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Anesthesiologist assistant.
A modified or changed claim that was originally allowed, at least in part, by Wisconsin Medicaid.
A Medicaid or Medicare claim that has at least one service that is reimbursable.
BadgerCare extends Medicaid coverage through a Medicaid expansion under Titles XIX and XXI to uninsured children and parents with incomes at or below 185% of the federal poverty level and who meet other program requirements. The goal of BadgerCare is to fill the gap between Medicaid and private insurance without supplanting or "crowding out" private insurance.
BadgerCare benefits are identical to the benefits and services covered by Wisconsin Medicaid and recipients’ health care is administered through the same delivery system.
Current Procedural Terminology. A listing of descriptive terms and codes for reporting medical, surgical, therapeutic, and diagnostic procedures. These codes are developed, updated, and published annually by the American Medical Association and adopted for billing purposes by the Health Care Financing Administration (HCFA) and Wisconsin Medicaid.
A Medicare-allowed claim for a dual entitlee submitted to Wisconsin Medicaid for possible additional payment of the Medicare coinsurance and deductible.
Certified registered nurse anesthetist.
Division of Health Care Financing. The DHCF administers Wisconsin Medicaid for the Department of Health and Family Services (DHFS) under statutory provisions, administrative rules, and the state’s Medicaid plan. The state’s Medicaid plan is a comprehensive description of the state’s Medicaid program that provides the Health Care Financing Administration (HCFA) and the U.S. Department of Health and Human Services (DHHS) assurances that the program is administered in conformity with federal law and HCFA policy.
Department of Health and Family Services. The DHFS administers Wisconsin Medicaid. Its primary mission is to foster healthy, self-reliant individuals and families by promoting independence and community responsibility; strengthening families; encouraging healthy behaviors; protecting vulnerable children, adults, and families; preventing individual and social problems; and providing services of value to taxpayers.
Department of Health and Human Services. The United States government’s principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves.
The DHHS includes more than 300 programs, covering a wide spectrum of activities, including overseeing Medicare and Medicaid; medical and social science research; preventing outbreak of infectious disease; assuring food and drug safety; and providing financial assistance for low-income families.
Date of service. The calendar date on which a specific medical service is performed.
A recipient who is eligible for both Medicaid and Medicare, either Medicare Part A, Part B, or both.
Electronic Claims Submission. Claims transmitted via the telephone line and fed directly into Wisconsin Medicaid’s claims processing subsystem.
Those services which are necessary to prevent death or serious impairment of the health of the individual.
Explanation of Benefits. Appears on the provider’s Remittance and Status (R/S) Report and notifies the Medicaid provider of the status or action taken on a claim.
Eligibility Verification System. Wisconsin Medicaid encourages all providers to verify eligibility before rendering services, both to determine eligibility for the current date and to discover any limitations to a recipient’s coverage. Providers may access recipient eligibility information through the following methods:
The traditional health care payment system under which physicians and other providers receive a payment for each unit of service provided rather than a capitation payment for each recipient.
The Medicaid fiscal agent (EDS) is under contract with the Department of Health and Family Services to certify providers, process and pay claims, answer provider and recipient questions, issue identification cards to recipients, publish information for providers and recipients, and maintain the Wisconsin Medicaid Web site.
Health Care Financing Administration. An agency housed within the U.S. Department of Health and Human Services (DHHS), HCFA administers Medicare, Medicaid, related quality assurance programs, and other programs.
HCFA Common Procedure Coding System. A listing of services, procedures, and supplies offered by physicians and other providers. HCPCS includes Current Procedural Terminology (CPT) codes, national alphanumeric codes, and local alphanumeric codes. The national codes are developed by the Health Care Financing Administration (HCFA) to supplement CPT codes.
Program which provides Medicaid-eligible children under age 21 with regular health screenings.
International Classification of Diseases, Ninth Revision, Clinical Modification. Nomenclature for medical diagnoses required for billing. Available through the American Hospital Association.
A listing of all procedure codes allowed by Wisconsin Medicaid for a given provider type and the maximum allowable fee and relative value units (RVUs) Wisconsin Medicaid assigns to each procedure code.
Medicaid is a joint federal/state program established in 1965 under Title XIX of the Social Security Act to pay for medical services for people with disabilities, people 65 years and older, children and their caretakers, and pregnant women who meet the program's financial requirements.
The purpose of Medicaid is to provide reimbursement for and assure the availability of appropriate medical care to persons who meet the criteria for Medicaid. Medicaid is also known as the Medical Assistance Program, Title XIX, or T19.
Those procedures performed by a certified registered nurse anesthetist (CRNA) or anesthesiologist assistant (AA) and directed by an anesthesiologist.
According to HFS 101.03 (96m), Wis. Admin.Code, a service that is:
(a) Required to prevent, identify or treat a recipient’s illness, injury or disability; and
(b) Meets the following standards:
Those procedures performed by a certified registered nurse anesthetist (CRNA) and supervised by the attending physician.
Party to whom checks are made payable. The payee’s address is used as the mailing address for checks and Remittance and Status (R/S) Reports.
Place of service. A single-digit code which identifies the place where the service was performed.
Qualified Medicare Beneficiary under the Medicare Catastrophic Health Act. These recipients are only eligible for the payment of the coinsurance and the deductible for Medicare-allowed claims.
Conditions that complicate the rendering of anesthesia services, including the extraordinary condition of the patient, special operative conditions, and unusual risk factors.
Remittance and Status Report. A statement generated by the Medicaid fiscal agent to inform the provider regarding the processing of the provider’s claims.
Relative value unit. A number assigned by Wisconsin Medicaid to indicate the relative clinical intensity and difficulty of the surgical, diagnostic, or therapeutic procedure code for which anesthesia services were performed. Relative value units are not necessarily equivalent to either federal or American Society of Anesthesiologists RVUs. Relative value units are indicated on the Physician Maximum Allowable Fee Schedule.
At least intermittent face-to-face contact between supervisor and assistant and a regular review of the assistant’s work by the supervisor, according to HFS 101.03 (173), Wis. Admin. Code.
Type of service. A single-digit code which identifies the general category of a procedure code.