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Family Care, Family Care Partnership, and PACE
Welcome  » April 18, 2024 10:32 AM
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Alerts
  • OnBase Outage: Portal users will be unable to access documents housed in OnBase from 4 a.m. on April 20, 2024, to midnight on April 21, 2024. During this window, we will make necessary upgrades to the OnBase system.

  • While some disruption is still occurring due to the cyber security incident involving Change Healthcare, providers who use Change Healthcare may once again submit pharmacy Point-of-Sale claims. Visit the ForwardHealth Change Healthcare Service Interruption: Resources page for more information.

  • Multi-factor authentication (MFA) is now required for the secure ForwardHealth Portal. Providers are encouraged to refer to the ForwardHealth Multi-Factor Authorization Instruction Sheet for help setting up MFA preferences.
    Providers may contact their Portal account administrator or call the ForwardHealth Portal Help Desk at 866-908-1363. Note: This is a project-specific announcement and is not related to the Change Healthcare disruption.

Family Care, Family Care Partnership, PACE Forms List


Category Form Number Title Direct Link to Form
Security F-00639 Agency Data Security Staff User Agreement www.dhs.wisconsin.gov/forms/f0/f00639.pdf
Other F-00759 Business Associate Agreement www.dhs.wisconsin.gov/forms/f0/f00759.pdf
Other F-00295 Medical and Remedial Expenses Checklist for Medicaid Long-Term Care Waiver Programs www.dhs.wisconsin.gov/forms/f0/f00295.docx
MCO Reporting F-02466 MCO Appeal Log for Family Care Family Care Partnership, and PACE www.dhs.wisconsin.gov/library/f-02466.htm
MCO Reporting F-01655 Enrollment Discrepancy Report www.dhs.wisconsin.gov/forms/f01655.xlsx
MCO Reporting F-01284 Family Care Family Care Partnership & PACE Financial Reporting Template www.dhs.wisconsin.gov/forms/f0/f01284.xlsx
MCO Reporting F-10137 Wisconsin Medicaid Change Report www.dhs.wisconsin.gov/forms/f1/f10137.pdf
Fiscal Reporting F-00152 MCO Notification to Pay Over the Medicaid Fee-for-Service Reimbursement Rate www.dhs.wisconsin.gov/forms/f0/f00152.docx
Fiscal Reporting F-02022 Claims Audit Report for Managed Long-Term Care MCOs www.dhs.wisconsin.gov/forms/f02022.docx
Eligibility F-01827 Application for Reduction of Cost Share www.dhs.wisconsin.gov/library/f-01827.htm
Enrollment and Disenrollment F-02140 Urgent Services Agreement www.dhs.wisconsin.gov/library/f-02140.htm
Grievance and Appeals F-00232 Notice of Adverse Benefit Determination (Notice of Action) www.dhs.wisconsin.gov/library/f-00232.htm
Grievance and Appeals F-00237 Appeal Request Forms www.dhs.wisconsin.gov/familycare/mcoappeal.htm
Grievance and Appeals F-01590 MCO Letter: Notice of Change in Level of Care www.dhs.wisconsin.gov/library/f-01590.htm
Grievance and Appeals F-00232D Decision Letter: Decision Reversed www.dhs.wisconsin.gov/library/f-00232d.htm
Grievance and Appeals F-00232E Decision Letter: Decision Upheld www.dhs.wisconsin.gov/library/f-00232e.htm
Grievance and Appeals F-00232B Notification of Extension for a Decision Request www.dhs.wisconsin.gov/library/f-00232b.htm
Grievance and Appeals F-00236 Request for a State Fair Hearing – MCO www.dhs.wisconsin.gov/library/f-00236.htm
Grievance and Appeals DHA-17 Fair Hearing Voluntary Withdrawal doa.wi.gov/DHA/WFSVW.pdf
Grievance and Appeals F-01283 Notification of Non-Covered Benefit Letter Template www.dhs.wisconsin.gov/library/f-01283.htm
Eligibility F-02558 Family Care Member County Notification www.dhs.wisconsin.gov/forms/f02558.docx
Eligibility F-10193 Divestment Penalty and Undue Hardship Notice Plus Waiver Request www.dhs.wisconsin.gov/library/F-10193.htm
Enrollment and Disenrollment F-02404 Family Care Partnership, PACE, or IRIS Change Routing www.dhs.wisconsin.gov/forms/f0/f02404.docx
Enrollment and Disenrollment F-00046 Family Care Program Enrollment www.dhs.wisconsin.gov/library/f-00046.htm
Enrollment and Disenrollment F-02483 PACE Program - Enrollment www.dhs.wisconsin.gov/forms/f02483.docx
Enrollment and Disenrollment F-00221 Family Care/IRIS Member Requested Disenrollment or Transfer and Instructions www.dhs.wisconsin.gov/library/F-00221.htm
Enrollment and Disenrollment F-02484 PACE Member Requested Disenrollment or Transfer www.dhs.wisconsin.gov/forms/f02484.docx
Enrollment and Disenrollment F-00533 Partnership Program - Enrollment www.dhs.wisconsin.gov/library/F-00533.htm
Enrollment and Disenrollment F-00534 Partnership Member Requested Disenrollment or Transfer and Instructions www.dhs.wisconsin.gov/library/f-00534.htm
Enrollment and Disenrollment F-02403 Family Care Partnership, PACE, and IRIS Program-Requested Disenrollment www.dhs.wisconsin.gov/forms/f02403.docx
Grievance and Appeals F-00950 Partnership Coverage Decision Letter www.dhs.wisconsin.gov/library/f-00950.htm
Grievance and Appeals F-00950a Notice of Denial of Medical Coverage – PACE www.dhs.wisconsin.gov/library/f-00950a.htm
Grievance and Appeals P-02915 Enrollment and Disenrollment Process Desk Aid for Publicly Funded Long-Term Care Programs www.dhs.wisconsin.gov/publications/p02915.pdf
Restrictive Measures F-62608 Request for Use of Medical Restraints www.dhs.wisconsin.gov/library/f-62608.htm
Restrictive Measures F-62607 Request for Use of Restraints Isolation, or Protective Equipment as Part of a Behavior Support Plan www.dhs.wisconsin.gov/library/f-62607.htm
 
 
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