Form F 01159 PDF Details

In the realm of health care administration, the precision and accuracy of information submitted by health care providers are paramount to ensuring that individuals receive the benefits they're entitled to without undue delay or error. Central to this intricate process in Wisconsin is the F-01159 form, endorsed by the Department of Health Services’ Division of Health Care Access and Accountability. This form, a vital tool in the coordination of benefits, acts as a conduit for notifying ForwardHealth—a crucial entity overseeing a gamut of state healthcare programs—of any discrepancies in insurance coverage details for members. Designed to streamline the verification and updating of a member's coverage information, the form seeks information ranging from basic member and provider details, Medicare parts A and B, to more intricate data on commercial health insurance and Medicare supplemental plans. Each submission mandates a meticulous report of current standing—be it an addition, change, or cessation of coverage—with supportive documents like insurance cards and Explanation of Benefits reports enhancing the speed and efficiency of processing. Rigor in fulfilling this requirement is not only a testament to the provider's commitment to upholding the highest standards of care but also safeguards the integrity of members’ access to entitled benefits, additionally punctuating the confidential handling of personally identifiable information. By necessitating the use of an unaltered version of the form and laying down clear instructions for its completion, ForwardHealth ensures uniformity in submissions, thereby facilitating a smoother operational workflow and reinforcing the overarching goal of administrative efficiency in healthcare provision.

QuestionAnswer
Form NameForm F 01159
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesF01159 forwardhealth electronic discrepancy report form

Form Preview Example

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Health Care Access and Accountability

 

F-01159 (09/12)

 

FORWARDHEALTH

OTHER COVERAGE DISCREPANCY REPORT

ForwardHealth requires certain information 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 (DHS 104.02[4], Wis. Admin. Code).

Personally identifiable information about 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.

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. Attach additional pages if more space is needed.

Instructions: Providers may use this form to notify ForwardHealth of discrepancies between other health care coverage information obtained through Wisconsin’s Enrollment Verification System and information received from another source. Always complete Sections I and IV. Complete Sections II and/or III as appropriate. ForwardHealth will verify the information provided and update the member’s file (if applicable). Attach photocopies of current insurance cards along with any available documentation, such as Explanation of

Benefits reports and benefit coverage dates/denials. This will allow records to be updated more quickly. Type or print clearly.

Allow five to seven business days for processing.

SECTION I  PROVIDER AND MEMBER INFORMATION

Name — Provider

Provider ID

 

 

 

 

 

Name — Member (Last, First, Middle Initial)

Date of Birth — Member

Member Identification Number

 

 

 

 

SECTION II  MEDICARE PART A AND B COVERAGE

 

 

 

 

 

 

Member Medicare / HIC Number

 

 

 

 

 

 

Add

Change

 

 

 

 

 

Part A Coverage

Start Date

Part A Coverage

End Date

 

 

 

 

 

 

Part B Coverage

Start Date

Part B Coverage

End Date

 

 

 

 

 

 

SECTION III  COMMERCIAL HEALTH INSURANCE, MEDICARE SUPPLEMENTAL, AND MEDICARE MANAGED CARE COVERAGE

Add

HMO

Medicare Managed Care

 

 

 

Change

Medicare Supplement

Other

 

 

 

Name — Insurance Company

 

 

Address — Insurance Company (Street, City, State, ZIP Code)

Name — Policyholder (Last, First, Middle Initial)

Social Security Number — Policyholder

Policy Number

Coverage Start Date

Coverage End Date

Member Left HMO Service Area

Yes

No

Date Member Left HMO Service Area (If Applicable)

Continued

OTHER COVERAGE DISCREPANCY REPORT

Page 2 of 2

F-01159 (09/12)

 

SECTION IV  REPORT INFORMATION

Name — Individual Completing This Report

Date Signed

Telephone Number / Extension

Name — Source of Information Included on This Report

Telephone Number / Extension

Mail to ForwardHealth Coordination of Benefits PO Box 6220 Madison WI 53716-6220

Fax to

Coordination of Benefits (608) 221-4567

Comments

(Attach copy of insurance card.)

How to Edit Form F 01159 Online for Free

Making use of the online tool for PDF editing by FormsPal, it is easy to fill in or edit Form F 01159 here and now. To make our editor better and less complicated to use, we consistently work on new features, taking into account suggestions from our users. This is what you'd want to do to get going:

Step 1: Press the orange "Get Form" button above. It is going to open our pdf tool so you could start filling in your form.

Step 2: Once you access the editor, there'll be the document prepared to be filled out. Aside from filling in various blank fields, you may also perform other things with the PDF, specifically adding any textual content, changing the original text, adding images, placing your signature to the document, and more.

In order to finalize this form, make certain you type in the necessary information in every area:

1. First, once filling out the Form F 01159, start in the form section with the next blank fields:

Best ways to fill out Form F 01159 stage 1

2. Right after this part is completed, go to type in the applicable information in all these - Policy Number, Coverage Start Date, Coverage End Date, Member Left HMO Service Area Yes, Date Member Left HMO Service Area, and Continued.

Form F 01159 conclusion process detailed (part 2)

Always be very careful while filling out Coverage Start Date and Date Member Left HMO Service Area, because this is the section in which most users make a few mistakes.

3. Completing SECTION IV REPORT INFORMATION, Date Signed, Telephone Number Extension, Name Source of Information, Telephone Number Extension, Mail to, ForwardHealth Coordination of, Fax to, Coordination of Benefits, Comments, and Attach copy of insurance card is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

SECTION IV REPORT INFORMATION, ForwardHealth Coordination of, and Telephone Number Extension in Form F 01159

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