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:
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:
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.
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
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.
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.