Home care billing · WI
Home care billing in Wisconsin
Short answer
Home care billing in Wisconsin depends on the program.
Family Care members are paid by their region's managed care organization, whose care team must approve every service in advance; IRIS participants self-direct, with a fiscal employer agent paying workers and vendors; BadgerCare Plus and SSI members are in HMOs with their own claim rules; and fee-for-service personal care and home health bill ForwardHealth, where a claim with no matching Sandata aggregator visit denies with EOB 1047 and a visit shorter than the billed units denies with EOB 1048. A dedicated Remitwright biller keeps each payer's authorization, EVV status and claim path in order, serving Wisconsin agencies remotely. Rules for other states are on the home care billing by state page.
Last reviewed by the Remitwright billing team. Editorial policy
Key facts for Wisconsin home care billing
| Fact | In Wisconsin | Source |
|---|---|---|
| Programs that pay | Family Care Waiver (0367.R05.00); IRIS, Include, Respect, I Self-Direct (0484.R04.00); Family Care Partnership and PACE; Children's Long-Term Support Waiver Program (0414.R04.00); Medicaid personal care and home health (ForwardHealth fee-for-service and the BadgerCare Plus and Medicaid SSI HMOs) | 1 |
| How it is delivered | Managed care and fee-for-service, by program | 10 |
| EVV | Open vendor model | 11 |
| Medicare home health and hospice | National Government Services, Jurisdiction 6 | 18 |
Programs that pay for home care in Wisconsin1
Family Care Waiver (0367.R05.00)
Supportive home care, self-directed personal care, skilled nursing services (RN and LPN), respite, adult day care, daily living skills training, day habilitation, home delivered meals, home modifications, personal emergency response systems, specialized medical equipment and supplies, assistive technology, residential services, supported employment, transportation and the rest of the Family Care benefit, for people 65 and older, adults 18 to 64 with physical or other disabilities and adults 18 and older with developmental or intellectual disabilities who meet a nursing facility or ICF/IID level of care.
Family Care is the state's Medicaid long-term care program for frail elders and adults with disabilities. A member must be at least 18, Medicaid-eligible, functionally eligible on the Long-Term Care Functional Screen and have a long-term care condition expected to last more than 90 days. DHS's Family Care page says the program reached the last county in 2018 and serves more than 57,000 members through managed care organizations that coordinate the member's services.
IRIS, Include, Respect, I Self-Direct (0484.R04.00)
Self-directed long-term care: supportive home care, nursing services, respite, adult day care, day habilitation, home delivered meals, home modifications, assistive technology, individual directed goods and services, supported employment, support broker services and IRIS consultant agency services, for the same older adult and disability groups as Family Care.
The participant or legal decision-maker chooses supports and services within an approved budget, hires providers and follows program rules, with an IRIS consultant agency to build the plan of care and a fiscal employer agent to pay workers and vendors. The plan must be approved before any service starts.
Family Care Partnership and PACE
Partnership mixes health care and long-term support services in home and community settings for members who have both Medicaid and Medicare, through Community Care Health Plan, Inc., Independent Care (iCare) Health Plan and My Choice Wisconsin Health Plan in participating counties; PACE serves people 55 and older who are eligible for nursing home care in Kenosha, Milwaukee, Racine and Waukesha counties through one organization that provides health care, long-term care and prescription drugs.
Partnership members must be at least 18, be a frail elder or adult with a disability, be eligible for Medicaid, be functionally eligible and have a long-term care condition lasting more than 90 days; the team of the member's doctor, nurses and social workers writes the care plan and the MCO arranges the services. A PACE care team includes a care manager, a dietitian, a home care coordinator, a PACE doctor, therapists and a registered nurse.
Children's Long-Term Support Waiver Program (0414.R04.00)
Personal supports, respite, daily living skills training, family and unpaid caregiver supports, financial management services, home modifications, specialized medical and therapeutic supplies, support and service coordination, transportation and other services for children ages 0 to 21 with physical or other disabilities, serious emotional disturbance, autism, intellectual or developmental disabilities who meet a hospital, nursing facility or ICF/IID level of care.
Medicaid personal care and home health (ForwardHealth fee-for-service and the BadgerCare Plus and Medicaid SSI HMOs)
Personal care in 15-minute units (T1019) and per day (T1020), nurse supervisory visits (99509), supportive home care (S5125 and S5126 in Family Care and IRIS), and the home health code set of skilled nursing, private duty nursing by RN or LPN, home health aide, therapy and medication administration visits, each tied to the payer that covers the member on the date of service.
How the program is delivered
Both, by program. CMS's 2024 state tables list Family Care as a region-specific MLTSS-only prepaid plan program under 1915(b)/1915(c) authority since February 1, 2000, mandatory for aged, blind or disabled adults and full duals, with Community Care, Inc., Lakeland Care, Inc., My Choice Wisconsin and Inclusa, Inc. as the plans; the Wisconsin Partnership Program as a region-specific full-benefit MCO plus MLTSS under 1932(a) and 1915(c) since December 1, 1995, with Community Care Health Plan, Independent Care Health Plan (iCare) and My Choice Wisconsin; and BadgerCare Plus (statewide since February 1, 2008) and SSI Managed Care (statewide since April 1, 2005) as full-benefit MCO programs that cover home health and state plan personal care but not HCBS waiver services.10 The May 2026 Family Care geographic service regions map, cited below, divides the state into numbered geographic service regions and shows Community Care, Inc., Inclusa, Lakeland Care, My Choice Wisconsin and Anthem as the managed care organizations by region, so the MCO an agency contracts with depends on the member's county. IRIS runs alongside Family Care as a self-directed 1915(c) waiver in which the fiscal employer agent, not an MCO, pays providers. Fee-for-service members bill ForwardHealth directly.
Electronic visit verification
Open vendor model: Sandata is the EVV system DHS provides, used from a smartphone or tablet, a small digital device or the member's landline telephone, and a provider may instead use an alternate EVV system that meets the state's business and technical requirements and integrates with the Sandata aggregator. EVV applies to Medicaid and BadgerCare Plus fee-for-service, the BadgerCare Plus and Medicaid SSI HMOs, Family Care and Family Care Partnership, and IRIS for personal care services. Personal care and supportive home care hard launched on May 1, 2023 and home health care services on October 1, 2024.11 An alternate system sends the provider's visits to the Sandata aggregator, where the provider confirms they arrived in verified status, and only verified visits are passed to the payer for claims processing; the certification and set-up can take up to three months and the provider bears its cost. Payers receive EVV visit information through the aggregator and compare it with the provider's claim records before payment, and HMOs and MCOs must send DHS accurate and timely service authorization information for EVV services. Live-in workers must use EVV for home health services and supervisory RN visits under 99509 but not for personal care services unless their employer requires it, and in IRIS a worker who lives with the participant is exempt.
Services under EVV12
- Personal care in 15-minute units, T1019, in fee-for-service, the HMOs, Family Care and IRIS
- Personal care per day, T1020, in Family Care and Family Care Partnership
- Supportive home care in 15-minute units and per day, S5125 and S5126, in Family Care and IRIS
- Nurse supervisory visits for personal care, 99509, in fee-for-service, the HMOs and Family Care
- Home health care services in fee-for-service, the HMOs and Family Care, codes 92507, 97139, 97799, 99504, 99600, S9123, S9124, T1001, T1021 and T1502
Authorizations
By the payer's care team or plan. In Family Care the MCO care team finds the mix of services for the member and must approve all services before the member receives them; a service has to be in the benefit package, support the member's long-term care outcomes and be the most cost-effective way to meet the need. In IRIS the participant's plan of care, built with the IRIS consultant, must be approved before services or supports begin, and the fiscal employer agent pays against that budget.3 HMOs and MCOs transmit their service authorization information for EVV services to DHS, and IRIS fiscal employer agents receive it from the state case management system, so a visit billed outside the authorization fails the payer's EVV comparison before payment. Partnership members' care plans are written by the team of the member's doctor, nurses and social workers. Fee-for-service personal care and home health follow ForwardHealth's own coverage and authorization rules, and DHS tells HMO providers to ask their HMO about billing and claims.
Where the claims go
Fee-for-service claims go to ForwardHealth, where a personal care or home health claim with no EVV information for the date of service denies on the remittance advice with EOB 1047, EVV System Visit not found, and a visit shorter than the billed units denies with EOB 1048; the fix is in the Sandata portal's Visit Maintenance, not on the claim form, because claim submission requirements did not change with EVV. Family Care and Partnership claims go to the member's MCO, HMO claims to the HMO, and IRIS participant-hired workers and vendors are paid by the fiscal employer agent.14 Sandata users set themselves up through the ForwardHealth Portal: current contact information in Demographic Maintenance, the self-paced administrator training, the Sandata welcome kit, and worker association in the Portal before visits can be recorded. Every payer, HMO, MCO or fiscal employer agent, receives EVV visits through the aggregator and compares them with the claim before paying. IRIS fiscal employer agents pay participant-hired workers' claims and work with participants and workers to resolve missing or inaccurate EVV data, and a participant whose workers do not comply with EVV may be disenrolled from IRIS. HMO and MCO providers take claim questions to the plan.
Medicare home health and hospice in Wisconsin
National Government Services, Inc., the A/B MAC for Jurisdiction 6, processes Medicare home health and hospice claims for Wisconsin, alongside Alaska, Arizona, California, Hawaii, Idaho, Michigan, Minnesota, Nevada, New Jersey, New York, Oregon, Washington and the Pacific and Caribbean territories; its Part A and Part B jurisdiction is Illinois, Minnesota and Wisconsin.18 For Medicaid, home health is a covered benefit in BadgerCare Plus, SSI Managed Care, Partnership, Family Care and PACE, and Wisconsin put home health care services under EVV on October 1, 2024 for fee-for-service, the HMOs and Family Care, including private duty nursing by RN or LPN, home health aide visits and therapy visits. Live-in workers are not exempt from EVV for home health or the 99509 supervisory visit. Section 12006 of the 21st Century Cures Act set the January 1, 2023 federal deadline for home health EVV.
Common rejections in Wisconsin, and the fix
EOB 1047, EVV System Visit not found
The fixForwardHealth found no EVV information for the date of service billed. The biller searches the Sandata portal's Visit Maintenance for the visit, has it corrected or created and verified, and only then releases the claim; for an alternate EVV system the check is whether the visit reached the aggregator in verified status, because only verified visits go to the payer.
EOB 1048, EVV units do not meet requirements
The fixThe recorded visit is shorter than the units billed. The biller bills the units the verified visit supports and sends time corrections through visit maintenance instead of adjusting the claim, since claim submission requirements did not change with EVV.
Family Care service delivered before the care team approved it
The fixThe MCO care team must approve all services before the member receives them, and the service has to be in the benefit package and the most cost-effective way to meet the need. The biller holds new or changed services until the MCO authorization is on file, and reconciles delivered units to it before the claim.
Claim sent to ForwardHealth for an HMO, MCO or IRIS member
The fixOnly fee-for-service members bill ForwardHealth; Family Care and Partnership claims go to the MCO for the member's region, HMO claims to the HMO, and IRIS workers and vendors are paid by the fiscal employer agent. The eligibility check records the payer on each date of service and the biller routes by that answer.
Live-in worker's home health or supervisory visit without EVV
The fixThe live-in exemption covers personal care only, and only when the employer allows it; home health services and the 99509 supervisory visit need EVV from every worker. The biller flags live-in caregivers by service code so the home health visits are clocked.
Alternate EVV visits never reached the payer
The fixAn alternate EVV system has to complete Sandata certification and aggregator set-up, which can take up to three months, and send visits into the aggregator where they must sit in verified status. The biller watches the aggregator for unverified visits before each billing cycle rather than discovering them on the remittance.
IRIS worker paid late or participant at risk over missing EVV data
The fixParticipant-hired workers who do not live with the participant must use EVV for personal care and supportive home care under S5125, S5126 and T1019, and the fiscal employer agent resolves missing or inaccurate data before paying the claim. The biller reconciles IRIS timesheets to EVV records before each FEA pay cycle so the FEA pays on time and the participant's enrollment is not put at risk.
Remitwright serves Wisconsin home care and home health agencies remotely, inside the agency software you already use, with a dedicated biller.
FAQ
Questions from Wisconsin agencies
Why did our personal care claim deny with EOB 1047?
Who authorizes a Family Care member's supportive home care hours?
How do we get paid for an IRIS participant we serve?
Can we use our own EVV system in Wisconsin?
Do live-in caregivers have to use EVV?
Which MCO do we bill for a Family Care member?
Who pays our Medicare home health and hospice claims in Wisconsin?
Which programs pay for home care in Wisconsin?
Which services fall under EVV in Wisconsin?
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