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State: Wisconsin
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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13046A (10/08)

STATE OF WISCONSIN

FORWARDHEALTH

ADJUSTMENT / RECONSIDERATION REQUEST COMPLETION INSTRUCTIONS
ForwardHealth requires certain information to enable the programs to authorize and pay for medical services provided to eligible members. ForwardHealth members 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 eligibility status, accurate name, address, and member number (HFS 104.02[4], 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 Adjustment/Reconsideration Request, F-13046, is used by ForwardHealth to request an adjustment of an allowed claim (a paid or partially paid claim). Providers may request an adjustment when claim data need to be changed or corrected. After the changes are made to the original claim, the adjusted claim is processed. Providers cannot adjust a totally denied claim. A claim that was totally denied must be resubmitted after the necessary corrections have been made. Questions about adjustments and other procedures or policies may be directed to Provider Services at (800) 947-9627. The Adjustment/Reconsideration Request is reviewed by ForwardHealth based on the information provided. Providers may photocopy the Adjustment/Reconsideration Request for their own use. Providers should be as specific as possible when describing how the original claim is to be changed. Providers may also attach a copy of the corrected claim. The provider is required to maintain a copy of this form for his or her records. The provider should mail the Adjustment/Reconsideration Request to the appropriate mailing address: BadgerCare Plus Claims and Adjustments 6406 Bridge Rd Madison WI 53784-0410 WCDP PO Box 6410 Madison WI 53716-0410 WWWP PO Box 6645 Madison WI 53716-0645 INSTRUCTIONS Type or print clearly. Enter the following information from the provider's Remittance Advice or the 835 Health Care Claim Payment/Advice (835) transaction. SECTION I -- BILLING PROVIDER AND MEMBER INFORMATION Check the appropriate box to indicate the applicable program to which the adjustment request is being submitted. Element 1 -- Name -- Billing Provider Enter the billing provider's name. Element 2 -- Billing Provider's Provider ID Enter the Provider ID of the billing provider. Element 3 -- Name -- Member Enter the complete name of the member for whom payment was received. Element 4 -- Member Identification Number Enter the member ID.

ADJUSTMENT / RECONSIDERATION REQUEST COMPLETION INSTRUCTIONS F-13046A (10/08)

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SECTION II -- CLAIM INFORMATION (Non-Pharmacy) Element 5 -- Remittance Advice or X12 835 Health Care Claim Payment / Advice, Check Issue Date, or Payment Date Enter the date of the remittance advice or the payment date or check issue date from the 835. Element 6 -- Internal Control Number / Payer Claim Control Number Enter the internal control number (ICN) from the remittance advice or the payer claim control number from the 835 of the paid or allowed claim. (When adjusting a previously adjusted claim, use the ICN assigned to the most recently processed claim or adjustment.) Add a new service line(s). Check if submitting an adjustment to add a service line(s) to a paid or allowed claim. Enter the complete information the provider is requesting to be added to the claim in Elements 7 through 15. Correct detail on previously paid/allowed claim. Check if correcting details on a previously paid or allowed claim. Element 7 -- Date(s) of Service Enter to and from date(s) of service (DOS) in MM/DD/YY or MM/DD/CCYY format. If the service was provided on only one DOS, enter the date under "From." Leave "To" blank or re-enter the "From" date. If grouping services, the place of service, procedure code, charges, and rendering provider for each line must be identical for that service line. Grouping is allowed only for services on consecutive dates. The number of days must correspond to the number of units in Element 24G of the 1500 Health Insurance Claim Form. Element 8 -- POS Enter the appropriate two-digit POS code for each service. Element 9 -- Procedure / NDC / Revenue Code Enter the single most appropriate procedure code. ForwardHealth will deny claims received without an appropriate procedure code, National Drug Code (NDC), or revenue code. When adjusting a detail that includes an NDC and a "J" code, providers are required to attach a paper claim form to the adjustment request and follow the claim form instructions for submitting the NDC. Element 10 -- Modifiers 1-4 Enter the appropriate modifier(s). Element 11 -- Billed Amount Enter the total billed amount for each line item. Providers are to indicate their usual and customary charge. The usual and customary charge is the provider's charge for providing the same service to persons not entitled to ForwardHealth benefits. Element 12 -- Unit Quantity Enter the number of units. Only include a decimal when billing fractions (e.g., 1.50). Element 13 -- Family Planning Indicator Enter a "Y" for each family planning procedure when applicable. Element 14 -- EMG Emergency Indicator. Enter a "Y" for each procedure performed as an emergency. If the procedure is not an emergency, leave this element blank. Dental providers should continue to enter an "E" to indicate each procedure performed as an emergency. Element 15 -- Rendering Provider Number Health care providers may enter their NPI and taxonomy code. Non-healthcare providers may enter their Provider ID. SECTION II -- CLAIM INFORMATION (Pharmacy) Element 5 -- Remittance Advice or X12 835 Health Care Claim Payment / Advice, Check Issue Date, or Payment Date Enter the date of the remittance advice or the payment date or check issue date from the 835. Element 6 -- Internal Control Number / Payer Claim Control Number Enter the ICN from the remittance advice or the payer claim control number from the 835 of the paid or allowed claim. (When adjusting a previously adjusted claim, use the ICN assigned to the most recently processed claim or adjustment.) Add a new service line(s). Check if submitting an adjustment to add a service line(s) to a paid or allowed claim. Enter the complete information the provider is requesting to be added to the claim in Elements 7 through 15.

ADJUSTMENT / RECONSIDERATION REQUEST COMPLETION INSTRUCTIONS F-13046A (10/08)

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Correct detail on previously paid/allowed claim. Check if correcting details on a previously paid or allowed claim. Element 7 -- Date(s) of Service Enter the date filled in MM/DD/YY or MM/DD/CCYY format for each NDC in the "From" field. Element 8 -- POS Enter the appropriate two-digit National Council for Prescription Drug Programs (NCPDP) patient location code for each NDC billed. Element 9 -- Procedure / NDC / Revenue Code Enter the NDC. Claims received without an appropriate NDC will be denied. Element 10 -- Modifiers 1-4 Not applicable for pharmacy claims. Element 11 -- Billed Amount Enter the total billed amount for each line item. Providers are to indicate their usual and customary charge. The usual and customary charge is the provider's charge for providing the same service to persons not entitled to ForwardHealth benefits. Element 12 -- Unit Quantity Enter the metric decimal quantity in the specified unit of measure according to the ForwardHealth drug file. Quantities billed should be rounded to two decimal places (i.e., nearest hundredth). Element 13 -- Family Planning Indicator Not applicable for pharmacy claims. Element 14 -- EMG Not applicable for pharmacy claims. Element 15 -- Rendering Provider Number Not applicable for pharmacy claims. SECTION III -- ADJUSTMENT INFORMATION Note: Additional information necessary for adjustment/reconsideration of an NDC should be included in Element 16 under "Other/comments." Element 16 -- Reason for Adjustment Check one of the following boxes indicating the provider's reason for submitting the adjustment: Consultant review requested. Indicate if there are extenuating circumstances or complicated or new procedures and attach a history and physical operative or anesthesia report. Recoup entire payment. This would include claims billed in error or completely paid by another insurance carrier. Other insurance payment. Enter the amount paid by the other insurance carrier. Copayment deducted in error. Indicate if the member was a nursing home resident on the DOS, the correct number of covered service days, or if an emergency service was provided. Medicare reconsideration. Attach both the original and the new Medicare remittance information. Correct service line. Provide specific information in the comments section or attach a corrected claim. Other / comments. Add any clarifying information not included above.* Element 17 -- Signature -- Billing Provider** Authorized signature of the billing provider. Element 18 -- Date Signed** Use either the MM/DD/YY format or the MM/DD/CCYY format. Element 19 -- Claim Form Attached Indicate if a corrected claim form is attached. Although this is optional, ForwardHealth encourages providers to attach a corrected claim form when adding additional service lines or correcting information from a previously adjusted claim.
This section of the Adjustment/Reconsideration Request form should be used for any pharmacy-specific fields (e.g., prescription number) pertaining to the NDC being adjusted or added to a previously processed claim. If either the Submission Clarification Code or the Unit Dose value is being adjusted on a drug claim, both values must be indicated in the comment area, even if one is not being adjusted. ** If the date or signature is missing on the Adjustment/Reconsideration Request form, the adjustment request will be denied. *