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Wisconsin Medicaid Companion Document to HIPAA
Implementation Guide — 837 Dental
837 Dental V3
PHC 13069 (4/08)
PDF (184 KB)
VERSION 3 REVISION LOG
Companion Document: 837D
Approved: 4/23/08
Modified by: SKR
Wisconsin Medicaid will begin accepting the National Provider Identifier (NPI)
on May 19, 2008. The provider’s NPI must be on file with Wisconsin Medicaid in
order for claims to process appropriately utilizing the NPI. Confirmation
letters were sent to providers once their NPI was reported and entered into the
Wisconsin Medicaid system. Wisconsin Medicaid will continue to accept the
eight-digit Medicaid provider number.
Wisconsin Medicaid has identified personal care only providers, specialized
medical vehicle providers, blood banks, and Community Care Organizations as
providers of non-healthcare services which makes them exempt from the NPI
requirement. These are the only providers required to continue indicating their
Medicaid provider number on standard electronic transactions. Transactions
submitted by these providers with an NPI will be denied.
| Loop/Segment Revised |
Page(s) Revised |
Text Revised |
| 2000A/PRV |
8 |
Added information on taxonomy. |
| 2010AA/NM1 |
8 |
Added information on NPI. |
| 2010AA/N4 |
8 |
Added information on ZIP+4 code. |
| 2310B/NM1 |
12 |
Added information on NPI. |
| 2310B/PRV |
13 |
Added information on taxonomy. |
| 2420A/NM1 |
18 |
Added information on NPI. |
| 2420A/PRV |
18 |
Added information on taxonomy. |
Version 2 Revision Log
Companion Document: 837D
Approved: 12/13/04
Modified by: KAM
| Loop/Segment
Revised |
Page(s) Revised |
Text Revised |
| Document Introduction |
2, 3 |
Added "Acceptable Characters" and "Example" sections. |
| 2000A/PRV |
6 |
Usage of PRV01 clarified. |
| 2010AA/REF |
7 |
Clarified which provider number should be used in the REF
general note, REF01, and REF02. |
| 2300/CLM |
9, 10 |
Added clarification to CLM05-3 that Wisconsin Medicaid does
not adjust denied claims. |
| 2310B/REF |
11, 12 |
Clarified which provider number should be used in REF01 and
REF02. |
| 2320/CAS |
12 |
Added segment note describing how the values in the segment
are used to derive the other insurance indicator. |
| 2320/AMT |
13 |
Clarified the amount is paid by the other payer, not the
other provider. |
| 2320/AMT |
13 |
Added note to AMT02 to describe how the allowed amount is
used in determining the other insurance indicator. |
| 2400/SV3 |
14 |
For SV301-1 added "ZZ" qualifier for local codes billed for
dates of service prior to October 1, 2003. |
| 2400/TOO |
15 |
Corrected qualifier for TOO01. |
| 2400/REF |
16 |
Clarified usage of the line item control number. |
| 2420A/REF |
16 |
Clarified which provider number should be used in REF01 and
REF02. |
| 2430/CAS |
17 |
Added segment note describing how the values in the segment
are used to derive the other insurance and Medicare disclaimer indicator. |
| Examples |
18 |
Added examples. |
X12 837 Health Care Claim
Appendix 1 — Examples
Appendix 2 — Assigned Contract Information Segment Value Codes
Appendix 3 — BadgerCare Plus Required Taxonomy Codes
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