of efforts to bill Medicare to

substantiate Medicare disclaimer codes used on any claim.

Adjustment Request for Crossover Claim

The provider may submit a paper or electronic adjustment request. If submitting a paper Adjustment/Reconsideration Request (F-

13046 (02/2025)) form, the provider should complete and submit the Explanation of Medical Benefits form, as applicable.

Provider-Submitted Crossover Claim

The provider may submit a provider-submitted crossover claim in the following situations:

• The automatic crossover claim is not processed by ForwardHealth within 30 days of the Medicare processing date.

• ForwardHealth denied the automatic crossover claim, and additional information may allow payment.

• The claim is for a member who is enrolled in a Medicare Advantage Plan.

• The claim is for a member who is enrolled in Medicare and commercial health insurance that is secondary to Medicare (for

example, Medicare Supplemental).

• The claim is for a member who was not enrolled in BadgerCare Plus at the time the service was submitted to Medicare for

payment, but the member was retroactively enrolled.*

When submitting provider-submitted crossover claims, the provider is required to follow all claims submission requirements in

addition to the following:

• For electronic claims, indicate the Medicare payment.

• For paper claims, complete the Explanation of Medical Benefits form.

When submitting provider-submitted crossover claims for members enrolled in Medicare and commercial health insurance that is

secondary to Medicare, the provider is also required to do the following:

• Refrain from submitting the claim to ForwardHealth until after the claim has been processed by the commercial health

insurance.

• Indicate the appropriate other insurance indicator on the claim or the Explanation of Medical Benefits form, as applicable.

* In this situation, a timely filing appeals request may be submitted if the services provided are beyond the claims submission

deadline. The provider is required to indicate "retroactive enrollment" on the provider-submitted crossover claim and submit the

claim with the Timely Filing Appeals Request (F-13047 (08/2015)) form and Explanation of Medical Benefits form, as applicable.

The provider is required to submit the timely filing appeals request within 180 days from the date the backdated enrollment was

added to the member's file.

Claim for Services Denied by Medicare

When Medicare denies payment for a service provided to a dual eligible that is covered by BadgerCare Plus or Wisconsin

Medicaid, the provider may proceed as follows:

• Bill commercial health insurance, if applicable.

• Submit a claim to ForwardHealth using the appropriate Medicare disclaimer code. If applicable, the provider should

indicate the appropriate other insurance indicator on the claim or the Explanation of Medical Benefits form, as applicable. A

copy of Medicare remittance information should not be attached to the claim.

Crossover Claim Previously Reimbursed

A crossover claim may have been previously reimbursed by Wisconsin Medicaid when one of the following has occurred:

• Medicare reconsiders services that were previously not allowed.

• Medicare retroactively determines a member eligible.

In these situations, the provider should proceed as follows:

• Refund or adjust Medicaid payments for services previously reimbursed by Wisconsin Medicaid.

• Bill Medicare for the services and follow ForwardHealth's procedures for submitting crossover claims.