• General Information
  • Introduction
  • Usual and Customary Charges
  • Acceptance of Payment
    • Introduction
    • Maximum Allowable Fees
• Submission Deadline
  • Introduction
  • Medicaid Claims
  • Crossover Claims
  • Exceptions to the Submission Deadline
• Claims Submission
  • Introduction
  • Transactions and Forms
  • Submission Options
    • Introduction
    • Electronic Claims
    • Paper Claims
  • Copayment Amounts
  • State-Contracted Managed Care Organizations
    • Introduction
    • Extraordinary Claims
  • Noncertified Providers
• Responses to Claims Submission
  • Introduction
  • Claim Number
  • Remittance Information
    • Introduction
    • Electronic Remittance Information
    • Paper Remittance and Status Report
  • Verifying Accuracy of Claims Processing
    • Introduction
    • Split Claims May Appear Separately
  • Verifying the Check Amount on Remittance and Status Reports
  • Claim Status
• Adjustment Requests
  • Introduction
  • Electronic Adjustment Requests
    • Introduction
    • Provider Electronic Solutions Software
  • Paper Adjustment Requests
  • Follow-Up to Adjustment Requests
• Good Faith Claims
• Timely Filing Appeals Requests
• Overpayments
  • Introduction
  • Return of Overpayments Through Adjustment Requests
    • Introduction
    • Electronic Adjustment Requests
    • Paper Adjustment Requests
  • Return of Overpayments with Cash Refunds
  • Adjustment Request vs. Cash Refund
  • Medicaid-Initiated Adjustments
• Appendix
  • Appendix 1 — Allowable Exceptions to the Submission Deadline
  • Appendix 2 — Interpreting Claim Numbers
  • Appendix 3 — Sample Remittance and Status Report
  • Appendix 4 — Reading the Remittance and Status Report
  • Appendix 5 — Reading Adjustments on the Remittance and Status Report
  • Appendix 6 — Adjustment/ Reconsideration Request Completion Instructions
  • Appendix 7 — Adjustment/ Reconsideration Request Form
  • Appendix 8 — Explanation of Benefits Codes That Qualify for Good Faith Claims Submission
  • Appendix 9 — Timely Filing Appeals Request Form
  • Appendix 10 — Claim Refund Completion Instructions
  • Appendix 11 — Claim Refund Form
• PDF

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Claims Information

Appendix

Appendix 1 — Allowable Exceptions to the Submission Deadline

The following table lists the eight allowable exceptions to the claim submission deadline. It also provides the filing deadlines and documentation requirements for each exception. In addition to the documentation listed below, providers are required to submit a Timely Filing Appeals Request form, HCF 13047 (fillable PDF, 144 KB), and a paper claim or an Adjustment/Reconsideration Request form, HCF 13046 (fillable PDF, 310 KB), for each exception.

Change in Nursing Home Resident's Level of Care or Liability Amount
Description of the Exception	Documentation Requirements	Submission Address
This exception occurs when a nursing home claim is initially received by Wisconsin Medicaid within the submission deadline and reimbursed incorrectly due to a change in the recipient's authorized level of care or liability amount.	To receive consideration, the request must be submitted within 455 days from the date of service (DOS) and the correct liability amoun or level of care must be indicated on the Adjustment/ Reconsideration Request form (fillable PDF, 310 KB). The most recent claim number (also known as the internal control number or ICN) must be indicated on the Adjustment/Reconsideration Request form. This number may be the result of a Medicaid-initiated adjustment.	Wisconsin Medicaid Timely Filing Ste 50 6406 Bridge Rd Madison, WI 53784-0050

Decision Made by a Court, Fair Hearing, or the Department of Health and Family Services
Description of the Exception	Documentation Requirements	Submission Address
This exception occurs when a decision is made by a court, fair hearing, or the Department of Health and Family Services (DHFS).	To receive consideration, the request must be submitted within 90 days from the date of the decision of the hearing. A complete copy of the notice received from the court, fair hearing, or DHFS must be submitted with the request.	Wisconsin Medicaid Timely Filing Ste 50 6406 Bridge Rd Madison, WI 53784-0050

Denial Due to Discrepancy Between the Recipient's Eligibility File and the Recipient's Actual Eligibility
Description of the Exception	Documentation Requirements	Submission Address
This exception occurs when a claim is initially received by Wisconsin Medicaid within the submission deadline but is denied due to a discrepancy between the recipient's eligibility file and the recipient's actual eligibility.	To receive consideration, the following documentation must be submitted within 455 days from the DOS: A copy of Medicaid remittance information showing the claim was submitted in a timely manner and denied with a qualifying eligibility-related explanation. A photocopy of one of the following indicating eligibility on the DOS: Beige paper Presumptive Eligibility (PE) for Pregnant Women Benefit identification card. Green paper temporary identification card. White paper PE for the Family Planning Waiver Program identification card. The response received through the Medicaid Eligibility Verification System from a commercial eligibility vendor. The transaction log number received through the Automated Voice Response system. Pharmacy providers should refer to service-specific publications for more information.	Wisconsin Medicaid Timely Filing Ste 50 6406 Bridge Rd Madison, WI 53784-0050

Medicaid Reconsideration or Recoupment
Description of the Exception	Documentation Requirements	Submission Address
This exception occurs when Wisconsin Medicaid reconsiders a previously processed claim. Wisconsin Medicaid will initiate an adjustment on a previously paid claim.	If a subsequent provider submission is required, the request must be submitted within 90 days from the date of the Remittance and Status (R/S) Report message. A copy of the R/S Report message that shows the Medicaid-initiated adjustment must be submitted with the request.	Wisconsin Medicaid Timely Filing Ste 50 6406 Bridge Rd Madison WI 53784-0050

Medicaid Retroactive Eligibility for Persons on General Relief
Description of the Exception	Documentation Requirements	Submission Address
This exception occurs when the local county/tribal social or human services agency requests a return of a general relief payment from the provider because a recipient has become retroactively eligible for Wisconsin Medicaid.	To receive consideration, the request must be submitted within 180 days from the date the backdated eligibility was added to the recipient's eligibility file. The request must be submitted with one of the following: "GR retroactive eligibility" indicated on the claim. A copy of the letter received from the county/tribal social or human services agency.	Wisconsin Medicaid GR Retro Eligibility Ste 50 6406 Bridge Rd Madison WI 53784-0050

Medicare Denial Occurs After Wisconsin Medicaid's Submission Deadline
Description of the Exception	Documentation Requirements	Submission Address
This exception occurs when claims submitted to Medicare (within 365 days of the DOS) are denied by Medicare after the Medicaid 365-day submission deadline. A waiver of the submission deadline will not be granted when Medicare denies a claim for one of the following reasons: The charges were previously submitted to Medicare. The recipient name and identification number do not match. The services were previously denied by Medicare. The provider retroactively applied for Medicare enrollment and did not become enrolled.	To receive consideration, the following must be submitted within 90 days of the Medicare processing date: A copy of the Medicare remittance information. The appropriate Medicare disclaimer code must be indicated on the claim.	Wisconsin Medicaid Timely Filing Ste 50 6406 Bridge Rd Madison WI 53784-0050

Refund Request from Other Health Insurance Source
Description of the Exception	Documentation Requirements	Submission Address
This exception occurs when an other health insurance source reviews a previously paid claim and determines that reimbursement was inappropriate.	To receive consideration, the following documentation must be submitted within 90 days from the date of recoupment notification: A copy of the commercial health insurance remittance information. A copy of the Medicaid remittance information showing recoupment for crossover claims when Medicare is recouping payment.	Wisconsin Medicaid Timely Filing Ste 50 6406 Bridge Rd Madison WI 53784-0050

Retroactive Recipient Eligibility
Description of the Exception	Documentation Requirements	Submission Address
This exception occurs when a claim cannot be submitted within the submission deadline due to a delay in the determination of a recipient's retroactive eligibility.	To receive consideration, the request must be submitted within 180 days from the date the backdated eligibility was added to the recipient's eligibility file. In addition, "retroactive eligibility" must be indicated on the claim.	Wisconsin Medicaid Timely Filing Ste 50 6406 Bridge Rd Madison WI 53784-0050

Next — Appendix 2 — Interpreting Claim Numbers
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