Free Wisconsin Medicaid Urgent Care Dental In-State Emergency Provider Data Sheet, F-11013A - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11013A (02/09)

STATE OF WISCONSIN DHS 105.03(1), Wis. Admin. Code

WISCONSIN MEDICAID

URGENT CARE DENTAL IN-STATE EMERGENCY PROVIDER DATA SHEET COMPLETION INSTRUCTIONS
Wisconsin Medicaid requires certain information to enable Medicaid to certify providers and to authorize and pay for dental services provided to eligible members. A dental provider's personally identifiable information is used for purposes directly related to Medicaid administration such as determining the temporary certification of providers or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of Medicaid payment for the services. The use of this form is mandatory to receive reimbursement. The dental provider is considered a Medicaid provider only for purposes of the care provided to the member indicated in the Urgent Care Dental In-State Emergency Provider Data Sheet, F-11013, on the date indicated ("the care"). By submitting a claim for Medicaid payment for the care, the dental provider agrees to keep records disclosing the extent of the care and Medicaid payments claimed for the care and, upon request, to furnish to state or federal Medicaid authorities any such records. Under state and federal laws, by accepting Medicaid payment for the care, the dental provider is prohibited from seeking payment from the member, or other person on behalf of the member, even if there is a difference between the dental provider's usual and customary charge and the Medicaid payment for the care. INSTRUCTIONS Complete the Urgent Care Dental In-State Emergency Provider Data Sheet for whomever performed dental services on a Wisconsin Medicaid member. This is required in order to submit claims for urgent dental services. Attach the claim form to the Urgent Care Dental In-State Emergency Provider Data Sheet. Submit the completed form with any applicable attachments to the following address: ForwardHealth In-State Emergency Claims 6406 Bridge Rd Madison WI 53784-0011 To be reimbursed for services provided, Wisconsin Medicaid must receive correct and complete claims, including resubmissions and adjustments, within 365 days from the date the service was provided. Important: For a provider to be paid for services, the provider is required to verify member enrollment. This can be done by calling Provider Services at (800) 947-9627. Refer to the procedure codes on page 3 of the Urgent Care Dental In-State Emergency Provider Data Sheet for allowable emergency procedure codes for dental care. All elements are required unless otherwise indicated. SECTION I -- PRACTICE LOCATION INFORMATION Practice location is the street address where a provider office is physically located and where the records are normally kept. Element 1 -- Name -- Provider Enter the individual provider's first name, middle initial, and last name or the name of the clinic or facility. Element 2 -- National Provider Identifier Enter the provider's National Provider Identifier (NPI). Elements 3-7 -- Address Enter the provider's complete physical location address (street, city, state, and ZIP+4 code). This address is the location where services are primarily provided. Element 8 -- County -- County of Provider's Practice Enter the Wisconsin county of the provider's practice location. Element 9 -- License Number Enter the provider's license number. Element 10 -- Gender Enter the individual provider's gender.

URGENT CARE DENTAL IN-STATE EMERGENCY PROVIDER DATA SHEET COMPLETION INSTRUCTIONS F-11013A (02/09)

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Elements 11 and 12 -- Name and Telephone Number -- Contact Person Enter the contact name and the telephone number for the contact person. The contact person's information is used for Wisconsin Medicaid administrative purposes only. SECTION II -- PROVIDER FINANCIAL INFORMATION Wisconsin Medicaid will generate payments to the dental provider and report income to the Internal Revenue Service (IRS) using this information. This information must be the current taxpayer information on file with the IRS. Taxpayer Information Element 13 -- Taxpayer Identification Number (TIN) Enter the TIN that should be used to report income to the IRS. Element 14 -- Name -- Taxpayer Enter the taxpayer's name for the TIN indicated in Element 15. The name entered must be the same name that is on file with the IRS. Element 15 -- TIN Type Indicate whether the TIN indicated in Element 15 is an Employer Identification Number (EIN) or a Social Security number (SSN). Element 16 -- TIN Effective Date Enter the effective date of the TIN. Element 17 -- TIN End Date Enter the end date of the TIN. Checks and Remittance Advice Information Elements 18-22 -- Address Enter the complete address to which checks and remittance advices should be mailed. Elements 23-24 -- Name and Telephone Number -- Contact Person Enter the financial contact person's name and telephone number. IRS Form 1099 Mailing Address IMPORTANT: Only one 1099 will be sent per TIN. If the provider completing this form is not responsible for receiving the 1099, the provider should not complete this section. Elements 25-29 -- IRS Form 1099 Mailing Address Enter the complete address to which the IRS Form 1099 should be sent. (Enter either a P.O. Box or street address [include a suite number, if applicable], city, state, and ZIP+4 code). SECTION III -- MAILING INFORMATION Indicate the address where Wisconsin Medicaid should send general information and correspondence. Element 30 -- Name -- Mail To Enter the first name, middle initial, last name, or the name of the office, clinic, facility, or place of business for the mailing address. Element 31 -- Name -- Attention Line Enter attention line information that Wisconsin Medicaid should use for mailing general information and correspondence. Elements 32-36 -- Mailing Address Enter the provider's complete mailing address (enter either a P.O. Box or street address [include a suite number, if applicable], city, state, and ZIP+4 code). SECTION IV -- MEMBER INFORMATION Element 37-- Name -- Member Enter the name of the member who received the urgent dental services. Element 38 -- Member Identification Number Enter the member identification number of the member who received the urgent dental services.

URGENT CARE DENTAL IN-STATE EMERGENCY PROVIDER DATA SHEET COMPLETION INSTRUCTIONS F-11013A (02/09)

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SECTION V -- AUTHORIZED SIGNATURE INFORMATION Element 39 -- Signature -- Provider The signature of the individual provider or authorized representative of a clinic or facility provider is required. Signature stamps and electronic signatures are not acceptable. Element 40 -- Date Signed Enter the month, day, and year (in MM/DD/CCYY format) this form was completed and signed.