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System Generated Claim Adjustment Messages

ForwardHealth System Generated Claim Adjustments

Week of November 6, 2017

Affected Providers Description of Adjustment
Providers Submitting Claims with Procedure Codes 77063 and 77067 ForwardHealth is automatically reprocessing certain outpatient hospital and professional claims with dates of service between January 1, 2017, and September 21, 2017, that processed between March 29, 2017, and September 21, 2017. Claims submitted with Current Procedural Terminology (CPT) add-on procedure code 77063 (Screening digital breast tomosynthesis, bilateral [List separately in addition to code for primary procedure]) in conjunction with CPT code 77067 (Screening mammography, bilateral [2-view study of each breast], including computer-aided detection [CAD] when performed) were incorrectly denied with Explanation of Benefits Code 1306, "Add-on codes are not separately reimbursable when submitted as a stand-alone code."
Providers Submitting Claims with Procedure Code G0279 ForwardHealth is automatically reprocessing Wisconsin Well Woman Program (WWWP) claims with dates of service from January 1, 2017, through August 31, 2017. Claims submitted with Healthcare Common Procedure Coding System procedure code G0279 (Diagnostic digital breast tomosynthesis, unilateral or bilateral) were incorrectly denied with Explanation of Benefits code 1186, "The Procedure Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service". The procedure code has been added to the WWWP benefit.

Week of October 9, 2017

Affected Providers Description of Adjustment
Ambulatory Surgery Centers ForwardHealth is automatically reprocessing certain professional claims for Ambulatory Surgery Centers (ASC) that originally processed and paid between July 1, 2016, and February 16, 2017, due to rate changes. Additional access payments will be applied to all eligible professional claims for ASCs that meet the criteria.
Providers Submitting Outpatient Hospital and Outpatient Hospital Crossover Claims ForwardHealth is automatically adjusting and resubmitting certain outpatient hospital claims with From dates of service on and after October 1, 2016, through April 17, 2017, that were processed on and after November 21, 2016, through April 17, 2017. ForwardHealth will apply Enhanced Ambulatory Patient Groups (EAPG) reimbursement to certain International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes that were added to the October 2016 3M GPS software quarterly release version 3.1. Claims submitted with these ICD-10-CM codes will be reprocessed due to some EAPG processing-related interChange tables that did not get updated with the new codes.

Week of September 18, 2017

Affected Providers Description of Adjustment
Non-Pharmacy Providers ForwardHealth is automatically reprocessing certain claims that were submitted with American National Standards Institute (ANSI) reason codes 1 (Deductible amount), 2 (Coinsurance amount), 3 (Co-payment amount), 66 (Blood deductible), and/or 122 (Psychiatric reduction) that processed between March 1, 2011, and February 11, 2017, and were incorrectly denied. ForwardHealth will automatically assign the "OI-P" indicator to these claims. Refer to the September ForwardHealth Update (2017-29), titled "New Billing Instructions for Claims with Deductible, Coinsurance, Copayment, Blood Deduction, or Psychiatric Reduction," for more information.

Week of September 11, 2017

Affected Providers Description of Adjustment
Dental Providers Submitting Claims with Procedure Codes D9223 or D9243 ForwardHealth is automatically reprocessing certain dental claims with dates of service between January 1, 2016, and December 29, 2016, that were submitted with Current Dental Terminology (CDT) procedure code D9223 (deep sedation/general anesthesia – each 15 minute increment) or D9243 (Intravenous moderate [conscious] sedation/analgesia – each 15 minute increment). Claims were incorrectly denied with Explanation of Benefits code 0289, "Out-of-State non-emergency services require Prior Authorization." CDT procedure codes D9223 and D9243 do not require prior authorization.

Week of September 4, 2017

Affected Providers Description of Adjustment
Providers Submitting Claims with Procedure Code 31575 or 31579 ForwardHealth is automatically reprocessing outpatient hospital claims with dates of service between January 1, 2015, and March 28, 2017, that were submitted with Current Procedural Terminology procedure code 31575 (Laryngoscopy, flexible; diagnostic) or 31579 (Laryngoscopy, flexible or rigid telescopic, with stroboscopy) and incorrectly denied. Effective for DOS on and after January 1, 2015, CPT codes 31575 and 31579 have been added as covered procedure codes when submitted on outpatient hospital claims.
Providers Submitting Professional and Professional Crossover Claims ForwardHealth is automatically reprocessing certain professional claims for physician-administered drugs that originally processed between 2012 and 2014 and again in December 2016 and June 2017 to ensure that invoicing for federal drug rebates associated with the claims occurred. For the affected claims, providers do not need to take any action and there will be no change in the amounts that were reimbursed for these claims. The Remittance Advice will include the Explanation of Benefits code 8234, "ForwardHealth-initiated claim adjustment," to indicate these affected claims. Adjusted claims will be assigned a new claim number, known as an internal control number (ICN). The new ICN will begin with "58." If the provider adjusts any of these claims in the future, the new ICN will be required when submitting the claim. Refer to the ForwardHealth-Initiated Claim Adjustments topic (topic #13437) of the Responses chapter of the Claims section of the ForwardHealth Online Handbook for complete information.

Week of August 28, 2017

Affected Providers Description of Adjustment
Providers Submitting Professional and Professional Crossover Claims and Outpatient and Outpatient Crossover Claims ForwardHealth is automatically reprocessing certain claims with dates of service between January 1, 2017, and April 22, 2017, to apply updated maximum allowable fee rates. Medicaid's maximum allowable fees will be adjusted to equal Medicare's maximum allowable fees.

Week of August 14, 2017

Affected Providers Description of Adjustment
Providers Submitting Claims with Procedure Code H1010 ForwardHealth is automatically reprocessing certain family planning claims submitted with Healthcare Common Procedure Coding System procedure code H1010 (Non-medical family planning education, per session) with dates of service and dates of process between April 1, 2017, and June 2, 2017, to apply updated maximum allowable fee rates.

Week of August 7, 2017

Affected Providers Description of Adjustment
Providers Submitting Claims with Procedure Code 58661 ForwardHealth is automatically adjusting certain claims submitted with Current Procedural Terminology procedure code 58661 (Laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salphingectomy]) with dates of service (DOS) on and after August 1, 2015, that processed between August 1, 2015, and February 10, 2017. Claims were incorrectly denied with Explanation of Benefits Code 1174, "The procedure code is not reimbursable for a Family Planning Waiver member." Procedure code 58661 is reimbursable under the Family Planning Only Services benefit effective for DOS on and after August 1, 2015.

Week of July 24, 2017

Affected Providers Description of Adjustment
Providers Submitting Claims for Advanced Imaging Services ForwardHealth is automatically reprocessing certain professional and outpatient hospital claims that were submitted between May 3, 2017, and May 19, 2017. Claims submitted for advanced imaging services may have been incorrectly denied with Explanation of Benefits code 0192, "Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim." Reprocessed claims with a matching approved PA on file will be reimbursed.

Week of July 3, 2017

Affected Providers Description of Adjustment
Providers Submitting Outpatient Hospital and Outpatient Hospital Crossover Claims ForwardHealth is automatically reprocessing certain outpatient hospital claims with dates of service between January 1, 2017, and March 15, 2017, to apply updated maximum allowable fee rates. Medicaid's maximum allowable fees will be adjusted to equal Medicare's maximum allowable fees.

Week of June 26, 2017

Affected Providers Description of Adjustment
Providers Submitting Professional and Professional Crossover Claims ForwardHealth is automatically reprocessing certain professional claims for professional-administered drugs that originally processed between 2012 and 2014 and again in December 2016 to ensure that invoicing for federal drug rebates associated with the claims occurs. For the affected claims, providers do not need to take any action and there will be no change in the amounts that were reimbursed for these claims. The Remittance Advice will include the Explanation of Benefits code 8234, "ForwardHealth-initiated claim adjustment," to indicate these affected claims. Adjusted claims will be assigned a new claim number, known as an internal control number (ICN). The new ICN will begin with "58." If the provider adjusts any of these claims in the future, the new ICN will be required when submitting the claim. Refer to the ForwardHealth-Initiated Claim Adjustments topic (topic #13437) of the Responses chapter of the Claims section of the ForwardHealth Online Handbook for complete information.

Week of June 12, 2017

Affected Providers Description of Adjustment
Providers Submitting Professional Claims ForwardHealth is automatically reprocessing certain professional claims with dates of service (DOS) between January 1, 2017, and February 14, 2017, due to system updates for selected International Classification of Diseases, 10th Revision (ICD-10) diagnosis codes. Effective for DOS on and after January 1, 2017, the following ICD-10 diagnosis codes have been added: O09.291, O09.292, O09.293, O09.299, O09.891, O09.892, O09.893, O09.899, O35.1XX0, O35.1XX9, O35.9XX0, O35.9XX9, Q92.8 and Q95.0. Effective for DOS on and after January 1, 2017, ICD-10 diagnosis codes Z13.79 and Z36 have been end dated.

Week of May 29, 2017

Affected Providers Description of Adjustment
Providers Submitting Pharmacy Claims ForwardHealth is reprocessing certain noncompound claims for SeniorCare members that processed and paid between April 1, 2017, and April 17, 2017, due to a change in the professional dispensing fee rate. The Federally Qualified Health Center (FQHC) professional dispensing fee rate will be applied to the affected claims resulting in a higher reimbursement. ForwardHealth sent a letter to pharmacy providers in late March 2017 about this issue. The letter indicated that ForwardHealth would assign an interim FQHC professional dispensing fee rate to payable claims for SeniorCare members until reprocessing could occur.
Providers Submitting Institutional Claims ForwardHealth is automatically reprocessing certain long-term care, inpatient, inpatient crossover, and outpatient institutional claims that were incorrectly denied with payment dates from February 10, 2017, through April 15, 2017. The affected claims were incorrectly denied with Explanation of Benefits code 1104, "A number is required in the Covered Days field."

Week of May 8, 2017

Affected Providers Description of Adjustment
Providers Submitting Claims for Birth to 3 Services ForwardHealth is automatically reprocessing certain claims for Birth to 3 services with dates of service between November 10, 2008, and October 17, 2016. For the affected claims, providers do not need to take any action, and there will be no change in reimbursement. The provider's Remittance Advice will include the Explanation of Benefits code 8234, "ForwardHealth-initiated claim adjustment," to indicate these affected claims.
Adjusted claims will be assigned a new claim number, known as an internal control number (ICN). The new ICN will begin with "58." If the provider adjusts this claim in the future, the new ICN will be required when submitting the claim. Refer to the ForwardHealth-Initiated Claim Adjustments topic (topic #13437) in the Responses chapter of the Claims section of the ForwardHealth Online Handbook for complete information.

Week of April 24, 2017

Affected Providers Description of Adjustment
Providers Submitting Birth to 3 claims with procedure code 97112 ForwardHealth is automatically reprocessing certain Birth to 3 claims submitted with procedure code 97112 (Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities) that were eligible for enhanced reimbursement with dates of service (DOS) between November 10, 2008, and October 17, 2016, and received between October 18, 2016, and October 27, 2016. The enhanced reimbursement was incorrectly applied more than once when procedure code 97112 was submitted with another therapy procedure code for the same therapy discipline, on the same DOS, for a member.
As indicated in the Online Handbook, the enhanced reimbursement applies on a per child, per DOS, per therapy discipline basis when certain services are provided in the natural environment of a member who participates in the Birth to 3 Program.

Week of April 3, 2017

Affected Providers Description of Adjustment
Providers Submitting Claims for Dental Services Eligible for the Targeted Reimbursement Increase ForwardHealth is automatically adjusting claims for certain dental services that are eligible for the targeted rate reimbursement increase with dates of service between October 1, 2016, and December 18, 2016, for reporting purposes. There is no financial impact to providers.
Providers Submitting Claims ForwardHealth is automatically reprocessing certain claims with dates of service on and after March 10, 2013, that processed between March 10, 2013, and July 13, 2013. The affected claims were previously reprocessed or adjusted based on other insurance information and the third-party liability indicator was not processed correctly.

Week of March 20, 2017

Affected Providers Description of Adjustment
Providers Submitting Claims with Procedure Code D0150 ForwardHealth is automatically reprocessing claims submitted with Current Dental Terminology procedure code D0150, "Comprehensive Evaluation for New Patients," that processed on November 29, 2016. These claims will be adjusted to deduct the correct copayment amount based on the maximum allowable fee.

Week of March 13, 2017

Affected Providers Description of Adjustment
Providers Submitting Claims with Procedure Code J7304 ForwardHealth is automatically reprocessing certain professional claims submitted with procedure code J7304 (Contraceptive supply, hormone containing patch, each) with dates of service between January 1, 2016, and December 16, 2016. Affected claims were incorrectly denied with Explanation of Benefits code 0485, "Quantity limit exceeded."
Providers Submitting Claims for Birth to 3 Services ForwardHealth is automatically reprocessing certain professional claims with dates of service between November 10, 2008, and October 17, 2016, that were processed between October 15, 2014, and October 17, 2016. Certain claims for Birth to 3 services submitted with procedure codes 92506-92508, 92521-92526, 92597, 92607-92610, 97001-97004, 97110, 97112-97113, 97116, 97140, 97150, and 97530-97535 with modifier TL were incorrectly denied with Explanation of Benefits code 0278, "Member is covered by a commercial health insurance on the Date(s) of Service."

Week of March 6, 2017

Affected Providers Description of Adjustment
Outpatient Hospital Providers ForwardHealth is automatically reprocessing certain outpatient hospital claims with dates of service between November 10, 2008, and April 29, 2016. Claim details requiring a valid Clinical Laboratory Improvement Amendment (CLIA) type were inappropriately paid. These claim details will be denied with Explanation of Benefits code 0794, "Procedure not allowed for the CLIA Certification Type."

Week of January 2, 2017

Affected Providers Description of Adjustment
Providers Submitting Claims with Procedure Code B9002 or B9006 with Modifier RR ForwardHealth is automatically reprocessing certain home health and professional claims with dates of service on and after March 1, 2016, that were processed between March 1, 2016, and June 30, 2016. Certain claims submitted with procedure code B9002 (Enteral nutrition infusion pump – with alarm) or B9006 (Parenteral nutrition infusion pump, stationary) with modifier RR (rental) were incorrectly denied with Explanation of Benefits code 0192, "Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim." Prior authorization is only needed if the rental exceeds 180 days.

Week of December 19, 2016

Affected Providers Description of Adjustment
Providers Submitting Claims with Procedure Codes 74712 and 74713 ForwardHealth is automatically reprocessing certain professional claims with dates of service between January 1, 2016, and June 30, 2016. Certain claims submitted with Current Procedural Terminology procedure code 74712 (Magnetic resonance [eg, proton] imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation) or 74713 (Magnetic resonance [eg, proton] imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation [list separately in addition to code for primary procedure]) were incorrectly denied with Explanation of Benefits code 1279, "Procedure not payable for Place of Service."
Providers Submitting Professional Claims and Professional Crossover Claims ForwardHealth is automatically reprocessing certain professional claims that processed between January 1, 2012, and December 31, 2014, to ensure that invoicing for federal rebates associated with the claims occurs. For the affected claims, providers do not need to take any action, and there will be no change in reimbursement. The provider's Remittance Advice will include the Explanation of Benefits code 8234, "ForwardHealth-initiated claim adjustment," to indicate these affected claims.

Adjusted claims will be assigned a new claim number, known as an internal control number (ICN). The new ICN will begin with "58." If the provider adjusts this claim in the future, the new ICN will be required when submitting the claim. Refer to the ForwardHealth-Initiated Claim Adjustments topic (topic #13437) in the Responses chapter of the Claims section of the ForwardHealth Online Handbook for complete information.
Providers Submitting Claims with Procedure Codes 90791, H0031, H0032, or H2012 ForwardHealth is automatically reprocessing professional claims with procedure codes 90791, H0031, H0032, or H2012 with detail dates of service between January 1, 2016, and August 9, 2016, to apply updated maximum allowable fee rates.
Providers Submitting Claims with Procedure Code G0479 or G0480 ForwardHealth is automatically reprocessing certain professional, professional crossover, outpatient, and outpatient crossover claims submitted with procedure code G0479 or procedure code G0480 with dates of service from January 1, 2016, through May 10, 2016, to apply the correct maximum allowable fee rate.

Week of November 7, 2016

Affected Providers Description of Adjustment
Providers Submitting Claims with Procedure Code D9110 ForwardHealth is automatically adjusting certain dental claims submitted with Current Dental Terminology procedure code D9110 (Palliative [emergency] treatment of dental pain-minor procedures) with dates of service between October 1, 2016, and October 27, 2016. Affected claims were incorrectly denied with Explanation of Benefits code 1024, "Denied/Cutback. Exceeds policy limitation."
Providers Submitting Claims for Dental Services Eligible for the Targeted Rate Reimbursement Increase ForwardHealth is automatically adjusting claims processed prior to October 16, 2016, for certain dental services rendered in Brown, Marathon, Polk, and Racine Counties with dates of service between October 1, 2016, and October 15, 2016, that are eligible for the targeted rate reimbursement increase. Providers are encouraged to refer to their Remittance Advice for adjustment information.
Providers Submitting Inpatient and Outpatient Hospital Claims ForwardHealth is automatically reprocessing certain inpatient and outpatient hospital claims with a discharge date ("To" date of service) between July 1, 2016, and October 4, 2016, to apply correct access payments.

Week of October 10, 2016

Affected Providers Description of Adjustment
Providers Submitting Claims with Procedure Code 99001 ForwardHealth is automatically reprocessing certain outpatient claims with dates of service between July 1, 2016, and August 4, 2016. Claims submitted with procedure code 99001 (Handling and/or conveyance of specimen for transfer from the patient in other than an office to a laboratory [distance may be indicated]) and a revenue code in the 300-319 range were incorrectly denied.

Week of September 5, 2016

Affected Providers Description of Adjustment
Providers Submitting Professional Claims ForwardHealth is automatically reprocessing certain professional claims with dates of service on and after October 1, 2014. Claims submitted fee-for-service with procedure codes 99201-99203, 99212, 99213, 90656, 90658, 90670, 90672, 90703, 90714, 90715, or 90732 and place of service 17 (walk-in retail health clinic) were incorrectly reimbursed for members under age 6 years. Claim details will be denied with Explanation of Benefits code 0184, "Procedure Code is restricted by member age."

Week of August 19, 2016

Affected Providers Description of Adjustment
Case Management Providers Submitting Claims with Procedure Code T1017 ForwardHealth is automatically reprocessing certain case management claims with dates of service between July 1, 2014, and October 12, 2014. Claims submitted with Healthcare Common Procedure Coding System code T1017 (Targeted case management, each 15 minutes) in combination with certain diagnosis code(s) were incorrectly paid. The affected claim details will be denied and reimbursement recouped.

Week of June 27, 2016

Affected Providers Description of Adjustment
Providers Submitting Professional Claims, Professional Crossover Claims, and Outpatient Hospital Claims ForwardHealth is automatically reprocessing certain claims with dates of service before March 1, 2015, that processed between May 1, 2015, and December 18, 2015. Claims submitted with Reason Code 55, "Procedure/treatment/drug is deemed experimental/investigational by the payer," were incorrectly denied with Explanation of Benefits code 0278, "Member is covered by a commercial health insurance on the Date(s) of Service."

Week of June 20, 2016

Affected Providers Description of Adjustment
Providers Submitting Inpatient Crossover Claims and Institutional Inpatient Claims ForwardHealth is automatically adjusting certain inpatient crossover claims and institutional inpatient claims that processed between January 1, 2016, and March 2, 2016, with detail "From" dates of service (DOS) before January 1, 2016, and detail "To" DOS on and after January 1, 2016. Services for members enrolled in managed care programs were incorrectly paid fee-for-service. The affected claims will be denied with Explanation of Benefits code 0287, "Member is enrolled in a State-contracted managed care program for the Date(s) of Service."
Providers Submitting Professional and Professional Crossover Claims and Outpatient and Outpatient Crossover Claims ForwardHealth is automatically reprocessing certain claims that processed between February 11, 2013, and November 16, 2015. The affected claims were incorrectly denied with Explanation of Benefits code 1271, "The Total Billed Amount is missing or incorrect".
Providers Submitting Procedure Codes 59025, 93307, 93308, 93312, 93320, or 93321 ForwardHealth is automatically reprocessing certain professional claims with dates of service between January 1, 2016, and March 15, 2016. Claims with Current Procedural Terminology procedure code 59025 or procedure codes 93307, 93308, 93312, 93320 or 93321 submitted with modifier 26 (professional component) were incorrectly denied.
Dental Providers ForwardHealth is automatically reprocessing certain dental claims with dates of service (DOS) on and after January 1, 2016. Certain claims submitted with Current Procedural Terminology procedure codes D9223 (Deep sedation/general anesthesia – each 15 minute increment) and D9243 (Intravenous moderate [conscious] sedation/analgesia – each 15 minute increment) were incorrectly denied with Explanation of Benefits code 0192, "Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim." As indicated in the Online Handbook for procedure codes D9223 and D9243, anesthesia/sedation performed during rendering of dental services are exempted from PA requirements when either of the following are true:
  • The member is under age 21 on the DOS and the rendering provider is an oral surgeon or pediatric dentist.
  • The service is rendered on an emergency basis.

Week of May 23, 2016

Affected Providers Description of Adjustment
Providers Submitting Claims with Diagnosis Code E015.9 ForwardHealth is automatically reprocessing professional claims with detail dates of service (DOS) between October 1, 2009, and September 30, 2015, that were denied in error. Claims submitted with diagnosis code E015.9 (Other activity involving cooking and grilling) may have incorrectly denied because ForwardHealth did not recognize the diagnosis code as valid for the DOS.

Week of March 28, 2016

Affected Providers Description of Adjustment
Providers Submitting Claims for Transplant Services ForwardHealth is automatically reprocessing certain claims for transplant services processed between October 1, 2015, and January 30, 2016, with "To" dates of service on and after October 1, 2015. Bone marrow, stem cell, other medically necessary, and all out-of-state transplant claims submitted with certain International Classification of Diseases, 10th Revision procedure codes did not have an approved prior authorization request on file and were paid in error. Affected claims will be denied with either Explanation of Benefits (EOB) code 0192, "Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim," or EOB code 0289, "Out-of-State non-emergency services require Prior Authorization."

Week of March 21, 2016

Affected Providers Description of Adjustment
Hospice Providers Submitting Claims With Procedure Code T2042 ForwardHealth is automatically reprocessing certain hospice claims submitted with Healthcare Common Procedure Coding System procedure code T2042 (Hospice routine home care; per diem) with detail dates of service (DOS) between January 1, 2016, and February 25, 2016. Effective for DOS on and after January 1, 2016, ForwardHealth implemented a two-tiered reimbursement rate structure for hospice routine care services based on the count of a member's hospice days. For procedure code T2042, ForwardHealth reimburses a higher reimbursement rate for a member's first 60 days of hospice care and a lower reimbursement rate for days 61 and after. Claim details for hospice care after the member's first 60 days are reimbursed at a lower rate for procedure code T2042. For more information, refer to the Routine Care Services topic (topic #1155) of the Covered Services and Requirements chapter of the Covered and Noncovered Services section of the Hospice service area of the ForwardHealth Online Handbook. Providers may also refer to the December 2015 ForwardHealth Update (2015-64), titled "Changes to Reimbursement for Hospice Routine Care Services."

Week of February 29, 2016

Affected Providers Description of Adjustment
Ambulatory Surgery Centers ForwardHealth is automatically reprocessing certain fee-for-service ambulatory surgical center crossover claims with dates of service on and after July 1, 2015, that were processed between July 1, 2015, and January 14, 2016, to apply appropriate access payments.
Providers Submitting Outpatient Claims, Institutional Inpatient Claims, and Professional Claims ForwardHealth is automatically reprocessing certain denied outpatient claims, institutional inpatient claims, and professional claims that processed between October 1, 2015, and January 5, 2016, due to system updates regarding substance abuse diagnosis codes. Professional claims submitted with procedure code H2012 (Behavioral health day treatment, per hour) with the following International Classification of Diseases, 10th Revision (ICD-10) diagnosis codes will be resubmitted: F1020, F1021, and F1022. Outpatient and Inpatient claims submitted with revenue code 0945 (Other therapeutic services; alcohol rehabilitation) with the following ICD-10 diagnosis codes will be resubmitted: F1010, F1012, F1020, F1021, and F1022.

Week of February 29, 2016

Affected Providers Description of Adjustment
Providers Submitting Claims with Procedure Codes 62310 or 62311 ForwardHealth is automatically reprocessing certain professional claims with dates of service on and after September 1, 2015. Certain claims submitted with Current Procedural Terminology procedure codes 62310 or 62311 were incorrectly denied with Explanation of Benefits code 1279, "Procedure not payable for Place of Service."
Providers Submitting Outpatient Claims ForwardHealth is automatically adjusting certain outpatient claims with dates of service on or after January 1, 2015 due to pricing changes.

Week of February 22, 2016

Affected Providers Description of Adjustment
Providers Submitting Outpatient Hospital Crossover Claims ForwardHealth is automatically reprocessing certain outpatient hospital crossover claims with dates of service (DOS) on and after January 1, 2015, due to reimbursement changes. In addition, certain claims were previously denied for services that are now reimbursable for DOS on and after January 1, 2015. These claims will be reprocessed for possible payment.
Providers Submitting Outpatient Claims ForwardHealth is automatically adjusting certain outpatient claims with dates of service on or after January 1, 2015 due to pricing changes.

Week of February 1, 2016

Affected Providers Description of Adjustment
Providers Submitting Claims with Procedure Codes A0380 and A0390 ForwardHealth is automatically adjusting previously paid claims for ambulance mileage codes A0380 or A0390 that processed without a corresponding emergency base rate code between September 1, 2013, and September 11, 2015. Claims will be denied with Explanation of Benefits code 3056, "Ambulance mileage requires a paid equivalent ambulance base code; Basic Life Support (BLS), Advanced Life Support (ALS) or Non-Emergency Medical Transport (NEMT)."

Week of January 25, 2016

Affected Providers Description of Adjustment
Providers Submitting Inpatient Hospital Claims ForwardHealth is automatically reprocessing certain institutional inpatient hospital claims that processed after January 1, 2014. An incorrect emergency diagnoses list was applied to the affected claims resulting in inappropriately paid or denied claims.

Week of January 18, 2016

Affected Providers Description of Adjustment
Non-Pharmacy Providers Submitting Claims ForwardHealth is automatically reprocessing claims submitted with other insurance indicator OI-Y that were incorrectly denied with payment dates from June 13, 2015, through July 3, 2015. The affected claims were incorrectly denied with Explanation of Benefits (EOB) code 0278, "Member is covered by a commercial health insurance on the Date(s) of Service," or EOB code 0702, "Member has commercial dental insurance for the Date(s) of Service."

Week of January 4, 2016

Affected Providers Description of Adjustment
Providers Submitting Professional Claims ForwardHealth is automatically reprocessing certain professional claims with dates of service between November 10, 2008, and December 14, 2015. Affected claims were incorrectly denied with Explanation of Benefits code 1271, "The Total Billed Amount is missing or incorrect."

Week of January 4, 2016

Affected Providers Description of Adjustment
Providers Submitting Claims With Procedure Code G0277 ForwardHealth is automatically adjusting outpatient hospital claims with dates of service (DOS) between January 1, 2015, and September 3, 2015. Procedure code G0277 (Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval) was incorrectly denied on some outpatient hospital claims for not being a covered service. Effective for DOS on and after January 1, 2015, G0277 has been added as a covered procedure code when submitted on outpatient hospital claims.

Week of December 7, 2015

Affected Providers Description of Adjustment
Providers Submitting Outpatient Hospital Claims and Outpatient Hospital Crossover Claims ForwardHealth is reprocessing Enhanced Ambulatory Patient Groups (EAPG)-eligible outpatient hospital claims for emergency room services that processed between April 1, 2013, and April 11, 2015, to refund copayment amounts deducted in error. Copayment was incorrectly applied to emergency room services for Medicaid and BadgerCare Plus members. Emergency room services for Medicaid and BadgerCare Plus members are exempt from copayment. Providers are required to refund the members for any copayment amount collected in error.

Week of November 23, 2015

Affected Providers Description of Adjustment
Podiatrists ForwardHealth is automatically reprocessing paid claims for certain laboratory procedure codes with dates of service between January 1, 2015, and April 29, 2015. These claims will be adjusted to apply updated maximum allowable fee rates.

Week of November 16, 2015

Affected Providers Description of Adjustment
Providers Submitting Claims for Laboratory Services ForwardHealth is automatically reprocessing paid claims for certain laboratory procedure codes with dates of service between January 1, 2015, and April 29, 2015. These claims will be adjusted to apply updated maximum allowable fee rates.

Week of October 26, 2015

Affected Providers Description of Adjustment
All Providers ForwardHealth is automatically reprocessing or adjusting certain claims that processed under an incorrect member identification number. There are a few situations where claims will be recouped because the claim paid under the wrong member ID and the provider was paid twice for the same service (once under the wrong member ID and once under the correct member ID after the claim was resubmitted by the provider).

Week of October 19, 2015

Affected Providers Description of Adjustment
Providers Submitting Professional Claims ForwardHealth is automatically adjusting some professional claims that processed between April 23, 2015, and April 30, 2015, that were denied incorrectly due to system updates regarding diagnosis codes. Claims submitted with the following procedure codes will be reprocessed: 96150, 96151, 96152, 96153, 96154, and 96155.

Week of October 12, 2015

Affected Providers Description of Adjustment
Providers Providing Services to Members Enrolled in Care4Kids Managed Care ForwardHealth is automatically reprocessing certain outpatient hospital, outpatient hospital crossover, professional, and professional crossover claims for members enrolled in the Care4Kids managed care program with dates of service from January 1, 2014, through July 23, 2015. Certain family planning services provided to Care4Kids members that, in some circumstances, should be billed fee-for-service, were incorrectly denied when billed fee-for-service. Affected claims were incorrectly denied with Explanation of Benefits Code 0287, "Member is enrolled in a State-contracted managed care program for the Date(s) of Service."

Week of September 28, 2015

Affected Providers Description of Adjustment
Providers Submitting Professional Claims and Professional Crossover Claims ForwardHealth is automatically reprocessing certain claims with dates of service from January 1, 2015, through June 10, 2015, due to the implementation of ClaimCheck policy on January 1, 2015. Claims submitted with the following Current Procedural Terminology procedure codes will be reprocessed: 15956, 20101, 20697, 21338, 32960, 33270, 33418-33419, 33947, 33951-33964, 33987-33988, 33990-33993, 37191-37193, 37218, 40525-40527, 40654-40700, 40720, 43030, 43420, 47383. ClaimCheck reviews submitted claims for billing inconsistencies and errors during claims processing.

Week of September 21, 2015

Affected Providers Description of Adjustment
Providers Who Submit Home Health, Professional or Outpatient Hospital Claims ForwardHealth is automatically reprocessing home health, professional, and outpatient hospital claims with dates of service from January 1, 2015, through June 10, 2015. Claims with modifiers 24, 57, XE, XS, XP, and XU were incorrectly denied with Explanation of Benefits code 1686, "This service is not payable with another service on the same date of service due to National Correct Coding Initiative."
Providers Submitting Procedure Codes L0621 and L0623 ForwardHealth is automatically reprocessing certain professional and professional crossover claims that processed between January 1, 2014, and June 12, 2015. Claims submitted with Healthcare Common Procedure Coding System procedure codes L0621 and L0623 will be reprocessed for payment as these services are now reimbursable.

Week of September 14, 2015

Affected Providers Description of Adjustment
Providers Submitting Outpatient Hospital Claims and Professional Claims ForwardHealth is automatically reprocessing certain outpatient hospital and professional claims as a result of the National Correct Coding Initiative (NCCI). Certain claims that were previously submitted related to the NCCI were not correctly identified. The Centers for Medicare and Medicaid Services requires ForwardHealth to implement the NCCI, which ensures correct coding on claims submitted for Medicaid reimbursement.

Week of September 7, 2015

Affected Providers Description of Adjustment
Hospice Providers In July 2015, ForwardHealth revised the hospice service reimbursement rates for revenue codes 0651, 0652, and 0655 for all counties. To receive the higher reimbursement rates for dates of service on and after October 1, 2014, providers will need to adjust their claims no later than October 1, 2015. The corrected rates have been posted in the September 2014 ForwardHealth Update (2014-56), titled "Hospice Reimbursement Rate Changes."

Week of August 17, 2015

Affected Providers Description of Adjustment
Providers Submitting Outpatient Hospital and Outpatient Hospital Crossover Claims ForwardHealth is automatically reprocessing certain outpatient hospital and outpatient hospital crossover claims that were processed between November 10, 2008, and May 31, 2014. Affected outpatient hospital crossover claims were incorrectly denied with Explanation of Benefits code 0273, "Resubmit charges for ForwardHealth covered service(s) denied by Medicare on a ForwardHealth claim." Some outpatient hospital claims may have already been resubmitted by providers for payment prior to the adjustment. These payments may be recouped prior to processing the crossover claims.
Wheaton Franciscan Providers ForwardHealth is automatically reprocessing certain inpatient and outpatient claims that processed between February 1, 2013, and April 5, 2015. Affected claims will be adjusted to apply the correct reimbursement rates.

Week of August 10, 2015

Affected Providers Description of Adjustment
Providers Submitting Pharmacy Claims ForwardHealth is reprocessing certain pharmacy claims for SeniorCare members retroactively enrolled in Medicare Part D from July 1, 2010, through September 30, 2014. The affected claims were submitted directly to Medicare Part D and a payment was received; however, some of the same claims were recouped in error from the pharmacy provider. Amounts recouped in error will appear on providers' Remittance Advices received on and after August 17, 2015.

Week of July 6, 2015

Affected Providers Description of Adjustment
Providers Submitting Paper Claims with Other Health Insurance Information ForwardHealth is automatically reprocessing certain paper claims that were processed on and after October 14, 2014. Some paper claims submitted with detailed other health insurance information using the new Explanation of Medical Benefits form, F-01234, were incorrectly processed due to a system error. These claims will be reprocessed using the correct information.

Week of June 22, 2015

Affected Providers Description of Adjustment
Providers Submitting Pharmacy Claims ForwardHealth is reprocessing certain pharmacy claims for SeniorCare members retroactively enrolled in Medicare Part D from July 1, 2010, through September 30, 2014. The affected claims were submitted directly to Medicare Part D and a payment was received; however, some of the same claims were recouped in error from the pharmacy provider. These claims will be reprocessed to reimburse the erroneously recouped amount from the pharmacies. Providers are encouraged to refer to their Remittance Advice for adjustment and recoupment information.

Week of June 1, 2015

Affected Providers Description of Adjustment
Providers Submitting Professional Crossover Claims for Laboratory Services ForwardHealth is automatically reprocessing certain professional claims for laboratory services with dates of service from January 1, 2015, to present that were processed between January 1, 2015, and March 5, 2015. Affected claims were paid; however, they were submitted with multiple units per day (UPD). Due to a change to the billing rules policy, only one UPD is allowed for procedure codes G6030-G6058. The affected claims will be recouped with Explanation of Benefits code 1275, "Quantity Billed is restricted for this Procedure Code."

Week of May 25, 2015

Affected Providers Description of Adjustment
Providers Submitting Professional Crossover Claims ForwardHealth is automatically reprocessing certain professional crossover claims with dates of service from January 1, 2015, through April 6, 2015. Crossover claims submitted with procedure code G0279 (Diagnostic digital breast tomosynthesis, unilateral or bilateral) were inappropriately denied due to a system issue.

Week of May 18, 2015

Affected Providers Description of Adjustment
Providers Submitting Professional Claims ForwardHealth is automatically adjusting claims that processed between February 20, 2015, and March 1, 2015. Due to system updates regarding diagnosis codes, claims were incorrectly denied with Explanation of Benefits code 0080, "Diagnosis Code submitted does not indicate medical necessity or is not appropriate for service billed."

Week of May 11, 2015

Affected Providers Description of Adjustment
Pharmacy Providers ForwardHealth is reprocessing certain pharmacy claims submitted May 10, 2015, through May 12, 2015, that may have incorrectly denied for prior authorization-related edits.

Week of April 20, 2015

Affected Providers Description of Adjustment
Home Health/Personal Care Providers ForwardHealth has identified some claims with personal care procedure codes T1019 (with same modifier) or 99509 indicated on claim details that had overlapping detail dates of service (DOS) on that same claim and/or on another claim. ForwardHealth does not accept claim details with overlapping DOS. ForwardHealth will automatically begin reprocessing the affected claims on May 1, 2015, for personal care services with DOS on and after July 1, 2014, that resulted in overpayment. Providers who discover claims paid in error are to return overpayments, per DHS 106.04(5), Wis. Admin. Code.
Providers Submitting Inpatient and Inpatient Crossover Hospital Claims ForwardHealth is automatically reprocessing certain institutional inpatient hospital claims with dates of service on and after January 1, 2015, that processed between January 1, 2015, and January 15, 2015. Diagnosis-Related Group rates were not applied to these claims due to an incorrect end date, which resulted in inappropriate denials.

Week of April 13, 2015

Affected Providers Description of Adjustment
Wisconsin Well Woman Providers ForwardHealth is automatically reprocessing certain professional and outpatient claims with dates of service from January 1, 2015, through February 18, 2015, that were incorrectly denied. Claims will be reprocessed to apply new Current Procedural Terminology procedure codes 76641, 76642, 87624, 88341, and 88342, as applicable.

Week of April 3, 2015

Affected Providers Description of Adjustment
Providers Submitting Claims for Laboratory Services ForwardHealth is reprocessing certain claims for laboratory services processed and paid between November 8, 2008, and January 12, 2015. Clinical Laboratory Improvement Amendment (CLIA) certification information submitted on the original claim was not transferred to any related claim adjustments resulting in claim details being incorrectly denied with Explanation of Benefits code 0794, "Procedure not allowed for the CLIA Certification Type."

Week of March 16, 2015

Affected Providers Description of Adjustment
Providers Submitting Outpatient Hospital Crossover Claims ForwardHealth is automatically reprocessing certain outpatient crossover claims with dates of service on and after April 1, 2013, that were processed between April 1, 2013, and December 31, 2014. Affected claims were incorrectly denied due to detail dates of service spanning across months and pricing methods (e.g., per diem into Enhanced Ambulatory Patient Groups).
Providers Submitting Compound Claims ForwardHealth is automatically reprocessing compound claims that processed between November 8, 2008, and February 26, 2015, for compound drugs dispensed to members enrolled in multiple programs. These compound claims processed for a single program, in error. The compound claims have been reprocessed to correctly apply the programs the member is enrolled in for the date of service.

Week of March 9, 2015

Affected Providers Description of Adjustment
Providers Submitting Professional Claims and Professional Crossover Claims ForwardHealth is automatically reprocessing certain claims that processed between November 8, 2008, and January 7, 2015. Affected claims were incorrectly denied with Explanation of Benefits code 1296, which states "Services billed are included in the nursing home rate structure. These services are not billable for dates of service the member is in a nursing home."

Week of February 9, 2015

Affected Providers Description of Adjustment
Providers Submitting Claims with Procedure Code G0431 ForwardHealth is automatically reprocessing professional claims with procedure code G0431 (Drug screen, qualitative; multiple drug classes by high complexity test method [e.g., immunoassay, enzyme assay], per patient encounter) with detail dates of service from January 1, 2015, through January 9, 2015, to apply updated maximum allowable fee rates.
Providers Submitting Claims with Procedure Code E0935 ForwardHealth is automatically reprocessing professional and professional crossover claims submitted with durable medical equipment procedure code E0935 (Continuous passive motion exercise device for use on knee only) with dates of service from May 1, 2014, through November 9, 2014, to apply the correct maximum allowable fee rate.

Week of February 2, 2015

Affected Providers Description of Adjustment
Providers Submitting Professional Claims ForwardHealth is automatically reprocessing certain professional claims with detail dates of service from October 1, 2014, through October 29, 2014. Affected claims were paid, however, they were submitted with multiple units per day (UPD). Due to a change to the billing rules based on decisions from the Centers for Medicare and Medicaid Services, only one UPD is allowed for the procedure code under which the details were billed. The affected details will be recouped with Explanation of Benefits code 1275, "Quantity Billed is restricted for this Procedure Code."

Week of January 26, 2015

Affected Providers Description of Adjustment
Providers Submitting Professional and Professional Crossover Claims ForwardHealth is automatically reprocessing certain professional and professional crossover claims submitted on paper with more than four International Classification of Diseases (ICD) diagnosis codes indicated. The claims were incorrectly processed as not all diagnosis codes were captured and will be reprocessed.
Providers Submitting Inpatient Hospital Claims ForwardHealth is automatically reprocessing certain inpatient hospital claims that processed between November 8, 2008, and December 1, 2014. Affected claims were incorrectly denied with Explanation of Benefits message 0232, "Source of Admit is missing or invalid."

Week of January 19, 2015

Affected Providers Description of Adjustment
Providers Submitting Outpatient Hospital and Outpatient Hospital Crossover Claims ForwardHealth is automatically reprocessing certain outpatient hospital and outpatient hospital crossover claims with dates of service on and after April 1, 2013. The affected claims had multiple details submitted for a visit where one of the details considered as the main reason for the visit was denied. Other details on the claim for the same visit were paid but should have been denied with Explanation of Benefits code 3018, "Detail denied because a related significant procedure and/or medical visit was denied for the same visit."
Inpatient and Outpatient Hospital Providers ForwardHealth is automatically reprocessing inpatient and outpatient hospital claims with an admission date ("from" date of service) on or before June 30, 2014, and a discharge date ("to" date of service) between July 1, 2014, and September 3, 2014, with dates of process between July 1, 2014, and September 3, 2014, when the access payment was not paid and should have been. Appropriate access payments will be applied to the affected claims.

Week of November 24, 2014

Affected Providers Description of Adjustment
Providers Submitting Claims with Procedure Code H0039 ForwardHealth is automatically reprocessing certain professional claims with dates of service from January 1, 2014, to present that were processed between August 1, 2014, and September 24, 2014. Claims submitted with procedure code H0039 (Assertive community treatment, face-to-face, per 15 minutes) with any H modifier and place of service 21, 25, 31, 32, 33, 51, 54, or 61 were not processed accurately resulting in incorrect denials.

Week of November 10, 2014

Affected Providers Description of Adjustment
Providers Submitting Outpatient Hospital Claims ForwardHealth is automatically reprocessing certain outpatient hospital claim adjustments that processed between December 1, 2012, and April 15, 2014. Access payments that were correctly applied to the original claim should have been applied to any related claim adjustments. These claims will be reprocessed and the access payment will be paid.

Week of October 13, 2014

Affected Providers Description of Adjustment
Providers Submitting Professional Claims for Laboratory Services ForwardHealth is automatically reprocessing certain professional claims for laboratory services with dates of service on and after November 8, 2008, through July 14, 2014, that were incorrectly processed. Affected claims were submitted with a CLIA-certified rendering provider indicated at the header level, but not the detail level.

Week of October 6, 2014

Affected Providers Description of Adjustment
Providers Submitting Claims for Physician Services ForwardHealth is automatically adjusting certain claims for physician services that processed between October 11, 2011, and June 17, 2014, that were inappropriately paid or denied. Claim details submitted with a diagnosis code that was not allowable for the date of service (DOS) were incorrectly paid and should have denied with Explanation of Benefits (EOB) message 1159, "One or More Diagnosis Code(s) is invalid for the Date(s) of Service." Other claim details submitted with an allowable diagnosis code for the DOS were incorrectly denied with EOB message 1159.

Week of September 29, 2014

Affected Providers Description of Adjustment
Providers Submitting Inpatient Hospital Claims with Hospital Access Payments ForwardHealth is automatically reprocessing inpatient hospital claims paying under Diagnosis Related Groupings (DRGs) with dates of service on and after July 1, 2013, that processed between July 1, 2013, and September 15, 2014. Access payments were not paid for these claims due to an error checking benefit plans. These claims will be reprocessed and the access payment will be paid.
Providers Submitting Institutional Claims ForwardHealth is automatically adjusting certain inpatient, inpatient crossover, long term care, Wisconsin Chronic Disease Program (WCDP) inpatient crossover, and WCDP outpatient crossover claims that originally processed and paid on and after June 20, 2014. For the initial claims, although cost share was applied correctly, the cost share amount was not deducted from the remaining balance, leaving the balance incorrect. ForwardHealth is also reprocessing subsequent claims where cost sharing was applied correctly, but the amount applied may have been incorrect because the balance was not updated appropriately by the initial claim.
Providers Submitting Professional Claims, Professional Crossover Claims, Outpatient Claims, and Outpatient Crossover Claims ForwardHealth is automatically reprocessing previously paid claims with detail dates of service from January 1, 2014, through June 17, 2014, that processed on or after January 1, 2014, through June 17, 2014 to apply updated maximum allowable fee rates. Medicaid's maximum allowable fees will be adjusted to equal Medicare's maximum allowable fees, which will result in recoupments.

Week of September 22, 2014

Affected Providers Description of Adjustment
Providers Submitting Inpatient and Outpatient Hospital Claims ForwardHealth is automatically reprocessing certain inpatient and outpatient hospital claims to apply correct access payments for dates of service from July 1, 2014, through September 3, 2014. New access payment amounts effective July 1, 2014, are posted on the ForwardHealth Portal at www.forwardhealth.wi.gov/WIPortal/Content/provider/medicaid/hospital/drg/drg.htm.spage.

Week of September 15, 2014

Affected Providers Description of Adjustment
Providers Submitting Home Health or Professional Claims ForwardHealth is automatically reprocessing certain home health and professional claims with detail "From" dates of service (DOS) before September 16, 2013, and detail "To" DOS on and after September 16, 2013. The affected claims were previously adjusted by ForwardHealth; however, some claims had already been resubmitted by providers prior to the adjustment, resulting in duplicate payments. Duplicate paid services will be recoup
Providers Submitting Dental Claims ForwardHealth is automatically reprocessing certain dental claims that processed on and after September 15, 2012, through January 2, 2014, and were paid or denied inappropriately due to a system error.

Week of September 1, 2014

Affected Providers Description of Adjustment
Providers Submitting Procedure Codes P9045-P9048, P9050, or P9604 ForwardHealth is automatically reprocessing certain outpatient and outpatient crossover claims that processed between April 1, 2013, and August 6, 2014. Claims submitted with Healthcare Common Procedure Coding System procedure codes P9045-P9048, P9050, or P9604 will be reprocessed for payment as these services are now reimbursable.

Week of August 18, 2014

Affected Providers Description of Adjustment
Providers Submitting Outpatient Hospital Crossover Claims ForwardHealth is automatically reprocessing certain outpatient hospital crossover claims that processed and paid on and after May 28, 2010, through April 22, 2014. ForwardHealth paid for services on an outpatient crossover claim and an inpatient crossover claim when only the inpatient crossover claim should have been paid. Outpatient crossover claims that were incorrectly paid will be recouped.

Week of August 11, 2014

Affected Providers Description of Adjustment
Wisconsin Chronic Disease Program Providers ForwardHealth is automatically reprocessing certain Wisconsin Chronic Disease Program outpatient claims and outpatient crossover claims that processed between November 8, 2008, and June 22, 2014. Affected claims were incorrectly paid a zero amount.

Week of August 4, 2014

Affected Providers Description of Adjustment
Providers Submitting Wisconsin Chronic Disease Program Claims ForwardHealth is automatically reprocessing certain WCDP claims that processed between February 28, 2009, and July 4, 2014, in which details related to a timely filing deadline were incorrectly denied with Explanation of Benefits message 0171, "Claim or Adjustment received beyond 365-day filing deadline."
Providers Submitting Inpatient Claims and Outpatient Crossover Claims ForwardHealth is automatically reprocessing certain inpatient claims and outpatient crossover claims with dates of receipt between February 14, 2014, and June 14, 2014. Affected claims were incorrectly denied with Explanation of Benefits code 0278, "Member is covered by a commercial health insurance on the Date(s) of Service," as other insurance billing requirements were incorrectly applied to the claims. Claims will be reprocessed to apply the correct claim submission policy.

Week of July 28, 2014

Affected Providers Description of Adjustment
Providers Submitting Procedure Codes 97597 and 97598 ForwardHealth is automatically reprocessing certain outpatient claims with dates of service beginning April 1, 2013, and dates of process between April 1, 2013, and May 13, 2014. Claims submitted with Current Procedural Terminology codes 97597 and 97598, not accompanied by modifiers GO or GP, will be reprocessed for possible payment.

Week of July 21, 2014

Affected Providers Description of Adjustment
Wisconsin Well Woman Program Providers ForwardHealth is automatically reprocessing certain professional and outpatient claims with dates of service from January 1, 2014, through June 12, 2014, that were incorrectly denied due to new procedure codes not being applied.

Week of July 14, 2014

Affected Providers Description of Adjustment
Providers Submitting Professional Claims and Professional Crossover Claims ForwardHealth is automatically reprocessing claims with certain vaccine procedure codes in the range of 90476-90749 and evaluation and management procedure codes in the range of 99201-99499 with dates of service between January 1, 2014, and March 19, 2014. ForwardHealth will adjust eligible claims to ensure the claims are processed using the most accurate rates that reflect the primary care rate increase for eligible services provided to eligible members under the Affordable Care Act.

Week of July 7, 2014

Affected Providers Description of Adjustment
Providers Submitting Claims ForwardHealth is automatically reprocessing certain claims that processed between September 14, 2012, and August 31, 2013, for members with more than one benefit plan under which the billed service is allowed and where an incorrect adjustment was made to the copay amount. This adjustment should have been made for only diagnosis related group reimbursement priced inpatient and inpatient crossover claims and not for all claims. These adjustments displayed with Explanation of Benefits code 9001, "Pricing Adjustment - Reimbursement reduced by the member's copayment amount."
Providers Submitting Outpatient Hospital Claims and Outpatient Hospital Crossover Claims ForwardHealth is automatically reprocessing Enhanced Ambulatory Patient Groups (EAPG)-eligible outpatient hospital claims with dates of service on and after April 1, 2013, in which copayment may not have been applied when it should have been, copayment may have been applied in the wrong amount, or copayment may have been applied to the wrong detail on the claim.

Week of June 16, 2014

Affected Providers Description of Adjustment
Providers Submitting Outpatient Hospital Claims and Outpatient Hospital Crossover Claims ForwardHealth is automatically reprocessing Enhanced Ambulatory Patient Groups (EAPG)-eligible outpatient hospital claims with dates of service on and after April 1, 2013, in which copayment may not have been applied when it should have been, copayment may have been applied in the wrong amount, or copayment may have been applied to the wrong detail on the claim.

Week of June 9, 2014

Affected Providers Description of Adjustment
Providers Submitting Crossover Claims ForwardHealth is automatically reprocessing certain adjusted crossover claims with other insurance header information that processed on and after February 14, 2014, through May 12, 2014. These claims may have denied in error.
Providers Submitting Outpatient, Outpatient Crossover, and Long Term Care Claims ForwardHealth is automatically reprocessing certain outpatient, outpatient crossover, and long term care claims with dates of service between January 1, 2013, and March 19, 2014, and dates of process between February 14, 2014, and March 19, 2014. These claims may have been incorrectly denied due to a system error.

Week of June 2, 2014

Affected Providers Description of Adjustment
Hospice Providers ForwardHealth is automatically reprocessing certain claims for hospice services with dates of service on and after April 1, 2013. These duplicate claims were paid in error and will be recouped.

Week of May 5, 2014

Affected Providers Description of Adjustment
Providers Submitting Noncompound Claims ForwardHealth is automatically reprocessing noncompound claims with dates of service on or between April 1, 2014, and April 25, 2014, for Hydrocodone/Acetaminophen 7.5-325/15 solution, oral, which paid using an incorrect Expanded Maximum Allowed Cost (EMAC) rate. These claims will be reprocessed using the appropriate EMAC rate.

Week of April 28, 2014

Affected Providers Description of Adjustment
Kindred Transitional Care Nursing Home ForwardHealth is automatically reprocessing long term care claims that processed between April 18, 2014, and April 20, 2014, with dates of service from January 1, 2013, through April 20, 2014, to apply correct reimbursement rates.

Week of April 21, 2014

Affected Providers Description of Adjustment
Providers Submitting Professional and Professional Crossover Claims ForwardHealth is automatically reprocessing certain professional and professional crossover claims with dates of service between January 1, 2013, and November 14, 2013, and dates of process between October 13, 2013, and November 14, 2013, that were paid inappropriately. The claims should have been adjusted to apply a primary care rate increase for eligible services provided to eligible members under the Affordable Care Act (ACA). Providers can refer to the October 2013 ForwardHealth Update (2013-54), titled "Reimbursement for Services Provided Under the Affordable Care Act Primary Care Rate Increase," for more information related to the ACA primary care rate increase.
Providers Submitting Inpatient Hospital Claims ForwardHealth is automatically reprocessing certain inpatient hospital claims with dates of service on and after January 1, 2014, through March 4, 2014. Diagnosis-Related Group (DRG) rates were not applied to these claims resulting in an incorrect payment. This adjustment will apply the correct DRG payment to the claims.

Week of April 7, 2014

Affected Providers Description of Adjustment
Pharmacies, Physician Clinics, Individual Medical Supply Providers, and Medical Equipment Vendors ForwardHealth is automatically reprocessing certain professional claims that may have been incorrectly denied with Explanation of Benefits message 3029, "Claim filing value is invalid."
Providers Submitting Home Health, Professional Claims, or Outpatient Hospital Claims ForwardHealth is automatically reprocessing certain claims with detail "From" dates of service (DOS) before September 16, 2013, and detail "To" dates of service on and after September 16, 2013. Claims with detail DOS spanning multiple days were incorrectly denied with Explanation of Benefits (EOB) message 0116, "Procedure Code or Drug Code not a benefit on Date of Service."

Week of March 31, 2014

Affected Providers Description of Adjustment
Providers Submitting Professional Claims ForwardHealth is automatically reprocessing preventive services claims that processed between January 1, 2014, and January 27, 2014. Claims will be adjusted to ensure the federal share of the reimbursement rate has been appropriately applied and reported to the Centers for Medicare and Medicaid Services. For the affected claims, providers do not need to take any action.
Providers Submitting Outpatient Hospital and Outpatient Hospital Crossover Claims ForwardHealth is automatically reprocessing certain outpatient hospital and outpatient hospital crossover claims with dates of service between April 1, 2013, and December 13, 2013, that were paid inappropriately. These claims should have been denied with Explanation of Benefits code 3018, "Detail denied because a related significant procedure and/or medical visit was denied for the same visit."
Providers Submitting Home Health or Professional Claims ForwardHealth is automatically reprocessing certain home health and professional claims with dates of service on and after September 16, 2013. Claims with certain radiology and ambulatory surgical center procedure codes may have been inappropriately paid and will be reprocessed to apply correct billing rules for services that are prescribed, referred, or ordered.

Week of March 10, 2014

Affected Providers Description of Adjustment
Providers Submitting Professional Claims and Professional Crossover Claims ForwardHealth is automatically reprocessing claims with certain vaccine procedure codes with dates of process from October 13, 2013, through November 25, 2013. ForwardHealth will adjust eligible claims to ensure the claims are processed using the most accurate rates that reflect the primary care rate increase for eligible services provided to eligible members under the Affordable Care Act (ACA). Providers can refer to the October 2013 ForwardHealth Update (2013-54), titled "Reimbursement for Services Provided Under the Affordable Care Act Primary Care Rate Increase," for more information related to the ACA primary care rate increase.
Wheaton Franciscan St. Joseph Hospital ForwardHealth is automatically reprocessing outpatient and outpatient crossover claims that processed on and after January 1, 2014, due to a new outpatient Enhanced Ambulatory Patient Groups (EAPG) payment rate. The new payment rate applies to the following hospitals: Wheaton Franciscan Healthcare — St. Joseph's; Wheaton Franciscan Healthcare — Elmbrook Memorial; and The Wisconsin Heart Hospital. For the affected claims, hospitals do not need to resubmit previously submitted claims.
Providers Submitting Home Health or Professional Claims ForwardHealth is automatically reprocessing certain home health and professional claims with dates of service on or after September 16, 2013. Claim details may have been incorrectly denied with Explanation of Benefits message 0091, "A valid enrolled prescribing/referring/ordering provider NPI is required."

Week of March 3, 2014

Affected Providers Description of Adjustment
Providers Submitting Inpatient Hospital Claims ForwardHealth is automatically reprocessing certain inpatient hospital claims processed between October 1, 2011, and January 1, 2014, with dates of services on and after October 1, 2011, through January 1, 2013. Claims may have been incorrectly denied with Explanation of Benefits message 0810, "A covered DRG cannot be assigned to the claim. The information on the claim is invalid or not specific enough to assign a DRG.".

Week of February 24, 2014

Affected Providers Description of Adjustment
Providers Submitting Professional Crossover Claims ForwardHealth is automatically reprocessing certain professional crossover claims for eligible services provided to eligible members for the primary care rate increase under the Affordable Care Act (ACA) that were processed incorrectly between October 13, 2013, and October 18, 2013, resulting in inappropriate payments.

Week of February 17, 2014

Affected Providers Description of Adjustment
Providers Submitting Outpatient Hospital Claims ForwardHealth is automatically reprocessing certain outpatient hospital crossover claims with dates of service on and after April 1, 2013, that processed and paid prior to November 11, 2013. The sum of the Medicare detail amounts calculated by the system did not match the Medicare amounts billed at the header level on these claims.

Week of January 13, 2014

Affected Providers Description of Adjustment
Providers Submitting Professional and Professional Crossover Claims ForwardHealth is automatically reprocessing professional and professional crossover claims that were paid incorrectly between October 13, 2013, and December 12, 2013, resulting in recoupments. The services submitted on these claims did not meet the criteria for the primary care rate increase under the Affordable Care Act.

Week of January 6, 2014

Affected Providers Description of Adjustment
Hospice Providers ForwardHealth is automatically reprocessing claims for hospice services with dates of service from April 1, 2013, through December 3, 2013. Certain duplicate claims were erroneously paid and will be recouped.

Week of December 9, 2013

Affected Providers Description of Adjustment
Providers Submitting Outpatient Hospital Claims and Professional Crossover Claims ForwardHealth is automatically reprocessing eligible outpatient hospital claims and professional crossover claims that processed between October 13, 2013, and November 21, 2013, to apply appropriate access payments.

Week of December 2, 2013

Affected Providers Description of Adjustment
Wisconsin Well Woman Program Providers ForwardHealth is automatically reprocessing claims with dates of service from July 1, 2013, through November 6, 2013, with the updated 2013-2014 reimbursement rates.

Week of November 25, 2013

Affected Providers Description of Adjustment
Providers Submitting Professional Claims and Professional Crossover Claims ForwardHealth is automatically reprocessing certain claims with dates of service from January 1, 2013, through October 12, 2013. ForwardHealth will adjust eligible claims to apply a primary care rate increase for eligible services provided to eligible members under the Affordable Care Act (ACA). Providers can refer to the October 2013 ForwardHealth Update (2013-54), titled "Reimbursement for Services Provided Under the Affordable Care Act Primary Care Rate Increase," for more information related to the ACA primary care rate increase.

Week of November 18, 2013

Affected Providers Description of Adjustment
Hospitals ForwardHealth is automatically reprocessing certain hospital claims to apply increased reimbursement rates. The new rates apply to previously submitted EAPG outpatient claims that processed on or after April 1, 2013, and inpatient and outpatient claims that processed on or after February 1, 2013. No action is required on the hospital's part.
Providers Submitting Procedure Code J1050 ForwardHealth is automatically reprocessing certain professional claims and professional crossover claims with dates of service from January 1, 2013, through January 29, 2013; April 1, 2013, through April 11, 2013; and October 1, 2013, through October 4, 2013. Claims submitted with procedure code J1050 (Injection, medroxyprogesterone acetate, 1 mg) were underpaid due to an incorrect rate for the procedure code.
Providers Submitting Pharmacy Claims ForwardHealth is automatically reprocessing previously paid pharmacy claims with dates of service between July 1, 2013, and October 31, 2013, for Cimetidine oral 400 mg tablets. These claims incorrectly paid using a State Maximum Allowed Cost (SMAC) rate. The claims will be reprocessed to pay using the appropriate Wholesale Acquisition Cost (WAC) rate.

Week of November 11, 2013

Affected Providers Description of Adjustment
Providers Submitting Claims ForwardHealth is automatically reprocessing certain claims processed between October 28, 2013, and November 1, 2013. The claims were incorrectly denied for prior authorization-related edits.
Providers Submitting Pharmacy Claims ForwardHealth is automatically recouping pharmacy claims for specific diabetic supplies with dates of service on and after September 16, 2013, that paid in error.

Week of November 4, 2013

Affected Providers Description of Adjustment
Providers Submitting Professional Claims for Speech Therapy Services ForwardHealth is automatically reprocessing professional claims for speech therapy services that originally processed between November 10, 2008, and April 2, 2013, in which certain speech therapy service details were incorrectly recouped on October 5 and 6, 2013. These claims will be reprocessed to reimburse the amount recouped in error.
Providers Submitting Vaccine Procedure Code 90710 ForwardHealth is automatically reprocessing some professional claims with dates of service from July 1, 2012, to June 30, 2013, with vaccine procedure code 90710 (Measles, mumps, rubella, and varicella vaccine [MMRV], live, for subcutaneous use) indicated. These claims may have been incorrectly denied with Explanation of Benefits message 1178, "Service is not reimbursable for Date(s) of Service."

Week of October 28, 2013

Affected Providers Description of Adjustment
Providers Submitting Outpatient Hospital Claims and Outpatient Hospital Crossover Claims ForwardHealth is automatically reprocessing outpatient hospital claims that processed between April 1, 2013, and September 13, 2013, in which details related to a denied visit were incorrectly paid. As a result, these details will be denied with Explanation of Benefits message 3018, "Detail denied because a related significant procedure and/or medical visit was denied for the same visit."

Week of September 30, 2013

Affected Providers Description of Adjustment
Providers Submitting Professional and Outpatient Hospital Claims ForwardHealth is automatically reprocessing certain professional and outpatient hospital claims with dates of process between May 12, 2013, and September 8, 2013, that were paid inappropriately. Detail allowed amounts on these claims were processed incorrectly causing the detail to bypass a dollar limitation audit in error, or the detail may have hit the dollar limitation audit, but the wrong amount was cutback.
Providers Submitting Professional Claims for Speech Therapy Services ForwardHealth is automatically reprocessing professional claims for speech therapy services that processed between November 10, 2008, and April 2, 2013. Certain therapy claims were incorrectly paid at the detail level after a 35-visit limitation for speech therapy services had been met. The impacted detail(s) on these claims will be denied with Explanation of Benefits message 0961, "Speech therapy limited to 35 treatment days per lifetime without prior authorization."

Week of September 16, 2013

Affected Providers Description of Adjustment
Providers Submitting Inpatient and Outpatient Hospital Claims ForwardHealth is automatically reprocessing inpatient and outpatient hospital claims in which a 1.5 percent pay for performance (P4P) payment was withheld for dates of service from April 1, 2013, through May 14, 2013. Pay for performance should not have been withheld from claims due to a Medicaid P4P criterion change, i.e., the P4P is to be paid instead of deducted. Hospital claims for services provided both before and after the April 1, 2013, through May 14, 2013, time period are unaffected.

Week of September 9, 2013

Affected Providers Description of Adjustment
Providers Submitting Professional Claims, Professional Crossover Claims, Outpatient Claims, and Outpatient Crossover Claims ForwardHealth is automatically reprocessing previously paid claims with detail dates of service from January 1, 2013, through April 30, 2013, to apply updated maximum allowable fee rates. Medicaid's maximum allowable fees will be adjusted to equal Medicare's maximum allowable fees which will result in recoupments.

Week of September 2, 2013

Affected Providers Description of Adjustment
Providers Submitting Inpatient and Outpatient Hospital Claims ForwardHealth is automatically reprocessing inpatient and outpatient hospital claims to apply correct access payments for dates of service from July 1, 2013, through August 14, 2013. New access payment amounts effective July 1, 2013, are posted on the ForwardHealth Portal at www.forwardhealth.wi.gov/WIPortal/Content/provider/medicaid/hospital/drg/drg.htm.spage#.

Week of August 19, 2013

Affected Providers Description of Adjustment
Providers Submitting End-Stage Renal Disease Claims ForwardHealth is automatically reprocessing institutional end-stage renal disease claims that processed between September 10, 2011 and July 25, 2013, and were incorrectly paid or denied. Some services denied in error for being considered a duplicate service, and other services were paid in error that should have denied for being considered a duplicate service.

Week of July 29, 2013

Affected Providers Description of Adjustment
Providers Submitting Outpatient Hospital Crossover Claims ForwardHealth is automatically reprocessing outpatient hospital crossover claims with dates of service on or after April 1, 2013, that were incorrectly denied with Explanation of Benefits message 3017, "Professional services are not reimbursed on outpatient claims" when professional services were submitted on the claim.

Week of July 15, 2013

Affected Providers Description of Adjustment
Providers Submitting Professional Claims and Professional Crossover Claims ForwardHealth is automatically adjusting claims for vision services under the BadgerCare Plus Basic Plan that processed between November 19, 2010, and May 2, 2013, with dates of service on and after July 1, 2010. An incorrect copayment amount was deducted.
Providers Submitting Outpatient Hospital Claims and Outpatient Hospital Crossover Claims ForwardHealth is automatically adjusting outpatient hospital claims that processed between February 8, 2013, and March 31, 2013, with dates of service from January 1, 2010, through March 31, 2013. An incorrect copayment amount was deducted for claims with revenue or procedure codes in the continuous visit group.

Week of July 8, 2013

Affected Providers Description of Adjustment
Providers Submitting Claims ForwardHealth is automatically reprocessing or adjusting claims that denied inappropriately between July 1, 2010, and November 2, 2012 with Explanation of Benefits code 1309, "Drug has been paid under equivalent code within seven days of this DOS." Please note, the reprocessed/adjusted claims may appropriately deny for other policy reasons. Providers may correct and resubmit these claims, as appropriate.

Week of April 29, 2013

Affected Providers Description of Adjustment
Providers Submitting Professional Claims, Professional Crossover Claims, Dental Claims and Home Health Claims ForwardHealth is automatically reprocessing certain claims for medical, chiropractic, and dental services for members enrolled in Supplemental Security Income (SSI) Managed Care with dates of service between November 10, 2008, and November 10, 2012, that were incorrectly paid fee-for-service. SSI Managed Care is responsible for reimbursing providers for these services. The affected claims will be denied with Explanation of Benefits code 0287, "Member is enrolled in a State-contracted managed care program for the Date(s) of Service."
Providers Submitting Inpatient Hospital Claims ForwardHealth is automatically reprocessing certain inpatient hospital claims with dates of service between November 10, 2008, and March 7, 2013. Inpatient and long term care services were incorrectly reimbursed under the tuberculosis-related services-only benefit plan. Inpatient hospital services are not covered through the tuberculosis-related services-only benefit.

Week of April 22, 2013

Affected Providers Description of Adjustment
Providers Submitting Claims for Child/Adolescent Day Treatment Services ForwardHealth is automatically reprocessing claims for child/adolescent day treatment services with dates of service on and after August 15, 2010, that were processed prior to January 9, 2013. ForwardHealth inadvertently deducted copayments from provider reimbursement on the affected claims. Providers will be reimbursed for copayments that were inappropriately deducted. Providers are required to reimburse members for copayments collected for child/adolescent day treatment services. For additional information, refer to the April 2013 ForwardHealth Update (2013-24), titled "Policy Clarification: No Copayments for Child/Adolescent Day Treatment Services Provided to Benchmark Plan Members."
Providers Submitting Professional and Outpatient Hospital Claims and Professional and Outpatient Hospital Crossover Claims ForwardHealth is automatically reprocessing certain claims that processed between January 1, 2013, and March 1, 2013, with dates of service on and after January 1, 2013. ForwardHealth incorrectly paid for services for certain members enrolled in Children Come First and WrapAround Milwaukee. Claims will be denied with Explanation of Benefits code 0287, "Member is enrolled in a State-contracted managed care program for the Date(s) of Service."

Week of April 15, 2013

Affected Providers Description of Adjustment
Attention All Providers ForwardHealth is automatically reprocessing certain claims with dates of service from November 1, 2011, through March 8, 2013, that were incorrectly denied for not having other insurance information on the claim for members with other insurance coverage.

Week of April 8, 2013

Affected Providers Description of Adjustment
Attention Providers Submitting Claims for Never Events ForwardHealth is automatically reprocessing all claims, except pharmacy claims, with dates of service on and after July 1, 2012, for never events. Claims with modifiers PA, PB, and/or PC present on at least one detail were incorrectly paid and will be denied with Explanation of Benefits message 1713, "Claim denied for wrong surgical or other invasive procedure performed on a patient."

Week of March 25, 2013

Affected Providers Description of Adjustment
Non-pharmacy Providers Submitting Claims ForwardHealth is automatically reprocessing claims that processed between November 8, 2008, and May 2, 2012, and denied in error with Explanation of Benefits (EOB) code 0278, "Member is covered by a commercial health insurance on the Date(s) of service"; EOB code 0702, "Member has commercial insurance for the Date(s) of Service"; or EOB code 0130, "Member has Medicare Supplemental coverage for the Date(s) of Service." Please note, the reprocessed claims may appropriately deny for other policy reasons. Providers may correct and resubmit these claims, as appropriate.

Week of March 11, 2013

Affected Providers Description of Adjustment
Providers Submitting Inpatient Hospital Claims ForwardHealth is automatically reprocessing certain inpatient hospital claims processed between April 14, 2012, and August 14, 2012, with dates of services on and after March 1, 2010, through August 14, 2012. Claims with a present on admission code of "1" or a blank space were incorrectly denied.
Providers Submitting Inpatient Hospital Claims ForwardHealth is reprocessing inpatient hospital claims for ventilator, neurobehavioral, and coma recovery services that were processed between February 1, 2013, and February 27, 2013, with dates of service (DOS) from February 1, 2013, through February 27, 2013. ForwardHealth will apply updated per diem rates effective for DOS on and after February 1, 2013.
Aurora Medical Center — Grafton ForwardHealth is automatically reprocessing all inpatient hospital claims with dates of discharge between December 20, 2010, through February 14, 2013, to pay at the higher 2011 and 2012 Diagnosis Related Group rates.
Non-pharmacy Providers Submitting Claims ForwardHealth is automatically reprocessing claims that processed between November 8, 2008, and May 2, 2012, and denied in error with Explanation of Benefits (EOB) code 0278, "Member is covered by a commercial health insurance on the Date(s) of service"; EOB code 0702, "Member has commercial insurance for the Date(s) of Service"; or EOB code 0130, "Member has Medicare Supplemental coverage for the Date(s) of Service."

Week of March 4, 2013

Affected Providers Description of Adjustment
Certified Registered Nurse Anesthetists ForwardHealth is automatically reprocessing professional claims processed between January 1, 2011, and December 17, 2012, with dates of service (DOS) on and after January 1, 2011, through December 14, 2012, due to changes in coverage. Current Procedural Terminology procedure code 62273 has been added to the list of covered codes for certified registered nurse anesthetists effective for DOS on and after January 1, 2011.
Providers Submitting Professional Claims ForwardHealth is automatically reprocessing certain professional crossover claims that processed between November 10, 2008, and January 20, 2012, and were incorrectly denied with Explanation of Benefits message 1526, "Services billed exceed PA amount." Details for services on paid claims that were incorrectly denied for PA will also be adjusted. Prior authorization should not have been required for the services submitted on the impacted crossover claims.

Week of February 25, 2013

Affected Providers Description of Adjustment
Wisconsin Well Woman Program Providers Submitting Physician Claims ForwardHealth is reprocessing certain physician claims that were originally processed between May 2002 and July 2008. The claims were incorrectly reprocessed in December 2012, which caused them to deny with Explanation of Benefits code 1158, "Primary Diagnosis Code is required."

Week of February 11, 2013

Affected Providers Description of Adjustment
Non-pharmacy Providers Submitting Claims ForwardHealth is automatically reprocessing claims that processed between November 8, 2008, and May 2, 2012, and denied in error with Explanation of Benefits (EOB) code 0278, "Member is covered by a commercial health insurance on the Date(s) of service"; EOB code 0702, "Member has commercial insurance for the Date(s) of Service"; or EOB code 0130, "Member has Medicare Supplemental coverage for the Date(s) of Service."

Week of February 11, 2013

Affected Providers Description of Adjustment
Providers Submitting Professional and Professional Crossover Claims ForwardHealth is automatically reprocessing previously paid claims for certain laboratory procedure codes with dates of service between January 1, 2009, and April 12, 2011, that were processed between January 1, 2009, and April 12, 2011, to apply updated maximum allowable fee rates. Medicaid's maximum allowable fees will be adjusted to equal Medicare's maximum allowable fees for certain laboratory procedure codes, which will result in recoupments.
Providers Submitting Outpatient Hospital Claims with Access Payments ForwardHealth is automatically reprocessing outpatient hospital claims with dates of service between October 13, 2010, and November 10, 2012, when the access payment was not paid and should have been. These claims will be reprocessed and the access payment will be paid.

Week of January 7, 2013

Affected Providers Description of Adjustment
Providers Submitting Professional and Professional Crossover Claims ForwardHealth is automatically reprocessing previously paid claims for certain laboratory procedure codes with dates of service between January 1, 2009, and April 12, 2011, that were processed between January 1, 2009, and April 12, 2011, to apply updated maximum allowable fee rates. Medicaid's maximum allowable fees will be adjusted to equal Medicare's maximum allowable fees for certain laboratory procedure codes, which will result in recoupments.

Week of December 31, 2012

Affected Providers Description of Adjustment
Providers Submitting Professional Claims ForwardHealth is automatically reprocessing some professional claims that processed between November 8, 2008 and September 23, 2012, which should have been denied with Explanation of Benefits (EOB) code, "Primary Diagnosis Code Missing — Detail." These claims will be reprocessed and denied with this EOB.

Week of December 24, 2012

Affected Providers Description of Adjustment
Providers Submitting Professional and Professional Crossover Claims ForwardHealth is automatically reprocessing certain professional claims that processed between November 8, 2008, and July 19, 2012, with dates of service from November 8, 2008, through July 19, 2012. Claims were incorrectly denied with Explanation of Benefits message 1306, "Add-on codes are not separately reimbursable when submitted as a stand-alone code."

Week of December 17, 2012

Affected Providers Description of Adjustment
Providers Submitting Dental, Pharmacy, and Physician Claims ForwardHealth is automatically reprocessing certain dental, pharmacy, and physician claims that processed on and after October 1, 2010. Claims will be adjusted in order to ensure that the federal share of the reimbursement rate has been appropriately applied and reported to the Centers for Medicare and Medicaid Services. For the affected claims, providers do not need to take any action.
Providers Submitting Pharmacy Claims ForwardHealth is automatically reprocessing erroneously paid pharmacy claims with dates of service on and after September 1, 2012. A Pharmaceutical Care (PC) dispensing fee was incorrectly paid on the affected pharmacy claims. As a result of the implementation of the Medication Therapy Management (MTM) benefit on September 1, 2012, PC services are no longer reimbursable. Providers may be able to resubmit services that were previously reimbursed under PC codes as a MTM service on a professional claim. Providers can refer to the August 2012 ForwardHealth Update (2012-39), titled "Medication Therapy Management Benefit," for more information about the MTM benefit.
Wisconsin Chronic Renal Disease
Program Providers
ForwardHealth is automatically reprocessing some outpatient hospital claims with dates of service on and after September 11, 2011, that paid in error.

Week of December 3, 2012

Affected Providers Description of Adjustment
Providers Submitting Professional and Professional Crossover Claims ForwardHealth is automatically reprocessing previously paid claims for certain laboratory procedure codes with dates of service between January 1, 2009, and April 12, 2011, that were processed between January 1, 2009, and April 12, 2011, to apply updated maximum allowable fee rates. Medicaid's maximum allowable fees will be adjusted to equal Medicare's maximum allowable fees for certain laboratory procedure codes, which will result in recoupments.

Week of December 3, 2012

Affected Providers Description of Adjustment
Providers Submitting Claims with Acute Care and Rehab Access Payments ForwardHealth will be automatically adjusting inpatient and outpatient hospital claims with acute care and/or rehab access payments with dates of service from July 1, 2012, to July 19, 2012, to apply the updated 2013 reimbursement rates.
Dental Providers ForwardHealth is automatically reprocessing dental claims processed between November 10, 2008, and October 31, 2012, that were submitted with an invalid other insurance code. The affected claims will be updated with other insurance code OI-D.
Inpatient Hospital Providers in the Pay for Performance Program ForwardHealth is automatically reprocessing some inpatient hospital claims from providers in the Pay for Performance program that processed from July 1, 2012, through July 15, 2012. These claims will be reprocessed to have a percentage of their payment withheld prior to any Access Payment additions.
Inpatient and Outpatient Hospital Claims ForwardHealth is automatically reprocessing certain institutional inpatient and outpatient hospital claims with dates of service on or before October 3, 2012, that were processed on or before October 3, 2012. Duplicate claims were paid in error and will be recouped.

Week of November 26, 2012

Affected Providers Description of Adjustment
Providers Submitting Professional and Professional Crossover Claims ForwardHealth is automatically reprocessing previously paid claims for certain laboratory procedure codes with dates of service between January 1, 2009, and April 12, 2011, that were processed between January 1, 2009, and April 12, 2011, to apply updated maximum allowable fee rates. Medicaid's maximum allowable fees will be adjusted to equal Medicare's maximum allowable fees for certain laboratory procedure codes, which will result in recoupments.
Providers Submitting Professional Claims ForwardHealth is automatically reprocessing some professional claims that processed between November 8, 2008, and September 23, 2012, which should have been denied with Explanation of Benefits (EOB) code, "Primary Diagnosis Code Missing — Detail." These claims will be reprocessed and denied with this EOB.

Week of November 12, 2012

Affected Providers Description of Adjustment
Providers Submitting Claims for Family Planning Only Services ForwardHealth is automatically reprocessing Family Planning Only Services claims that processed on or after November 1, 2010. Claims will be adjusted in order to ensure that the federal share of the reimbursement rate has been appropriately applied and reported to the Centers for Medicare and Medicaid Services. For the affected claims, providers do not need to take any action.
Providers Hospitals Billing Laboratory Services ForwardHealth is automatically reprocessing certain outpatient laboratory claims with dates of service and dates of process between November 8, 2008, and December 23, 2011. These claims were processed and paid at an incorrect rate.

Week of November 5, 2012

Affected Providers Description of Adjustment
Providers Submitting Institutional Outpatient Hospital Claims ForwardHealth is automatically reprocessing certain institutional outpatient hospital claims processed between November 8, 2008, and June 12, 2012, that were incorrectly reimbursed and should have denied with Explanation of Benefits message 1257, "Member is enrolled in Medicare Part B on the Date(s) of Service."
Providers Submitting Professional and Professional Crossover Claims ForwardHealth is automatically reprocessing previously paid claims for certain laboratory procedure codes with dates of service between January 1, 2009, and April 12, 2011, that were processed between January 1, 2009, and April 12, 2011, to apply updated maximum allowable fee rates. Medicaid's maximum allowable fees will be adjusted to equal Medicare's maximum allowable fees for certain laboratory procedure codes, which will result in recoupments.

Week of October 15, 2012

Affected Providers Description of Adjustment
Providers Submitting Inpatient Hospital and Outpatient Hospital ClaimsForwardHealth is automatically reprocessing inpatient hospital and inpatient hospital crossover claims that were processed after March 1, 2010, for services provided to members with multiple benefit plans that were reimbursed an incorrect amount.

Week of October 1, 2012

Affected Providers Description of Adjustment
Providers Submitting Claims with Acute Care and Rehab Access Payments ForwardHealth will be automatically adjusting inpatient and outpatient hospital claims with acute care and/or rehab access payments with dates of service from July 1, 2012, to July 19, 2012, to apply the updated 2013 reimbursement rates.
Providers Submitting Professional, Inpatient Hospital and Outpatient Hospital Claims ForwardHealth is automatically reprocessing professional, inpatient hospital, and outpatient hospital claims for which Medicare and/or private insurance payments were not properly applied prior to ForwardHealth reimbursing the claim.
Providers Submitting Professional and Professional Crossover Claims ForwardHealth is automatically reprocessing certain professional claims that processed between November 8, 2008, and July 19, 2012, with dates of service from November 8, 2008, through July 19, 2012. Claims were incorrectly denied with Explanation of Benefits message 1306, "Add-on codes are not separately reimburseable when submitted as a stand-alone code."
Providers Submitting Claims with Critical Access Hospital Payments ForwardHealth will be automatically adjusting inpatient and outpatient hospital claims with critical access hospital payments with dates of service from July 1, 2012, to August 26, 2012, to apply the updated 2013 reimbursement rates.
Providers Submitting Professional Crossover Claims ForwardHealth is automatically reprocessing certain professional crossover claims that processed between November 10, 2008, and January 20, 2012, and were incorrectly denied with Explanation of Benefits message 1526, "Services billed exceed PA amount." Details for services on paid claims that were incorrectly denied for PA will also be adjusted. Prior authorization should not have been required for the services submitted on the impacted crossover claims.

Week of September 24, 2012

Affected Providers Description of Adjustment
Providers Submitting Professional and Professional Crossover Claims ForwardHealth is automatically reprocessing some professional and professional crossover claims with dates of service on and after January 1, 2012, to apply the 2012 reimbursement rates for Healthcare Common Procedure Coding System surgical procedure codes.
Providers Submitting Institutional Outpatient Hospital Claims ForwardHealth is automatically reprocessing certain institutional outpatient hospital claims processed after April 18, 2012, that were incorrectly denied due to Medicare coverage. The services should have been reimbursed by a ForwardHealth program.
Providers Submitting Professional Claims ForwardHealth is reprocessing certain professional claims with dates of service from November 10, 2008, through June 10, 2012, that were incorrectly denied with Explanation of Benefits message 0794, "Procedure not allowed for the CLIA Certification Type."

ForwardHealth System Generated Claim Adjustments

Week of September 17, 2012

Affected Providers Description of Adjustment
Providers Submitting Claims for Family Planning Only Services ForwardHealth is automatically reprocessing Family Planning Only Services claims that processed on or after April 1, 2010. Claims will be adjusted in order to ensure that the federal share of the reimbursement rate has been appropriately applied and reported to the Centers for Medicare and Medicaid Services. For the affected claims, providers do not need to take any action.

Week of September 10, 2012

Affected Providers Description of Adjustment
Wisconsin Well Woman Program Providers ForwardHealth is automatically reprocessing claims with dates of service from July 1, 2008, through August 1, 2012, with the updated 2012-2013 reimbursement rates.

Week of September 3, 2012

Affected Providers Description of Adjustment
Providers Submitting Claims for Therapy Services ForwardHealth is automatically adjusting claims for certain therapy services originally processed and paid between November 10, 2008, and June 1, 2009. Claims for therapy services that were previously recouped will be reprocessed to reimburse for services.
Providers Submitting Professional Claims ForwardHealth is reprocessing certain professional claims processed between September 1, 2011, and May 12, 2012, that were submitted with more than eight diagnosis codes and were incorrectly denied. Up to 12 diagnosis codes are allowed.
Providers Submitting Crossover Claims for Mental Health Services, Substance Abuse Services, Physicial Therapy and Occupational Therapy ForwardHealth is automatically reprocessing crossover claims for mental health services, substance abuse services, physical therapy and occupational therapy for members enrolled in Family Care processed between November 10, 2008, and June 19, 2012, that were incorrectly paid fee-for-service. Family Care is responsible for reimbursing providers for these services.

Week of August 27, 2012

Affected Providers Description of Adjustment
Providers Submitting Outpatient Hospital Claims for End-Stage Renal Disease Services ForwardHealth is automatically reprocessing outpatient hospital claims for end-stage renal disease (ESRD) services that processed between September 1, 2011, and June 12, 2012. ForwardHealth incorrectly paid for ESRD services for certain members enrolled in Medicare Part A on the date of service.

Week of August 13, 2012

Affected Providers Description of Adjustment
Providers Submitting Professional Claims ForwardHealth is reprocessing professional claims and professional crossover claims that were processed between January 25, 2012, and June 28, 2012. Claims submitted with non-specific "J" procedure codes were incorrectly denied for a National Drug Code.

Week of August 6, 2012

Affected Providers Description of Adjustment
Providers Submitting Professional Claims ForwardHealth is automatically reprocessing professional crossover claims that processed under a FamilyCare plan between November 10, 2008, and January 20, 2011. The claims will be reprocessed to allow for physicians and inpatient hospital places of service 21, 25, 51, and 61, to be reimbursed fee-for service by ForwardHealth.

Week of July 30, 2012

Affected Providers Description of Adjustment
Providers Submitting Professional Claims ForwardHealth is automatically reprocessing professional claims associated with obstetrical services that processed between April 5, 2009, and March 8, 2012, that were incorrectly paid or denied.
Providers Submitting Professional Claims ForwardHealth is automatically reprocessing professional claims that processed between August 6, 2009, and March 8, 2012, that were incorrectly paid or denied. Certain claims were paid that should have denied with Explanation of Benefits message 0595, "The service was previously paid for this Date of Service." Other claims were denied incorrectly.

Week of July 23, 2012

Affected Providers Description of Adjustment
Providers Submitting Noncompound Pharmacy Claims ForwardHealth is automatically reprocessing noncompound pharmacy claims that processed on and after April 1, 2010, to ensure that the federal share of the reimbursement rate has been appropriately applied and reported to the Centers for Medicare and Medicaid Services. In addition, certain noncompound pharmacy claims are being adjusted to refund copayment amounts deducted in error. Providers are required to refund the members for any copayment amount collected in error.

Week of July 9, 2012

Affected Providers Description of Adjustment
Miller Dwan Medical Center ForwardHealth is automatically reprocessing inpatient claims with dates of service between July 1, 2011, and April 11, 2012, to apply the new diagnosis-related group rate.

Week of June 18, 2012

Affected Providers Description of Adjustment
Providers Submitting Claims for Family Planning Only Services ForwardHealth is automatically reprocessing Family Planning Only Services claims that processed on or after April 1, 2010. Claims will be adjusted in order to ensure that the federal share of the reimbursement rate has been appropriately applied and reported to the Centers for Medicare and Medicaid Services. For the affected claims, providers do not need to take any action.

Week of June 11, 2012

Affected Providers Description of Adjustment
Providers Submitting Compound and Noncompound Claims ForwardHealth is automatically reprocessing compound and noncompound claims that processed between March 27, 2010, and June 15, 2012, to ensure that the federal share of the reimbursement rate has been appropriately applied and reported to the Centers for Medicare and Medicaid Services. For the affected claims, providers do not need to take any action, and there will be no change in reimbursement. Explanation of Benefits code 8234, "ForwardHealth-initiated claim adjustment. See Topic #13437 in the Online Handbook for complete information on this type of claim adjustment," will appear on the provider's Remittance Advice. Adjusted claims will be assigned a new claim number, known as an internal control number (ICN). The new ICN will begin with "58." If the provider adjusts this claim in the future, the new ICN will be required when submitting the claim. Refer to the June 2012 ForwardHealth Update (2012-22), titled "New Type of FowardHealth-Initiated Claim Adjustment," for additional information.

Week of June 4, 2012

Affected Providers Description of Adjustment
Wisconsin Chronic Disease Program Providers Submitting Outpatient Hospital Claims ForwardHealth is automatically reprocessing certain Wisconsin Chronic Disease Program outpatient hospital claims that processed between February 1, 2012, and April 9, 2012. Claims were incorrectly assigned a status of being paid but allowed zero.

Week of May 28, 2012

Affected Providers Description of Adjustment
Nursing Home Providers ForwardHealth is reprocessing certain nursing home claims billing ventilator and AIDS/ARC services that were originally processed between December 9, 2011, and April 13, 2012. ForwardHealth used an incorrect pricing structure for services billed on these claims.

Week of May 7, 2012

Affected Providers Description of Adjustment
Providers Submitting Claims for Laboratory Services ForwardHealth is automatically reprocessing claims for certain laboratory procedure codes that have dates of service on and after January 1, 2012, and were processed between January 1, 2012, and April 17, 2012, to apply updated maximum fee rates for these procedure codes. Providers are reminded that if ForwardHealth deducts less copayment than the member paid, the provider is required to return or credit the remainder to the member.
Pharmacy Providers ForwardHealth is reprocessing certain compound and noncompound claims for SeniorCare members with Medicare Part D that processed between October 16, 2011, and March 7, 2012. These claims were paid in error due to a defect found after the implementation of National Council for Prescription Drug Programs Telecommunication Standard D.0. As a result of this error, these claims will be reprocessed and will be denied with Explanation of Benefits code 1141, "Member enrolled in Medicare Part D. PDP payment/denial required on claim."

Providers are required to submit claims for SeniorCare members who are enrolled in a Medicare Part D Prescription Drug Plan (PDP) to the member's PDP and other health insurance sources before submitting claims to SeniorCare. SeniorCare is payer of last resort. Providers should submit the claims to the appropriate PDP. Once payment or denial from the PDP is received, providers may submit their coordination of benefit claim to SeniorCare with the payment or denial from the PDP.

If the date of service on the claim is outside the PDP's filing deadline, providers may submit a completed paper Noncompound Drug Claim, F-13072, or Compound Drug Claim, F-13073, to ForwardHealth with a Pharmacy Special Handling Request, F-13074, indicating "SeniorCare/Medicare Part D Coordination of Benefits Error," in Element 4. Providers are required to submit the paper claims and Pharmacy Special Handling Request by August 31, 2012. After this time, claims for this error will no longer be accepted.

As a reminder, SeniorCare members can only be held responsible for their SeniorCare spenddown, deductible, or copayment.

Week of April 23, 2012

Affected Providers Description of Adjustment
Providers Submitting Procedure Codes S9484 and S9485 ForwardHealth is automatically reprocessing claims for crisis services that processed between November 10, 2008, and July 31, 2010, with procedure codes S9484 and S9485 that were incorrectly denied.

Week of April 16, 2012

Affected Providers Description of Adjustment
Providers Submitting Claims with Laboratory Procedure Codes ForwardHealth is automatically reprocessing claims billed with certain laboratory procedure codes with dates of service from January 1, 2011, to December 27, 2011, that were reimbursed at an incorrect maximum allowable fee rate resulting in overpayments.

Week of April 9, 2012

Affected Providers Description of Adjustment
Inpatient, Outpatient, End-Stage Renal Disease, and Long Term Care Providers ForwardHealth is reprocessing certain institutional claims with dates of process between July 1, 2010, and February 1, 2012, and dates of service from January 1, 2009, through February 1, 2012. ForwardHealth incorrectly paid for services for certain members enrolled in state-contracted HMOs.
Hospitals Billing Laboratory Services ForwardHealth is automatically reprocessing certain outpatient laboratory claims with dates of service and dates of process between November 8, 2008, and December 23, 2011. These claims were processed and paid at an incorrect rate.

Week of April 2, 2012

Affected Providers Description of Adjustment
Ambulatory Surgery Centers ForwardHealth is automatically reprocessing claims for ambulatory surgery center access payments for dates of service between July 1, 2011, and November 17, 2011, that processed on and after November 18, 2011, that were paid without the additional access payment.

Week of March 26, 2012

Affected Providers Description of Adjustment
Hospice Providers ForwardHealth is automatically reprocessing hospice claims with dates of service (DOS) between January 1, 2010, and July 31, 2011, that processed between March 3, 2010, and August 15, 2011, to apply the patient liability that was initially applied to a long-term care claim for the same DOS that was subsequently recouped.
All Providers ForwardHealth is automatically reprocessing duplicate claims that processed between October 16, 2011, and December 10, 2011, for members that may have more than one benefit plan under which the billed service is allowed. The claim will be reprocessed under the benefit plan with greater benefit coverage.

Week of March 19, 2012

Affected Providers Description of Adjustment
Providers Submitting Crossover Claims for Family Care Members ForwardHealth is automatically reprocessing some crossover claims for Family Care members that processed between November 10, 2008, and May 15, 2010, for services that should be covered under the member's managed care plan.

Week of March 12, 2012

Affected Providers Description of Adjustment
Hospitals ForwardHealth is reprocessing certain inpatient claims and inpatient crossover claims with dates of process and dates of service from July 1, 2008, to November 13, 2011. Certain claims were incorrectly denied with Explanation of Benefits code 0051, "The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days, or the From and To Dates of Services cannot be the same." Other claims were incorrectly paid but should have been denied with EOB code 0051 and were paid in error. All of the affected claims will be reprocessed.

Week of February 27, 2012

Affected Providers Description of Adjustment
All Providers ForwardHealth is automatically reprocessing claims with dates of service on and after July 1, 2009, that processed for members identified as part of a federally recognized tribe and cost share was applied to the claim. On and after July 1, 2009, members identified as part of a federally recognized tribe are exempt from the cost share requirements for covered services when provided by a tribal health center or a tribal contracted entity. Refer to the November 2011 ForwardHealth Update (2011-73), "Cost Share Exemptions for Tribal Members," for more information.
Providers Submitting End Stage Renal Disease Claims ForwardHealth is automatically reprocessing end stage renal disease claims that processed between September 8, 2011, and December 21, 2011, that were denied incorrectly.
Nursing Home Providers ForwardHealth has identified two separate pricing issues for certain nursing home claims billing ventilator and AIDS/ARC services with dates of process on and after December 9, 2011. ForwardHealth is inappropriately paying for these ancillary services on bedhold days, and ancillary services are being inappropriately paid when a condition code is not billed. ForwardHealth is working to resolve these issues and will be adjusting all claims that were priced inappropriately.

Week of February 13, 2012

Affected Providers Description of Adjustment
Hospitals ForwardHealth is automatically reprocessing outpatient claims and outpatient crossover claims processed between November 8, 2008, and June 2, 2011, for dates of service prior to June 2, 2011, that were not correctly identified as family planning services. As a result, claims were paid even though family planning services are not covered for BadgerCare Plus Basic Plan or BadgerCare Plus Core Plan members. Other claims for family planning services were correctly paid, but copayment was deducted in error. Family planning services are exempt from copayment. Providers are required to refund the members for any copayment amounts collected in error.
Providers Submitting Claims for Home Health Services ForwardHealth is automatically reprocessing certain home health services claims with dates of process and dates of service from November 10, 2008, to present. Some providers submitted a professional and institutional claim for the same home health services and were reimbursed by ForwardHealth for both claims. In these cases of duplicate payment, ForwardHealth will automatically reprocess and automatically recoup the payment for the professional claim (with dates of process on and after November 10, 2008). Refer to the June 2011 ForwardHealth Update (2011-32), titled "Reminder: Claims for Home Health, Personal Care, and Private Duty Nursing Services Must be Submitted as Institutional Claims," for additional information.
Providers Submitting Procedure Code 58300 ForwardHealth is reprocessing certain professional claims submitted with procedure code 58300 (Insertion of intrauterine device [IUD]) that processed between September 1, 2009, and November 1, 2011. Office visit procedure codes were separately billed on the same date of service as procedure code 58300 and incorrectly paid. Payment for the office visit is included in the reimbursement for procedure code 58300.
Providers Submitting Professional Claims ForwardHealth is reprocessing certain professional claims, regardless of the date of service. ForwardHealth paid for services on a professional claim and a professional crossover claim when only the crossover claim should have been paid. Professional claims that were incorrectly paid will be recouped.

Week of February 6, 2012

Affected Providers Description of Adjustment
Providers Submitting Professional Claims with the "AS" Modifier ForwardHealth is reprocessing professional claims processed between November 20, 2008, and August 31, 2010. Certain claims submitted with the "AS" modifier (physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) may have processed incorrectly and may have been reimbursed at 100 percent of the corresponding rate for the surgical procedure resulting in overpayments. These claims should have been reimbursed at 20 percent of the reimbursement rate allowed for the provider type for the surgical procedure. Refer to the August 2010 ForwardHealth Update (2010-77), titled "Changes to Assistant Surgeon Policy," for more information.
Hospitals ForwardHealth is automatically reprocessing certain inpatient claims and inpatient crossover claims processed between November 10, 2008, and April 8, 2011, with dates of service on and after November 10, 2008. ForwardHealth misinterpreted certain claim data resulting in incorrectly processed claims.
Durable Medical Equipment Providers ForwardHealth is automatically reprocessing certain professional claims with dates of process and dates of service between May 1, 2011, and November 1, 2011. ForwardHealth incorrectly required prior authorization for gradient compression garments and compression burn garments in certain circumstances.
Nursing Home Providers ForwardHealth is automatically reprocessing certain nursing home claims with dates of service (DOS) on and after January 1, 2010, to identify duplicate claims that paid in error. Certain nursing home claims were reimbursed even though they had the same DOS as a paid hospice claim for the same member. When a resident of a Medicaid-certified nursing home elects to receive hospice care services, the hospice assumes responsibility for the management of the individual's hospice care and the hospice must contract with that nursing home to provide the member's room and board.

Week of January 30, 2012

Affected Providers Description of Adjustment
Hospitals ForwardHealth is automatically reprocessing hospital claims for Benchmark Plan members that processed between November 10, 2008, and June 28, 2011, with dates of service between February 1, 2008, and June 28, 2011. Copayment for emergency room services was deducted at an incorrect rate.
Richland Hospital ForwardHealth is automatically reprocessing inpatient and outpatient hospital claims for dates of service from July 1, 2011, through January 4, 2012, due to updated reimbursement rates.

Week of January 16, 2012

Affected Providers Description of Adjustment
Providers Submitting Compound and Noncompound Claims ForwardHealth is automatically reprocessing previously paid compound and noncompound claims with dates of service on and after October 1, 2011, for Gemcitabine HCL. These claims paid using an incorrect State Maximum Allowed Cost (SMAC) rate and will be reprocessed to pay using the appropriate SMAC rate.

Week of January 2, 2012

Affected Providers Description of Adjustment
Providers Submitting Claims for End-Stage Renal Disease ForwardHealth is automatically reprocessing end-stage renal disease claims that processed between September 10, 2011, and November 4, 2011. These claims will be reprocessed to pay at a higher per diem rate.

Week of November 14, 2011

Affected Providers Description of Adjustment
Providers Submitting Compound and Noncompound Claims ForwardHealth is automatically reprocessing compound and noncompound claims with dates of service between July 31, 2011 and September 21, 2011, for Triamcinolone 0.1% ointment, which paid using an incorrect State Maximum Allowed Cost (SMAC) rate. These claims will be reprocessed to pay using the appropriate SMAC rate.
End-Stage Renal Disease Providers ForwardHealth is automatically reprocessing end-stage renal disease claims that processed on and after September 10, 2011. Claims will be reimbursed at the interim per diem rate of $214.60. A ForwardHealth Update will be published announcing the interim per diem rate of $214.60.
Providers Submitting Pharmacy Claims ForwardHealth is reprocessing paid compound and noncompound claims that processed between October 17, 2011, and October 20, 2011, without a dispensing fee. The dispensing fee was not applied to claims received without a unit dose indicator or special packaging indicator present. These claims were identified in Alert number 002, "Dispensing Fees."

Week of November 7, 2011

Affected Providers Description of Adjustment
Inpatient Hospitals ForwardHealth is automatically reprocessing certain inpatient hospital claims with dates of process and dates of service between November 8, 2008, and February 24, 2011. There was a problem in determining Neonate enhanced Diagnosis Related Group (DRG) reimbursement when more than nine diagnosis codes were indicated on the claim. These claims will be reprocessed to pay at the correct DRG rate.
Anesthesia Providers ForwardHealth is automatically reprocessing anesthesia claims that processed between November 10, 2008, and September 26, 2011, with dates of service between November 10, 2008, and September 30, 2009. Certain anesthesia claims submitted with procedure code 01953 were reimbursed at an incorrect rate.
Providers Submitting Pharmacy Claims ForwardHealth is reprocessing certain compound and noncompound claims for drugs and diabetic supplies that processed between October 19, 2011, and October 20, 2011, and were incorrectly denied. These denials were identified in Alert number 004, titled "Compound and Noncompound Claim Denials."
Providers Submitting Pharmacy Claims ForwardHealth is automatically reprocessing noncompound claims for DEXTROAMPHETAMINE SULFATE with dates of service on and after September 1, 2011. These claims incorrectly paid using a State Maximum Allowed Cost (SMAC) rate. The claims will be reprocessed to pay using the appropriate Expanded Maximum Allowed Cost (EMAC) or Wholesale Acquisition Cost (WAC) rate.
Anesthesia Providers ForwardHealth is automatically reprocessing anesthesia claims that processed incorrectly between November 10, 2008, and January 21, 2011, with the following procedure codes for qualifying circumstances: 99100, 99166, 99116 and 99140. Providers are reminded that qualifying circumstances are to be billed with a quantity of "1" and modifier "AA."

Week of October 31, 2011

Affected Providers Description of Adjustment
Physicians ForwardHealth is automatically reprocessing professional claims that processed between November 10, 2008, and August 13, 2010, and were paid over the allowed physician daily maximum reimbursement. Claims will be reprocessed to recoup these overpayments.
Providers Submitting Claims for Vision Services ForwardHealth is automatically reprocessing claims for vision services under the BadgerCare Plus Core Plan and the BadgerCare Plus Basic Plan for dates of service between July 1, 2009, and December 1, 2010. These claims will be reprocessed to cover general ophthalmological examinations submitted with Current Procedural Terminology codes 92002-92014, if the member's primary diagnosis includes an International Classification of Diseases, Ninth Revision, Clinical Modification code from the range 360.00-379.99 (excluding 367.0-367.9, 368.02, 368.30-368.34, 368.51-368.59, 368.60-368.69, 378.40-378.45).
Nursing Home Providers ForwardHealth is automatically reprocessing nursing home claims that processed between October 15, 2011, and October 27, 2011, and paid at an incorrect rate due to the condition code "A5" not being processed correctly. These claims will be reprocessed to pay at the appropriate accommodation rate.
Dental Providers ForwardHealth is automatically reprocessing certain dental claims that originally processed between October 15, 2011, and October 28, 2011. These claims incorrectly denied with Explanation of Benefits code 1505, "The Billing Provider's taxonomy code in the header is invalid."

Week of October 24, 2011

Affected Providers Description of Adjustment
Providers Submitting Pharmacy Claims ForwardHealth is reprocessing certain noncompound and compound claims with a date of service of October 1, 2011, that processed on October 1, 2011. These claims incorrectly denied with Explanation of Benefits code 2040, "NDC is obsolete for dates of service."

Week of October 17, 2011

Affected Providers Description of Adjustment
Inpatient Providers ForwardHealth is automatically reprocessing inpatient hospital claims with diagnosis codes V902, V909, V9001, V9009-V9012, V9031-V9033, V9039, V9081, V9083, and V9089, which were processed and denied in error from October 1, 2010, through September 28, 2011.

Week of September 26, 2011

Affected Providers Description of Adjustment
Providers Submitting Procedure Codes S9484 and S9485 ForwardHealth is automatically reprocessing claims with procedure codes S9484 and S9485 with dates of service on and after July 1, 2006, that processed between April 15, 2011, and September 11, 2011. These claims will be reprocessed to allow both procedure codes on the same date of service when submitted by the same billing provider.

Week of September 12, 2011

Affected Providers Description of Adjustment
Dental Providers In a Remittance Advice banner message that was first posted the week of December 27, 2010, ForwardHealth announced that it was reprocessing certain dental claims with procedure codes D0270, D0272, and D0274. These claims were incorrectly paid for Medicaid, BadgerCare Plus Standard Plan, and BadgerCare Plus Benchmark Plan members having commercial dental insurance. However, due to timely filing requirements of the commercial dental insurance companies, some providers have been unable to collect insurance payments. In response to this situation, ForwardHealth is reprocessing these claims to restore the original payment to the providers.

Week of August 29, 2011

Affected Providers Description of Adjustment
End Stage Renal Disease and Hospice Providers ForwardHealth is automatically reprocessing institutional outpatient claims for end stage renal disease and hospice services that originally processed between February 19, 2009, and October 27, 2010. Certain duplicate claims that were not previously identified as duplicates were erroneously paid and will be recouped.

Week of August 22, 2011

Affected Providers Description of Adjustment
Community Support Program, Comprehensive Community Services, Crisis Intervention Providers ForwardHealth is automatically adjusting Community Support Program, Comprehensive Community Services, and Crisis Intervention claims with dates of service and dates of process between November 10, 2008, and April 26, 2011. Certain claims were incorrectly denied with Explanation of Benefits Code 0278, "Member is covered by a commercial health insurance on the Date(s) of Service." These providers are not required to bill commercial health insurance before submitting claims to Wisconsin Medicaid.
Providers Billing Laboratory Services ForwardHealth is automatically adjusting outpatient, professional claims, and professional crossover claims for Healthcare Common Procedure Coding System procedure code G0434 (Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter) with dates of process and dates of service between January 1, 2011, and June 29, 2011. Claims with procedure code G0434 are being adjusted to apply maximum allowable fee pricing.
ForwardHealth Providers ForwardHealth is automatically reprocessing all claims that denied as a result of the system accumulating services toward a prior authorization threshold incorrectly.
Providers Submitting Claims for Dental Services Provided to Certain Benchmark Plan Tribal Members ForwardHealth is adjusting dental claims processed on and after February 1, 2008, for certain BadgerCare Plus Benchmark Plan tribal members under 19 years of age receiving dental services to refund cost-sharing amounts deducted in error. Providers are required to refund the members for any cost-sharing amount collected in error.

Week of August 1, 2011

Affected Providers Description of Adjustment
Providers Submitting Outpatient Hospital Crossover Claims ForwardHealth is automatically reprocessing some outpatient hospital crossover claims that processed between November 8, 2008, and June 6, 2011, and paid incorrectly due to a system error.

Week of July 25, 2011

Affected Providers Description of Adjustment
Providers Submitting Claims for Hospice Members ForwardHealth is automatically reprocessing claims for services provided to members enrolled in hospice that processed between March 23, 2009, and October 19, 2010, and paid in error. For hospice members, ages 21 and older, Wisconsin Medicaid only reimburses services unrelated to the terminal illness that are otherwise medically necessary

Week of July 18, 2011

Affected Providers Description of Adjustment
Providers Submitting Procedure Codes 95926, 95927, 95930, 95934, or 95936 on Professional Claims ForwardHealth is automatically adjusting certain professional claims with dates of process and dates of service between January 1, 2011, and June 29, 2011. Claims with procedure codes 95926, 95927, 95930, 95934, and 95936 submitted with modifier "26" (professional component) were incorrectly denied.
Providers Submitting Claims with Procedure Code 99600 ForwardHealth is automatically reprocessing claims with procedure code 99600 (unlisted home visit service or procedure) with dates of service on and after January 1, 2011, that processed between January 1, 2010, and May 22, 2011. Due to a system error, these claims were processed without checking for prior authorization.
Providers Submitting Claims for Dental Services ForwardHealth is automatically adjusting claims with dates of service (DOS) on and after January 1, 2010, that processed between January 1, 2010, and September 28, 2010, to recoup payments paid for dental services provided to members enrolled in managed care organizations (MCO) that cover dental services, as those claims should be billed to the MCO. Conversely, claims with DOS on and after January 1, 2010, that processed between January 1, 2010, and September 28, 2010, with dental services provided to members enrolled in MCOs that do not cover dental services will be reprocessed also.
Providers Submitting Pharmacy Claims ForwardHealth is processing erroneously paid pharmacy claims with dates of service between July 1, 2011, and July 11, 2011, for Ondansetron Liquid. These claims paid in error without prior authorization for diagnosis outside approved diagnosis restrictions.
Providers Submitting Radiology Claims ForwardHealth is automatically adjusting certain radiology claims with dates of service (DOS) between November 10, 2008, and April 28, 2011, that processed and paid on and after November 10, 2008. Radiology claims in which modifiers TC (technical component) or 26 (professional component) were billed in addition to the complete procedure on the same DOS were incorrectly paid. ForwardHealth does not reimburse both the global service and the individual component parts of the service for the same DOS.

Week of July 11, 2011

Affected Providers Description of Adjustment
Inpatient Hospitals ForwardHealth is automatically reprocessing certain inpatient hospital claims that processed and paid on and after November 1, 2008. These claims paid even though all accommodation revenue codes on the claim were denied. These claims should have been denied as ForwardHealth policy is a member is considered an inpatient member when they are admitted to the hospital as an inpatient and counted in the midnight census. If they are not counted in the midnight census, they are considered outpatient visits and claims should not be submitted as inpatient stays.
Lakeview Neurorehab Center ForwardHealth is automatically reprocessing your inpatient claims which originally processed from November 1, 2010, to January 10, 2011. These claims were reimbursed using a per diem rate and are now being reprocessed so that they may be reimbursed using the diagnosis related group payment system.

Week of June 27, 2011

Affected Providers Description of Adjustment
Inpatient Hospital Providers ForwardHealth is automatically reprocessing institutional inpatient hospital claims with dates of process and dates of service between October 1, 2010, and April 26, 2011. Claims submitted with certain International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes were incorrectly denied with Explanation of Benefits Code 0807, "Diagnosis code indicated is not valid as a primary diagnosis. Correct and resubmit."

Week of June 13, 2011

Affected Providers Description of Adjustment
Providers Submitting Claims for Members Enrolled in the Birth to Three Program For members enrolled in the Birth to Three Program, ForwardHealth is recouping all natural environment enhanced reimbursement payments made via financial transactions from November 10, 2008 through June 30, 2009. ForwardHealth will reprocess all claims that billed for the natural environment enhanced reimbursement using the "TL" modifier to include the full, applicable natural environment enhanced reimbursement in the reimbursement for the claims that processed from November 10, 2008 through mid-September, 2010.
Inpatient Hospital Providers ForwardHealth is automatically reprocessing inpatient hospital claims with dates of process between November 10, 2008, and October 9, 2010, if the member's enrollment began on the date of discharge. These claims paid in error and will be recouped.
Chiropractors ForwardHeatlh is automatically adjusting chiropractor claims that originally processed between April 1, 2011, and April 7, 2011, for dates of service between January 1, 2011, and April 7, 2011. Claims with procedure code 99201 (office visit) billed with procedure codes 98941 or 98942 (manipulation codes) were incorrectly denied with Explanation of Benefits code 1686, "This service is not payable with another service on the same date of service due to National Correct Coding Initiative."
Providers Billing for Mental Health and Substance Abuse Services ForwardHealth is automatically reprocessing claims for BadgerCare Plus Core Plan and BadgerCare Plus Basic Plan members that incorrectly processed and paid from April 1, 2010, through March 29, 2011. Procedure codes 90801-90899, 96150-96155, T1006, H0005, H0022, and H0047 that were submitted with modifiers "HN" (Bachelors degree level), "HO" (Master's-degree level), and "HP" (Doctoral level) were reimbursed in error. Modifiers "UA" (Psychiatrist) and "UB" (Advanced practice nurse prescriber with a psychiatric specialty) should only be used with the affected procedure codes. Only physicians, physician assistants, and nurse practitioners can be reimbursed for services provided to Core Plan and Basic Plan members.

Week of June 6, 2011

Affected Providers Description of Adjustment
Providers Submitting Claims for Members Enrolled in the Birth to Three Program For members enrolled in the Birth to Three Program, ForwardHealth is recouping all natural environment enhanced reimbursement payments made via financial transactions from November 10, 2008 through June 30, 2009. ForwardHealth will reprocess all claims that billed for the natural environment enhanced reimbursement using the "TL" modifier to include the full, applicable natural environment enhanced reimbursement in the reimbursement for the claims that processed from November 10, 2008 through mid-September, 2010.

Week of May 30, 2011

Affected Providers Description of Adjustment
Wisconsin Chronic Disease Program Providers ForwardHealth is automatically reprocessing erroneously denied noncompound drug claims for calcium acetate 667 mg gel caps with dates of service between July 1, 2010, and May 24, 2011.

Week of May 23, 2011

Affected Providers Description of Adjustment
Providers Submitting Noncompound and Compound Claims ForwardHealth is automatically reprocessing erroneously denied noncompound and compound claims for amphetamine salts 15 mg tab that were received between April 5, 2010, and May 10, 2011.
Providers Submitting Institutional Outpatient Crossover Claims ForwardHealth is automatically reprocessing institutional outpatient crossover claims that processed between February 17, 2009, and April 10, 2010, to recoup duplicate payments.
Providers Submitting Procedure Code S9445 ForwardHealth is automatically reprocessing professional claims with dates of service on and after November 8, 2008, and processed on and after September 12, 2010, with Healthcare Common Procedure Coding System procedure code S9445 (Patient education, not otherwise classified, non-physician provider, individual, per session). These claims denied in error as this procedure code does not require an attachment.
Providers Billing Procedure Code E0247 ForwardHealth is automatically reprocessing claims incorrectly processed from January 1, 2010, to February 24, 2011, for procedure code E0247 (Transfer bench for tub or toilet with or without commode opening). These claims were denied in error with explanation of benefits (EOB) code 0443 (Repair services billed in excess of the amount specified in the Durable Medical Equipment handbook require Prior Authorization).
Home Health Agencies ForwardHealth is automatically reprocessing claims for BadgerCare Plus Core Plan members denied in error from April 1, 2010, to the present. Claims were denied even though the home health services were provided within a 30-day contiguous period following an inpatient hospital stay.
Nursing Homes ForwardHealth is automatically reprocessing claims that were processed from January 12, 2009, to March 9, 2011. Some of the claims may have been duplicate claims and incorrectly reimbursed.

Week of May 16, 2011

Affected Providers Description of Adjustment
Nurse Midwives ForwardHealth is automatically reprocessing denied claims with dates of service on and after January 1, 2011, for procedure code J7307 (Etonogestrel [contraceptive] implant system, including implant and supplies). Nurse midwives may now be reimbursed by ForwardHealth for J7307.
Providers Submitting Procedure Code 86780 ForwardHealth is automatically reprocessing professional claims with Current Procedural Terminology procedure code 86780 (Antibody; influenza virus; treponema pallidum) with dates of service on and after January 1, 2010, that denied incorrectly.
Inpatient Hospital Providers ForwardHealth is automatically reprocessing inpatient hospital claims with an admission date ("from" date of service) before October 1, and a discharge date ("to" date of service) after October 1, with dates of process between November 8, 2008, and January 18, 2011. These claims denied in error with the Explanation of Benefits code, "The Surgical Procedure Code is not payable for the Date of Service."

Week of May 9, 2011

Affected Providers Description of Adjustment
Providers Submitting Claims for Hospice Members ForwardHealth is automatically reprocessing claims for services provided to members enrolled in hospice that processed between March 23, 2009, and October 19, 2010, and paid in error. For hospice members, ages 21 and older, Wisconsin Medicaid only reimburses services unrelated to the terminal illness that are otherwise medically necessary.
Certain Vision Providers ForwardHealth is automatically reprocessing denied claims with dates of service from January 1, 2009, to the present for vision services rendered by optometrists for BadgerCare Plus Basic Plan and BadgerCare Plus Core Plan members. For information on the reason for adjustments, refer to the December 2010 ForwardHealth Update (2010-107), titled "Certain Ophthalmological Examinations Covered Under the BadgerCare Plus Core Plan and the BadgerCare Plus Basic Plan."

Week of May 2, 2011

Affected Providers Description of Adjustment
Pharmacy Providers ForwardHealth is automatically reprocessing erroneously denied noncompound claims received on or after April 10, 2010. These claims were denied due to the absence of a drug rebate agreement for the drug on the date of service.

Week of April 18, 2011

Affected Providers Description of Adjustment
Providers Submitting Procedure Code T2023 ForwardHealth is automatically reprocessing professional claims with procedure code T2023 (Targeted case management; per month) with dates of service between October 1, 2009, and September 30, 2010, with dates of process between October 1, 2009, and March 24, 2011, due to a rate change.

Week of April 11, 2011

Affected Providers Description of Adjustment
Podiatrists ForwardHealth is automatically reprocessing professional claims processed between July 1, 2010, and February 16, 2011, with dates of service (DOS) on and after July 1, 2010, due to changes in coverage. Current Procedural Terminology procedure code 97597 has been added to the list of covered podiatry codes effective for DOS on and after July 1, 2010.
All Providers ForwardHealth is automatically reprocessing claims that originally processed from November 8, 2008, through November 13, 2010. Copayment amounts that are to be deducted per date of service were not fully deducted from these claims.
Providers Billing for Mental Health and Substance Abuse Services ForwardHealth is automatically reprocessing claims that incorrectly processed and paid from December 28, 2010, through March 29, 2011. Procedure codes 90805, 90807, 90809, 90811, 90813, 90815, 90817, 90819, 90822, 90824, 90827, and 90829 that were submitted with modifiers "HP" (doctoral level) and "HO" (master's-level psychotherapist) were reimbursed in error.

Week of April 4, 2011

Affected Providers Description of Adjustment
Ambulance Providers ForwardHealth is automatically reprocessing ambulance claims that processed from July 1, 2009, through February 28, 2011. For certain Core Plan members, copayment was deducted in error.
Nursing Home Providers ForwardHealth is automatically reprocessing certain retroactive rate adjustments which were processed incorrectly from January 12, 2009 to March 9, 2011. Several ForwardHealth policies failed to be applied to the original adjustments.
Inpatient Hospital Providers ForwardHealth is automatically reprocessing certain retroactive rate adjustments which were processed incorrectly from January 12, 2009 to March 9, 2011. Several ForwardHealth policies failed to be applied to the original adjustments.

Week of March 28, 2011

Affected Providers Description of Adjustment
Outpatient Hospitals Billing Laboratory Services ForwardHealth is automatically reprocessing claims for HCPCS procedure codes G0430 (Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure) and G0431 (Drug screen, qualitative; multiple drug classes by high complexity test method, per patient encounter), which were processed from January 1, 2010, through October 14, 2010. Claims for G0430, with dates of service (DOS) from January 1, 2010, through December 31, 2010, were denied in error. And for procedure code G0431, claims with DOS on and after January 1, 2010, were denied in error.
Providers Submitting Inpatient Hospital Claims ForwardHealth is automatically reprocessing certain inpatient hospital claims with dates of payment from November 15, 2008, through January 12, 2011. Claims will be adjusted so that they are priced as Medicare benefits exhausted claims.
Providers Submitting Claims for Diabetic Supplies ForwardHealth is automatically reprocessing noncompound claims for certain diabetic supplies billed using National Drug Codes, denied in error with dates of service on and after June 1, 2010.
Providers Submitting Inpatient, Inpatient Crossover and Long Term Care Claims ForwardHealth is automatically reprocessing inpatient hospital, inpatient crossover and long term care claims that processed between November 12, 2008, and October 6, 2010, for dates of service before October 6, 2010. These claims paid in error as inpatient hospital services or nursing home services are not covered for the member on the date of service.
Providers Submitting Claims for Members in Hospice Lock-In ForwardHealth is automatically reprocessing some professional claims with dates of service on and after July 1, 2010, to allow for reimbursement of medically necessary treatment services provided concurrently with hospice care. Claims that denied for medical necessity treatment services for members age 20 and under enrolled in Wisconsin Medicaid or BadgerCare Plus who are also in hospice care, will be adjusted. Refer to the December 2010 ForwardHealth Update (2010-121), titled "Members 20 and Under May Elect Hospice and Continue with Active Treatment," for more information.
Prenatal Care Coordination Providers ForwardHealth is automatically adjusting prenatal care coordination claims processed between November 10, 2008, and August 26, 2010, due to a processing error.
Family Planning Clinic Providers ForwardHealth is automatically reprocessing non-compound claims for Aldara 5% cream denied in error for dates of service on or after June 12, 2010.

Week of March 21, 2011

Affected Providers Description of Adjustment
Providers Submitting Noncompound and Compound Claims ForwardHealth is automatically reprocessing paid noncompound and compound claims for potassium chloride 20 meq tablets. Claims processed between November 28, 2010, and January 31, 2011, for dates of service on and after August 1, 2010, incorrectly paid using a Maximum Allowable Cost (MAC) rate. These claims are being reprocessed to pay correctly.

Week of March 14, 2011

Affected Providers Description of Adjustment
Residential Care Center Providers ForwardHealth is automatically reprocessing Residential Care Center claims with dates of service on and after January 1, 2010, due to rate changes.

Week of February 21, 2011

Affected Providers Description of Adjustment
Dental Providers In a Remittance Advice banner message that was first posted the week of December 27, 2010, ForwardHealth announced that it was reprocessing certain dental claims with procedure codes D0270, D0272, and D0274. These claims were incorrectly paid for Medicaid, BadgerCare Plus Standard Plan, and BadgerCare Plus Benchmark Plan members having commercial dental insurance. However, due to timely filing requirements of the commercial dental insurance companies, some providers have been unable to collect insurance payments. In response to this situation, ForwardHealth is reprocessing these claims to restore the original payment to the providers.
Providers Submitting Inpatient, Inpatient Crossover, and Long Term Care Claims ForwardHealth is automatically reprocessing inpatient hospital, inpatient crossover, and long term care claims that processed between November 12, 2008, and October 6, 2010, for dates of service (DOS) before October 6, 2010. These claims paid in error as inpatient hospital services or nursing home services are not covered for the member on the DOS.
Providers Submitting Inpatient Hospital Claims ForwardHealth is automatically reprocessing certain inpatient hospital claims with dates of payment from November 15, 2008, through January 12, 2011. Claims will be adjusted so that they are priced as Medicare benefits exhausted claims.
Providers Submitting Claims for Blood Lead Testing Services ForwardHealth is automatically reprocessing some claims with dates of service (DOS) from April 1, 2008, through December 31, 2010, for blood lead testing services. Current Procedural Terminology procedure code 83655 (lead) will be denied when billed with CPT code 99000 (Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory) on the same DOS for the same member and the same provider.

Week of February 14, 2011

Affected Providers Description of Adjustment
Dental Providers In a Remittance Advice banner message that was first posted the week of December 27, 2010, ForwardHealth announced that it was reprocessing certain dental claims with procedure codes D0270, D0272, and D0274. These claims were incorrectly paid for Medicaid, BadgerCare Plus Standard Plan, and BadgerCare Plus Benchmark Plan members having commercial dental insurance. However, due to timely filing requirements of the commercial dental insurance companies, some providers have been unable to collect insurance payments. In response to this situation, ForwardHealth is reprocessing these claims to restore the original payment to the providers.
Podiatrists ForwardHealth is reprocessing professional claims processed between January 1, 2010, and September 29, 2010 for dates of service (DOS) between January 1, 2010, and September 29, 2010, due to changes in coverage. Healthcare Common Procedure Coding System procedure code Q4038 and Current Procedural Terminology procedure code 64455 have been added to the list of covered podiatry codes effective for DOS on and after January 1, 2010.
Providers Submitting Inpatient Hospital Claims ForwardHealth is automatically reprocessing some inpatient hospital claims with dates of service from November 8, 2008 through October 6, 2010 with dates of process from November 8, 2008 through October 7, 2010. Inpatient claims with details that denied or suspended in error with diagnosis codes in the range of 339 through 339.89 will be adjusted.
Providers Submitting Professional Claims with Modifier "AS" ForwardHealth is reprocessing professional claims processed between September 1, 2010, and October 14, 2010. Certain claims with modifier "AS" were incorrectly denied with a message indicating the modifier was not valid for the date of service.
Providers Submitting Procedure Codes G0430 or G0431 on Professional Claims ForwardHealth is reprocessing professional claims and professional crossover claims processed between January 1, 2010, and October 14, 2010, for dates of service (DOS) on and after January 1, 2010, due to changes in coverage. Procedure codes G0430 and G0431 have been added to the list of covered codes effective for DOS on and after January 1, 2010.
Podiatrists Submitting Procedure Codes Q4106 and 15365 ForwardHealth is reprocessing professional claims processed between July 1, 2009, and December 1, 2010, for dates of service (DOS) between July 1, 2009, and December 1, 2010, due to changes in coverage. Healthcare Common Procedure Coding System procedure code Q4106 and Current Procedural Terminology procedure code 15365 have been added to the list of covered podiatry codes effective for DOS on and after July 1, 2009.

Week of February 7, 2011

Affected Providers Description of Adjustment
Providers Submitting Claims for Members Enrolled in the Chronic Renal Disease Program ForwardHealth is automatically reprocessing claims for Wisconsin Chronic Disease Program members enrolled in the Chronic Renal Disease program that denied in error with Explanation of Benefits code 0116, "Procedure Code or Drug Code not a benefit on Date of Service." This adjustment affects claims for dates of service on and after January 1, 2008, that originally processed between January 1, 2008, and October 12, 2010, to apply reimbursement as appropriate.
Providers Submitting Vaccine Codes for BadgerCare Plus Basic Plan Members ForwardHealth is adjusting professional and professional crossover claims processed between December 31, 2010, and January 20, 2011, for dates of service (DOS) between July 1, 2010, and December 31, 2010. A required copayment amount of $10.00 per DOS was not deducted when the claim contained certain vaccine codes (90632, 90636, 90649, 90650, 90656, 90658, 90660, 90707, 90714, 90715, 90716, 90734, 90746) and the vaccine code was the only paid service on the claim for BadgerCare Plus Basic Plan members.
Providers Submitting Outpatient Crossover Claims for End Stage Renal Disease (ESRD) Services ForwardHealth is automatically reprocessing outpatient crossover claims for ESRD services with dates of process from November 10, 2008, through November 4, 2010. Crossover claims submitted by billing providers who are out-of-state providers or border status providers will be adjusted due to a system pricing issue.

Week of January 31, 2011

Affected Providers Description of Adjustment
Providers Submitting Institutional Outpatient Claims for Basic Plan Members ForwardHealth is automatically reprocessing claims for Basic Plan members that denied in error with Explanation of Benefits code 1378, "The Revenue Code is not payable for the Date of Service." This adjustment affects claims submitted with revenue codes in the 900-999 range for dates of service from July 1, 2010, through December 20, 2010.
Dental Providers In a Remittance Advice banner message that was first posted the week of December 27, 2010, ForwardHealth announced that it was reprocessing certain dental claims with procedure codes D0270, D0272, and D0274. These claims were incorrectly paid for Medicaid, BadgerCare Plus Standard Plan, and BadgerCare Plus Benchmark Plan members having commercial dental insurance. However, due to timely filing requirements of the commercial dental insurance companies, some providers have been unable to collect insurance payments. In response to this situation, ForwardHealth is reprocessing these claims to restore the original payment to the providers.

Week of January 24, 2011

Affected Providers Description of Adjustment
Providers Submitting Outpatient Mental Health or Substance Abuse Treatment Claims on the Institutional Claim Form ForwardHealth is automatically reprocessing some institutional claims with dates of process from June 1, 2009, through September 17, 2009. An overpayment may have occurred as claims without prior authorization processed without the service limit being correctly applied. Prior authorization is required after a member receives 15 hours/$825.00 of mental health or substance abuse services in a calendar year.
Providers Submitting Pharmacy Claims ForwardHealth is automatically adjusting pharmacy claims with dates of service on and after February 1, 2010, for Mirapex 1mg tablet. Certain claims paid in error without prior authorization for this brand medically necessary drug.

Week of January 17, 2011

Affected Providers Description of Adjustment
Wisconsin Chronic Renal Disease Providers ForwardHealth is automatically reprocessing claims with dates of receipt January 1, 2009, through December 3, 2010, due to changes in coverage. Procedure codes 36120, 37204 and 75822 have been added to the list of covered codes and place of service (POS) 11 has been added as an allowable POS for procedure code G0365.
Providers Submitting Claims for Members Enrolled in the Chronic Renal Disease Program ForwardHealth is automatically reprocessing claims for Wisconsin Chronic Disease Program members enrolled in the Chronic Renal Disease program that denied in error with Explanation of Benefits code 0116, "Procedure Code or Drug Code not a benefit on Date of Service." This adjustment affects claims for dates of service on and after January 1, 2008, that originally processed between January 1, 2008, and October 12, 2010, to apply reimbursement as appropriate.
Attention Providers Submitting Prior Authorization Requests ForwardHealth is reprocessing claims that originally processed after March 13, 2010, and incorrectly denied or suspended for not having a prior authorization (PA) even though a PA is on file.

Week of January 10, 2011

Affected Providers Description of Adjustment
Providers Submitting Procedure Codes T1999 or E1399 on Professional Claims ForwardHealth is reprocessing professional claims that originally processed between September 1, 2010, and December 1, 2010, with detail dates of service between September 1, 2010, and December 1, 2010. Claims submitted with procedure codes T1999 or E1399 were incorrectly denied with Explanation of Benefits code 0653, "Insufficient Info On Unlisted Med Proc; Submit Claim Or Attachment With A Complete Description Of The Procedure As Described In History and Physical Exam Report, Med Progress, anesthesia or Op Report." Since the procedure codes require prior authorization, additional documentation is not required to be submitted with the claim.

Week of January 3, 2011

Affected Providers Description of Adjustment
Providers Submitting Unlisted Procedure Codes on Professional Claims ForwardHealth is reprocessing professional claims that originally processed between September 1, 2010, and September 3, 2010, and incorrectly denied with Explanation of Benefits code 0653, "Insufficient Info On Unlisted Med Proc; Submit Claim Or Attachment With A Complete Description Of The Procedure As Described In History and Physical Exam Report, Med Progress, anesthesia or Op Report." These claims are being reprocessed to remove that denial.
Providers Submitting Outpatient Hospital Claims ForwardHealth is automatically reprocessing outpatient hospital claims with dates of receipt on and after July 1, 2010. Certain revenue codes were incorrectly denied with Explanation of Benefits Code 1649, "Revenue code requires submission of associated HCPCS (Healthcare Common Procedure Coding System) code." The affected revenue codes do not require a HCPCS code.

Week of December 27, 2010

Affected Providers Description of Adjustment
Dental Providers ForwardHealth is reprocessing dental claims with procedure codes D0270, D0272, and D0274 processed between November 1, 2008, and October 12, 2010. These procedure codes were incorrectly paid for Medicaid, BadgerCare Plus Standard Plan, and BadgerCare Plus Benchmark Plan members with commercial dental insurance.

Week of December 20, 2010

Affected Providers Description of Adjustment
Ambulatory Surgery Center Providers ForwardHealth is automatically reprocessing claims for Ambulatory Surgery Centers (ASC) that originally processed and paid between July 1, 2009, and August 13, 2010, due to rate changes. The adjustment will apply an additional access payment to ASC claims that meet the criteria.

Week of December 13, 2010

Affected Providers Description of Adjustment
Ambulatory Surgery Center Providers ForwardHealth is automatically reprocessing claims for Ambulatory Surgery Centers (ASC) that originally processed and paid between July 1, 2009, and June 30, 2010, due to rate changes. The adjustment will apply an additional access payment to ASC claims that meet the criteria.

Week of December 6, 2010

Affected Providers Description of Adjustment
Providers Submitting Claims for Members Enrolled in the Chronic Renal Disease Program ForwardHealth is automatically reprocessing claims for Wisconsin Chronic Disease Program members enrolled in the Chronic Renal Disease program that denied in error with Explanation of Benefits code 0116, "Procedure Code or Drug Code not a benefit on Date of Service." This adjustment affects claims for dates of service on and after January 1, 2008, that originally processed between January 1, 2008, and October 12, 2010, to apply reimbursement as appropriate.
Providers Submitting Physician Professional Crossover Claims ForwardHealth is automatically adjusting physician professional crossover claims that processed from November 19, 2008, to July 10, 2010, because Medicaid's crossover reimbursement was not calculated correctly for procedures manually priced by ForwardHealth.
End-Stage Renal Disease Providers ForwardHealth is automatically adjusting outpatient claims for dates of service (DOS) on and after January 1, 2009, to return amounts deducted for copayment. All services rendered by end-stage renal disease (ESRD) providers are now exempted from the copayment requirement, even services rendered on a DOS when dialysis was not provided. This policy of exempting ESRD services from copayment does not apply to claims for members enrolled in the BadgerCare Plus Basic Plan. Copayments collected for services on DOS on and after January 1, 2009, should be returned to the member.

Week of November 29, 2010

Affected Providers Description of Adjustment
Inpatient Hospital Providers ForwardHealth is automatically reprocessing inpatient hospital claims that grouped to Diagnosis Related Groupings (DRGs) 981, 982, or 983 (Unrelated Operating Procedures) and denied incorrectly.

Week of November 22, 2010

Affected Providers Description of Adjustment
Providers Submitting Professional Claims ForwardHealth is adjusting claims submitted for educational services (procedure codes 98960-98962) that were incorrectly reimbursed for dates of service on and after January 1, 2010. Educational services are covered for members enrolled in the BadgerCare Plus Core Plan only. Educational Services were inadvertently reimbursed for members enrolled in other plans.
Pharmacy Providers ForwardHealth is automatically adjusting previously paid pharmacy claims processed between August 14, 2010, and October 12, 2010, with dates of service on and after July 1, 2010 for recoupment. ForwardHealth processed claims for Prenatabs RX Tablet and Re-nata 29 OB Prenatal Tablet incorrectly by not applying diagnosis and age restrictions. The provider cannot collect payment from a member unless the provider informed the member, prior to filling the prescription, that the member will be responsible for payment.
Nursing Home Providers ForwardHealth is automatically reprocessing non-emergency transportation claims for Family Care members that incorrectly paid for dates of service on and after March 1, 2010. Providers should submit claims to the member's Family Care program for reimbursement.
J&B Medical Supply Company ForwardHealth is reprocessing professional claims for dates of service from December 1, 2009, to September 17, 2010, that were denied with Explanation of Benefits code 1296: "Services billed are included in the nursing home rate structure."
Providers Submitting Professional Claims FowardHealth is automatically adjusting professional claims processed and paid between April 14, 2009, and January 8, 2010. ForwardHealth may have paid for multiple surgical procedure codes billed on the same date of service (DOS) in error. Providers are reminded that only one surgical procedure code is reimbursable per DOS.
Inpatient Hospital Providers ForwardHealth is automatically reprocessing inpatient hospital claims that grouped to Diagnosis Related Groupings (DRGs) 981, 982, or 983 (Unrelated Operating Procedures) and denied incorrectly.

Week of November 15, 2010

Affected Providers Description of Adjustment
Providers Submitting Inpatient Hospital Claims for Mental Health Services ForwardHealth is reprocessing certain inpatient hospital claims with a mental health diagnosis for BadgerCare Plus Core Plan members processed between January 1, 2009, and July 30, 2010, with dates of service between January 1, 2009, and July 30, 2010. These claims were incorrectly processed. Inpatient hospital psychiatric stays are not covered under the Core Plan.
Inpatient and Outpatient Hospital Providers ForwardHealth is automatically reprocessing inpatient and outpatient crossover claims for dates of process on and after June 11, 2009, to correct potential overpayments for claims submitted with Medicare dollar amounts incorrectly included at both the header and detail level.

Week of November 8, 2010

Affected Providers Description of Adjustment
Wisconsin Chronic Disease Program Providers Billing Procedure Code J1756 ForwardHealth is automatically reprocessing claims that were denied for procedure code J1756 (Injection, iron sucrose, 1 mg) for dates of service (DOS) from January 1, 2009, to February 2, 2010. Effective for DOS on and after January 1, 2009, procedure code J1756 is an allowable procedure code for Wisconsin Chronic Disease Program claims.
Critical Access Hospitals ForwardHealth is automatically adjusting inpatient and outpatient hospital claims for critical access hospitals that processed between July 1, 2010, and September 2, 2010, with dates of service (DOS) on and after July 1, 2010. Access payments resulting in increased reimbursement will be applied to claims retroactive to July 1, 2010, DOS.
Providers Submitting Claims for Durable Medical Equipment and Disposable Medical Supplies ForwardHealth is adjusting certain professional claims for durable medical equipment and disposable medical supplies processed between September 21, 2010, and September 24, 2010. Limitations were incorrectly bypassed for services requiring prior authorization.
Providers Submitting Institutional Outpatient Claims ForwardHealth is reprocessing outpatient claims that were processed between June 18, 2010, and September 10, 2010, with dates of service between June 18, 2010, and September 10, 2010. A restriction was incorrectly applied to outpatient claims with mental health diagnoses for BadgerCare Plus Core Plan members causing claims to be denied inappropriately.
Dentists, Home Health Agencies, and Physicians ForwardHealth is adjusting certain dental, home health, and physician professional claims and physician professional crossover claims processed between November 10, 2008, and July 30, 2010. Services billed on the affected claims were applied to a prior authorization (PA) where the authorized number of services had already been met or where the services billed on the claim met and then exceeded the number of authorized services on the PA. The charge for the service may be collected from the member if the following conditions are met prior to the delivery of that service: the member accepts responsibility for payment and the provider and member make payment arrangements for the service. Providers are strongly encouraged to monitor the services used on the PA and obtain a written statement in advance documenting that the member has accepted responsibility for the payment of the service when no services are remaining on the PA.
Inpatient and Outpatient Hospital Providers ForwardHealth is automatically reprocessing inpatient and outpatient crossover claims for dates of process on and after June 11, 2009, to correct potential overpayments for claims submitted with Medicare dollar amounts incorrectly included at both the header and detail level.

Week of November 1, 2010

Affected Providers Description of Adjustment
Providers Submitting Inpatient and Outpatient Hospital Claims ForwardHealth is reprocessing inpatient and outpatient hospital claims for BadgerCare Plus Basic Plan members processed between July 7, 2010, and September 10, 2010. Inpatient and outpatient hospital claims were applied to the Basic Plan member's deductible because the hospital did not request an authorization even though the member had authorizations available for an inpatient stay or an outpatient visit. ForwardHealth will reprocess the claims and automatically apply the available authorizations to the claim, which may allow the provider to be reimbursed and the charges removed from the member's inpatient and outpatient hospital deductible.
Providers Submitting Outpatient Hospital Claims ForwardHealth is automatically adjusting outpatient hospital claims with dates of service on and after July 1, 2010. A required copayment amount was not applied to claims with emergency room revenue codes for BadgerCare Plus Basic Plan members resulting in overpayments.
Providers Submitting Professional Claims and Professional Crossover Claims ForwardHealth is adjusting claims for tuberculosis-related procedures processed between November 10, 2008, and August 12, 2010, to refund copayment amounts deducted in error. Copayment was incorrectly applied to claims with procedure codes 86580, 94664, 99401, 99402, 99403, 99404, and S9445. Providers are required to refund the members for any copayment amount collected in error.
Inpatient Hospital Providers ForwardHealth is automatically reprocessing inpatient hospital claims that grouped to Diagnosis Related Groupings (DRGs) 981, 982, or 983 (Unrelated Operating Procedures) and denied incorrectly.
Providers Submitting Professional Medicare Crossover Claims ForwardHealth is automatically reprocessing professional Medicare crossover claims that processed between November 10, 2008, and July 30, 2010, and denied in error with Explanation of Benefits code 1269, "The sum of the Medicare paid, deductible(s), coinsurance, copayment, and psychiatric reduction amounts does not equal the Medicare allowed amount."

Week of October 25, 2010

Affected Providers Description of Adjustment
Providers Submitting Claims for Mental Health and Substance Abuse Services ForwardHealth is automatically reprocessing claims for mental health and substance abuse services requiring prior authorization (PA) that originally processed between June 1, 2009, and September 17, 2009, that denied in error with Explanation of Benefits code 0218, "Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines." The claim adjustment will correctly apply the PA thresholds per billing provider.
Providers Submitting Inpatient Hospital Claims ForwardHealth is adjusting inpatient hospital claims that were processed and incorrectly paid between July 13, 2010, and August 18, 2010. Certain services requiring prior authorization (PA) on a claim were denied when the entire claim should have been denied for PA.
Providers Submitting Hospital Claims and Hospital Crossover Claims ForwardHealth is reprocessing inpatient hospital claims for emergency services that processed between July 1, 2010, and September 12, 2010. The BadgerCare Plus Basic Plan member deductible was incorrectly applied to emergency room services (revenue codes in the range of 450-459). Providers should not bill the member for these services and are required to refund the member for any payment collected in error.
Providers Submitting the Following Claim Types (Inpatient, Outpatient, Professional, Pharmacy, Compound) ForwardHealth is automatically adjusting claims that were originally processed between September 1, 2010, and September 23, 2010. These claims were processed incorrectly due to incorrect information supplied by a commercial health insurance carrier.

Week of October 11, 2010

Affected Providers Description of Adjustment
Providers Billing Procedure Code 96361 ForwardHealth is automatically reprocessing professional claims with a denied detail for CPT (Current Procedural Terminology) code 96361 (Intravenous infusion, hydration; each additional hour) for dates of service from January 1, 2009, to June 3, 2010. Effective for dates of service on and after January 1, 2009, procedure 96361 is an allowable add-on code for primary procedures 96365, 96374, 96409, and 96413.
Physicians, Physician Assistants, Nurse Practitioners and Federally Qualified Health Centers ForwardHealth is automatically reprocessing claims for Current Procedural Terminology procedure codes 51728 and 51729 that originally processed between January 1, 2010, and July 2, 2010, using incorrect reimbursement rates. These adjustments will apply the correct reimbursement rate to the claims.
Nurse Practitioners and Family Planning Clinics ForwardHealth is automatically reprocessing denied professional claims for Healthcare Common Procedure Coding System (HCPCS) procedure codes J7304 (Contraceptive supply, hormone containing patch, each) and S4993 (Contraceptive pills for birth control) processed between August 1, 2010 and August 5, 2010.
Border Status Outpatient Hospitals ForwardHealth is automatically adjusting border status outpatient hospital claims with dates of service from July 1, 2009, to June 30, 2010, to apply a retroactive rate reduction.

Week of September 27, 2010

Affected Providers Description of Adjustment
Providers Submitting Crossover Claims for Members Enrolled in Medicare Part B ForwardHealth is automatically reprocessing crossover claims for anesthesia services for dates of service prior to April 1, 2010, that originally processed and paid between April 1, 2010, and July 12, 2010, to apply the correct reimbursement rates. Wisconsin Medicaid reimburses the full coinsurance amount for anesthesia services for members enrolled in Medicare Part B.

Week of September 20, 2010

Affected Providers Description of Adjustment
Providers Submitting Professional Crossover Claims ForwardHealth is automatically adjusting professional crossover claims that originally processed and paid between November 10, 2008, and April 29, 2009, and did not properly apply a coinsurance, copayment, or psychiatric reduction amount. The affected claims did not indicate paid amounts at the detail level, which is contrary to ForwardHealth policy.

Crossover claims submitted on paper with the Medicare remittance advice attached and crossover claims with only one detail will be adjusted to apply the correct cutback amount. Providers are not required to take any action on these claims. All other crossover claims will be denied with Explanation of Benefits (EOB) code 1549, "Sum of detail Medicare paid amounts does not equal header Medicare paid amount." Providers are required to resubmit crossover claims that deny as a result of this adjustment in order to receive payment. Providers are reminded that ForwardHealth requires a paid amount to be indicated at the detail level for professional crossover claims.

Claims that are beyond the timely filing deadline must be received by ForwardHealth Timely Filing before November 30, 2010. Providers may submit one Timely Filing Appeals Request form, F-13047, per batch of claims. When completing the form, providers should place a check in the "ForwardHealth Reconsideration" box and write "Adjust claim denials for EOB message 1549 for professional crossover claims without claim detail amounts" to explain the nature of the problem.

Pharmacy Providers Submitting Claims for Members Enrolled in the BadgerCare Plus Basic Plan ForwardHealth is automatically reprocessing pharmacy claims for members enrolled in the BadgerCare Plus Basic Plan for dates of service (DOS) on and after July 1, 2010, that originally processed between July 1, 2010, and August 26, 2010, and denied in error with Explanation of Benefits codes 1359, 1365, 1366, or 1382. This adjustment affects claims for diabetic supplies that were covered under the Basic Plan for the DOS and will pay the claims as appropriate.
Providers Submitting Claims for Members Enrolled in the Chronic Renal Disease Program ForwardHealth is automatically reprocessing claims for Wisconsin Chronic Disease Program members enrolled in the Chronic Renal Disease program that denied in error with Explanation of Benefits code 0116, "Procedure Code or Drug Code not a benefit on Date of Service." This adjustment affects claims for dates of service between August 1, 2008, and May 31, 2009, that originally processed between November 10, 2008, and June 1, 2010, to apply reimbursement as appropriate.

Week of September 13, 2010

Affected Providers Description of Adjustment
Providers Submitting Professional Crossover Claims ForwardHealth is automatically adjusting professional crossover claims that originally processed and paid between November 10, 2008, and April 29, 2009, and did not properly apply a coinsurance, copayment, or psychiatric reduction amount. The affected claims did not indicate paid amounts at the detail level, which is contrary to ForwardHealth policy.

Crossover claims submitted on paper with the Medicare remittance advice attached and crossover claims with only one detail will be adjusted to apply the correct cutback amount. Providers are not required to take any action on these claims. All other crossover claims will be denied with Explanation of Benefits (EOB) code 1549, "Sum of detail Medicare paid amounts does not equal header Medicare paid amount." Providers are required to resubmit crossover claims that deny as a result of this adjustment in order to receive payment. Providers are reminded that ForwardHealth requires a paid amount to be indicated at the detail level for professional crossover claims.

Claims that are beyond the timely filing deadline must be received by ForwardHealth Timely Filing before November 30, 2010. Providers may submit one Timely Filing Appeals Request form, F-13047, per batch of claims. When completing the form, providers should place a check in the "ForwardHealth Reconsideration" box and write "Adjust claim denials for EOB message 1549 for professional crossover claims without claim detail amounts" to explain the nature of the problem.

Providers Submitting Outpatient Claims for Mental Health and Substance Abuse Services ForwardHealth is automatically reprocessing outpatient claims for mental health and substance abuse services requiring prior authorization (PA) that processed between June 1, 2009, and September 17, 2009, with dates of service on and after January 1, 2009. These claims were denied in error with Explanation of Benefits code 0218, "Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines." The claim adjustment will correctly apply the PA thresholds per billing provider.
Providers Submitting Institutional Inpatient Claims ForwardHealth is automatically reprocessing claims that originally processed between November 10, 2008, and June 12, 2010, and denied in error. Due to a system issue, the primary diagnosis code was not properly identified and the claim denied. This adjustment will identify the correct primary diagnosis code and pay claims if appropriate.
Chiropractic Providers ForwardHealth is automatically reprocessing chiropractic claims for X-rays (including procedure codes 72010 through 73564) that originally processed between November 10, 2008, and June 24, 2010, and denied in error with Explanation of Benefits code 0139, "Four X-rays are allowed per spell of illness per provider. Reconsideration With Documentation Warranting More X-rays." Providers are reminded that four X-rays are allowed per member per date of service during the member's spell of illness.
Nursing Homes ForwardHealth is adjusting certain long term care claims that were processed and paid after November 10, 2008. Long term care claims that exceeded the number of allowable days for accommodations details are being adjusted. The affected claims are being voided with Explanation of Benefits code 0636, "Program limits were exceeded," attached to them and will need to be resubmitted by the provider with the correct number of units on the accommodation details.

Week of September 6, 2010

Affected Providers Description of Adjustment
Providers Submitting Professional Crossover Claims ForwardHealth is automatically adjusting professional crossover claims that originally processed and paid between November 10, 2008, and April 29, 2009, and did not properly apply a coinsurance, copayment, or psychiatric reduction amount. The affected claims did not indicate paid amounts at the detail level, which is contrary to ForwardHealth policy.

Crossover claims submitted on paper with the Medicare remittance advice attached and crossover claims with only one detail will be adjusted to apply the correct cutback amount. Providers are not required to take any action on these claims. All other crossover claims will be denied with Explanation of Benefits (EOB) code 1549, "Sum of detail Medicare paid amounts does not equal header Medicare paid amount." Providers are required to resubmit crossover claims that deny as a result of this adjustment in order to receive payment. Providers are reminded that ForwardHealth requires a paid amount to be indicated at the detail level for professional crossover claims.

Claims that are beyond the timely filing deadline must be received by ForwardHealth Timely Filing before November 30, 2010. Providers may submit one Timely Filing Appeals Request form, F-13047, per batch of claims. When completing the form, providers should place a check in the "ForwardHealth Reconsideration" box and write "Adjust claim denials for EOB message 1549 for professional crossover claims without claim detail amounts" to explain the nature of the problem.

Providers Submitting Institutional Claims ForwardHealth is automatically adjusting institutional claims that originally processed and paid between November 10, 2008, and October 1, 2009, to identify duplicate claims that were submitted for the same member during the same time period. Claims identified as duplicates as a result of this adjustment will be denied.
Home Health Providers ForwardHealth is automatically adjusting claims for home health services originally processed and paid between July 1, 2008, and August 29, 2008, that paid at the incorrect rate. The adjustment will apply the correct rate increase for home health services.

Week of August 30, 2010

Affected Providers Description of Adjustment
Dental Providers ForwardHealth is automatically reprocessing dental claims for dates of service prior to June 30, 2010, that originally processed between June 25, 2010, and June 30, 2010, and denied in error. Providers received Explanation of Benefit code 0287, "Member is enrolled in a State-contracted managed care program for the Date(s) of Service," when submitting claims for certain dental services for members enrolled in a Social Security Income (SSI) managed care program that covers only medical services. Most dental services are reimbursed under fee-for-service for members enrolled in SSI managed care programs that only cover medical services.

Week of August 23, 2010

Affected Providers Description of Adjustment
Providers Submitting Claims for Mental Health and Substance Abuse Services ForwardHealth is automatically reprocessing claims for mental health and substance abuse services requiring prior authorization (PA) that originally processed between June 1, 2009, and September 17, 2009, that denied in error with Explanation of Benefits code 0218, "Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines." The claim adjustment will correctly apply the PA thresholds per billing provider.
Providers Submitting Crossover Claims for Members Enrolled in Medicare Part B ForwardHealth is automatically reprocessing crossover claims for anesthesia services for dates of service prior to April 1, 2010, that originally processed and paid between April 1, 2010, and July 12, 2010, to apply the correct reimbursement rates. Wisconsin Medicaid reimburses the full coinsurance amount for anesthesia services for members enrolled in Medicare Part B.

Week of August 16, 2010

Affected Providers Description of Adjustment
Hospital Providers Submitting Claims for Neonates ForwardHealth is automatically adjusting institutional claims submitted for neonates that were originally processed between November 10, 2008, and August 5, 2010, and were reimbursed incorrectly having been assigned to the wrong Diagnosis-Related Group (DRG). Wisconsin Medicaid is adjusting the claims to assign the correct DRG so that the claims can be reimbursed correctly.
Providers Submitting Professional and Dental Claims ForwardHealth is adjusting claims that were originally processed between August 21, 2009, and January 15, 2010. The billing provider was incorrectly identified as the rendering provider on certain claims resulting in improper payments. This adjustment may result in recouping payment on individual details or on the entire claim.

Week of August 9, 2010

Affected Providers Description of Adjustment
Wisconsin Chronic Disease Program Providers Submitting Claims for Procedure Code J2997 ForwardHealth is automatically reprocessing claims for procedure code J2997 for dates of service (DOS) on and after January 1, 2008, through the present that originally processed between January 1, 2008, and June 11, 2010, and denied in error with Explanation of Benefits code 0116, "Procedure Code or Drug Code not a benefit on Date of Service." Procedure code J2997 is a reimbursable procedure code for members enrolled in the Wisconsin Chronic Disease Program Chronic Renal Program for DOS on and after January 1, 2008.
Wisconsin Chronic Disease Program Providers Submitting Claims for Procedure Code Q4081 ForwardHealth is automatically reprocessing claims for procedure code Q4081 for dates of service (DOS) on and after January 1, 2009, that originally processed between January 1, 2009, and June 1, 2010, and denied in error with Explanation of Benefits code 0116, "Procedure Code or Drug Code not a benefit on Date of Service." Procedure code Q4081 is a reimbursable procedure code for members enrolled in the Wisconsin Chronic Disease Program Chronic Renal Program for DOS on and after January 1, 2009.
Hospital Providers Submitting Claims for Neonates ForwardHealth is automatically adjusting institutional claims submitted for neonates that were originally processed between November 10, 2008, and August 5, 2010, and were reimbursed incorrectly having been assigned to the wrong Diagnosis-Related Group (DRG). Wisconsin Medicaid is adjusting the claims to assign the correct DRG so that the claims can be reimbursed correctly.

Week of August 2, 2010

Affected Providers Description of Adjustment
Providers Submitting Dental Claims ForwardHealth is automatically reprocessing dental claims that originally processed and paid between November 10, 2008, and August 1, 2009. Certain duplicate claims that were not previously identified as duplicates were erroneously paid and will be recouped.
Providers Submitting Claims for Therapy Services ForwardHealth is automatically adjusting claims for certain therapy services originally processed and paid between November 8, 2008, and June 1, 2009. Claims for procedure codes 97530, 97532, 97533, and 97535 were reimbursed at the incorrect maximum allowable fee rate. This adjustment will apply the correct reimbursement rate to the claims.
Providers Submitting Claims for Members Enrolled in Express Enrollment for Pregnant Women ForwardHealth is automatically reprocessing claims for members enrolled in Express Enrollment for Pregnant Women with dates of service between November 10, 2008, and April 2, 1010. Claims with diagnosis code V72.42 denied in error. Providers are required to return any payment collected from members for these services.
Providers Submitting Professional and Institutional Outpatient Claims ForwardHealth is automatically adjusting certain claims with dates of service between November 10, 2008, and June 10, 2010, to apply the correct policy-specific quantity cutback amount for the procedure code billed.
Providers Submitting Professional Claims ForwardHealth is reprocessing professional claims that originally processed between November 10, 2008, and March 3, 2009. Certain duplicate claims that were not previously identified as duplicates were erroneously paid and will be recouped.
Outpatient Mental Health and Substance Abuse Services Providers ForwardHealth is reprocessing certain professional mental health and substance abuse services claims that were originally processed between November 10, 2008, and March 18, 2009. Claims originally processed and paid or denied without reference to the rendering provider that was indicated on the claim. ForwardHealth will reprocess all of these paid and denied claims, some of which will process as they originally did. Claims that are denied may be corrected and resubmitted. Denied claims that are beyond the 365-day timely filing deadline must be submitted to Timely Filing Appeals to be considered for reimbursement. Timely filing appeals requests for this issue must be received by ForwardHealth on or before September 30, 2010. When completing the Timely Filing Appeals Request, F-13047, providers should check the "ForwardHealth Reconsideration" box and write in the comment section at the bottom of the form, "Outpatient mental health and substance abuse services professional claim adjustment for rendering provider issue." Providers do not need to indicate the claim number or payer claim control number, the Remittance Advice number, the 835 Health Care Claim Payment/Advice transaction number, or the check issue date on the form. Providers may complete a single Timely Filing Appeals Request to serve as the cover sheet for all claims or adjustments to claims that are beyond the 365-day timely filing deadline.
Ambulance Providers, Dentists, Home Health Agencies, Hospital Providers, Independent Labs, Individual Medical Supply Providers, Medical Equipment Vendors, Personal Care Agencies, Pharmacies, Physician Clinics, Physicians, and Portable X-ray Providers ForwardHealth is reprocessing certain claims for services that require prior authorization that originally processed on and after March 13, 2010. Claims were incorrectly identified as duplicate claims and were denied with Explanation of Benefits code 0289, "Out-of-State non-emergency services require Prior Authorization."

Week of July 19, 2010

Affected Providers Description of Adjustment
Pharmacies ForwardHealth is adjusting pharmacy claims processed between April 1, 2010, and April 12, 2010, with dates of service on and after April 1, 2010, that were paid in error. Quantity limits for certain drugs were incorrectly bypassed. Providers can contact the Drug Authorization and Policy Override (DAPO) Call Center at (800) 947-9627 between 8:00 a.m. and 5:30 p.m. Monday through Friday to request policy overrides for quantity limit restrictions. If a policy override is granted, providers may resubmit the claim for payment.
Pharmacies ForwardHealth is adjusting pharmacy claims for the drug Alprazolam processed between May 1, 2010, and June 16, 2010, with dates of service on and after May 1, 2010. ForwardHealth applied brand name pricing with the corresponding copayment when the drug should have been paid with generic pricing and the corresponding copayment. Providers are required to refund the members for any copayment collected in error.

Week of July 12, 2010

Affected Providers Description of Adjustment
Advanced Practice Nurse Prescribers and Physician Assistants Billing for Mental Health Services ForwardHealth is reprocessing certain crossover claims processed between November 10, 2008, and April 13, 2010, that were denied in error. Providers received Explanation of Benefits code 0287, "Member is enrolled in a State-contracted managed care program for the Date(s) of Service," when submitting claims for mental health services for members enrolled in Family Care. Mental health services are reimbursed under fee-for-service for members enrolled in Family Care when performed by advanced practice nurse prescribers or physician assistants.
Providers Submitting Professional Crossover Claims ForwardHealth is automatically adjusting certain professional crossover claims that originally processed between November 10, 2008, and April 10, 2010. The affected claims were paid in error and will be denied with Explanation of Benefits code 0841, "The timely filing deadline was exceeded."
Day Treatment Providers, HealthCheck "Other Services" Providers, Mental Health and Substance Abuse Services Providers, Psychiatrists, and Nurse Practitioners Effective on and after July 8, 2010, the ForwardHealth Portal has been modified to allow providers to override prior authorization (PA) edit 2017, "The member is enrolled in a Medicaid or BadgerCare Plus HMO or other managed care program," for certain services when the PA request is for a member who is enrolled in a BadgerCare Plus HMO or Supplemental Security Income (SSI) HMO. The PA edit 2017 override allows PA requests to be submitted via the Portal and the requests are no longer required to be submitted on paper by mail or fax."

Fee-for-service PA requests for certain services are accepted by ForwardHealth for members enrolled in a BadgerCare Plus HMO or SSI HMO who are applying for an exemption from HMO enrollment and will receive their services on a fee-for-service basis if their HMO exemption is approved.

To override PA Edit 2017, providers are required to do the following:
  • Resolve all other messages and edits.
  • Click on "Ignore."
  • Click on "Continue."
Providers may refer to the ForwardHealth Online Handbook for policy about HMO member enrollment and disenrollment.
Providers Submitting Claims for Members Enrolled in a Medicaid HMO ForwardHealth is automatically reprocessing claims for members enrolled in Medicaid HMOs that processed between January 1, 2010, and May 14, 2010, and paid in error. Providers should submit claims to the member's HMO for payment.

Week of July 5, 2010

Affected Providers Description of Adjustment
Wisconsin Chronic Disease Program Providers ForwardHealth is automatically adjusting claims for Wisconsin Chronic Disease Program services that denied in error with Explanation of Benefits codes 0116, "Procedure Code or Drug Code not a benefit on Date of Service," and 1321, "Incorrect or invalid NDC/Procedure Code/Revenue Code billed for Date of Service." This adjustment affects claims for procedure codes 90951 — 90970 for dates of service (DOS) after January 1, 2009, and claims for procedure code 90999 for DOS after January 1, 2008, originally processed between January 1, 2009, and November 16, 2009.
Providers Submitting Professional Claims for Anesthesia Services ForwardHealth is adjusting anesthesia claims that were processed between May 1, 2010, and May 27, 2010, with dates of service on (DOS) or after May 1, 2010. Effective for DOS on or after May 1, 2010, relative value units (RVUs) have been updated for the following anesthesia Current Procedural Terminology (CPT) codes: 00142, 00147, 00300, 00326, 00529, 00540, 00797, 01173, 01916, 01924, 01925, 01926, 01932, 01933, 01963, and 01968. Relative value units are assigned for certain anesthesia CPT codes and are used in determining reimbursement for a major procedure. Providers are reminded that they should not submit claims with RVUs for the procedure performed. ForwardHealth automatically includes RVUs when reimbursement is calculated.
Providers Submitting Claims for Members Enrolled in Medicare Advantage Plan ForwardHealth is automatically reprocessing claims for members enrolled in the Medicare Advantage Plan that were originally processed and paid between November 10, 2008, and April 23, 2010, and denied in error with Explanation of Benefits Code 0771, "Member has Medicare Managed Care for the Date(s) of Service." This adjustment applies the correct reimbursement rate to claims submitted with Medicare disclaimer codes "M-7" or "M-8," which are reimbursable by ForwardHealth for members enrolled in the Medicare Advantage Plan.
Providers Submitting Claims for Members Enrolled in a Medicaid HMO ForwardHealth is automatically reprocessing claims for members enrolled in Medicaid HMOs that processed between January 1, 2010, and May 14, 2010, and paid in error. Providers should submit claims to the member's HMO for payment.
Hospice Providers Submitting Claims for Members Enrolled in the Pharmacy Services Lock-In Program ForwardHealth is automatically reprocessing hospice claims processed between November 10, 2008, and March 25, 2010, for members enrolled in hospice care and the Pharmacy Services Lock-In Program that denied in error.
Disposable Medical Supply Providers ForwardHealth is automatically adjusting claims for disposable medical supplies (DMS) for members enrolled in the BadgerCare Plus Benchmark Plan with dates of process between October 1, 2008, and December 4, 2008, that paid in error. This adjustment will recoup reimbursement for DMS items that are not covered under the Benchmark Plan. Providers may collect payment for noncovered services from members if the member accepted responsibility for payment and the provider and member made payment arrangements for the service prior to delivery of the services. Providers are prohibited from collecting payment from members if the member was not informed of his or her financial responsibility prior to the delivery of the services.

Week of June 28, 2010

Affected Providers Description of Adjustment
Pharmacy Providers Attention Pharmacy Providers:
ForwardHealth is reprocessing pharmacy claims processed on and after May 1, 2010, for certain generic statins. The claims denied in error when the day's supply exceeded 34 days.
In-State Emergency Dental Providers ForwardHealth is automatically reprocessing dental claims for in-state emergency dental services that originally processed between November 10, 2008, and February 13, 2010, and denied in error with Explanation of Benefits code 0289, "Out-of-State non-emergency services require Prior Authorization." Claims for covered emergency dental services that indicate an in-state emergency dental provider as the rendering provider are reimbursable by ForwardHealth.

Week of June 14, 2010

Affected Providers Description of Adjustment
Providers Submitting Professional Crossover Claims ForwardHealth is automatically adjusting professional crossover claims that originally processed and paid between November 10, 2008, and April 29, 2009, and did not properly apply a coinsurance, copayment, or psychiatric reduction amount. The affected claims did not indicate paid amounts at the detail level, which is contrary to ForwardHealth policy.

Crossover claims submitted on paper with the Medicare remittance advice attached and crossover claims with only one detail will be adjusted to apply the correct cutback amount. Providers are not required to take any action on these claims. All other crossover claims will be denied with Explanation of Benefits (EOB) code 1549, "Sum of detail Medicare paid amounts does not equal header Medicare paid amount." Providers are required to resubmit crossover claims that deny as a result of this adjustment in order to receive payment. Providers are reminded that ForwardHealth requires a paid amount to be indicated at the detail level for professional crossover claims.

Claims that are beyond the timely filing deadline must be received by ForwardHealth Timely Filing before September 30, 2010. Providers may submit one Timely Filing Appeals Request form, F-13047, per batch of claims. When completing the form, providers should place a check in the "ForwardHealth Reconsideration" box and write "Adjust claim denials for EOB message 1549 for professional crossover claims without claim detail amounts" to explain the nature of the problem.
Providers Submitting Dental Claims ForwardHealth is automatically reprocessing dental claims that originally processed and paid between November 10, 2008, and August 1, 2009. Certain duplicate claims that were not previously identified as duplicates were erroneously paid and will be recouped.
Wisconsin Chronic Disease Program Providers Submitting Claims for Procedure Code 80195 ForwardHealth is automatically reprocessing Wisconsin Chronic Disease Program (WCDP) claims for procedure code 80195 for dates of service (DOS) on and after January 1, 2008, that originally processed between January 1, 2008, and November 30, 2009, and denied in error with Explanation of Benefits code 0116, "Procedure Code or Drug Code not a benefit on Date of Service." Procedure code 80195 is a reimbursable procedure code for members enrolled in the WCDP Chronic Renal Program for DOS on and after January 1, 2008.
HealthCheck Providers ForwardHealth is automatically reprocessing claims for procedure codes 99382 and 99392 that originally processed and paid between November 10, 2008, and April 7, 2010, and paid in error. The adjustment will recoup payment for services that exceeded the allowed amounts.

Week of June 7, 2010

Affected Providers Description of Adjustment
Providers Submitting Professional Crossover Claims ForwardHealth is automatically adjusting professional crossover claims that originally processed and paid between November 10, 2008, and April 29, 2009, and did not properly apply a coinsurance, copayment, or psychiatric reduction amount. The affected claims did not indicate paid amounts at the detail level, which is contrary to ForwardHealth policy.

Crossover claims submitted on paper with the Medicare remittance advice attached and crossover claims with only one detail will be adjusted to apply the correct cutback amount. Providers are not required to take any action on these claims. All other crossover claims will be denied with Explanation of Benefits (EOB) code 1549, "Sum of detail Medicare paid amounts does not equal header Medicare paid amount." Providers are required to resubmit crossover claims that deny as a result of this adjustment in order to receive payment. Providers are reminded that ForwardHealth requires a paid amount to be indicated at the detail level for professional crossover claims.

Claims that are beyond the timely filing deadline must be received by ForwardHealth Timely Filing before September 30, 2010. Providers may submit one Timely Filing Appeals Request form, F-13047, per batch of claims. When completing the form, providers should place a check in the "ForwardHealth Reconsideration" box and write "Adjust claim denials for EOB message 1549 for professional crossover claims without claim detail amounts" to explain the nature of the problem.

Week of May 31, 2010

Affected Providers Description of Adjustment
HealthCheck Providers ForwardHealth is automatically reprocessing claims for procedure codes 99382 and 99392 that originally processed and paid between November 10, 2008, and April 7, 2010, and paid in error. The adjustment will recoup payment for services that exceeded the allowed amounts.
Providers Submitting Professional and Professional Crossover Claims ForwardHealth is automatically reprocessing claims that originally processed between November 10, 2008, and March 3, 2010, and denied in error during manual processing with Explanation of Benefits codes 1246 or 1510, "Rendering Provider indicated is not certified as a rendering provider."

Week of May 24, 2010

Affected Providers Description of Adjustment
Providers Submitting Claims for Services Requiring Prior Authorization ForwardHealth is automatically adjusting claims for services that require prior authorization (PA) that originally processed and paid between November 10, 2008, and January 16, 2010. In certain cases, ForwardHealth paid in error for services requiring PA when the date of service (DOS) on the claim detail was before the PA grant date or after the PA expiration date. Providers are reminded that services requiring PA are not reimbursable unless a valid PA is on file for the DOS that the service is rendered.
Providers Submitting Professional Claims ForwardHealth is reprocessing claims billed with procedure code 90698 (Diptheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated [DtaP-Hib-IPV], for intramuscular use) that were processed between September 1, 2008, and December 3, 2009. The maximum allowable fee for procedure code 90698 has been updated.
Providers Submitting Professional Claims ForwardHealth is adjusting certain vision claims originally processed between November 8, 2008, and February 17, 2010. Copayment was incorrectly deducted from vision claims for members under age 18.
Providers Submitting Professional Claims ForwardHealth is reprocessing professional claims that originally processed between June 23, 2006, and April 8, 2010. Certain duplicate claims that were not previously identified as duplicates were erroneously paid and will be recouped.
Providers Billing for Procedure Codes 90760 and 90766 ForwardHealth is automatically reprocessing claims for procedure codes 90760 and 90766 with dates of service prior to January 1, 2009, that originally processed between January 1, 2009, and August 20, 2009, and were denied in error.
Providers Submitting Claims for Mental Health and Substance Abuse Services ForwardHealth is automatically reprocessing claims for mental health and substance abuse services requiring prior authorization (PA) that originally processed between June 1, 2009, and September 17, 2009, that denied in error with Explanation of Benefits code 0218, "Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines." The claim adjustment will properly adjudicate claims to apply the new PA limits for mental health and substance abuse services.

Week of May 17, 2010

Affected Providers Description of Adjustment
Providers Submitting Claims for Services Requiring Prior Authorization ForwardHealth is automatically adjusting claims for services that require prior authorization (PA) that originally processed and paid between November 10, 2008, and January 16, 2010. In certain cases, ForwardHealth paid in error for services requiring PA when the date of service (DOS) on the claim detail was before the PA grant date or after the PA expiration date. Providers are reminded that services requiring PA are not reimbursable unless a valid PA is on file for the DOS that the service is rendered.
Adult Mental Health Day Treatment Providers ForwardHealth is automatically reprocessing claims for procedure code H2012 (Behavioral health day treatment, per hour) with modifier "HE" that originally processed between November 10, 2008, and March 22, 2009, and denied in error with Explanation of Benefits code 1282, "PA required for payment of this service. Procedure Code and modifiers billed must match approved PA." Providers are reminded that procedure code H2012 with modifier "HE" does not require prior authorization until the member has exceeded 90 units per calendar year.
Providers Submitting Institutional Inpatient Claims ForwardHealth is automatically adjusting certain institutional inpatient claims originally processed and paid between March 12, 2010, and April 23, 2010, that were assigned the wrong diagnosis-related group (DRG) resulting in an incorrect payment. This adjustment will apply the correct DRG payment to the claims.
Providers Submitting Claims With Manually Priced Procedure Codes ForwardHealth is initiating adjustments to correctly process claims that processed after November 10, 2008. Certain claims with manually priced procedure codes may have been reimbursed an incorrect amount due to a clerical error. The affected claims are being adjusted to apply the correct reimbursement amount.
Providers Submitting Institutional Claims for Members Enrolled in Medicare Part A ForwardHealth is automatically reprocessing institutional claims for members enrolled in Medicare Part A that originally processed between November 8, 2008, and April 16, 2009. Due to a system issue, these claims may have been adjudicated incorrectly. The adjustment will properly apply billing rules for Medicare Part A.
Attention Providers Submitting Institutional Inpatient Claims ForwardHealth is adjusting claims that were processed between November 8, 2008, and March 29, 2010. Institutional inpatient claims with certain revenue codes were incorrectly denied with Explanation of Benefits codes 0116, "Procedure Code or Drug Code not a benefit on Date of Service," and 0770, "The Revenue Code is not allowed for the Type of Bill indicated on the claim."

Week of May 10, 2010

Affected Providers Description of Adjustment
Providers Submitting Claims for Services Requiring Prior Authorization ForwardHealth is automatically adjusting claims for services that require prior authorization (PA) that originally processed and paid between November 10, 2008, and January 16, 2010. In certain cases, ForwardHealth paid in error for services requiring PA when the date of service (DOS) on the claim detail was before the PA grant date or after the PA expiration date. Providers are reminded that services requiring PA are not reimbursable unless a valid PA is on file for the DOS that the service is rendered.
Adult Mental Health Day Treatment Providers ForwardHealth is automatically reprocessing claims for procedure code H2012 (Behavioral health day treatment, per hour) with modifier "HE" that originally processed between November 10, 2008, and March 22, 2009, and denied in error with Explanation of Benefits code 1282, "PA required for payment of this service. Procedure Code and modifiers billed must match approved PA." Providers are reminded that procedure code H2012 with modifier "HE" does not require prior authorization until the member has exceeded 90 units per calendar year.
Providers Submitting Institutional Inpatient Claims ForwardHealth is automatically adjusting certain institutional inpatient claims originally processed and paid between March 12, 2010, and April 23, 2010, that were assigned the wrong diagnosis-related group (DRG) resulting in an incorrect payment. This adjustment will apply the correct DRG payment to the claims.
Attention Providers Submitting Institutional Outpatient Claims ForwardHealth is reprocessing institutional outpatient claims that originally processed between February 1, 2008, and September 22, 2009. Certain duplicate claims that were not previously identified as duplicates were erroneously paid and will be recouped.
Attention Providers Submitting Institutional Inpatient Crossover Claims, Institutional Outpatient Crossover Claims, or Institutional Outpatient Claims ForwardHealth is reprocessing institutional inpatient and outpatient crossover claims and institutional outpatient claims that originally processed between May 2, 2008, and August 14, 2009. Certain duplicate claims that were not previously identified as duplicates were erroneously paid and will be recouped.
Mental Health Providers ForwardHealth is reprocessing claims that were processed between November 26, 2008, and September 25, 2009. Certain mental health claims with central nervous system assessment procedure codes 96101-96120 were incorrectly denied.
Providers Submitting Claims With Manually Priced Procedure Codes ForwardHealth is initiating adjustments to correctly process claims that processed after November 10, 2008. Certain claims with manually priced procedure codes may have been reimbursed an incorrect amount due to a clerical error. The affected claims are being adjusted to apply the correct reimbursement amount.
Providers Submitting Long Term Care Claims ForwardHealth is automatically reprocessing long term care claims that originally processed between November 8, 2008, and April 10, 2010, and denied in error with Explanation of Benefits code 1509, "Billing Provider indicated is not certified as a billing provider."

Week of May 3, 2010

Affected Providers Description of Adjustment
Wisconsin Well Woman Program Providers ForwardHealth is automatically adjusting professional claims and outpatient claims with dates of service on and after January 1, 2009, to apply retroactive rate adjustments for Wisconsin Well Woman Program services.
Providers Billing for Disposable Medical Supplies ForwardHealth is automatically adjusting claims for certain disposable medical supply (DMS) procedure codes that processed and paid between September 23, 2009, and November 9, 2009. Due to a system issue, copayment was not deducted from the DMS items when it should have been. The adjustment will apply the appropriate copayment amount for the DMS items.
Advanced Practice Nurse Prescribers and Physician Assistants Billing for Mental Health Services ForwardHealth is reprocessing certain crossover claims processed between November 10, 2008, and April 13, 2010, that were denied in error. Providers received Explanation of Benefits code 0287, "Member is enrolled in a State-contracted managed care program for the Date(s) of Service," when submitting claims for mental health services for members enrolled in Family Care. Mental health services are reimbursed under fee-for-service for members enrolled in Family Care when performed by advanced practice nurse prescribers or physician assistants.
Advanced Practice Nurse Prescribers and Physician Assistants Billing for Mental Health Services ForwardHealth is reprocessing certain crossover claims processed between November 10, 2008, and April 13, 2010, that were denied in error. Providers received Explanation of Benefits code 0287, "Member is enrolled in a State-contracted managed care program for the Date(s) of Service," when submitting claims for mental health services for members enrolled in Family Care. Mental health services are reimbursed under fee-for-service for members enrolled in Family Care when performed by advanced practice nurse prescribers or physician assistants.
Providers Submitting Claims for Services Requiring Prior Authorization ForwardHealth is automatically adjusting claims for services that require prior authorization (PA) that originally processed and paid between November 10, 2008, and January 16, 2010. In certain cases, ForwardHealth paid in error for services requiring PA when the date of service (DOS) on the claim detail was before the PA grant date or after the PA expiration date. Providers are reminded that services requiring PA are not reimbursable unless a valid PA is on file for the DOS that the service is rendered.
Adult Mental Health Day Treatment Providers ForwardHealth is automatically reprocessing claims for procedure code H2012 (Behavioral health day treatment, per hour) with modifier "HE" that originally processed between November 10, 2008, and March 22, 2009, and denied in error with Explanation of Benefits code 1282, "PA required for payment of this service. Procedure Code and modifiers billed must match approved PA." Providers are reminded that procedure code H2012 with modifier "HE" does not require prior authorization until the member has exceeded 90 units per calendar year.
Providers Submitting Institutional Inpatient Claims ForwardHealth is automatically adjusting certain institutional inpatient claims originally processed and paid between March 12, 2010, and April 23, 2010, that were assigned the wrong diagnosis-related group (DRG) resulting in an incorrect payment. This adjustment will apply the correct DRG payment to the claims.
Providers Billing for Procedure Code 99509 ForwardHealth is automatically reprocessing claims with procedure code 99509 (Home visit for assistance with activities of daily living and personal care) that originally processed between November 10, 2008, and October 1, 2009, and denied in error with Explanation of Benefits (EOB) code 0278, "Member is covered by a commercial health insurance on the Date(s) of Service" or EOB code 1252, "Member is enrolled in Medicare Part A on the Date(s) of Service."
Providers Billing for Procedure Code T1502 ForwardHealth is automatically reprocessing claims with procedure code T1502 (Administration of oral, intramuscular and/or subcutaneous medication by health care agency/professional, per visit) that originally processed between November 10, 2008, and October 1, 2009, and denied in error with Explanation of Benefits code 0278, "Member is covered by a commercial health insurance on the Date(s) of Service."
Mental Health Providers ForwardHealth is reprocessing claims that were processed between November 26, 2008, and September 25, 2009. Certain mental health claims with central nervous system assessment procedure codes 96101-96120 were incorrectly denied.
Providers Submitting Paper Institutional Outpatient Crossover Claims ForwardHealth is automatically reprocessing institutional outpatient crossover claims submitted on paper that originally processed between November 10, 2008, and May 27, 2009, and denied in error with Explanation of Benefits code 0152, "The sum of the Medicare paid, deductible(s), coinsurance and copayment amounts does not equal the Medicare allowed amount."

Week of April 26, 2010

Affected Providers Description of Adjustment
Providers Billing for Purchased Durable Medical Equipment ForwardHealth is automatically adjusting claims for purchased durable medical equipment (DME) that originally processed and paid between May 14, 2009, and March 30 2010, and overpaid because rental charges were not deducted from the allowable reimbursement amount in error. Providers are reminded that rental charges for DME are deducted from the Medicaid-allowed amount for the subsequent purchase of the DME item.
Providers Providing Intensive In-Home Mental Health and Substance Abuse Services for Children ForwardHealth is automatically reprocessing claims for intensive in-home mental health and substance abuse services for children that processed between November 10, 2008, and July 24, 2009, and were denied in error with Explanation of Benefits message 1503, "A Rendering Provider number is required." The service denied in error because the rendering provider was not recognized as a Medicaid-certified provider.
Wisconsin Well Woman Program Providers ForwardHealth is automatically adjusting professional claims and outpatient claims with dates of service on and after January 1, 2009, to apply retroactive rate adjustments for Wisconsin Well Woman Program services.
Providers Billing for Disposable Medical Supplies ForwardHealth is automatically adjusting claims for certain disposable medical supply (DMS) procedure codes that processed and paid between September 23, 2009, and November 9, 2009. Due to a system issue, copayment was not deducted from the DMS items when it should have been. The adjustment will apply the appropriate copayment amount for the DMS items.
Physicians and Audiologists Submitting Claims for Therapy Services ForwardHealth is automatically reprocessing certain crossover claims processed between November 10, 2008, and June 21, 2009, that were denied in error. Providers received Explanation of Benefits code 0287, "Member is enrolled in a State-contracted managed care program for the Date(s) of Service," when submitting claims for physical therapy, occupational therapy, or speech-language pathology services for members enrolled in Family Care. Therapy services are reimbursed under fee-for-service for members enrolled in Family Care when performed by physicians or audiologists.
Providers Submitting Claims for Members with Medicare Supplemental Insurance ForwardHealth is automatically reprocessing Medicare crossover claims that originally processed between November 8, 2008, and February 2, 2009, and paid in error. Services on crossover claims for members who also have supplemental Medicare insurance must first be submitted to the supplemental insurance carrier before being submitted to ForwardHealth.
Providers Submitting Professional Claims ForwardHealth is reprocessing certain paper claims that were processed between November 10, 2008, and November 23, 2009. ForwardHealth incorrectly processed the provider's taxonomy code with a letter "O" instead of the number zero, resulting in claim denials.

Week of April 19, 2010

Affected Providers Description of Adjustment
Providers Billing for Purchased Durable Medical Equipment ForwardHealth is automatically adjusting claims for purchased durable medical equipment (DME) that originally processed and paid between May 14, 2009, and March 30 2010, and overpaid because rental charges were not deducted from the allowable reimbursement amount in error. Providers are reminded that rental charges for DME are deducted from the Medicaid-allowed amount for the subsequent purchase of the DME item.
Providers Providing Intensive In-Home Mental Health and Substance Abuse Services for Children ForwardHealth is automatically reprocessing claims for intensive in-home mental health and substance abuse services for children that processed between November 10, 2008, and July 24, 2009, and were denied in error with Explanation of Benefits message 1503, "A Rendering Provider number is required." The service denied in error because the rendering provider was not recognized as a Medicaid-certified provider.
Wisconsin Well Woman Program Providers ForwardHealth is automatically adjusting professional claims and outpatient claims with dates of service on and after January 1, 2009, to apply retroactive rate adjustments for Wisconsin Well Woman Program services.
Providers Billing for Disposable Medical Supplies ForwardHealth is automatically adjusting claims for certain disposable medical supply (DMS) procedure codes that processed and paid between September 23, 2009, and November 9, 2009. Due to a system issue, copayment was not deducted from the DMS items when it should have been. The adjustment will apply the appropriate copayment amount for the DMS items.
Dental Providers ForwardHealth is reprocessing certain claims originally processed between November 10, 2008, and November 16, 2009. Dental claims with procedure codes D2390, D2791, D2931, D2932, and D2933 that had a once per year limitation were incorrectly processed with a once per five years limitation, resulting in claim denials.

Week of April 12, 2010

Affected Providers Description of Adjustment
Providers Billing for Laparoscopic Hysterectomy Surgeries ForwardHealth is automatically reprocessing certain professional claims processed between November 10, 2008, and May 22, 2009, for Current Procedural Terminology procedure codes 58570 — 58573. Claims for these codes denied due to a system error with Explanation of Benefits code 0192, "Prior Authorization Not Found." Laparoscopic hysterectomy surgeries do not require prior authorization, but claims for these surgeries do require medical review and must meet documentation requirements as outlined in the Online Handbook. Adjudication of the reprocessed claims will take several weeks since each claim is required to undergo medical review prior to final adjudication.
Nursing Homes ForwardHealth is automatically adjusting certain nursing home claims to apply the correct reimbursement rate. Retroactive rate adjustments for some nursing home claims did not process correctly in the ForwardHealth system. ForwardHealth is identifying affected nursing home claims to be adjusted. No further action is required by the provider.
Providers Billing for Purchased Durable Medical Equipment ForwardHealth is automatically adjusting claims for purchased durable medical equipment (DME) that originally processed and paid between May 14, 2009, and March 30 2010, and overpaid because rental charges were not deducted from the allowable reimbursement amount in error. Providers are reminded that rental charges for DME are deducted from the Medicaid-allowed amount for the subsequent purchase of the DME item.
Providers Providing Intensive In-Home Mental Health and Substance Abuse Services for Children ForwardHealth is automatically reprocessing claims for intensive in-home mental health and substance abuse services for children that processed between November 10, 2008, and July 24, 2009, and were denied in error with Explanation of Benefits message 1503, "A Rendering Provider number is required." The service denied in error because the rendering provider was not recognized as a Medicaid-certified provider.
Physicians and Independent Labs Billing for Wisconsin Chronic Disease Program Renal Disease Services ForwardHealth is automatically reprocessing Wisconsin Chronic Disease Program Chronic Renal Disease services claims submitted by physicians and independent labs and billed with diagnosis code V58.44 (Aftercare following organ transplant). The claims originally processed between July 1, 2008, and December 29, 2009, with dates of service (DOS) on and after July 1, 2008, and were denied. Diagnosis code V58.44 was added as an allowable diagnosis code for revenue codes and procedure codes effective for DOS on and after July 1, 2008.
Pharmacy Providers ForwardHealth is adjusting pharmacy claims for the Wisconsin Chronic Disease Program processed between November 8, 2008, and December 19, 2008. Claims were underpaid due to an incorrect spenddown amount deducted from the provider's reimbursement.
HealthCheck Providers ForwardHealth is automatically reprocessing claims for Current Dental Terminology procedure code D0120 (periodic oral evaluation) that originally processed between November 10, 2008, and September 25, 2009, and denied in error with Explanation of Benefits 0116, "Procedure Code or Drug Code not a benefit on Date of Service."
Pharmacy Providers ForwardHealth is adjusting pharmacy claims processed between November 1, 2008, and November 30, 2008. Copayment was incorrectly deducted from the provider's reimbursement after the Medicaid or BadgerCare Plus Standard Plan member had met his or her copayment upper limit resulting in underpaid claims. Providers are required to refund the members for any copayment amount collected in error.
Outpatient Hospital Providers ForwardHealth is reprocessing claims that were processed between July 22, 2009, and October 14, 2009. Mental health services submitted on outpatient hospital claims for Family Care members were denied in error.
Mental Health Providers ForwardHealth is reprocessing claims that were processed between November 26, 2008, and September 25, 2009. Certain mental health claims with central nervous system assessment procedure codes 96101-96120 were incorrectly denied.
Providers Submitting Professional Claims ForwardHealth is reprocessing certain paper claims that were processed between November 10, 2008, and November 23, 2009. ForwardHealth incorrectly processed the provider's taxonomy code with a letter "O" instead of the number zero, resulting in claim denials.

Week of April 5, 2010

Affected Providers Description of Adjustment
Providers Billing for Laparoscopic Hysterectomy Surgeries ForwardHealth is automatically reprocessing certain professional claims processed between November 10, 2008, and May 22, 2009, for Current Procedural Terminology procedure codes 58570 - 58573. Claims for these codes denied due to a system error with Explanation of Benefits code 0192, "Prior Authorization Not Found." Laparoscopic hysterectomy surgeries do not require prior authorization, but claims for these surgeries do require medical review and must meet documentation requirements as outlined in the Online Handbook. Adjudication of the reprocessed claims will take several weeks since each claim is required to undergo medical review prior to final adjudication.
Nursing Homes ForwardHealth is automatically adjusting certain nursing home claims to apply the correct reimbursement rate. Retroactive rate adjustments for some nursing home claims did not process correctly in the ForwardHealth system. ForwardHealth is identifying affected nursing home claims to be adjusted. No further action is required by the provider.
Wisconsin Well Woman Program Providers Billing for Anesthesia Services ForwardHealth is automatically adjusting claims for anesthesia services that processed and paid between January 1, 2009, and October 23, 2009. Claims for Current Procedural Terminology procedure code 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified) overpaid due to a system issue. The adjustment will recoup the overpayment amount.
Providers Billing for Purchased Durable Medical Equipment ForwardHealth is automatically adjusting claims for purchased durable medical equipment (DME) that originally processed and paid between May 14, 2009, and March 30 2010, and overpaid because rental charges were not deducted from the allowable reimbursement amount in error. Providers are reminded that rental charges for DME are deducted from the Medicaid-allowed amount for the subsequent purchase of the DME item.
Providers Providing Intensive In-Home Mental Health and Substance Abuse Services for Children ForwardHealth is automatically reprocessing claims for intensive in-home mental health and substance abuse services for children that processed between November 10, 2008, and July 24, 2009, and were denied in error with Explanation of Benefits message 1503, "A Rendering Provider number is required." The service denied in error because the rendering provider was not recognized as a Medicaid-certified provider.
Pharmacy Providers ForwardHealth is reprocessing certain pharmacy claims that were processed between November 25, 2009, and December 11, 2009. Claims with the drug Armour Thyroid were incorrectly denied due to a system issue.
Pharmacy Providers ForwardHealth is adjusting pharmacy claims for the drug Benazepril processed and paid between October 1, 2009, and October 22, 2009. ForwardHealth applied an incorrect reimbursement rate and overpaid claims.

Week of March 29, 2010

Affected Providers Description of Adjustment
Providers Billing for Laparoscopic Hysterectomy Surgeries ForwardHealth is automatically reprocessing certain professional claims processed between November 10, 2008, and May 22, 2009, for Current Procedural Terminology procedure codes 58570 - 58573. Claims for these codes denied due to a system error with Explanation of Benefits code 0192, "Prior Authorization Not Found." Laparoscopic hysterectomy surgeries do not require prior authorization, but claims for these surgeries do require medical review and must meet documentation requirements as outlined in the Online Handbook. Adjudication of the reprocessed claims will take several weeks since each claim is required to undergo medical review prior to final adjudication.
Nursing Homes ForwardHealth is automatically adjusting certain nursing home claims to apply the correct reimbursement rate. Retroactive rate adjustments for some nursing home claims did not process correctly in the ForwardHealth system. ForwardHealth is identifying affected nursing home claims to be adjusted. No further action is required by the provider.
Pharmacy Providers ForwardHealth is adjusting pharmacy claims with dates of service between May 1, 2009, and July 9, 2009, for fentanyl, calcium acetate, and finasteride. Pharmacy claims overpaid due to an incorrect copayment deduction for BadgerCare Plus Standard Plan, Medicaid, and SeniorCare claims. Providers are required to refund the members for any copayment collected in error. Refer to the August 2009 ForwardHealth Update (2009-46), titled "Claims Submitted with Dispense As Written Code '6'," for more information.
Pharmacy Providers ForwardHealth is adjusting pharmacy claims for the drug alprazolam processed and paid between April 1, 2009, and May 8, 2009. ForwardHealth applied an incorrect reimbursement rate and overpaid claims.
Dental Providers ForwardHealth is automatically reprocessing and adjusting dental claims for pregnant women enrolled in the BadgerCare Plus Benchmark Plan originally processed between February 1, 2008, and March 24, 2010. Cost-sharing requirements, including coinsurance and deductible, were applied to these claims in error. Claims may have denied or reimbursed at the wrong rate as a result. Pregnant women are not subject to cost-sharing requirements under the Benchmark Plan. Providers who have collected coinsurance or deductible amounts from pregnant women enrolled in the Benchmark Plan for dental services should reimburse the members.

Week of March 22, 2010

Affected Providers Description of Adjustment
Providers Billing for Laparoscopic Hysterectomy Surgeries ForwardHealth is automatically reprocessing certain professional claims processed between November 10, 2008, and May 22, 2009, for Current Procedural Terminology procedure codes 58570 - 58573. Claims for these codes denied due to a system error with Explanation of Benefits code 0192, "Prior Authorization Not Found." Laparoscopic hysterectomy surgeries do not require prior authorization, but claims for these surgeries do require medical review and must meet documentation requirements as outlined in the Online Handbook. Adjudication of the reprocessed claims will take several weeks since each claim is required to undergo medical review prior to final adjudication.
Nursing Homes ForwardHealth is automatically adjusting certain nursing home claims to apply the correct reimbursement rate. Retroactive rate adjustments for some nursing home claims did not process correctly in the ForwardHealth system. ForwardHealth is identifying affected nursing home claims to be adjusted. No further action is required by the provider.
Pharmacy Providers ForwardHealth is reprocessing paper pharmacy claims processed between November 8, 2008, and February 14, 2010, for BadgerCare Plus, Medicaid, SeniorCare, and Wisconsin Chronic Disease Program that denied in error. The other coverage code on the paper claim was not captured for claims processing.
Pharmacy Providers ForwardHealth is reprocessing denied pharmacy claims for BadgerCare Plus Core Plan members for the drug Nitrofurantoin processed between January 1, 2009, and February 15, 2010. Nitrofurantoin denied in error as a noncovered service.
Providers Submitting Claims for Assessment Services ForwardHealth is automatically reprocessing claims for mental health and substance abuse assessment services that originally processed between June 1, 2009, and August 3, 2009 with dates of service (DOS) on or after January 1, 2009. The adjustments will apply policy changes for procedure codes 90801, 90802, H2012 with modifiers "U6" and "HF," and H2012 with modifiers "U6" and "HE." Providers are reminded that for DOS on and after January 1, 2009, assessments count against a limit of 8 hours per rolling 12 months before prior authorization is required.
Physicians, Physician Assistants, and Nurse Practitioners ForwardHealth is automatically reprocessing the denied claims for procedure code 96375 that originally processed between January 1, 2009, and November 9, 2009, and received Explanation of Benefits code 1306, "Add-on codes are not separately reimbursable when submitted as a stand-alone code." For members enrolled in a managed care organization (MCO), if a primary procedure code is one of the codes that must be billed to the MCO, fee-for-service will not deny the corresponding add-on code even though it is billed as a stand-alone code. Refer to the Online Handbook for more information on add-on procedure code policy and provider-administered drugs that must be billed fee-for-service.

Week of March 15, 2010

Affected Providers Description of Adjustment
Providers Billing for Laparoscopic Hysterectomy Surgeries ForwardHealth is automatically reprocessing certain professional claims processed between November 10, 2008, and May 22, 2009, for Current Procedural Terminology procedure codes 58570 - 58573. Claims for these codes denied due to a system error with Explanation of Benefits code 0192, "Prior Authorization Not Found." Laparoscopic hysterectomy surgeries do not require prior authorization, but claims for these surgeries do require medical review and must meet documentation requirements as outlined in the Online Handbook. Adjudication of the reprocessed claims will take several weeks since each claim is required to undergo medical review prior to final adjudication.
Nursing Homes ForwardHealth is automatically adjusting certain nursing home claims to apply the correct reimbursement rate. Retroactive rate adjustments for some nursing home claims did not process correctly in the ForwardHealth system. ForwardHealth is identifying affected nursing home claims to be adjusted. No further action is required by the provider.
Inpatient Hospital Providers ForwardHealth is automatically adjusting certain inpatient claims processed and paid between November 10, 2008, and February 23, 2010, when ForwardHealth applied an incorrect reimbursement rate. Due to a system issue, the diagnosis related group reimbursement was not calculated correctly and affected claims overpaid.
Pharmacy Providers ForwardHealth is automatically adjusting pharmacy claims for the Wisconsin Chronic Disease Program processed between November 10, 2008, and August 11, 2009. Claims denied in error due to the absence of a diagnosis code.
Providers Submitting Claims for HealthCheck Services ForwardHealth is automatically reprocessing professional claims originally processed between November 10, 2008, and August 20, 2009, that denied in error. Claims for procedure codes 99382 and 99392 for members who were under 3 years of age on the date of service may have denied inappropriately due to a system issue.
Providers Submitting Inpatient and Long Term Care Claims ForwardHealth is automatically adjusting certain inpatient claims and long term care claims that processed and paid between February 19, 2009, and February 24, 2009, to identify duplicate claims that paid in error. Due to a systems issue, ForwardHealth paid claims that should have denied as duplicates because the dates of service overlapped with a claim that had already paid for the same member and billing provider. Providers may adjust and resubmit claims that deny as a result of this adjustment. Claims that are beyond the timely filing deadline must be received by ForwardHealth Timely Filing before June 30, 2010. When completing the Timely Filing Appeals Request form, F-13047, providers should place a check in the "ForwardHealth Reconsideration" box and write "adjustment to ForwardHealth claim resubmission for duplicate claims" to explain the nature of the problem.
Providers Providing Services to Members Enrolled in Family Care ForwardHealth is automatically adjusting certain institutional crossover claims and outpatient hospital claims processed between November 10, 2008, and July 24, 2009, that paid in error. Claims for members enrolled in Family Care with revenue codes 0290 — 0299, 0420 — 0449, and 0977 — 0979 will be denied by ForwardHealth. ForwardHealth paid these claims in error. Providers should submit claims for these revenue codes to Family Care for payment.
Nursing Homes Providing Services to Members Enrolled in Family Care ForwardHealth is automatically adjusting certain crossover claims processed between November 10, 2008, and July 24, 2009, that paid in error. Claims for members enrolled in Family Care will be denied by ForwardHealth. ForwardHealth paid coinsurance and deductible for these claims in error. Providers should submit the claims to Family Care for payment.

Week of March 8, 2010

Affected Providers Description of Adjustment
Providers Billing for Laparoscopic Hysterectomy Surgeries ForwardHealth is automatically reprocessing certain professional claims processed between November 10, 2008, and May 22, 2009, for Current Procedural Terminology procedure codes 58570 - 58573. Claims for these codes denied due to a system error with Explanation of Benefits code 0192, "Prior Authorization Not Found." Laparoscopic hysterectomy surgeries do not require prior authorization, but claims for these surgeries do require medical review and must meet documentation requirements as outlined in the Online Handbook. Adjudication of the reprocessed claims will take several weeks since each claim is required to undergo medical review prior to final adjudication.
Nursing Homes ForwardHealth is automatically adjusting certain nursing home claims to apply the correct reimbursement rate. Retroactive rate adjustments for some nursing home claims did not process correctly in the ForwardHealth system. ForwardHealth is identifying affected nursing home claims to be adjusted. No further action is required by the provider.
Inpatient Hospital Providers ForwardHealth is automatically adjusting certain inpatient claims processed and paid between November 10, 2008, and February 23, 2010, when ForwardHealth applied an incorrect reimbursement rate. Due to a system issue, the diagnosis related group reimbursement was not calculated correctly and affected claims overpaid.
Providers Submitting Claims with Attachments ForwardHealth is automatically reprocessing certain claim adjustment requests that originally processed between November 8, 2008, and December 30, 2008, and denied in error. Due to a system issue, these adjustments were not matched with the original claim attachment and were subsequently denied.
Dental Providers ForwardHealth is automatically reprocessing certain claims originally processed between November 10, 2008, and April 9, 2009, and denied in error. Certain dental claims denied with Explanation of Benefits code 0923, "Reimbursement for this procedure and a related procedure is limited to once per Date of Service," when two claims were submitted for the same member for the same date service and the same procedure code. If the services were performed by different rendering providers, both claims are reimbursable.
Inpatient Hospital Providers ForwardHealth is automatically reprocessing inpatient hospital claims that originally processed between January 1, 2008, and July 31, 2009, for diagnosis codes 349.0 (Reaction to spinal or lumbar puncture) and 975.0 (Poisoning by agents primarily acting on the smooth and skeletal muscles and respiratory system, oxytocic agents). Due to a system issue, these claims denied in error.
Pharmacy Providers ForwardHealth is automatically reprocessing pharmacy claims for Finasteride with dates of service on and after May 1, 2009. Finasteride was incorrectly denied as noncovered for BadgerCare Plus Core Plan and BadgerCare Plus Benchmark Plan members.
Pharmacy Providers ForwardHealth is automatically adjusting pharmacy claims for the Wisconsin Chronic Disease Program processed between November 10, 2008, and August 11, 2009. Claims denied in error due to the absence of a diagnosis code.
Targeted Case Management Providers ForwardHealth is automatically adjusting certain claims originally processed between November 8, 2008, and October 22, 2009. Claims submitted with procedure code T1017 (Targeted case management, each 15 minutes) with modifier "U4" (discharge planning) were incorrectly denied due to a system issue with the implementation of interChange.
Providers Submitting Professional Claims ForwardHealth is automatically reprocessing certain claims originally processed between January 1, 2009, and November 12, 2009, with dates of service on and after January 1, 2007. Procedure code 85060 (Blood smear, peripheral, interpretation by physician with written report) was incorrectly end dated causing claims submitted with this procedure code to deny.

Week of March 1, 2010

Affected Providers Description of Adjustment
Pharmacy Providers ForwardHealth is automatically reprocessing certain pharmacy claims that processed between November 8, 2008, and June 29, 2009 for Antimigraine Agents. Claims were incorrectly processed without quantity limits for specific drugs with the implementation of interChange.
Pharmacy Providers ForwardHealth is automatically reprocessing certain pharmacy claims that were processed between July 1, 2009, and November 9, 2009. Claims with specific chemotherapy drugs were inadvertently omitted from the BadgerCare Plus Core Plan's drug expansion and denied in error.
Providers Submitting Professional Claims ForwardHealth is automatically adjusting claims billed with procedure code 99476 (Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age) that were processed between January 1, 2009, and April 16, 2009, with dates of service (DOS) on and after January 1, 2009. Claims with procedure code 99476 were processed with the incorrect maximum allowable fee.
Dental Providers ForwardHealth is automatically adjusting certain dental claims processed between November 10, 2008, and May 15, 2009. Claims for procedure code D2335 (resin-based composite - four or more surfaces or involving incisal angle [anterior]) with tooth surface "I" were inappropriately denied.
Providers Billing for Laparoscopic Hysterectomy Surgeries ForwardHealth is automatically reprocessing certain professional claims processed between November 10, 2008, and May 22, 2009, for Current Procedural Terminology procedure codes 58570 - 58573. Claims for these codes denied due to a system error with Explanation of Benefits code 0192, "Prior Authorization Not Found." Laparoscopic hysterectomy surgeries do not require prior authorization, but claims for these surgeries do require medical review and must meet documentation requirements as outlined in the Online Handbook. Adjudication of the reprocessed claims will take several weeks since each claim is required to undergo medical review prior to final adjudication.
Nursing Homes Providing Services to Members Enrolled in Family Care ForwardHealth is automatically adjusting certain crossover claims processed between November 10, 2008, and November 18, 2009, that paid in error. Claims for members enrolled in Family Care with revenue codes 0300, 0320, 0962, and 0969 will be denied by ForwardHealth. ForwardHealth paid coinsurance and deductible for these claims in error. Providers should submit claims for these revenue codes to Family Care for payment.
Ambulatory Surgery Centers ForwardHealth is automatically adjusting claims for multiple surgical procedure codes processed and paid between April 14, 2009, and January 8, 2010. ForwardHealth may have paid for multiple surgical procedure codes billed on the same date of service (DOS) in error. Providers are reminded that only one surgical procedure code is reimbursable per ambulatory surgery center per DOS.
Nursing Homes ForwardHealth is automatically adjusting certain nursing home claims to apply the correct reimbursement rate. Retroactive rate adjustments for some nursing home claims did not process correctly in the ForwardHealth system. ForwardHealth is identifying affected nursing home claims to be adjusted. No further action is required by the provider.
Inpatient Hospital Providers ForwardHealth is automatically adjusting certain inpatient claims processed and paid between November 10, 2008, and February 23, 2010, when ForwardHealth applied an incorrect reimbursement rate. Due to a system issue, the diagnosis related group reimbursement was not calculated correctly and affected claims overpaid.

Week of February 22, 2010

Affected Providers Description of Adjustment
Pharmacy Providers ForwardHealth is automatically reprocessing certain pharmacy claims processed between November 9, 2008, and October 7, 2009. Claims with legend drugs for nursing home members were inappropriately denied.
Pharmacy Providers ForwardHealth is automatically reprocessing certain pharmacy claims processed between November 10, 2008, and April 25, 2009. Some paper claims submitted with an Other Coverage Code were incorrectly denied due to a system error.
Providers Providing Chiropractic Services for BadgerCare Plus Core Plan Members ForwardHealth is automatically reprocessing claims for BadgerCare Plus Core Plan members processed and paid between January 1, 2009, and February 9, 2009. Claims for Current Procedural Terminology procedure codes 98940, 98941, and 98942 were paid in error by ForwardHealth. Providers are reminded that Core Plan coverage of chiropractic services began on July 1, 2009, and chiropractic services provided for Core Plan members before that date are considered noncovered.
Physicians and Nurse Practitioners ForwardHealth is automatically reprocessing certain claims processed between January 1, 2009, and February 7, 2009, that denied due to a systems issue. This adjustment affects claims for new Healthcare Common Procedure Coding System and Current Procedural Terminology procedure codes that were effective on January 1, 2009.
Inpatient Hospital Providers ForwardHealth is automatically adjusting certain inpatient hospital claims processed before March 1, 2009. Claims with Patient Status code "05" may have paid the wrong Diagnosis Related Group rate due to a system error. The adjustment will apply the correct rate to the claims.

Week of February 15, 2010

Affected Providers Description of Adjustment
Case Management Providers ForwardHealth is automatically reprocessing claims for Healthcare Common Procedure Coding System procedure code T1017 (Targeted case management, each 15 minutes) with modifiers "U1" and "U2" processed between November 10, 2008, and January 15, 2010, that denied in error.
Nursing Home Providers ForwardHealth is automatically adjusting certain long term care claims that processed and paid between November 10, 2008, and October 1, 2009 to identify duplicate claims that paid in error. Due to a systems issue, ForwardHealth paid claims that should have denied as duplicates because the dates of service overlapped with a claim that had already paid for the same member and billing provider. Providers may adjust and resubmit claims that deny as a result of this adjustment. Claims that are beyond the timely filing deadline must be received by ForwardHealth Timely Filing before May 31, 2010. When completing the Timely Filing Appeals Request form, F-13047, providers should place a check in the "ForwardHealth Reconsideration" box and write "adjustment to ForwardHealth long term care claim resubmission for duplicate claims" to explain the nature of the problem.
Providers Dispensing Drugs to BadgerCare Plus Core Plan Members ForwardHealth is automatically resubmitting pharmacy claims for BadgerCare Plus Core Plan members enrolled in an HMO that processed between December 12, 2009, and December 14, 2010, and denied in error. Providers received Explanation of Benefits code 0287, "Member is enrolled in a State-contracted managed care program for the Date(s) of Service" when submitting pharmacy claims for members enrolled in an HMO. Drugs are covered by fee-for-service for all Core Plan members.
Inpatient Hospital Providers ForwardHealth is reprocessing certain inpatient hospital claims for gastric bypass/stapling procedures processed and paid between November 10, 2008, and February 3, 2010. Claims for these procedures were paid in error by ForwardHealth. Providers are reminded that all claims for gastric bypass/stapling procedures undergo additional review to determine medical necessity and may not be reimbursable by ForwardHealth.
Wisconsin Chronic Disease Program Providers ForwardHealth is automatically reprocessing Wisconsin Chronic Disease Program Chronic Renal Disease services claims billed with diagnosis code V58.44 (Aftercare following organ transplant) that were processed between July 1, 2008, and December 29, 2009, with dates of service (DOS) on and after July 1, 2008, that were denied. Diagnosis code V58.44 was added as an allowable diagnosis code for revenue codes and procedure codes effective for DOS on and after July 1, 2008.
Pharmacy Providers ForwardHealth is automatically reprocessing incorrectly denied pharmacy claims for BadgerCare Plus Core Plan members for Singulair that processed between March 12, 2009, and March 25, 2009, with dates of service on and after January 1, 2009.
Pharmacy Providers ForwardHealth is automatically reprocessing Wisconsin Chronic Disease Program Chronic Renal Disease, Adult Cystic Fibrosis, and Hemophilia Home Care services pharmacy claims for Armour Thyroid that processed between November 9, 2008, and December 29, 2009. Claims were incorrectly denied due to a system error with the implementation of interChange.
Pharmacy Providers ForwardHealth is automatically adjusting certain pharmacy claims that were processed between November 8, 2008, and February 2, 2009. Claims for drugs considered "less than effective" were paid in error due to a system error with the implementation of interChange.

Week of February 8, 2010

Affected Providers Description of Adjustment
Pharmacies ForwardHealth is automatically reprocessing certain pharmacy claims for the drug Strattera with dispense dates on and after October 1, 2009. Claims for Strattera that did not have a valid prior authorization (PA) on file when the member was not grandfathered for Strattera may have paid in error. Providers are reminded that as of October 1, 2009, Strattera became a non-preferred drug for all members, including members 19 years of age and older, and requires PA.
Providers Submitting Claims for Members Enrolled in the Tuberculosis-Related Services-Only Benefit ForwardHealth is automatically reprocessing claims for services provided to members enrolled in the Tuberculosis-Related Services-Only benefit that processed between November 10, 2008, and February 25, 2009, and denied in error due to a systems issue.
HealthCheck Providers ForwardHealth is automatically reprocessing certain claims processed between November 10, 2008, and February 18, 2009. Claims for procedure code 99211 (office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician) for members 19 years of age and older denied in error.
Providers Submitting Claims for the Human Papilloma Virus Vaccine ForwardHealth is automatically resubmitting certain claims processed and paid between November 10, 2008, and February 18, 2009. Claims for procedure code 90649 (human papilloma virus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent], 3 dose schedule, for intramuscular use) were reimbursed incorrectly. Providers are reminded that ForwardHealth reimburses only the administration fee on claims for procedure code 90649 for members 18 years of age and younger. ForwardHealth reimburses both the cost of the vaccine and the administration fee on claims for procedure code 90649 with modifier "U1" for members 19 years of age and older.

Week of February 1, 2010

Affected Providers Description of Adjustment
Wisconsin Well Woman Program Outpatient Hospital Providers ForwardHealth is automatically adjusting certain outpatient hospital claims processed and paid between November 11, 2008, and February 6, 2009, when an incorrect rate of reimbursement was applied to the claim.
Case Management Providers ForwardHealth is automatically reprocessing certain claims for case management services processed between November 10, 2008, and January 11, 2010. Due to a clerical error, procedure code T1017 (Targeted case management, each 15 minutes) may have been inappropriately denied.
Pharmacies ForwardHealth is automatically reprocessing certain pharmacy claims processed between September 23, 2009, and December 15, 2009, that were denied in error. Claims for Finasteride 5 mg and Zaleplon 5 mg and 10 mg for BadgerCare Plus Benchmark Plan and BadgerCare Plus Core Plan members were incorrectly denied for no prior authorization (PA) on file. These drugs were exempt from PA requirements on the date of service and were denied in error.
Physicians Providing Services for Members Enrolled in Family Care ForwardHealth is automatically reprocessing certain crossover claims processed between November 10, 2008, and March 12, 2009, that were denied in error. Providers received Explanation of Benefits code 0287, "Member is enrolled in a State-contracted managed care program for the Date(s) of Service," when submitting claims for the following mental health and substance abuse procedure codes for members enrolled in Family Care: 90801 - 90870, 90875 - 90882, 90887 - 90889, H0005, H0022, H0046, H0047, and T1006. These procedure codes are reimbursed under fee-for-service for members enrolled in Family Care when performed by a physician.

Week of January 19, 2010

Affected Providers Description of Adjustment
Dental ProvidersForwardHealth is automatically adjusting certain dental claims for dates of service on and after January 1, 2009, which were reimbursed an incorrect amount. The adjustments correct claims for pregnant women enrolled in the BadgerCare Plus Benchmark Plan. Cost-sharing requirements were applied to the reimbursement rate for these claims in error. Pregnant women are not subject to cost-sharing requirements under the Benchmark Plan.
Nursing HomesForwardHealth is reprocessing certain nursing home rate adjustments that were processed without an updated nursing home retroactive rate applied. The adjustments in question would have appeared on Remittance Advices (RAs) issued on December 4, 2009, and were included on the providers' remittance with new day claim submissions. ForwardHealth has identified and reprocessed the adjustments for providers which will appear beginning on RAs received after January 22, 2010. No further action is required by the provider.

Week of January 4, 2010

Affected Providers Description of Adjustment
Ambulance Providers ForwardHealth is automatically adjusting claims for ambulance services processed and paid between November 10, 2008, and May 16, 2009, to refund copayment amounts deducted in error. ForwardHealth applied a $50.00 copayment to procedure codes A0382, A0384, A0392, A0394, A0396, A0398, A0420, A0422, A0424, A0425, A0427, A0429, A0435, A0436, A0999, and T2006 on claims for members enrolled in the BadgerCare Plus Benchmark Plan. These procedure codes are not subject to copayment under the Benchmark Plan.
Providers Submitting Medicare Crossover Claims ForwardHealth is automatically resubmitting certain institutional Medicare crossover claims processed and paid between November 10, 2008, and December 30, 2009, for duplicate services. ForwardHealth will deny the claim as a duplicate if the claim's dates of service and details match the dates of service and details of another crossover claim processed and paid for the same member.

Week of December 28, 2009

Affected Providers Description of Adjustment
Providers Submitting Institutional Claims Attention Providers Submitting Institutional Claims:
ForwardHealth is automatically resubmitting institutional claims processed between November 10, 2008, and February 18, 2009, that were denied in error. Claims with diagnosis codes E927.0 — E927.9 may have denied because ForwardHealth did not recognize the diagnosis codes as valid for the date of service.

Week of December 21, 2009

Affected Providers Description of Adjustment
End-Stage Renal Disease Providers Claims for procedure codes 82040, 82310, 82374, 82435 and 82565 that processed between November 10, 2008, and February 2, 2009, denied due to a processing error. ForwardHealth has automatically resubmitted end-stage renal disease (ESRD) claims with these procedure codes. Claims that are resubmitted by ForwardHealth and that subsequently deny for other billing errors may be corrected and resubmitted by providers. Claims that are beyond the timely filing deadline must be received by ForwardHealth Timely Filing before March 31, 2010. When completing the Timely Filing Appeals Request form, F-13047, providers should place a check in the "ForwardHealth Reconsideration" box and write "adjustment to ForwardHealth ESRD claim resubmission for system error" to explain the nature of the problem.

Week of December 14, 2009

Affected Providers Description of Adjustment
Family Planning Clinics ForwardHealth is initiating adjustments to correctly process certain claims that originally processed between November 10, 2008, and February 17, 2009. Claims for Healthcare Common Procedure Coding System (HCPCS) procedure code J7300 (Intrauterine copper contraceptive) were reimbursed the wrong amount. Claims for HCPCS code J7307 (Etonogestrel [contraceptive] implant system, including implant and supplies) were denied in error.
Dental Providers ForwardHealth is automatically adjusting certain dental claims processed between November 10, 2008, and August 19, 2009. Dental claims for BadgerCare Plus Benchmark Plan members with Current Dental Terminology procedure code D2330 (resin-based composite-one surface, anterior) may have been reimbursed an incorrect amount. The affected claims are being adjusted to apply the correct reimbursement amount.
Hospital Providers Certain claims for inpatient hospital services processed and paid between November 10, 2008, and July 2, 2009, were processed in error. ForwardHealth is automatically adjusting the claims to identify errors in the number of covered days indicated on the claim. Providers are reminded that the total number of covered and noncovered days must match the number of days indicated in the Statement Covers Period (To-From) fields. Claims identified with the error will be denied. Providers may correct and resubmit claims that were adjusted and denied. Claims that are beyond the timely filing deadline must be received by ForwardHealth Timely Filing before March 31, 2010. When completing the Timely Filing Appeals Request form, F-13047, providers should place a check in the "ForwardHealth Reconsideration" box and write "adjustment to correct covered days error" to explain the nature of the problem.
Providers Submitting Outpatient Crossover Claims ForwardHealth is reprocessing certain outpatient crossover claims that have been denied in error since November 10, 2008. Certain outpatient crossover claims were submitted with the required Medicare information, but the Medicare information was not used to process the claims. As a result, the claims were incorrectly denied with Explanation of Benefits code 0152 which states, "The sum of the Medicare paid, deductible(s), coinsurance and copayment amounts does not equal the Medicare allowed amount." The affected claims are being reprocessed with the Medicare information that was originally submitted on the claim.

Week of November 16, 2009

Affected Providers Description of Adjustment
Providers Submitting Medicare Crossover Claims for Disposable Medical Supplies ForwardHealth is denying adjustments to certain Medicare crossover claims because the Medicare data submitted on the claim is out of balance. The claim denials are indicated by Explanation of Benefits messages 1549, "Sum of detail Medicare paid amounts does not equal header Medicare paid amount," and 0273, "Resubmit charges for ForwardHealth covered service(s) denied by Medicare on a ForwardHealth claim." Providers are required to correct the errors and resubmit the claims to be reimbursed. Claims that are beyond the timely filing deadline must be received by ForwardHealth Timely Filing before February 28, 2010. When completing the Timely Filing Appeals Request form, F-13047, providers should place a check in the "ForwardHealth Reconsideration" box and write "DMS crossovers to correct copayment" to explain the nature of the problem.

Issues with the claims were identified last week when ForwardHealth automatically adjusted certain crossover claims for disposable medical supplies (DMS) processed and paid from November 2008 through November 2009. The adjustment was intended to reimburse any copayment amount(s) that ForwardHealth deducted in error for certain DMS items.
Hospice Providers ForwardHealth is automatically adjusting claims for hospice services to apply the retroactive rate increase for hospice services. The rate increase is effective for dates of service on and after October 1, 2008, and the adjustment will apply the new rate as appropriate to claims processed and paid between October 1, 2008, and June 6, 2009.

Week of November 9, 2009

Affected Providers Description of Adjustment
Providers Submitting Medicare Crossover Claims for Disposable Medical Supplies ForwardHealth is automatically adjusting certain Medicare professional crossover claims for disposable medical supplies (DMS) processed and paid between November 10, 2008, and November 6, 2009. This adjustment will reimburse any copayment amount(s) that ForwardHealth deducted in error for certain DMS items. Copayment for DMS should be applied per DMS item, but ForwardHealth applied copayment per date of service.
Providers Submitting Claims for Laboratory Services In November 2009, ForwardHealth is reprocessing additional claims for laboratory services that were denied in error and not previously adjusted for a limited number of providers. Affected claims were originally processed and paid between November 10, 2008, and September 1, 2009, and may have denied claim details for procedure codes requiring Clinical Laboratory Improvement Amendment (CLIA) certification. These denials displayed with Explanation of Benefits (EOB) code 0794, which states "Procedure not allowed for the CLIA Certification Type."
Providers in a Health Professional Shortage Area: ForwardHealth is adjusting certain claims processed and paid during November 2008 through November 2009 to apply the Health Professional Shortage Area (HPSA) enhanced reimbursement when appropriate. ForwardHealth did not apply the HPSA enhanced reimbursement for certain HPSA-eligible services during that time period. Refer to the March 2009 Alert, titled "Health Professional Shortage Area Enhanced Reimbursement System Error," for additional information.

Week of October 12, 2009

Affected Providers Description of Adjustment
Providers Submitting
Point-of-Sale
Pharmacy Claims
ForwardHealth is automatically resubmitting certain pharmacy Point-of-Sale (POS) claims that were originally submitted by providers between November 8, 2008, and May 26, 2009. ForwardHealth sent a letter to pharmacy providers in July 2009 about this issue. Pharmacy providers were asked to identify prescriptions that the pharmacy dispensed to members after the POS claim was denied as a duplicate. Claims for prescriptions identified in the pharmacy's response to that letter will be resubmitted by ForwardHealth during this process.

Week of September 28, 2009

Affected Providers Description of Adjustment
Providers Submitting Claims for Laboratory Services ForwardHealth is reprocessing certain claims for laboratory services processed and paid between November 10, 2008, and September 1, 2009. ForwardHealth may have denied claim details for procedure codes requiring Clinical Laboratory Improvement Amendment (CLIA) certification in error. These denials displayed with Explanation of Benefits (EOB) code 0794, which states "Procedure not allowed for the CLIA Certification Type."

Week of August 24, 2009

Affected Providers Description of Adjustment
Community Support Programs ForwardHealth is adjusting claims for community support program (CSP) services that processed and paid between November 10, 2008, and February 27, 2009. ForwardHealth denied certain claim details for CSP services in error because they were incorrectly identified as duplicate services. Refer to the March 2009 Alert (0081), titled "Claim Details for Community Support Program Services Denied in Error," for more information.

Week of August 17, 2009

Affected Providers Description of Adjustment
Hospice Providers, Hospital Providers, and Nursing Homes During the transition to the ForwardHealth interChange system, ForwardHealth overdeducted patient liability on certain nursing home, hospice, and inpatient hospital claims. ForwardHealth is adjusting affected claims to reimburse providers for patient liability amount deducted in error.

Week of August 10, 2009

Affected Providers Description of Adjustment
Providers Submitting Institutional Claims Due to a systems error, certain institutional claims processed between January 1, 2009, and January 15, 2009, were paid in error. These claims were duplicates of claims that ForwardHealth had already paid. ForwardHealth is recouping the payment for duplicate claims processed and paid between January 1, 2009, and January 15, 2009.

Week of August 3, 2009

Affected Providers Description of Adjustment
Providers Submitting Claims for Drug-Related J-Codes New Average Sales Price (ASP) rates for certain drug-related Healthcare Common Procedure Coding System J-codes were effective as of January 1, 2009. Claims processed and paid between January 1, 2009, and January 7, 2009, applied the incorrect ASP rates to these procedure codes. ForwardHealth has adjusted the affected claims to reflect the new ASP rates.
Providers Submitting Institutional Outpatient Crossover Claims ForwardHealth is recouping Medicare Part B cutback amounts from overpaid outpatient hospital Medicare crossover claims processed and paid during November 2008 through August 2009. A systems issue prevented ForwardHealth from applying the Medicare Part B cutback amount to these claims.
Selected Providers Claims for the influenza vaccine processed and paid between November 10, 2008, and November 18, 2008, have been adjusted to reflect the correct rate, which includes both the cost of the vaccine and the administration fee. The adjustment applies to HealthCare Common Procedure Coding System procedure code 90658 billed with modifier "U1."
 
 
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