Wis. ForwardHealth Online Handbook, Hospice, Topic #605

Other insurance indicators are used to report results of commercial health insurance billing and to report when existing insurance

was not billed according to Wisconsin Medicaid expectations. Providers are required to use these indicators as applicable on

professional, institutional, or dental claims or on the Explanation of Medical Benefits form, as applicable, submitted for members

with commercial health insurance. The intentional misuse of other insurance indicators to obtain inappropriate reimbursement

constitutes fraud.

Other insurance indicators identify the status and availability of commercial health insurance. The indicators allow providers to be

reimbursed correctly when the following occur:

• Commercial health insurance exists, does not apply, or when, for some valid reason, the provider is unable to obtain such

reimbursement by reasonable means.

• Commercial health insurance does not cover the service provided.

• Full or partial payment was made by commercial health insurance.

Code Description

OI-P PAID in part or in full by commercial health insurance, and/or was applied toward the deductible,

Note: The provider may not use OI-D or OI-Y if the member is covered by a commercial HMO and the HMO denied payment

because an otherwise covered service was not rendered by a designated provider. Services covered by a commercial HMO are

not reimbursable by ForwardHealth except for the copay and deductible amounts. Providers who receive a capitation payment

from the commercial HMO may not bill ForwardHealth for services that are included in the capitation payment.

Providers should not use other insurance indicators when the following occur:

• Wisconsin's EVS (Enrollment Verification System) indicates no commercial health insurance for the DOS (date of service).

• The service does not require other health insurance billing.

• Claim denials from other payers relating to NPI (National Provider Identifier) and related data should be resolved with that

payer and not submitted to ForwardHealth. Payments made in these situations may be recouped.

Documentation Requirements

Providers are required to prepare and maintain truthful, accurate, complete, legible, and concise documentation of efforts to bill

commercial health insurance sources to substantiate other insurance indicators used on any claim, according to Wis. Admin. Code

§ DHS 106.02(9)(a).