Professional Claims

Completing New Professional Claims

Click on the professional button on your toolbar and follow these steps:

1. Enter data into all of the required boxes on Header 1 using the following table as a guide.

Tip In general, no special characters (such as apostrophes) may be entered in name boxes. Spaces are allowed. When entering names, verify the spelling with Wisconsin’s Enrollment Verification System (EVS) and enter the same spelling in PES.

Professional Header 1
Field	Description
Program	Select Medicaid or WWWP.
Claim Frequency	Select "1" to submit an original claim.
Provider ID	Select the eight-digit Medicaid billing provider number.
Client ID	Select the 10-digit recipient identification number.
Medical Record #	Enter the medical record number that identifies the client in your records. This box is optional.
Release of Medical Data	Select "N" only to indicate that the provider does not have a statement on file signed by the client authorizing the release of medical data to other organizations. This box defaults to "Y."
Patient Signature	Select the code indicating how the patient or authorized person’s signature was obtained and how the provider is retaining the signature.

Select the Header 2 tab. Enter data into all of the required boxes on Header 2 using the following table as a guide.

Tip Prior authorization (PA) numbers and Place of Service (POS) codes entered on Header 2 will apply to all lines on the claim unless overridden by PA numbers and POS codes entered on the Service 1 tab.

Professional Header 2
Field	Description
Diagnosis Code	Enter the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code(s) related to the visit.
Referring Provider Provider ID	Select the provider identification number that identifies the referring provider (if applicable).
Similar Illness Date	Enter the date of services rendered to a patient experiencing symptoms similar to previously reported symptoms (if applicable). Use the MM/DD/CCYY format.
Onset of Current Illness Date	Enter the date when the onset of the patient’s illness or symptoms is different from the DOS, if applicable. Use the MM/DD/CCYY format.
Place of Service	Enter or select the two-digit place of service code.
Prior Authorization	Enter the seven-digit prior authorization (PA) number (if applicable). The same PA cannot be entered both here and on the Service 1 screen.
Rendering Provider Provider ID	Select the eight-digit rendering provider identification number, if it is different from the billing provider.

4. Select the Header 3 tab.
5. Enter data into all of the required boxes on Header 3 using the table below as a guide.

Professional Header 3
Field	Description
Accident Related Causes	Select the related cause value(s) if the services are a result of an accident. If "AA" is selected, enter the state where the accident occurred.
Date	Enter the date the accident occurred (if applicable).
Patient Weight	Enter the patient’s weight.
Other Insurance Ind	Select "Y" if the client has other insurance coverage for professional services.
Billing Contract Code	Enter the contract code to further identify provider type and service of the billing provider, if applicable. Refer to Appendix 2 for more information.
Medicare Ind	Select "Y" if the client has Medicare coverage for professional services.

If you do not have commercial insurance carrier information to enter, proceed to step 11. If you have commercial insurance carrier information to enter, select the OI tab. Enter data into all the required boxes on the OI tab using the table below as a guide. Refer to the Other Insurance and Medicare chapter of this manual for more information.

Tip You should report other insurance payments or adjustments on the OI Adjustment tab (header level) in PES. The maximum number of details that can be submitted per form is 50.

Professional OI
Field	Description
Release of Medical Data	Select an option to indicate whether the provider has a statement on file signed by the client authorizing the release of medical data to other organizations. The information entered in this box has no impact on the outcome of your claim.
Benefits Assignment	Select "N" only to indicate that the client, or authorized person, did not authorize benefits to be assigned to the provider. This box defaults to "Y." The information entered in this box has no impact on the outcome of your claim.
Claim Filing Ind Code	Select the type of other insurance claim being submitted.
Carrier Code	Select the policyholder carrier code. Then tab off the field to populate the Policyholder Last Name and First Name boxes.

Select the OI Adj tab. Enter data into all the required boxes on the OI Adj tab using the following table as a guide.

Tip When there are multiple payers for a single client, complete all information for each payer prior to beginning a new payer.

Professional OI Adjustment
Field	Description
OI-Y	Select "Y" if other insurance exists, but was not billed for reasons described in your Wisconsin Medicaid Updates and service-specific handbook. This box defaults to "N." If you indicate "Y" for OI-Y, refer to the Claim Filing Ind Code under the Professional OI tab.
Paid Date/Amount	Enter the date the other insurance paid the claim using the MM/DD/CCYY format and the total amount paid by other insurance (if applicable). This box is required if the information was not entered in the service adjustment tab.
Allowed Amount	Enter the amount allowed by other insurance (if applicable).
Adjustment Group Cd	Select the code identifying the general category of payment adjustment by the other insurance (if applicable). Enter "PR" if insurance deductible, coinsurance, or co-pay has been indicated on the insurance claim or remittance advice. If you enter an adjustment group code, you must also enter at least one adjustment reason code. You may enter up to six adjustment reason codes per adjustment group code. This box is only required if an insurance carrier did not pay the claim in full.
Reason Codes/Amts	Select the code identifying the reason for the adjustment — the difference between the billed and paid amounts — made by Medicare. Enter the amount indicated Medicare for each reason code. This box is only required if Medicare made an adjustment.

11. If the client does not have Medicare insurance information, proceed to step 14.
12. If the client has Medicare insurance information, select the Medicare tab.
13. Enter data into all the required fields on the Medicare tab, using the table below as a guide. Refer to the Other Insurance and Medicare chapter of this manual for more information.

Tip Depending on how Medicare reported their payment information to you, you are required to either report Medicare payments and adjustments on the Medicare tab (header level) or Service Adjustment tab (detail level) in PES. Look at the remittance advice that was sent to you by Medicare. If the payment information sent was reported at the header level, complete the Medicare screen in PES for that payer. If the payment information sent was at the service level, complete the Service Adjustment screen for that payer. To access the Service Adjustment screen, select "Y" in the Service Adjustment Ind box on the Srv 1 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 select "Y." Do not complete both the bottom portion of the Medicare screen and the Service Adjustment screen for the same payer. Refer to the Other Insurance and Medicare chapter of this manual for more information.

Tip Medicaid providers should refer to their service-specific handbook and Updates for more information on procedure codes and modifiers.

Professional Medicare
Field	Description
Release of Medical Data	Select an option to indicate whether the provider has a statement on file signed by the client authorizing the release of medical data to other organizations. This box defaults to "Y."
Benefits Assignment	Select "N" only to indicate that the client, or authorized person, did not authorize benefits to be assigned to the provider. This box defaults to "Y."
Claim Filing Ind Code	Select the type of other insurance claim being submitted. This field defaults to "MB."
Carrier Code	Select the carrier code for the policyholder. Tab off the box to populate the policyholder first and last name boxes.
M-8	Select "Y" if Medicare exists, but was not billed for reasons described in your Wisconsin Medicaid Updates and service-specific handbook. This box defaults to "N."
Paid Date/Amount	Enter the Medicare date of payment, if applicable, using the MM/DD/CCYY format. Enter the amount paid by Medicare (if applicable). This box is required if the information was not entered on the Service Adjustment tab.
Allowed Amount	Enter the allowed amount from Medicare (if applicable).
Adjustment Group Cd	Select the code identifying the general category of payment adjustment by the Medicare (if applicable). Enter "PR" if Medicare deductible, coinsurance, or copay has been indicated on the Medicare claim or remittance advice. If you enter an adjustment group code, you must also enter at least one adjustment reason code. You may enter up to six adjustment reason codes per adjustment group code.
Reason Codes/Amts	Select the code identifying the reason for the adjustment — the difference between the billed and paid amounts — made by Medicare. Enter the amount indicated Medicare for each reason code. This box is only required if Medicare made an adjustment.

Select the Service 1 tab. Enter data into all of the required boxes on Service 1 using the following table as a guide.

Tip Medicaid providers should refer to the Medicaid provider handbook and Updates for more information on procedure codes and modifiers.

Professional Service 1
Field	Description
From DOS	Enter the "from" date of service (DOS) using the MM/DD/CCYY format.
To DOS	Enter the "to" DOS using the MM/DD/CCYY format, if applicable.
Emergency Ind	Select "Y" only if the services provided were emergency related. This box defaults to "N."
Place of Service	Enter or select the place of service (POS) in this field if it is different from the POS code entered at the Header 2 tab.
Procedure	Enter or select the procedure code related to the visit.
Modifiers	Enter or select the modifier(s) (if applicable).
Diag Pointer	Enter the number from the Header 2 tab that is associated with the procedure rendered.
CLIA Number	Enter your organization’s Clinical Laboratory Improvement Amendment (CLIA) number, if yours is a facility certified to perform CLIA covered laboratory services. This box is required for any laboratory performing tests covered by the CLIA act.
Basis of Measurement	Select the code that specifies the units in which a value is being expressed. This box defaults to "UN" (unit).
Units	Enter the number of units performed for the service billed. Example: 1.00 = 1 unit.
Billed Amount	Enter the total amount billed for the services performed for this procedure. Include the charge for all units listed.
Family Planning	Select "Y" if the service provided was related to family planning. This box defaults to "N."
Prior Authorization	Enter the seven-digit prior authorization (PA) number (if applicable). The same PA cannot be entered both here and on the Header 2 screen.
Service Adjustment Ind	Select "Y" or "N" to indicate whether service-level payments or adjustments were made by the other insurance and/or Medicare. This box defaults to "N."

16. Select the Service 2 tab.
17. Enter data into all the required boxes on the Service 2 tab using the table below as a guide.

21. Click Save, then Close. Proceed to Submitting New Professional Claims.

Next — Correcting Errors on Professional Claims
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