The BadgerCare Plus and Medicaid SSI HMO Contract outlines the appeal rights allowed to ForwardHealth providers who contract with HMOs. The contract includes the responsibilities the HMOs have to BadgerCare Plus and Medicaid SSI HMO providers, including the right to appeal a non-payment or partial payment, and the steps the provider must take to appeal a decision to ForwardHealth.
For current information on how to file an appeal with a BadgerCare Plus or Medicaid SSI member's HMO, refer to that HMO’s provider handbook. Some HMOs provide more time to appeal than others. Providers must exhaust all appeal options with the HMO before filing an appeal to ForwardHealth. Providers may not appeal to ForwardHealth until after they have already appealed to the HMO.
When a provider submits an appeal to the HMO, the HMO has 45 days to respond to their appeal. As a reminder, if the provider does not provide evidence of an appeal to the HMO, ForwardHealth will reject the appeal.
The decision to overturn an HMO's denial must be clearly supported by the documentation the provider submits. Submitting incomplete or insufficient documentation may lead to ForwardHealth upholding the HMO’s denial.
A provider may submit an appeal using the Managed Care Program Provider Appeal form or using their own letter. If the provider submits their own letter, they must include all of the information from the Managed Care Program Provider Appeal form. Providers should attach readable copies of the following:
Only relevant documentation should be included. Large documents may be submitted on a CD.
Appeals may be faxed to ForwardHealth at 608-224-6318 or mailed to the following address: BadgerCare Plus and Medicaid SSI Managed Care Unit—Provider Appeal PO Box 6470 Madison WI 53716-0470
Providers can find additional information about managed care claims in the Claims chapter of the Online Handbook or in one of the topics listed below:
Below is a list of Online Handbook topics that address common situations that lead to denied claims. Providers may want to review the topic relevant to their appeal.
Providers should contact the member’s HMO for questions regarding a specific claim or for more information on the HMO's appeal process.
Providers may contact ForwardHealth Provider Services (Managed Care Unit) at 800-760-0001, option 1, to check the status of an appeal submitted to ForwardHealth.