| 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 "004010X096A1", 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 |
Reference
Identification |
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 |
Reference
Identification |
Enter the value
"004010X096A1" to indicate an institutional 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 |
Name Last or
Organization 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 |
Receiver
Primary Identification Number |
Enter the same
value as GS03, "WISC_TXIX" for Wisconsin Medicaid. |
| 2000A |
PRV |
Billing Provider Specialty Information |
Use this segment to include the taxonomy code for the
billing provider.
Note: Taxonomy code is required when using NPI. |
| 2000A |
PRV02 |
Reference Identification Qualifier |
Enter the value “ZZ”, mutually defined, to indicate the
next element will be the taxonomy code of the billing provider. |
| 2000A |
PRV03 |
Reference Identification |
Enter the taxonomy code for the billing provider.
Note: The provider must use the appropriate taxonomy code that is
associated to the provider type and specialty currently on file with WI
Medicaid. Refer to Appendix 3 for a crosswalk of taxonomy codes to types
and specialties. |
| 2010AA |
NM1 |
Billing Provider Name |
Include this segment when NPI is the identifier
used for the billing provider. |
| 2010AA |
NM108 |
ID Code Qualifier |
Enter the value “XX” to indicate that the next element
will be the NPI for the billing provider. |
| 2010AA |
NM109 |
Identification Code |
Enter the NPI for the billing provider. |
| 2010AA |
N4 |
Geographic Location |
Use the physical address as reported on the provider’s
Wisconsin Medicaid certification. |
| 2010AA |
N403 |
Zip Code |
Enter the ZIP+4 code that corresponds to the
physical address on file with Wisconsin Medicaid. |
| 2010AA |
REF |
Billing
Provider Secondary ID |
Include this segment if the provider in loop 2010AA is the
provider certified by Wisconsin Medicaid to submit claims. |
| 2010AA |
REF01 |
Reference
Identification Qualifier |
Enter the value
"1D" for the Wisconsin Medicaid provider number. |
| 2010AA |
REF02 |
Billing
Provider Additional 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. |
| 2000B |
SBR |
Subscriber Information |
When the claim is going to be processed by multiple payers,
follow the instructions of the primary payer for information on how to
complete this loop. |
| 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 patient account numbers up to 20 characters
in length. |
| 2300
|
CLM02 |
Total Claim
Charge Amount |
Enter the
total billed amount for the entire claim.
Note: Total claim charge
amount replaces the use of revenue code 001, used prior to HIPAA to indicate
total billed amount.
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 first
two digits of the type of bill. See the National Uniform Billing Committee (NUBC)
manual or Web site www.nubc.org for appropriate value selections. |
| 2300 |
CLM05-3 |
Claim Frequency
Code |
The third digit
of the type of bill, as defined by the 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.
It is always appropriate to use the following values when
submitting claims to Wisconsin Medicaid:
- 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 that Wisconsin Medicaid should recoup
the previously submitted claim in its entirety.
When
submitting claims with type of bill 11X, 15X, 16X, 17X, or 18X it is also
appropriate to use the following values (if these values are used with other
types of bill, the claims will be processed as if a "1" was submitted):
- Enter the value "2" to indicate this is the first claim in an interim
billing situation. Wisconsin Medicaid will process the claim as if the
provider submitted a "1".
- Enter the value "3" to indicate this is a continuing claim of an
interim billing situation. Wisconsin Medicaid will process the claim as if
the provider submitted a "7". See the notes for the usage of "7" above.
- Enter the value "4" to indicate this is the last claim in an interim
billing situation. Wisconsin Medicaid will process the claim as if the
provider submitted a "7". See the notes for the usage of "7" above.
- Enter the value "5" to indicate this is a late billing situation, as
defined by the NUBC. Wisconsin Medicaid will adjust the previously
submitted claim and add these new service lines to the claim.
Note: The use of values "3", "4", "5", "7", and "8" can 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 of "3", "4", "5", "7", and "8". When using the
values "3", "4", or "5", the ICN provided should be the one to which the
provider wants to add the service lines. 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.
See the NUBC manual or Web site,
www.nubc.org/FL4forWeb2_RO.pdf,
for additional information on value selections. |
| 2300
|
DTP01 |
Date Time
Qualifier |
Enter the value
"434" for statement dates. |
| 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 all the services being billed on the
claim were not performed on the same date. |
| 2300
|
DTP03 |
Statement from
and to Date |
If "D8" was
used in the previous element, enter the date on which all the services were
performed.
If "RD8" was used in the previous element, enter the date
period that covers all the services on the claim. |
| 2300
|
DTP01 |
Date Time
Qualifier |
Enter the value
"435" for admission date. |
| 2300
|
DTP02 |
Date Time
Period Format Qualifier |
Enter the value
"DT" to indicate the date is displayed in CCYYMMDDHHMM. |
| 2300
|
DTP03 |
Admission Date
and Hour |
Enter the date
the patient was admitted for care. |
| 2300
|
CL101 |
Admission Type
Code |
Enter the type
of admission code.
Note: Consult the NUBC manual for appropriate
value selections. |
| 2300
|
CL102 |
Admission
Source Code |
Enter the
source of admission code.
Note: Consult the NUBC manual for
appropriate value selections. |
| 2300
|
CL103 |
Patient Status
Code |
Enter the
patient status code.
Note: Consult the NUBC manual for appropriate
value selections. |
| 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 |
CN1 |
Contract Information |
Use this segment to include contract type information for
the billing provider. |
| 2300 |
CN101 |
Contract Type Code |
Enter “09” to indicate “other”. |
| 2300 |
CN104 |
Reference Identification |
Enter the CN1 code assigned by Wisconsin Medicaid for the
billing provider’s type and specialty — if applicable.
Refer to Appendix 2 of this companion
document for a full listing of CN1 values. |
| 2300
|
AMT01 |
Amount
Qualifier Code |
Enter the value
"F3" to indicate patient responsibility. |
| 2300
|
AMT02 |
Patient
Responsibility Amount |
Enter the
patient liability amount as determined by Wisconsin Medicaid. |
| 2300
|
REF |
Original
Reference Number |
Include this
segment when requesting an electronic adjustment. (The value in CLM05-3
indicates if an adjustment is being requested.)
Note: If this segment is not included, the claim will be processed as
a new claim and not an adjustment regardless of the value in CLM05-3. |
| 2300
|
REF01 |
Reference
Identification Qualifier |
Enter the value
"F8" for original ICN. |
| 2300
|
REF02 |
Original
Reference Number |
Enter the most
recent ICN assigned by Wisconsin Medicaid. |
| 2300 |
REF |
Peer Review
Organization (PRO) Approval Number |
Enter the
pre-admission review number in this segment. |
| 2300
|
REF01 |
Reference
Identification Qualifier |
Enter the value
"G4" to indicate the pre-admission review (PAR) number. |
| 2300
|
REF02 |
Peer Review
Authorization Number |
Enter the PAR (WIPRO)
number. |
| 2300
|
REF |
Prior
Authorization or Referral Number |
Enter the
prior authorization (PA) number in this segment.
Note: Wisconsin Medicaid will use the first PA number submitted at
the claim level to adjudicate the claim.
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 |
Prior
Authorization Number |
Enter Wisconsin
Medicaid’s seven-digit PA number. |
| 2300 |
REF |
Medical Record
Number |
Enter the
medical record number (MRN) in this segment. |
| 2300
|
REF01 |
Reference
Identification Qualifier |
Enter the value
"EA" for MRN. |
| 2300
|
REF02 |
Medical Record
Number |
Enter the MRN. |
| 2300
|
HI |
Health Care
Diagnosis Code |
Enter the
principal diagnosis, admitting diagnosis, and E-code in this segment. |
| 2300
|
HI01-1 |
Code List
Qualifier Code |
Enter the value
"BK" for Principal Diagnosis. |
| 2300
|
HI01-2 |
Industry Code |
Enter the
principal diagnosis code.
Note: Wisconsin Medicaid will use up to
nine diagnosis codes to process a claim. The principal diagnosis code is
included in the nine. |
| 2300
|
HI02-1 |
Code List
Qualifier Code |
Enter the value
"BJ" for admitting diagnosis. |
| 2300
|
HI02-2 |
Industry Code |
Enter the
admitting diagnosis code. |
| 2300
|
HI03-1 |
Code List
Qualifier Code |
Enter the value
"BN" for United States Department of Health and Human Services, Office of
Vital Statistics E-code. |
| 2300
|
HI03-2 |
Industry Code |
Enter the value
"E". |
| 2300
|
HI |
Other
Diagnosis Information |
Enter
additional diagnosis codes in this segment, if necessary.
Note: Wisconsin Medicaid will use up to eight diagnosis codes in this
segment, in addition to the principal diagnosis, to process a claim.
|
| 2300
|
HI01-1
HI02-1
HI03-1
HI04-1
HI05-1
HI6-01
HI7-01
HI8-01 |
Code List
Qualifier Code |
Enter the value
"BF" for diagnosis. |
| 2300
|
HI01-2
HI02-2
HI03-2
HI04-2
HI05-2
HI06-2
HI07-2
HI08-2 |
Other Diagnosis |
Enter
additional diagnosis codes in order of importance. |
| 2300
|
HI |
Principal
Procedure Information |
Enter principal
procedure information in this segment. |
| 2300
|
HI01-1 |
Code List
Qualifier Code |
Enter the value
"BR" for the International Classification of Diseases, Ninth Edition,
Clinical Modification (ICD-9-CM) principal procedure code. |
| 2300
|
HI01-2 |
Principal
Procedure Code |
Enter the
principal procedure code.
Note: Wisconsin Medicaid will use up to
six procedure codes to process the claim. |
| 2300
|
HI01-3 |
Date Time
Period Format Qualifier |
Enter the value
"D8" for format CCYYMMDD. |
| 2300
|
HI01-4 |
Date Time
Period |
Enter the date
corresponding to the principal procedure code. |
| 2300
|
HI |
Other
Procedure Information |
Enter
additional procedure information in this segment.
Note: Wisconsin Medicaid will use up to five procedure codes in
addition to the principal procedure to process the claim. |
| 2300
|
HI01-1
HI02-1
HI03-1
HI04-1
HI05-1 |
Code List
Qualifier Code |
Enter the value
"BQ" for the ICD-9-CM procedure code. |
| 2300
|
HI01-2
HI02-2
HI03-2
HI04-2
HI05-2 |
Procedure Code |
Enter
additional procedure codes. |
| 2300
|
HI01-3
HI02-3
HI03-3
HI04-3
HI05-3 |
Date Time
Period Format Qualifier |
Enter the value
"D8" for format CCYYMMDD. |
| 2300
|
HI01-4
HI02-4
HI03-4
HI04-4
HI05-4 |
Procedure Date |
Enter the date
corresponding to the additional procedure code. |
| 2300
|
HI |
Occurrence Span
Information |
Enter
occurrence span information in this segment. |
| 2300
|
HI01-1
HI02-1
HI03-1
HI04-1
HI05-1 |
Code List
Qualifier Code |
Enter the value
"BI" for occurrence span. |
| 2300
|
HI01-2
HI02-2
HI03-2
HI04-2
HI05-2 |
Occurrence
Span Code |
Enter the
occurrence code.
Note: Wisconsin Medicaid will use up to five
occurrence codes or occurrence code spans to process the claim. |
| 2300 |
HI01-3
HI02-3
HI03-3
HI04-3
HI05-3 |
Date Time Period Format
Qualifier |
Enter the value "RD8" for
format CCYYMMDD - CCYYMMDD. |
| 2300 |
HI01-4
HI02-4
HI03-4
HI04-4
HI05-4 |
Occurrence Span Code
Associated Date |
Enter the date
corresponding to the occurrence code. |
| 2300 |
HI |
Occurrence Information |
Enter the occurrence
information in this segment. |
| 2300 |
HI01-1
HI02-1
HI03-1
HI04-1
HI05-1 |
Code List Qualifier Code |
Enter the value "BH" for
occurrence code. |
| 2300 |
HI01-2
HI02-2
HI03-2
HI04-2
HI05-2 |
Occurrence Code |
Enter the occurrence code.
Note: Wisconsin Medicaid will use up to five occurrence codes or
occurrence code spans to process the claim. |
| 2300 |
HI01-3
HI02-3
HI03-3
HI04-3
HI05-3 |
Date Time Period Format
Qualifier |
Enter the value "D8" for
format CCYYMMDD. |
| 2300 |
HI01-4
HI02-4
HI03-4
HI04-4
HI05-4 |
Occurrence or Occurrence
Span Code Associated Date |
Enter the date
corresponding to the occurrence code. |
| 2300 |
HI |
Value Information |
Enter value code
information in this segment. |
| 2300 |
HI01-1
HI02-1
HI03-1
HI04-1
HI05-1
HI06-1
HI07-1
HI08-1
HI09-1
HI10-1 |
Code List Qualifier Code |
Enter the value "BE" for
value code. |
| 2300 |
HI01-2
HI02-2
HI03-2
HI04-2
HI05-2
HI06-2
HI07-2
HI08-2
HI09-2
HI10-2 |
Value Code |
Enter the value code.
Note: Wisconsin Medicaid will use up to five value codes to process most
institutional claims. Wisconsin Medicaid will use up to ten value codes to
process End Stage Renal Disease (ESRD) related claims.
|
| 2300 |
HI01-5
HI02-5
HI03-5
HI04-5
HI05-5
HI06-5
HI07-5
HI08-5
HI09-5
HI10-5 |
Value Code Associated
Amount |
Enter the dollar amount
corresponding to the value code. |
| 2300 |
HI |
Condition Information |
Enter condition code
information in this segment. |
| 2300 |
HI01-1
HI02-1
HI03-1
HI04-1
HI05-1 |
Code List Qualifier Code |
Enter the value "BG" for
condition code. |
| 2300 |
HI01-2
HI02-2
HI03-2
HI04-2
HI05-2 |
Condition Code |
Enter the condition code.
Note: Wisconsin Medicaid will use up to five condition codes to process
the claim. |
| 2300 |
QTY |
Claim Quantity |
This segment repeats
multiple times. Use one iteration for covered days and a second iteration
for non-covered days.
Note: This segment is required for all inpatient claims, including
nursing home claims. |
| 2300 |
QTY01 |
Quantity Qualifier |
Enter the value "CA" for
covered days or "NA" for non-covered days. |
| 2300 |
QTY02 |
Claim Days Count |
Enter the number of covered
or non-covered days.
Note: This element is required on all
inpatient claims, including nursing home claims.
Note: With implementation of UB04, continue to use the claims day
count to indicate your covered and non covered days. Absence of this
information may result in claim denials. |
| 2310A |
NM101 |
Entity Identifier Code |
Enter the value "71" for
attending physician. |
| 2310A |
NM103 |
Attending Physician Last
Name |
Enter the attending
provider’s last name. |
| 2310A |
NM108 |
ID Code Qualifier |
Enter the value “XX” to indicate that the next element
will be the attending provider’s NPI. |
| 2310A |
NM109 |
Identification Code |
Enter the NPI for the attending provider. |
| 2310A |
REF01 |
Reference Identification
Qualifier |
Enter the value "1D" for
the Wisconsin Medicaid provider number or "1G" for the provider UPIN number.
Although other values are acceptable, Wisconsin Medicaid prefers the
eight-digit Wisconsin Medicaid provider number or the UPIN. |
| 2310A |
REF02 |
Attending Physician
Secondary Identifier |
Enter the provider’s
individual eight-digit Wisconsin Medicaid provider number or the provider’s
UPIN number. |
| 2310B |
NM101 |
Entity Identifier Code |
Enter the value "72" for
operating physician. |
| 2310B |
NM103 |
Operating Physician Last
Name |
Enter the operating
physician’s last name. |
| 2310B |
NM108 |
ID Code Qualifier |
Enter the value “XX” to indicate that the next element
will be the operating physician’s NPI. |
| 2310B |
NM109 |
Identification Code |
Enter the NPI for the operating physician. |
| 2310B |
REF01 |
Reference Identification
Qualifier |
Enter the value "1D" for
the Wisconsin Medicaid provider number. |
| 2310B |
REF02 |
Operating Physician
Secondary Identifier |
Enter the provider’s
individual eight-digit Wisconsin Medicaid provider number. |
| 2320 |
SBR |
Other Subscriber
Information |
Include this loop when any
of the following occur:
- The claim will be processed by multiple payers.
- The recipient has commercial health insurance or commercial HMO
coverage, but the claim was not billed to the other payer for reasons
including, but not limited to:
- The recipient denied coverage or will not cooperate.
- The provider knows the service in question is not covered by the
carrier.
- The recipient’s commercial health insurance failed to respond to
initial and follow-up claims.
- Benefits are not assignable or cannot get assignment.
- Benefits are exhausted.
- The claim was not sent to Medicare Part A, the billing provider
identified is certified for Medicare Part A, the recipient is eligible for
Medicare Part A, and the service is usually covered by Medicare Part A but
not in this circumstance.
- The claim was not sent to Medicare Part B, the billing provider
identified is certified for Medicare Part B, the recipient is eligible for
Medicare Part B, and the service is usually covered by Medicare Part B but
not in this circumstance.
Note: Wisconsin Medicaid will use this loop to derive the "Other
Insurance" and "Medicare Disclaimer" codes. |
| 2320 |
SBR09 |
Claim Filing Indicator Code |
Enter the type of payer.
Wisconsin Medicaid uses this element to classify the payer identified in
each iteration of the loop as either a "Medicare Payer" or an "Other
Insurance Payer". This classification is used to determine the other
insurance indicator, other insurance amounts, Medicare disclaimer codes,
Medicare paid date, and Medicare dollars. Multiple elements in this loop and
its subloops are required to generate the Medicaid values.
If this claim was not submitted to a commercial health insurance plan or
commercial HMO plan based on the reasons listed for the SBR segment in loop
2320, enter one of the following values:
- "12" for Preferred Provider Organization (PPO).
- "13" for Point of Service (POS).
- "14" for Exclusive Provider Organization (EPO).
- "BL" for Blue Cross/Blue Shield.
- "CH" for Champus.
- "CI" for Commercial Insurance Co.
- "DS" for Disability.
- "HM" for HMO.
- "VA" for Veteran Administration Plan.
Note: One of these values is required to have an other insurance
indicator of "Y" assigned to the claim.
If this claim was not submitted to Medicare based on the reasons listed
for the SBR segment in loop 2320, enter one of the following values:
- "MA" for Medicare Part A.
- "MB" for Medicare Part B.
- "16" for HMO Medicare risk.
Note: One of these values is required to have a Medicare disclaimer
code of "8" assigned to the claim. |
| 2320 |
CAS |
Claim Level Adjustment |
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 a Medicare disclaimer code of "5" or "7", a CAS segment for a
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 which value is applied.
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 |
Payer Prior Payment |
This segment contains the
amount paid on this claim by the payer within this 2320 loop. |
| 2320 |
AMT01 |
Amount Qualifier Code |
Enter the value "C4" for
prior payment-actual. |
| 2320 |
AMT02 |
Other Payer Patient Paid
Amount |
Enter the amount paid on
this claim by the payer within this 2320 loop. |
| 2320 |
AMT |
Coordination of Benefits
(COB) Total Allowed Amount |
Enter how much the other
payer allowed in this segment.
If this iteration of 2320 is being used to indicate that the claim was
not submitted to another payer based on the notes in the SBR segment of loop
2320 of this document, include 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 Medicare disclaimer
and other insurance indicator.
If a Medicare payer denied the claim, a zero in this element or the
absence of the segment will be used to generate a Medicare disclaimer of
either "5" or "7".
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.
If the claim was not submitted to another payer, a zero must be used to
generate either an other insurance indicator of "Y" or a Medicare disclaimer
of "8". |
| 2320 |
AMT01 |
Amount Qualifier Code |
Enter the value "A8" for
non-covered charges actual. |
| 2320 |
AMT02 |
Non-Covered Charge Amount |
Enter the non-covered
charges. |
| 2320 |
MIA |
Medicare Inpatient
Adjudication Information |
Include this segment when
it is returned in the 835 from a previous payer or if this iteration of 2320
is being used to indicate that an inpatient hospital or nursing home claim
was not submitted to another payer based on the notes in the SBR segment of
loop 2320 of this document. |
| 2320 |
MIA05 |
Remark Code |
If the claim is an
inpatient claim and it was not submitted to another payer, enter "MA07" in
this element to generate either an other insurance indicator of "Y" or a
Medicare disclaimer code of "8". |
| 2320 |
MOA |
Medicare Outpatient
Adjudication Information |
Include this segment when
it is returned in the 835 from a previous payer or if this iteration of 2320
is being used to indicate an outpatient claim was not submitted to another
payer based on the notes in the SBR segment of loop 2320 of this document. |
| 2320 |
MOA03 |
Remark Code |
If the claim is an
outpatient claim and it was not submitted to another payer, enter "MA07" in
this element to generate either an other insurance indicator of "Y" or a
Medicare disclaimer code of "8". |
| 2330B |
NM109 |
Other Payer Primary
Identifier |
Enter the other payer’s
identifier.
Note: Wisconsin Medicaid will use this number in
combination with loop 2430 to calculate other insurance and Medicare
payments. |
| 2330B |
DTP03 |
Adjudication or Payment
Date |
Enter Medicare’s claim paid
date. |
| 2330E |
NM1 |
Other Payer Operating Provider |
Include this segment when NPI is the identifier used for
the other payer operating provider. |
| 2330E |
NM108 |
ID Code Qualifier |
Enter the value “XX” to indicate that the next element
will be the NPI for the other payer operating provider. |
| 2330E |
NM109 |
Identification Code |
Enter the NPI for the other payer operating provider. |
| 2330E |
REF |
Other Payer Operating Provider Secondary Information |
Include this segment to further identify the other payer
operating provider.
|
| 2330E |
REF01 |
Reference Identification Qualifier |
Enter the value "1D" for the Wisconsin Medicaid provider
number. |
| 2330E |
REF02 |
Other Payer Operating Provider Additional Identifier |
Enter the eight-digit Wisconsin Medicaid billing provider
number assigned by Wisconsin Medicaid. |
| 2400 |
SV202-1 |
Product or Service ID
Qualifier |
Enter the value "HC" for
national HCPCS codes regardless of date of service.
Enter the value "ZZ"
for local HCPCS codes billed for dates of service prior to October 1, 2003.
Note: Because the AMA’s CPT codes are also level 1 HCPCS codes, they
are reported under qualifier "HC". |
| 2400 |
SV202-2 |
Procedure Code |
Enter the HCPCS/CPT code
for the services performed. |
| 2400 |
SV202-3 |
HCPCS Modifier 1 |
Enter a HCPCS/CPT modifier
code, if necessary, to clarify the procedure code. |
| 2400 |
SV202-4 |
HCPCS Modifier 2 |
Enter a HCPCS/CPT modifier
code, if necessary, to clarify the procedure code. |
| 2400 |
SV202-5 |
HCPCS Modifier 3 |
Enter a HCPCS/CPT modifier
code, if necessary, to clarify the procedure code. |
| 2400 |
SV202-6 |
HCPCS Modifier 4 |
Enter a HCPCS/CPT modifier
code, if necessary, to clarify the procedure code. |
| 2400 |
SV203 |
Line Item Charge Amount |
Enter the billed amount for
each service line.
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 |
SV204 |
Unit or Basis for
Measurement |
Enter the value "DA" for
days or "UN" for units. |
| 2400 |
SV205 |
Service Unit Count |
Enter the number of days or
units for the services provided. |
| 2400 |
SV207 |
Line Item Denied Charge or
Non-Covered Charge Amount |
Enter the service line
non-covered amount. |
| 2400 |
DTP01 |
Date Time Qualifier |
Enter the value "472" for
service dates. |
| 2400 |
DTP02 |
Date Time Period Format
Qualifier |
Enter the value "D8" to
indicate a single date of service or "RD8" to indicate a range of service
dates for the service line.
Note: When "RD8" is used on outpatient
claims, Wisconsin Medicaid will assume the exact same service, including the
number of units, was performed on each day within the range. |
| 2400 |
DTP03 |
Service Date |
Enter the date(s) the
procedure was performed.
Note: Wisconsin Medicaid requires service
line dates on all outpatient and nursing home claims. |
| 2420A |
NM101 |
Entity Identifier Code |
Enter the value "71" for
attending physician. |
| 2420A |
NM103 |
Attending Physician Last
Name |
Enter the attending
physician’s last name. |
| 2420A |
NM108 |
ID Code Qualifier |
Enter the value “XX” to indicate the next element will
contain the NPI for the attending physician. |
| 2420A |
NM109 |
Identification Code |
Enter the attending physician’s NPI. |
| 2420A |
REF01 |
Reference Identification
Qualifier |
Enter the value "1D" for
the Wisconsin Medicaid provider number or "1G" for the provider UPIN number.
Although other values are acceptable, Wisconsin Medicaid prefers the
eight-digit Wisconsin Medicaid provider number or the UPIN. |
| 2420A |
REF02 |
Attending Physician
Secondary Identifier |
Enter the provider’s
individual eight-digit Wisconsin Medicaid provider number or the provider’s
UPIN number. |
| 2420B |
NM101 |
Entity Identifier Code |
Enter the value "72" for
operating physician. |
| 2420B |
NM103 |
Operating Physician Last
Name |
Enter the operating
physician's last name. |
| 2420B |
NM108 |
ID Code Qualifier |
Enter the value “XX” to indicate the next element will
contain the NPI for the operating physician. |
| 2420B |
NM109 |
Identification Code |
Enter the operating physician’s NPI. |
| 2420B |
REF01 |
Reference Identification
Qualifier |
Enter the value "1D" for
the Wisconsin Medicaid provider number. |
| 2420B |
REF02 |
Operating Physician
Secondary Identifier |
Enter the provider’s
individual eight-digit Wisconsin Medicaid provider number. |
| 2430 |
SVD01 |
Payer Identifier |
Enter the payer identifier
when 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 Line Adjustment |
Include this segment when
another payer has made payment at the service line. If the other payer
returned an 835 with a service line CAS, 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 a Medicare disclaimer code of "5" or "7", a CAS segment for a
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 which value is applied.
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 |
Service 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 the value "573" for
the claim paid date. |
| 2430 |
DTP02 |
Date Time Period Format
Qualifier |
Enter the value "D8" to
indicate format CCYYMMDD. |
| 2430 |
DTP03 |
Service Adjudication or
Payment Date |
Enter the date the other
payer paid the claim. |
