Form F 12022 PDF Details

Navigating the complexities of healthcare administration requires an understanding of the intricate processes designed to ensure providers are reimbursed for services rendered to patients eligible for government healthcare programs. The F 12022 form, issued by the Wisconsin Department of Health Services under the Division of Health Care Access and Accountability, is integral in the appeal process for providers within the Wisconsin Medicaid and BadgerCare Plus Managed Care Programs. This form serves as a vehicle for providers to contest denials of payment for services provided to members covered under these programs. To facilitate the process, the form gathers detailed information about the provider, the Health Maintenance Organization (HMO) or Special Needs Managed Care Organization (SSI MCO) involved, and the enrolled member, coupled with a comprehensive description of the issue at hand and desired resolution. Mandatory for the initiation of an appeal, the form requests the inclusion of supporting documentation and relevant correspondence, outlining a structured pathway for providers to challenge decisions they find unfavorable. While completing and submitting this form is voluntary, failure to do so may result in a continued denial of payment, highlighting its importance in the administrative healthcare landscape in Wisconsin.

QuestionAnswer
Form NameForm F 12022
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesF12022 badgercare plus managed care program address form

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DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Health Care Access and Accountability

s. 49.45, Wis. Stats.

F-12022 (03/09)

 

WISCONSIN MEDICAID AND BADGERCARE PLUS

MANAGED CARE PROGRAM PROVIDER APPEAL

ForwardHealth requires certain information to enable the programs to authorize and pay for medical services provided to eligible members.

Personally identifiable information about providers is used for purposes directly related to program administration such as determining the certification of providers or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of payment for the services. The use of this form is voluntary.

Providers may send this completed form and other written complaints to the following address:

ForwardHealth

Managed Care Appeals

PO Box 6470

Madison WI 53716-0470

INSTRUCTIONS: Type or print clearly.

SECTION I — PROVIDER INFORMATION

Name — Provider Filing Appeal

Telephone Number — Provider Filing

Name — HMO / SSI MCO Involved

 

Appeal

 

 

 

 

Address — Provider Filing Appeal (Street, City, State, ZIP Code)

Name and Telephone Number —

 

 

Contact Person

 

 

 

SECTION II — ENROLLEE INFORMATION

 

 

Name — Medicaid HMO / SSI MCO Enrollee

Member Identification Number

Date of Service

SECTION III — DESCRIPTION OF PROBLEM

Describe the problem in detail. Use additional paper, if necessary. Attach copies of any supporting documentation relevant to the problem.

(Continued)

MANAGED CARE PROGRAM PROVIDER APPEAL

Page 2 of 2

F-12022 (03/09)

 

SECTION III — DESCRIPTION OF PROBLEM (Continued)

Insert date the appeal was sent to HMO / SSI MCO or claim reconsideration was requested.

Insert date the appeal / reconsideration request was denied by

HMO / SSI MCO.

What response was received from the HMO / SSI MCO? Attach a photocopy of any relevant correspondence.

What does the provider consider to be a fair resolution of this matter?

SECTION IV — SIGNATURE

This information is accurate to the best of my knowledge. A copy of this information may be forwarded to the Medicaid HMO/SSI MCO involved.

SIGNATURE — Provider

Date Signed

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1. Whenever filling in the Form F 12022, make sure to incorporate all necessary fields in its associated section. It will help expedite the process, allowing for your details to be handled quickly and appropriately.

Filling in part 1 in Form F 12022

2. The next part would be to fill in the next few blanks: Insert date the appeal was sent to, Insert date the appeal, and What response was received from.

Filling out part 2 in Form F 12022

It's easy to get it wrong while filling out the What response was received from, and so be sure you look again before you decide to submit it.

3. The following section is about What does the provider consider to, SECTION IV SIGNATURE, This information is accurate to, SIGNATURE Provider, and Date Signed - fill out each of these fields.

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