MedicaidReimbursementHigh impact
New Reimbursement Policy for Certain Claims and Claim Adjustments with Other Commercial Health Insurance Indicated
Wisconsin Medicaid (ForwardHealth)·WI·Billing
Effective date
Jun 16, 2014
We identified it
Jun 20, 2026
Summary
ForwardHealth is changing how Medicaid reimbursement is calculated when other commercial insurance is involved. Starting June 16, 2014, Medicaid will deduct both the discount amounts AND the payments from other insurance when calculating reimbursement, which will reduce Medicaid payments for dual-coverage patients.
Action Required
By June 16, 2014: Billing team must update electronic claim submissions to use HIPAA adjustment reason code 45 when indicating other insurance discounts. Update billing software to properly calculate and report discount amounts from commercial payers on all professional, institutional, and dental claims submitted via ForwardHealth Portal or 837 transactions. Train staff to recognize new EOB code 3032 on Remittance Advices indicating TPL contractual discount adjustments.