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To submit a Medicare Managed Care (MMC, also known as Medicare + Choice, Medicare Cost, or Medicare Risk) claim to Wisconsin Medicaid using PES software, you will need to use the Medicare tabs. To activate and make the Medicare tabs visible, set the Medicare Ind box to “Y.” This indicator may be found on the last Header Tab of any open claim form.
Once the Medicare Ind has been set to “Y,” a new Medicare tab will appear. Medicare Managed Care information can be entered at the header level on this tab. When MMC information is entered at the header level, all payments and dollar amounts will be applied to every service line on the claim.
To supply information and payments made by the MMC organization on individual service lines, you will need to use the Srv Adj tab. As with the header Medicare tab, the Srv Adj tab will not be immediately visible until you set the Service Adjustment Ind to “Y.” This indicator is found on the Srv tab.
After setting the Service Adjustment Ind to “Y,” the Srv Adj tab should appear, allowing you to enter MMC information at the detail level.
After sending the claim first to the MMC organization, you should receive from the organization either an electronic (835 Health Care Claim Payment/Advice transaction) or paper remittance advice. If the remittance advice gives header-level payments, you should report the information to Wisconsin Medicaid using the Medicare tab. If the remittance advice gives detail-level payments for each service, you should report the information to Wisconsin Medicaid using the Srv Adj tab.
Please note that for each detail in which you wish to complete service adjustment information, you will need to highlight that service line and set the Service Adjustment Ind to “Y.”
Note: Adjustment reason codes should be submitted on either the Medicare or Srv Adj Tab, but not both.
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