Provider Validation for Claims Processing
- Click on "Online Handbook"
- Click “I Accept” and Submit Agreement
- Under User Type, select “Provider”
- Under Program, select “BadgerCare Plus & Medicaid”
- Click Advanced Search
- Enter appropriate topic number in Advanced Search Field
- Click Search
Forward Health Topic # 17797, 1500 Health Insurance Claim Form Completion Instructions, provides details on how to complete the 1500 Health Insurance Claim Form specific for BadgerCare. Use the ForwardHealth claim form completion instructions in conjunction with the 1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 02/12, prepared by NUCC, to avoid denial or inaccurate claim payment.
Forward Health Topic # 3448, UB-04 (CMS 1450) Claim Form Instructions for Inpatient Hospital Services, provides details on how to complete the UB-04 Claim Form specific for BadgerCare Inpatient Claims.
Forward Health Topic # 4453, UB-04 (CMS 1450) Claim Form Instructions for Outpatient Hospital Services, provides details on how to complete the UB-04 Claim Form specific for BadgerCare Outpatient Claims.
Security Health Plan Provider Validation Process (Referring, Rendering and Billing Provider)
Information submitted in the referring, rendering and billing provider fields must match what is registered with ForwardHealth. For questions or to confirm your provider enrollment:
- See ForwardHealth Topic # 474
- Call ForwardHealth Provider Services Call Center: 1-800-947-9627
- See ForwardHealth Portal – indicates current provider registration
- Click on Providers
- Click on Request Portal Access under Quick Links
- Enter NPI and click Search
- Provider name, address (including zip+4), taxonomy, and provider description will populate
Referring Provider Requirements:
In alignment with ForwardHealth Topic # 15737, claims submitted with a referring provider must include both the referring provider name in element 17 and a valid Medicaid enrolled NPI in element 17b.
- 17: Name of Referring Provider or Other Source - Enter “DN” qualifier (for referring provider only) followed by the provider name
- 17a: Other ID Number – Not required
- 17b: NPI Number - Enter valid, Medicaid enrolled provider NPI
Rendering Provider Requirements:
ForwardHealth has the below requirements when the rendering provider is different than the billing provider in element 33a or the billing provider is registered with the State of WI as a biller only (refer to ForwardHealth Topic # 3969).
- 24i: ID Qual - Enter a qualifier of "PXC" indicating provider taxonomy, in the shaded area of the detail line. (Refer to ForwardHealth Update 2012-28)
- 24j: Rendering provider’s NPI - Enter the 10-digit taxonomy code in the shaded area of this element and enter the rendering provider's NPI in the white area.
Billing Provider Requirements:
ForwardHealth has the below requirements for billing provider information.
Billing provider address on both a CMS 1500 and UB must be the physical location; not a PO Box. Claims must include the zip+4 of the billing provider’s address on file with ForwardHealth. The zip+4 helps identify a provider when the NPI reported to ForwardHealth corresponds to multiple enrollments and the reported taxonomy code does not uniquely identify the provider. See Forward Health Topic #5097.
- CMS 1500
- 33: Billing provider info & ph # - Enter the Medicaid enrolled provider or supplier’s billing name, physical address, and zip+4.
- 33a: NPI Number – Enter the Medicaid enrolled Billing Provider NPI
- 33b: Other ID Number – Enter the qualifier “PXC" plus the Medicaid enrolled 10-digit billing provider taxonomy that corresponds to the entered NPI and zip+4
- Field 1: Provider Name, Address, and Telephone Number – Enter the Medicaid enrolled provider information including zip+4
- Field 56: NPI – Enter the Medicaid enrolled NPI that corresponds with the provider in Field 1
- Field 81CC a: Enter the qualifier “PXC" plus the Medicaid enrolled 10-digit billing provider taxonomy that corresponds to the entered NPI and zip+4