Review / Adjustment

Review/Adjustment is the first level review of a processed claim whenever a provider does not agree with the outcome and feels the claim warrants an adjustment. To request review/adjustment, providers may submit a request and attach any relevant supporting documentation. Review/Adjustment requests can also be made over the phone by calling Customer Service or can be mailed/faxed within applicable timely filing limits.

Requests for Review / Adjustment should be submitted to:
Attention: Claims Department –Review/Adjustment
Fax: (414) 385-6615
Mail: Community Care Inc.
P.O. Box 923
Brookfield, WI 53008-0923

Appeals:

If you disagree with a claim decision, you have the right to appeal. Providers are encouraged to submit a review/reopening request before submitting an appeal, however this is not required. Formal appeals must be submitted in writing within 60 calendar days of the initial claim determination. Non-contracted providers must include a signed Waiver of Liability Form which holds the enrollee harmless regardless of the outcome of the appeal. Appeals must be clearly marked "APPEAL", and contain the provider name, date of service, date of billing, date of rejection and reason(s) claim should be reconsidered. Community Care must respond in writing within 45 calendar days of receipt of appeal.

Submit Appeals to:
Attention: Appeal - Claims Department
Fax: (414) 385-6615
Mail: Community Care Inc.
P.O. Box 923
Brookfield, WI 53008-0923

If, after appealing to Community Care, you are not satisfied with Community Care’s response to your original appeal OR if Community Care fails to respond to the appeal within 45 days, you have the right to appeal to Wisconsin Department of Health and Services (DHS) regarding the payment or non-payment of services. DHS will not consider your appeal if you do not first submit it to Community Care.

You must submit appeals to the DHS in writing within 60 days of Community Care's final decision, or in the case of no response, within 60 days from the end of the 45-daytimeline allotted to Community Care.

All provider appeals to DHS must:
• Be clearly marked "appeal"
• Include the member's name
• Include a specific explanation of the payment amount or a specific reason for the  nonpayment, partial payment, or denial
• Contain the provider's name, date of service, date of billing, date of rejection, and reason(s) the claim merits reconsideration for each appeal
• Include a copy of the Community Care appeal denial letter

If appropriate, submit your DHS appeal to:
Provider Appeals Investigator
Division of Medicaid Services
1 W Wilson St
Room 518
PO Box 309
Madison WI 53701-0309
Fax: 608-266-5629