Free ForwardHealth Timely Filing Appeals Request, F-13047 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13047A (10/08)

STATE OF WISCONSIN

FORWARDHEALTH

TIMELY FILING APPEALS 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 (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. This form is mandatory; use an exact copy of this form. ForwardHealth will not accept alternate versions (i.e., retyped or otherwise reformatted) of this form. If necessary, attach additional pages if more space is needed. Refer the ForwardHealth Online Handbook and the applicable service-specific handbook for service restrictions and additional documentation requirements. Attach the completed Timely Filing Appeals Request, F-13047, to the claim or adjustment form and attachments and submit them to ForwardHealth at the following address: ForwardHealth Timely Filing Ste 50 6406 Bridge Rd Madison WI 53784-0050

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13047 (10/08)

STATE OF WISCONSIN

FORWARDHEALTH

TIMELY FILING APPEALS REQUEST
Instructions: Type or print clearly. Refer to the Timely Filing Appeals Request Completion Instructions, F-13047A, for more information. The attached claim / adjustment meets one or more of the following criteria that are considered for late processing approval (check the appropriate statement[s]). Claim(s) denied for an enrollment-related explanation of benefits (EOB), reason, remark, or National Council for Prescription Drug Programs (NCPDP) reject code. Claim number / payer claim control number, Care Claim Payment / Advice (835) transaction number , originally processed on the Remittance Advice (RA) or the 835 Health , with the RA / check issue date of (attach RA, if

available, and one of the following items documenting enrollment: a copy of the magnetic stripe card reader printout, Automated Voice Response log number, or a copy of a paper temporary or Express Enrollment card). Nursing home level of care / liability amount changes. Claim number / payer claim control number, with the RA / check issue date of New level of care New liability amount . . , originally processed on RA or the 835 transaction number (RA attached, if available). ,

Retroactive member enrollment for ForwardHealth (attach appropriate documentation for retroactive period, if available). Retroactive enrollment for general relief. Other insurance / Medicare recoupment (recoupment dated Medicare denial or reconsideration (reconsideration date ForwardHealth reconsideration. Claim number / payer claim control number, with the RA / check issue date of , originally processed on RA or the 835 transaction number (RA attached, if available). (complete copy attached). (complete copy attached). , attached). attached).



Fair hearing decision, with signature dated Court order, with signature dated

Briefly explain the nature of the problem and previous efforts made to resolve the claims.

SIGNATURE -- Provider

Date Signed

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