|
Loop |
Element |
Name |
Instructions |
| |
ISA |
Interchange
Control Header |
The ISA is a
fixed-length record with fixed-length elements.
Note: Deviating from the standard's ISA element sizes will cause the
interchange to be rejected. |
| |
ISA05 |
Interchange ID
(Sender) Qualifier |
Enter the value
"ZZ", mutually defined. |
| |
ISA06 |
Interchange
Sender ID |
Enter the
eight-digit numeric vendor number assigned by Wisconsin Medicaid.
|
| |
ISA07 |
Interchange ID
(Receiver) Qualifier |
Enter the value
"ZZ", mutually defined. |
| |
ISA08 |
Interchange
Receiver ID |
Enter "WISC_DHFS". |
| |
GS02 |
Application
Sender's Code |
Enter the same
value as ISA06, the eight-digit numeric vendor number assigned by Wisconsin
Medicaid. |
| |
GS03 |
Application
Receiver's Code |
Enter "WISC_TXIX"
for Wisconsin Medicaid. |
| |
GS08 |
Version /
Release / Industry Identifier Code |
Enter the value
"004010X097A1", the HIPAA-mandated implementation guide release for this
transaction.Note: This code represents the HIPAA implementation
guide with the most recent addenda changes. Using an earlier guide, without
the most recent addenda changes, does not comply with the HIPAA rule and
will cause the transaction to be rejected. |
| |
BHT03 |
Originator
Application Transaction Identifier |
Make this
identifier unique to a single transaction (ST to SE envelope). Repeating a
value will cause the transaction to be rejected. Wisconsin Medicaid
recommends using a value with an easily identifiable pattern to aid research
(e.g., "ANY_GROUP_PRACTICE_20031016" or "ANY GROUP PRACTICE #00001"). |
| |
REF02 |
Transmission
Type Code |
Enter the value
"004010X097DA1" to indicate a dental claim.
Note: This version includes the addenda. |
| 1000A |
NM109 |
Submitter
Primary Identification Number |
Enter the same
value as ISA06, the eight-digit numeric vendor number assigned by Wisconsin
Medicaid. Note: A new vendor number will be issued for submitting
HIPAA transactions. This number will replace the submitter’s current vendor
number. |
| 1000B |
NM101 |
Entity
Identifier Code |
Enter the value
"40" for receiver. |
| 1000B |
NM102 |
Entity Type
Qualifier |
Enter the value
"2" for non-person entity. |
| 1000B |
NM103 |
Receiver Name |
Enter
"Wisconsin Medicaid" to indicate that the claims are being sent to Wisconsin
Medicaid. |
| 1000B |
NM108 |
Identification
Code Qualifier |
Enter the value
"46" for electronic transmitter identification number. |
| 1000B |
NM109 |
Identification
Code or Receiver Primary Identifier |
Enter the same
value as GS03, "WISC_TXIX" for Wisconsin Medicaid. |
| 2000A |
PRV01 |
Provider Code |
Enter "PT" to
indicate the rendering/performing provider is the same entity as the pay-to
provider. Note: If a rendering/performing provider is not indicated
on the claim, Wisconsin Medicaid will assume the rendering/performing
provider and the billing provider are the same entity. |
| 2010AA |
REF |
Billing
Provider Secondary Identification |
Include this
segment if the provider in loop 2010AA is the provider certified by
Wisconsin Medicaid to submit claims.
Note: Wisconsin Medicaid requires that all claims be submitted with
the eight-digit Wisconsin Medicaid billing provider number. |
| 2010AA |
REF01 |
Reference
Identification Qualifier |
Enter the value
"1D" for the Wisconsin Medicaid provider number. |
| 2010AA |
REF02 |
Billing
Provider Identifier |
Enter the
eight-digit Wisconsin Medicaid billing provider number assigned by Wisconsin
Medicaid. |
| 2010AB |
NM1 |
Pay-To
Provider Name |
Note:
The information in this segment will not be used to determine where to send
the provider Remittance and Status (R/S) Report and/or 835 HealthCare Claim
Payment/Advice (835). The R/S Report and/or the 835 will be sent to the
entity established during the provider certification process. |
| 2010BA |
NM1 |
Subscriber Name |
Enter
information about the subscriber/recipient in this loop. |
| 2010BA |
NM102 |
Entity Type
Qualifier |
Enter the value
"1" to indicate the subscriber is a person. |
| 2010BA |
NM103 |
Subscriber Last
Name |
Enter the
recipient’s last name.
Note: 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 identification card and the EVS do not match, use the
spelling from the EVS. |
| 2010BA |
NM104 |
Subscriber
First Name |
Enter the
recipient’s first name.
Note: Use the EVS to obtain the correct spelling of the recipient’s
name. If the name or spelling of the name on the Medicaid identification
card and the EVS do not match, use the spelling from the EVS. |
| 2010BA |
NM108 |
Identification
Code Qualifier |
Enter the value
"MI" for the member identification number. |
| 2010BA |
NM109 |
Subscriber
Primary Identifier |
Enter the
recipient’s 10-digit Medicaid identification number.
Note: Do not enter any other numbers or letters. Use the Medicaid
identification card or EVS to obtain the correct identification number. |
| 2300 |
CLM01 |
Patient Account
Number |
Note:
Wisconsin Medicaid will process up to 20 characters. |
| 2300 |
CLM02 |
Total Claim
Charge Amount |
Enter the
total billed amount for the entire claim.
Note: Wisconsin Medicaid will process claims submitted with a
negative total billed amount as if the provider submitted a zero total
billed amount. |
| 2300 |
CLM05-1 |
Facility Code
Value |
Enter the
place of service (POS) code.
Note: The national two-digit codes replace the one-digit POS codes
that were locally defined by Wisconsin Medicaid. This is an external code
set of the 837. See the CMS Web site,
cms.hhs.gov/states/posdata.pdf,
for appropriate value selections. |
| 2300 |
CLM05-3 |
Claim
Frequency Code |
The third
digit of the type of bill, as defined by the National Uniform Billing
Committee (NUBC), is the frequency. Use the claim frequency code to indicate
if the claim is being submitted for the first time or if it is a
replacement/void of a previously adjudicated claim and paid claim:
- Enter the value "1" to indicate it is the first time a claim is
submitted to Wisconsin Medicaid.
- Enter the value "7" to indicate this claim is replacing a previously
submitted and adjudicated claim. Wisconsin Medicaid will null and void the
previously submitted claim and completely replace it with this corrected
claim.
- Enter the value "8" to indicate Wisconsin Medicaid should recoup the
previously submitted claim in its entirety.
Note: The use of values "7" and "8" will result in the previously
submitted claim being adjusted. Include the internal control number (ICN)
from the previously submitted claim in the original reference number segment
in loop 2300. Any adjustment request without the previous ICN will be
processed as if the provider submitted a "1" in this element.
If the previously submitted claim was returned with multiple ICNs from
Wisconsin Medicaid, the provider must take that into account when using the
values "7" and "8". When using the value "7", the claim must contain the
exact service lines that were previously processed for the ICN being
adjusted, in addition to any new service lines. If multiple service lines
need to be replaced and they are on different ICNs, an adjustment must be
submitted for each ICN. When using the value of "8", an adjustment must be
submitted for each ICN.
Electronic adjustments are subject to the same requirements as paper
adjustments and therefore may result in a letter to the provider if the
requirements are not met. Wisconsin Medicaid does not adjust claims if all
the details are denied from the previous submission. Replacements for denied
claims should be submitted with a frequency of "1".
Do not use adjustment values if reconsideration of the original payment
is needed. All requests for reconsideration should be submitted on paper
with supporting documentation.
The claim frequency code was switched to an external code source during
the addenda process. See the NUBC manual or Web site,
www.nubc.org/FL4forWeb2_RO.pdf,
for additional information on value selections. |
| 2300
|
CLM19 |
Claim
Submission Reason Code |
Note:
Wisconsin Medicaid does not support predetermination of benefits. |
| 2300
|
DTP01 |
Date/Time
Qualifier |
Enter the value
"472" for service date. |
| 2300
|
DTP02 |
Date Time
Period Format Qualifier |
Enter the value
"D8" if all the services being billed on the claim were performed on the
same date, or enter the value "RD8" if the services being billed on the
claim were not performed on the same date. |
| 2300
|
DTP03 |
Service Date |
If "D8" was
used in the previous element, this is the date on which all the services
were performed. If "RD8" was used, this is the date period that covers all
the services on the claim. |
| 2300
|
PWK |
Claim
Supplemental Information |
Note:
Prior to the implementation of the 275 –Additional Information to Support a
HealthCare Claim or Encounter transaction, Wisconsin Medicaid will not be
matching attachments to electronic claims. Submit all claims requiring
attachments on paper. |
| 2300 |
REF02 |
Service
Authorization Exception Code |
Enter the value
"03" to indicate all services on the claim are the result of emergency care.
Note: If not all services were the result of emergency care, submit
multiple claims. |
| 2300
|
REF |
Original
Reference Number |
Include this
segment when requesting an electronic adjustment. (A value of "7" or "8" in
CLM05-3 indicates that an adjustment is being requested.) Note: If
this segment is not included, the claim will be processed as a new claim and
not as an adjustment regardless of the value in CLM05-3. |
| 2300
|
REF01 |
Reference
Identification Qualifier |
Enter the value
"F8" for original ICN. |
| 2300
|
REF02 |
Claim Original
Reference Number |
Enter the most
recent ICN assigned by Wisconsin Medicaid. |
| 2300
|
REF |
Prior
Authorization or Referral Number |
Enter the
prior authorization (PA) number.
Note: Wisconsin Medicaid will use the first PA number submitted at
the claim level (loop 2300) unless overridden in the service line segment
(loop 2400).
Wisconsin Medicaid does not use referral numbers in the adjudication of
claims. |
| 2300
|
REF01 |
Reference
Identification Qualifier |
Enter the value
"G1" for PA. |
| 2300
|
REF02 |
Referral Number |
Enter
Medicaid’s seven-digit PA number. |
| 2310B |
REF |
Rendering
Provider Secondary Identification |
Enter the
rendering (performing) provider’s eight-digit Wisconsin Medicaid provider
number in this segment if the performing provider is Medicaid certified and
different than the Wisconsin Medicaid billing provider. |
| 2310B |
REF01 |
Reference
Identification Qualifier |
Enter the value
"1D" for the Wisconsin Medicaid provider number. |
| 2310B |
REF02 |
Rendering
Provider Secondary Identifier |
Enter the
rendering (performing) provider’s eight-digit Wisconsin Medicaid provider
number. |
| 2320 |
SBR |
Other
Subscriber Information |
Include this
loop when multiple payers will process the claim. |
| 2320 |
CAS |
Claim Level
Adjustments |
Include this
segment when another payer has made payment at the claim level. If the other
payer returned an 835, the CAS segment from the 835 should be copied to this
CAS. Note: Wisconsin Medicaid will use the information in the CAS segment
in place of the "other insurance indicator" and "Medicare disclaimer code"
submitted prior to HIPAA.
To generate an other insurance indicator of "D", a CAS segment for a
non-Medicare payer must be used in either loop 2320 or 2430. The value(s) of
the claim adjustment reason code(s) is used to determine if the other
insurance indicator is "D" or blank.
If this iteration of loop 2320 contains information from a Medicare
payer, Wisconsin Medicaid will also look for Medicare's coinsurance,
copayment, and deductible in this segment. |
| 2320 |
AMT |
Coordination of
Benefits (COB) Payer Paid Amount |
This segment
contains the amount paid on this claim by the payer within this 2320 loop. |
| 2320 |
AMT01 |
Amount
Qualifier Code |
Enter the value
"D" for payer amount paid. |
| 2320 |
AMT02 |
Payer Paid
Amount |
Enter the
amount paid on this claim by the payer within this 2320 loop. |
| 2320 |
AMT |
Coordination of
Benefits (COB) Allowed Amount |
Enter how much
the other payer allowed for the claim in this segment. |
| 2320 |
AMT01 |
Amount
Qualifier Code |
Enter the value
"B6" for the allowed amount. |
| 2320 |
AMT02 |
Allowed Amount |
Enter the other
payer’s allowed amount. Note: This dollar amount is used to determine the other insurance
indicator.
If a non-Medicare payer denied the claim, a zero in this element will be
used to generate an other insurance indicator of "D".
If a non-Medicare payer allowed dollars on this claim (i.e., value
greater then zero), an other insurance indicator of "P" is generated
regardless of the claim adjustment reason codes found in the CAS segments. |
| 2330B |
DTP |
Claim Paid Date |
Enter the date
Medicare paid the claim in this segment if the recipient is a dual-entitlee
and loop 2320 contains information about the Medicare payer. Note:
This information is either included here or in loop 2430. |
| 2330B |
DTP01 |
Date/Time
Qualifier |
Enter the value
"573" for date claim paid. |
| 2330B |
DTP02 |
Date Time
Period Format Qualifier |
Enter "D8" for
format ccyymmdd. |
| 2330B |
DTP03 |
Adjudication or
Payment Date |
Enter
Medicare’s claim paid date. |
| 2400 |
SV301-1 |
Product or
Service ID Qualifier |
Enter the value
"AD" for national American Dental Association (ADA) codes regardless of date
of service.
Enter the value "ZZ" for local ADA codes billed for dates of
service prior to October 1, 2003. |
| 2400 |
SV301-2 |
Procedure Code |
Enter the CDT
procedure code published by the ADA for the services performed. |
| 2400 |
SV301-3 |
Procedure Code
Modifier 1 |
Note:
With the implementation of HIPAA, only ADA-approved modifiers can be
submitted on the dental 837. Wisconsin Medicaid will not use any ADA
modifiers for the adjudication of claims. |
| 2400 |
SV301-4 |
Procedure Code
Modifier 2 |
Note:
With the implementation of HIPAA, only ADA-approved modifiers can be
submitted on the dental 837. Wisconsin Medicaid will not use any ADA
modifiers for the adjudication of claims. |
| 2400 |
SV301-5 |
Procedure Code
Modifier 3 |
Note:
With the implementation of HIPAA, only ADA-approved modifiers can be
submitted on the dental 837. Wisconsin Medicaid will not use any ADA
modifiers for the adjudication of claims. |
| 2400 |
SV301-6 |
Procedure Code
Modifier 4 |
Note:
With the implementation of HIPAA, only ADA-approved modifiers can be
submitted on the dental 837. Wisconsin Medicaid will not use any ADA
modifiers for the adjudication of claims. |
| 2400 |
SV302 |
Line Charge
Amount |
Enter the
billed amount for each service line procedure. Note: Wisconsin
Medicaid will process claims submitted with a negative service line billed
amount as if the provider submitted a zero service line billed amount. |
| 2400 |
SV303 |
Facility Type
Code (Place of Service) |
Enter the POS
code.
Note: The national two-digit codes replace the one-digit POS codes
that were locally defined by Wisconsin Medicaid. The facility type code is
an external code set of the 837. See the CMS Web site,
www.cms.hhs.gov/,
for appropriate value selections. |
| 2400 |
SV304 |
Oral Cavity
Designation |
Enter the area
of the oral cavity in which the service was performed. |
| 2400 |
SV306 |
Procedure Count
Quantity |
Enter the
quantity or number of units for the services provided. |
| 2400 |
TOO |
Tooth
Information |
Note: The 4010 version of the 835 does not allow for
the tooth number to be returned. If the tooth number is necessary for your
system’s reconciliation, create separate service lines for each tooth and
use a unique value in the line item control number segment for each service
line.
This segment can repeat 32 times per procedure billed. If multiple tooth
numbers are submitted on one service line, Wisconsin Medicaid will create
one service line for each tooth number to adjudicate the claim. |
| 2400 |
TOO01 |
Code List
Qualifier Code |
Enter the value
"JP" for the national standard tooth-numbering system. |
| 2400 |
TOO02 |
Tooth Code |
Enter the tooth
number for which the service was provided. |
| 2400 |
TOO03 |
Tooth Surface |
Enter the tooth
surface for which the service was provided. Five surfaces can be indicated. |
| 2400 |
DTP01 |
Date and Time
Qualifier |
Enter the value
"472" for service date. |
| 2400 |
DTP02 |
Date Time
Period Format Qualifier |
Enter "D8" for
format ccyymmdd. |
| 2400 |
DTP03 |
Service Date |
Enter the date
the procedure was performed. |
| 2400 |
REF |
Prior
Authorization or Referral Number |
Enter the PA
number in this segment. This number overrides any values submitted at the
claim level (loop 2300).
Note: Wisconsin Medicaid will use the first PA number submitted at
the service line (loop 2400) to process the claim.
Wisconsin Medicaid does not use referral numbers in the adjudication of
claims. |
| 2400 |
REF01 |
Reference
Identification Qualifier |
Enter the value
"G1" for PA. |
| 2400 |
REF02 |
Referral Number |
Enter Wisconsin
Medicaid’s seven-digit PA number. |
| 2400 |
REF |
Line Item
Control Number |
Enter the line
item control number in this segment. |
| 2400 |
REF01 |
Reference
Identification Qualifier |
Enter the value
"6R" for provider control number. |
| 2400 |
REF02 |
Line Item
Control Number |
This field will
be returned on the 835. Providers should use it if they need a way to
uniquely match up service lines in their payment reconciliation process. |
| 2420A |
REF |
Rendering
Provider Secondary Identification |
Enter the
rendering (performing) provider’s Wisconsin Medicaid provider number in this
segment if the performing provider is Medicaid certified and different than
the Wisconsin Medicaid billing provider. |
| 2420A |
REF01 |
Reference
Identification Qualifier |
Enter the value
"1D" for the Wisconsin Medicaid number. |
| 2420A |
REF02 |
Rendering
Provider Secondary Identifier |
Enter the
rendering (performing) provider’s eight-digit Wisconsin Medicaid provider
number. |
| 2430 |
SVD01 |
Other Payer
Primary Identifier |
Enter the other
payer primary identifier if another payer has paid on the service line. |
| 2430 |
SVD02 |
Service Line
Paid Amount |
Enter the
amount the other payer paid on the service line. |
| 2430 |
CAS |
Service
Adjustment |
Include this
segment when another payer has made payment at the service line. If the
other payer returned an 835, the CAS segment from the 835 should be copied
to this CAS. Note: Wisconsin Medicaid will use the information in the CAS segment
in place of the "other insurance indicator" and "Medicare disclaimer code"
submitted prior to HIPAA.
To generate an other insurance indicator of "D", a CAS segment for a
non-Medicare payer must be used in either loop 2320 or 2430. The value(s) of
the claim adjustment reason code(s) is used to determine if the other
insurance indicator is "D" or blank.
If this iteration of loop 2430 contains information from a Medicare
payer, Wisconsin Medicaid will also look for Medicare's coinsurance,
copayment, and deductible. |
| 2430 |
DTP |
Line
Adjudication Date |
Include this
segment when another payer has made payment at the service line of this
claim. |
| 2430 |
DTP01 |
Date/Time
Qualifier |
Enter "573" for
the claim paid date. |
| 2430 |
DTP02 |
Date Time
Period Format Qualifier |
Enter "D8" for
format ccyymmdd. |
| 2430 |
DTP03 |
Adjudication or
Payment Date |
Enter the date
the other payer paid the claim. |
