| Loop/Segment
Revised |
Page(s) Revised |
Text Revised |
| Document Introduction |
2, 3 |
Added "Acceptable Characters" and "Example" sections. |
| 2000A/PRV |
8 |
PRV01 was deleted from Companion Document. This element is
not used to process claims submitted on this format. |
| 2010AA/REF |
8, 9 |
Clarified which provider number should be used in the REF
general note, REF01, and REF02. |
| 2300/CLM |
12 |
Added clarification to CLM05-3 that Wisconsin Medicaid does
not adjust denied claims. |
| 2300/REF |
15 |
Corrected the name from "Prior authorization or referral
number" to Medical record number".
Changed REF02 name to reflect the
industry name "Medical record number". |
| 2300/HI |
17 |
Corrected reference of HI05-5 to HI05-4 in the HI segment
representing Occurrence Span Code Associated Date. |
| 2300/HI |
18 |
Added clarification to the HI representing Value Codes
about how many value codes will be used to process a claim by Wisconsin
Medicaid. |
| 2310A/REF |
20 |
Added qualifier "1G" for UPIN usage in REF01.
Added text
referring to UPIN usage in REF02.
Clarified which provider number should be used in REF01 and REF02. |
| 2310B/REF |
20 |
Clarified which provider number should be used in REF01 and
REF02. |
| 2310E/REF |
20 |
In REF01 and REF02, the facility provider's secondary
identification number was deleted from the Companion Document. These
elements are not used to process claims submitted in this format. |
| 2320/SBR |
21,22 |
Added note to this segment and SBR09 to connect the loop to
Wisconsin Medicaid's other insurance indicator and Medicare disclaimer code. |
| 2320/CAS |
23 |
Added segment note describing how the values in the segment
are used to derive the other insurance and Medicare disclaimer code. |
| 2320/AMT |
23, 24 |
Added AMT segment for the allowed amount to clarify the
usage of the segment.
Added note to AMT02 to describe how the allowed
amount is used in determining the other insurance indicator and Medicare
disclaimer codes. |
| 2320/MIA |
24 |
Added text to MIA05 to explain how the value is used to
determine the other insurance indicator and Medicare disclaimer codes. |
| 2320/MOA |
25 |
Added text to MOA03 to explain how the
value is used to determine the other insurance indicator and Medicare
disclaimer codes. |
| 2400/SV2 |
26 |
Added "ZZ" qualifier to SV202-1 for local codes billed for
dates of service prior to October 1, 2003. |
| 2420A/REF |
27 |
Added qualifier "1G" for UPIN usage in REF01.
Added text
referring to UPIN usage in REF02.
Clarified which provider number should be used in REF01 and REF02. |
| 2420B/REF |
27 |
Clarified which provider number should be used in REF01 and
REF02. |
| 2430/CAS |
28 |
Added segment note describing how the values in the segment
are used to derive the other insurance and Medicare disclaimer code. |
| Examples |
30 |
Added examples. |
