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Welcome  » April 25, 2019 5:42 PM
Provider Enrollment Information
Out-of-State Providers

ForwardHealth requires all out-of-state providers who render services to BadgerCare Plus, Medicaid, or SeniorCare members to be enrolled in Wisconsin Medicaid. To be eligible for enrollment as an out-of-state provider, a provider is required to do all of the following:

  • Have a valid National Provider Identifier (NPI) per 45 C.F.R. Part 162.
  • Be licensed in the United States (and its territories), Mexico, or Canada.
  • Be licensed in his or her own state of practice.

Wisconsin Medicaid reimburses out-of-state providers for providing emergency medical services to a BadgerCare Plus or Medicaid member or providing services to a member during a time designated by the governor as a state of emergency. The emergency situation or the state of emergency must be sufficiently documented on the claim. Reimbursement rates are consistent with rates for other Wisconsin Medicaid-enrolled providers providing the same service.

Note: Wisconsin Medicaid is prohibited from paying providers located outside of the United States and its territories, including the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.

Out-of-state providers are reimbursed for services provided to eligible BadgerCare Plus or Medicaid members in either of the following situations:

  • The service was provided in an emergency situation, as defined in Wis. Admin. Code § DHS 101.03(52).
  • PA (prior authorization) was obtained from ForwardHealth before the nonemergency service was provided.
Medicaid Enrollment for Providers Who Only Prescribe, Refer, or Order Services

Out-of-state providers who only prescribe, refer, or order services should enroll as prescribing/referring/ordering providers by completing a Medicaid Prescribing/Referring/Ordering Provider Enrollment Application. For more information regarding the requirements for prescribing/referring/ordering providers, refer to Prescribing/Referring/Ordering Providers.

Medicaid Enrollment for Out-of-State Providers

Providers may apply for Medicaid enrollment as an out-of-state provider by completing the Medicaid Out-of-State Provider Enrollment Application.

Effective Date of Enrollment

The effective date of enrollment as an out-of-state provider is the date the provider rendered the service to the BadgerCare Plus, Medicaid, or SeniorCare member. Out-of-state providers continue to be Medicaid-enrolled until it is time to revalidate their enrollment. (Note: Out-of-state providers should not complete a new enrollment application each time they submit a prior authorization request or claim.)

Revalidation of Enrollment

Out-of-state providers are required to revalidate their Medicaid enrollment every three years. Out-of-state providers will receive a Provider Revalidation Notice in the mail from ForwardHealth when it is time to undergo revalidation. For more information on the revalidation process, providers may refer to Medicaid Provider Revalidation.

Risk Level Assignment

All Medicaid-enrolled providers are assigned one of three risk levels (limited, moderate, high) based on provider type. During the enrollment process, ForwardHealth performs certain screening activities based on the provider's risk level assignment. Refer to Risk Level Classification by Provider Type for additional information on risk level assignments and the screening activities for each risk level.

Application Fee

Providers who apply for Medicaid enrollment as an out-of-state provider are assessed an application fee. This fee has been federally mandated and may be adjusted annually.

The provider application fee will only be assessed to provider organizations. A provider will not be required to pay ForwardHealth the application fee if the provider is currently enrolled in or is in the process of enrolling in Medicare or another state's Medicaid or Children's Health Insurance Program (CHIP). Instead, ForwardHealth will verify the provider's enrollment in Medicare or with the other state and confirm that the fee has been paid.

Medicaid-Enrolled Providers May Not Charge Members as Private-Pay Patients

While out-of-state providers are enrolled in Wisconsin Medicaid, they may not charge BadgerCare Plus, Medicaid, or SeniorCare members directly for services that are covered by Wisconsin Medicaid.

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