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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.
Care and treatment for a pregnant woman and her fetus to protect and promote the woman’s health and the healthy development of the fetus.
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.
A collateral is anyone who has direct supportive contacts with the recipient. Collaterals include family members, friends, service providers, guardians, housemates, or school officials.
Evaluation and management services provided by two or more physicians to a recipient during an inpatient hospital or nursing home stay.
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.
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.
Wisconsin Department of Health and Family Services. The DHFS administers the Wisconsin Medicaid program. 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.
Those services which are necessary to prevent the death or serious impairment of the health of the individual. (For the Medicaid managed care definition of emergency, refer to the Managed Care Guide or the Medicaid managed care contract.)
Explanation of Benefits. Appears on the providers’ Remittance and Status (R/S) Report and informs Medicaid providers of the status of or action taken on their claims.
Eligibility Verification System. The EVS allows providers to verify recipient eligibility prior to providing services. Providers may access recipient eligibility information through the following methods:
Family-centered care refers to a provider’s or agency’s ability to:
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 Department of Health and Family Services (DHFS) contracts with Electronic Data Systems (EDS) to provide health claims processing services for Wisconsin Medicaid, including provider certification, claims payment, provider services, and recipient services. The fiscal agent also issues identification cards to recipients, publishes information for providers and recipients, and maintains 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) in order to supplement CPT codes.
A situation where a pregnant woman requires additional prenatal care services and follow up because of medical or nonmedical factors that significantly increase the probability of having a preterm birth, a low-birth-weight baby, or other negative birth outcome.
Health Maintenance Organization. Provides health care services to enrolled recipients.
International Classification of Diseases, Ninth Revision, Clinical Modification. Nomenclature for all medical diagnoses required for billing. Available through the American Hospital Association.
A birth weight less than 2500 grams (5.5 pounds).
A listing of all procedure codes allowed by Wisconsin Medicaid for a provider type and Wisconsin Medicaid’s maximum allowable fee for 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.
According to HFS 101.03 (96m), Wis. Admin. Code, a Medicaid service that is:
(a) Required to prevent, identify or treat a recipient’s illness, injury or disability; and
(b) Meets the following standards:
Place of service. A single-digit code which identifies where the service was performed.
A birth before the gestational age of 37 weeks.
Remittance and Status Report. A statement generated by the Medicaid fiscal agent to inform providers regarding the processing of their claims.
Type of service. A single-digit code which identifies the general category of a procedure code.