• 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

Select a section » Certification and Ongoing Responsibilities Claims Information Coordination of Benefits Covered and Noncovered Services Informational Resources Managed Care Prior Authorization Recipient Eligibility

 

 

Claims Information

Good Faith Claims

A good faith claim may be submitted when a claim is denied by Wisconsin Medicaid due to a discrepancy between the recipient’s eligibility file and the recipient’s actual eligibility. Good faith claims must be submitted on paper because a national standard for electronic claim attachments has not been established at this time.

When both of the following circumstances occur, a claim may be denied by Wisconsin Medicaid:

• The recipient presents a beige paper Presumptive Eligibility (PE) for Pregnant Women Benefit identification card, green paper temporary identification card, or white paper PE for the Family Planning Waiver Program (FPWP) identification card.
• The provider submits the claim prior to Wisconsin Medicaid receiving the recipient’s eligibility information.

In this situation, a claim may be denied with an eligibility-related Explanation of Benefits (EOB) code, and a good faith claim may then be submitted. Submitting good faith claims to Wisconsin Medicaid eliminates the need for the provider to contact the recipient’s certifying agency.

A claim that is denied based on an EOB code listed in Appendix 8 of this section may be submitted to Good Faith if the dates of service (DOS) are within the claim submission deadline.

Before submitting a good faith claim, the provider is encouraged to verify through the Medicaid Eligibility Verification System (EVS) that Wisconsin Medicaid has not received the recipient’s correct eligibility information. If the recipient’s eligibility information has been updated, the provider should not submit a good faith claim. Instead, the provider should submit one of the following to Wisconsin Medicaid:

• An adjustment request if the original claim is in an allowed status.
• A new claim if the original claim is in a denied status.

To receive Medicaid consideration for a good faith claim, providers are required to submit the following:

• A legible copy of the claim.
• A copy of Medicaid remittance information showing a qualifying eligibility-related denial.
• A photocopy of one of the following indicating eligibility on the DOS:
• Beige paper PE for Pregnant Women Benefit identification card.
• Green paper temporary identification card.
• White paper PE for the FPWP identification card.
• The response received through the EVS from a commercial eligibility verification vendor.
• The transaction log number received through the Automated Voice Response system.

Pharmacy providers should refer to service-specific publications for more information about submitting good faith claims.

Wisconsin Medicaid will do the following when a good faith claim is received:

• Enter the claim into the claims processing system.
• Suspend the claim.
• Make an inquiry to the certifying agency in an effort to update the recipient’s eligibility file (this includes waiting for a response for a period of up to 70 days).
• Update the recipient’s file.
• Release the claim to complete processing when the recipient’s file is updated.

Submit good faith claims to the following address:

Wisconsin Medicaid
Good Faith
PO Box 6215
Madison WI 53784-6215

A good faith claim that contains DOS beyond the claim submission deadline must be submitted to Good Faith/Timely Filing. Refer to the Timely Filing Appeals Requests chapter of this section and Appendix 1 of this section for more information about submitting these claims.

Next — Timely Filing Appeals Requests
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