Free Wisconsin Funeral and Cemetary Aids Program Reimbursement Notice, HCF 10143 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division Of Health Care Access and Accountability F-10143 (07/08)

STATE OF WISCONSIN

WISCONSIN FUNERAL AND CEMETERY AIDS PROGRAM REIMBURSEMENT NOTICE
Decedent's Name

Your request for reimbursement under the Wisconsin Funeral and Cemetery Aids Program for the above decedent has been approved in . the amount of $ Your request for reimbursement under the Wisconsin Funeral and Cemetery Aids Program has been denied for the reason(s) indicated below: The reimbursement request was not submitted on the proper form. The decedent is not eligible for benefits under the Wisconsin Funeral and Cemetery Aids Program. The reimbursement request does not contain sufficient identification information to allow us to determine whether the decedent is eligible for benefits under the Wisconsin Funeral and Cemetery Aids Program. (Section 1 of the reimbursement request is not properly completed.) The reimbursement request was received more than one year after the date of death. The reimbursement request does not indicate the provider name, address, telephone or service provider type. (Section 2 of the reimbursement request is not properly completed.) The reimbursement request was submitted by an entity other than a funeral home, cemetery, or crematorium. Reimbursement for funeral expenses was requested, but the "Statement of Funeral Goods and Services Selected" was not submitted. The "Statement of Funeral Goods and Services Selected" indicates cash advances, but adequate verification is not present. Reimbursement for cemetery expenses was requested, but the cemetery goods and services provided are not indicated on the reimbursement request form. Total funeral charges are unclear. Total funeral charges exceed $3,500 and no special circumstances are indicated or special circumstances were not approved by the Department of Health Services. Total cemetery charges are unclear. Total cemetery charges exceed $3,500 and no special circumstances are indicated or special circumstances were not approved by the Department of Health Services. Reimbursement for funeral expenses was requested, but the funeral provider and/or the executor or family representative have not signed and dated the form. Reimbursement for cemetery expenses was requested, but the cemetery provider and/or the executor or family representative have not signed and dated the form. Comments

If you do not agree with this decision, you may request a Fair Hearing, by writing to: Division of Hearings and Appeals P.O. Box 7875 Madison, WI 53707-7875 Hearing requests should include: provider name and mailing address, a brief description of the problem, which county or state agency took the action or denied the service, provider social security number and signature. Should you have questions regarding this action, please contact

RESET FORM