DEPARTMENT OF HEALTH SERVICES Department of Long Term Care F-00022A (02/09)
STATE OF WISCONSIN
NURSING HOME RATE ADMINISTRATIVE REVIEW REQUEST COMPLETION INSTRUCTIONS
ForwardHealth requires certain information to enable the programs to authorize and pay for medical services provided to eligible members. Members of ForwardHealth are required to give providers full, correct, and truthful information for the submission of correct and complete claims for reimbursement. This information should include, but is not limited to, information concerning enrollment status, accurate name, address, and member identification number (DHS 104.02, Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about program applicants and members is confidential and is used for purposes directly related to ForwardHealth administration such as determining eligibility of the applicant, processing prior authorization (PA) requests, or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of PA or payment for the service. The Nursing Home Rate Administrative Review Request form is used to bring major problems about nursing home reimbursement to the attention of the Division of Long Term Care (DLTC) Administrative Review Committee. To be considered an acceptable issue for administrative review, all attributes listed below must be adequately addressed. This will require those with a problem to adequately research the issue before transmittal. If more space is required, additional sheets can be submitted. Pertinent correspondence should accompany this transmittal. Nursing homes are expected to send information to their respective associations. The associations, in turn, complete the requested information and documentation as required below. The following is a description of the attributes: Statement of Condition. What is the problem? Outline the problem or state "what is going on." Criteria. Why is it a problem? Indicate and cite federal and state statutory requirements or regulations, acceptable business or accounting practices that are being measured against, and provisions of the rate "Methods of Implementation" that are being interpreted. Cause. What caused the problem? Cite specific examples. Effect. What is the extent of the problem? Be specific. Simple statements without information necessary to determine validity or materiality are inadequate. For collective requests, indicate the number or list homes affected. Recommendation. What is the recommended solution? This should be specific and, if possible, address what effect there is on Medicaid costs. PROCEDURE FOR REVIEW The following are the procedures for review: The DLTC Administrative Review Committee conducts the review, consulting with other members of the DLTC, when appropriate. If a request or recommendation is denied, the rationale for that decision is given to the home. If a rate adjustment is warranted, the regional auditor is notified and adjusts the rate and notifies the home.