Claims : Submission

1500 Health Insurance Claim Form Completion Instructions

These instructions are for the completion of the 1500 Health Insurance Claim Form for ForwardHealth. Refer to the 1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 02/12, prepared by the NUCC and available on their website, to view instructions for all item numbers not listed below.

Use the following claim form completion instructions, in conjunction with the 1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 02/12, prepared by the NUCC, to avoid denial or inaccurate claim payment. Be advised that every code used is required to be a valid code, even if it is entered in a non-required field. Do not include attachments unless instructed to do so.

Members enrolled in BadgerCare Plus or Medicaid receive a ForwardHealth member identification card. Always verify a member's enrollment before providing nonemergency services to determine if there are any limitations to covered services and to obtain the correct spelling of the member's name.

When submitting a claim with multiple pages, providers are required to indicate page numbers using the format "Page X of X" in the upper right corner of the claim form.

Other health insurance sources must be billed prior to submitting claims to ForwardHealth, unless the service does not require commercial health insurance billing as determined by ForwardHealth. When submitting paper claims, if the member has any other health insurance sources, providers are required to complete and submit an Explanation of Medical Benefits form, along with the completed paper claim.

Submit completed paper claims and the completed Explanation of Medical Benefits form, as applicable, to the following address:

ForwardHealth
Claims and Adjustments
313 Blettner Blvd
Madison WI 53784

Item Number 6 — Patient Relationship to Insured
Enter "X" in the "Self" box to indicate the member's relationship to insured when Item Number 4 is completed. Only one box can be marked.

Item Number 9 — Other Insured's Name (not required)
This field is not required on the claim.

Note: When submitting paper claims to ForwardHealth, if the member has any other health insurance sources (for example, commercial health insurance, Medicare, Medicare Advantage Plans), providers are required to complete and submit a separate Explanation of Medical Benefits form for each other payer as an attachment(s) to their completed paper claim.

Item Number 9a — Other Insured's Policy or Group Number (not required)
This field is not required on the claim.

Note: When submitting paper claims to ForwardHealth, if the member has any other health insurance sources (for example, commercial health insurance, Medicare, Medicare Advantage Plans), providers are required to complete and submit a separate Explanation of Medical Benefits form for each other payer as an attachment(s) to their completed paper claim.

Item Number 9d — Insurance Plan Name or Program Name (not required)
This field is not required on the claim.

Note: When submitting paper claims to ForwardHealth, if the member has any other health insurance sources (for example, commercial health insurance, Medicare, Medicare Advantage Plans), providers are required to complete and submit a separate Explanation of Medical Benefits form for each other payer as an attachment(s) to their completed paper claim.

Item Number 10d — Claim Codes (Designated by NUCC)
When applicable, enter the Condition Code. The Condition Codes approved for use on the 1500 Health Insurance Claim Form are available on the NUCC website under Code Sets.

Item Number 11 — Insured's Policy Group or FECA Number (not required)
This field is not required on the claim.

Note: When submitting paper claims to ForwardHealth, if the member has any other health insurance sources (for example, commercial health insurance, Medicare, Medicare Advantage Plans), providers are required to complete and submit a separate Explanation of Medical Benefits form for each other payer as an attachment(s) to their completed paper claim.

Item Number 11d — Is There Another Health Benefit Plan?
This field is not used for processing by ForwardHealth.

Item Number 19 — Additional Claim Information (Designated by NUCC)
When applicable, enter provider identifiers or taxonomy codes. A list of applicable qualifiers are defined by the NUCC and can be found in the NUCC 1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 02/12, prepared by the NUCC.

If a provider bills an unlisted (or not otherwise classified) procedure code, a description of the procedure must be indicated in this field. If a more specific code is not available, the provider is required to submit the appropriate documentation, which could include a PA request, to justify use of the unlisted procedure code and to describe the procedure or service rendered.

Item Number 22 — Resubmission Code and/or Original Reference Number
This field is not used for processing by ForwardHealth.

Section 24
The six service lines in section 24 have been divided horizontally. Enter service information in the bottom, unshaded area of the six service lines. The horizontal division of each service line is not intended to allow the billing of 12 lines of service.

For physician-administered drugs: NDCs must be indicated in the shaded area of Item Numbers 24A-24G. Each NDC must be accompanied by an NDC qualifier, unit qualifier, and units. To indicate an NDC, providers should do the following:

• Indicate the NDC qualifier N4, followed by the 11-digit NDC, with no space in between.
• Indicate one space between the NDC and the unit qualifier.
• Indicate one unit qualifier (F2 [International unit], GR [Gram], ME [Milligram], ML [Milliliter], or UN [Unit]), followed by the NDC units, with no space in between.

For additional information about submitting a 1500 Health Insurance Claim Form with supplemental NDC information, refer to the completion instructions located under "Section 24" in the Field Specific Instructions section of the NUCC's 1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 02/12.

Item Number 24C — EMG
Enter a "Y" in the unshaded area for each procedure performed as an emergency. If the procedure was not an emergency, leave this field blank.

Item Number 29 — Amount Paid (not required)
This field is not required on the claim.

Note: When submitting paper claims to ForwardHealth, if the member has any other health insurance sources (for example, commercial health insurance, Medicare, Medicare Advantage Plans), providers are required to complete and submit a separate Explanation of Medical Benefits form for each other payer as an attachment(s) to their completed paper claim.

Advanced Imaging Services

Claims for advanced imaging services should be submitted to ForwardHealth using normal procedures and claim completion instructions. When PA is required, providers should always wait two full business days from the date on which eviCore healthcare approved the PA request before submitting a claim for an advanced imaging service that requires PA. This will ensure that ForwardHealth has the PA on file when the claim is received.

Submitting Claims for Situations Exempt From the Prior Authorization Requirement

PA is not required for advanced imaging services when:

• The service is provided during a member's inpatient hospital stay.
• The service is provided when a member is in observation status at a hospital.
• The service is provided as part of an emergency room visit.
• The service is provided as an emergency service.

Service Provided During an Inpatient Stay

Advanced imaging services provided during a member's inpatient hospital stay are exempt from PA requirements.

Institutional claims for advanced imaging services provided during a member's inpatient hospital stay are automatically exempt from PA requirements.

Providers submitting a professional claim for advanced imaging services provided during a member's inpatient hospital stay should indicate POS code 21 (Inpatient Hospital) on the claim.

Service Provided for Observation Status

Advanced imaging services provided when a member is in observation status at a hospital are exempt from PA requirements when completed during a covered observation stay.

Providers using a paper institutional claim form should include modifier UA in Form Locator 44 (HCPCS/Rate/HIPPS Code) with the procedure code for the advanced imaging service. To indicate a modifier on an institutional claim, enter the appropriate five-digit procedure code in Form Locator 44, followed by the two-digit modifier. Providers submitting claims electronically using the 837I should refer to the appropriate companion guide for instructions on including a modifier.

Providers using a professional claim form should indicate modifier UA with the advanced imaging procedure code.

Service Provided as Part of Emergency Room Visit

Advanced imaging services provided as part of an emergency room visit are exempt from the PA requirements.

Providers using an institutional claim form should include modifier UA in Form Locator 44 with the procedure code for the advanced imaging service. Providers submitting claims electronically using the 837I should refer to the appropriate companion guide for instructions on including a modifier.

Providers using a professional claim form should indicate POS code 23 (Emergency Room — Hospital) on the claim.

Service Provided as Emergency Service

Advanced imaging services provided as emergency services are exempt from the PA requirements.

Providers using an institutional claim form should include modifier UA in Form Locator 44 with the procedure code for the advanced imaging service. Providers submitting claims electronically using the 837I should refer to the appropriate companion guide for instructions on including a modifier.

Providers using a professional claim form should submit a claim with an emergency indicator.

Attached Documentation

Providers should not submit additional documentation with a claim unless specifically requested.

Bone-Anchored Hearing Devices and Cochlear Implants

Wisconsin Medicaid separately reimburses DME providers for bone-anchored hearing devices and cochlear implants when the implant surgery is performed in an ASC or outpatient hospital and the rendering surgeon has submitted a claim for the surgery. The POS codes for these facilities are as follows:

• "11" (Office)
• "19" (Off Campus — Outpatient Hospital)
• "22" (On Campus — Outpatient Hospital)
• "24" (Ambulatory Surgical Center)

Claims for bone-anchored hearing devices and bone-anchored hearing device surgery and cochlear implants and cochlear implant surgery are required to be submitted in a professional claim format (for example, electronically using and 837 transaction, Direct Data Entry on the Portal, or Provider Electronic Solutions claims submission software, or on paper using the 1500 Health Insurance Claim Form).

The rendering surgeon is required to submit the claim for the surgery; the DME provider is required to submit the claim for the device.

Note: ForwardHealth will confirm that a claim for the bone-anchored hearing device surgery or cochlear implant surgery has been submitted prior to processing the DME provider's claim for the device. The DME provider is required to coordinate with the surgeon to ensure that the surgical claim is submitted first.

Claims for Services Prescribed, Referred, or Ordered

Claims for services that are prescribed, referred, or ordered must include the Type 1 NPI of the Medicaid-enrolled provider who prescribed, referred, or ordered the service. ForwardHealth will deny claims if they do not include a Medicaid-enrolled provider's NPI or if they are submitted with the NPI of a provider who is not enrolled with Wisconsin Medicaid. (However, providers should not include the NPI of a provider who prescribes, refers, or orders services on claims for services that are not prescribed, referred, or ordered, as those claims will also deny if the provider is not enrolled in Medicaid.)

Note: Claims submitted for ESRD services do not require referring provider information; however, prescribing and ordering provider information will still be required on claims.

Contacting Prescribing/Referring/Ordering Provider After a Claim Denial

If a claim is denied for prescribed, referred, or ordered services because the prescribing/referring/ordering provider was not Medicaid-enrolled, the rendering provider should contact the prescribing/referring/ordering provider and:

• Communicate that the prescribing/referring/ordering provider is must be enrolled in Wisconsin Medicaid.
• Inform the prescribing/referring/ordering provider of the limited enrollment available for prescribing/referring/ordering providers.
• Resubmit the claim once the prescribing/referring/ordering provider has enrolled in Wisconsin Medicaid.

Exception for Prescribed, Referred, or Ordered Services Prior to a Member's Medicaid Enrollment

Providers may submit claims for prescribed, referred, or ordered services by a non-Medicaid-enrolled provider if the member was not yet enrolled in Wisconsin Medicaid at the time the prescription, referral, or order was written (and the member has since enrolled in Wisconsin Medicaid). However, once the prescription, referral, or order expires, the prescribing/referring/ordering provider is required to enroll in Wisconsin Medicaid if they continue to prescribe, refer, or order services for the member.

The procedures for submitting claims for this exception depend on the type of claim submitted:

• Institutional, professional, and dental claims for this exception must be sent to the following address:

ForwardHealth
P.R.O. Exception Requests
Ste 50
313 Blettner Blvd
Madison WI 53784

A copy of the prescription, referral, or order must be included with the claim.

• Pharmacy and compound claims for this exception do not require any special handling. These claims include a prescription date, so they can be processed to bypass the prescriber Medicaid enrollment requirement in situations where the provider prescribed services before the member was enrolled in Wisconsin Medicaid.

Copy Claims on the ForwardHealth Portal

Providers can copy institutional, professional, and dental paid claims on the ForwardHealth Portal. Providers can open any paid claim, click the "Copy" button, and all of the information on the claim will be copied over to a new claim form. Providers can then make any desired changes to the claim form and click "Submit" to submit as a new claim. After submission, ForwardHealth will issue a response with a new ICN along with the claim status.

Correct Errors on Claims and Resubmit to ForwardHealth on the Portal

Providers can view EOB codes and descriptions for any claim submitted to ForwardHealth on the ForwardHealth Portal. The EOBs help providers determine why a claim did not process successfully, so providers may correct the error online and resubmit the claim. The EOB appears on the bottom of the screen and references the applicable claim header or detail.

Direct Data Entry of Professional and Institutional Claims on the Portal

Providers can submit the following claims to ForwardHealth via DDE on the ForwardHealth Portal:

• Professional claims
• Institutional claims
• Dental claims
• Compound drug claims
• Noncompound drug claims

DDE is an online application that allows providers to submit claims directly to ForwardHealth.

When submitting claims via DDE, required fields are indicated with an asterisk next to the field. If a required field is left blank, the claim will not be submitted, and a message will appear prompting the provider to complete the specific required field(s). Portal help is available for each online application screen. In addition, search functions accompany certain fields so providers do not need to look up the following information in secondary resources.

On professional claim forms, providers may search for and select the following:

• Procedure codes
• Modifiers
• Diagnosis codes
• Place of service codes

On institutional claim forms, providers may search for and select the following:

• Type of bill
• Patient status
• Visit point of origin
• Visit priority
• Diagnosis codes
• Revenue codes
• Procedure codes
• HIPPS codes
• Modifiers

On dental claims, providers may search for and select the following:

• Procedure codes
• Rendering providers
• Area of the oral cavity
• Place of service codes

On compound and noncompound drug claims, providers may search for and select the following:

• Diagnosis codes
• NDCs
• Place of service codes
• Professional service codes
• Reason for service codes
• Result of service codes

Using DDE, providers may submit claims for compound drugs and single-entity drugs. Any provider, including a provider of DME or of DMS who submits noncompound drug claims, may submit these claims via DDE. All claims, including POS claims, are viewable via DDE.

Electronic Claim Submission

Providers are encouraged to submit claims electronically. Electronic claim submission does the following:

• Adapts to existing systems
• Allows flexible submission methods
• Improves cash flow
• Offers efficient and timely payments
• Reduces billing and processing errors
• Reduces clerical effort

Electronic Claim Submission for Hearing Instrument Specialists Services

Electronic claims for hearing instrument specialists services must be submitted using the 837P transaction. Electronic claims for hearing instrument specialists services submitted using any transaction other than the 837P will be denied.

Providers should use the companion guide for the 837P transaction when submitting these claims.

Provider Electronic Solutions Software

The DMS offers electronic billing software at no cost to the provider. The PES software allows providers to submit electronic claims using the 837 transaction. To obtain PES software, providers may download it from the ForwardHealth Portal. For assistance installing and using PES software, providers may call the EDI Helpdesk.

Electronic Claims and Claim Adjustments With Other Commercial Health Insurance Information

Effective for claims and claim adjustments submitted electronically via the Portal or PES software on and after June 16, 2014, other insurance information must be submitted at the detail level on professional, institutional, and dental claims and adjustments if it was processed at the detail level by the primary insurance. Except for a few instances, Wisconsin Medicaid or BadgerCare Plus is the payer of last resort for any covered services; therefore, providers are required to make a reasonable effort to exhaust all existing other health insurance sources before submitting claims to ForwardHealth or to a state-contracted MCO.

Other insurance information that is submitted at the detail level via the Portal or PES software will be processed at the detail level by ForwardHealth.

Under HIPAA, claims and adjustments submitted using an 837 transaction must include detail-level information for other insurance if they were processed at the detail level by the primary insurance.

Adjustments to Claims Submitted Prior to June 16, 2014

Providers who submit professional, institutional, or dental claim adjustments electronically on and after June 16, 2014, for claims originally submitted prior to June 16, 2014, are required to submit other insurance information at the detail level on the adjustment if it was processed at the detail level by the primary insurance.

Extraordinary Claims

Extraordinary claims are claims that have been denied by a BadgerCare Plus HMO or SSI HMO and should be submitted to fee-for-service.

HIPAA-Compliant Data Requirements

Procedure Codes

All fields submitted on paper and electronic claims are edited to ensure HIPAA compliance before being processed. Compliant code sets include CPT and HCPCS procedure codes entered into all fields, including those fields that are Not Required or Optional.

If the information in all fields is not valid and recognized by ForwardHealth, the claim will be denied.

Provider Numbers

For health care providers, NPIs are required in all provider number fields on paper claims and 837 transactions, including rendering, billing, referring, prescribing, attending, and Other provider fields.

Non-healthcare providers, including personal care providers, SMV providers, blood banks, and CCOs should enter valid provider numbers into fields that require a provider number.

Initial Hearing Aid and Accessories

When submitting claims for the initial hearing aid purchase, providers are required to indicate the name and NPI of the referring prescribing physician or audiologist in Item Numbers 17 and 17b of the 1500 Health Insurance Claim Form.

Terms of Reimbursement

Wisconsin Medicaid reimbursement for the majority of covered hearing instruments is made under contract between the Wisconsin DHS and hearing aid manufacturers that were chosen as a result of a competitive bid process.

DHS establishes maximum allowable fees for all covered hearing aid dispensing services, equipment, and supplies provided to members enrolled on the date of service. The maximum allowable fees are based on various factors, including a review of usual and customary charges submitted to Wisconsin Medicaid, the Wisconsin State Legislature’s Medicaid budgetary constraints, the results of a competitive bid process for volume purchase discounted prices, and other relevant economic limitations. Likewise, specific hearing aid models were chosen during the competitive bid process based on the price of the model in relationship to the maximum allowable fee. Maximum allowable fees may be adjusted to reflect reimbursement limits or limits on the availability of federal funding as specified in federal law.

For hearing aids that are available under contract, the provider may order only the models available under contract. The provider receives up to the maximum allowable fee for dispensing the hearing aid plus the contracted price for the specific hearing aid model.

For hearing aids that are not available under contract, the provider receives up to the maximum allowable fee for dispensing the hearing aid plus the lesser of the provider’s net cash outlay (the manufacturer’s invoice cost including end-of-month volume discounts) or the maximum allowable fee for the materials and supplies purchased.

The purchase of a hearing aid package (including, but not limited to, a hearing aid, ear mold, and cord) is reimbursed at the contracted price for the specific hearing aid model being dispensed. For hearing aids that are not available under contract, the provider receives reimbursement based on the lesser of the maximum allowable fee or the manufacturer’s invoice cost including end-of-month volume discounts. For these hearing aid styles, the provider is required to bill the manufacturer's actual invoice cost including end-of-month volume discounts. That amount is considered the net cash outlay or the actual cost to the provider. It allows the provider to fully recover their out-of-pocket cost for the purchase of the hearing aid furnished to members.

Managed Care Organizations

Claims for services that are covered in a member's state-contracted MCO should be submitted to that MCO.

Non-Specific Procedure Codes

To receive reimbursement for a service identified by an unlisted procedure code, a description of the service must be indicated in Item Number 19 of the 1500 Health Insurance Claim Form. If Item Number 19 does not provide enough space for the description, or if a provider is billing multiple unlisted procedure codes, documentation may be attached to the claim. In this instance, the provider should indicate "see attachment" in Item Number 19.

The description in Item Number 19 or the documentation attached to the claim must be sufficient to allow BadgerCare Plus to determine the nature and scope of the procedure and whether the procedure was medically necessary as defined in Wisconsin Administrative Code.

Unlisted Audiology Procedure Code 92599

Providers are to use CPT code 92599 (unlisted otorhinolaryngological service or procedure) for services or procedures for which there is no specific CPT procedure code.

Procedure code 92599 (unlisted otorhinolaryngological service or procedure) should be used only when there is no other code that describes the service or procedure being offered. Claims for procedure code 92599 require documentation describing the procedure performed. Only audiologists may request PA or submit claims for this code; PA requests and claims submitted by hearing instrument specialists will be denied. Use of this procedure code always requires PA.

Procedure code 92599 is individually priced based on information provided on the PA request and claim form.

Nonspecific Procedure Code or Repair V5299

HCPCS code V5299 should be used only when there is no other code that describes the item being offered. Use of HCPCS code V5299 always requires PA.

HCPCS code V5299 is individually priced based on information provided on the PA request and claim form.

Note Field for Most Claims Submitted Electronically

In some instances, ForwardHealth requires providers to include a description of a service identified by an unlisted, or NOC, procedure code. Providers submitting claims electronically should include a description of an NOC procedure code in a Notes field, if required. The Notes field allows providers to enter up to 80 characters. In some cases, the Notes field allows providers to submit NOC procedure code information on a claim electronically instead of on a paper claim or with a paper attachment to an electronic claim.

The Notes field should only be used for NOC procedure codes that do not require PA.

Claims Submitted via the ForwardHealth Portal Direct Data Entry or Provider Electronic Solutions

A notes field is available on the ForwardHealth Portal DDE and PES software when providers submit the following types of claims:

• Professional
• Institutional
• Dental

On the professional form, the Notes field is available on each detail. On the institutional and dental forms, the Notes field is only available on the header.

Claims Submitted via 837 Health Care Claim Transactions

ForwardHealth accepts and utilizes information submitted by providers about NOC procedure codes in certain loops/segments on the 837 transactions. Refer to the companion guides for more information.

Paper Claim Form Preparation and Data Alignment Requirements

Optical Character Recognition

Paper claims submitted to ForwardHealth on the 1500 Health Insurance Claim Form and UB-04 Claim Form are processed using OCR software that recognizes printed, alphanumeric text. OCR software increases efficiency by alleviating the need for keying in data from paper claims.

The data alignment requirements do not apply to the Compound Drug Claim form and the Noncompound Drug Claim form.

Speed and Accuracy of Claims Processing

OCR software processes claim forms by reading text within fields on claim forms. After a paper claim form is received by ForwardHealth, the claim form is scanned so that an image can be displayed electronically. The OCR software reads the electronic image on file and populates the information into the ForwardHealth interChange system. This technology increases accuracy by removing the possibility of errors being made during manual keying.

OCR software speeds paper claim processing, but only if providers prepare their claim forms correctly. In order for OCR software to read the claim form accurately, the quality of copy and the alignment of text within individual fields on the claim form need to be precise. If data are misaligned, the claim could be processed incorrectly. If data cannot be read by the OCR software, the process will stop and the electronic image of the claim form will need to be reviewed and keyed manually. This will cause an increase in processing time.

Handwritten Claims

Submitting handwritten claims should be avoided whenever possible. ForwardHealth accepts handwritten claims; however, it is very difficult for OCR software to read a handwritten claim. If a handwritten claim cannot be read by the OCR software, it will need to be keyed manually from the electronic image of the claim form. Providers should avoid submitting claims with handwritten corrections as this can also cause OCR software processing delays.

Use Original Claim Forms

Only original 1500 Health Insurance Claim Forms and UB-04 Claim Forms should be submitted. Original claim forms are printed in red ink and may be obtained from a federal forms supplier. ForwardHealth does not provide these claim forms. Claims that are submitted as photocopies cannot be read by OCR software and will need to be keyed manually from an electronic image of the claim form. This could result in processing delays.

Use Laser or Ink Jet Printers

It is recommended that claims are printed using laser or ink jet printers rather than printers that use DOT matrix. DOT matrix printers have breaks in the letters and numbers, which may cause the OCR software to misread the claim form. Use of old or worn ink cartridges should also be avoided. If the claim form is read incorrectly by the OCR software, the claim may be denied or reimbursed incorrectly. The process may also be stopped if it is unable to read the claim form, which will cause a delay while it is manually reviewed.

Alignment

Alignment within each field on the claim form needs to be accurate. If text within a field is aligned incorrectly, the OCR software may not recognize that data are present within the field or may not read the data correctly. For example, if a reimbursement amount of $300.00 is entered into a field on the claim form, but the last "0" is not aligned within the field, the OCR software may read the number as $30.00, and the claim will be reimbursed incorrectly.

To get the best alignment on the claim form, providers should center information vertically within each field, and align all information on the same horizontal plane. Avoid squeezing two lines of text into one of the six line items on the 1500 Health Insurance Claim Form.

The following sample claim forms demonstrate correct and incorrect alignment:

• Correct alignment for the 1500 Health Insurance Claim Form.
• Incorrect alignment for the 1500 Health Insurance Claim Form.
• Correct alignment for the UB-04 Claim Form.
• Incorrect alignment for the UB-04 Claim Form.

Clarity

Clarity is very important. If information on the claim form is not clear enough to be read by the OCR software, the process may stop, prompting manual review.

The following guidelines will produce the clearest image and optimize processing time:

• Use 10-point or 12-point Times New Roman or Courier New font.
• Type all claim data in uppercase letters.
• Use only black ink to complete the claim form.
• Avoid using italics, bold, or script.
• Make sure characters do not touch.
• Make sure there are no lines from the printer cartridge anywhere on the claim form.
• Avoid using special characters such as dollar signs, decimals, dashes, asterisks, or backslashes, unless it is specified that these characters should be used.
• Use Xs in check boxes. Avoid using letters such as Y for Yes, N for No, M for Male, or F for Female.
• Do not highlight any information on the claim form. Highlighted information blackens when it is imaged, and the OCR software will be unable to read it.

Note: The above guidelines will also produce the clearest image for claims that need to be keyed manually from an electronic image.

Staples, Correction Liquid, and Correction Tape

The use of staples, correction liquid, correction tape, labels, or stickers on claim forms should be avoided. Staples need to be removed from claim forms before they can be imaged, which can damage the claim and cause a delay in processing time. Correction liquid, correction tape, labels, and stickers can cause data to be read incorrectly or cause the OCR process to stop, prompting manual review. If the form cannot be read by the OCR software, it will need to be keyed manually from an electronic image.

Additional Diagnosis Codes

ForwardHealth will accept up to 12 diagnosis codes in Item Number 21 of the 1500 Health Insurance Claim Form.

 

 

 

 

Topic #3000

Paper Claims Submission

Paper claims for hearing instrument specialists services must be submitted using the 1500 Health Insurance Claim Form. Paper claims for hearing instrument specialists submitted on any other claim form will be denied.

Providers should use the appropriate claim form instructions for hearing instrument specialists services when submitting these claims.

Obtaining the Claim Forms

ForwardHealth does not provide the 1500 Health Insurance Claim Form. The form may be obtained from any federal forms supplier.

Topic #22797

Payment Integrity Review Supporting Documentation

Providers are notified that an individual claim is subject to PIR through a message on the Portal when submitting claims. When this occurs, providers have seven calendar days to submit the supporting documentation that must be retained in the member's record for the specific service billed. This documentation must be attached to the claim. The following are examples of documentation providers may attach to the claim; however, this list is not exhaustive, and providers may submit any documentation available to substantiate payment:

• Case management or consultation notes
• Durable medical equipment or supply delivery receipts or proof of delivery and itemized invoices or bills
• Face-to-face encounter documentation
• Individualized plans of care and updates
• Initial or program assessments and questionnaires to indicate the start DOS
• Office visit documentation
• Operative reports
• Prescriptions or test orders
• Session or service notice for each DOS
• Testing and lab results
• Transportation logs
• Treatment notes

Providers must attach this documentation to the claim at the time of, or up to seven days following, submission of the claim. A claim may be denied if the supporting documentation is not submitted. If a claim is denied, providers may submit a new claim with the required documentation for reconsideration. To reduce provider impact, claims reviewed by the OIG will be processed as quickly as possible, with an expected average adjudication of 30 days.

Prior Authorization Numbers on Claims

Providers are not required to indicate a PA number on claims. ForwardHealth interChange matches the claim with the appropriate approved PA request. ForwardHealth's RA and the 835 report to the provider the PA number used to process a claim. If a PA number is indicated on a claim, it will not be used, and it will have no effect on processing the claim.

When a PA requirement is added to the list of drugs requiring PA and the effective date of a PA falls in the middle of a billing period, two separate claims that coincide with the presence of PA for the drug must be submitted to ForwardHealth.

Procedure Codes

To be eligible for Wisconsin Medicaid reimbursement, all claims for hearing services and hearing instruments submitted to ForwardHealth must include CPT or HCPCS codes that are allowable for the DOS. Hearing services claims or adjustments received without allowable codes are denied.

Audiologists may submit claims for both CPT and HCPCS codes. For hearing instrument specialists, Wisconsin Medicaid will only reimburse claims for HCPCS codes. Wisconsin Medicaid will not reimburse hearing instrument specialists for claims for CPT codes.

Reimbursement Reduction for Most Paper Claims

As a result of the Medicaid Rate Reform project, ForwardHealth will reduce reimbursement on most claims submitted to ForwardHealth on paper. Most paper claims will be subject up to a $1.10 reimbursement reduction per claim.

For each claim that a reimbursement reduction was applied, providers will receive an EOB to notify them of the payment reduction. For claims with reimbursement reductions, the EOB will state the following, "This claim is eligible for electronic submission. Up to a $1.10 reduction has been applied to this claim payment."

If a paid claim's total reimbursement amount is less than $1.10, ForwardHealth will reduce the payment up to a $1.10. The claim will show on the RA as paid but with a $0 paid amount.

The reimbursement reduction applies to the following paper claims:

• 1500 Health Insurance Claim Form
• UB-04 (CMS 1450) Claim Form
• Compound Drug Claim form
• Noncompound Drug Claim form

Exceptions to Paper Claim Reimbursement Reduction

The reimbursement reduction will not affect the following providers or claims:

• In-state emergency providers
• Out-of-state providers
• Medicare crossover claims
• Any claims that ForwardHealth requires additional supporting information to be submitted on paper, such as:
  • Hysterectomy claims must be submitted along with an Acknowledgment of Receipt of Hysterectomy Information form.
  • Sterilization claims must be submitted along with a paper Consent for Sterilization form.
  • Claims submitted to Timely Filing appeals must be submitted on paper with a Timely Filing Appeals Request form.
  • In certain circumstances, drug claims must be submitted on paper with a Pharmacy Special Handling Request form.
  • Claims submitted with four or more NDCs for compound and noncompound drugs with specific and non-specific HCPCS procedure codes.

Repairs

Major Repairs

Repairs needed within 24 months of purchase will be made by the manufacturer at no cost to the provider, member, or Wisconsin Medicaid. After the 24-month equipment warranty has expired, major repairs (V5014) completed by the manufacturer are allowed subject to the repair warranty. PA is not required to repair a hearing aid that is covered under the equipment warranty, unless a second, unrelated repair is needed during the repair warranty. After the dispensing service guarantee expires, providers may use procedure code 92592 (Hearing aid check; monaural) or 92593 (Hearing aid check; binaural) for professional services associated with a major repair.

BadgerCare Plus covers major repairs once within the duration of the repair warranty. After the dispensing service guarantee expires, providers may use procedure code 92592 or 92593 for professional services associated with a major repair.

Repair rates have also been contracted separately for each hearing aid model. When submitting claims for major repairs done on contracted hearing aid models, providers are required to indicate the contracted repair rate. Providers are reimbursed at the net cash outlay for major repairs done on contracted hearing aids; the net cash outlay for major repair is the contracted repair rate.

Minor Repairs

After 12 months from the dispensing date for hearing aids purchased through a volume purchase contract, BadgerCare Plus covers minor repairs (V5014 + modifier 52) (repairs done in the office that involve care and cleaning) once every six months. PA is not required for minor repairs unless a second repair is needed within six months of another minor repair.

Providers are required to bill their usual and customary charges for minor repairs.

Noncontracted Hearing Aids

After 12 months from the dispensing date of a hearing aid purchased outside a volume purchase contract, repairs are allowed once every six months. Wisconsin Medicaid will not reimburse the following:

• Major and minor repairs on items that are covered under warranty
• Major and minor repairs on the same DOS for the same hearing aid

Using Modifiers with Procedure Code V5014

Providers are required to indicate either the LT or RT modifier on separate line items, as appropriate, when requesting PA or submitting a claim for procedure code V5014. Claims submitted with more than one of these modifiers on the same line will be denied.

In addition, when using procedure code V5014 for minor repairs, providers are required to use modifier 52. When billing V5014 for recasing or replating, providers are required to use modifier 22. For major repairs performed by the hearing instrument manufacturer, providers are required to use V5014 without modifier 52 or 22.

Submitting Paper Attachments With Electronic Claims

Providers may submit paper attachments to accompany electronic claims and electronic claim adjustments. Providers should refer to their companion guides for directions on indicating that a paper attachment will be submitted by mail.

Paper attachments that go with electronic claim transactions must be submitted with the Claim Form Attachment Cover Page. Providers are required to indicate an ACN for paper attachment(s) submitted with electronic claims. (The ACN is an alphanumeric entry between two and 80 digits assigned by the provider to identify the attachment.) The ACN must be indicated on the cover page so that ForwardHealth can match the paper attachment(s) to the correct electronic claim.

ForwardHealth will hold an electronic claim transaction or a paper attachment(s) for up to seven calendar days to find a match. If a match cannot be made within seven days, the claim will be processed without the attachment and will be denied if an attachment is required. When such a claim is denied, both the paper attachment(s) and the electronic claim will need to be resubmitted.

Providers are required to send paper attachments relating to electronic claim transactions to the following address:

ForwardHealth
Claims and Adjustments
313 Blettner Blvd
Madison WI 53784

This does not apply to compound and noncompound claims.

Uploading Claim Attachments Via the Portal

Providers are able to upload attachments for most claims via the secure Provider area of the ForwardHealth Portal. This allows providers to submit all components for claims electronically.

Providers are able to upload attachments via the Portal when a claim is suspended and an attachment was indicated but not yet received. Providers are able to upload attachments for any suspended claim that was submitted electronically. Providers should note that all attachments for a suspended claim must be submitted within the same business day.

Claim Types

Providers will be able to upload attachments to claims via the Portal for the following claim types:

• Professional
• Institutional
• Dental

The submission policy for compound and noncompound drug claims does not allow attachments.

Document Formats

Providers are able to upload documents in the following formats:

• JPEG (.jpg or .jpeg)
• PDF (.pdf)
• Rich Text Format (.rtf)
• Text File (.txt)

JPEG files must be stored with a .jpg or .jpeg extension; text files must be stored with a .txt extension; rich text format files must be stored with a .rtf extension; and PDF files must be stored with a .pdf extension.

Microsoft Word files (.doc) cannot be uploaded but can be saved and uploaded in Rich Text Format or Text File formats.

Uploading Claim Attachments

Claims Submitted by Direct Data Entry

When a provider submits a DDE claim and indicates an attachment will also be included, a feature button will appear and link to the DDE claim screen where attachments can be uploaded.

Providers are still required to indicate on the DDE claim that the claim will include an attachment via the Attachments panel.

Claims will suspend for seven days before denying for not receiving the attachment.

Claims Submitted by Provider Electronic Software and 837 Health Care Claim Transactions

Providers submitting claims via 837 transactions are required to indicate attachments via the PWK segment. Providers submitting claims via PES software will be required to indicate attachments via the attachment control field. Once the claim has been submitted, providers will be able to search for the claim on the Portal and upload the attachment via the Portal. Refer to the Implementation Guides for how to use the PWK segment in 837 transactions and the PES Manual for how to use the attachment control field.

Claims will suspend for seven days before denying for not receiving the attachment.