All Provider - Wisconsin Handbook — Managed Care ... information about the EVS. SSI MCOs Recipients of the following Medicaid subprograms are eligible for enrollment in an

All ProviderAll Provider

ManagedCare

ManagedCare

ARCHIVAL USE ONLY Refer to the Online Handbook

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CContacting Wisconsin Medicaid

Web Site dhfs.wisconsin.gov/

The Web site contains information for providers and recipients about the following:

Available 24 hours a day, seven days a week

• Program requirements. • Publications. • Forms.

• Maximum allowable fee schedules. • Professional relations representatives. • Certification packets.

Automated Voice Response System (800) 947-3544 (608) 221-4247

The Automated Voice Response system provides computerized voice responses about the following:

Available 24 hours a day, seven days a week

• Recipient eligibility. • Prior authorization (PA) status.

• Claim status. • Checkwrite information.

Provider Services (800) 947-9627 (608) 221-9883

Correspondents assist providers with questions about the following: • Clarification of program

requirements. • Recipient eligibility.

• Resolving claim denials. • Provider certification.

Available: 8:30 a.m. - 4:30 p.m. (M, W-F) 9:30 a.m. - 4:30 p.m. (T)

Available for pharmacy services: 8:30 a.m. - 6:00 p.m. (M, W-F) 9:30 a.m. - 6:00 p.m. (T)

Division of Health Care Financing Electronic Data Interchange Helpdesk

(608) 221-9036 e-mail: [email protected]

Correspondents assist providers with technical questions about the following: Available 8:30 a.m. - 4:30 p.m. (M-F) • Electronic transactions. • Companion documents.

• Provider Electronic Solutions software.

Web Prior Authorization Technical Helpdesk (608) 221-9730

Correspondents assist providers with Web PA-related technical questions about the following:

Available 8:30 a.m. - 4:30 p.m. (M-F)

• User registration. • Passwords.

• Submission process.

Recipient Services (800) 362-3002 (608) 221-5720

Correspondents assist recipients, or persons calling on behalf of recipients, with questions about the following:

Available 7:30 a.m. - 5:00 p.m. (M-F)

• Recipient eligibility. • General Medicaid information.

• Finding Medicaid-certified providers. • Resolving recipient concerns.


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HHandbook OrganizationThe following tables show the organization of this All-Provider Handbook and list some of the topics included ineach section. It is essential that providers refer to service-specific publications for information about service-specificprogram requirements.

Certification and Ongoing Responsibilities Claims Information

• Certification and recertification. • Change of address or status. • Documentation requirements. • Noncertified providers. • Ongoing responsibilities. • Provider rights. • Provider sanctions. • Recipient discrimination prohibited. • Release of billing information.

• Follow-up procedures. • Good Faith claims. • Preparing and submitting claims. • Reimbursement information. • Remittance information. • Submission deadline. • Timely filing appeals requests.

Coordination of Benefits Covered and Noncovered Services

• Commercial health insurance. • Crossover claims. • Medicare. • Other Coverage Discrepancy Report, HCF 1159. • Primary and secondary payers. • Provider-based billing.

• Collecting payment from recipients. • Covered services. • Emergency services. • HealthCheck “Other Services.” • Medical necessity. • Noncovered services.

Informational Resources Managed Care

• Electronic transactions. • Eligibility Verification System. • Maximum allowable fee schedules. • Forms. • Medicaid Web site. • Professional relations representatives. • Provider Services. • Publications.

• Covered and noncovered HMO and SSI MCO services. • Enrollee HMO and SSI MCO eligibility. • Enrollment process. • Extraordinary claims. • HMO and SSI MCO claims submission. • Network and non-network provider information. • Provider appeals.

Prior Authorization Recipient Eligibility

• Amending prior authorization (PA) requests. • Appealing PA decisions. • Grant and expiration dates. • Prior authorization for emergency services. • Recipient loss of eligibility during treatment. • Renewal requests. • Review process. • Submitting PA requests.

• Copayment requirements. • Eligibility categories. • Eligibility responsibilities. • Eligibility verification. • Identification cards. • Limited benefit categories. • Misuse and abuse of benefits. • Retroactive eligibility.


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TPreface .......................................................................................................................... 3

General Information ....................................................................................................... 5

Special Managed Care Programs ................................................................................. 5Low Income Family Medicaid and BadgerCare HMO Program ........................................ 5SSI MCO Program ..................................................................................................... 5Recipient Enrollment Eligibility ................................................................................... 6

HMOs .................................................................................................................. 6SSI MCOs ............................................................................................................ 6

Copayments ............................................................................................................. 6Covered Services ....................................................................................................... 6

HMOs .................................................................................................................. 6SSI MCOs ............................................................................................................ 7

Managed Care Contracts ............................................................................................ 7Noncovered Services ................................................................................................. 7Other Managed Care Service Information .................................................................... 7

Out-of-Area Care ................................................................................................. 7Prior Authorization ............................................................................................... 7Emergency Services.............................................................................................. 7

Provider Participation ................................................................................................ 7Release of Billing or Medical Information..................................................................... 8

Enrollment Information .................................................................................................. 9

Recipient Enrollment in Managed Care ........................................................................ 9HMOs .................................................................................................................. 9SSI MCOs ............................................................................................................ 9

Enrollment Periods .................................................................................................... 9HMOs .................................................................................................................. 9SSI MCOs ............................................................................................................ 9

Disenrollment and Exemption Situations ................................................................... 10Enrollment Specialist ............................................................................................... 10Ombudsman Program ............................................................................................. 10Enrollee Grievances ................................................................................................. 10

Non-network Providers ................................................................................................. 11

Emergencies ........................................................................................................... 11Referrals................................................................................................................. 11Services Not Provided by Enrollee’s HMO or SSI MCO ................................................ 11

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Claims Submission ....................................................................................................... 13

Medicaid as Payer of Last Resort ............................................................................... 13Extraordinary Claims ............................................................................................... 13

Submitting Extraordinary Claims ......................................................................... 13

Provider Appeals .......................................................................................................... 15

Appeals to HMOs and SSI MCOs .............................................................................. 15Appeals to Wisconsin Medicaid ................................................................................. 15

Appendix .................................................................................................................... 17

1. Managed Care Program Provider Appeal (for photocopying)....................................... 19

Index .......................................................................................................................... 23


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All-Provider Handbook — Managed Care November 2005 3

Preface

PPreface

This All-Provider Handbook is issued to all Medicaid-certified providers. The information in this handbookapplies to Medicaid and BadgerCare.

Medicaid is a joint federal and state program establishedin 1965 under Title XIX of the federal Social Security Act.Wisconsin Medicaid is also known as the MedicalAssistance Program, WMAP, MA, Title XIX, and T19.

BadgerCare extends Medicaid coverage through aMedicaid expansion under Titles XIX and XXI. The goalof BadgerCare is to fill the gap between Medicaid andprivate insurance without supplanting or crowding outprivate insurance. BadgerCare recipients receive thesame benefits as Medicaid recipients, and their healthcare is administered through the same delivery system.

Wisconsin Medicaid and BadgerCare are administered bythe Department of Health and Family Services (DHFS).Within the DHFS, the Division of Health Care Financingis directly responsible for managing Wisconsin Medicaidand BadgerCare.

Wisconsin Medicaid andBadgerCare Web SitesPublications (including provider handbooks and WisconsinMedicaid and BadgerCare Updates), maximumallowable fee schedules, telephone numbers, addresses,and more information are available on the following Websites:

• dhfs.wisconsin.gov/medicaid/.• dhfs.wisconsin.gov/badgercare/.

PublicationsMedicaid publications apply to both Wisconsin Medicaidand BadgerCare. Publications interpret and implement thelaws and regulations that provide the framework forWisconsin Medicaid and BadgerCare. Medicaidpublications provide necessary information about programrequirements.

Legal FrameworkThe following laws and regulations provide the legalframework for Wisconsin Medicaid and BadgerCare:

• Federal Law and Regulation:✓ Law — United States Social Security Act;

Title XIX (42 US Code ss. 1396 andfollowing) and Title XXI.

✓ Regulation — Title 42 CFR Parts 430-498 andParts 1000-1008 (Public Health).

• Wisconsin Law and Regulation:✓ Law — Wisconsin Statutes: 49.43-49.499 and

49.665.✓ Regulation — Wisconsin Administrative Code,

Chapters HFS 101-109.

Laws and regulations may be amended or added at anytime. Program requirements may not be construed tosupersede the provisions of these laws and regulations.


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4 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ November 2005


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General

Information

GThis section of the All-Provider Handbook isdesigned to aid both managed care networkproviders and non-managed care networkproviders who work with HMO enrollees andthe managed care program.

Wisconsin Medicaid Managed Care refers tothe Low Income Family Medicaid andBadgerCare HMO program, the SupplementalSecurity Income (SSI) Managed CareOrganization (MCO) program, and the severalspecial managed care programs available. Thissection focuses on the Low Income FamilyMedicaid and BadgerCare HMO program andthe SSI MCO program.

The primary goals of the managed careprograms are:

• To improve the quality of recipient care byproviding continuity of care and improvedaccess.

• To reduce the cost of health care throughbetter care management.

Special Managed CareProgramsWisconsin Medicaid has several specialmanaged care programs that provide servicesto individuals who are elderly and/or who havedisabilities. These recipients may be eligible toenroll in voluntary regional managed careprograms such as Family Care, the Program ofAll-Inclusive Care for the Elderly, and theWisconsin Partnership Program. Additionalinformation on these special managed careprograms may be obtained from the ManagedCare section of the Wisconsin Medicaid Website.

General Information

Low Income FamilyMedicaid and BadgerCareHMO ProgramAn HMO is a system of health care providersthat provide a comprehensive range of medicalservices to a group of enrollees. WisconsinMedicaid HMOs serve more than 356,000low-income children and family members (asof June 2005). HMOs receive a fixed, prepaidamount per enrollee from Wisconsin Medicaid(called a capitation payment) to providemedically necessary services.

Medicaid HMOs are responsible for providingor arranging all contracted Medicaid-coveredmedically necessary services to enrollees.Medicaid and BadgerCare recipients enrolledin state-contracted HMOs are entitled to atleast the same benefits as Medicaid fee-for-service recipients; however, HMOs mayestablish their own requirements regardingprior authorization (PA), claims submission,adjudication procedures, etc., which may differfrom Medicaid fee-for-service policies andprocedures. Medicaid HMO networkproviders should contact their HMO for moreinformation about its policies and procedures.

SSI MCO ProgramSupplemental Security Income recipients andSSI-related Medicaid recipients in MilwaukeeCounty may be eligible to enroll in one of theSSI MCOs.

SSI MCOs provide the same benefits asMedicaid fee-for-service (e.g. medical, dental,mental health/substance abuse, vision, andprescription drug coverage) at no cost to theirenrollees through a care management model.Through the care management model, eachenrollee receives an initial health assessment,as well as assistance in choosing providers,

MMedicaid HMOsare responsiblefor providing orarranging allcontractedMedicaid-coveredmedicallynecessaryservices toenrollees.


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accessing social and community serviceoptions, health education programs, andtreatment and follow-up information.

Supplemental Security Income recipients andSSI-related Medicaid recipients who live inother counties will continue to receive servicesthrough Medicaid fee-for-service.

Recipient EnrollmentEligibility

HMOsRecipients of the following Medicaid sub-programs are eligible for enrollment in aMedicaid HMO:

• Low Income Family Medicaid —Comprised of low-income pregnantwomen, children, and families with childrenwho are less than 19 years of age.

• BadgerCare — Comprised of low-incomeuninsured families.

• Healthy Start — Comprised of low-incomepregnant women and children.

An individual who receives the FamilyPlanning Waiver Benefit, the Tuberculosis-Related Services Only Benefit, SeniorCare, orWisconsin Well Woman Medicaid cannot beenrolled in a Medicaid HMO.

Information about a recipient’s HMOenrollment status and commercial healthinsurance coverage may be verified by usingWisconsin Medicaid’s Eligibility VerificationSystem (EVS). Refer to the RecipientEligibility section of this handbook for furtherinformation about the EVS.

SSI MCOsRecipients of the following Medicaidsubprograms are eligible for enrollment in anSSI MCO:

• Medicaid-eligible individuals living inMilwaukee County.

• Individuals ages 19 and older, who meetthe SSI and SSI-related disability criteria.

• Dual eligibles for Medicare and Medicaid.

Individuals who are living in an institution,nursing home, or participating in a Home andCommunity-Based Waiver program are noteligible to enroll in an SSI MCO.

CopaymentsProviders cannot charge enrollees copaymentsfor Medicaid-covered services except in caseswhere the HMO or SSI MCO do not coverservices such as chiropractic and dental. Whenservices are provided through Medicaid fee-for-service, copayments will apply.

Covered Services

HMOsAlthough Wisconsin Medicaid requirescontracted HMOs to provide all medicallynecessary Medicaid-covered services, thefollowing services may be provided byMedicaid HMOs at their discretion:

• Dental.• Chiropractic.

If the HMO does not include these services intheir benefit package, the enrollee receives theservices on a Medicaid fee-for-service basis.Enrollees are responsible for the copaymentfor services not covered by their HMO.

PProviders cannotcharge enrolleescopayments forMedicaid-coveredservices except incases where theHMO or SSI MCOdo not coverservices such aschiropractic anddental.


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SSI MCOsWisconsin Medicaid requires contracted SSIMCOs in Milwaukee County to provide allmedically necessary Medicaid-coveredservices, including dental. If the SSI MCOdoes not include services such as chiropractic,the enrollee receives these services on aMedicaid fee-for-service basis.

Managed Care ContractsThe contract between the Wisconsin Departmentof Health and Family Services (DHFS) and theHMO or SSI MCO takes precedence overother Medicaid provider publications.Information contained in this and otherMedicaid publications is used by the Division ofHealth Care Financing to resolve disputesregarding covered benefits that cannot behandled internally by HMOs and SSI MCOs.If there is a conflict, the HMO or SSI MCOcontract prevails. If the contract does notspecifically address a situation, WisconsinAdministrative Code ultimately prevails. HMOand SSI MCO contracts can be found in theManaged Care section of the Medicaid Website.

Noncovered ServicesThe following are not covered by MedicaidHMOs or SSI MCOs but are provided toenrollees on a fee-for-service basis:

• Community Support Program benefits.• Crisis intervention services.• Environmental lead inspections.• Milwaukee child care coordination services.• Prenatal care coordination services.• School-Based Services.• Targeted case management services.• Transportation by common carrier (unless

the HMO has made arrangements toprovide this service as a benefit).Milwaukee HMOs and MCOs aremandated to provide transportation fortheir enrollees.

Other Managed CareService InformationOut-of-Area CareHMOs and SSI MCOs may cover medicallynecessary care provided to enrollees whenthey travel outside the HMO’s or SSI MCO’sservice area. The HMO or SSI MCO isrequired to authorize the services before theservices are provided, except in cases ofemergency. If the HMO or SSI MCO does notauthorize the services, the enrollee may be heldresponsible for the cost of those services.

Prior AuthorizationMedicaid HMOs and SSI MCOs may developPA guidelines that differ from Medicaid’s fee-for-service guidelines. However, the applicationof such guidelines may not result in lesscoverage than fee-for-service. Contact theenrollee’s HMO or SSI MCO for moreinformation regarding PA procedures.

Emergency ServicesIn emergency situations, enrollees may seekmedical services from providers not affiliatedwith the HMO or SSI MCO, if necessary. Thecontract between the DHFS and the HMO orSSI MCO defines an emergency situation andincludes general payment requirements.

Unless the HMO or SSI MCO has a writtenagreement with the non-network provider, theHMO or SSI MCO is only liable to the extentMedicaid fee-for-service would be liable for anemergency situation, as defined in 42 CFR s.438.114.

Provider ParticipationProviders interested in participating in aMedicaid HMO or SSI MCO or changingHMO or SSI MCO network affiliations shouldcontact the HMO or SSI MCO for moreinformation. Conditions and terms ofparticipation in an HMO or SSI MCO arepursuant to specific contract agreements

TThe contractbetween theWisconsinDepartment ofHealth and FamilyServices (DHFS)and the HMO orSSI MCO takesprecedence overother Medicaidproviderpublications.


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between HMOs or SSI MCOs and providers.An HMO or SSI MCO has the right to choosewhether or not to contract with any provider.

Release of Billing orMedical InformationWisconsin Medicaid supports HMO and SSIMCO enrollee rights regarding theconfidentiality of health care records.Wisconsin Medicaid has specific standardsregarding the release of a Medicaid HMO orSSI MCO enrollee’s billing information ormedical claim records. Providers should referto the Certification and OngoingResponsibilities section of this handbook forfurther information about the release of enrolleebilling or medical information.

WWisconsinMedicaid hasspecific standardsregarding therelease of aMedicaid HMO orSSI MCOenrollee’s billinginformation ormedical claimrecords.


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Enrollment

Information

EEnrollment Information

Recipient Enrollment inManaged Care

HMOsMedicaid HMO enrollment is either mandatoryor voluntary based on ZIP code-definedenrollment areas as follows:

• Mandatory enrollment — Enrollment ismandatory for eligible recipients whoreside in ZIP code areas served by two ormore Medicaid HMOs. Some recipientsmay meet criteria for exemption fromMedicaid HMO enrollment.

• Voluntary enrollment — Enrollment isvoluntary for recipients who reside in ZIPcode areas served by only one MedicaidHMO.

Wisconsin Medicaid recipients living in areaswhere enrollment is mandatory are encouragedto choose their Medicaid HMO. Automaticassignment to a Medicaid HMO occurs if therecipient does not choose a Medicaid HMO.Recipients in voluntary enrollment areas canchoose whether or not to enroll in a MedicaidHMO. There is no automatic assignment forrecipients who live within ZIP codes whereenrollment is voluntary.

The Department of Health and FamilyServices (DHFS) contracts with an enrollmentspecialist who provides unbiased counseling tohelp recipients choose an HMO that bestmeets their needs. In general, all members of arecipient’s immediate family eligible forenrollment must choose the same HMO.

SSI MCOsSSI MCO enrollment is either mandatory orvoluntary as follows:

• Mandatory enrollment — MostSupplemental Security Income (SSI) andSSI-related Medicaid recipients arerequired to enroll in an SSI MCO. Arecipient may choose the SSI MCO inwhich he or she wishes to enroll.

• Voluntary enrollment — Some SSI andSSI-related Medicaid recipients maychoose to enroll in an SSI MCO on avoluntary basis.

The DHFS contracts with an enrollmentspecialist who provides unbiased counseling tohelp recipients choose an SSI MCO that bestmeets their needs.

Enrollment Periods

HMOsRecipients are sent enrollment packets thatexplain the HMOs and the enrollment processand provide contact information. Onceenrolled, enrollees may change their HMOassignment within the first 90 days ofenrollment in an HMO (whether they chosethe HMO or were auto-assigned). If anenrollee no longer meets the criteria, he or shewill be disenrolled from the HMO.

SSI MCOsRecipients are sent enrollment packets thatexplain the SSI MCO’s enrollment process andprovide contract information. Once enrolled,enrollees may disenroll after a 60-day trialperiod and up to 120 days after enrollment andreturn to Medicaid fee-for-service if theychoose.

WWisconsinMedicaidrecipients living inareas whereenrollment ismandatory areencouraged tochoose theirMedicaid HMO.


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Disenrollment andExemption SituationsIn some situations, a recipient may be exemptfrom enrolling in an HMO or SSI MCO.Exempted recipients receive health care underMedicaid fee-for-service. Exemptions allowrecipients to complete a course of treatmentwith a provider who is not contracted with therecipient’s HMO or SSI MCO. For example,in certain circumstances, women in high-riskpregnancies or women who are in the thirdtrimester of pregnancy when they are enrolledin an HMO or SSI MCO may qualify for anexemption.

The contracts between the DHFS and theHMO/SSI MCO provide more detail on theexemption and disenrollment requirements. Thecurrent contract is available on the WisconsinMedicaid Web site.

Enrollment SpecialistThe Wisconsin Medicaid and BadgerCareEnrollment Specialist provides objectiveenrollment, education, outreach, and advocacyservices to HMO and SSI MCO enrollees.The Enrollment Specialist is a knowledgeablesingle point of contact for enrollees, solelydedicated to managed care issues. TheEnrollment Specialist is not affiliated with anyhealth care agency.

The Enrollment Specialist is available from 7:00a.m. to 6:00 p.m., Monday through Friday,excluding holidays, at (800) 291-2002.

The Enrollment Specialist provides thefollowing services to HMO and SSI MCOenrollees:

• Education regarding the correct use ofHMO and SSI MCO benefits.

• Telephone and face-to-face support.• Assistance with enrollment, disenrollment,

and exemption procedures.

Ombudsman ProgramThe Wisconsin Medicaid and BadgerCareHMO and SSI MCO Ombudsmen, orOmbuds, are resources for enrollees who havequestions or concerns about their HMO or SSIMCO. Ombuds provide advocacy andassistance to help enrollees understand theirrights and responsibilities in the grievance andappeal process.

Ombuds are available Monday through Friday,excluding holidays, from 7:30 a.m. to 4:00 p.m.at (800) 760-0001 or may be contacted at thefollowing address:

Medicaid and BadgerCare HMO/SSIMCO Ombudsmen

PO Box 6470Madison WI 53716-0470

Enrollee GrievancesEnrollees have the right to file grievancesabout services or benefits provided by anHMO or SSI MCO. Enrollees also have theright to file a grievance when the HMO or SSIMCO refuses to provide a service. All HMOsand SSI MCOs are required to have writtenpolicies and procedures in place to handleenrollee grievances. Enrollees should beencouraged to work with their HMO’s or SSIMCO’s customer service department toresolve problems first.

If enrollees are unable to resolve problems bytalking to their HMO or SSI MCO, or if theywould prefer to speak with someone outsidetheir HMO or SSI MCO, they should contactthe Enrollment Specialist or the OmbudsmanProgram.

The contract between the DHFS and theHMO or SSI MCO describes theresponsibilities of the HMO or SSI MCO andthe DHFS regarding enrollee grievances.

TThe WisconsinMedicaid andBadgerCareEnrollmentSpecialist providesobjectiveenrollment,education,outreach, andadvocacy servicesto HMO and SSIMCO enrollees.


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NNon-network Providers

Providers who do not have a contract with theenrollee’s HMO or SSI MCO are referred toas non-network providers. (HMO and SSIMCO network providers agree to paymentamounts and billing procedures in a contractwith the HMO or SSI MCO.) Non-networkproviders are required to direct enrollees toHMO or SSI MCO network providers exceptin the following situations:

• When a non-network provider is treatingan HMO or SSI MCO enrollee for anemergency medical condition as defined inthe contract between the Department ofHealth and Family Services (DHFS) andthe HMO or SSI MCO.

• When the HMO or SSI MCO hasauthorized (in writing) an out-of-planreferral to a non-network provider.

• When the service is not provided under theHMO’s or SSI MCO’s contract with theDHFS (such as dental or chiropracticservices).

Non-network providers may not serveMedicaid HMO or SSI MCO enrollees asprivate-pay patients.

EmergenciesNon-network providers may provide services toHMO and SSI MCO enrollees in anemergency without authorization or in urgentsituations when authorized by the HMO or SSIMCO. The contract between the DHFS andthe HMO or SSI MCO defines an emergencysituation and includes general paymentrequirements. Billing procedures foremergencies may vary depending on the HMOor SSI MCO. For specific billing instructions,non-network providers should always contactthe enrollee’s HMO or SSI MCO.

ReferralsNon-network providers may at times provideservices to HMO and SSI MCO enrollees on areferral basis. Non-network providers arealways required to contact the enrollee’s HMOor SSI MCO. Before services are provided,the non-network provider and the HMO or SSIMCO should discuss and agree upon billingprocedures and fees for all referrals. Non-network providers and HMOs/SSI MCOsshould document the details of any referral inwriting before services are provided.

Billing procedures for out-of-plan referrals mayvary depending on the HMO or SSI MCO. Forspecific billing instructions, non-networkproviders should always contact the enrollee’sHMO or SSI MCO.

Services Not Provided byEnrollee’s HMO or SSIMCOIf an enrollee’s HMO’s or SSI MCO’s benefitpackage does not include a Medicaid-coveredservice, such as chiropractic or dental services,any Medicaid-certified provider may providethe service to the enrollee and submit claims toMedicaid fee-for-service.

IIf an enrollee’sHMO’s or SSIMCO’s benefitpackage does notinclude aMedicaid-coveredservice, such aschiropractic ordental services,any Medicaid-certified providermay provide theservice to theenrollee andsubmit claims toMedicaid fee-for-service.


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Claims

Submission

CClaims Submission

HMOs and SSI MCOs have requirements fortimely filing of claims, and providers arerequired to follow HMO and SSI MCO claimssubmission guidelines. Contact the enrollee’sHMO or SSI MCO for organization-specificsubmission deadlines.

If an HMO or SSI MCO denies a claim,providers may file an appeal with the HMO orSSI MCO. If a provider disagrees with theHMO’s or SSI MCO’s decision, he or she mayfile an appeal with Wisconsin Medicaid. Referto the Provider Appeals chapter of this sectionfor more information on appeals.

Medicaid as Payer of LastResortWisconsin Medicaid is the payer of last resortfor most Medicaid-covered services, even whena recipient is enrolled in a Medicaid HMO orSSI MCO. Before submitting claims toMedicaid HMOs and SSI MCOs, providersare required to submit claims to other healthinsurance sources. Contact the enrollee’sHMO or SSI MCO for more information aboutbilling other health insurance sources. Refer tothe Coordination of Benefits section of thishandbook for more information aboutcoordinating benefits with other healthinsurance sources.

Extraordinary ClaimsExtraordinary claims are Medicaid claims foran HMO or SSI MCO enrollee that have beendenied by an HMO or SSI MCO but may bepaid as fee-for-service claims.

The following are some examples ofextraordinary claims situations:

• The enrollee was not enrolled in an HMOor SSI MCO at the time he or she wasadmitted to an inpatient hospital, but thenenrolled in an HMO or SSI MCO duringthe hospital stay. In this case, all claimsrelated to the stay (including physicianclaims) should be submitted to Medicaidfee-for-service. These claims (includingphysician claims) must include admittanceand discharge dates.

• The claims are for orthodontia/prosthodontia services that began beforeHMO or SSI MCO coverage. Include arecord with the claim of when the bandswere placed.

Submitting Extraordinary ClaimsWhen submitting an extraordinary claim,include the following:

• A legible copy of the completed claimform, in accordance with Medicaid billingguidelines.

• A letter detailing the problem, any claimdenials, and any steps taken to correct thesituation.

Submit extraordinary claims to:

Wisconsin MedicaidManaged Care Extraordinary ClaimsPO Box 6470Madison WI 53716-0470

EExtraordinaryclaims areMedicaid claimsfor an HMO or SSIMCO enrollee thathave been deniedby an HMO or SSIMCO but may bepaid as fee-for-service claims.


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Provider Appeals

PProvider Appeals

When a Medicaid HMO or SSI MCO denies aprovider’s claim, the HMO or SSI MCO isrequired to send the provider a notice informinghim or her of the right to file an appeal.

An HMO or SSI MCO network or non-network provider may file an appeal to theHMO or SSI MCO when:

• A claim submitted to the HMO or SSIMCO is denied payment.

• The full amount of a submitted claim is notpaid.

Appeals to HMOs and SSIMCOsProviders are required to first file an appealdirectly with the HMO or SSI MCO within 60calendar days of receipt of the initial denial.Providers are required to include a letterexplaining why the HMO or SSI MCO shouldpay the claim. The appeal should be sent to theaddress indicated on the HMO’s or SSIMCO’s denial notice.

The HMO or SSI MCO then has 45 calendardays to respond in writing to the appeal. TheHMO or SSI MCO decides whether to paythe claim and sends the provider a letter statingthe decision.

If the HMO or SSI MCO does not respond inwriting within 45 calendar days, or if theprovider is dissatisfied with the HMO’s or SSIMCO’s response, the provider may send awritten appeal to Wisconsin Medicaid within 60calendar days.

Appeals to WisconsinMedicaidThe provider has 60 calendar days to file anappeal with Wisconsin Medicaid after the HMOor SSI MCO either does not respond in writingwithin 45 calendar days or if the provider isdissatisfied with the HMO’s or SSI MCO’sresponse.

Wisconsin Medicaid will not review appealsthat were not first made to the HMO or SSIMCO. If a provider sends an appeal directly toWisconsin Medicaid without first filing it withthe HMO or SSI MCO, Wisconsin Medicaidwill return the appeal to the provider.

Wisconsin Medicaid will only review appealsfor enrollees who were eligible for WisconsinMedicaid and who were enrolled in a MedicaidHMO or SSI MCO on the date of service inquestion.

Appeals to Wisconsin Medicaid must be madein writing and must include:

• A letter, clearly marked “APPEAL,”explaining why the claim should be paid ora completed provider appeal form. Referto Appendix 1 of this section for a copy ofthe Managed Care Program ProviderAppeal form, HCF 12022.

• A copy of the claim, clearly marked“APPEAL.”

• A copy of the provider’s letter to the HMOor SSI MCO.

• A copy of the HMO’s or SSI MCO’sresponse to the provider.

• Any documentation that supports the case.

IIf a providersends an appealdirectly toWisconsinMedicaid withoutfirst filing it withthe HMO or SSIMCO, WisconsinMedicaid willreturn the appealto the provider.


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Wisconsin Medicaid will review the appeal andgather any additional information needed fromthe provider or the HMO/SSI MCO. Once allpertinent information is received, WisconsinMedicaid has 45 calendar days to make a finaldecision.

Wisconsin Medicaid will notify the providerand the HMO or SSI MCO in writing of itsfinal decision. If Wisconsin Medicaid decides infavor of the provider, the HMO or SSI MCO isrequired to pay the provider within 45 calendardays of the final decision. WisconsinMedicaid’s decision is final and all parties mustabide by the decision.

WWisconsinMedicaid willnotify the providerand the HMO orSSI MCO inwriting of its finaldecision.


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All-Provider Handbook – Managed Care November 2005 17

Appendix

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Appendix

Appendix 1Managed Care Program Provider Appeal

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(A copy of the Managed Care Program Provider Appeal is located on thefollowing pages.)


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DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSIN Division of Health Care Financing s. 49.45, Wis. Stats. HCF 12022 (Rev. 08/05)

WISCONSIN MEDICAID MANAGED CARE PROGRAM PROVIDER APPEAL

Wisconsin Medicaid requires certain information to enable Medicaid to authorize and pay for medical services provided to eligible recipients. Personally identifiable information about Medicaid providers is used for purposes directly related to Medicaid administration such as determining the certification of providers or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of Medicaid payment for the services. The use of this form is voluntary. Providers may send this completed form and other written complaints to: Wisconsin Medicaid Managed Care Appeals PO Box 309 Madison WI 53701-0309 INSTRUCTIONS: Type or print clearly.

SECTION I — PROVIDER INFORMATION Name — Provider Filing Appeal Telephone Number — Provider Filing

Appeal Name — HMO / SSI MCO Involved

Address — Provider Filing Appeal (Street, City, State, Zip Code) Name and Telephone Number — Contact Person

SECTION II — ENROLLEE INFORMATION Name — Medicaid HMO / SSI MCO Enrollee Medicaid Identification Number Date of Service

SECTION III — DESCRIPTION OF PROBLEM

Describe the problem in detail. Use additional paper, if necessary. Attach copies of any supporting documentation relevant to the problem.

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MANAGED CARE PROGRAM PROVIDER APPEAL Page 2 of 2 HCF 12022 (Rev. 08/05)

SECTION III — DESCRIPTION OF PROBLEM (Continued) Insert date the appeal was sent to HMO / SSI MCO or claim reconsideration was requested.

Insert date the appeal / reconsideration request was denied by HMO / SSI MCO.

What response was received from the HMO / SSI MCO? Attach a photocopy of any relevant correspondence.

What does the provider consider to be a fair resolution of this matter?

SECTION IV — SIGNATURE

This information is accurate to the best of my knowledge. A copy of this information may be forwarded to the Medicaid HMO/SSI MCO involved. SIGNATURE — Provider Date Signed


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Index

IIndex

Automatic Assignment, 9

Capitation Payment, 5

Claims Submission, 13

Copayments, 6

Disenrollment, 10

Eligibility Verification System, 6

Emergencies, 7, 11

Enrollee Grievances, 10

Enrollmentpackets, 9periods, 9specialist, 10exemptions, 10of pregnant women, 10

Extraordinary Claimssituations, 13submission of, 13

Healthy Start, 6

HMOcovered services, 6definition of, 5enrollment in an, 9recipient enrollment eligibility, 6

Low Income Family Medicaid, 5, 6

Managed Carecontracts, 7program goals, 5special programs, 5

Noncovered Services, 7

Ombudsmen, 10

Other Health Insurance Sources, 13

Out-of-Area Care, 7

Prior Authorization, 7

Provider Appealsform, 19to HMOs and SSI MCOs, 15to Wisconsin Medicaid, 15

Providerschanging network affiliations, 7interest in HMO participation, 7non-network providers, 7, 11

Recipientsmandatory enrollment, 9voluntary enrollment, 9

Referrals, 11

Release of Enrollee Information, 8

Supplemental Security Income Managed Care Organiza-tion (SSI MCO) Program, 5

SSI MCOcovered services, 7definition of, 5enrollment in an, 9recipient enrollment eligibility, 6


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Inde

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Documents

All Provider - Wisconsin Handbook — Managed Care ... information about the EVS. SSI MCOs Recipients of the following Medicaid subprograms are eligible for enrollment in an