DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Health Care Access and Accountability F-13046 (08/15) FORWARDHEALTH ADJUSTMENT / RECONSIDERATION REQUEST Instructions: Type or print clearly. Refer to the Adjustment/Reconsideration Request Completion Instructions, F-13046A, for information about completing this form. The provider is required to maintain a copy of this form for his or her records. SECTION I BILLING PROVIDER AND MEMBER INFORMATION — Indicate appropriate program. BadgerCare Plus / SeniorCare / Wisconsin Medicaid ADAP WCDP WWWP 2. Billing Provider ID 1. Name Billing Provider Provider’s — 4. Member Identification Number 3. Name Member — SECTION II CLAIM INFORMATION — 6. Internal Control Number / Payer Claim Control Number 5. Remittance Advice (RA) or X12 835 Health Care Claim Payment / Advice (835) Report Date, Check Issue Date, or Payment Date Add a new service line(s) to previously paid / allowed claim. (In Elements 7-15, enter information to be added.) Correct detail on previously paid / allowed claim. (In Elements 7-12, enter information as it appears on the RA or 835.) 7. Date(s) of Service 8. 9. 10. Modifiers 1-4 11. Billed 12. Unit 13. 14. 15. Rendering Provider POS Procedure Amount Quantity Family EMG Number From To Mod 1 Mod 2 Mod 3 Mod 4 / NDC / Planning Revenue Indicator Code SECTION III ADJUSTMENT INFORMATION — 16. Reason for Adjustment Consultant review requested (include supporting documentation). Recoup entire payment. Other insurance dental / pharmacy with OI-P $ . — Other insurance professional / institutional (attach Explanation of Medical Benefits form, F-01234). — Copayment deducted in error. Member in nursing home. Covered days . Emergency. Primary payer reconsideration. Correct service line. Other / comments. 17. SIGNATURE Billing Provider 18. Date Signed — 19. Claim Form Attached (Optional) Yes No
DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Health Care Access and Accountability F-13046 (08/15) FORWARDHEALTH ADJUSTMENT / RECONSIDERATION REQUEST Instructions: Type or print clearly. Refer to the Adjustment/Reconsideration Request Completion Instructions, F-13046A, for information about completing this form. The provider is required to maintain a copy of this form for his or her records. SECTION I — BILLING PROVIDER AND MEMBER INFORMATION Indicate appropriate program. BadgerCare Plus / SeniorCare / Wisconsin Medicaid ADAP WCDP WWWP 1. Name — Billing Provider 2. Billing Provider’s Provider ID 3. Name — Member 4. Member Identification Number SECTION II — CLAIM INFORMATION 5. Remittance Advice (RA) or X12 835 Health Care Claim Payment / Advice (835) Report Date, Check Issue Date, or Payment Date 6. Internal Control Number / Payer Claim Control Number Add a new service line(s) to previously paid / allowed claim. (In Elements 7-15, enter information to be added.) Correct detail on previously paid / allowed claim. (In Elements 7-12, enter information as it appears on the RA or 835.) 7. Date(s) of Service From To 8. POS 9. Procedure / NDC / Revenue Code 10. Modifiers 1-4 Mod 1 Mod 2 Mod 3 Mod 4 11. Billed Amount 12. Unit Quantity 13. Family Planning Indicator 14. EMG 15. Rendering Provider Number SECTION III — ADJUSTMENT INFORMATION 16. Reason for Adjustment Consultant review requested (include supporting documentation). Recoup entire payment. Other insurance — dental / pharmacy with OI-P $ . Other insurance — professional / institutional (attach Explanation of Medical Benefits form, F-01234). Copayment deducted in error. Member in nursing home. Covered days . Emergency. Primary payer reconsideration. Correct service line. Other / comments. 17. SIGNATURE — Billing Provider 18. Date Signed 19. Claim Form Attached (Optional) Yes No
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