Medicine and Surgery Section - Wisconsin.gov

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Appendix Appendix 4 (Continued) Element 26 — Patient’s Account No. (not required) Optional — Providers may enter up to 20 characters of the patient’s internal office account number. This number will appear on the Remittance and Status Report and/or the 835 Health Care Claim Payment/Advice transaction. Element 27 — Accept Assignment (not required) Element 28 — Total Charge Enter the total charges for this claim. Element 29 — Amount Paid Enter the actual amount paid by commercial health insurance. (If a dollar amount indicated in Element 29 is greater than zero, “OI-P” must be indicated in Element 9.) If the commercial health insurance denied the claim, enter “000.” Do not enter Medicare-paid amounts in this field. Element 30 — Balance Due Enter the balance due as determined by subtracting the amount paid in Element 29 from the amount in Element 28. Element 31 — Signature of Physician or Supplier The provider or the authorized representative must sign in Element 31. The month, day, and year the form is signed must also be entered in MM/DD/YY or MM/DD/YYYY format. Note: The signature may be a computer-printed or typed name and date or a signature stamp with the date. Element 32 — Name and Address of Facility Where Services Were Rendered (not required) Element 33 — Physician’s, Supplier’s Billing Name, Address, Zip Code, and Phone # Enter the name of the provider submitting the claim and the complete mailing address. The minimum requirement is the provider's name, street, city, state, and ZIP code. At the bottom of Element 33, enter the billing provider’s eight-digit Medicaid provider number. 82 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005
P Recipient, Im A. MM DD YY X 609 Willow Anytown WI 55555 XXX XXX-XXXX 480.0 OI - P 1234567890 MM DD YY DD DD 11 99213 TJ 1 XXX XX 3.0 MM/DD/YY Appendix 5 Sample CMS 1500 Claim Form — Physician Medical Services (Three Evaluation and Management Visits with Pediatric Modifier) 1234JED XXX XX XX XX XX XX I.M. Physician 1 W. Williams Anytown, WI 55555 87654321 Physician Services Handbook — Medicine and Surgery December 2005 83 Appendix
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Physician Services Medicine and Sur
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T Table of Contents Preface .......
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Telemedicine ......................
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Health Professional Shortage Areas
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Legal Framework The following laws
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General Information Treatment (EPSD
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General Information Category III Co
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General Information collecting the
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General Information • The current
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Evaluation and Management reimburse
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Evaluation and Management in an out
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Evaluation and Management 22 Wiscon
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Medicine Services System [HCPCS] co
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Medicine Services In cases where mo
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Medicine Services documentation in
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Medicine Services Providers of ment
Page 34 and 35: Medicine Services Substance Abuse S
Page 36 and 37: Surgery Services Appendix 10 of thi
Page 38 and 39: Surgery Services Cataract Surgery W
Page 40 and 41: Surgery Services and the insertion
Page 42 and 43: Surgery Services Note: A telephone
Page 44 and 45: Surgery Services • Sterilization.
Page 46 and 47: Surgery Services live with her sinc
Page 48 and 49: Surgery Services by a multi-discipl
Page 50 and 51: Prescription Requirements Prescribe
Page 52 and 53: Prescription Requirements Approval
Page 54 and 55: Prescription Requirements prescribe
Page 56 and 57: Prescription Requirements 54 Wiscon
Page 58 and 59: Claims Submission adjustment reques
Page 60 and 61: Claims Submission 58 Wisconsin Medi
Page 62 and 63: Reimbursement • Confirming or rev
Page 64 and 65: Reimbursement about whether a speci
Page 66 and 67: Reimbursement 64 Wisconsin Medicaid
Page 68 and 69: Appendix 66 Wisconsin Medicaid and
Page 70 and 71: Appendix Surgery Services Appendix
Page 72 and 73: Appendix Medicine Services (Continu
Page 74 and 75: Appendix Other Services Appendix 1
Page 80 and 81: Appendix Appendix 4 (Continued) If
Page 82 and 83: Appendix Appendix 4 (Continued) Ele
Page 96 and 97: Appendix (This page was intentional
Page 98 and 99: ABORTION CERTIFICATION STATEMENTS P
Page 102 and 103: STERILIZATION INFORMED CONSENT FORM
Page 104 and 105: DEPARTMENT OF HEALTH AND FAMILY SER
Page 114 and 115: Appendix Appendix 15 (Continued) Pe
Page 116 and 117: Appendix Category Musculoskeletal S
Page 118 and 119: Appendix Category Musculoskeletal S
Page 120 and 121: Appendix Category Female Genital Sy
Page 122 and 123: Appendix SECTION II — RECIPIENT I
Page 132 and 133: Appendix PRIOR AUTHORIZATION / PHYS
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Appendix (This page was intentional
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PRIOR AUTHORIZATION / PHYSICIAN ATT
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PRIOR AUTHORIZATION / “J” CODE
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PRIOR AUTHORIZATION / “J” CODE
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PRIOR AUTHORIZATION / PHYSICIAN OTO
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DEPARTMENT OF HEALTH AND FAMILY SER
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Appendix Health Professional Shorta
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Appendix HPSA Name County ZIP Codes
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Appendix 154 Wisconsin Medicaid and
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Appendix Appendix 26 (Continued) ma
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Appendix The following table lists
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Appendix 160 Wisconsin Medicaid and
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DECLARATION OF SUPERVISION FOR NONB
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Appendix HCPCS Code* Drug Name Diag
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Index Organ Transplants, 44 Provide
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