Provider Appeal Process for Managed Care Providers

The BadgerCare Plus and Medicaid SSI HMO Contract (the Contract) between the Department of Health Services (the Department) and BadgerCare Plus and Medicaid SSI HMO outlines Provider Appeal rights allowed to contracted providers. The Contract outlines the responsibilities the HMOs must provide in allowing providers the right to appeal a non-payment or partial payment to the HMO and the steps the Provider must take to appeal an upheld decision to the Department. The Contract is available here.

For current information on how to file an appeal with a BadgerCare Plus or Medicaid SSI member's HMO refer to the Provider Handbook provided by that HMO. Some HMOs provide more time to appeal to the HMO. Providers must exhaust all appeal options with the HMO before filing an appeal to the Department if they disagree with the HMO's final appeal response.

Follow these steps if you decide to appeal to the Department after receiving the HMO's denial of your appeal:

• Appeals to the Department must be submitted in writing within 60 calendar days of the HMO's final decision or, in the case of no response, within 60 calendar days from the 45 calendar day timeline allotted the HMO to respond to your appeal submission.
  
  

Required Documentation

Providers are required to submit an appeal with legible copies of all of the following documentation, regardless of whether the Managed Care Program Provider Appeal form or their own appeal letter is used:

• A copy of the original claim submitted to the HMO. If applicable, include a copy of all corrected claims submitted to the HMO
• A copy of all of the HMO's payment denial remittance(s) showing the date(s) of denial and reason code with a description of the exact reason(s) for the claim denial
• A copy of the provider's written appeal to the HMO
• A copy of the HMO response to the appeal
• A copy of the medical record for appeals regarding coding issues, medical necessity, or emergency determination. Providers should only send relevant medical documentation that supports the appeal. Large documents should be submitted on a CD.
• A copy of any contract language that supports your appeal. If contract language is submitted, indicate the exact language that supports overturning the payment denial.
• Any other documentation that supports the appeal (e.g., commercial insurance Explanation of Benefits/Explanation of Payment to support Wisconsin Medicaid as the payer of last resort)

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

A decision to uphold the HMO's original payment denial or to overturn the denial will be made based on the documentation submitted for review. Failure to submit the required documentation or submitting incomplete/insufficient documentation may lead to an upholding of the original denial. The decision to overturn an HMO's denial must be clearly supported by the documentation.

Additional information about Managed Care Claims submission and appeal can be found here (all topics listed below) or individually in the following ForwardHealth Handbook Topics:

384 – Appeals to HMO's and SSI HMO
385 – Appeals to ForwardHealth
386 – Claims Submission
387 – Extraordinary Claims
388 – Medicaid as Payer of Last Resort
389 – Provider Appeals

Other Important ForwardHealth Handbook Topics

Below is a list of ForwardHealth Handbook Topics that address many situations for which claims are denied and appeals are submitted to the HMO and to the Department. You may want to review the ForwardHealth Handbook Topic for your specific provider type/service area for relevance to the issue you are appealing.
393 – Enrollee Grievance – When the HMO refuses to provide a service to a member.
516 – Accuracy of Claim – Provider responsibility when submitting a claim.
203 – Preparation and Maintenance of Records – Provider responsibility for record documentation.
4901 – Enrollment Verification on the Portal – Be sure to verify member managed care enrollment when scheduling an appointment and before delivering a service.
644 – ClaimCheck Review – Each HMO has its own claim edit review product that reviews submitted claims. As a contracted provider you've agreed to the review of your claim, and result, by the individual product.
258 – Acceptance of Payment – Payment amount cannot exceed allowed amount.
402 – Managed Care Contracts – Contract precedence.
844 – Claims for Services Denied by Commercial Health Insurance – Coordination of benefits between BCP HMO and Commercial insurance coverage.
4456 – Provider Services and Resources Reference Guide.

Other Resources:

Contact the enrollee's HMO for questions regarding a specific claim or for more information on the HMO's appeal process.
Contact ForwardHealth Provider Services (Managed Care Unit) at 800-760-0001, option 1, to check on the status of an appeal submitted to the Department.