Health care services provided in Wisconsin must be provided by a Wisconsin Medicaid-certified health care provider. Providers are required to obtain this certification before providing services to HIRSP/HIRSP Federal members. HIRSP will pay benefits up to the HIRSP/HIRSP Federal allowed amount.
Health care services provided outside of Wisconsin can be provided by a provider who is not Wisconsin Medicaid-certified. In these cases, HIRSP will pay benefits for allowable health care services up to the HIRSP or HIRSP Federal allowed amount. HIRSP or HIRSP Federal members are responsible for any amounts billed over the HIRSP or HIRSP Federal allowed amount, including any applicable deductible and coinsurance amounts.
Providers may request an application for certification by Wisconsin Medicaid either by telephone or written request to the Wisconsin Medicaid fiscal agent. HIRSP encourages providers to contact the fiscal agent for certification materials at the time the materials will be submitted because Wisconsin Medicaid periodically revises application materials, including provider agreements. Submission of outdated materials may result in delayed certification. For more information visit ForwardHealth: Wisconsin Medicaid.
If Wisconsin Medicaid requires HIRSP providers to be Medicare certified, providers are required to submit the appropriate Medicare certification materials with the Wisconsin Medicaid application. Wisconsin Medicaid certification materials tell providers whether they need Medicare certification. HIRSP encourages providers to apply for certification to Wisconsin Medicaid at the same time they apply to the Medicare program. Delays in applying to Wisconsin Medicaid may result in assignment of an effective date that is different than the certification effective date for Medicare.