|
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 "004010X098A1", 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 "004010X098A1" to indicate a professional
claim.
Note: This version includes the addenda. |
| 1000A |
NM109 |
Submitter Identifier |
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 |
Receiver 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 |
Identification Code or Receiver Primary Identifier |
Enter the same value as GS03, "WISC_TXIX" for Wisconsin
Medicaid. |
| 2000A |
PRV01 |
Provider Code |
Enter "PT" to indicate the rendering/performing provider is
the same entity as the pay-to provider.
Note: If a
rendering/performing provider is not indicated on the claim, Wisconsin
Medicaid will assume the rendering/performing provider and the billing
provider are the same entity. |
| 2010AA |
REF |
Billing Provider Secondary Identification |
Include this segment if the provider in loop 2010AA is the
provider certified by Wisconsin Medicaid to submit claims.
Note: Wisconsin Medicaid requires that all claims be submitted
with the eight-digit Wisconsin Medicaid billing provider number. |
| 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 835 will be sent to the entity established during the provider
certification process. |
| 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 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 up to 20
characters. |
| 2300 |
CLM02 |
Total Claim Charge Amount |
Enter the total billed amount for the entire claim.
Note: 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 place of service (POS) code.
Note: This national two-digit code replaces the one-digit POS
codes that were locally defined by Wisconsin Medicaid. This is an external
code set of the 837. See the CMS Web site,
cms.hhs.gov/states/posdata.pdf, for appropriate value selections. |
| 2300 |
CLM05-3 |
Claim Frequency Code |
The third digit of the type of bill, as defined by the
National Uniform Billing Committee (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:
- 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 Wisconsin Medicaid should recoup the
previously submitted claim in its entirety.
Note: The use of values "7" and "8" will 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 "7" and "8". 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.
The claim frequency code was switched to an external code source during
the addenda process. See the NUBC manual or Web site,
www.nubc.org/FL4forWeb2_RO.pdf, for additional information on 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 |
REF |
Prior Authorization or Referral Number |
Enter the prior authorization (PA) number.
Note: Wisconsin Medicaid will use the first PA number submitted at
the claim level (loop 2300) unless overridden in the service line segment
(loop 2400).
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 or Referral Number |
Enter Medicaid's seven-digit PA number. |
| 2300 |
REF |
Original Reference Number |
Include this segment when requesting an electronic
adjustment. (A value of "7" or "8" in CLM05-3 indicates that an adjustment
is being requested.)
Note: If this segment is not included, the claim will be processed
as a new claim and not as an adjustment regardless of the value in CLM05-3. |
| 2300 |
REF01 |
Reference Identification Qualifier |
Enter the value "F8" for the original ICN. |
| 2300 |
REF02 |
Claim Original Reference Number |
Enter the most recent ICN assigned by Wisconsin Medicaid. |
| 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 diagnosis in this segment.
Note:
Wisconsin Medicaid will use up to eight diagnosis codes to process a claim.
|
| 2300 |
HI01-1 |
Diagnosis Type Code |
Enter the value "BK" for principal diagnosis. |
| 2300 |
HI01-2 |
Principal Diagnosis |
Enter the principal diagnosis code. |
| 2300 |
HI02-1 |
Diagnosis Type Code |
Enter the value "BF" for each additional diagnosis code. |
| 2300 |
HI02-2
HI03-2
HI04-2
HI05-2
HI06-2
HI07-2
HI08-2 |
Diagnosis Code |
Enter additional diagnosis codes in order of importance.
|
| 2310A |
NM101 |
Entity Identifier Code |
Enter the value "DN" for referring provider. |
| 2310A |
NM103 |
Referring Provider Last Name |
Enter the referring provider's last name. |
| 2310A |
REF |
Referring Provider Secondary Identification |
Include this segment to further identify the referring
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 |
Referring Provider Secondary Identifier |
Enter the provider’s individual eight-digit Wisconsin
Medicaid provider number or the provider’s UPIN number. |
| 2310B |
REF |
Rendering Provider Secondary Identification |
Enter the rendering (performing) provider’s eight-digit
Wisconsin Medicaid provider number in this segment if the performing
provider is Medicaid certified and different than the Wisconsin Medicaid
billing provider. |
| 2310B |
REF01 |
Reference Identification Qualifier |
Enter the value "1D" for Wisconsin Medicaid provider
number. |
| 2310B |
REF02 |
Rending Provider Secondary Identifier |
Enter the rendering (performing) provider’s 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, use 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 Health Maintenance Organization.
- "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, use one of the following values:
- "MB" for Medicare Part B.
- "16" for Health Maintenance Organization 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 Adjustments |
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 |
Coordination of Benefits (COB) Payer Paid Amount |
This segment contains the amount paid on this claim by the
payer within this 2320 loop. |
| 2320 |
AMT01 |
Amount Qualifier Code |
Enter the value "D" for payer amount paid. |
| 2320 |
AMT02 |
Payer Paid Amount |
Enter the amount paid on this claim by the payer within
this 2320 loop. |
| 2320 |
AMT |
Coordination of Benefits (COB) 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 |
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 that
the 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 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 |
DTP |
Claim Adjudication Date |
Enter the date Medicare paid the claim in this segment if
the recipient is a dual-entitlee and loop 2320 contains information about
the Medicare payer.
Note: This information is either included here
or in loop 2430. |
| 2330B |
DTP01 |
Date/Time Qualifier |
Enter "573" for date claim paid. |
| 2330B |
DTP02 |
Date Time Period Format Qualifier |
Enter the value "D8" for format ccyymmdd. |
| 2330B |
DTP03 |
Adjudication or Payment Date |
Enter Medicare's claim paid date. |
| 2400 |
SV101-1 |
Product or Service ID Qualifier |
Enter the value "HC" for national Healthcare Common
Procedure Coding System (HCPCS) 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 with qualifier "HC". |
| 2400 |
SV101-2 |
Procedure Code |
Enter the HCPCS/CPT code for the procedures performed. |
| 2400 |
SV101-3 |
Procedure Modifier 1 |
Enter a HCPCS/CPT modifier code, if necessary, to clarify
the procedure code. |
| 2400 |
SV101-4 |
Procedure Modifier 2 |
Enter a HCPCS/CPT modifier code, if necessary, to clarify
the procedure code. |
| 2400 |
SV101-5 |
Procedure Modifier 3 |
Enter a HCPCS/CPT modifier code, if necessary, to clarify
the procedure code. |
| 2400 |
SV101-6 |
Procedure Modifier 4 |
Enter a HCPCS/CPT modifier code, if necessary, to clarify
the procedure code. |
| 2400 |
SV102 |
Line Item Charge Amount |
Enter the billed amount for each service line.
Note:
Wisconsin Medicaid will process claims with a negative service line billed
amount as if the provider submitted a zero service line billed amount. |
| 2400 |
SV103 |
Unit or Basis for Measurement Code |
Enter the value "UN" for units. |
| 2400 |
SV104 |
Service Unit Count |
Enter the number of units for the services provided. |
| 2400 |
SV105 |
Place of Service |
Enter the Place of Service (POS) code.
Note: This national two-digit code replaces the one-digit POS
codes that were locally defined by Wisconsin Medicaid. This is an external
code set of the 837. See the CMS Web site,
cms.hhs.gov/states/posdata.pdf, for appropriate value selections. |
| 2400 |
SV107-1 |
Diagnosis Code Pointer |
Enter a value of 1 through 8 corresponding to the primary
diagnoses in element HI01-2, HI02-2, HI03-2, HI04-2, HI05-2, HI06-2, HI07-2,
or HI08-2. |
| 2400 |
SV109 |
Emergency Indicator |
Enter the value "Y" if the services were performed as a
result of an emergency. |
| 2400 |
SV112 |
Family Planning Indicator |
Enter the value "Y" if the services are related to family
planning. |
| 2400 |
DTP01 |
Date/Time Qualifier |
Enter the value "472" for service dates. |
| 2400 |
DTP02 |
Date Time Period Format Qualifier |
Enter value "D8" to indicate a single date of service or
"RD8" to indicate a range of service dates.
Note: When "RD8" is
used, Wisconsin Medicaid will assume the exact same service, including an
equal number of units per day, was performed on each day within the range. |
| 2400 |
DTP03 |
Service Date |
Enter the date(s) the procedure was performed. |
| 2400 |
REF |
Prior Authorization or Referral Number |
Enter the PA number in this segment. This number overrides
any values submitted at the claim level (loop 2300).
Note: Wisconsin Medicaid will use the first PA number submitted at
the service line (loop 2400) to process the claim.
Wisconsin Medicaid does not use referral numbers in the adjudication of
claims. |
| 2400 |
REF01 |
Reference Identification Qualifier |
Enter the value "G1" for PA. |
| 2400 |
REF02 |
Prior Authorization or Referral Number |
Enter Wisconsin Medicaid's seven-digit PA number. |
| 2400 |
REF |
Line Item Control Number |
Enter the line item control number in this segment. |
| 2400 |
REF01 |
Reference Identification Qualifier |
Enter the value "6R" for provider control number. |
| 2400 |
REF02 |
Line Item Control Number |
This field will be returned on the 835. Providers should
use it if they need a way to uniquely match up service lines in their
payment reconciliation process. |
| 2420A |
REF |
Rendering Provider Secondary Identification |
Enter the rendering (performing) provider’s Wisconsin
Medicaid provider number in this segment if the performing provider is
Medicaid certified and different than the Wisconsin Medicaid billing
provider. |
| 2420A |
REF01 |
Reference Identification Qualifier |
Enter the value "1D" for the Wisconsin Medicaid number. |
| 2420A |
REF02 |
Rendering Provider Secondary Identifier |
Enter the rendering (performing) provider’s eight-digit
Wisconsin Medicaid provider number. |
| 2420F |
NM101 |
Entity Identifier Code |
Enter the value "DN" for referring provider. |
| 2420F |
NM103 |
Referring Provider Last Name |
Enter the referring provider's last name. |
| 2420F |
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. |
| 2420F |
REF02 |
Referring Provider Secondary Identifier |
Enter the provider’s individual eight-digit Wisconsin
Medicaid provider number or the provider’s UPIN number. |
| 2430 |
SVD01 |
Other Payer Primary Identifier |
Enter the other payer’s primary identifier if 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 |
Line Adjudication Information |
Include this segment when another payer has made payment at
the service line. 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 2430 contains information from a Medicare
payer, Wisconsin Medicaid will also look for Medicare's coinsurance,
copayment, and deductible. |
| 2430 |
DTP |
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 |
Adjudication or Payment Date |
Enter the date the other payer paid the claim. |
