State Medical Review Team (SMRT) Disability Examination

SMRT is a unit at the Department of Human Services that makes disability determinations for applicants or MHCP enrollees. SMRT works with providers, counties or tribal agencies to schedule exams, other tests and transportation. SMRT issues an approved authorization which allows providers to bill for services (including ancillary services) and counties or tribal agencies to be reimbursed for costs associated with obtaining medical records and providing transportation.

Providers, counties or tribal agencies may bill MHCP electronically using the secure MN–ITS Direct Data Entry (DDE/Interactive) 837P Professional claim. If the recipient is eligible for MHCP; bill using the actual procedures that were provided, not the disability examination code.

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)
  • Using MN–ITS DDE

    Complete all fields with a single red asterisk, *=Required Field.

    Complete double red asterisked fields as appropriate for your claim, **=Situational: if applicable, complete all ** fields within a section (Fields within a sections are outlined with a blue box).

    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. The Address fields auto-populate information in either Line 1, Line 2 or both.

    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/UMPI used to login to MN-ITS. MN–ITS DDE auto-populates the required fields on the Billing Provider Screen.

    If multiple locations are associated to the NPI/UMPI, a table will display with the name and address and taxonomy codes for each location. Select the radio button to identify the appropriate location for this claim.

    Taxonomy
    (Loop: 2000A, PRV03)

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

    Address 1
    (Loop: 2010AA, N301)

    The first address line reported on the provider file.

    The auto-populated information in the Address field will appear in Line 1, Line 2 or both fields.

    Address 2
    (Loop: 2010AA, N302)

    The second address line reported on the provider file.

    The auto-populated information in the Address field will appear in Line 1, Line 2 or both fields.

    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 using the following format 2-digit month, 2-digit day, and 4-digit year (MMDDYYYY).

    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 is not the correct recipient.

    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 using copy, replace or void from a submit response or from the request status feature, the claim frequency code will display with the appropriate 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 replacement or void 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 appropriate Place of Service code that applies to the claim. Default is 11 (office).

    Counties and Tribal Agencies use place of service code 99 (Other Unlisted Facility).

    Patient Control Number
    (Loop: 2300, CLM01)

    Enter the unique 1-38 character alpha/numeric code you assign to this claim in the Patient Account Number field. This number will appear on your remittance advice (RA) once your claim is received by MHCP.

    Assignment/ Plan Participation
    (Loop: 2300, CLM07)

    Code indicating whether the provider accepts payment from MHCP. Use the default response – Assigned.

    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. Use the default response – Yes.

    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. Use the default response – Yes.

    Provider Indicator
    (Loop: 2300, CLM06)

    Identifies whether the provider’s signature is on file, certifying services were performed by the provider. Use the default response – Yes.

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

    A diagnosis code must be entered:

  • • Providers must enter the highest level of specificity ICD diagnosis in the Diagnosis Code field
  • • Counties and tribal agencies use V68.9 (Administrative Encounter) in the first Diagnosis Code field

  • 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)

    Enter the 11 – digit authorization number that was approved by the SMRT division.

    Note: Providers may retrieve their SMRT authorization letter from their MN–ITS Mailbox in the Miscellaneous Received PAL file folder listed with the recipients ID number.

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

    Rendering Provider

    NPI/UMPI
    (Loop: 2310B, NM109)

    Identify the provider who performed (rendering provider) or ordered (county or tribal agency) the services related to the SMRT disability examination based on your provider type and the service provided.

    If different than the billing provider:

  • • Enter the NPI/UMPI 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
  • • Select the Continue action button to move to the COB screen

  • Coordination of Benefits (COB) Screen

    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 Continue button at the bottom of this screen to proceed to the next screen.

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

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


    Medicare/HMO Medicare Risk


    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 use the instructions in the Medicare/HMO Medicare Risk table below.

    Field Name*
    (X12 Loop & Element)

    Field Instruction

    Other Payer Name
    (Loop: 2330B, NM103)

    Enter the full name of the insurance carrier.
    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 number is available on the MN–ITS eligibility response for this recipient located in the Other Insurance section as a 6 – digit Carrier ID number). If unknown enter 999999.

    Do not use symbols such as slashes, dashes, periods or plus signs.

    Claim Filing Indicator
    (Loop: 2320, SBR09)

    From the drop down menu, select the code identifying the type of insurance. Use CI – Commercial Insurance for general insurance plans.

    Once the claim filing indicator is selected, additional fields will display for reporting TPL/private insurance.

    Payer Responsibility
    (Loop: 2320, SBR01)

    From the drop down menu, select the code identifying the insurance carrier’s level of responsibility for payment of the claim.

    Insured ID
    (Loop: 2330A, NM109)

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

    Relationship Code
    (Loop: 2320, SBR02)

    From the drop down menu, select the relationship of the MHCP subscriber (recipient) to the policy holder

    Claim Adjustment Group Code
    (Loop: 2320, CAS01)

    This field is used only when reporting TPL/private insurance at the claim (header) level rather than at the service line.

    From the drop down menu, select the adjustment code identifying the general category of payment adjustment.

    Use the Washington Publishing Company link, on right, to find the HIPAA compliant code that matches the adjustment response on the other payer’s EOB.

    Adj Reason Code
    (Loop: 2320, CAS02, CAS05, CAS08, CAS11, CAS14, CAS17)

    This field is used only when reporting TPL/private insurance at the claim (header) level rather than at the service line.

    Enter the code identifying the reason the other payer adjusted the payment. Refer to the other payer EOB or EOMB.

    Use the Washington Publishing Company link, on right, to find the HIPAA compliant code that matches the adjustment response on the other payer’s EOB.

    Adj Amount
    (
    Loop: 2320, CAS03, CAS06, CAS09, CAS12, CAS15 CAS18)

    This field is used only when reporting TPL/private insurance at the claim (header) level rather than at the service line.

    Enter the dollar amount of the adjustment.

    Adj Quantity
    (Loop: 2320, CAS04, CAS07, CAS10, CAS13, CAS16, CAS19)

    This field is used only when reporting TPL/private insurance at the claim (header) level rather than at the service line.

    Enter the number of units not paid when the units paid are different than the number of units submitted on the claim.

    Select the Add action button in this section to include the adjustment entries on the claim. Repeat the Claim Adjustment entries to report all adjustments as noted on the EOB from the TPL/private insurance.

    Select the Delete action button next to an adjustment to remove it from the claim.

    Payer Paid Amount
    (Loop: 2320, AMT02)

    This field is used only when reporting TPL/private insurance at the claim (header) level rather than at the service line.

    Enter the total dollar amount paid by ther other payer.

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

    Not used by MHCP

    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 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 in this section to remove this payer from the claim level and at the line level
  • Save in this section to include the TPL/private insurance information on the claim
  • Section Action Button

    Select the ADD action button in this section to enter additional payers. Repeat the COB entry process to report all payers for the claim.

    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

  • Medicare 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 full name of the insurance carrier.
    Do not use symbols such as slashes, dashes, periods or plus signs.

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

    Enter the Payer ID of the Medicare contractor or Medicare Risk (Advantage) health plan.

  • • For Medicare: Refer to the CMS Provider Compliance Group Map for contractor contact information in your area
  • • For HMO/Medicare Risk/Advantage (Coverage Type: 07): Refer to the recipient’s MN–ITS Eligibility Response. The Payer ID is displayed in the Carrier ID field
  • Claim Filing Indicator
    (Loop: 2320, SBR09)

    Select the down arrow in the Claim Filing Indicator field to indicate the type of claim you are filing; select MB for Medicare part B or 16 for a Medicare Advantage Plan.

    Once the claim filing indicator is selected, additional fields will display for reporting Medicare part B or a Medicare Advantage Plans payments.

    Payer Responsibility
    (Loop: 2320, SBR01)

    From the drop down menu, select the code identifying the insurance carrier’s level of responsibility for payment of the claim.

    Insured ID
    (Loop: 2330A, NM109)

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

    Relationship Code
    (Loop: 2320, SBR02)

    From the drop down menu, 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.

    Payment Remark Code
    (Loop: 2320, MOA03-MOA07)

    Enter the remittance advice remark codes reported on the Medicare EOMB. Report only if on the Medicare EOMB.

    Select the Add action button in this section to include the remark code on the claim. Repeat the remark code entries to report all remark codes as noted on the Medicare EOMB.

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

    Payer Paid Amount
    (Loop: 2320, AMT02)

    This field is not used when reporting Medicare or HMO Medicare risk insurance COB. This information should be reported at the service line.

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

    Not used by MHCP

    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 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 in this section to remove this payer from the claim level and at the line level
  • Save in this section to include the TPL/private insurance information on the claim
  • Section Action Button

    Select the ADD action button in this section to enter additional payers. Repeat the COB entry process to report all payers for the claim.

    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 the disability examination 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 of the disability examination services or the date when medical records or transportation services were paid for by the county or tribal agency using the MMDDYYYY format in the From Date.

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

    Not used for SMRT claims.

    Place of Service
    (Loop: 2400, SV105)

    This field is defaulted with the place of service code 99 that was selected at the Claim Information Screen.

    Procedure Code
    (Loop: 2400, SV101-2)

    Enter the Disability Examination procedure code 99456 in the Procedure code field.

    If the recipient is eligible for MHCP; bill using the actual procedure codes that were provided, not the disability examination code.

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

    Not used on SMRT claims.

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

    Providers: From the drop down menu, select the diagnosis code(s), in the order of importance, that best describes the need for this service.

    Counties and Tribal agencies: use the defaulted diagnosis V68.9 (Administrative Encounter).

    Line Item Charge
    (Loop: 2400, SV102)

    The CPT code 99456 includes all components of the medical disability examination. Providers must add all of their usual/customary charges for each service performed (including ancillary services that were sent to an outside lab or other provider) to calculate the total charge amount. The authorized provider must have a contractual agreement to pay for any ancillary services sent to an outside lab or other provider.

    Counties add all payments made for medical records, transportation, and exams to calculate the total charge amount.

    Service Unit Count
    (Loop: 2400, SV104)

    Enter the number of units for the service as 1.

    Other Payer – Not used for SMRT Claims.

    Situational Services – Not used for SMRT Claims.

    Other Providers – Not used for SMRT Claims. Rendering Provider is identified at the Other Providers – Claim Level

    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
  • Do not Add or Copy lines. SMRT claims only have one service line for procedure 99456
  • 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 the service line, to view or change the information
  • Do not select Add. SMRT claims only have one service line for procedure 99456
  • 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 a Claim User Guides for step-by-step instructions when completing these transactions.

    Questions on:

  • • Authorization to receive reimbursement for providing the Disability Examination or for the costs associated to obtaining medical records and providing transportation should be directed to: SMRT Hotline: 651-431-2493 or 1-800-235-7396
  • Billing should be directed to the Provider Call Center at 651-431-2700 or 1-800-366-5411
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