MedicaidAdministrativeMedium impact
Changes to the Wisconsin Medicaid Adjustment Request form and instructions
Wisconsin Medicaid (ForwardHealth)·WI·Medical Policy
Effective date
Oct 1, 2003
We identified it
Jun 20, 2026
Summary
Wisconsin Medicaid has revised their Adjustment Request form, now called the Adjustment/Reconsideration Request (HCF 13046), which will be required for all claim adjustments beginning October 2003. The new form allows up to four modifiers per procedure code and eliminates the requirement for type of service codes.
Action Required
Before October 2003: Wisconsin Medicaid providers must transition to using the new Adjustment/Reconsideration Request form (HCF 13046) for all claim adjustments. Download the revised form from the Wisconsin Medicaid website at www.dhfs.state.wi.us/medicaid/ under Provider Forms, or request paper copies by calling (800) 947-9627. Update billing workflows to use the new form which now supports four modifiers per procedure code and no longer requires type of service codes.