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UPDATED: Residential Claim Form and Revised General Services Claim Form All Providers are asked to use a standard claim form (CMS 1500, UB04), one of Care Wisconsin’s two claim forms or a claim format approved by Care Wisconsin for submitting bills, invoices or claims. We have updated our Residential Claim Form template and instructions with the new billing address. We are also introducing a revised General Services Claim Form template and instructions (formerly the Non-Residential Claim Form) to use if you bill for non-residential services. This claim form has been re-designed so that it can be quickly and smoothly scanned into the claims system. Please use only the codes contained in your Authorization Letters, contract and/or individual member agreement if you are a residential facility. Missing and/or non-standard codes will cause confusion and delays in payment.
ATTENTION: “Fillable” Claim Form Templates Both claim forms are available in fillable formats so you can complete, download and print them for submission. Also, we are now offering the claim form templates in the “excel” format.  Residential Claim Form Template PDF – Fillable format
Residential Claim Form Instructions
(***NOTE: Please bill only residential services, such as “room & board” and “care & supervision” on the Residential Claim Form. Use the General Services Claim Form for all non-residential services.) General Services Claim Form Template PDF – Fillable format
General Services Claims Instructions ***NEW ITEM If you are interested in a fillable Excel version of either the Residential or General Services claim form, please contact the Provider Help Desk: Provider Help Desk
(608) 245-3053
Toll-free 1-877-496-3858
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Monday through Friday, 8:30 a.m. to 4:00 p.m.
Health Insurance Claim Form / CMS-1500 You will need Adobe Acrobat Reader to view and use the PDF Claim Forms. To download a free copy of Adobe Acrobat Reader, click here.
IMPORTANT: Where to Send Your Claims After filling out the claim form, please print copies and then mail the completed claim to: Care Wisconsin
PO Box 849
Buckeystown, MD 21717
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