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Wisconsin Medicaid Companion Document to HIPAA Implementation Guide — X12 835 Health Care Claim Payment/Advice

X12 835 V3
PHC 13049 (4/08)
PDF, 96 KB
Revision Log

X12 835 Health Care Claim Payment/Advice

Loop Element Name Instructions
None ISA06 Interchange sender ID This element is populated with "WISC_DHFS."
None ISA08 Interchange receiver ID This element is the eight-digit numeric vendor number assigned by Wisconsin Medicaid.
None GS02 Application sender's code This element is populated with "WISC_TXIX" for Wisconsin Medicaid.
None GS03 Application receiver's code This element is the eight-digit numeric vendor number assigned by Wisconsin Medicaid.
None ST02 Transaction set control number This element contains a unique transaction set control number assigned by Wisconsin Medicaid.
None BPR01 Transaction handle code This element is populated with "I," indicating that the 835 is sent separately from the check.
None BPR02 Total actual provider payment amount This is the total amount of the check.
None BPR04 Payment method This element is populated with "CHK," indicating that a check is being sent.
None BPR16 Check issue date This is the date of process.
None TRN02 Check number This is the check number. If there is no check number, Wisconsin Medicaid populates this element with ‘NO CHECK,’ followed by the remittance and status number.
None TRN03 Payer identification This is the number "1" followed by the Wisconsin Medicaid tax identification number.
None REF02 Reference identification This is the vendor number.
1000A N102 Payer name This is the name of the payer, Wisconsin TXIX Medicaid.
1000A N104 Payer identification This field is spaces until a National Payer Identification (NPI) number is assigned.
1000A N301 Payer address line This is the address of the payer, 6406 Bridge Road.
1000A N401 Payer city name This is the city of the payer, Madison.
1000A N402 Payer state code This is the state of the payer, Wisconsin.
1000A N403 Payer postal zone or ZIP code This is the ZIP code of the payer, 53784.
1000B N102 Payee name This is the billing provider’s name.
1000B N103 ID Code Qualifier “FI” will be indicated when N104 contains the billing provider’s tax identification number. “XX” will be indicated when N104 contains the billing provider’s NPI.
1000B N104 Payee identification code This is the billing provider's tax identification number or NPI.
1000B N301 Payee address line This is the address of the billing provider.
1000B N401 Payee city name This is the city of the billing provider.
1000B N402 Payee state code This is the state of the billing provider.
1000B N403 Payee postal zone or ZIP code This is the ZIP code of the billing provider.
1000B REF Payee additional identification This segment is populated if the billing provider's Medicaid identification number or the payee’s identification number was submitted on the claim.
1000B REF01 Reference identification qualifier This element is 1D, indicating that the next element is the billing provider's Medicaid identification number.
1000B REF02 Reference identification This element is the Medicaid identification number.
2100 CLP02 Claim status code This element is one of the following:
  • 1 – Processed as primary.
  • 2 – Processed as secondary.
  • 4 – Denied.
  • 22 – Reversal claim.
2100 CLP05 Patient responsibility amount This is the sum of copay, spenddown, SeniorCare deductible, patient liability, and nursing home personal needs allowance.
2100 CLP06 Claim filing indicator This element always contains "MC," indicating that this claim was processed by Medicaid.
2100 CLP07 Payer claim control number This is the Internal Control Number (ICN) as assigned by Wisconsin Medicaid for this claim.
2100 NM1 Patient name This is the recipient's information as submitted on the claim.
2100 NM108 ID code qualifier This element is populated with “MR” indicating that the next is the Medicaid recipient identification.
2100 NM109 Identification code This is the recipient's Medicaid recipient identification as submitted on the claim.
2100 NM1 Service provider name This segment is populated if performing provider information was submitted on the claim.
2100 NM108 ID code qualifier “FI” will be indicated when NM109 contains the performing provider’s tax identification number. “XX” will be indicated when NM109 contains the billing provider’s NPI.
2100 NM109 Rendering provider number This is the performing provider's federal taxpayer identification number or NPI as submitted on the claim.
2100 MIA Inpatient adjudication information This segment may be populated for inpatient claims.
2100 MOA Outpatient adjudication information This segment may be populated for outpatient claims.
2100 REF Other claim related identification This segment is populated if medical record number (MRN), adjustment ICN, or claim level prior authorization number is known.
2100 REF01 Reference identification qualifier This element is populated with any of the following:
  • EA - Indicating that the next element is the medical record number (MRN). For professional claims that came in on the proprietary electronic format, EA indicates patient control number (PCN).
  • G1 – Indicating that the next element is the prior authorization number.
  • F8 - Indicating that the next element is the adjustment ICN.
2100 REF Rendering provider identification This segment is populated if a Medicaid identification number was submitted on the claim.
2100 REF01 Reference identification qualifier This element is 1D, indicating that the next element is the performing provider's Medicaid identification number.
2100 AMT Claim supplemental information This segment is populated with the allowed amount or patient amount paid if known.
2100 AMT01 Amount qualifier code This element is populated with any of the following:
  • AU – Indicating that the next element is the claim total allowed amount.
  • F5 – Indicating that the next element is the patient amount paid.
2110 SVC02 Line item charge amount This is the billed amount from the claim unless the line has been split for processing. If the line has been split for processing, the dollars would be prorated across the split lines.
2110 REF Service identification This segment is populated if prior authorization number, provider control number/line item control number, or prescription number is known.
2110 REF01 Reference identification qualifier This element is populated with any of the following:
  • G1 – Indicating that the next element is the prior authorization number.
  • 6R – Indicating that the next element either is the provider control number/line item control number submitted on the 837, or the Prescription number from an NCPDP claim.
2110 REF Rendering provider information This segment is populated if a provider’s Medicaid identification number, federal taxpayer identification number, or NPI is known.
2110 REF01 Reference identification qualifier This element is populated with any of the following:
  • 1D — Indicating that the next element is the provider’s Medicaid identification number.
  • TJ — Indicating that the next element is the federal taxpayer’s identification number.
  • HPI — Indicating that the next element is the provider’s NPI.
2110 AMT Service supplemental amount This segment is populated if detail allowed amount is known.
2110 AMT01 Amount qualifier code This element is populated with "B6."
None PLB02 Fiscal period date This date is December 31st of the current year.
None SE02 Transaction set control number This element contains a unique transaction set control number assigned by Wisconsin Medicaid. This value is the same value indicated in ST02.

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