Wis. ForwardHealth Online Handbook, Hospice, Topic #744

To receive consideration for an exception to the submission deadline, providers are required to submit the following:

• A properly completed Timely Filing Appeals Request (F-13047 (08/2015)) form for each claim and each adjustment to

allow for documentation of individual claims and adjustments submitted to ForwardHealth

• A legible claim or Adjustment/Reconsideration Request (F-13046 (02/2025)) form

• All required documentation as specified for the exception to the submission deadline

• A properly completed Explanation of Medical Benefits form for paper claims and paper claim adjustments where other

health insurance sources are indicated

Note: Providers are reminded to complete and submit the most current versions of these forms supported by ForwardHealth.

To receive consideration for an exception, a Timely Filing Appeals Request form must be received by ForwardHealth before the

applicable submission deadlines specified for the exception.

When completing the claim or adjustment request, providers are required to indicate the procedure code, diagnosis code, POS

(place of service) code, and all other required claims data elements effective for the DOS (date of service). However, providers

should use the current claim form and instructions or adjustment request form and instructions. Reimbursement for Timely Filing

Appeals Requests is contingent upon the claim or adjustment request meeting program requirements for the DOS.

The following table lists the filing deadlines and additional documentation requirements as they correspond to each of the eight

allowable exceptions.

Change in Nursing Home Resident's Level of Care or Liability Amount

Description of the Exception Documentation Requirements Submission

Address

This exception occurs when a nursing

home claim is initially received within the

submission deadline and reimbursed

incorrectly due to a change in the

member's authorized LOC (level of care)

or liability amount.

To receive consideration, the request must be submitted within 455

days from the DOS. Include the following documentation as part of

the request:

• The correct liability amount or LOC must be indicated on the

Adjustment/Reconsideration Request form.

• The most recent claim number (also known as the ICN

(internal control number)) must be indicated on the

Adjustment/Reconsideration Request form. This number may

be the result of a ForwardHealth-initiated adjustment.

• A copy of the Explanation of Medical Benefits form, if

applicable.

ForwardHealth

Timely Filing

Ste 50

313 Blettner

Blvd

Madison WI

53784

Decision Made by a Court, Fair Hearing, or the Wisconsin Department of Health Services

Description of the Exception Documentation Requirements Submission

Address

This exception occurs when a decision is

made by a court, fair hearing, or the

Wisconsin DHS (Department of Health

Services).

To receive consideration, the request must be submitted within 90

days from the date of the decision of the hearing. Include the

following documentation as part of the request:

• A complete copy of the decision notice received from the

court, fair hearing, or DHS

ForwardHealth

Timely Filing

Ste 50

313 Blettner

Blvd

Madison WI

53784

Denial Due to Discrepancy Between the Member's Enrollment Information in ForwardHealth interChange and the

Member's Actual Enrollment

Description of the Exception Documentation Requirements Submission

Address

This exception occurs when a claim is

initially received by the deadline but is

denied due to a discrepancy between the

member's enrollment information in

ForwardHealth interChange and the

member's actual enrollment.

To receive consideration, the request must be submitted within 455

days from the DOS. Include the following documentation as part of

the request:

• A copy of remittance information showing the claim was

submitted in a timely manner and denied with a qualifying

enrollment-related explanation.

• A photocopy of one of the following indicating enrollment on

the DOS:

ForwardHealth

Good

Faith/Timely

Filing

Ste 50

313 Blettner

Blvd

Madison WI

53784

» Temporary Identification Card for Express Enrollment

in BadgerCare Plus

» Temporary Identification Card for Express Enrollment

in Family Planning Only Services

» The response received through Wisconsin's EVS

(Enrollment Verification System) from a commercial

eligibility vendor

» The transaction log number received through WiCall

» The enrollment tracking number received through the

ForwardHealth Portal

ForwardHealth Reconsideration or Recoupment

Description of the Exception Documentation Requirements Submission

Address

This exception occurs when

ForwardHealth reconsiders a previously

processed claim. ForwardHealth will

initiate an adjustment on a previously paid

claim.

If a subsequent provider submission is required, the request must be

submitted within 90 days from the date of the RA (Remittance

Advice) message. Include the following documentation as part of the

request:

• A copy of the RA message that shows the ForwardHealth-initiated adjustment

• A copy of the Explanation of Medical Benefits form, if

applicable

ForwardHealth

Timely Filing

Ste 50

313 Blettner

Blvd

Madison WI

53784

Retroactive Enrollment for Persons on General Relief

Description of the Exception Documentation Requirements Submission

Address

This exception occurs when the income

maintenance or tribal agency requests a

return of a GR (general relief) payment

from the provider because a member has

become retroactively enrolled for

Wisconsin Medicaid or BadgerCare Plus.

To receive consideration, the request must be submitted within 180

days from the date the backdated enrollment was added to the

member's enrollment information. Include the following

documentation as part of the request:

• A copy of the Explanation of Medical Benefits form, if

applicable

And

• GR retroactive enrollment indicated on the claim

Or

• A copy of the letter received from the income maintenance or

tribal agency

ForwardHealth

GR Retro

Eligibility

Ste 50

313 Blettner

Blvd

Madison WI

53784

Medicare Denial Occurs After the Submission Deadline

Description of the Exception Documentation Requirements Submission

Address

This exception occurs when claims

submitted to Medicare (within 365 days

of the DOS) are denied by Medicare

after the 365-day submission deadline. A

waiver of the submission deadline will not

be granted when Medicare denies a claim

for one of the following reasons:

• The charges were previously

submitted to Medicare.

• The member name and

identification number do not match.

• The services were previously

denied by Medicare.

• The provider retroactively applied

for Medicare enrollment and did

not become enrolled.

To receive consideration, the request must be submitted within 90

days of the Medicare processing date. Include the following

documentation as part of the request:

• A copy of the Medicare remittance information

• A copy of the Explanation of Medical Benefits form, if

applicable

ForwardHealth

Timely Filing

Ste 50

313 Blettner

Blvd

Madison WI

53784

Refund Request from an Other Health Insurance Source

Description of the Exception Documentation Requirements Submission

Address

This exception occurs when an other

health insurance source reviews a

previously paid claim and determines that

reimbursement was inappropriate.

To receive consideration, the request must be submitted within 90

days from the date of recoupment notification. Include the following

documentation as part of the request:

• A copy of the recoupment notice

• An updated Explanation of Medical Benefits form, if

applicable

Note: When the reason for resubmitting is due to Medicare

recoupment, ensure that the associated Medicare disclaimer code

(M-7 or M-8) is included on the updated Explanation of Medical

Benefits form.

ForwardHealth

Timely Filing

Ste 50

313 Blettner

Blvd

Madison WI

53784

Retroactive Member Enrollment into Medicaid

Description of the Exception Documentation Requirements Submission

Address

This exception occurs when a claim

cannot be submitted within the submission

deadline due to a delay in the

To receive consideration, the request must be submitted within 180

days from the date the backdated enrollment was added to the

member's enrollment information. In addition, retroactive enrollment

ForwardHealth

Timely Filing

Ste 50

determination of a member's retroactive

enrollment.

must be indicated by selecting Retroactive member enrollment for

ForwardHealth (attach appropriate documentation for retroactive

period, if available) box on the Timely Filing Appeals Request (F-

13047 (08/15)) form.

313 Blettner

Blvd

Madison WI

53784