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State of Wisconsin |
Release 25-02 |
A good faith claim is a claim that has been denied by BadgerCare Plus with an eligibility-related Explanation of Benefits (EOB) code. This occurs even though the provider verified eligibility for the dates of service billed and submitted a correct and complete claim. Providers can resubmit the claim to ForwardHealth to be processed as a good faith claim. If the eligibility file has been updated by the time the claim is resubmitted, it will be paid automatically. If the file still does not reflect eligibility for the period covered by the claim, ForwardHealth will try to resolve the eligibility discrepancy. If they are unable to resolve it from the information available, they will contact the IM agency to verify eligibility. The Good Faith Medicaid/BadgerCare Plus Certification form (F-10111) is used for this purpose. A good faith claim cannot be reimbursed until the member file has been updated.
If a provider receives a claim denial for one of the following reasons on the Remittance Advice, the provider can resubmit it as a Good Faith claim
| R/A Report Denial Code | Reason |
| 029 | Medicaid number doesn’t match recipient’s last name. |
| 172 | Recipient Medicaid ID number not eligible for dates of service. |
| 281 | Recipient Medicaid ID number is incorrect. Verify and correct the Medicaid number and resubmit claim. |
| 614 | Medicaid number doesn’t match recipient’s first name. |
Causes and a good faith claim can occur when:
With the implementation of the ForwardHealth cards, providers are less likely to receive one of the eligibility-related denials used for Good Faith claims submission. Providers are told to verify eligibility using the variety of methods available to them through the Eligibility Verification System (EVS). When the provider verifies the member’s eligibility, they are getting the most current information available on the ForwardHealth interChange. Therefore, it is unlikely that they will be told the member is eligible when they are not.
The most likely reason a Good Faith situation arises is when a provider sees a temporary paper ID card issued by the agency. The provider may bill BadgerCare Plus before the eligibility is updated on ForwardHealth interChange, or perhaps the eligibility was never sent to ForwardHealth interChange. In either case, if the member presents a valid temporary BadgerCare Plus ID card for the dates of service, and the provider sends a copy of the card with the Good Faith claim, ForwardHealth will update the member’s eligibility file with a good faith segment and pay the claim immediately.
ForwardHealth will then attempt to resolve the discrepancy from information on file or contact you to confirm eligibility and correct the eligibility segment. If the provider does not send a copy of the ID card with the claim, ForwardHealth must confirm eligibility with you before the claim can be paid.
The definition of a "valid" card is either a:
ForwardHealth initiates claim processing by sending workers a partially completed Good Faith Medicaid/BadgerCare Plus Certification form (F-10111) and one or two letters, depending on the eligibility documentation the provider included with the claim. Workers should finish completing the Good Faith Medicaid/BadgerCare Plus Certification form if this is a new member (cert. 1) or complete the Medicaid/BadgerCare Plus Eligibility Certification form (F-10110) for amended certifications (cert. 3). Send completed forms by fax to 608-221-8815 or by mail to:
ForwardHealth
Eligibility Unit
P.O. Box 7636
Madison, WI 53707
Agency Denial
If the member identified on the Good Faith form was neither eligible nor possessed a valid ID card for the dates of service indicated in field six, place an "X” in this box. If you check "Yes” here, you must also check the reason in the field below.
Recipient Did Not Have ID Card After Date of Service
Place an "X "in this box if you are certain that the member did not possess a valid ID card for the date of service. In the blank provided, enter the closing date of eligibility.
Recipient Not Eligible
Place an "X” in this box if the member was not eligible for any of the dates of service shown. If the member was eligible for some of the dates of service, follow the instructions for completing the Partial Deny box.
Record Not Found
Place an "X” in this box if the member has never been eligible for BadgerCare Plus in your agency.
Dates of Services
ForwardHealth enters the dates of service for the claim.
Partial Deny
Use this field only if the member had eligibility for some of the dates of service. Enter the "from” and "to” dates which cover the portion of the dates of service for which the member did not have eligibility.
Type of Certification
ForwardHealth will check one of these boxes:
Initial Certification: ForwardHealth will place an "X” in this box when the member and BadgerCare Plus ID number submitted on the claim cannot be found on the eligibility master file.
Amended Certification: ForwardHealth will place an "X” in this box when the member is on interChange, but no eligibility exists for the claimed dates of service.
Agency Number
ForwardHealth will enter the three-digit code of the agency they believe may have certified the member during the dates in question.
Casehead ID Number
ForwardHealth will enter the known or suspected interChange case number (primary person’s SSN + tiebreaker) of the member listed on the provider’s claim.
Action Date
ForwardHealth enters the date they completed the Good Faith form.
Medical Status Code
When ForwardHealth receives the provider’s claim along with a photocopy of an ID card, a hard copy response received through EVS or a transaction log number from the Automated Voice Response (AVR). ForwardHealth compares the dates of service with the dates on the card. If the dates of service fall within the dates of eligibility for the ID number on the card, ForwardHealth enters a "71” medical status code and pays the claim immediately. ForwardHealth then enters the eligibility dates for the entire month in which services were provided.
If the member was eligible for the entire period of certification shown on the Good Faith Medicaid/BadgerCare Plus Certification form (F-10111) remove the "71” medical status code and write in the correct code. Attach a Medicaid/BadgerCare Plus Eligibility Certification form (F-10110) to add the certification period and appropriate medical status code for the time when the member was eligible for BadgerCare Plus.
Period of Certification
If ForwardHealth has entered the suspected period of certification to be added to the member master file, check it for accuracy. Then complete an F-10110 and enter the period of certification if the member file does not show eligibility for the time when the member was eligible or for the time covered by an ID card issued to the member.
Control Name Year of Birth
ForwardHealth will enter the suspected control name and year of birth (YOB) for the member. This control name must be the first four letters of the member’s last name. The YOB is the last two digits in the member’s year of birth. Both of these items must match the information currently in the member’s file.
Current ID Number
ForwardHealth will enter the member’s current ID number.
Date of Birth
ForwardHealth completes this field only for initial certifications. Change this birth date if the date entered is incorrect. Indicate birth date as MM/DD/CCYY.
Signature of Agency Director
Good Faith forms must have an authorized signature for initial certifications.
Worker ID
On initial certifications, enter the six-digit worker code of the certifying IM worker.
This page last updated in Release Number: 17-04
Release Date: 12/13/2017
Effective Date: 12/13/2017
The information concerning the BadgerCare Plus program provided in this handbook release is published in accordance with: Titles XI, XIX and XXI of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapter 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2 and 101 through 109 of the Wisconsin Administrative Code.
Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.
Publication Number: P-10171