• 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 4 — Reading the Remittance and Status Report

This appendix provides information about reading the Remittance and Status (R/S) Report.

Financial items and identifying information may appear on the R/S Report to acknowledge special transactions such as cash refunds made by the provider or any Medicaid check that is outstanding beyond 90 days. Pharmacy Point-of-Sale claims that were denied are not included on the R/S Report for Wisconsin Medicaid, BadgerCare, or SeniorCare.

Banner Page

The banner page provides important, time-sensitive information that may apply to all providers or to specific provider groups. The page may include messages about Medicaid-initiated adjustments, submission deadlines, and upcoming provider training sessions. Providers may also view the R/S messages on the Medicaid Web site.

Header Information

1H. Provider Name and Address

Indicates the name and address of the billing provider’s payee as indicated on the Medicaid file. The payee’s name and address is used for tax purposes on the 1099. (This is not necessarily the name of the billing provider.)

2H. R/S Number

Indicates the R/S Report number.

3H. Provider Number

Indicates the billing provider’s eight-digit Medicaid provider number.

4H. Date

Indicates the date the R/S Report was printed.

5H. Page

Indicates the page number of the R/S Report. Information about the status of a claim generally starts on page 2.

6H. Report Seq Number

Indicates the number of R/S Reports the provider has received in the current calendar year.

Paid or Denied Claims Information

Review and verify the accuracy of individual claim and adjustment information to determine appropriate follow-up action — these are key items that could affect payment or denial.

1A. Patient Name

Indicates the recipient’s last name and first name or first initial. The recipient’s most current name on the Medicaid eligibility file always appears on the R/S Report. If the recipient has changed names, the name on the R/S Report may not be the name on the claim submitted by the provider.

2A. Patient Identification No.

Indicates the recipient’s ten-digit Medicaid identification number.

3A. Medical Record No.

Indicates the first 18 characters of the recipient’s medical record number as recorded on the Medicaid claim or adjustment request.

4A. Patient Control Number

Indicates the recipient’s account number as recorded on the Medicaid claim.

5A. Claim Number

Indicates the unique claim number assigned by Wisconsin Medicaid to the claim or adjustment.

6A. Service Dates

Indicates the dates of service (or date range) corresponding to the date(s) the service(s) were provided.

7A. UD (when applicable)

Gives the unit dose indicator as recorded on the Medicaid drug claim.

8A. NS (when applicable)

Gives the no substitute indicator as recorded on the Medicaid drug claim.

9A. Perf Prov/Rx Number (when applicable)

Indicates the performing provider number of the provider who performed the service or the prescription number.

10A. Days/Qty

Indicates the number of units, services, accommodation days, or supply quantity billed.

11A. Proc/Accom/Drug Cde/M1 M2 M3 M4

Provides the procedure code for the service(s) provided. Modifiers may also be indicated following the code.

12A. Procedure/Accommodation/Drug Description

Provides the procedure code description of the service(s) provided.

13A. Total Billed

Indicates the total billed charges for the service(s) shown on that line for claims or adjustments.

14A. Total Allowed

Indicates the Medicaid payment allowance (determined according to appropriate reimbursement criteria).

15A. Other Deducted Charges (when applicable)

Indicates the charges deducted from the total allowed for reasons such as other health insurance payment or patient liability (hospice and nursing home claims).

16A. Copay (when applicable)

Indicates the recipient Medicaid copayment amount deducted from total allowed amount.

17A. Paid Amount

Indicates the actual amount paid by Wisconsin Medicaid.

18A. EOB Codes

Indicates the numeric Explanation of Benefits (EOB) code(s) that is specific to Wisconsin Medicaid and corresponds to a printed message about the status or action taken on a claim, claim detail, adjustment, or adjustment detail. A list of the EOB codes used, with their descriptions, appears on the last page of each R/S Report. The EOB code(s) that appears in the far right-hand column of the R/S Report explains either why that claim was paid as it was or why it was denied.

1R. Reminder

Medicaid checks cannot be cashed after 180 days.

1P. Claims Payment Summary

Payment summary information follows.

2P. Claims Paid

1. Current Processed — Indicates the total number of claims and adjustments processed on this R/S Report.
2. Year-to-Date Total — Indicates the total number of claims and adjustments processed since the beginning of the calendar year.

3P. Claims Amount

1. Current Processed — Indicates the total dollar amount for the claims paid on this R/S Report.
2. Year-to-Date Total — Indicates the total actual amount for the claims paid since the beginning of the calendar year.

4P. Withheld Amount

1. Current Processed — Indicates the dollar amount of any withheld payments (e.g., negative adjustments) on this R/S Report.
2. Year-to-Date Total — Indicates the dollar amount of payments withheld (e.g., negative adjustments) since the beginning of the calendar year.

5P. Credit Amount

1. Current Processed — Indicates the dollar amount of any voluntary refunds dispositioned in the previous week.
2. Year-to-Date Total — Indicates the dollar amount of voluntary refunds dispositioned since the beginning of the calendar year.

6P. Net 1099 Amount

1. Current Processed — Indicates the net earnings for the claims shown on this R/S Report.
2. Year-to-Date Total — Indicates the net earnings calculated from the beginning of the calendar year.

Next — Appendix 5 — Reading Adjustments on the Remittance and Status Report
Previous — Appendix 3 — Sample Remittance and Status Report