• General Information
  • Introduction
  • Usual and Customary Charges
  • Acceptance of Payment
    • Introduction
    • Maximum Allowable Fees
• Submission Deadline
  • Introduction
  • Medicaid Claims
  • Crossover Claims
  • Exceptions to the Submission Deadline
• Claims Submission
  • Introduction
  • Transactions and Forms
  • Submission Options
    • Introduction
    • Electronic Claims
    • Paper Claims
  • Copayment Amounts
  • State-Contracted Managed Care Organizations
    • Introduction
    • Extraordinary Claims
  • Noncertified Providers
• Responses to Claims Submission
  • Introduction
  • Claim Number
  • Remittance Information
    • Introduction
    • Electronic Remittance Information
    • Paper Remittance and Status Report
  • Verifying Accuracy of Claims Processing
    • Introduction
    • Split Claims May Appear Separately
  • Verifying the Check Amount on Remittance and Status Reports
  • Claim Status
• Adjustment Requests
  • Introduction
  • Electronic Adjustment Requests
    • Introduction
    • Provider Electronic Solutions Software
  • Paper Adjustment Requests
  • Follow-Up to Adjustment Requests
• Good Faith Claims
• Timely Filing Appeals Requests
• Overpayments
  • Introduction
  • Return of Overpayments Through Adjustment Requests
    • Introduction
    • Electronic Adjustment Requests
    • Paper Adjustment Requests
  • Return of Overpayments with Cash Refunds
  • Adjustment Request vs. Cash Refund
  • Medicaid-Initiated Adjustments
• Appendix
  • Appendix 1 — Allowable Exceptions to the Submission Deadline
  • Appendix 2 — Interpreting Claim Numbers
  • Appendix 3 — Sample Remittance and Status Report
  • Appendix 4 — Reading the Remittance and Status Report
  • Appendix 5 — Reading Adjustments on the Remittance and Status Report
  • Appendix 6 — Adjustment/ Reconsideration Request Completion Instructions
  • Appendix 7 — Adjustment/ Reconsideration Request Form
  • Appendix 8 — Explanation of Benefits Codes That Qualify for Good Faith Claims Submission
  • Appendix 9 — Timely Filing Appeals Request Form
  • Appendix 10 — Claim Refund Completion Instructions
  • Appendix 11 — Claim Refund Form
• PDF

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Claims Information

Appendix

Appendix 2 — Interpreting Claim Numbers

Each claim and adjustment by Wisconsin Medicaid is assigned a unique claim number (also known as the internal control number or ICN). This number identifies valuable information about the claim and adjustment request. The following diagram and table provide detailed information about interpreting the claim number.

Type of Number and Description	Applicable Numbers and Description
09 — When reported on the 835 transaction, claim numbers begin with 09.	Not applicable.
Claim type — Two digits indicate the claim type.	10 — Drug claim 19 — Drug adjustment 20 — Professional claim (e.g., physicians, chiropractors, nurse practitioners) 21 — Dental claim 23 — Outpatient hospital claim 24 — Miscellaneous claim (e.g., transportation, physical therapy, home health) 30 — Professional crossover claim, drug crossover claim, or miscellaneous crossover claim   31 — Outpatient hospital crossover claim 39 — Professional adjustment, dental adjustment, miscellaneous adjustment, or outpatient hospital adjustment 40 — Inpatient hospital claim 41 — Nursing home claim 49 — Inpatient hospital adjustment 50 — Inpatient hospital crossover 51 — Nursing home crossover claim 59 — Nursing home adjustment
Region — Two digits indicate the region. The region indicates how Wisconsin Medicaid received the claim or adjustment request.	10 — Retroactive rate adjustment 11 — Electronic claim or adjustment submitted using an 837 Health Care Claim transaction 12 — Automatic crossover claim, automatic crossover adjustment, electronic provider-submitted crossover claim, or electronic provider-submitted adjustment   80 — Medicaid-initiated adjustment 84 — Provider-based billing adjustment 85 — Pharmacy claim submitted using Point-of-Sale (POS) 86 — Pharmacy claim submitted using POS 87 — Pharmacy claim submitted using POS 98 — Paper claim, paper adjustment, paper provider-submitted crossover claim, or pharmacy adjustment submitted using POS
Year — Two digits indicate the year Wisconsin Medicaid received the claim or adjustment request.	For example, the year 2005 would appear as 05.
Julian date — Three digits indicate the day of the year, by Julian date, that Wisconsin Medicaid received the claim or adjustment request.	For example, February 2 would appear as 033.
Batch range — Three digits indicate the batch range assigned to the claim.	The batch range is used internally by Wisconsin Medicaid.
Sequence number — Three digits indicate the sequence number assigned within the batch range.	The sequence number is used internally by Wisconsin Medicaid.

Next — Appendix 3 — Sample Remittance and Status Report
Previous — Appendix 1 — Allowable Exceptions to the Submission Deadline