Billing Market Rate Services to ForwardHealth
The Wisconsin Department of Health Services (DHS) and the Children's Long-Term Support (CLTS) Program are providing guidance on billing market rate services to prevent claim recoupments from ForwardHealth.
Billing market rate services
When billing market rate services to ForwardHealth, providers are required to claim the usual and customary rate approved on their prior authorization. Rates should be identical to what has been authorized on the corresponding prior authorization for that service. Billing over the approved rate on a claim can result in overpayments and lead to reimbursements being recouped by ForwardHealth.
Providers that bill or have billed rates over the amount authorized on their prior authorization will be contacted by DHS regarding payment recoupment. The recoupment will be the total amount of dollars exceeding the usual and customary rate authorized. Providers that repeatedly claim over the approved amount will be investigated and can be terminated from the CLTS Program for fraudulent billing behavior.
How to prevent claim recoupment
This guidance will help providers submit claims correctly for market rate services and prevent claim recoupments by ForwardHealth:
- Confirm your usual and customary rate with county waiver agencies
- Review approved rates on prior authorizations
- Utilize the void claim and claim adjustment functions in ForwardHealth
In December 2025, the ForwardHealth Portal will undergo an enhancement to prevent claims related to market rate services from exceeding the approved rate on prior authorizations. A limit will be enforced to restrict providers from billing over the rate authorized on their prior authorization for market rate services.
Have questions or need help with claims?
For more details related to this topic access the ForwardHealth Portal Professional Claims User Guide (PDF).
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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