Provider Certification Information

Certification Requirement

HIRSP providers are required to be certified by Wisconsin Medicaid in order to receive payment from the Health Insurance Risk-Sharing Plan (HIRSP) for claims.

All providers located in Wisconsin and outside of Wisconsin are required to obtain this certification before providing services to HIRSP members, except for urgent or emergent services. Emergent is defined as any condition in which a delay in treatment may result in permanent impairment of the member's health. Urgent is defined as an acute condition, less serious than an emergency, yet necessitating prompt health care services.

Medicaid certification does not require providers to accept Wisconsin Medicaid recipients.

Wisconsin In-state Certification Procedure

Providers may request an application for certification by Wisconsin Medicaid either by telephone or written request to the Wisconsin Medicaid fiscal agent. HIRSP encourages providers to contact the fiscal agent for certification materials at the time the materials will be submitted because Wisconsin Medicaid periodically revises application materials, including provider agreements. Submission of outdated materials may result in delayed certification. For more information visit ForwardHealth: Wisconsin Medicaid.

If Wisconsin Medicaid requires HIRSP providers to be Medicare certified, providers are required to submit the appropriate Medicare certification materials with the Wisconsin Medicaid application. Wisconsin Medicaid certification materials tell providers whether they need Medicare certification. HIRSP encourages providers to apply for certification to Wisconsin Medicaid at the same time they apply to the Medicare program. Delays in applying to Wisconsin Medicaid may result in assignment of an effective date that is different than the certification effective date for Medicare.