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Appeals Process

To file an appeal, the Eligible Professional or Hospital should log into the secure ForwardHealth Portal and select the new quick link called the "Wisconsin Medicaid PI Incentive Program Appeal" on the secure Portal homepage.

Eligible Professionals and Hospitals (or an authorized preparer) filing a Wisconsin Medicaid PI Program appeal should have the following information on hand when initiating an appeal:

The NPI of the Eligible Hospital or Eligible Professional submitting the appeal

The payment year for which the appeal is being submitted

The name, phone number, email address, and the preferred method of contact of the person submitting the appeal (that is, the Eligible Hospital, Eligible Professional, or authorized preparer)

Once the Wisconsin Medicaid PI Program has validated that the NPI matches a current application, the Eligible Professional or Hospital will then be able to select the reason to appeal from a drop-down list of reasons or will be able to provide a statement in a free-form comment box.

If the Wisconsin Medicaid PI Program cannot match the NPI supplied with a current application, the Eligible Professional or Hospital will receive the following message: "A Wisconsin Medicaid PI Program application that is denied or approved for payment is not found for the Eligible Hospital/Professional submitted. Please verify the information entered. If you believe this message was received in error, contact Provider Services." The Eligible Professional or Hospital should then contact Provider Services.

After selecting the reason for the appeal or providing a statement in the free-form comment box, the Eligible Professional or Hospital will then be able to upload any relevant supporting documentation in support of their appeal. This documentation may include any PDF files up to 5 MBs each. Eligible Hospitals and Eligible Professionals should note that they must upload all relevant supporting documentation at the time of submission, as they will not be able to return to the appeal application to upload any documentation after submitting the appeal. Eligible Professionals and Eligible Hospitals will also have the option of creating a PDF of their appeal for their files.

After submission of the appeal, Eligible Professionals or Hospitals will receive a tracking number that is assigned to each appeal. Eligible Professionals and Hospitals should have this tracking number on hand to reference if they need to contact Provider Services regarding their appeal.

Once an appeal has been filed, the Eligible Professional or Hospital will receive an email confirming the receipt of the appeal request and a second email confirming that the appeal request has been adjudicated. The Wisconsin Medicaid PI Program will communicate the appeal determination through a decision letter, sent to the address provided during Wisconsin Medicaid PI Program application process, within 90 days of receipt of all information needed to make a determination. The decision letter will state whether the appeal has been denied or approved.

Topic #12477

Appealing a Denied Wisconsin Medicaid Promoting Interoperability Program Application

Eligible Professionals and Hospitals who do not qualify for a Wisconsin Medicaid PI Program payment will receive a denial letter in the mail, sent to the address provided during the Wisconsin Medicaid PI Program application process. The letter will explain why their Wisconsin Medicaid PI Program application was denied. Eligible Professionals and Hospitals who wish to appeal a denied Wisconsin Medicaid PI Program application must do so within 45 calendar days from the date on the denial letter.

Eligible Professionals and Hospitals should refer to the tables below for the following information:

A complete list of valid application denial appeal reasons

Additional supporting documentation that the Eligible Professional or Hospital may be required to upload based on the type of appeal, including instances when a statement is needed from the Eligible Professional or Hospital in the appeals application free-form comment box

Appealing the payment amount

Denied Application Appeals

Reason for Appeal

Documentation Needed

The patient volume required by CMS have not been met, see federal rule 42 CFR 495.304.

For Eligible Hospitals, provide the out-of-state patient volume for the reported 90-day period on the Wisconsin Medicaid PI Program application.
For Eligible Professionals, provide the patient volume for the reported 90-day period on the Wisconsin Medicaid PI Program application.

The Eligible Hospital has indicated it is not an acute care hospital with an average length of stay of 25 days or less or a children's hospital.

Acute care and children's hospitals are required to have an average length of stay for patients of 25 days or less to qualify for the Wisconsin Medicaid PI Program. If the question was answered incorrectly when completing the original Wisconsin Medicaid PI Program application, provide a clarifying statement indicating the reason why the Eligible Hospital meets the requirements for the program.

The Eligible Hospital did not confirm to only participate in the Wisconsin Medicaid PI Program.

Eligible Hospitals must agree to participate in only one state's Medicaid PI Program. If the question was answered incorrectly when completing the original Wisconsin Medicaid PI Program application, provide a clarifying statement that the Eligible Hospital confirms to only participate in the Wisconsin Medicaid PI Program.

The Eligible Professional has indicated that they have current or pending sanctions with Medicare or Medicaid and therefore does not qualify for the Wisconsin Medicaid PI Program.

Upload documentation proving the Eligible Professional has been reinstated by the Office of Inspector General. If the question was answered incorrectly when completing the original Wisconsin Medicaid PI Program application, provide a clarifying statement that the Eligible Professional has no current or pending sanctions with Medicare or Medicaid.

The Eligible Professional has indicated that they are hospital based.

Eligible Professionals are not eligible for the Wisconsin Medicaid PI Program if they provide 90 percent or more of their services to eligible members in an inpatient hospital or emergency department. If the question was answered incorrectly when completing the original Wisconsin Medicaid PI Program application, provide a clarifying statement that the Eligible Professional is not hospital based.

The Eligible Professional has indicated they are not waiving their right to a Medicare PI Program payment for this payment year. Eligible Professionals must select to register with either Medicare or Medicaid PI Program, but not both.

Eligible Professionals may participate in either Medicare or Medicaid PI Programs, but not both. If the question was answered incorrectly when completing the original Wisconsin Medicaid PI Program application, provide a clarifying statement that the Eligible Professional is waiving their right to a Medicare PI Program payment for this year.

Payment Amount Appeals

Reason for Appeal

Documentation Needed

Eligible Professional payment amount (pediatrician only)

Provide the patient volume numbers for the reported 90-day period that should have been reported on the original Wisconsin Medicaid PI Program application.

Eligible Hospital payment amount

Upload the Eligible Hospital's Medicare and Medicaid Cost Reports for the last four years.

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Promoting Interoperability Program : Appeals

Appeals Process

Valid Reasons to Appeal

Appealing a Payment Amount

Appealing a Denied Wisconsin Medicaid Promoting Interoperability Program Application