| Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Nurse Midwife | | 07/13/2020 | Promoting Interoperability Program : AppealsTopic #12137 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 Valid Reasons to Appeal
Eligible Professionals may only appeal to the Wisconsin Medicaid PI Program for the following reasons:
- To dispute the payment amount
- To appeal a denied Wisconsin Medicaid PI Program application
Appealing a Payment Amount
Eligible Professionals who wish to appeal a payment amount must do so within 45 calendar days of the RA date of the Wisconsin Medicaid PI Program payment.
Appealing a Denied Wisconsin Medicaid Promoting Interoperability Program Application
Eligible Professionals 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 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 may be required to upload based on the type of appeal, including instances when a statement is needed from the Eligible Professional in the appeals application free-form comment box
- Appealing the payment amount
| Denied Application Appeals |
| Reason for Appeal |
Explanation |
Documentation Required |
| Patient Volume |
The provider was denied approval for not meeting the patient volume requirement during the 90-day reporting timeframe but believes they met the appropriate patient volume requirement. |
Provide the patient volume for the reported 90-day period on the Wisconsin Medicaid PI Program application. |
| Sanctioned by Medicare or Medicaid |
The provider was denied for having current or pending sanctions with Medicare or Medicaid but does not have any sanctions. |
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. |
| Demonstration of AIU |
The provider was denied for failing to meet the AIU requirements but believes they met the AIU requirements. |
Provide a statement explaining how AIU requirements were met. Include documentation supporting the adoption, implementation, or upgrade of certified EHR technology. |
| Demonstration of Meaningful Use |
The provider was denied for failing to meet Meaningful Use requirements for the reporting period specified but believes they did meet Meaningful Use requirements. |
Provide a statement explaining how Meaningful Use requirements were met. Include documentation to support the satisfaction of the Meaningful Use measure(s) in question. |
| Duplicate Payment |
The provider was denied due to a history of prior payments for the specified program year but has not received any prior payments from the Wisconsin Medicaid PI Program, the Medicare PI Program, or the PI Program of another state. |
Eligible Professionals may only receive one incentive payment for a given program year. The Eligible Professional must submit a copy of their full incentive payment history as reported on the CMS Promoting Interoperability Programs Registration System. |
| Eligible Provider and Specialty Type |
The provider was denied due to not meeting the eligible provider type requirement but believes their scope of practice falls under the eligible provider types. |
To qualify for a Wisconsin Medicaid PI payment, Eligible Professionals must be one of the provider types and specialties indicated within the SMHP, Section 3?Program Administration and Oversight, subsection 1.4. The Eligible Professional must submit evidence that they are one of the provider type and specialty combinations allowed per the SMHP. |
| Hospital Based |
The Eligible Professional was denied for being hospital based but believes they meet the requirement of providing less than 90 percent of their services in an inpatient hospital or emergency department or of funding the acquisition, implementation, and maintenance of CEHRT without reimbursement from a hospital. |
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. |
| Payment Amount Appeals |
| Reason for Appeal |
Explanation |
Documentation Required |
| Pediatrician Reduced Payment Amount Applied Incorrectly |
Pediatricians received reduced payment because they were deemed to have met the reduced Medicaid patient volume criteria (20 percent) by the Wisconsin Medicaid PI Program, but the Eligible Professional believes that they have fulfilled the 30 percent Medicaid patient volume requirement. |
Provide the patient volume numbers for the reported 90-day period that should have been reported on the original Wisconsin Medicaid PI Program application. |
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