Filing a claim

It couldn’t be any simpler

No claim filing is required when you see a Health Tradition network provider

When you visit a provider who is part of your plan’s network, your provider will file your medical claims for you. Please inform your provider that you are a Health Tradition member. That’s all it takes. See network providers for your plan (by selecting your plan type).

Out-of-network claims

Most often, you will only be covered for care that is received from in-network health care providers. However, care received from out-of-network providers may be covered if certain conditions are met, or for emergency or urgent care.

Claims for non-urgent or non-emergency care received out-of-network are generally not covered by your benefit plan if you did not receive prior authorization or a referral approved by Health Tradition. You may receive a denial notice instead of payment, and may be billed directly by the out-of-network provider for charges other than copayments, coinsurance, or any amounts that may remain on a deductible. This is often referred to as balance billing.

You are responsible to know if your care will be covered for out-of-network services

If you have questions about whether your care will be covered, or about this process, please refer to your Certificate of Coverage, or call customer service.

Claim procedure

Out-of-network healthcare providers will generally file medical claims for you; simply provide your membership card. When you have a claim for services received from an out-of-network provider, you should notify Health Tradition in writing as soon as reasonably possible.

However, an out-of-network provider may instead require immediate payment. If you are required to make immediate payment, you may be eligible for reimbursement. To have services processed towards your benefit, please follow these simple steps.

  • Obtain an itemized bill and receipt of payment from the healthcare provider. Each bill should include items such as the patient’s full name, date(s) of service, type(s) of service, diagnosis, healthcare provider’s name, address and itemized statement charges.
  • Fill out member claim form.
  • Submit the original itemized bill, receipt of payment, and member claim form to:
    Health Tradition Health Plan
    1808 E Main St.
    Onalaska, WI 54650

Health Tradition will process the claim, resulting in charges being applied towards deductible and coinsurance. If applicable, payment for covered services will be mailed directly to the healthcare provider unless you provide proof of payment. If you provide proof of payment, the reimbursement will be sent to you.

Time limit to file claims

Claims must be filed within the required 90 days unless these three conditions are met, or you do not have legal capacity.

  • It was not reasonably possible to give proof within that time
  • The information is furnished as soon as possible
  • No later than 15 months after the date services were received

Retroactive denial of claims

A retrospective review (post-service review) applies when the claim is received after the service has already been provided, or  when notification of an admission occurs after the member has been admitted and discharged. The request for the retrospective review may be made by the member, or by the facility which provided the services.

No retrospective reviews will be conducted more than 24 months after services were provided, or 24 months after the discharge date. If Health Tradition does not receive the required information within 45 calendar days, the claim will be denied.

Retroactive denial can be avoided by obtaining prior authorization, or by notifying Health Tradition upon admission. See prior authorization

Prescription drug claims

Your prescriptions are covered using Health Tradition’s drug formulary, subject to deductible, copay and coinsurance shown in your Summary of Benefits and Coverage (SBC).
See Filling prescriptions

Questions about a claim?

For questions on the status of a claim, benefits and eligibility, or a particular billing concern, please call the toll-free number listed on the back of your health plan membership card. You may also reach customer service at 877-832-1823. A representative with information specific to your health plan will be available to assist you Monday through Friday, 7:00am to 7:00pm, CT.

For Medicaid/BadgerCare, call 608-781-9692 or toll-free at 1-800-545-8499. We are available from 7 a.m. to 7 p.m., Monday through Friday. A 24-hour voice response unit is also available for when you may not need to speak directly with a customer service representative, or for calls after hours.