Reimbursement : Amounts

Fee Schedules

Maximum allowable fee information is available on the Max Fee Schedules page of the ForwardHealth Portal in the following forms:

• An interactive maximum allowable fee schedule
• Downloadable fee schedules by service area only in TXT or CSV files

Policy information is not displayed in the fee schedules. Providers should refer to their specific service area in the Online Handbook for more information about coverage policy related to a specific procedure code.

Certain fee schedules are interactive. On the interactive fee schedule, providers have more search options for looking up some coverage information, as well as the maximum allowable fees, as appropriate, for reimbursable HCPCS, CPT, or CDT procedure codes for most services.

Providers have the ability to independently search by:

• A single HCPCS, CPT, or CDT procedure code
• Multiple HCPCS, CPT, or CDT procedure codes
• A pre-populated code range
• A service area (Service areas listed in the interactive fee schedule more closely align with the provider service areas listed in the Online Handbook, including the WCDP programs and WWWP.)

The downloadable fee schedules, which are updated monthly, provide basic maximum allowable fee information by provider service area.

Through the interactive fee schedule, providers can export their search results for a single code, multiple codes, a code range, or by service area. The export function of the interactive fee schedule will return a zip file that includes seven CSV files containing the results.

Note: The interactive fee schedule will export all associated information related to the provider's search criteria except the procedure code descriptions.

Providers may call Provider Services in the following cases:

• The ForwardHealth Portal is not available.
• There is uncertainty as to which fee schedule should be used.
• The appropriate fee schedule cannot be found on the Portal.
• To determine coverage or maximum allowable fee of procedure codes not appearing on a fee schedule.

Targeted Reimbursement Rate Increase

In accordance with a provision of the 2015-17 biennial state budget (2015 Wisconsin Act 55), ForwardHealth implemented a targeted enhanced reimbursement rate for pediatric dental care and certain adult dental services. The targeted reimbursement rate applies to all Medicaid-enrolled provider types eligible to render dental services and applies to services rendered in Brown, Marathon, Polk, and Racine counties. The rendering provider's practice location is considered the county where the services are rendered, not the county of the billing provider or the member.

The reimbursement rate increase applies to all Medicaid-enrolled provider types eligible to render dental services in a target county; however, the reimbursement rate increase does not apply to dental services billed through a federally qualified health center. The reimbursement rate applies to services provided fee-for-service and via managed care.

If the rendering provider practices in both a target county and non-target county, the rendering provider is required to obtain separate Medicaid enrollment for both the target county and the non-target county. The address of the rendering provider should be indicated in the appropriate field on submitted claims, including the zip code matching the Medicaid enrollment address. Rendering providers who need to set up separate Medicaid enrollment for separate locations can begin the process as follows:

• Go to the Provider Enrollment page.
• Click the Start or Continue Your Enrollment Application link to begin a new Medicaid enrollment.

Providers with questions regarding the enrollment process can call ForwardHealth Provider Services.

Maximum Allowable Fees

ForwardHealth reimburses the lesser of the provider's billed amount or the increased reimbursement rate. The maximum daily reimbursement rate policy applies only for services eligible for the rate increase.

The maximum allowable fee schedule includes all current reimbursement rates. Providers should indicate their usual and customary charges when submitting claims for services.