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Children's Long-Term Support: Third Party Administration Transition for County Waiver Agencies

The claims processor for the CLTS Program will transition from third party administrator (TPA) Wisconsin Physicians Service (WPS) to fiscal agent Gainwell Technologies, LLC (GWT). The anticipated date of this transition is May 5, 2025. This is a temporary webpage that provides information on processes with GWT after the transition. Find information on current processes with WPS.

TPA information for providers

Prior authorization

Direct entry via the ForwardHealth Portal

  • County waiver agencies (CWAs) use this method for PA entry directly into the portal.
  • This method is a one-at-a-time PA entry.
  • The Portal delivers real-time validation response.

Flat file (.csv) upload via the ForwardHealth Portal

  • CWAs use this method to upload a flat file in a state-approved format to the Portal.
  • PA file formatting:
  • File upload has an initial validation in real-time for file structure and data integrity.
  • In addition to the initial validation, file upload will have an overnight batch validation.
  • The portal accepts multiple file submissions per day from each CWA Monday through Friday.
  • Files may contain a mixture of new, amended (revised), and inactive reversal (cancelled) PAs.

  • Amending a PA is the same as a PA revision.
  • CWAs can amend through the direct entry submission or through flat file upload.
  • CWAs must use the ForwardHealth PA number on their amended PA for PA matching purposes.
  • Fields on the PA that can be amended will vary depending on whether a claim has been submitted or not.
  • See the CLTS Guide to Amending Prior Authorizations (PDF) for more information.

  • CWAs will receive a list of Medicaid IDs (MA IDs) for providers who are approved for their counties. The list will be emailed to the leads for that CWA before the transition date.
  • PA will require the provider’s MA ID. Tax IDs will not be accepted.
  • CWAs will have their own unique MA ID for claims submission under the Children's Long-Term Support (CLTS) Program.
    • The waiver portal administrator will receive the PIN letter with their CWA’s MA ID.

New requirement to submit International Classification of Diseases (ICD)-10th Revision Clinical Modification (CM) codes on PAs.

  • CWAs may use a participant-specific diagnosis code or Z41.8 – “encounter for other procedures for purposes other than remedying health state, unspecified.”
  • CWAs must recode any electronic health record (EHR) systems that are currently passing a different generic ICD-10 code to WPS.

  • CWAs will not be required to submit their support and service coordination rate on PAs.
  • SSC rates will be uploaded in a table in the claim payment system for each CWA.

  • CWAs may provide an internal PA number on the PA.
  • This number will be returned to the CWA in the response file.
  • Internal PA numbers will be available and searchable on the ForwardHealth Portal.

  • Payment methods are synonymous with WPS’ “frequency types.”
  • Payment methods will be automated in the claim payment system depending on number of units identified on the PA.
  • 0 units = Dollar limit. The dollar amount is approved with zero (0) units. The system will pay until approved dollars have been decremented.
  • 1 unit or more = Pay unit fee price with unit limit. Units are approved with a certain dollar amount for each unit. The system will pay until approved units have been decremented.

  • CWAs will have a comprehensive view of their PAs, whereas providers will only have access to their allocated PA.
  • The portal administrator will need to assign access and user roles to enter PAs or upload a flat file.

Claim submission

  • Medicaid IDs (MA IDs) or National Provider Identifiers (NPIs) are required to process CLTS claims.
  • Tax IDs will no longer be accepted.
  • Non-healthcare providers who do not have an NPI will submit claims using their MA ID with all claim submission methods.
  • Healthcare providers who do have an NPI:
    • Must submit the NPI on claims submitted via the electronic 837 method. Cannot submit MA ID on an 837.
    • Will use the MA ID to submit on all other claim submission methods. Can also include NPI.
  • New and existing providers will be assigned an MA ID for the CLTS Program.
  • Providers will receive a letter that will contain their PIN to log in to the ForwardHealth Portal. This letter will also contain their MA ID.
  • Each service location/directory location will have a unique MA ID.
    • Providers are encouraged to ensure their registration is up to date now.
    • The DHS CLTS Registry remains the “source of truth” regarding provider information, meaning all changes must be made in this registry. DHS passes this information to Gainwell to upload to their provider file and ForwardHealth Portal.
    • If the provider has one location:
      • They should enter this as their main Business Name and Business Address.
      • They should enter this as their Directory Location.
    • If the provider has more than one location:
      • They should enter their main location as their Business Name and Business Address.
      • They should enter their main location as a Directory Location.
      • They should enter all other service locations as a Directory Location.

ForwardHealth Portal

  • Direct Data Entry (DDE)
    • Claim Wizard allows providers to directly enter a claim into the ForwardHealth Portal.
  • Copy a Claim
    • The ForwardHealth Portal saves claim information and allows providers to copy a claim, in a paid status, to a new claim for easy editing before submitting it as a new claim.
  • Create a Claim from a prior authorization (PA)
    • Allows users to create a claim based on information from the PA, with information prepopulated on the claim.
  • Electronic Data Interchange (EDI): 837 Health Care Claim transactions

Paper

  • 1500 Health Insurance Claim Form and UB-04 Claim Form
    • Providers can mail in paper claim forms.

Claim adjustments

  • Claim adjustments can be submitted using 837 transactions and DDE.
  • Any claim that is in a Pay status can be adjusted and resubmitted through DDE regardless of how the claim was originally submitted.

CLTS maximum (max) fee schedules

  • Max fee schedules can be accessed from the Portal home page and the provider home page.
  • CLTS fee schedules will be available Spring 2025.

CWA claims submission limitations

  • The only services the CWA may deliver to a CLTS Program participant, in addition to support and service coordination, are:
    • Allowable services provided through foster care.
    • Purchased products and supplies from third-party entities and vendors (typically web-based vendors) for which the CWA receives no benefit from the vendor.
  • See the Federal Procedure Code Limitations on Claims for County Waiver Agencies (PDF) document for further guidance on CWA claim submission limitations.

Date-span billing

  • Bill dates of service when services were provided within the authorized date span.
  • When to use a date span versus one day of service:
    • Services were performed on consecutive dates: Bill a date span (for example, Aug. 1–7).
    • Services were performed on two or more different dates: Bill one date per claim line (for example, Aug. 1, Aug. 3, and Aug. 7).

Place of service (POS)

  • New requirement to submit POS code on claims.
  • Will not be included on PA to continue to allow flexibility for POS 02 Remote Services.
    • Guidance will be found in the ForwardHealth Portal in the CLTS Max Fee Schedule.
    • Guidance will also be found in the Claims Submission User Guide.
    • Will be included in claims submission training closer to the transition date.

Resources

The ForwardHealth Portal has prior authorization (PA) and claims information and secure messaging, including a new CLTS Program Third-Party Administration Transition page.

User guides show users how to perform tasks on the ForwardHealth Portal.

Training and other educational resources are also available.

TPA events

CWA teleconferences

  • December 12, 2024, from 10–11 a.m.

Demonstration sessions

August 13 and 15, 2024, How to Submit an 837 Demonstration
July 24 and 25, 2024, Portal and Claims Submission Demonstration Sessions

Forums

October 16, 2024, CLTS TPA Transition
  • Agenda: Project timeline, webpage, ForwardHealth CWA user roles, date span billing,  Medicaid IDs, ending PAs, prior authorization uploads, Payment schedules and remittance advice (RA) schedules, support and service coordinator (SSC) case management rates, financial management services (FMS)
  • Oct. 16, 2024, recording
  • Oct. 16, 2024, presentation (PDF)
August 7, 2024, CLTS TPA Transition
May 15, 2024, CLTS TPA Transition
February 21, 2024, CLTS TPA Transition
December 19, 2023, CLTS Program TPA Transition
October 26, 2024, CLTS Program TPA Transition

Glossary

 
Last revised November 14, 2024