MedicaidAdministrativeHigh impact
Coverage Policy Changes, Contracting With HMOs, and Claims Process Updates for Child Care Coordination Providers
Wisconsin Medicaid (ForwardHealth)·WI · Pediatrics, Family Medicine, General Practice·Medical Policy
Effective date
Jul 1, 2025
We identified it
Aug 26, 2026
Summary
Effective July 1, 2025, Wisconsin Medicaid HMOs will now directly reimburse contracted Child Care Coordination (CCC) providers for services to HMO-enrolled members in Milwaukee County and the City of Racine. CCC providers must submit claims to HMOs for enrolled members and to ForwardHealth for fee-for-service members. Claims submitted under the old PNCC provider type will be denied; providers must use the new CCC provider type.
Action Required
By June 30, 2025: (1) Billing team must verify all CCC providers are enrolled under the NEW CCC provider type (not PNCC type). (2) Update billing software routing rules to direct CCC claims to ForwardHealth ONLY for fee-for-service Medicaid/BadgerCare Plus members and to the specific HMO for HMO-enrolled members. (3) Create a member enrollment verification process to determine coverage type before claim submission. (4) Configure system to REJECT any CCC claims submitted under PNCC provider type after July 1, 2025. (5) Contact each HMO partner to obtain their specific billing requirements, claim submission timelines, coding standards, and documentation needs. (6) Train billing staff on the new dual-pathway submission process. (7) Update templates and encounter forms to capture HMO vs. fee-for-service status at point of service. Consequence: Claims submitted to wrong payer or under wrong provider type will be denied and delay reimbursement.