• Eligibility Categories
  • Introduction
  • Medicaid Recipients
  • BadgerCare Recipients
  • Wisconsin Well Woman Medicaid
  • Limited Benefit Categories
    • Introduction
    • Family Planning Waiver Program
    • Presumptive Eligibility for Pregnant Women Benefit
    • Tuberculosis-Related Services-Only Benefit
    • Qualified Medicare Beneficiary-Only Recipients
    • Specified Low Income Medicare Beneficiaries
    • Qualifying Individual 1 Recipients
    • Qualified Disabled Working Individual Recipients
• Medicaid Identification Cards
  • Introduction
  • Forward Cards
    • Introduction
    • Forward Card Features
    • Identification Number Changes
    • Recipient Name Changes
    • Deactivated Cards
    • Defective Cards
    • Lost Cards
    • Managed Care Organization Enrollment Changes
  • Temporary Medicaid Cards
  • Presumptive Eligibility for Pregnant Women Temporary Cards
  • Presumptive Eligibility for the Family Planning Waiver Program Temporary Cards
• Eligibility Verification Methods
  • Introduction
  • 270/271 Transactions
  • Automated Voice Response System
    • Introduction
    • Dates of Services
    • Hours
  • Commercial Eligibility Verification Vendors
    • Introduction
    • Magnetic Stripe Card Readers
    • Personal Computer Software
    • Internet Access
  • Provider Services
    • Introduction
    • Hours
  • Recipient Forgets Identification Card
• Eligibility Rights
  • Introduction
  • Prompt Decisions on Eligibility
  • Requesting Retroactive Eligibility
  • Appealing Eligibility Determinations
    • Introduction
    • Claims for Appeal Reversals
  • Freedom of Choice
  • Notification of Discontinued Benefits
• Eligibility Responsibilities
  • Introduction
  • Prior Identification of Eligibility
  • Loss of Medicaid Eligibility — Financial Liability
  • Reporting Changes to Caseworkers
• Copayment Requirements
  • Introduction
  • Copayment Exemptions
  • Copayment Amounts
  • Copayment Limitations
  • Copayment Refund/Collection Requirement
• Special Eligibility Circumstances
  • Retroactive Eligibility
    • Introduction
    • Reimbursing Recipients in Cases of Retroactive Eligibility
  • Spenddown to Meet Medicaid Financial Eligibility Requirements
  • Persons Detained by Legal Process
  • Recipients Traveling Out of State
  • Non-U.S. Citizens — Emergency Services
  • Medicaid Recipients from Other States
• Misuse and Abuse of Benefits
  • Introduction
  • Examples of Misuse and Abuse
  • Requesting Additional Proof of Identity
  • Notifying Wisconsin Medicaid
  • Providers May Refuse to Provide Services
  • Recipient Lock-In Program
    • Introduction
    • Providers May Make Referrals
• Appendix
  • Appendix 1 — Limited Benefit Categories
  • Appendix 2 — Quick-Entry Guide for the Automated Voice Response System
  • Appendix 3 — Eligibility Verification Vendors
  • Appendix 4 — Certification of Emergency for Non-U.S. Citizens Form Completion Instructions
  • Appendix 5 — Certification of Emergency for Non-U.S. Citizens
• 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

 

 

Recipient Eligibility

Special Eligibility Circumstances

Retroactive Eligibility

Reimbursing Recipients in Cases of Retroactive Eligibility

When a recipient receives retroactive eligibility, he or she has the right to request the return of payments made to a Medicaid-certified provider for a Medicaid-covered service during the period of retroactive eligibility, according to HFS 104.01(11), Wis. Admin. Code. A Medicaid-certified provider is required to submit claims to Wisconsin Medicaid for covered services provided to a recipient during periods of retroactive eligibility. Wisconsin Medicaid cannot directly refund the recipient.

If a service(s) that requires prior authorization (PA) was performed during the recipient’s period of retroactive eligibility, the provider is required to submit a PA request and receive approval from Wisconsin Medicaid before submitting a claim. Refer to the Prior Authorization section of this handbook for more information on requesting PA for recipients with retroactive eligibility.

If a provider receives reimbursement from Wisconsin Medicaid for services provided to a retroactively eligible recipient and the recipient has paid for the service, the provider is required to reimburse the recipient or authorized person acting on behalf of the recipient (e.g., local General Relief agency) no less than the amount paid by Wisconsin Medicaid. The provider is not required to reimburse the recipient more than the amount paid by Wisconsin Medicaid according to HFS 106.04(3)(b), Wis. Admin. Code.

For example: A provider receives $100 from a client for a given service. One month later, the client is granted retroactive eligibility for Wisconsin Medicaid for the previous dates of service (DOS). The provider submits a claim and is reimbursed $62 by Wisconsin Medicaid. (This total is reached by taking the maximum allowable fee [$65] minus the applicable copayment [$3].) The provider is then required to refund the $62 to the recipient.

If a claim cannot be filed within 365 days of the DOS due to a delay in the determination of a recipient’s retroactive eligibility, the provider is required to submit the claim to Timely Filing within 180 days of the date the retroactive eligibility is entered into the Medicaid Eligibility Verification System (if the services provided during the period of retroactive eligibility were Medicaid covered). Refer to the Claims Information section of this handbook for more information on filing claims for services performed with DOS beyond the claims submission deadline (timely filing appeals requests).

Next — Special Eligibility Circumstances, Spenddown to Meet Medicaid Financial Eligibility Requirements
Previous — Special Eligibility Circumstances, Retroactive Eligibility