Wisconsin Medicaid claims: Field requirements

Correctly completing paper and electronic Medicaid claims will expedite the reimbursement process and help avoid claim denials. When submitting claims, you must follow specific guidelines created by the National Uniform Claim Committee (NUCC) and enforced by UnitedHealthcare Community Plan of Wisconsin. Also, health care professionals registered with Medicaid must use the taxonomy code that matches the one entered in the Wisconsin ForwardHealth Portal.

For details on each field in the paper claims form, go to the 1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 02/12
See the NUCC data map for a complete list of the 1500 paper claim form locator numbers and titles and the corresponding 837P electronic claim form loop IDs and segments

Use the table below to verify that you’ve entered the required information correctly on paper and electronic claim forms.

1500 paper claims		837P electronic claims			Field information
Item number	Title	Loop ID	Segment/Data element	Title	Field information
24I shaded line	ID qualifier	2310B	PRV02 REF01	Reference identification qualifier	Use this field when the provider doesn’t have an NPI number and the provider identification number differs from the data entered in items 33a and 33b. Enter the 2-character non-NPI qualifier in the shaded area (e.g., G2 to indicate Provider Commercial Number); or enter ZZ as the qualifier for the 1500 paper claim form.
24I shaded line	ID qualifier	2420A	PRV02 REF01	Reference identification qualifier
24J shaded line	Rendering Provider ID number	2310B	PRV03 REF02	Provider taxonomy code and rendering provider secondary identifier	Use this field to enter the payer-assigned unique identifier when the rendering provider doesn’t have an NPI number. Enter the non-NPI identifying number in the shaded area, up to 11 characters.
24J shaded line	Rendering Provider ID number	2420A	PRV03 REF02
24J	Rendering Provider ID number	2310B	NM109	Rendering provider identifier	Use this field to enter the NPI for the rendering provider.
24J	Rendering Provider ID number	2420A	NM109	Rendering provider identifier	Use this field to enter the NPI for the rendering provider.
32b shaded line	Other ID number	2310C	REF01 REF02	Reference identification qualifier and laboratory or facility secondary identifier	Use this field to enter the payer-assigned unique identifier when the rendering provider doesn’t have an NPI number. Enter the 2-character non-NPI qualifier followed by the ID number, up to 14 characters in total. Do not enter spaces, hyphens or other separators between the qualifier and ID number (e.g., G2A1234567890).
33b shaded line	Other ID number	2000A	PRV03	Provider taxonomy code	Use this field to enter the payer-assigned unique identifier when the rendering provider doesn’t have an NPI number. Enter the 2-character non-NPI qualifier followed by the ID number, up to 17 characters in total. Do not enter spaces, hyphens or other separators between the qualifier and ID number (e.g., G2A1234567890); or enter ZZ as the qualifier for the 1500 paper claim form, followed by the ID number. The field allows up to 17 characters total. Do not enter spaces, hyphens or other separators between the qualifier and ID number (e.g., ZZ1234567890).
33b shaded line	Other ID number	2010AA	REF01 REF02	Reference identification qualifier and billing provider additional identifier