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Provider Manual

Medicaid propagation logic

Last Updated on January 24, 2019

Wisconsin ForwardHealth requires HMOs to report encounter data to analyze and monitor medical utilization and ensure quality of care. Encounter data utilizes propagation logic on Medicaid encounters and adjustments for billing providers to assist in adjudicating encounters.

Forward Health policy dictates that each provider service location is assigned a billing status. There are three values for billing status: Biller and Performer, Biller Only, and Performer Only. Certain providers are designated to be both billing and rendering (performing) providers. In some cases, these providers are treated as the performing provider even when a performing provider ID is submitted on the encounter.

When the provider billing status is both billing and performing, and the billing provider’s type and primary specialty are in the group that is designated to always use the billing provider as rendering, the encounter is processed using the rule that the billing provider is processed as both the billing and performing provider.

Provider Types

Primary Specialty

Billing Indicator

Resolution

01, 02, 04, 05, 06, 12,

21, 24, 25, 26, 28, 29,

30, 53, 58, 61, 63, 67,

71, 72, 73

All

B (both billing and performing)

The billing provider is processed as both the billing and performing provider.

All

900

B (both billing and performing)

The billing provider is processed as both the billing and performing provider.

11

801, 802,

803

B (both billing and performing)

The billing provider is processed as both the billing and performing provider.

19

191

B (both billing and performing)

The billing provider is processed as both the billing and performing provider.

33

333, 341

B (both billing and performing)

The billing provider is processed as both the billing and performing provider.

All others

All others

B (both billing and performing)

The billing provider and performing provider are processed as submitted.