BadgerCare Plus/Medicaid SSI HMO or Children’s Specialty Managed Care Prepaid Inpatient Health Plan Provider Appeals

The BadgerCare Plus/Medicaid SSI HMO or Children’s Specialty Managed Care Prepaid Inpatient Health Plan (PIHP) Contracts outline the appeal rights allowed to ForwardHealth providers who contract with HMOs/PIHPs. The contract includes the responsibilities the HMOs/PIHPs have to BadgerCare Plus/Medicaid SSI HMO or Children’s Specialty Managed Care PIHP providers, including the right to appeal a non-payment or partial payment and the steps the provider must take to appeal a decision to ForwardHealth.

For current information on how to file an appeal with a member’s BadgerCare Plus/Medicaid SSI HMO or Children’s Specialty Managed Care PIHP, refer to that HMO’s/PIHP’s provider handbook. Some HMOs/PIHPs provide more time to appeal than others. Providers must exhaust all appeal options with the HMO/PIHP before filing an appeal to ForwardHealth. Providers may not appeal to ForwardHealth until after they have already appealed to the HMO/PIHP.

Appeal Deadlines

When a provider submits an appeal to the HMO/PIHP, the HMO/PIHP has 45 days to respond to their appeal. As a reminder, if the provider does not provide evidence of an appeal to the HMO/PIHP, ForwardHealth will reject the appeal.

Required Documentation

The decision to overturn an HMO's/PIHP’s denial must be clearly supported by the documentation the provider submits. Submitting incomplete or insufficient documentation may lead to ForwardHealth upholding the HMO’s/PIHP’s denial.

Providers are required to submit appeals to ForwardHealth through the Provider Appeals portal. Information regarding registering for a Provider Appeals portal account is available. The following documentation must be submitted/attached in required fields:

• The original claim submitted to the HMO/PIHP and all corrected claims submitted to the HMO/PIHP
• All of the HMO's/PIHP’s payment denial remittances showing the dates of denial and reason codes with descriptions of the exact reasons for the claim denial
• The provider’s written appeal to the HMO/PIHP
• The HMO’s/PIHP’s response to the provider’s appeal
• Relevant medical documentation for appeals regarding coding issues or emergency determination that supports the appeal (Providers should only submit relevant documentation that supports the appeal. Large medical records submitted with no indication of where supporting information is found will not be reviewed.)
• Any contract language that supports the provider’s appeal with the exact language that supports overturning the payment denial indicated (Contract language submitted with no indication of where supporting information is found will not be reviewed, and the denial will be upheld.)
• Any other documentation that supports the provider’s appeal (for example, commercial insurance Explanation of Benefits/Explanation of Payment to support Wisconsin Medicaid as the payer of last resort)

Only relevant documentation should be included.

Managed Care Online Handbook Topics

Providers can find additional information about managed care claims in the Claims chapter of the Online Handbook or in one of the topics listed below:

• Appeals to BadgerCare Plus/Medicaid SSI HMOs or Children’s Specialty Managed Care Prepaid Inpatient Health Plans (#384)
• Appeals to ForwardHealth (#385)
• Claims Submission (#386)
• Extraordinary Claims (#387)
• Medicaid as Payer of Last Resort (#388)
• Provider Appeals (#389)

Below is a list of Online Handbook topics that address common situations that lead to denied claims. Providers may want to review the topic relevant to their appeal:

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

Other Resources

Providers should contact the member’s HMO/PIHP for questions regarding a specific claim or for more information on the HMO’s/PIHP’s appeal process.

To check the status of an appeal submitted to ForwardHealth, providers can:

• Access the Provider Appeals portal.
• Call the ForwardHealth Managed Care Unit at 800-760-0001, option 1.