Wisconsin Medicaid Companion Document to HIPAA
Implementation Guide — 837 Dental
837 Dental V3
PHC 13069 (4/08)
PDF (184 KB)
Revision Log
Appendix 1
Examples
Wisconsin Medicaid must derive coordination of benefit information from the
837 that providers previously directly submitted. This companion document has
pointed out the pieces of information Wisconsin Medicaid uses to derive those
values; however, the Implementation Guide frequently requires additional
information in the segments where this information is found. Below are examples
that show how the information may appear on the 837.
Other Insurance Indicators
In order to have an other insurance indicator assigned to a claim, at least
one additional payer must be represented on the claim. The inclusion of a 2320
loop and any required subloops represent each payer. Wisconsin Medicaid can assign one of two Other Insurance codes to electronic
claims based on information supplied on the claim.
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Other Insurance = D |
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In this example, the provider billed $100.00.
The other payer has paid $0.00. The reason that payer did not pay the claim
is indicated with the CAS segment copied from the 835 received from that
payer. |
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Loop 2320 |
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SBR*P*19*******CI~
CAS*PR*35*100~
AMT*D*0~
DMG*D8*19400101*M~
OI***Y***Y~ |
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Loop 2330A |
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NM1*IL*1*LAST NAME*FIRST NAME****MI*999999999~ |
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Loop 2330B |
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NM1*PR*2*COMMERCIAL/OTHER INS*****PI*001~
DTP*573*D8*20031016~ |
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Other Insurance = P |
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In this example, the provider billed $115.66.
The other payer allowed $115.66 and has paid $83.56. The difference between
the allowed amount and the paid amount is $32.10 and is represented on the
CAS segment copied from the 835 received from that payer. |
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Loop 2320 |
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SBR*P*18******CI~
CAS*PR*2*32.10~
AMT*D*83.56~
AMT*B6*115.66~
DMG*D8*19400101*M~
OI***Y*B**Y~ |
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Loop 2330A |
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NM1*IL*1*LAST NAME*FIRST NAME****MI*999999999~ |
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Loop 2330B |
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NM1*PR*2*OTHER INSURANCE CARRIER*****PI*001~
DTP*573*D8*20031016~ |
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X12 837 Health Care Claim
Appendix 2 — Assigned Contract Information Segment Value Codes
Appendix 3 — BadgerCare Plus Required Taxonomy Codes
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