Free Wisconsin Medicaid In-State Emergency Provider Data Sheet Completion Instructions, F-11002A - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11002A (10/08)

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

WISCONSIN MEDICAID

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 medical services provided to eligible members. Personally identifiable information about Medicaid providers is used for purposes directly related to Medicaid administration such as determining the 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. INSTRUCTIONS Complete the In-State Emergency Provider Data Sheet, F-11002, for whomever performed medical services on a Wisconsin Medicaid member. This is required in order to submit claims for emergency services. Attach the claim to the In-State Emergency Provider Data Sheet along with an explanation of the exact nature of this emergency; include a description of the member's condition or cause of the emergency, if known. State the diagnosis and extent of the injuries. Be sure to explain any extenuating circumstances. 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. Note: For a provider to submit claims for services, the provider is required to submit copies of the provider's current license(s), approval(s), or certification(s) to Wisconsin Medicaid. (See the indicators in the "Key" and "Materials to Be Submitted with Data Sheet" column on the last page of the In-State Emergency Provider Data Sheet for requirements.) Attach required copies to the In-State Emergency Provider Data Sheet. All elements are required unless otherwise indicated. SECTION I -- PRACTICE LOCATION INFORMATION A practice location is the street address where a provider's 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 -- Provider ID This is a required field for health care providers. Health care providers, as defined by the Centers for Medicare and Medicaid Services, will enter their National Provider Identifier (NPI). Non-healthcare providers will enter their eight or nine-digit Wisconsin Medicaid number. Do not enter any other numbers or letters. Non-healthcare providers who do not have a ForwardHealth identification number should leave this element blank. Elements 3-7 -- Address Enter the provider's complete practice 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 -- Gender Enter the individual provider's gender. Elements 10 and 11 -- Name and Telephone Number -- Contact Person Enter the name and telephone number for the contact person. The contact person's information is used for Wisconsin Medicaid administrative purposes only.

IN-STATE EMERGENCY PROVIDER DATA SHEET COMPLETION INSTRUCTIONS F-11002A (10/08)

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SECTION II -- PROVIDER FINANCIAL INFORMATION Wisconsin Medicaid will generate payments to the 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 12 -- Taxpayer Identification Number (TIN) Enter the TIN that should be used to report income to the IRS. Element 13 -- Name -- Taxpayer Enter the taxpayer's name for the TIN indicated in Element 12. The name entered must be the same name that is on file with the IRS. Element 14 -- TIN Type Indicate whether the TIN indicated in Element 12 is an Employer Identification Number (EIN) or a Social Security number (SSN). Element 15 -- TIN Effective Date Enter the effective date of the TIN. Element 16 -- TIN End Date Enter the end date of the TIN. Checks and Remittance Advice Information Elements 17-21 -- Address Enter the complete address to which checks and remittance advices should be mailed. Elements 22-23 -- 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 24-28 -- 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 lII -- MAILING INFORMATION Indicate the address where Wisconsin Medicaid should send general information and correspondence. Element 29 -- 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. The name could be the same as the provider name listed in Section I, but do not write "same" in this field. Element 30 -- Name -- Attention Line Enter attention line information that Wisconsin Medicaid should use for mailing general information and correspondence. Elements 31-35 -- 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).

IN-STATE EMERGENCY PROVIDER DATA SHEET COMPLETION INSTRUCTIONS F-11002A (10/08)

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SECTION IV -- GENERAL INFORMATION Enter other miscellaneous information regarding the individual provider. Element 36 Refer to the list on page 3 of the In-State Emergency Provider Data Sheet and circle the appropriate provider type and specialty that accurately describes the type of services performed by the applicant. The provider is required to submit the materials specific to the provider type selected with the completed In-State Emergency Provider Data Sheet. Element 37 -- Medicare Enrollment Information This is a situational field. Check all applicable types of Medicare enrollment that the provider holds and enter the enrollment effective date. Note: Wisconsin Medicaid will use the NPI indicated in Section I of this form for processing automatic Medicare crossover claims. Element 38 -- Clinical Laboratory Improvement Amendment Number This is a situational field. Enter the Laboratory Improvement Amendment Number (CLIA) for the provider. Elements 39a-d -- Drug Enforcement Agency (DEA) Information These are situational fields. Enter the DEA number(s) for the provider. Additional space is provided to allow for multiple DEA numbers. Element 40 -- Individual or Organization License and State of License This is a situational field. Enter the provider's license number and the state through which the provider's license was received. SECTION V -- AUTHORIZED SIGNATURE INFORMATION Element 41 -- 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 42 -- Date Signed Enter the month, day, and year (in MM/DD/CCYY format) this form was completed and signed.