Note: Out-of-state provider policy does not apply to adult long-term care waiver providers who only serve members or participants in Family Care, Family Care Partnership, Program of All-Inclusive Care for the Elderly (PACE), and IRIS (Include, Respect, I Self-Direct).

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 meet 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 their own state of practice

Wisconsin Medicaid reimburses out-of-state providers in the following situations:

• The provider renders emergency medical services as defined in Wis. Admin. Code § DHS 101.03(52).
• The provider renders services during a state of emergency, as designated by the Wisconsin governor. The provider is required to sufficiently document the state of emergency on claims.
• The provider obtains prior authorization (PA) from ForwardHealth before providing a nonemergency service.

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 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 the Prescribing/Referring/Ordering Providers page.

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

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 PA request or claim.

ForwardHealth requires out-of-state providers to revalidate their Medicaid enrollment every three years. ForwardHealth will mail out-of-state providers a Provider Revalidation Notice when it is time to revalidate enrollment. An application fee may be assessed to organizations at revalidation.

For more information on the revalidation process, refer to Medicaid Provider Revalidation Medicaid Provider Revalidation.

ForwardHealth assigns all Medicaid-enrolled providers one of three risk levels (limited, moderate, or high) based on provider type. During the enrollment process, ForwardHealth performs certain screening activities based on the provider's risk level assignment.

Refer to the Risk Level Classification by Provider Type page for additional information on risk level assignments and the screening activities for each risk level.

Providers who apply for Medicaid enrollment as an out-of-state provider are assessed an application fee. This fee is 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. Instead, ForwardHealth will verify the provider's enrollment in Medicare or with the other state and will confirm that the fee has been paid.

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.