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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13047A (08/15) STATE OF WISCONSIN FORWARDHEALTH TIMELY FILING APPEALS REQUEST COMPLETION INSTRUCTIONS ForwardHealth.

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Medicaid Claims To receive reimbursement, claims and adjustment requests must be received by Wisconsin Medicaid within 365 days of the date of service (DOS). This deadline applies to claims, corrected claims, and adjustments to claims.

Medicaid's Look-Back Rule Wisconsin has a 5-year Medicaid Look-Back Period that immediately precedes one's date of Nursing Home Medicaid or Waiver application. During this period, Medicaid checks to ensure no assets were gifted or sold under fair market value.

To receive consideration, the request must be submitted within 180 days from the date the backdated enrollment was added to the member's enrollment information.

The request for an appeal must be made no more than 60 days after you receive notice of services being denied, limited, reduced, delayed, or stopped. If you disagree with your HMO's decision about your appeal, you may request a fair hearing with the Wisconsin Division of Hearing and Appeals.

2. Submit an Adjusted or Corrected Claim to Michigan Complete Health, Attn: Corrected Claim, PO Box 3060, Farmington MO 63640-3060. The claim must clearly be marked as “RE-SUBMISSION” and must include the original claim number or the original EOP must be included with the resubmission.

Medicaid Income Limits for Adults 19-64 1 person household. $1,132 / month. 2 person household. $1,525 / month. 3 person household. $1,919 / month. 4 person household. $2,312 / month. 5 person household. $2,705 / month. 6 person household. $3,099 / month. 7 person household. $3,492 / month. Each additional person. +$393 / month.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232