100100000330 20121019WISC FORWARDHEALTHvedshmosupport@wisconsin.gov 150100000330_20121018_001.DAT PM 2001437152345BELLIN MEMORIAL HOSPITAL 282N00000X543053505 5009010002203 7012292001001CRIST ENCPHYSEOB 52189_001_CRIST_46340 69002030M11954081911201210032012100399678 PYY 150.00 113.85 0.00 0.00 113.85 5207012292001001 19817Billing provider number was used to adjudicate the service(s) 0.00I 6007012292001001 152189DETAIL 2012100320121003 01999AA 82.00 82.000 PYY 150.00 113.85 113.85SYSMANDEF 6207012292001001 1 10000This claim/service is pending for program review. 36.15I 6207012292001001 1 29953HMO Encounter detail manually priced. 36.15I 6207012292001001 1 39817Billing provider number was used to adjudicate the service(s) 0.00I 150100000330_20121018_002.DAT DD 2001669702460PFEIFER, ERIN 1223G0001X537041234 5009010002200 7012292001003XXIST ENCFIVEB 52158_001_CRIST_46340 33812500 SCHLICHTIG MARK 1223G0001X69000930D120110401112012071820120718 DYY 145.00 0.00 0.00 0.00 0.00 5207012292001003 10029LAST NAME DOES NOT MATCH MEMBER ID. 145.00D 5207012292001003 29817Billing provider number was used to adjudicate the service(s) 0.00I 6007012292001003 1LINEITEMCONTROL52158A 2012071820120718 D01508082AAAS 1.00 0.000 DYY 53.00 0.00 0.00 6207012292001003 1 11644Valid Other Payer Date required. 0.00D 6207012292001003 1 29817Billing provider number was used to adjudicate the service(s) 0.00I 6007012292001003 2LINEITEMCONTROL52158B 2012071820120718 D0272 1.00 0.000 DYY 39.00 0.00 0.00 6207012292001003 2 11644Valid Other Payer Date required. 0.00D 6207012292001003 2 29817Billing provider number was used to adjudicate the service(s) 0.00I 6007012292001003 3LINEITEMCONTROL52158C 2012071820120718 D1120 1.00 0.000 DYY 53.00 0.00 0.00 6207012292001003 3 11644Valid Other Payer Date required. 0.00D 6207012292001003 3 29817Billing provider number was used to adjudicate the service(s) 0.00I 150100000330_20121018_003.DAT II 2001437152345BELLIN MEMORIAL HOSPITAL 282N00000X543053505 5004110707544 7012292001002CRIST ENCSEVEN 52159_001_CRIST_46340 1124079876SUTO BONNIE 69002030I12012042111201203152012031777089 7784 YDYY 10033.81 0.00 0.00 0.00 0.00 0331 0331 6007012292001002 1LINEITEMCONTROL52159A 20120315201203170123 2.00 0.000 DYY 928.00 0.00 0.00 6207012292001002 1 10172Member is not enrolled for the detail Date(s) of Service. 928.00D 6007012292001002 2LINEITEMCONTROL52159B 20120315201203170230 2.00 0.000 DYY 3418.50 0.00 0.00 6207012292001002 2 10172Member is not enrolled for the detail Date(s) of Service. 3418.50D 6007012292001002 3LINEITEMCONTROL52159C 20120315201203170250 2.00 0.000 DYY 1116.56 0.00 0.00 6207012292001002 3 10172Member is not enrolled for the detail Date(s) of Service. 1116.56D 6007012292001002 4LINEITEMCONTROL52159D 20120315201203170258 2.00 0.000 DYY 98.50 0.00 0.00 6207012292001002 4 10172Member is not enrolled for the detail Date(s) of Service. 98.50D 6007012292001002 5LINEITEMCONTROL52159E 20120315201203170270 17.00 0.000 DYY 839.25 0.00 0.00 6207012292001002 5 10172Member is not enrolled for the detail Date(s) of Service. 839.25D 6007012292001002 6LINEITEMCONTROL52159F 20120315201203170272 5.00 0.000 DYY 591.25 0.00 0.00 6207012292001002 6 10172Member is not enrolled for the detail Date(s) of Service. 591.25D 6007012292001002 7LINEITEMCONTROL52159G 20120315201203170300 1.00 0.000 DYY 117.25 0.00 0.00 6207012292001002 7 10172Member is not enrolled for the detail Date(s) of Service. 117.25D 6007012292001002 8LINEITEMCONTROL52159H 20120315201203170301 4.00 0.000 DYY 186.00 0.00 0.00 6207012292001002 8 10172Member is not enrolled for the detail Date(s) of Service. 186.00D 6007012292001002 9LINEITEMCONTROL52159I 20120315201203170305 3.00 0.000 DYY 200.50 0.00 0.00 6207012292001002 9 10172Member is not enrolled for the detail Date(s) of Service. 200.50D 6007012292001002 10LINEITEMCONTROL52159J 20120315201203170306 6.00 0.000 DYY 850.25 0.00 0.00 6207012292001002 10 10172Member is not enrolled for the detail Date(s) of Service. 850.25D 6007012292001002 11LINEITEMCONTROL52159K 20120315201203170324 1.00 0.000 DYY 220.00 0.00 0.00 6207012292001002 11 10172Member is not enrolled for the detail Date(s) of Service. 220.00D 6007012292001002 12LINEITEMCONTROL52159L 20120315201203170361 1.00 0.000 DYY 516.75 0.00 0.00 6207012292001002 12 10172Member is not enrolled for the detail Date(s) of Service. 516.75D 6007012292001002 13LINEITEMCONTROL52159M 20120315201203170402 1.00 0.000 DYY 541.25 0.00 0.00 6207012292001002 13 10172Member is not enrolled for the detail Date(s) of Service. 541.25D 6007012292001002 14LINEITEMCONTROL52159N 20120315201203170450 1.00 0.000 DYY 409.75 0.00 0.00 6207012292001002 14 10172Member is not enrolled for the detail Date(s) of Service. 409.75D 150100000330_20121018_004.DAT PM 2001467462432MARSHIELD LAB OUTREACH 207ZC0500X544490000 5009010002203 7012292001005CRIST ENCPHYSEOB 52179_010_CRIST_46340 69002030M11954081911201210082012101030300 DYY 130.00 0.00 0.00 0.00 0.00 5207012292001005 10084PROVIDER SIGNATURE AND/OR DATE REQUIRED. 0.00W 5207012292001005 29817Billing provider number was used to adjudicate the service(s) 0.00I 6007012292001005 1LINE52179A 2012101020121010 H0047HP 1.00 0.000 DYY 80.00 0.00 0.00 6207012292001005 1 11644Valid Other Payer Date required. 80.00D 6207012292001005 1 29817Billing provider number was used to adjudicate the service(s) 0.00I 6007012292001005 2LINE52179B 2012100820121008 H0022HP 1.00 0.000 DYY 50.00 0.00 0.00 6207012292001005 2 11644Valid Other Payer Date required. 50.00D 6207012292001005 2 29817Billing provider number was used to adjudicate the service(s) 0.00I 150100000330_20121018_006.DAT II 2001437152345BELLIN MEMORIAL HOSPITAL 282N00000X543053505 5004110707544 7012292001009CRIST ENCSEVEN 52182_001_CRIST_46340 1124079876SUTO BONNIE 69002030I12012042111201210012012100377089 7784 YPYY 10033.81 10305.81 67.62 0.00 1132.38 794 9677150331 0331 5207012292001009 11564Payment may be reduced due to submitted "Present on Admission" (POA) indicator. 0.00I 6007012292001009 1LINEITEMCONTROL52182A 20121001201210030123 2.00 2.000 PYY 928.00 1200.00 1132.38IPDIEMDEF 6207012292001009 1 19902Pricing Adjustment - Inpatient Per-Diem pricing. -272.00I 6207012292001009 1 29907Pricing Adjustment - Third party liability deductible amount applied. 67.62I 6007012292001009 2LINEITEMCONTROL52182B 20121001201210030230 2.00 2.000 PYY 3418.50 3418.50 0.00PAY0 DEF 6207012292001009 2 19919Pricing Adjustment - Provider Level of Care (LOC) pricing applied. 3418.50I 6007012292001009 3LINEITEMNUMBER52182C 20121001201210030250 2.00 2.000 PYY 1116.56 1116.56 0.00PAY0 DEF 6207012292001009 3 19919Pricing Adjustment - Provider Level of Care (LOC) pricing applied. 1116.56I 6007012292001009 4LINEITEMCONTROL52182D 20121001201210030258 2.00 2.000 PYY 98.50 98.50 0.00PAY0 DEF 6207012292001009 4 19919Pricing Adjustment - Provider Level of Care (LOC) pricing applied. 98.50I 6007012292001009 5LINEITEMCONTROL52182E 20121001201210030270 17.00 17.000 PYY 839.25 839.25 0.00PAY0 DEF 6207012292001009 5 19919Pricing Adjustment - Provider Level of Care (LOC) pricing applied. 839.25I 6007012292001009 6LINEITEMCONTROL52182F 20121001201210030272 5.00 5.000 PYY 591.25 591.25 0.00PAY0 DEF 6207012292001009 6 19919Pricing Adjustment - Provider Level of Care (LOC) pricing applied. 591.25I 6007012292001009 7LINEITEMCONTROL52182G 20121001201210030300 1.00 1.000 PYY 117.25 117.25 0.00PAY0 DEF 6207012292001009 7 19919Pricing Adjustment - Provider Level of Care (LOC) pricing applied. 117.25I 6007012292001009 8LINEITEMCONTROL52182H 20121001201210030301 4.00 4.000 PYY 186.00 186.00 0.00PAY0 DEF 6207012292001009 8 19919Pricing Adjustment - Provider Level of Care (LOC) pricing applied. 186.00I 6007012292001009 9LINEITEMCONTROL52182I 20121001201210030305 3.00 3.000 PYY 200.50 200.50 0.00PAY0 DEF 6207012292001009 9 19919Pricing Adjustment - Provider Level of Care (LOC) pricing applied. 200.50I 6007012292001009 10LINEITEMCONTROL52182J 20121001201210030306 6.00 6.000 PYY 850.25 850.25 0.00PAY0 DEF 6207012292001009 10 19919Pricing Adjustment - Provider Level of Care (LOC) pricing applied. 850.25I 6007012292001009 11LINEITEMCONTROL52182K 20121001201210030324 1.00 1.000 PYY 220.00 220.00 0.00PAY0 DEF 6207012292001009 11 19919Pricing Adjustment - Provider Level of Care (LOC) pricing applied. 220.00I 6007012292001009 12LINEITEMCONTROL52182L 20121001201210030361 1.00 1.000 PYY 516.75 516.75 0.00PAY0 DEF 6207012292001009 12 19919Pricing Adjustment - Provider Level of Care (LOC) pricing applied. 516.75I 6007012292001009 13LINEITEMCONTROL52182M 20121001201210030402 1.00 1.000 PYY 541.25 541.25 0.00PAY0 DEF 6207012292001009 13 19919Pricing Adjustment - Provider Level of Care (LOC) pricing applied. 541.25I 6007012292001009 14LINEITEMCONTROL52182N 20121001201210030450 1.00 1.000 PYY 409.75 409.75 0.00PAY0 DEF 6207012292001009 14 19919Pricing Adjustment - Provider Level of Care (LOC) pricing applied. 409.75I 150100000330_20121018_007.DAT IL 2001770756587NORTHERN WI CTR FOR DD 315P00000X547290000 5009010002388 7012292001008CRIST ENCNOLOC 52183_001_CRIST_46340 1003883786CASPER N THOMAS 69002030L119520706212012070120120731317 317 YPYY 26519.00 29233.00 13038.00 0.00 16195.00 6007012292001008 1LINEITEMCONTROL52183A 20120701201207310190 29.00 29.000 PYY 26319.00 27347.00 14309.00LTCLOCDEF 6207012292001008 1 19907Pricing Adjustment - Third party liability deductible amount applied. 13038.00I 6207012292001008 1 29919Pricing Adjustment - Provider Level of Care (LOC) pricing applied. -1028.00I 6207012292001008 1 30404The member has no Level of Care (LOC) authorization on file or the LOC on file does not match the LOC on the claim. 0.00I 6007012292001008 2LINEITEMCONTROL52183B 20120701201207310185 2.00 2.000 PYY 200.00 1886.00 1886.00LTCLOCDEF 6207012292001008 2 19919Pricing Adjustment - Provider Level of Care (LOC) pricing applied. -1686.00I 6207012292001008 2 20404The member has no Level of Care (LOC) authorization on file or the LOC on file does not match the LOC on the claim. 0.00I 150100000330_20121018_008.DAT IH 2001750586608EDI RESTRICTED HH 251E00000X537131234 5009010002213 7012292001007CRIST ENCSIXB 52184_001_CRIST_46340 1124079876SUTO BONNIE 69002030H11991082333201210012012101470724 YDYY 200.00 0.00 0.00 0.00 0.00 5207012292001007 10074Billing Provider is restricted from submitting electronic claims. 0.00I 6007012292001007 152184A 1003875642CHOHANEY MARILYN 20121001201210010551996000A0B0C0D 1.00 0.000 DYY 100.00 0.00 0.00 6207012292001007 1 11644Valid Other Payer Date required. 100.00D 6007012292001007 252184B 20121014201210140551996000A0B0C0D 1.00 0.000 DYY 100.00 0.00 0.00 6207012292001007 2 11644Valid Other Payer Date required. 100.00D 150100000330_20121018_010.DAT IL 2001770756587NORTHERN WI CTR FOR DD 315P00000X547290000 5009010002269 7012292001019CRIST ENCNINEB 52189_002_CRIST_46340 1003883786CASPER N THOMAS 69002030L119520706212012080120120831317 317 YDYY 0.00 0.00 0.00 0.00 0.00 5207012292001019 11260The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days. 0.00D 5207012292001019 21270The header total billed amount is required and must be greater than zero. 0.00D 6007012292001019 1LINEITEMCONTROL52189A 20120801201208310190 0.00 0.000 DYY 0.00 0.00 0.00 6207012292001019 1 10221The detail billed amount is required. 0.00D 6207012292001019 1 21456Detail Quantity Billed must be greater than zero. 0.00W 6007012292001019 2LINEITEMCONTROL52189B 20120801201208310185 0.00 0.000 DYY 0.00 0.00 0.00 6207012292001019 2 10221The detail billed amount is required. 0.00D 6207012292001019 2 21456Detail Quantity Billed must be greater than zero. 150100000330_20121024_003.DAT PM 200100000016 RASMUSSEN, JAMES 193400000X539111234 5003110740630 7012298001001CRIST ATYPICAL 52185_101_CRIST_46340 69002030M119471017992012102020121020V630 PYY 45.00 23.98 0.00 0.00 23.98 6007012298001001 1 2012102020121020 A0130U1 1.00 1.000 PYY 22.50 11.99 11.99MAXFEEC47 6207012298001001 1 19918Pricing Adjustment - Maximum allowable fee pricing applied. 10.51I 6007012298001001 2 2012102020121020 A0130U2 1.00 1.000 PYY 22.50 11.99 11.99MAXFEEC47 6207012298001001 2 19918Pricing Adjustment - Maximum allowable fee pricing applied. 10.51I 150100000330_20121024_004.DAT PM 2001114920048MERITER 537151507 5003110740630 7012298001002CRIST ATYPICAL 52181_102_CRIST_46340 1376595488CROUSE BYRON 10030019M119471017112012102020121020V745 DNY 24.00 0.00 0.00 0.00 0.00 5207012298001002 11824HMO ID is invalid or not present on encounter claim. 24.00D 5207012298001002 21347Billing provider number is not found. 0.00W 5207012298001002 39817Billing provider number was used to adjudicate the service(s) 0.00I 6007012298001002 152181 2012102020121020 36415 1.00 0.000 DNY 24.00 0.00 0.00 6207012298001002 1 19817Billing provider number was used to adjudicate the service(s) 0.00W 900 143 10