DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Medicaid Services F-01234 (04/2018) FORWARDHEALTH EXPLANATION OF MEDICAL BENEFITS INSTRUCTIONS: Type or print clearly. If submitting a multiple page claim, include this form for each detail being billed. Refer to the Explanation of Medical Benefits Instructions, F-01234A, for more information. Providers should submit one completed form per payer. SECTION I PAYER INFORMATION – 1. Medicare Medicare Advantage Commercial Insurance SECTION II MEMBER INFORMATION – 2. Name Member (Last Name, First Name, Middle Initial) 3. Member ID 4. Relationship to Policyholder – SECTION III PRIMARY POLICYHOLDER INFORMATION – 5. Name Primary Policyholder (Last Name, First Name, Middle Initial) 6. Primary Policy ID 7. Policy / Group Number – SECTION IV HEADER ADJUDICATION INFORMATION – 8. Date Payer 11. Paid / Deny 13. Allowed 15. Coins PR 2 17. Noncovered CO 19. Blood Deduct PR 66 21. ANSI Reason Codes Processed 96 ANSI Rsn Amount Code 9. From Date of 12. Billed 14. Paid 16. Deductible 18. Copay PR 3 20. Psych Reduct PR 122 Service Amount PR 1 10. To Date of Service SECTION V DETAIL ADJUDICATION INFORMATION – Detail 22. Date Payer 25. Paid / Deny 27. Proc. 29. Allowed 31. Coins 33. Noncovered 35. Blood 37. ANSI Reason Codes No. Processed Code PR 2 CO 96 Deduct PR 66 ANSI Rsn Amount Code 23. From Date 26. Billed 28. 30. Paid 32. 34. Copay PR 3 36. Psych of Service Amount Revenue Deductible Reduct PR Code PR 1 122 24. To Date of Service Detail 22. 25. 27. 29. 31. 33. 35. 37. No. 23. 26. 28. 30. 32. 34. 36. 24. Detail 22. 25. 27. 29. 31. 33. 35. 37. No. 23. 26. 28. 30. 32. 34. 36. 24. Detail 22. 25. 27. 29. 31. 33. 35. 37. No. 23. 26. 28. 30. 32. 34. 36. 24. (Continued) EXPLANATION OF MEDICAL BENEFITS 2 of 2
DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Medicaid Services F-01234 (04/2018) FORWARDHEALTH EXPLANATION OF MEDICAL BENEFITS INSTRUCTIONS: Type or print clearly. If submitting a multiple page claim, include this form for each detail being billed. Refer to the Explanation of Medical Benefits Instructions, F-01234A, for more information. Providers should submit one completed form per payer. SECTION I – PAYER INFORMATION 1. Medicare Medicare Advantage Commercial Insurance SECTION II – MEMBER INFORMATION 2. Name – Member (Last Name, First Name, Middle Initial) 3. Member ID 4. Relationship to Policyholder SECTION III – PRIMARY POLICYHOLDER INFORMATION 5. Name – Primary Policyholder (Last Name, First Name, Middle Initial) 6. Primary Policy ID 7. Policy / Group Number SECTION IV – HEADER ADJUDICATION INFORMATION 8. Date Payer Processed 11. Paid / Deny 13. Allowed 15. Coins PR 2 17. Noncovered CO 96 19. Blood Deduct PR 66 21. ANSI Reason Codes ANSI Rsn Code Amount 9. From Date of Service 12. Billed Amount 14. Paid 16. Deductible PR 1 18. Copay PR 3 20. Psych Reduct PR 122 10. To Date of Service SECTION V – DETAIL ADJUDICATION INFORMATION Detail No. 22. Date Payer Processed 25. Paid / Deny 27. Proc. Code 29. Allowed 31. Coins PR 2 33. Noncovered CO 96 35. Blood Deduct PR 66 37. ANSI Reason Codes ANSI Rsn Code Amount 23. From Date of Service 26. Billed Amount 28. Revenue Code 30. Paid 32. Deductible PR 1 34. Copay PR 3 36. Psych Reduct PR 122 24. To Date of Service Detail No. 22. 25. 27. 29. 31. 33. 35. 37. 23. 26. 28. 30. 32. 34. 36. 24. Detail No. 22. 25. 27. 29. 31. 33. 35. 37. 23. 26. 28. 30. 32. 34. 36. 24. Detail No. 22. 25. 27. 29. 31. 33. 35. 37. 23. 26. 28. 30. 32. 34. 36. 24. (Continued) EXPLANATION OF MEDICAL BENEFITS 2 of 2
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