Claims and Billing

The most efficient method of claim submission is electronic. For details on how to submit claims electronically, contact Janet at (608)223-5858.

• Free Access to GAMP Providers submitting electronically
   
• Requires Internet Access
   
• Real-time approvals & denials
   
• WPS membership segments

• Timely file for claims 1yr from date of service
• Response time is 45 days for electronic, 60 days for paper.
• WPS scans paper claims, which must be aligned. They are not entered manually.

UB-92 or HFCA 1500 Paper Claims Only
Response time approximately 90 days

 

If problems occur with electronic error reports, call the support line at 1-608-221-7115.

If a request needs to be researched, provide the following:

 

Claims Processing

 

Claims passing initial edits will either be paid or rejected. The results of claims processed are reported on an Explanation of Benefits from WPS. If a claim does not pass initial edits, it means that there was no membership segment on which to process the claim. These claims appear as error messages on electronic bulletin boards or returned paper claims. Providers not having access to the GAMP Eligibility System should contact the GAMP office at (414)289-5700 to determine patient eligibility.

Common Rejection Reasons

1. Reject 16 - Invalid CPT or ICD-9 Code. Please review coding on claim and resubmit.
   
    
2. Reject 28 - Outside effective dates before coverage. Providers not having access to the GAMP Eligibility System should contact the GAMP office.
   
    
3. Reject 46 - Non-covered service. The following ICD-9 Codes will ALWAYS be rejected.
   
   
   • Routine Vaccinations
     V03.0-V03.3
     V04.4
     V06.0
     
      
   • Fertility Diagnosis
     V26.1-V26.9
     606-606.1
     606.8
     606.9
     628.0-628.9
     
      
   • Organ Transplants
     V42-V42.9
     996.8-996.89
     V59.0-V59.9
     V45.76
     996.8
     
      
   • Abortion
     635.0-638.9
     
      
   • Mental Health and Substance Abuse
     290.0-319.9
     Except 291.0 and 292.0
     
      
   • Administrative Services
     V61.1
     V70.3-V70-7
     
     If you receive a Reject 46, please review the diagnosis code to determine if another code would be more appropriate. If so, please use the more appropriate code and resubmit the claim.
     
      
4. Reject 79 - Workmen's Compensation. Anytime you indicate that a claim was related to the patient's occupation or employment, it will be rejected.
   
    
5. V Code Rejections. The WPS Claims System employs a "Value Coder" rebundling system. The GAMP Program aligns itself with WPS policy except in extraordinary situations.
   
    
6. Reject 18. Duplicate Claim. Call the GAMP Claims Department immediately. Do not resubmit a Reject 18 Claim.
   
    
7. Reject 27 - Outside effective dates after coverage. Providers not having access to the GAMP Eligibility System should contact the GAMP office.

Other rejection reasons:

 

• RA Rejection - Non-authorized Tax ID number, CPT Code, DX Code, or suffix not loaded.
  (No prior authorization for service obatined)
  
   
• Claim not properly aligned on form (paper claims)
  
   
• Reject 28's and 27's (Outside effective dates) - Bill submitted too soon; No continuing care date.
  
  Family Planning Rejection
• Services covered under T19: Family planning diagnosis regardless of CPT code V25 - V25.9 and 72.3
  (For CPT Code - That can Rej. go to "Family Planning" at www.dhfs.state.wi.us)
  
  Funding Rejection
• K-6: GAMP contract maximum reached. (by provider)
  
   
• K-7: A Title XIX GAMP Reimbursement balance exists. Monetary services suspended. Contact Sandra at: (414) 289-6251
  
  Inpatient Hosptial
• Reject 46 - Non-covered services or no authorization ER inpatient admissions.
• Reject 62 - No prior authorization for service obtained.
• Contact UM at (414) 289-6731. Incomplete info, no discharge date
  
  ______________________________________________________
  
  Appeals & Tracers
  
  

  Requests must be labled with proper instructions to expedite your claim and should be sent to the following address below.

  
  
  Appeals
  
  

  Packet must include the HCFA or UB copy of original rejected EOB(?), and medical records and proof of authorization if obtained.

  
  
  Tracer
  
  

  Must include patient name, DOB, SS#, DOS, amount of claim, and the provider federal tax ID number.

  
  
  

  Due to high volume, requests are handled in order as received (first come basis) and a written response will be returned upon completion of review.

  
  
  Milwaukee County General Assistance Medical Program
  1220 W. Vliet St.
  Milwaukee, WI 53205
  ATTN: Claims
  
  Click here for a sample claims processing letter.
  
  ______________________________________________________
  
  Commonly Asked Questions
  
  Q1. I am on GAMP and I have received a bill.
  
  
  • Contact the name on the statement to make sure they are aware you are on GAMP.
    
    NOTE: GAMP does not cover all services.
    GAMP does not cover services outside Milwaukee County,Regardless of Emergency level.
    GAMP does not cover unauthorized emergency room visits.
    
    To seek EMR services you MUST have prior authorization from the *following:
    
     
  • Contact your clinic during office hours
    
    or
    
     
  • Contact the GAMP nurse line, which is available 24/7 to answer your questions: 1-888-833-7913
    
    * These are the only two valid authorizations.
    
     
  Q2. I just got approved for GAMP but I can't get prescriptions.
  
  
  • There is a 72 hour window for eligibility to reach the pharmacy database.
    
     
  Q3. How do I get refunded for the meds paid for.
  
  
  • You must seek refunds from the pharmacy. GAMP does not give refunds.
  
  
  
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