February 01, 2023
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 | |
| 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. |
| 2420A | PRV02 REF01 |
||||
| 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. |
| 2420A | PRV03 REF02 |
||||
| 24J | Rendering Provider ID number | 2310B | NM109 | Rendering provider identifier | Use this field to enter the NPI for the rendering provider. |
| 2420A | NM109 | ||||
| 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). |
| 2010AA | REF01 REF02 |
Reference identification qualifier and billing provider additional identifier | |||
Questions?
Please reach out to your provider advocate.
