Free ForwardHealth Interchange Implementation Transitional Payment Request, F13622 - Wisconsin

File Size: 84.2 kB
Pages: 1
Date: January 30, 2009
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHCAA
Word Count: 227 Words, 1,723 Characters
Page Size: Letter (8 1/2" x 11")

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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13622 (10/08)


BILLING PROVIDER AND CLAIM INFORMATION 1. Name -- Billing Provider 2. Name -- Program Medicaid 4. Type of Provider WCDP WWWP 5. Name -- Billing Service, Vendor, Trading Partner Paper Portal PES Software 837 Health Care Claim Electronic Transaction 7. Description of Billing or Processing Issues Causing Delay 3. Program Provider Number or National Provider Identifier

6. Type of Media for the Claim Submission

8. Provider Information Regarding the Number of Claims (if known) Not Processed or Denied

9. Describe Impact of Payment Delay

10. Transitional Payment Request Amount $ _______________________________________________________

11. The submission beginning and ending dates for these claims are ____________________________________________ through (MM/DD/CCYY) ________________________________________________. (MM/DD/CCYY) PROVIDER'S ATTESTMENT Provider attests that the charges listed above have been submitted and not paid and that the information is truthful and accurate. Provider attests to, and understands that, the transitional payment will be automatically recouped when the provider's claims are later processed through the automated claims processing system and must be fully repaid within 60 days of issuance. Provider attests to, and understands, that the appeal rights have been waived for the transitional payment. SIGNATURE 12. Name -- Authorized Person (Print)

13. SIGNATURE -- Authorized Person

14. Date Signed

Fax completed form back to ForwardHealth Financial Services at (608) 221-4567.

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