Caring Starts with Speedy Service
We know that a simple authorization process and getting paid promptly is important to you. To help facilitate this, we:
- Streamline steps where we can, even eliminating the pre-authorization process in some situations.
- Have authorization and claims experts on hand to offer speedy responses via phone, email or fax.
- Keep you informed when we roll out new policies, through email notifications, in-person forums and webinars.
- Have Provider Service team members located at our “hub” offices throughout the state.
In the library below, you will find links to our claims and authorization-specific documents. To search for or view all of our resources for provider, check out our Resources Library. There, you’ll find instructions, training documents, and forms you need to make the authorization and claims process run smoothly.
For your convenience, our most commonly referenced documents are:
- Prior Authorization Reference Document – Requirements By Program
- Provider Quick Reference Guide
- Prior Authorization Request Form (DME/DMS)
- Prescription Drug Coverage Determination Form (Medicare)
Where to Send Claims and Authorizations
See our Contacts for Providers page. Please allow up to 30 days from claim submission date to receive payment.
Claims Electronic Data Interchange
Care Wisconsin accepts standard electronic billing for Professional and Institutional claims (837P or 837I as appropriate) using Payer ID 27004. Please contact our vendor Change Healthcare at 800-845-6592 for additional information on this billing option.
Care Wisconsin administers Wisconsin Medicaid health care benefits through our SSI Medicaid, Family Care, and Partnership programs and complies with Wisconsin Administrative code outlined in DHS 107.03. Care Wisconsin provides Medicare benefits to members in our Dual Advantage program, as well as dual eligible members in our Partnership program. Care Wisconsin administers the benefits consistent with original Medicare. Please see Items and Services Not Covered Under Medicare for more information. The Family Care and Partnership programs include Home and Community-based Waiver benefits in addition to traditional Medicaid coverage.
Coordination of Benefits – Prior Authorization
Care Wisconsin does not require prior authorization for outpatient services for in-network, outpatient services for secondary coverage, when Medicare or other commercial insurance is providing primary coverage consistent with DHS 107.02 .
NOTE: If Medicare or other primary insurance does not cover a service and you are seeking primary coverage from Care Wisconsin, all prior authorization requirements apply.
Retroactive Authorization Requests
Care Wisconsin will accept a request for retroactive authorization if the request meets the following requirements:
- The request is received by Care Wisconsin within 14 calendar days of the start of the provision of services;
- The request precedes a bill for services; and
- The request includes justification for beginning the service prior to receiving authorization:
- The member was not able to tell the provider about their insurance coverage prior to rendering services, or
- The provider verified different insurance coverage prior to rendering services
Please note: All authorization requests are subject to member eligibility, benefit plan coverage and medical necessity.
Resource Downloads For Claims & Authorizations
Resources are listed in alphabetical order. You will need Adobe Acrobat Reader to view and print PDF files. Download A Free Copy. If you need materials in other formats or languages, visit Help In Other Languages.
April 30, 2018 | pdf (1.79 MB) | Claims Information
Follow the instructions in this guide to sign up for and navigate the Care Wisconsin claims web portal.
April 30, 2018 | pdf (117.39 KB) | Claims Information
Complete this form to enroll in electronic funds transfer (EFT).
April 30, 2018 | pdf (53.70 KB) | Claims Information
Use this form to submit a claim for any non-residential services.
April 30, 2018 | pdf (109.53 KB) | Claims Information
Refer to this guide if you're having trouble with any part of the general services claim form.
April 30, 2018 | pdf (106.42 KB) | Claims Information
If you submitted a claim via paper, spreadsheet, or electronically, learn how to find your EOB on the Care Wisconsin claims web portal.
April 30, 2018 | pdf (211.39 KB) | Claims Information
If you believe your claim was denied when it should not have been, use this form to submit an appeal.
April 30, 2018 | pdf (195.72 KB) | Claims Information
If Care Wisconsin overpaid your claim, cut a check payable to Care Wisconsin and complete this form.
April 30, 2018 | pdf (217.32 KB) | Claims Information
Use this form to submit a residential claim.