| Loop/Segment
Revised |
Page(s) Revised |
Text Revised |
| Document Introduction |
2, 3 |
Added "Acceptable Characters" and "Example"
sections. |
| 2000A/PRV |
8 |
Usage of PRV01 clarified. |
| 2010AA/REF |
8 |
Clarified which provider number
should be used in the REF general note, REF01, and REF02. |
| 2300/CLM |
10, 11 |
Added clarification to CLM05-3 that
Wisconsin Medicaid does not adjust denied claims. |
| 2300/REF |
12, 13 |
Corrected the name from "Prior
authorization or referral number" to "Medical record number." |
| 2310A/REF |
13, 14 |
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 |
14 |
Clarified which provider number
should be used in REF01 and REF02. |
| 2320/SBR |
15, 16, 17 |
Added note to the segment and SBR09
to connect the loop to Wisconsin Medicaid’s other insurance indicator and
Medicare disclaimer code. |
| 2320/CAS |
17 |
Added text to segment describing
how the values in the segment are used to derive the other insurance and
Medicare disclaimer code. |
| 2320/AMT |
18, 19 |
Added note to AMT02 to describe how the allowed
amount is used in determining the other insurance indicator and Medicare
disclaimer codes. |
| 2320/MOA |
19 |
Added text to MOA03 to explain how the value is
used to determine the other insurance indicator and Medicare disclaimer
codes. |
| 2400/SV1 |
20 |
For SV101-1 added "ZZ" qualifier for local
codes billed for dates of service prior to October 1, 2003.
Removed "MJ" code from SV103. |
| 2400/REF |
22 |
Clarified usage of REF02. |
| 2420A/REF |
22, 23 |
Clarified which provider number should be used
in REF01 and REF02. |
| 2420F/REF |
23 |
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. |
| 2430/CAS |
23, 24 |
Added segment note describing how the values in
the segment are used to derive the other insurance and Medicare disclaimer
code. |
| Examples |
25 |
Added examples. |
