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Family Care, Family Care Partnership, and PACE

Welcome » May 1, 2025 11:04 PM

	Alerts
	Children’s Long-Term Support (CLTS) Program Providers and County Waiver Agencies: The CLTS Operations Team is available for your questions about submitting prior authorizations (PAs) or claims for CLTS services. Reach the CLTS Operations Team at 844-942-5870 or CLTSOperations@gainwelltechnologies.com. Attention CLTS Providers: The CLTS Prior Authorization Conversion is still processing. If you have any difficulties submitting claims, please contact the CLTS Operations Team at 844-942-5870 or CLTSOperations@gainwelltechnologies.com.

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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Wisconsin Department of Health Services

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