Form F 01159 PDF Details

In most cases, the Form F 01159 is completed and submitted to the Service Canada Centre. The form is then processed and if all required information has been provided, a confirmation of coverage letter will be issued indicating the effective date of coverage. It's important to note that this letter is not an insurance policy but rather proof that you have elected to opt out of the Canadian health care system and are now covered under a private plan. As such, it's important to keep a copy of this letter in case you need to prove your coverage status while travelling outside of Canada. If you're considering opting out of the Canadian health care system and instead electing to purchase private health insurance, there are a few things you should know about Form F 01159. This article will provide an overview of what the form is, who needs to complete it, and what happens after it's been submitted.

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

Step 3: Right after double-checking the entries, press "Done" and you're done and dusted! Sign up with us now and immediately use Form F 01159, ready for downloading. Every last edit made is handily preserved , which means you can edit the form later on if required. Here at FormsPal, we do our utmost to be sure that all of your details are stored secure.