ForwardHealth Claim Information
The Wisconsin Department of Health Services (DHS) is providing Children's Long-Term Support (CLTS) providers with information on how to correctly enter claims in the ForwardHealth portal. This will help ensure that claims are processed in the portal appropriately.
Topics covered in this message include:
Billing With Matching Prior Authorization
Error code “192 - Prior Authorization (PA) is required for this service” for direct data entry claims and error code “3001 PA Not Found” on an 835 Electronic Remittance Advice is the result of claims not matching the PA for the identified provider, member, and service information. The PA is approved and available for claims, but the ForwardHealth Portal cannot match the claim with that PA, due to the misinformation.
The following situations may cause this to happen:
- Claim detail lines entered for dates of service are outside the PA.
Example: the PA is dated 04/01/2025-04/30/2025, but the claim is for date of service 05/01/2025. To fix this error, please ensure that you are entering dates for claims allowable on the PA.
- Claim detail lines are entered for procedure codes not included on the PA.
Example: the PA is for procedure code T2027. The claim is submitted with two detail lines: one is billed as code T2027 and detail line two is billed as code T1005. The claim will deny due to detail line two not having a matching prior authorization. To fix this error, please ensure you are entering only procedure codes identified on the header of the PA.
Date Span Billing
Do you provide consecutive dates of services (days in a row, including weekends)?
The date span should be billed on one claim detail line. For example, services provided each day from 08/01 – 08/07 would be on one claim line.
Do you provide non-consecutive dates of services (gaps in days)?
The dates that were performed on two or more non-consecutive dates should be billed one date per claim detail line. For example, 08/01, 08/03, and 08/07, would be three claim lines.
Do you provide a per diem rate service (for example, overnight respite)?
The claim must be billed with the From Date of Service and the To Date of Service with the date the service ended. For example, the service started on 05/23 and ended on 05/24, the claim detail would have dates of service 05/23.
- Services provided overnight from 05/09-05/10, claim detail dates of service will be 05/10-05/10 for 01 unit.
- Services provided overnight on two consecutive nights from 05/09-05/11, will be billed 05/10-05/11 for 02 units.
Do you provide services that are billed with procedure codes that have monthly or session units (for example financial management services, personal emergency response services, respite camps per session)?
The claim must be billed with the From Date of Service and To Date of Service both being the end of the month or session, with 01 unit. For example, monthly service for May would be billed as 05/31-05/31 with 01 unit.
Diagnosis Code Pointer
When submitting a claim, you must enter a Diagnosis Code Pointer in the claim’s detail line. The diagnosis code pointer is a number 1 through 12 that corresponds to the diagnoses entered on the header of the claim. Providers can open the diagnosis panel and determine which diagnosis code pointer to enter in the claim detail line, to correspond with a specific code. For CLTS, most PAs will only have 1 diagnosis code in the diagnosis panel, therefore the diagnosis code pointer will be the number 1. Providers should note that the diagnosis code pointer is not a diagnosis code, it is a field to identify which diagnosis number to point to.
Place of Service 02 - Remote Services
Do you provide remote services?
Providers billing with place of service (POS) 02 for remote services must add the GT modifier on the claim. The GT modifier will not appear on the PA. Refer to the CLTS Code Crosswalk for more information.
“Add” Button on Claims
The portal has an “Add” button in the Attachment section that providers can use to upload an explanation of benefits (EOB) from a primary insurance carrier. If providers click this button without uploading a document, the claim will suspend for seven days as the system waits for the attachment. If the attachment is not received after seven days, the claim will deny.
The portal will state: “This claim/service is pending for program review.” Providers who accidentally click the “Add” button must submit a new claim to remedy this situation. You do not have to wait seven days to submit a new claim.
Resources
More details on these topics can be found in the resources below:
Have questions or need help?
If you have questions or need help, please contact the CLTS Operations Team at cltsoperations@gainwelltechnologies.com or 844-942-5870.
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