Jeffrey Wade
Wisconsin Medicaid is a federal-state program that provides healthcare coverage to over a million Wisconsin residents. To submit a Wisconsin Medicaid claim with other insurance, providers must first submit claims to the primary insurer. After the primary insurance determination, providers must submit paper copies of the original claim form and the primary insurance remittance advice to My Choice Wisconsin for secondary benefit determination. My Choice Wisconsin will coordinate benefits to ensure maximum coverage without duplicate payments.
How to submit a WI Medicaid claim with other insurance
| Characteristics | Values |
|---|---|
| Claim Submission Deadline | Claims must be submitted within 120 days of the date of service or discharge or as per the timeframe specified in the provider's contract. |
| Claim Submission Process | Submit claims to the primary insurer first, then submit paper copies of the original claim form and primary insurance Remittance Advice to My Choice Wisconsin for secondary benefit determination. |
| Claim Forms | Use standard CMS-1500 or UB-04 claims form (or electronic 837P or 837I) when billing My Choice Wisconsin for Medicare and Medicaid services. |
| Claim Appeals | If you disagree with the appeal decision, you can submit a second-level appeal to the State of Wisconsin via fax or mail. |
| Coordination of Benefits | My Choice Wisconsin coordinates benefits for members with multiple insurers to ensure maximum coverage without duplicate payments. |
| Medicare Remittance Advice | If Medicare Remittance Advice indicates a claim was forwarded to My Choice Wisconsin, do not submit a claim. If not processed within 60 days, submit your claim with a paper copy of the advice. |
| Claim Inquiries | For billing and claim inquiries, contact the relevant Third-Party Administrator (TPA). For Partnership and Dual Advantage member claims, the TPA is Cognizant (phone: 1-855-878-6699). For Family Care claims, the TPA is WPS (phone: 1-800-223-6016). |
| Claim Corrections | Claim corrections must be submitted within the same 120-day deadline as the original claim. |
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What You'll Learn
Claim submission deadlines
When submitting a Wisconsin Medicaid claim with other insurance, there are specific deadlines that must be adhered to. The deadlines can vary depending on the specific program and the type of claim being submitted. Here is an overview of the claim submission deadlines for various scenarios:
My Choice Wisconsin:
Claims must be submitted to My Choice Wisconsin within 120 days of the date of service, discharge, or within the timeframe specified in the provider's contract. This includes claim corrections, which must also be submitted within the same 120-day deadline. When My Choice Wisconsin is the secondary payer due to other insurance coverage, providers must submit the primary claim first and then submit the secondary claim to My Choice Wisconsin within 120 days from the date of the primary carrier's Explanation of Benefits (EOB).
Security Health Plan:
Security Health Plan encourages providers to submit claims as soon as possible after services occur. For original claim submissions, providers have 365 days from the date of service. For correction or adjustment claims, the deadline is 365 days from the date of service or 60 days from the date of payment/denial/rejection of the original claim, whichever is later. In cases of Coordination of Benefits (COB), the deadline is 60 days from the date of the primary payer's statement or within the original claim submission timely filing period, whichever is later.
Wisconsin Department of Public Instruction:
For reimbursement claims related to child nutrition programs, the federal regulations impose a claim submission deadline of 60 calendar days after the last day of the month for which the claim applies. If the 60th day falls on a weekend or federal holiday, the claim is due on the next business day, and a paper copy of the claim must be submitted.
Medicare Advantage HMO-POS and Medicare Advantage Ally Rx D-SNP:
For original claim submissions, providers have 365 days from the date of service. For correction or adjustment claims, the deadline is 365 days from the date of service or 60 days from the date of payment/denial/rejection of the original claim, whichever is later. In cases of COB, the deadline is 365 days from the date of service or 60 days from the date of the other payer's statement, whichever is later.
Medicare Select-Senior Security:
For original claim submissions, providers have 180 days from the date of service. For correction or adjustment claims, the deadline is 180 days from the date of service or 60 days from the date of payment/denial/rejection of the original claim, whichever is later. In cases of COB, the deadline is 180 days from the date of service or 60 days from the date of the other payer's statement, whichever is later.
It is important to note that claim submission deadlines may vary depending on specific circumstances and contractual agreements. Always refer to the official websites and guidelines for the most up-to-date and accurate information.
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Primary insurance claims
When it comes to submitting primary insurance claims for Wisconsin Medicaid when a patient has other insurance, there are several important steps and considerations to keep in mind. Firstly, it is essential to understand that My Choice Wisconsin, a managed care organization, coordinates benefits to ensure maximum coverage without duplication of payments when a member has insurance through multiple insurers. This coordination of benefits is detailed in the Provider Handbook.
In terms of the claims submission process, providers must submit claims to the primary insurance carrier before submitting to My Choice Wisconsin. After the primary insurance determination, providers are required to submit paper copies of both the original claim form and the primary insurance Remittance Advice (RA) to My Choice Wisconsin for secondary benefit determination. This submission must be made within 120 days from the date on the primary RA, and My Choice Wisconsin cannot accept these secondary claims electronically.
It is worth noting that in cases where traditional Medicare is the primary carrier, Medicare will often automatically forward claims to My Choice Wisconsin. If the Medicare Remittance Advice indicates that the claim was forwarded, there is no need to submit a claim to My Choice Wisconsin. However, if the claim has not been processed within 60 days of the Medicare Remittance Advice, a claim should be submitted to My Choice Wisconsin, along with a paper copy of the advice.
When My Choice Wisconsin is the secondary payer due to other insurance coverage, providers must submit the claim along with the Explanation of Benefits (EOB) or an explanation of payment from the primary carrier. My Choice Wisconsin allows 120 days from the date of the primary carrier's EOB or the providers' contracted limits. If a claim is denied, an explanation voucher with a reason code will be provided.
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Secondary benefit determination
When submitting a Wisconsin Medicaid claim with other insurance, providers must first submit claims to the primary insurer. After the primary insurance determination, providers must submit paper copies of the original claim form and the primary insurance remittance advice (RA) to My Choice Wisconsin for secondary benefit determination. This must be done within 120 days from the date on the primary RA. My Choice Wisconsin cannot accept secondary claims electronically.
When My Choice Wisconsin is the secondary payer due to other insurance coverage, the provider must submit the claim along with the EOB (explanation of benefits) or an explanation of payment from the primary carrier. My Choice Wisconsin will then allow 120 days from the date of the primary carrier's EOB or the provider's contracted limits.
In cases where traditional Medicare is the primary carrier, Medicare will often automatically forward claims to My Choice Wisconsin. If the Medicare Remittance Advice indicates that the claim was forwarded, providers should not submit a claim to My Choice Wisconsin. However, if the claim has not been processed within 60 days of the Medicare Remittance Advice, providers should submit their claim to My Choice Wisconsin, along with a paper copy of the original claim form and the Medicare Remittance Advice.
My Choice Wisconsin will coordinate the benefits to ensure maximum coverage without duplication of payments. The Provider Handbook has more details on coordination of benefits.
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Appeal process
If your claim is denied, you will receive an explanation voucher with a reason code and an explanation of that code. If your claim was denied or paid incorrectly due to an error on the provider's end, you can resubmit it as a Corrected Claim. You can mail it to the normal claims address (excluding Dental claims). For legacy MCFC members, submit a corrected claim form to the normal WPS claims address.
Providers can resubmit appeals and claims that have been corrected or modified from the original within 60 days of the original payment/denial or the timeframe specified within the providers' contract. If you need clarification on a denial, contact the appropriate TPA. If you still believe a denial was in error or there are extenuating circumstances you would like considered, you may send an appeal to My Choice Wisconsin using their Appeal Form.
If you need help writing a request for an appeal, you can call your HMO Advocate at 1-800-713-6180, the BadgerCare Plus and Medicaid SSI Ombuds at 1-800-760-0001, or the HMO Enrollment Specialist at 1-800-291-2002. If you are enrolled in a Medicaid SSI Program, you can also call the SSI External Advocate at 1-800-708-3034 for help with your appeal. You have sixty days from the date of the denial letter to appeal the decision. MHS Health will acknowledge your appeal within ten days of receipt and complete the appeal within thirty days. This process can be extended by up to fourteen days. If more time is needed to gather facts about the requested service, you will receive a letter explaining the reason for the delay. You may request to have the disputed services continued while the HMO appeal and State fair hearing process are occurring.
If you disagree with the decision, you may file an appeal. You have the right to appeal if you believe your benefits are wrongly denied, limited, reduced, delayed, or stopped by MHS Health. Your authorized representative or your provider may request an appeal for you if you have given them consent to do so. When requesting an appeal, you must appeal to your HMO Program, MHS Health, first. The request for an appeal must be made no more than 60 days after you receive notice of services being denied, limited, reduced, delayed, or stopped. If you disagree with your HMO's decision about your appeal, you may request a fair hearing with the Wisconsin Division of Hearing and Appeals. The request for a fair hearing must be made no more than 90 days after your HMO/PIHP makes a decision about your appeal.
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Medicaid programs
Wisconsin Medicaid is a joint federal and state program that helps over 1 million residents access high-quality health care coverage, long-term care, and other services that promote physical and mental health and well-being. There are many types of Medicaid programs, each with its own set of requirements for enrollment.
One such program is BadgerCare Plus, which provides health insurance to certain childless, low-income adults. To apply for this program, you will need to have information about any health insurance you may have through your employer. You can apply for this program through the ACCESS website, by filling out and mailing a paper application, or by contacting your local county or tribal agency.
Another Medicaid program in Wisconsin is FoodShare, which helps people with limited money buy healthy food. The Wisconsin Department of Health Services also offers ForwardHealth, which provides information on all health care and nutritional assistance benefit programs. Additionally, certain Medicaid members can view their medical records on their phones through a mobile app.
For those who need help with childcare costs or are seeking employment, there are programs such as Wisconsin Shares Child Care Subsidy and Wisconsin Works (W-2) that can provide support.
When submitting a Medicaid claim with other insurance in Wisconsin, it is important to first submit claims to the primary insurance provider. Paper copies of the original claim form and the primary insurance remittance advice must then be submitted to My Choice Wisconsin for secondary benefit determination within 120 days from the date on the primary RA. My Choice Wisconsin will coordinate the benefits to ensure maximum coverage without duplication of payments.
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Frequently asked questions
Wisconsin Medicaid is a joint federal and state program that helps more than 1 million residents access high-quality health care coverage, long-term care, and other services that promote physical and mental health and well-being.
You can submit a claim to My Choice Wisconsin by filling out a standard CMS-1500 or UB-04 claims form (or electronic 837P or 837I). If you are a Family Care or Partnership waiver service provider and are unable to submit using one of the standard claims forms, you can submit your claim using one of the alternative methods described on the My Choice Wisconsin website.
Claims must be submitted to My Choice Wisconsin within 120 days of the date of service or discharge or the timeframe specified within the provider's contract.
If you have other insurance in addition to Wisconsin Medicaid, My Choice Wisconsin will coordinate the benefits to ensure maximum coverage without duplication of payments. Providers must submit claims to the primary insurance before submitting to My Choice Wisconsin.
If you had to pay out of pocket for services or supplies because your provider or supplier refused to submit a claim, you will need to submit your own claim. You can mail your claim form, itemized bill, and supporting documents to the address for your state, which is listed on the Medicare Administrative Contractor Address Table within the claim form.
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