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Minnesota Department of Human Services MN–ITS User Manual
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Billing for HIV Case Management

Revised: 09-16-2015

Review MHCP Billing Policy for general billing requirements and guidance when submitting claims.
Refer to additional billing requirements in the service specific section of the MHCP Provider Manual before you submit the claim for services.

Log in to MN–ITS

  • 1. Log in to MN–ITS
  • 2. From the left menu:
  • a) Select MN–ITS
  • b) Select Submit DDE Claims (837)
  • c) Select Professional (837P)
  • Submit the Claim

    To submit the claim follow the instructions in the tables below for each of the following claim screens:

    Billing Provider

    Subscriber

    Claim Information

    Coordination of Benefits (COB)

    Services

    Billing Provider

    The billing provider screen auto-populates with the information in the enrollment profile for the NPI/UMPI used to login to MN–ITS. If changes are needed, use the Change of Enrollment Information to notify MHCP Provider Enrollment.

    Refer to the table below for instruction and information about each field on this screen.

    Field Name *
    (X12 Loop & element)

    Field Instruction

    Organization
    (Loop: 2010AA, NM103 (last or organization)
    NM104 (first)

    The name of the Billing Provider: This could be an Organization, business or the Name of an individual provider identified by the NPI used to login to MN–ITS.

    Taxonomy
    (Loop: 2000A, PRV03)

    This field only displays information when a Health care provider specialty/ location code has been added to the provider file.

    If multiple taxonomy codes have been added, additional information will display. Select the radio button to identify the appropriate location for this claim.

    Address 1
    (Loop: 2010AA, N301)

    The first address line reported on the provider file

    Address 2
    (Loop: 2010AA, N302)

    The second address line reported on the provider file

    City
    (Loop: 2010AA, N401)

    The city name for the address in address fields 1 and 2

    State
    (Loop: 2010AA, N402)

    The state name for the address in address fields 1 and 2

    Zip
    (Loop: 2010AA, N403)

    The zip code for the address in address fields 1 and 2

    Telephone
    (Loop: 2010AA, PER04)

    Telephone number reported on the provider file

    Screen Action Buttons

    Select:

  • Cancel to cancel the claim entry
  • Continue to proceed to the next screen
  • Subscriber

    Use the Subscriber screen to report the recipient who received the service(s) reported on this claim.

    Refer to the table below for instruction and information about each field on this screen.

    Field Name*
    (X12 loop & element)

    Field Instruction

    Subscriber ID
    (Loop: 2010BA, NM109)

    Enter the 8-digit MHCP ID for the subscriber (recipient) indicated on the MHCP member identification card

    Birth Date
    (Loop: 2010BA, DMG02)

    Enter the birth date of the subscriber (MMDDCCYY).

    Select the Search action button.

    The following fields auto-populate based on the information entered in the Subscriber ID and Birth Date fields

    Subscriber First Name
    (Loop: 2010BA, NM104)

    The first name of the subscriber

    Middle Initial
    (Loop: 2010BA, NM105)

    The middle initial of the subscriber

    Last Name
    (Loop: 2010BA,NM103)

    The last name of the subscriber

    Gender
    (Loop: 2010BA, DMG03)

    The gender of the subscriber

    Select the Delete action button in this section to remove the subscriber information if not correct.

    Screen Action Buttons

    Select:

  • Back to go back to the previous screen
  • Cancel to cancel the claim entry
  • Continue to proceed to the next screen
  • Claim Information

    Use the Claim Information screen(s) to report claim level information that will identify the type of claim and details about the service(s).

    Refer to the table below for instruction and information about each field on this screen.

    Field Name*
    (X12 Loop & element)

    Field Instruction

    Claim Frequency Code
    (Loop: 2300, CLM05-3)

    Specifies if the claim is an original, replacement or void

    Default is original

    If hand keying a claim to be replaced or voided, select the radio button in front of replacement or void.

    If the claim has been retrieved from a submit response or from the request status feature, the claim will display with the option selected.

    Payer Claim Control Number
    (Loop: 2300, REF02)

    Identifies the previously processed claim when the claim frequency code is replacement or void.

    The payer claim control field is protected until replacement or void is selected. Once selected, enter the payer claim control number to be replaced or voided.

    If the claim has been retrieved from a submit response or the request status feature, the claim number will auto-populate.

    Place of Service
    (Loop: 2300 CLM05-1)

    From the drop down menu, select the code that identifies where the service was performed.

    Default is 11 (office)

    Patient Control Number
    (Loop: 2300, CLM01)

    Enter a unique identifier to help identify this claim for this recipient. This will be reported on the remittance advice.

    Assignment/ Plan Participation
    (Loop: 2300, CLM07)

    Code indicating whether the provider accepts payment from MHCP

    Default is Assigned

    Select the correct response if different than the default.

    Benefits Assignment
    (Loop: 2300, CLM08)

    The determination of the policy holder or person authorized to act on their behalf, to give MHCP permission to pay the provider directly

    Default is Yes

    Select the correct response if different than the default.

    Release of Information
    (Loop: 2300, CLM09)

    The determination of whether the provider has a signed statement by the recipient on file, authorizing the release of medical data to other organizations

    Default is Yes

    Select the correct response if different than the default.

    Provider Indicator
    (Loop: 2300, CLM06)

    Identifies whether the provider’s signature is on file, certifying services were performed by the provider

    Default is Signature on File

    Select the correct response if different than the default.

    Diagnosis Type Code
    (Loop: 2300, HI01-1)

    From the drop down menu, select whether the diagnosis code reported on this claim is in the ICD-9 or ICD-10 classification.

    Diagnosis Code
    (Loop: 2300, HI01-2, HI02-2, HI03-2, HI04-2)

    Enter the appropriate ICD code for HIV.

    Select the Add action button in this section to include the diagnosis code on the claim. Once a diagnosis code is entered it will display in the table below. Repeat the code entry to report all diagnoses for the claim.

    Select the Delete button next to a diagnosis code to remove it from the claim.

    Situational Claim Information – Select the situational claim information accordion panel to report situational information when required.

    Prior Authorization Number
    (Loop: 2300, REF02)

    When authorization is required, enter the approved authorization number.

    Medical Record Number
    (Loop: 2300, REF02)

    This field is not required for HIV Case Management.

    Claim Note
    (Loop: 2300, NTE02)

    Use only when additional information is required.
    Enter a free form description to provide additional information about this claim.

    Attachment Control Number
    (Loop: 2300, PWK06)

    Use only when an attachment is required.
    Enter a code/number, assigned by the provider, identifying an attachment for this claim. MHCP uses only the first 30 characters when matching the attachments to the claim

    Type
    (Loop: 2300, PWK01)

    Use only when an attachment is required.
    From the drop down select the code indicating the attachment type ID and the description of the attachment.

    Select the Add action button in this section to include the attachment information on the claim.

    Contact Name
    (Loop: 2010CA, PER02)

    This field is not required for HIV Case Management.

    Telephone Number
    (Loop: 2010CA, PER04)

    This field is not required for HIV Case Management.

    Extension
    (Loop: 2010CA, PER06)

    This field is not required for HIV Case Management.

    Related Causes
    (Loop: 2300, CLM11-1)

    This field is not required for HIV Case Management.

    Date of Accident
    (Loop: 2300, DTP03)

    This field is not required for HIV Case Management.

    Certification Condition
    (Loop: 2300, CRC02)

    This field is not required for HIV Case Management.

    Condition Code
    (Loop: 2300, CRC03, CRC04, CRC05)

    This field is not required for HIV Case Management.

    Situational Ambulance Information- Select the situational claim information accordion planel to report situational information for ambulance when required.

    Certification Code(Loop: 2300, CRC102)

    This field is not required for HIV Case Management.

    Condition Code
    (Loop: 2300, CRC03, CRC04, CRC05, CRC06, CRC07)

    This field is not required for HIV Case Management.

    Patient Weight
    (Loop: 2300, CR102)

    This field is not required for HIV Case Management.

    Transport Distance
    (Loop: 2300, CR106)

    This field is not required for HIV Case Management.

    Transport Reason Code
    (Loop:2300 CR104)

    This field is not required for HIV Case Management.

    Round Trip Purpose Description
    (Loop: 2300, CR109)

    This field is not required for HIV Case Management.

    Stretcher Purpose Description
    (Loop: 2300, CR110)

    This field is not required for HIV Case Management.

    Pickup Address
    (Loop: 2310E, N301)

    This field is not required for HIV Case Management.

    Address {contd}
    (Loop: 2310E, N302)

    This field is not required for HIV Case Management.

    City
    (Loop: 2310E, N401)

    This field is not required for HIV Case Management.

    State
    (Loop: 2310E, N402)

    This field is not required for HIV Case Management.

    Zip Code
    (Loop: 2310E, N403)

    This field is not required for HIV Case Management.

    Dropoff Address
    (Loop: 2310F, N301)

    This field is not required for HIV Case Management.

    Address {contd}
    (Loop: 2310F, N302)

    This field is not required for HIV Case Management.

    City
    (Loop: 2310F, N401)

    This field is not required for HIV Case Management.

    State
    (Loop: 2310F, N402)

    This field is not required for HIV Case Management.

    Zip Code
    (Loop: 2310F, N403)

    This field is not required for HIV Case Management.

    Other Providers (Claim Level) – Select the Other Providers accordion panel when required to report other provider information.

    Rendering Provider

    NPI/UMPI
    (Loop: 2310B, NM109)

    This field is not required for HIV Case Management.

    Pay-To Provider

    NPI/UMPI
    (Loop: 2010AB, NM109)

    This field is not required for HIV Case Management.

    Referring Provider

    NPI/UMPI
    (Loop: 2310A, NM109)

    This field is not required for HIV Case Management.

    Service Facility Location

    NPI/UMPI
    (Loop: 2310C, NM109)

    This field is not required for HIV Case Management.

    Supervising Provider

    NPI/UMPI
    (Loop: 2310D, NM109)

    This field is not required for HIV Case Management.

    Screen Action Buttons

    Select:

  • Back to go back to the previous screen
  • Cancel to cancel the claim entry
  • Continue to proceed to the next screen
  • Coordination of Benefits (COB)

    Use the COB screen to report other payers, private insurance (TPL) or Medicare’s financial responsibility for all or a portion of the claim.

    The COB screen is not required for HIV Case Management. Select Continue to move to the Services screen.

    Screen Action Buttons

    Select:

  • Back to go back to the previous screen
  • Cancel to cancel the claim entry
  • Continue to proceed to the next screen
  • Services

    Use the Services screen to describe details for each service being billed. Information reported on a service line will override information reported at the header (claim) level for that line.

    Refer to the table below for instruction and information about each field on this screen.

    Field Name*
    (X12 Loop and element)

    Field Instruction

    Date of Service (From)
    (Loop: 2400, DTP03)

    Enter each date services were provided, on separate service lines (MMDDCCYY). Bill only for services provided within the same calendar month.

    Date of Service (To)
    (Loop: 2400, DTP03 * RD8* required in DTP02 when TO date is reported)

    This field is not required for HIV Case Management.

    Place of Service
    (Loop: 2400, SV105)

    From the drop down menu, select the code that identifies where the service was performed, only when different than what was reported on the Claim Information screen.

    Procedure Code
    (Loop: 2400, SV101-2)

    Enter T1016.

    Procedure Code Modifier(s)
    (Loop: 2400, SV101-3, SV101-4, SV101-5, SV101-6)

    This field is not required for HIV Case Management.

    Diagnosis Pointer
    (Loop: 2400, SV107-1, SV107-2, SV107-3, SV107-4)

    From the drop down menu, select the appropriate ICD code for HIV.

    Line Item Charge Amount
    (Loop: 2400, SV102)

    Enter your usual and customary charge for this service. If other payers were involved with the determination of this claim/service line item, enter the charge that was submitted on the claim to the other payer.

    Service Unit Count
    (Loop: 2400, SV104)

    Enter the number of units for the service.

    Other Payer – Select the Other Payer accordion panel when reporting other payer (Medicare and/or TPL) payments or denials at the service (line) level.

    Other Payer Primary Identifier
    (Loop: 2430, SVD01)

    This field is not required for HIV Case Management.

    Service Line Paid Amount
    (Loop: 2430, SVD02)

    This field is not required for HIV Case Management.

    Adjudication - Payment Date
    (Loop: 2430, DTP03)

    This field is not required for HIV Case Management.

    Paid Unit Count
    (Loop: 2430,SVD05)

    This field is not required for HIV Case Management.

    Claim Adjustment Group Code
    (Loop: 2430, CAS01)

    This field is not required for HIV Case Management.

    Adjustment Reason Code
    (Loop: 2430, CAS02)

    This field is not required for HIV Case Management.

    Adjustment Amount
    (Loop: 2430, CAS03)

    This field is not required for HIV Case Management.

    Adjustment Quantity
    (Loop: 2430, CAS04)

    This field is not required for HIV Case Management.

    Situational Services – Select the Situational Services accordion panel to report additional information about the service line.

    Prior Authorization
    (Loop: 2400, REF02)

    Enter the approved authorization number for the service line, when different than the authorization number reported on the Claim Information screen.

    Ambulance Patient Count
    (Loop: 2400, QTY02)

    This field is not required for HIV Case Management.

    Line Note
    (Loop: 2400, NTE02)

    Enter a free form description to provide additional information about this service line, when required.

    Qualifier
    (Loop: 2400, K301)

    This field is not required for HIV Case Management.

    Value
    (Loop: 2400, K301)

    This field is not required for HIV Case Management.

    Description
    (Loop: 2400, SV101-7)

    This field is not required for HIV Case Management.

    NDC
    (Loop: 2410, LIN03)

    This field is not required for HIV Case Management.

    NDC Count
    (Loop: 2410, CPT04)

    This field is not required for HIV Case Management.

    CODE Qualifier
    (Loop: 2410, CTP05-1)

    This field is not required for HIV Case Management.

    Situational Ambulance Information- Select the Situational Ambulance Services accordion panel to report ambulance services information on the service line, if different than what was reported at the claim level.

    Certification Condition
    (Loop: 2400, CRC02)

    This field is not required for HIV Case Management.

    Condition Code
    (Loop: 2400, CRC03, CRC04, CRC05, CRC06, CRC07)

    This field is not required for HIV Case Management.

    Patient Weight
    (Loop 2400, CR102)

    This field is not required for HIV Case Management.

    Transport Distance
    (Loop 2400, CR106)

    This field is not required for HIV Case Management.

    Transport Reason Code
    (Loop 2400, CR104)

    This field is not required for HIV Case Management.

    Round Trip Purpose Description
    (Loop: 2400, CR109)

    This field is not required for HIV Case Management.

    Stretcher Purpose Description
    (Loop: 2400, CR110)

    This field is not required for HIV Case Management.

    Pickup Address
    (Loop 2420G, N301)

    This field is not required for HIV Case Management.

    Address (contd)

    (Loop: 2420G, N302)

    This field is not required for HIV Case Management.

    City
    (Loop: 2420G, N401)

    This field is not required for HIV Case Management.

    State
    (Loop: 2420G, N402)

    This field is not required for HIV Case Management.

    Zip Code
    (Loop: 2420G, N403)

    This field is not required for HIV Case Management.

    Dropoff Address
    (Loop: 2420H, N301)

    This field is not required for HIV Case Management.

    Address (contd)
    (Loop: 2420H, N302)

    This field is not required for HIV Case Management.

    City
    (Loop: 2420H, N401)

    This field is not required for HIV Case Management.

    State
    (Loop: 2420H, N402)

    This field is not required for HIV Case Management.

    Zip Code
    (Loop: 2420H, N403)

    This field is not required for HIV Case Management.

    Other Providers – Select the Other Providers accordion panel when required to report other provider information on the service line, if different than what was reported at the claim level.

    Rendering Provider

    NPI/UMPI
    (Loop: 2420A, NM109)

    This field is not required for HIV Case Management.

    Referring Provider

    NPI/UMPI
    (Loop: 2420F, NM109)

    This field is not required for HIV Case Management.

    Service Facility Location

    NPI/UMPI
    (Loop: 2420C, NM109)

    This field is not required for HIV Case Management.

    Ordering Provider

    NPI/UMPI
    (Loop: 2420E, NM109)

    This field is not required for HIV Case Management.

    Supervising Provider

    NPI/UMPI
    (Loop: 2420D, NM109)

    This field is not required for HIV Case Management.

    Section Action Buttons

    Select:

  • Save/View Line(s) to save the service line and view a summary table, displaying information for each line on the claim
  • Copy to save and copy the information to a duplicate service line. The information populated in the new service line is identical to what was entered on the copied line. Edit the information in each section of the new service line, as needed
  • Delete to remove the service line from the claim
  • Section Action Buttons

    Once saved, a summary table will display the following information for each line on the claim:

  • • Line number
  • • From and to date
  • • Procedure code
  • • Modifier
  • • Charge
  • • Place of service
  • Select:

  • Edit, next to a line, to change the information for that service line
  • Add to create a new service line that is blank. Repeat the service line entry steps to add all lines to the claim
  • Screen Action Buttons

    Select:

  • Back to go back to the previous screen
  • Cancel to cancel the claim entry
  • Validate to determine if the claim has met the HIPAA-compliant and certain basic requirements at both the claim and line level information. Use the Washington Publishing Company (WPC) health care codes to identify the claim status category and claim status codes displayed on the validate response
  • Submit to identify if the claim will be paid, denied or suspended for review at the claim level and the line level of the claim. Use the Washington Publishing Company (WPC) health care codes lists to identify the claim status category and claim status codes displayed on the claim response
  • Copy, Replace or Void the Claim

    After submitting the claim and receiving a claim response, an option to Copy, Replace, or Void the claim is available.
    Use each of these features to do the following:
    Copy
    - To correct an error of a denied claim or to copy information from other similar claims previously submitted
    Replace
    - If the claim paid, but paid incorrectly or a line item was denied. The user may access the claim, correct the information and resubmit. The original paid amount will be taken back and replaced with the correct information on the replacement claim
    Void
    - If the claim was submitted in error. This deletes the claim and takes the payment back

    Review the Copy, Replace or Void User Guide for step-by-step instructions when completing these transactions.

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