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Minnesota Department of Human Services MN–ITS User Manual
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Outpatient Chemical Dependency (CD) Services

Revised: 03-19-2015

Review MHCP Billing Policy for general billing requirements and the Alcohol and Drug Abuse Services section in the MHCP Provider Manual when submitting CD service claims.

Log in to MN–ITS

  • 1. Log in to MN–ITS
  • 2. From the left menu options:
  • a) Select MN–ITS
  • b) Select Submit DDE Claims (837)
  • c) Select Institutional (837I)
  • Submit an 837I Outpatient CD Claim

    To submit an 837I outpatient CD 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 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

    Select Locations

    When using a consolidated NPI, a table will display showing the locations and taxonomy code(s) information on file with MHCP.

    Select the radio button next to the location where the service(s) was provided.

    Screen Action Button

    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.

    Select Search to have MN–ITS find and display the subscriber associated with the subscriber ID and date of birth entered.

    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 Delete to remove the subscriber information if incorrect.

    Screen Action Button

    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 header (claim) level information that will identify the type of claim and details about the service(s). Information entered on the claim information screen will apply to all lines of the claim.

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

    Field Name*
    (X12 Loop & element)

    Field Instruction

    TOB
    (Loop: 2300, CLM05)

    Enter Type of Bill 891 or 131.

    Payer Claim Control Number
    (Loop: 2300, REF02)

    The Payer Claim Control Number (PCN) field will display when the TOB frequency code 7 (Replacement), or 8 (Void), is entered.

    Enter the 17-digit PCN to identify the previously paid claim to be replaced or void.

    If the claim has been retrieved from a submit response, or the request status feature, the payer claim number will display.

    Statement Date (From)
    (Loop: 2300, DTP03)

    Enter the service start date.

    Statement Date (To)
    (Loop 2300, DTP03)

    Enter the service end date.

    Patient Control Number
    (Loop: 2300, CLM01)

    Enter a unique identifier assigned by you, to help identify the claim for this recipient. The patient control number will be reported on your remittance advice.

    Assignment/ Plan Participation
    (Loop: 2300, CLM07)

    Code indicating whether the provider accepts payment from MHCP

    Defaulted 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.

    Admission Type
    (Loop: 2300, CL101)

    From the dropdown menu options, select admission type 3.

    Admission Source
    (Loop: 2300, CL102)

    From the dropdown menu options, select the appropriate admission source.

    Patient Status
    (Loop: 2300, CL103)

    From the dropdown menu options, select the appropriate patient status.

    Principal Diagnosis Code
    (Loop: 2300, HI01-2)

    Enter the highest level of ICD or other industry accepted code(s) that best describe the condition/reason the recipient needed the service(s).

    ICD-9-CM code

    Definition

    303.0X

    Acute alcoholic intoxication

    303.9X

    Other & unspecified alcohol dependence

    304.0X

    Opioid type dependence

    304.1X

    Barbiturate & similarly acting sedative or hypnotic dependence

    304.2X

    Cocaine dependence

    304.3X

    Cannabis dependence

    304.4X

    Amphetamine & other psychostimulant dependence

    304.5X

    Hallucinogen dependence

    304.6X

    Other specified drug dependence

    304.7X

    Combinations of opioid type drug with any other

    304.8X

    Combinations of drug dependence excluding opioid type drug

    304.9X

    Unspecified drug dependence

    305.0X

    Alcohol abuse

    305.2X

    Cannabis abuse

    305.3X

    Hallucinogen abuse

    305.4X

    Barbiturate & similarly acting sedative or hypnotic abuse

    305.5X

    Opioid abuse

    305.6X

    Cocaine abuse

    305.7X

    Amphetamine or related acting sympathomimetic abuse

    305.8X

    Antidepressant type abuse

    305.9X

    Other, mixed or unspecified drug abuse

    Use the appropriate fifth-digit sub-classification code (for X above):

    0 – unspecified
    1 – continuous
    2 – episodic
    3 – in remission

    Note
    : ICD-9-CM code 305.1 (tobacco use disorder) is not valid for billing the CCDTF for chemical dependency services. If it is billed, the claim will be denied.

    Other Diagnosis Code
    (Loop: 2300, HI01-2)

    Enter the ICD or other industry accepted code(s) that best describes the additional condition/reason the recipient needed the service(s) and select Add. Repeat this process to add all other diagnosis codes.

    To delete the entered code(s), select Delete.

    Situational Claim Information- Select the situational claim information accordion screen to report situational information when required

    Prior Authorization Number
    (Loop: 2300, REF02)

    Enter the service agreement or authorization number. This is a required field for billing the CCDTF.

    Attachment Control Number
    (Loop: 2400, PWK06)

    Enter the Code/number assigned by the provider, identifying an attachment for this claim.

    Review the Electronic Claim Attachments page for MHCP Attachment Criteria and additional information.

    Attachment Type
    (Loop: 2400, PWK01)

    From the dropdown menu options, select the code indicating the type ID and description of the attachment.

    Select Add to add the attachment Control Number and Type ID to the entire claim. To delete entry, select Delete.

    Situational (Continued) Claim Information

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

    Patient Responsibility Amt
    (Loop: 2300, AMT02)

    Enter the amount determined to be the recipient’s responsibility for payment.

    Rendering Provider

    NPI/UMPI
    (Loop: 2310B, NM109)

    If different than the Attending Provider:

  • • Enter the NPI of the Rendering Provider who provided the service
  • • Select Add to add the Rendering Provider NPI
  • • Select the radio button to add the Rendering Provider to the claim
  • • To delete, select Delete
  • Pay-To Provider

    NPI/UMPI
    (Loop: 2010AB, NM109)

    If different than the Billing Provider:

  • • Enter the NPI of the provider who should be paid for the item or service
  • • Select Add to add the other Pay-to Provider NPI
  • • Select the radio button to add the Pay-to Provider to the claim
  • • To delete, select Delete
  • Referring Provider

    NPI/UMPI
    (Loop: 2310A, NM109)

    If different than the Attending Provider:

  • • Enter the NPI of the provider who referred the recipient for the item or service
  • • Select Add to add the Referring Provider NPI
  • • Select the radio button to add the Referring Provider to the claim
  • • To delete, select Delete
  • Attending Provider

    NPI/UMPI
    (Loop: 2310A, NM101)

    Enter the NPI/UMPI of the provider who is attending the service:

  • • Select Add to add the Attending Provider NPI
  • • Select the radio button to add the Attending Provider to the claim
  • • To delete, select Delete
  • Operating Provider

    NPI/UMPI
    (Loop: 2330D, REF02)

    Enter the NPI/UMPI of the provider who did the operating for the service:

  • • Select Add to add the Operating Provider NPI
  • • Select the radio button to add the Operating Provider to the claim
  • • To delete, select Delete
  • Service Facility Location

    NPI/UMPI
    (Loop: 2310E, NM101)

    If different than the Billing Provider:

  • • Enter the NPI of the provider where the services were actually provided
  • • Select Add to add the Service Facility Location NPI
  • • Select the radio button to add Service Facility Location to the claim
  • • To delete, select Delete
  • 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. If no other payers are involved with this claim, select the action button at the bottom of this screen to proceed to the next screen and skip to the Services section of this user guide.

    To report each type of other payer information at the header (claim) level, use the tables below:

    Medicare Part B

    Third Party Liability (TPL)/Other insurance (non-Medicare)

    Medicare Part B and HMO Medicare Risk
    Complete the following fields to report adjustment, payments and denials from Medicare or an HMO Medicare Risk plan.

    Field Name*
    (X12 Loop & Element)

    Field Instruction

    Other Payer Name
    (Loop: 2330B, NM103)

    Enter the name of the Medicare or Medicare Advantage Plan.

    Other Payer Primary ID
    (Loop: 2330B, NM109)

    Enter the NPI listed on the Explanation of Medicare Benefits (EOMB) used to submit the claim to Medicare.

    Claim Filing Indicator
    (Loop: 2320, SBR09)

    From the dropdown menu options, select the code identifying the type of insurance. Once the claim filing indicator is selected, additional fields will display for reporting Medicare information.

    Payer Responsibility
    (Loop: 2320, SBR01)

    From the dropdown menu options, select the code identifying the payer’s level of responsibility for payment of a claim.

    Insured ID
    (Loop: 2330A, NM109)

    Enter the policy holder’s identification number as assigned by the payer.

    Relationship Code
    (Loop: 2320, SBR02)

    From the dropdown menu options, select the relationship of the MHCP subscriber (recipient) to the policy holder.

    Other Payers Claim Control Number
    (Loop: 2330B, REF02)

    Enter the claim number reported on the Medicare EOMB.

    Benefits Assignment
    (
    Loop: 2320, O103)

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

    Default is Yes. Select the correct response if different than the default.

    Release of Information
    (Loop 2320, O106)

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

    Default is Yes. Select the correct response if different than the default.

    Outpatient Adjudication Information (MOA)

    Remark Code
    (Loop: 2320, MOA03-MOA07)

    Enter the Medicare remark code(s) from the Medicare EOMB.

    Select Add to add the code to the claim.

    Section Action buttons

    Select:

  • Delete to remove the Medicare’s information from the claim level
  • Save to save the entered Medicare information
  • Add to add additional prior payer on this claim
  • Screen Action Buttons

    Select:

  • Back to return to the previous screen
  • Cancel to the entire claim entry
  • Continue to proceed to the next screen
  • TPL/Private Insurance
    Complete the following fields to report adjustment, payments and denials from the private insurance (Non-Medicare) carrier.

    If reporting MB-Medicare Part B or 16-Health Maintenance Organization, HMO Medicare Risk insurance uses the instructions in the Medicare/HMO Medicare Risk section above.

    Field Name*
    (X12 Loop & Element)

    Field Instruction

    Other Payer Name
    (Loop: 2330B, NM103)

    Enter the name of the TPL insurance payer.
    Do not use symbols such as slashes, dashes, periods or plus signs

    Other Payer Primary ID
    (Loop: 2330B, NM109)

    Enter the Identifier of the insurance carrier. (This is available on the recipient’s eligibility response).
    Do not use symbols such as slashes, dashes, periods or plus signs

    Claim Filing Indicator
    (Loop: 2320, SBR09)

    From the dropdown menu options, select the code identifying type of insurance. Once the claim filing indicator is selected, additional fields will display for reporting TPL/private insurance.

    Payer Responsibility
    (Loop: 2320, SBR01)

    From the dropdown menu options, select the code identifying the insurance carrier’s level of responsibility for payment.

    Insured ID
    (Loop: 2330A, NM109)

    Enter the policy holder’s identification number as assigned by the payer.

    Relationship Code
    (Loop: 2320, SBR02)

    From the dropdown menu options, select the relationship of the MHCP subscriber (recipient) to the policy holder.

    If reporting adjustments at the claim (header) level for TPL complete the remaining Claim Level Adjustments.

    If reporting adjustment at the line level select the Save action button in this section and then scroll to down to the Other Insurance Information section of this screen

    Claim Adjustment Group Code
    (Loop: 2320, CAS01)

    For header (claim) level adjustment, select the code identifying the general category of the payment adjustment for this line from the dropdown menu options.

    Adj Reason Code
    (Loop: 2320, CAS03)

    Enter the code identifying the reason the adjustment was made.

    Adj Amount
    (Loop: 2320, CAS03)

    Enter the total adjusted dollar amount for this line.

    Payer Paid Amount
    (Loop: 2320, AMT02)

    When reporting TPL adjustments at the claim (header level), enter the prior payer paid amount.

    Non-Covered Charge Amount
    (Loop: 2320, AMT02)

    When reporting TPL at the claim (header level), enter the non-covered charge amount.

    Benefits Assignment
    (Loop: 2320, O103)

    Other Insurance Information: The determination of the policy holder or person authorized to act on their behalf, to give the other payer permission to pay the provider directly.

    Default is Yes. Select the correct response if different than the default

    Release of Information
    (Loop 2320, O106)

    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

    Section Action Buttons

    Select:

  • Delete to remove this payer from the claim level
  • Save to include this TPL/private insurance information on the claim
  • Add to add additional prior payer on this claim
  • Screen Action Buttons

    Select:

  • Back to return to the previous screen
  • Cancel to cancel the entire 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 the date the item or service was provided, dispensed or delivered to the recipient.

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

    Enter the last date of a consecutive date range, the service was provided only when required.

    Revenue Code
    (Loop: 2400,SV201)

    Enter the appropriate revenue code used to specify the service line item detail for a health care institution.

    Reference the Revenue & Procedure Codes table under Billing on the Alcohol and Drug Abuse Services section of the MHCP Provider Manual for appropriate codes.

    Line Item Charge Amount
    (Loop: 2400, SV102)

    Enter the total charge for the service.

    Unit Code
    (Loop: 2400, SV204)

    Enter the unit(s) or manner in which a measurement has been taken.

    Service Unit Count
    (Loop: 2400, SV104)

    Enter the quantity of units, time, days, visits, services or treatments for the service.

    Procedure Code
    (Loop: 2400, SV101-2)

    Enter the CPT or HCPCS code identifying the product or service.

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

    Enter the modifier that clarifies or further identifies the service indicated in the procedure code field.

    NDC
    (Loop: 2410, LIN03)

    When appropriate, enter the National Drug Code (NDC) required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. Drugs and biologics reported in this segment are a further specification of service(s) described in the SV1 segment of this Service Line Loop ID-2400.

    NDC Count
    (Loop: 2410, CPT04)

    Enter the National Drug Unit Count– A numeric value used to specify pricing information.

    CODE Qualifier
    (Loop: 2410, CTP05-1)

    Enter the code specifying the units in which a value is being expressed, or manner in which a measurement has been taken.

    When no other payer information is required for this line, skip to the Screen Action Button section below.

    Other Payer – Use this accordion screen when reporting other payers (Medicare Part B and/or TPL) payments or denials for the line item or service

    Other Payer Primary Identifier
    (Loop: 2430, SVD01)

    From the dropdown menu options select the identifier of other payer entered on the COB screen.

    Service Line Paid Amount
    (Loop: 2430, SVD02)

    Enter the total dollar amount the other payer paid for this service line.

    Adjudication - Payment Date
    (Loop: 2430, DTP03)

    Enter the date of payment or denial determination by the Medicare payer for this service line.

    This field is not required for TPL/private insurance reporting.

    Paid Unit Count
    (Loop: 2430,SVD05)

    Enter the number of units identified as being paid from the other payer’s EOB/EOMB.

    Claim Adjustment Group Code
    (Loop: 2430, CAS01)

    Enter the code identifying the general category of the payment adjustment for this line.

    Adjustment Reason Code
    (Loop: 2430, CAS02)

    Enter the code identifying the reason the adjustment was made.

    Adjustment Amount
    (Loop: 2430, CAS03)

    Enter the total dollar amount of the specific adjustment for the reason code entered on this service line.

    Adjustment Quantity
    (Loop: 2430, CAS04)

    Use this field to enter the number of units not paid when the units paid are different than the number of units submitted on the claim sent to the other payer.

    Section Action Buttons

    Select:

  • Add to add the specific adjustment to this line
  • Save once all adjustment entries for the specific line has been added
  • Delete (next to the save button) to cancel all the line item adjustment entries for this line
  • Repeat the Other Payer COB Line Adjustment Entries to report all adjustments for this line as noted on the EOB /EOMB.

    Screen Action Button

    Select:

  • Save/View Line(s) to save and view all entered lines in the service line table
  • Edit to return and edit a particular line
  • Copy to save and copy the entire line information (including other payer information) to an additional service line
  • Delete to delete the entire service line information (including other payer information)
  • Add to add a new blank service line
  • Claim Action Button

    Select:

  • Save/View Lines(s) once all service lines have been entered
  • Validate to determine if the claim has met the HIPAA-compliant and certain basic requirements at both the claim and line level information
  • Submit to identify if the claim will be paid, denied, or suspended for review at the claim and service 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 validate and submit claim response.

    Other Providers

    Referring Provider

    (Loop 2420D, NM109)

    Any Provider listed here will override at header level.

  • • From the Other Providers accordion select Referring Provider
  • • Enter NPI of the provider who is not already reported at claim level as the Attending Provider or the Referring provider.
  • • When reporting the NPI use the recipient for the service associated with that line
  • • Select the Add action button in this section to add the provider information
  • • Select the radio button to add the provider to the claim
  • Copy, Replace or Void the Claim

    After submitting the claim and receiving a claim response, the Copy, Replace, or Void action buttons will appear at the bottom of the claim response screen. Use each of these features to do the following:
    Copy
    – Copy this exact claim. You may want to do this if you have to resubmit your claim with corrections
    Replace
    - If the claim paid incorrectly (including zero pay) and you want to resubmit to replace the previously paid claim. The original paid claim will be taken back and replaced with the new claim submission.
    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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