Free ForwardHealth Written Correspondence Inquiry, F01170 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1170 (10/08)

STATE OF WISCONSIN

FORWARDHEALTH

WRITTEN CORRESPONDENCE INQUIRY
ForwardHealth requires certain information to enable the program 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). 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 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 voluntary; providers may develop their own form as long as it includes all the information on this form. Attach additional pages if more space is needed. INSTRUCTIONS Complete only the first page of this form. The second page is for use by the Written Correspondence Unit and is returned to the provider after the inquiry is resolved. For more information on submitting written inquiries, contact Provider Services at (800) 947-9627. Retain a copy of this inquiry and send the original to ForwardHealth, Written Correspondence, 6406 Bridge Road, Madison, WI 53784-0005. SECTION I -- PROVIDER INFORMATION Name -- Provider Provider ID

Name -- Contact Person

Telephone Number -- Contact Person

Address -- Provider

SECTION II -- CLAIM / ADJUSTMENT IN QUESTION Name -- Member (Last, First, Middle Initial) Member ID

Claim Number

Date(s) of Service (MM/DD/CCYY)

Amount Billed

Date of Remittance Advice (RA) (MM/DD/CCYY)

$ Explanation of Benefits Code(s)

Other Information

Reason for Inquiry Provider Services could not assist with the claim denial in question (Explain below). Provider Services or Professional Relations representative advised writing (Explain below). Inquiry involves extensive documentation or research (Explain below). Other (Briefly explain the situation in question below).

SIGNATURE -- Provider

Date Signed

Continued

WRITTEN CORRESPONDENCE INQUIRY F-1170 (10/08)

Page 2 of 2

(THIS PAGE IS FOR FORWARDHEALTH USE ONLY.) SECTION III -- REQUEST FOR FURTHER INFORMATION In order to complete research on an inquiry, ForwardHealth needs the following information. Send the information checked below to Written Correspondence, along with all the materials originally sent to Written Correspondence. Provider ID Member Name and 10-digit Member ID Copy of Any Previous Response Related to the Inquiry Date of Service Amount Billed Other (Briefly explain the situation in question below.) Copy of the RA Copy of the Claim in Question Copy of the Medicare Explanation of Medicare Benefits Copy of the Adjustment in Question Record of Treatment Dates

SECTION IV -- RESOLUTION OF INQUIRY This inquiry was resolved in the following way. Claim / adjustment was resubmitted by ForwardHealth through normal processing channels. Claim / adjustment was resubmitted by ForwardHealth with special instructions for processing. Claim / adjustment has been forwarded for consultant review. Claim was denied correctly. Review and call Provider Services at (800) 947-9627 if more information is needed. . . Claim / adjustment was paid on RA dated (MMDDCCYY) Claim / adjustment was denied on RA dated (MMDDCCYY) Resubmit the claim / adjustment through normal processing channels. This claim exceeds the 12-month filing deadline. Refer to the ForwardHealth Online Handbook and resubmit the claim with documentation to Timely Filing Appeals only if the claim meets one of the criteria indicated for submission to Timely Filing Appeals. Other (briefly explain the situation in question below).

Claim and documentation was forwarded to Timely Filing Appeals for review.

SIGNATURE -- Correspondent

Date Signed

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