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Welcome  » May 16, 2024 7:01 AM
Program Name: BadgerCare Plus and Medicaid Handbook Area: Ambulance
05/16/2024  

Claims : Timely Filing Appeals Requests

Topic #549

Requirements

When a claim or adjustment request meets one of the exceptions to the submission deadline, the provider is required to mail ForwardHealth a Timely Filing Appeals Request form with a paper claim or an Adjustment/Reconsideration Request form to override the submission deadline. If claims or adjustment requests are submitted electronically, the entire amount of the claim will be recouped.

DOS that are beyond the submission deadline should be submitted separately from DOS that are within the deadline. Claims or adjustment requests received that contain both current and late DOS are processed through normal channels without review by Timely Filing and late DOS will be denied.

Topic #551

Resubmission

Decisions on Timely Filing Appeals Requests cannot be appealed. Providers may resubmit the claim to Timely Filing if both of the following occur:

  • The provider submits additional documentation as requested.
  • ForwardHealth receives the documentation before the specified deadline for the exception to the submission deadline.

Topic #744

Submission

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

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 code, and all other required claims data elements effective for the DOS. 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 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) 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. 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:
    • 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 from a commercial eligibility vendor
    • The transaction log number received through WiCall
    • The enrollment tracking number received through the ForwardHealth Portal
 ForwardHealth
Good Faith/Timely Filing
Ste 50
313 Blettner Blvd
Madison WI 53784
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 message. Include the following documentation as part of the request: 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 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: 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:
Note: When the reason for resubmitting is due to Medicare recoupment, ensure that the associated Medicare disclaimer code (i.e., 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 determination of a member's retroactive enrollment. 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 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 form. ForwardHealth
Timely Filing
Ste 50
313 Blettner Blvd
Madison WI 53784
 
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