BadgerCare Plus or Medicaid SSI HMO Provider Appeals

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.

Appeal Deadlines

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.

Required Documentation

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:

• The original claim submitted to the HMO and all corrected claims submitted to the HMO
• All of the HMO's payment denial remittances showing the dates of denial and reason codes with descriptions of the exact reasons for the claim denial
• The provider’s written appeal to the HMO
• The HMO’s response to the provider’s appeal
• For appeals regarding coding issues or emergency determination, relevant medical documentation that supports the appeal
• Any contract language that supports the provider’s appeal with the exact language that supports overturning the payment denial indicated
• Any other documentation that supports the provider’s appeal (for example, commercial insurance Explanation of Benefits/Explanation of Payment to support Wisconsin Medicaid as the payer of last resort)

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

Managed Care Online Handbook Topics

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:

• Appeals to BadgerCare Plus and Medicaid SSI HMOs (#384)
• Appeals to ForwardHealth (#385)
• Claims Submission (#386)
• Extraordinary Claims (#387)
• Medicaid as Payer of Last Resort (#388)
• Provider Appeals (#389)

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.

• When the HMO refuses to provide a service to a member—Enrollee Grievances (#393)
• Provider responsibility when submitting a claim—Accuracy of Claims (#516)
• Provider responsibility for record documentation—Preparation and Maintenance of Records (#203)
• Verification of member managed care enrollment when scheduling an appointment and before delivering a service—Enrollment Verification on the Portal (#4901)
• Allowed payment acceptance amounts—Acceptance of Payment (#258)
• Contract precedence—Managed Care Contracts (#402)
• Coordination of benefits between BadgerCare Plus HMO and commercial insurance coverage— Claims for Services Denied by Commercial Health Insurance (#844)
• Services and resources available to providers—Resources Reference Guide (#4456)

Other Resources

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.