[site map]
All claims, whether electronic or paper, are subject to the same Medicaid processing and legal requirements.
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 customer service at (800) 822-8050.
P
roviders submitting paper claims must use the HCFA 1500 claim form (dated 12/90). Refer to Appendix 2 of this handbook for HCFA 1500 claim form completion instructions and Appendices 3 and 4 of this handbook for sample completed claim forms.Wisconsin Medicaid denies claims for services submitted on any paper claim form other than the HCFA 1500 claim form.
Wisconsin Medicaid does not provide the HCFA 1500 claim form. You may obtain the form from any vendor that sells federal forms.
Mail completed HCFA 1500 claim forms for reimbursement to the following address:
Wisconsin Medicaid[site map] [chapter
contents] [next] [top]
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/. If you wish to make adjustments, refer to Appendices 5, 6, and 7 of this handbook.
[site map] [chapter
contents] [previous] [next] [top]
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 that have not established usual and customary charges, the charge should be reasonably related to the provider’s cost to provide the service.
[site map] [chapter
contents] [previous] [next] [top]
Wisconsin Medicaid reimburses certified registered nurse anesthetists (CRNAs) and anesthesiologist assistants (AAs) based on the type of service performed, time spent in anesthesia, and the level of medical direction provided. The level of medical direction is indicated by a modifier. (Refer to Appendix 1 of this handbook for a list of the Medicaid-allowed modifiers and their descriptions.)
Wisconsin Medicaid’s usual reimbursement for anesthesia is equal to the lesser of either the billed amount or the amount calculated by the following formula:
(RVUs + time units) x modifier coefficient
That is, the relative value units (RVUs) for the major procedure (assigned automatically by Medicaid), plus the number of 15-minute time units, multiplied by a specific coefficient amount for the modifier billed.
The RVU assigned to each procedure code and the modifier coefficient amount for each of the modifiers allowed for CRNAs and AAs is indicated on the Wisconsin Medicaid maximum allowable fee schedule for physician services.
Since the RVU includes usual pre- and post-operative care, the administration of the anesthetic, and incidental administration of fluids and/or blood, Wisconsin Medicaid will not reimburse these services in addition to the reimbursement for anesthesia.
Invasive monitoring and vascular procedures are reimbursed the lesser of either the billed amount or the quantity multiplied by Wisconsin Medicaid’s maximum allowable fee for the procedure.
Wisconsin Medicaid’s reimbursement calculation process differs from Medicare in the following ways:
The Wisconsin Medicaid maximum allowable fee schedule for physician services includes the following information for CRNAs and AAs:
To obtain a maximum allowable fee schedule, use one of the following methods:
[site map] [chapter contents] [previous] [next] [top]
The All-Provider Handbook includes the appropriate procedures for claim follow up, including:
[site map] [chapter contents] [previous] [next] [top]