Wisconsin Medicaid EDI Companion Document to HIPAA Implementation Guide: X12 837 Institutional

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Wisconsin Medicaid Companion Document to HIPAA Implementation Guide — 837 Institutional

PHC 13067 (12/04)
PDF (271 KB)

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.

	Other Insurance = D
	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.

	Loop 2320
		SBRP19******CI~ CASPR35100~ AMTB60~ DMGD819400101M~ OIY*Y~
	Loop 2330A
		NM1IL1LAST NAMEFIRST NAME***MI999999999~
	Loop 2330B
		NM1PR2COMMERCIAL/OTHER INS***PI001~ DTP573D8*20031016~

	Other Insurance = P
	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.

	Loop 2320
		SBRP18*****CI~ CASPR232.10~ AMTC483.56~ AMTB6115.66~ DMGD819400101M~ OIY*Y~
	Loop 2330A
		NM1IL1LAST NAMEFIRST NAME***MI999999999~
	Loop 2330B
		NM1PR2OTHER INSURANCE CARRIER***PI001~ DTP573D8*20031016~

	Other Insurance = Y
	In this example, the provider billed $52.00 on an outpatient claim. The recipient had a second insurance policy, but the claim was not submitted to the other payer. Refer to the Wisconsin Medicaid All-Provider Handbook to determine when it is appropriate to submit claims to Wisconsin Medicaid without first receiving payment from the primary payer.

	Loop 2320
		SBRP19*****CI~ AMTB60~ DMGD819400101F~ OI*YY~ MOA**MA07~
	Loop 2330A
		NM1IL1LAST NAMEFIRST NAME***MI999999999~
	Loop 2330B
		NM1PR2OTHER INSURANCE CARRIER***PI001~

Medicare Disclaimer

In order to have a Medicare disclaimer code assigned to a claim, at least one Medicare 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 three Medicare disclaimer codes to electronic claims based on information supplied on the claim.

	Medicare Disclaimer = 5
	In this example, the provider billed $115.50. Medicare allowed zero and paid zero. The reason Medicare did not pay the claim is indicated with the CAS segment copied from the 835 received from Medicare.

	Loop 2320
		SBRP18******MA~ CASOAB7115.5~ AMTB60~ DMGD819400101M~ OIY*Y~
	Loop 2330A
		NM1IL1LAST NAMEFIRST NAME***MI999999999~
	Loop 2330B
		NM1PR2MEDICARE PART B***PI001~ DTP573D8*20031016~

	Medicare Disclaimer = 7
	In this example, the provider billed $146.00. Medicare allowed zero and paid zero. The reason Medicare did not pay the claim is indicated with the CAS segment copied from the 835 received from Medicare.

	Loop 2320
		SBRP18******MA~ CASPR50146.00~ AMTB60~ DMGD810400101F~ OIY*Y~
	Loop 2330A
		NM1IL1LAST NAMEFIRST NAME***MI999999999~
	Loop 2330B
		NM1PR2MEDICARE***PI001~ DTP573D8*20031016~

	Medicare Disclaimer = 8
	In this example, the provider billed $40.00 on an outpatient claim. The recipient is a Medicare beneficiary, but the claim was not submitted to Medicare. Refer to the Wisconsin Medicaid All-Provider Handbook to determine when it is appropriate to submit claims to Wisconsin Medicaid without first receiving payment from Medicare.

	Loop 2320
		SBRP18******MA~ AMTB60~ DMGD819400101F~ OI*YM~ MOA**MA07~
	Loop 2330A
		NM1IL1LAST NAMEFIRST NAME***MI999999999~
	Loop 2330B
		NM1IL2MEDICARE***PI001~

	Dual-Entitlee Claim (Crossover Claim from Medicare to Medicaid)
	In this example, the provider billed $456.00. Medicare allowed $240.07 and paid $192.06. Medicare’s coinsurance is $48.01 and the non-covered amount is $215.93.

	Loop 2320
		SBRP18******MA~ AMTC4192.06~ AMTB6240.07~ DMGD819400101F~ OI*Y*Y~
	Loop 2330A
		NM1IL1LAST NAMEFIRST NAME***MI999999999~
	Loop 2330B
		NM1PR2MEDICARE***PI001~
	Loop 2430
		SVD001192.06HC:J7618025031.00~ CASPr248.01~ CASCO42215.93~ DTP573D820031016~

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