Wis. ForwardHealth Online Handbook, Hospice, Topic #770

Providers are required to bill the following services to the Medicare Advantage Plan before submitting claims to ForwardHealth:

• Ambulance services

• ASC (ambulatory surgery center) services

• Chiropractic services

• Dental anesthesia services

• Home health services (excluding PC (personal care) services)

• Hospital services, including inpatient or outpatient

• Medicare-covered services

• Osteopath services

• Physician services

Providers who are not within the member's Medicare Advantage network and are not providing an emergency service or

Medicare-allowed service with a referral are required to refer the member to a provider within their network.

ForwardHealth has identified services requiring commercial health insurance billing.

Reimbursement for Medicare Part A-Covered Inpatient Hospital Services Provided To Dual Eligibles

Explanation Example

1 2 3

Provider's billed amount $1,200 $1,200 $1,200

Medicare-allowed amount $1,000 $1,000 $1,000

Medicaid-allowed amount (for example, diagnosis-related group or per diem) $1,200 $750 $750

Medicare-paid amount $1,000 $800 $500

Difference between Medicaid-allowed amount and Medicare-paid amount $200 ($-50) $250

Medicare coinsurance, copay and deductible $0 $200 $500

Medicaid payment $0 $0 $250