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All claims, whether electronic or paper, are subject to the same Medicaid processing and legal requirements.
Child care coordination (CCC) providers are encouraged to submit claims electronically. Electronic claims submission:
Wisconsin Medicaid provides free software for billing electronically. For more information on electronic billing:
If you are currently using the free software and have technical questions, please contact Wisconsin Medicaid’s software customer service at (800) 822-8050.
Providers submitting paper claims are required to use the HCFA 1500 claim form (dated 12/90). Appendices 2 (PDF) and 3 (PDF) of this handbook contain completed samples of HCFA 1500 claim forms for CCC services. Refer to Appendix 1 of this handbook for HCFA 1500 claim form completion instructions.
Wisconsin Medicaid denies claims for CCC services submitted on any paper claim form other than the HCFA 1500 claim form.
Wisconsin Medicaid does not provide the HCFA 1500 claim form. Providers may obtain these forms from any vendor that sells federal forms.
Mail completed HCFA 1500 claim forms for reimbursement to the following address:
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Wisconsin Medicaid must receive properly completed claims within 365 days from the date the service was provided. This policy applies to all initial claim submissions, resubmissions, and adjustment requests.
Exceptions to the 365-day claim submission deadline and requirements for submission to Late Billing Appeals can be found in the Claims Submission section of the All-Provider Handbook. Providers may access the handbook on-line at dhs.wisconsin.gov/medicaid/.
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Care coordinators are required to use the mother’s Medicaid ID number when billing for CCC services.
If the mother becomes ineligible for Wisconsin Medicaid while receiving CCC services, providers may bill Wisconsin Medicaid for those services using the eligible child’s Medicaid ID number. Providers are required to document in the recipient’s file the reason for using the child’s Medicaid ID number when billing for CCC services.
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Providers are required to bill their usual and customary charge for the service performed. The usual and customary charge is the provider’s charge for providing the same service to persons not entitled to Wisconsin Medicaid benefits. For providers using a sliding fee scale for specific services, the usual and customary charge is the median of the individual provider’s charge for the service when provided to non-Medicaid patients.
Providers may not discriminate against Wisconsin Medicaid recipients by charging Medicaid a higher fee for the same service than that charged to a private-pay patient. For providers who have not established usual and customary charges, the charge should be reasonably related to the provider’s cost to provide the service.
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Providers are reimbursed at the lesser of their usual and customary charge or the maximum allowable fee established by the Department of Health and Family Services (DHFS).
The maximum allowable fee is the amount Wisconsin Medicaid will pay a provider for an allowable procedure code. Refer to Appendix 16 of this handbook for a copy of the Wisconsin Medicaid maximum allowable fee schedule for CCC services.
To obtain subsequent maximum allowable fee schedules, or to ensure you have the most recent fee schedule, you may:
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All claims submitted to Wisconsin Medicaid must include procedure codes. Allowable HCFA Common Procedure Coding System (HCPCS) codes for CCC services are listed in shaded box below and in Appendix 4 of this handbook. Claims or adjustments received without the appropriate HCPCS codes are denied.
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It is vital that you use the correct procedure codes, diagnosis codes, and modifiers when billing for CCC services:
Procedure Codes
Diagnosis Codes
Use V61.8 when billing for:
Use V61.9 when billing for:
Remember to use a modifier to indicate the recipient's risk assessment score when billing for procedure code W7095. Please refer to Appendix 4 of this handbook for the appropriate modifiers. |
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Claims submitted for CCC services must include either diagnosis code V61.8 (other specified family circumstances) or V61.9 (unspecified family circumstances).
Use diagnosis code:
Wisconsin Medicaid will deny claims if providers use other diagnosis codes when billing for CCC services.
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When billing for risk assessment (W7095) and initial care plan development (W7096), always bill for one unit.
Round time units to the nearest tenth of an hour when billing for ongoing care coordination and monitoring (W7097).
Refer to Appendix 6 of this handbook for more information on rounding guidelines for CCC services.
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Claims submitted for risk assessments (procedure code W7095) must include a modifier indicating the recipient’s total risk assessment score.
Allowable modifiers are located in Appendix 4 of this handbook. Claims for risk assessments that do not include the appropriate modifier are denied.
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The provider is responsible for initiating follow-up procedures on claims submitted to Wisconsin Medicaid. Processed claims appear on the Remittance and Status (R/S) Report either as paid, pending, or denied. Wisconsin Medicaid will take no further action on a denied claim until the provider corrects the information and resubmits the claim for processing.
If a claim was paid incorrectly, the provider is responsible for submitting an Adjustment Request Form (PDF, 89 KB | Instructions — PDF, 20 KB) to Wisconsin Medicaid. Refer to the Claims Submission section of the All-Provider Handbook for more information on filing Adjustment Request Forms.
To be reimbursed for additional ongoing care coordination time which may have been omitted from the original claim, providers are required to file an Adjustment Request Form.
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