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Minnesota Department of Human Services MN–ITS User Manual
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Outpatient Ambulance Services

Revised: 03-18-2015

Review MHCP Billing Policy for general billing requirements and the Ambulance Transportation 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)

  • Submit 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 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 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.
    Select Cancel to cancel the claim entry.
    Select 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 the appropriate Type of Bill (TOB) the TOB is a 3-digit code which defines the type of facility, bill classification, and frequency.

    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 drop down menu options, select the appropriate response to identify the priority of the admission/visit.

    Admission Source
    (Loop: 2300, CL102)

    From the drop down menu options, select the appropriate source code indicating the point of location/origin for this admission or visit.

    Patient Status
    (Loop: 2300, CL103)

    From the drop down 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.

    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).

    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)

    When appropriate, enter the service agreement or authorization number.

    Reference
    (Loop: 2300, NTE01)

    Select the code identifying the functional area or purpose for which the claim note applies.

    Text
    (Loop: 2300, NTE02)

    Use this field only when required for claim adjudication to report claim information/clarification about the product or service provided for the entire claim relating to the Reference Code. Adding note causes the claim to become complex and allows 90 days to process.

    Select Add to add the claim notes to the claim.
    To delete, select the Delete button.

    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 drop down 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

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

    When appropriate, enter the Occurrence Code defining a significant event relating to this claim.

    Date
    (Loop: 2300, HI01-4)

    Enter the date associated with the Occurrence Code.

    Select Add to add the Occurrence Code and Date.
    To delete entry, select Delete.

    Occurrence Span Code
    (Loop: 2300, HI01-2)

    When appropriate, enter the Occurrence Span Code that identifies an event, occurring over a span of days, that relates to this claim.

    From Date
    (Loop: 2300, HI01-3)

    Enter the beginning date associated with the Occurrence Span.

    To Date
    (Loop: 2300, HI01-4)

    Enter the end date associated with the Occurrence Span.

    Select Add to add the Occurrence Span Code and Dates.
    To delete entry, select Delete.

    Value Code
    (Loop: 2300, HI01-2)

    When appropriate, enter the Value Code that identifies data necessary for processing this claim.

    Use this field to report multiple riders use Value Code 32 and the number of riders if the number of riders is 2 or greater Using the multiple rider value code when there are not multiple riders may result in the denial of the claim.

    Amount
    (Loop: 2300, HI101-1)

    Enter the value or amount associated with the Value Code.

    Select Add to add the Value Code and Amount
    To delete entry, select Delete.

    When the number of riders is 2 or more enter the number of riders here.

    Condition Code
    (Loop: 2300 HI01-2)

    When appropriate, enter the Condition Code to identify a condition/event related to this claim.

    Select Add to add the condition code.
    To delete entry, select Delete.

    Patient Responsibility Amt
    (Loop: 2300, AMT02)

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

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

    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.
  • • The services intended for this guide does not require a referring provider.
  • 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.
  • • The services intended for this guide does not require an attending provider.
  • 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.
  • • The services intended for this guide do not require an operating provider.
  • 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.
  • • The services intended for this guide do not require a service facility location.
  • Screen Action Buttons

    Select Back to go back to the previous screen.
    Select Cancel to cancel the claim entry.
    Select 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/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 drop down 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 drop down 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 drop down 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.

    Screen Action Buttons

    Select Back to return to the previous screen.
    Select Cancel to the entire claim entry.
    Select 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 drop down 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 drop down 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 drop down 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.

    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.

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

    Enter the claim number reported on the Medicare EOMB.

    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.
    Select Save to include this TPL/private insurance information on the claim.
    Select Add to add additional prior payer on this claim.

    Screen Action Buttons

    Select Back to return to the previous screen.

    Select Cancel to cancel the entire claim entry.

    Select 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 service was provided 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 Charge Amount
    (Loop: 2400, SV102)

    Enter the total charge for the service.

    Multiply your usual and customary charge by the number of units if you are billing for multiple units.

    Unit Code
    (Loop: 2400, SV204)

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

    For the services intended for this guide you would select UN from the drop down menu.

    Service Unit Count
    (Loop: 2400, SV104)

    Enter the quantity of units for the service.

    Procedure Code
    (Loop: 2400, SV101-2)

    Enter the CPT or HCPCS code identifying the 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.

    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, situational services, or other provider information is required for this line, skip to Screen Action Button section.

    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 drop down 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.

    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:

    Save/View Line(s):
    to save the line item if only one line item is entered or if not using the Copy or Add action button for the next line.

    Copy:
    to save and copy the service line information that was just entered so that you can make changes to the copied service line.

    Delet
    e
    : to remove the service line information that is displayed.

    Add
    : to add a new service line to the claim. A new service line will display for you to enter new information for your next service line.

    Screen Action Buttons

    Select Save once all entries are complete.

    Each time you select save/view line(s), a summary table will display providing a summary for each line showing:

  • • Line number
  • • From and to Date
  • • Procedure Code
  • • Modifier
  • • Charge
  • • Units
  • Select the Edit button next to the line item if changes are needed to that service line.

    Select Add below the service line summary table to add additional service line(s).

    Screen Action Button

    Select one of the following:

  • Add to add additional payers
  • Back to return to the previous screen
  • Cancel to cancel the entire claim entry
  • Validate to determine if the claim entries have met HIPAA billing requirements and basic MHCP service specific requirements
  • Submit to send the claim to MHCP for adjudication
  • 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 and 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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    © 2017 Minnesota Department of Human Services Updated: 3/18/15 11:34 AM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 3/18/15 11:34 AM