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BadgerCare Plus Forms

Below is a list of all BadgerCare Plus forms. 

When you are searching for a document, enter the number or a portion of the title in the search box below.

Assigned Number Title Division Language Release Date File Type Available to Order
F-00286 Instructions DMS English 07/2015 PDF No
F-11040A Instructions DMS English 12/2019 PDF No
F-00556 Instructions DMS English 01/2018 PDF No
F-03112I Instructions for Logging HMO Appeals DMS English 01/2024 PDF No
F-00107 Instructions, Self-Employment Income Report DMS English 06/2019 PDF No
F-00107 Instructions, Self-Employment Income Report, Chinese Mandarin DMS Chinese Mandarin 06/2019 PDF No
F-00107 Instructions, Self-Employment Income Report, Hmong DMS Hmong 06/2019 PDF No
F-00107 Instructions, Self-Employment Income Report, Spanish DMS Spanish 06/2019 PDF No
F-01234A Instructions: Explanation of Medical Benefits DMS English 11/2023 PDF No
F-10110A Instructions: Medicaid/BadgerCare Plus Eligibility Certification DMS English 01/2018 HTML No
F-11133A Instructions: Personal Care Screening Tool (PCST) DMS English 08/2017 PDF No
F-11010A Instructions: Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format DMS English 01/2018 PDF No
F-11008A Instructions: Prior Authorization / Therapy Attachment (PA/TA) DMS English 05/2019 PDF No
F-00219 Instructions: Self-Employment Income Report: Farm Business DMS English 06/2019 PDF No
F-00219 Instructions: Self-Employment Income Report: Farm Business, Chinese Mandarin DMS Chinese Mandarin 06/2019 PDF No
F-00219 Instructions: Self-Employment Income Report: Farm Business, Hmong DMS Hmong 06/2019 PDF No
F-00219 Instructions: Self-Employment Income Report: Farm Business, Spanish DMS Spanish 06/2019 PDF No
F-16104 Local Agency Customer Feedback DMS English 10/2017 PDF Yes
F-16104H Local Agency Customer Feedback, Hmong DMS Hmong 10/2017 PDF No
F-16104S Local Agency Customer Feedback, Spanish DMS Spanish 10/2017 PDF Yes
F-12022 Managed Care Program Provider Appeal DMS English 02/2020 PDF No
F-12022 Managed Care Program Provider Appeal DMS English 02/2020 Word No
F-12022A Managed Care Program Provider Appeal Instructions DMS English 02/2020 PDF No
F-01915 Marketplace or Indicator Gap Filling Eligibility Determinations Supplemental Letter DMS English 07/2017 Word No
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information DMS English 06/2018 PDF No
F-10151H Medicaid / BadgerCare Plus Fair Hearing Information, Hmong DMS Hmong 06/2018 PDF No
F-10151S Medicaid / BadgerCare Plus Fair Hearing Information, Spanish DMS Spanish 06/2018 PDF No
F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update DMS English 02/2014 PDF No
F-10093S Medicaid and BadgerCare Overpayment Notice, Spanish DMS Spanish 09/2019 PDF No
F-10093 Medicaid and BadgerCare Plus Overpayment Notice DMS English 09/2019 PDF No
F-10093S Medicaid and BadgerCare Plus Overpayment Notice, Spanish DMS Spanish 09/2019 Word No
F-10110 Medicaid/BadgerCare Plus Eligibility Certification DMS English 07/2020 HTML No
F-00855 Medication Therapy Management Case Management Software Requirements DMS English 08/2014 PDF No
F-00855A Medication Therapy Management Case Management Software Vendor Steps for Software Approval Process DMS English 08/2013 PDF No
F-13026 Member / Employer Electronic Funds Transfer for BadgerCare Plus Premiums DMS English 05/2024 PDF No
F-13026S Member / Employer Electronic Funds Transfer for BadgerCare Plus Premiums, Spanish DMS Spanish 05/2024 PDF No
F-01915A Member Request Gap Filling Eligibility Determinations Supplemental Letter DMS English 07/2017 Word No
F-11090 Mental Health Day Treatment Functional Assessment DMS English 08/2015 PDF No
F-11090 Mental Health Day Treatment Functional Assessment DMS English 08/2015 Word No
F-11090A Mental Health Day Treatment Functional Assessment: Completion Instructions DMS English 08/2015 PDF No
F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version DMS English 07/2008 PDF No
F-01165 Newborn Report DMS English 09/2019 PDF No
F-01165 Newborn Report DMS English 09/2019 Word No
F-13072 Noncompound Drug Claim DMS English 04/2017 PDF No
F-13072 Noncompound Drug Claim DMS English 04/2017 Word No
F-13072A Noncompound Drug Claim: Completion Instructions DMS English 04/2017 PDF No
F-16015 Notice of Approval of Benefits/Positive Change in Benefits DMS English 07/2020 Word No
F-16015S Notice of Approval of Benefits/Positive Change in Benefits, Spanish DMS Spanish 07/2020 Word No
F-16001 Notice of Denial of Benefits/Negative Change in Benefits DMS English 05/2018 Word No
F-16001AR Notice of Denial of Benefits/Negative Change in Benefits, Arabic DMS Arabic 05/2018 PDF No

Glossary

 
Last revised January 24, 2023