Free ForwardHealth Other Coverage Discrepancy Report, F01159 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1159 (10/08)

STATE OF WISCONSIN

FORWARDHEALTH

OTHER COVERAGE DISCREPANCY REPORT
ForwardHealth requires certain information to authorize and pay for medical services provided to eligible members. 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 enrollment status, accurate name, address, and member identification number (HFS 104.02[4], Wis. Admin. Code). Personally identifiable information about applicants and members is confidential and is used for purposes directly related to program administration such as determining eligibility of the applicant or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of payment for the services. The use of this form is mandatory when notifying ForwardHealth of other health care coverage discrepancies. Attach additional pages if more space is needed. Instructions: Providers may use this form to notify ForwardHealth of discrepancies between other health care coverage information obtained through Wisconsin's Enrollment Verification System and information received from another source. Always complete Sections I and IV. Complete Sections II and/or III as appropriate. ForwardHealth will verify the information provided and update the member's file (if applicable). Attach photocopies of current insurance cards along with any available documentation, such as Explanation of Benefits reports and benefit coverage dates/denials. This will allow records to be updated more quickly. Type or print clearly. SECTION I PROVIDER AND MEMBER INFORMATION
Name Provider Name Member (Last, First, Middle Initial) Provider ID Date of Birth Member Member Identification Number

SECTION II MEDICARE PART A AND B COVERAGE
Member Medicare / HIC Number Add Part A Coverage Part B Coverage Start Date Start Date Remove Part A Coverage Part B Coverage End Date End Date

SECTION III COMMERCIAL HEALTH INSURANCE, MEDICARE SUPPLEMENTAL, AND MEDICARE MANAGED CARE COVERAGE
Add Remove Name Insurance Company Address Insurance Company (Street, City, State, ZIP Code) Name Policyholder (Last, First, Middle Initial) Policy Number Member Left HMO Service Area Yes No Coverage Start Date Social Security Number Policyholder Coverage End Date Date Member Left HMO Service Area (If Applicable) HMO Medicare Supplement Medicare Managed Care Other

SECTION IV REPORT INFORMATION
Name Individual Completing This Report Name Source of Information Included on This Report Mail to ForwardHealth Coordination of Benefits PO Box 6220 Madison WI 53716-6220 Fax to Coordination of Benefits (608) 221-4567 Comments Date Signed Telephone Number / Extension Telephone Number / Extension

(Attach additional pages if necessary.)

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