DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Medicaid Services Wis. Stat. § 49.45 F-12022 (07/2017) WISCONSIN MEDICAID AND BADGERCARE PLUS MANAGED CARE PROGRAM PROVIDER APPEAL Instructions: Type or print clearly. Refer to the Managed Care Program Provider Appeal Completion Instructions, F-12022A, for more information. SECTION I PROVIDER INFORMATION – 1. Name Provider Filing Appeal 2. Telephone Number Provider Filing Appeal – – 3. Address Provider Filing Appeal (Street, City, State, ZIP Code) – 4. Provider-Secure Email Address 5. The provider has a contractual arrangement with the HMO. Yes No 6. Name Contact Person 7. Telephone Number Contact Person – – 8. Name BadgerCare Plus / Medicaid SSI HMO Involved – SECTION II MEMBER INFORMATION – 9. Name BadgerCare Plus / Medicaid SSI HMO Member – 10. Member ID Number 11. Date(s) of Service SECTION III DESCRIPTION OF PROBLEM – 12. Describe the problem in detail. Use additional paper, if necessary. Attach copies of any supporting documentation relevant to the problem. Continued
DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Medicaid Services Wis. Stat. § 49.45 F-12022 (07/2017) WISCONSIN MEDICAID AND BADGERCARE PLUS MANAGED CARE PROGRAM PROVIDER APPEAL Instructions: Type or print clearly. Refer to the Managed Care Program Provider Appeal Completion Instructions, F-12022A, for more information. SECTION I – PROVIDER INFORMATION 1. Name – Provider Filing Appeal 2. Telephone Number – Provider Filing Appeal 3. Address – Provider Filing Appeal (Street, City, State, ZIP Code) 4. Provider-Secure Email Address 5. The provider has a contractual arrangement with the HMO. Yes No 6. Name – Contact Person 7. Telephone Number – Contact Person 8. Name – BadgerCare Plus / Medicaid SSI HMO Involved SECTION II – MEMBER INFORMATION 9. Name – BadgerCare Plus / Medicaid SSI HMO Member 10. Member ID Number 11. Date(s) of Service SECTION III – DESCRIPTION OF PROBLEM 12. Describe the problem in detail. Use additional paper, if necessary. Attach copies of any supporting documentation relevant to the problem. Continued
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