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Minnesota Department of Human Services MN–ITS User Manual
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Medicare Part A or Part B County Paid Premiums MN–ITS User Guide

Revised: 09-30-2015

When the Medicare premium cannot be paid through the Buy-in process, the county may reimburse the recipient or pay the premium directly and send a claim for the premium to DHS electronically using MN–ITS Direct Data Entry (DDE).

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 taxonomy (specialty) code has been added by the provider using MN–ITS to their provider file.

    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 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 place of service code 99 (other unlisted facility).


    Default is 11 (office).

    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 RA.

    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 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)

    For Medicare premiums covering months through September 2015, enter the ICD-9 diagnosis code V60.2.

    For Medicare premiums covering months October 2015 and after, enter the ICD-10 diagnosis code Z59.6.

    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 – Not used for Medicare Part A or Part B County Medicare Premiums

    Other Providers (Claim Level) – Not used for Medicare Part A or Part B County Medicare Premiums


    Coordination of Benefits (COB) Screen

    The COB screen is not used for Medicare Part A or B County Medicare Premiums. Select the Continue action button to move to the Services 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 first date of the Medicare premium reimbursement using the MMDDYYYY format in the From Date.

    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 of the Medicare premium reimbursement using the MMDDYYYY format in the To Date fields. (Only one calendar month may be billed per claim).

    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 the appropriate code in the Procedure field:

  • • X5620 (Part A Medicare Premium)
  • X5621 (Part B Medicare Premium)
  • Procedure Code Modifier(s)
    (Loop: 2400, SV101-3, SV101-4, SV101-5, SV101-6)

    Not used for Medicare part A or B claims.

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

    Leave the Diagnosis Pointer field in the first position defaulted.

    Line Item Charge
    (Loop: 2400, SV102)

    Enter the dollar amount of the Medicare premium that was paid by the county.

    Service Unit Count
    (Loop: 2400, SV104)

    Enter 1 as the number of units for the service.

    Other Payer Not used for Medicare Part A or Part B County Medicare Premiums

    Situational Services Not used for Medicare Part A or Part B County Medicare Premiums

    Other Providers – Not used for Medicare Part A or Part B County Medicare Premiums

    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. This may be helpful if payment was made for both Medicare part A and part B for the same month. 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 to add an additional Medicare premium for the same month
  • 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.


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    © 2017 Minnesota Department of Human Services Updated: 9/30/15 1:13 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 9/30/15 1:13 PM