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Minnesota Department of Human Services MN–ITS User Manual
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Home Care (Non-PCA) Services

Revised: 12-07-2015

Review MHCP Billing Policy for general billing requirements and the Home Care Services section in the MHCP Provider Manual when submitting 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)

  • Submitting an 837I Outpatient Claim

    To submit an 837I Outpatient 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 Location

    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 one of the following:
    Continue
    to proceed to the next screen
    Cancel
    to cancel the claim entry

    Subscriber

    Use the Subscriber screen to report the recipient who received the service(s) reported on this claim. The following fields auto-populate based on the information entered in the Subscriber ID and Birth Date fields.

    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 one of the following:
    Continue
    to proceed to the next screen.
    Back
    to go back to the previous screen
    Cancel
    to cancel the claim entry

    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 the appropriate Type of Bill (TOB). The TOB is a 3-digit code which defines the type of facility, bill classification, and frequency.

    Home care claims use the 32X-34X series.Critical Access hospitals must us the 34X TOB.

    Numeric values for frequency (third digit) are as follows:

  • • xx2 - first claim in a series of continuous claims or interim billing. When submitting the first claim, the admission date field must be the same as the statement date
  • • xx3 - continuous claim or interim billing
  • • xx4 - the last claim or discharge claim
  • • xx7 - a replacement claim
  • • xx8 - void
  • Payer Claim Control Number
    (Loop: 2300, REF02)

    Use only when replacing or voiding a claim (TOB xx7 or xx8)
    Enter the 17-digit PCN to identify the previously paid claim to be replaced or void.

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

    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 or first date of services that will be entered on this claim.

    Statement Date (To)
    (Loop 2300, DTP03)

    Enter the service end date or last date of services that will be entered on this claim.

    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)

    This is the code indicating whether the provider accepts payment from MHCP.
    Select the correct response if different than the default.
    Defaulted is Assigned

    Benefits Assignment
    (Loop: 2300, CLM08)

    This is the determination of the policy holder or person authorized to act on their behalf, to give MHCP permission to pay the provider directly.
    Select the correct response if different than the default.
    Default is Yes.

    Release of Information
    (Loop: 2300, CLM09)

    This is the determination of whether the provider has a signed statement by the recipient on file, authorizing the release of medical data to other organizations.
    Select the correct response if different than the default.
    Default is Yes.

    Admission Type
    (Loop: 2300, CL101)

    Select the appropriate response from the dropdown menu options, to identify the priority of the admission/visit.
    (3- Elective is the most appropriate choice for home care visits)

    Admission Source
    (Loop: 2300, CL102)

    Select the appropriate source code from the dropdown menu options, indicating the point of location/origin for this admission or visit. (For new or current patients enter “1”)

    Patient Status
    (Loop: 2300, CL103)

    From the dropdown menu options, select the appropriate code indicating the disposition or discharge status of the recipient on the date entered in the statement Date (To) field.

    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.

    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).

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

    Prior Authorization Number
    (Loop: 2300, REF02)

    When appropriate, enter the service authorization (SA) number. An authorization number is required when an authorization is already in the system for the recipient. An authorization number is not required if there is no authorization in the system and the service is a skilled nurse visit. [The first 9 skilled nurse visits in a calendar year do not require an authorization unless the recipient has a current waiver service authorization SA)].

    Attachment Control Number
    (Loop: 2400, PWK06)

    Use only when submitting a claim with attachment.
    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)

    Use only when submitting a claim with an attachment.
    Select the code indicating the type ID and description of the attachment from the dropdown menu options.
    Select Add to add the attachment Control Number and Type ID to the entire claim. To delete entry, select Delete.

    Situational (Continued) Claim Information

    Occurrence Code
    (Loop: 2300, HI02-2- HI12)

    Use only when you have determined the other payer (Medicare/TPL/Other insurance) will not cover the service, even with an authorization. Determine this based on the other payers’ process for determining if a service can be covered. You must have documentation in your files to support the determination.

    Enter the Occurrence Code defining a significant event relating to this claim.

    Home care uses the following for each payer:

  • • 24-Third Party Liability/Other insurance
  • • 25 - Medicare
  • Date
    (Loop: 2300, HI01-4)

    Enter the date associated with the Occurrence Code. (This must be the date the determination was made with the other payer.)
    Select Add to add the Occurrence Code and Date. To delete entry, select Delete.

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

    Attending Provider

    NPI/UMPI
    (Loop: 2310A, NM101)

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

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

    Screen Action Buttons

    Select one of the following:

  • 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 only if reporting payments or denials by another payer source. 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/HMO Medicare Risk


    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 one of the following:

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

    Select one of the follwoing:

  • Continue to proceed to the next screen
  • • Back to return to the previous screen
  • • Cancel to cancel the entire claim entry
  • 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 one of the following:

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

    Select one of the following:

  • • Continue to proceed to the next screen
  • • Back to return to the previous screen
  • Cancel to cancel the entire claim entry
  • 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. (To (End) date not required as must be the same as the From (start) date of this line. Dates must be within the statement dates enterd in the Claim Information Screen.

    Revenue Code
    (Loop: 2400,SV201)

    Enter the appropriate revenue code used to specify the service line item detail for a health care institution. Use the Home Care Service Billing Codes in the chart below to determine the revenue code used for MHCP home care services.

    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 HCPCS code identifying the product or service. This code must match the HCPCS code entered on your service authorization (SA).

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

    Use only when a modifier is listed on the service authorization (SA) or when a claim for private duty nursing shared services.
    Enter the modifier that clarifies or further identifies the service indicated in the procedure code field.

    Other Payer – Use this accordion screen when reporting COB at the line level for either (Medicare Part B and/or TPL).

    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.

    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.

    Referring Provider

    NPI/UMPI
    (Loop: 2420D, NM109)

    If different than the provider reported on the claim information screen:

  • • Enter the NPI of the provider who provided the service
  • • Select the Add action button in this section to add the other provider information
  • • Select the radio button to add the other provider to the claim
  • Section Action Buttons

    Select one of the following:

  • 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.

    Report adjustments to additional lines when entering service information for that other line.

    Screen Action Button

    Select one of the following screen action buttons:

  • 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 the entire service line information (including other payer information)
  • Add to add a new blank service line
  • Note: You must always select Save/View Lines(s) after entering all lines to see the validate and submit action buttons.

    Claim Action Button

    Select 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 lists to identify the claim status category and claim status odes displayed on the validate and submit claim response.

    Claim Action Button

    Select 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.

    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.

    Home Care Servies Billing Codes

    Home Care Service

    HCPCS
    (date of service)

    Revenue

    Mod

    Mod

    Shared Indicator

    Auth Required

    Unit

    Home Health Aide Visit

    T1021

    0571

         

    Yes

    Visit

    Home Health Aide Visit Extended (waivers)
    Home Health Aide Visit
    (AC Program)


    T1004

    0572

         

    Yes

    15 min

    Private Duty Nursing LPN
    Regular

    T1003

    0552

         

    Yes

    15 min

    Private Duty Nursing LPN
    Regular, Extended

    T1003

    0552

    UC

       

    Yes

    15 min

    Private Duty Nursing LPN
    Shared 1:2

    T1003

    0552

    TT

     

    Y

    Yes

    15 min

    Private Duty Nursing LPN
    Shared 1:2 Ratio, Extended

    T1003

    0552

    TT

    UC

    Y

    Yes

    15 min

    Private Duty Nursing LPN
    Complex

    T1003

    0552

    TG

       

    Yes

    15 min

    Private Duty Nursing LPN
    Complex, Extended

    T1003

    0552

    TG

    UC

     

    Yes

    15 min

    Occupational Therapy Visit

    S9129

    0431

         

    No

    Visit

    Occupational Therapy Assistant Visit

    S9129

    0431

    TF

       

    No

    Visit

    Occupational Therapy Extended

    S9129

    0431

    UC

       

    Yes

    Visit

    Occupational Therapy Assistant Extended

    S9129

    0431

    TF

    UC

     

    Yes

     

    Physical Therapy Visit

    S9131

    0421

         

    No

    Visit

    Physical Therapy Assistant Visit

    S9131

    0421

    TF

       

    No

    Visit

    Physical Therapy Extended

    S9131

    0421

    UC

       

    Yes

    Visit

    Physical Therapy Assistant Extended

    S9131

    0421

    TF

    UC

     

    Yes

     

    Respiratory Therapy Visit

    S5181

    0411

         

    No

    Visit

    Respiratory Therapy Visit Extended

    S5181

    0411

     

    UC

     

    Yes

     

    Private Duty Nursing RN
    Regular Private Duty

    T1002

    0552

         

    Yes

    15 min

    Regular Private Duty RN
    Extended

    T1002

    0552

    UC

       

    Yes

    15 min

    Private Duty Nursing RN
    Shared 1:2

    T1002

    0552

    TT

     

    Y

    Yes

    15 min

    Private Duty Nursing RN
    Shared 1:2, Extended

    T1002

    0552

    TT

    UC

    Y

    Yes

    15 min

    Private Duty Nursing RN
    Complex

    T1002

    0552

    TG

       

    Yes

    15 min

    Private Duty Nursing RN
    Complex, Extended

    T1002

    0552

    TG

    UC

     

    Yes

    15 min

    Skilled Nurse Visit

    T1030

    0551

         

    Yes**

    Visit

    Skilled Nurse Visit (RN)
    (AC Program only)

    G0154 (through 12/31/15)
    G0299 (01/01/16 and later)

    0552

         

    Yes

    15 min

    Skilled Nurse Visit (LPN)
    (AC Program only)

    G0154 (through 12/31/15)
    G0300 (01/01/16 and later)

               

    Skilled Nurse Visit Telehomecare

    T1030

    0551

    GT

       

    Yes

    Visit

    Speech Therapy Visit

    S9128

    0441

         

    No

    Visit

    Speech Therapy Visit
    Extended

    S9128

    0441

    UC

       

    Yes

    Visit

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