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Use the following claim form completion instructions, not the claim form’s printed descriptions, to avoid denial or inaccurate claim payment. Do not include attachments unless instructed to do so. Complete the elements listed below as appropriate.
Providers are not required to bill commercial health insurance for prenatal care coordination services.
Note: Medicaid providers should always verify recipient eligibility before rendering services.
Element 1— Program Block/Claim Sort Indicator
Enter claim sort indicator "P" in the Medicaid check box for the service billed.
Element 1a — Insured’s I.D. Number
Enter the recipient’s 10-digit Medicaid ID number. Do not enter any other numbers or letters.
Element 2 — Patient’s Name
Enter the recipient’s last name, first name, and middle initial. Use the Eligibility Verification System (EVS) to obtain the correct spelling of the recipient’s name. If the name or spelling of the name on the Medicaid ID card and the EVS do not match, use the spelling from the EVS.
Element 3 — Patient’s Birth Date, Patient’s Sex
Enter the recipient’s birth date in MM/DD/YY format (e.g., February 3, 1955, would be 02/03/55) or in MM/DD/YYYY format (e.g., February 3, 1955, would be 02/03/1955). Specify female by placing an "X" in the appropriate box.
Element 4 — Insured’s Name (not required)
Element 5 — Patient’s Address
Enter the complete address of the recipient’s place of residence.
Element 6 — Patient Relationship to Insured (not required)
Element 7 — Insured’s Address (not required)
Element 8 — Patient Status (not required)
Element 9 — Other Insured’s Name (not required)
Element 10 — Is Patient’s Condition Related to (not required)
Element 11— Insured’s Policy, Group, or FECA Number (not required)
Elements 12 and 13 — Authorized Person’s Signature (not required)
Element 14 — Date of Current Illness, Injury, or Pregnancy (not required)
Element 15 — If Patient Has Had Same or Similar Illness (not required)
Element 16 — Dates Patient Unable to Work in Current Occupation (not required)
Elements 17 and 17a — Name and I.D. Number of Referring Physician or Other Source (not required)
Element 18 — Hospitalization Dates Related to Current Services (not required)
Element 19 — Reserved for Local Use (not required)
Element 20 — Outside Lab? (not required)
Element 21 — Diagnosis or Nature of Illness or Injury
Enter the appropriate diagnosis code as follows:
Element 22 — Medicaid Resubmission (not required)
Element 23 —- Prior Authorization Number (not required)
Element 24A — Date(s) of Service
For ongoing care coordination and monitoring (W7092) and health education/nutrition counseling for an individual (W7093) or group (W7094), if the service was performed on more than one date of service within the month, indicate the last date the service was performed. If billing for more than one month of activities, or more than one procedure code, use one detail line for each month’s activities with the date of service determined as described below. Refer to Appendix 2 (PDF) in this handbook for a completed sample claim form that shows more than one month’s activities billed on the same claim form.
Enter the month, day, and year for each procedure using the following guidelines:
Element 24B — Place of Service
Enter the appropriate Medicaid single-digit place of service (POS) code for each service. Enter 0 (other) if the place of service occurred in more than one location. Refer to Appendix 5 of this handbook for Medicaid-allowable POS codes.
Element 24C — Type of Service
Enter "9" as the single-digit type of service code.
Element 24D — Procedures, Services, or Supplies
Enter the single most appropriate five-character procedure code (refer to Appendix 4 of this handbook for a list of Medicaid-allowable procedure codes). Claims received without an appropriate procedure code are denied by Wisconsin Medicaid.
Modifiers
Enter the appropriate two-digit procedure code modifier in the "Modifier" column of Element 24D when billing the initial risk assessment (Pregnancy Questionnaire), or for all procedures provided for a subsequent pregnancy within 185 days of the same procedures provided for a previous pregnancy. Refer to Appendix 4 of this handbook for definitions of modifiers.
Element 24E — Diagnosis Code
Enter the number (1, 2, 3, or 4) that corresponds to the appropriate diagnosis code listed in Element 21.
Element 24F — Charges
Enter the total charge for each line item.
Element 24G — Days or Units
Enter the appropriate number of hours billed on each line. Round to the nearest 0.1 hour. Appendix 6 of this handbook lists the rules for rounding. Always enter "1.0" when billing procedure codes W7090 and W7091.
Element 24H - EPSDT/Family Planning
Enter an "H" for each procedure that was performed as a result of a HealthCheck (EPSDT) referral. Enter an "F" for each family planning procedure. Enter a "B" if both a HealthCheck referral and family planning services were provided. If HealthCheck or family planning do not apply, leave this element blank.
Element 24I — EMG (not required)
Element 24J — COB (not required)
Element 24K — Reserved for Local Use (not required)
Element 25 — Federal Tax I.D. Number (not required)
Element 26 — Patient’s Account No.
Optional - provider may enter up to 12 characters of the patient’s internal office account number. This number will appear on the Remittance and Status (R/S) Report.
Element 27 — Accept Assignment (not required)
Element 28 — Total Charge
Enter the total charges for this claim.
Element 29 — Amount Paid (not required)
Element 30 — Balance Due
Enter the balance due. This will be the same amount as appears in Element 28.
Element 31 — Signature of Physician or Supplier
The provider or the authorized representative must sign in Element 31. The month, day, and year the form is signed must also be entered in MM/DD/YY or MM/DD/YYYY format.
Note: The signature may be a computer-printed or typed name and date, or a signature stamp with the date.
Element 32 — Name and Address of Facility Where Services Were Rendered (not required)
Element 33 — Physician’s, Supplier’s Billing Name, Address, ZIP Code, and Phone #
Enter the provider’s name (exactly as indicated on the provider’s notification of certification letter) and address of the billing provider. At the bottom of Element 33, enter the billing provider’s eight-digit Medicaid provider number.