• 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

Claims Information

General Information

Usual and Customary Charges

For most services, providers are required to indicate their usual and customary charge when submitting claims to Wisconsin Medicaid. The usual and customary charge is the provider’s charge for providing the same service to persons not entitled to Medicaid benefits. For providers using a sliding fee scale, the usual and customary charge is the median of the individual provider’s charge for the service when provided to non-Medicaid patients. For providers who have not established usual and customary charges, the charge should be reasonably related to the provider’s cost for providing the service.

Providers may not discriminate against Medicaid recipients by charging Wisconsin Medicaid a higher fee for the same service than that charged to a private-pay patient.

For services requiring a recipient copayment, providers should still indicate their usual and customary charge. The copayment amount collected from the recipient should not be deducted from the charge submitted to Wisconsin Medicaid. When applicable, Wisconsin Medicaid automatically deducts the copayment amount.

For most services, Wisconsin Medicaid reimburses the lesser of the provider’s usual and customary charge or the maximum allowable fee established by Wisconsin Medicaid. Refer to service-specific publications for more information about Medicaid reimbursement.

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