Wis. Admin. Code Office of the Commissioner of Insurance Ins 3.65

Current through October 28, 2024

Section Ins 3.65 - Standardized claim format

(1) PURPOSE; APPLICABILITY. This section implements s. 632.725(2) (a) and (b), Stats., by designating and establishing requirements for use of the forms that health care providers in this state shall use on and after July 1, 1993, for providing a health insurance claim form directly to a patient or filing a claim with an insurer on behalf of a patient.

(2) DEFINITIONS. In this section and in s. Ins 3.651:

(a) "ADA dental claim form" means the uniform dental claim form approved by the American dental association for use by dentists.

(b) "CDT-1 codes" means the current dental terminology published by the American dental association.

(c) "CPT-4 codes" means the current procedural terminology published by the American medical association.

(d) "DSM-III-R codes" means the American psychiatric association's codes for mental disorders.

(e) "HCFA" means the federal health care financing administration of the U.S. department of health and human services.

(f) "HCFA-1450 form" means the health insurance claim form published by HCFA for use by institutional providers.

(g) "HCFA-1500 form" means the health insurance claim form published by HCFA for use by health care professionals.

(h) "HCPCS codes" means HCFA's common procedure coding system which includes all of the following:

1. Level 1 codes which are the CPT-4 codes.

2. Level 2 codes which are codes for procedures for which there are no CPT-4 codes.

3. Levels 1 and 2 modifiers.

(i) "Health care provider" has the meaning given in s. 632.725(1), Stats.

(j) "ICD-9-CM codes" means the disease codes in the international classification of diseases, 9th revision, clinical modification published by the U.S. department of health and human services.

(k) "Medicare" means Title XVIII of the federal social security act.

(L) "Medical assistance" means Title XIX of the federal social security act.

(m) "Revenue codes" means the codes which are included in the Wisconsin uniform billing manual and which are established for use by institutional health care providers by the national uniform billing committee.

Note: The publications and forms referred to in subsection (2) may be obtained as follows: HCFA-1500 form and instructions

From the U.S. Government Printing Office, 710 North Capitol Street NW, Washington, DC 20401, all of the following:

HCPCS codes

ICD-9-CM codes

HCFA-1450 form and instructions

From the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611, both of the following:

CDT-1 codes

ADA dental claim form and CDT-1 User's Manual

From Order Department: OP054192, the American Medical Association, P. O. Box 10950, Chicago, IL 60610: CPT-4 codes

From the American Psychiatric Association, 1400 K Street, NW, Washington, DC 20005: DSM-III-R codes

From the Wisconsin Hospital Association, 5721 Odana Road, Madison, WI 53719: Wisconsin Uniform Billing Manual and revenue codes

(3) USE OF HCFA-1500 FORM.

(a)Required users; instructions. For providing a health insurance claim form directly to a patient or filing a claim with an insurer on behalf of a patient, all of the following health care providers shall use the format of the HCFA-1500 form, following HCFA's instructions for use:

1. A nurse licensed under ch. 441, Stats.

2. A chiropractor licensed under ch. 446, Stats.

3. A physician, podiatrist or physical therapist licensed under ch. 448, Stats.

4. An occupational therapist, occupational therapy assistant or respiratory care practitioner certified under ch. 448, Stats.

5. An optometrist licensed under ch. 449, Stats.

6. An acupuncturist licensed under ch. 451, Stats.

7. A psychologist licensed under ch. 455, Stats.

8. A speech-language pathologist or audiologist licensed under subch. II of ch. 459, Stats., or a speech and language pathologist licensed by the department of public instruction.

9. A social worker, marriage and family therapist or professional counselor certified under ch. 457, Stats.

10. A partnership of any providers specified under subds. 1. to 9.

11. A corporation of any providers specified under subds. 1. to 9. that provides health care services.

12. An operational cooperative sickness care plan organized under ss. 185.981 to 185.985, Stats., that directly provides services through salaried employees in its own facility.

(b)Coding requirements. In addition to HCFA's coding instructions, the following restrictions and conditions apply to the use of the HCFA-1500 form:

1. The only coding systems an insurer may require a health care provider to use are the following:

a. HCPCS codes.

b. ICD-9-CM codes.

c. DSM-III-R codes, if no ICD-9-CM code is available.

2. For anesthesia services for which there is no applicable HCPCS level 1 anesthesia code, a health care provider shall use the applicable HCPCS level 1 surgery code.

3. An insurer may not require a health care provider to use any other verbal descriptor with a code or to furnish additional information with the initial submission of a HCFA-1500 form except under the following circumstances:

a. When the procedure code used describes a treatment or service which is not otherwise classified.

b. When the procedure code is followed by the CPT-4 modifier 22, 52 or 99. A health care provider using the modifier 99 may use item 19 of the HCFA-1500 form to explain the multiple modifiers.

c. When required by a contract between the insurer and health care provider.

4. A health care provider may use item 19 of the HCFA-1500 form to indicate that the form is an amended version of a form previously submitted to the same insurer by inserting the word amended" in the space provided.

(c)Use of unique identifiers. In completing the HCFA-1500 form, the individual or entity filing the claim shall do all of the following:

1. In item 17a, use the unique physician identifier number assigned by HCFA or, if the physician does not have such a number, the physician's taxpayer identification number assigned by the U. S. internal revenue service.

2. In item 33, use both of the following:

a. The name and address of the payee.

b. The unique physician identifier number assigned by HCFA to the individual health care provider who performed the procedure or ordered the service or, if the individual does not have such a number, the individual's taxpayer identification number assigned by the U. S. internal revenue service.

(4) USE OF HCFA-1450 FORM.

(a)Required users; instructions. For providing a health insurance claim form directly to a patient or filing a claim on behalf of a patient, all of the following health care providers shall use the format of the HCFA-1450 form, following the instructions for use in the Wisconsin uniform billing manual:

1. A hospice licensed under subch. VI of ch. 50, Stats.

2. An inpatient health care facility, as defined in s. 50.135(1), Stats.

3. A community-based residential facility, as defined in s. 50.01(1g), Stats.

(b)Coding requirements. The only coding systems an insurer may require a health care provider to use are the following:

1. ICD-9-CM codes.

2. Revenue codes.

3. If charges for professional health care provider services are included, HCPCS or DSM-III-R codes.

(c)Claims for outpatient services; supplemental form permitted. A hospital may use a HCFA-1500 form to supplement a HCFA-1450 form if necessary to complete a claim for outpatient services.

(5) USE OF ADA DENTAL CLAIM FORM.

(a)Required users; instructions. For providing a health insurance claim form directly to a patient or filing a claim with an insurer on behalf of a patient, a dentist or a corporation or partnership of dentists shall use the format of the ADA dental claim form, following the instructions for use in the American dental association CDT-1 user's manual.

(b)Coding. An insurer may not require a dentist to use any code other than the following:

1. CDT-1 codes.

2. CPT-4 codes.

(6) GENERAL PROVISIONS.

(a)Insurers to accept forms. No insurer may refuse to accept a form specified in sub. (3) (a), (4) (a) or (5) (a) as proof of a claim.

(b)Filing claims. A health care provider may file a claim with an insurer using either a paper form or electronic transmission. If a health care provider does not file a claim on behalf of a patient, the health care provider shall provide the patient with the same form that would have been used if the provider had filed a claim on behalf of the patient.

(c)Insurers may require additional information.

1. If the information conveyed by standard coding is insufficient to enable an insurer to determine eligibility for payment, the insurer may require a health care provider to furnish additional medical records to determine medical necessity or the nature of the procedure or service provided.

2. The 30-day period allowed for payment of a claim under s. 628.46(1), Stats., begins when the insurer has sufficient information to determine eligibility for payment.

(d)Use of current forms and codes. In complying with this section, a health care provider shall do all of the following that are applicable:

1. Use the most current version of the HCFA-1500 or HCFA-1450 claim form and accompanying instructions by the mandatory effective date HCFA specifies for use in filing medicare claims.

2. Begin using modifications to a required coding system for all billing and claim forms by the mandatory effective date HCFA specifies for use in filing medicare claims.

3. Use the most current version of the ADA dental claim form.

Wis. Admin. Code Office of the Commissioner of Insurance Ins 3.65

Cr. Register, August, 1993, No. 452, eff. 9-1-93; am. (6) (b), Register, February, 1994, No. 458, eff. 3-1-94; corrections in (4) (a) 2. and 3. made under s. 13.93(2m) (b) 7, Stats., Register, July, 1999, No. 523.

Amended by, correction in (4) (a) 1. made under s. 13.92(4) (b) 7, Stats., Register March 2017 No. 735, eff. 4/1/2017