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Minnesota Department of Human Services MN–ITS User Manual
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Outpatient Services for Rehabilitative Services, OT, PT and SLP

Revised: 03-19-2015

Review MHCP Billing Policy for general billing requirements and the Rehabilitative 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 Cancel to cancel the claim entry.

    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 entry.

    Screen Action Button

    Select Back to go back to the previous screen.

    Screen Action Button

    Select Cancel to cancel the claim entry.

    Screen Action Button

    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

    Type of Bill (TOB)
    (Loop: 2300, CLM05)

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

    Refer to the UB-04 Manual for values available.

    Payer Claim Control Number
    (Loop: 2300, REF02)

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

    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 date the service was performed or the date the service started.

    Statement Date (To)
    (Loop 2300, DTP03)

    Enter the date the service ended.

    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 or not 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)

    Admission Information:
    This field is not used for the outpatient services identified in this guide.

    An indicator code used to identify the priority of the admission/visit.

    Admission Source
    (Loop: 2300, CL102)

    This field is not used for the outpatient services identified in this guide.
    A source code indicating the point of location/origin for this admission or visit.

    Patient Status
    (Loop: 2300, CL103)

    Select from the drop down, the appropriate code indicating the disposition or discharge status of the recipient on the date entered in the statement Date (To) field.

    Admission Date (Loop: 2300, DTP02)

    This field is not used for the outpatient services identified in this guide.

    The date the episode of care began or the admission date to the facility.

    Admission Time (Loop: 2300,(DPT03)

    This field is not used for the outpatient services identified in this guide.

    The date the episode of care began or the time of admission to the facility.

    Discharge Time

    This field is not used for the outpatient services identified in this guide.

    The time the recipient was discharged for the inpatient care

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

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

    Present on Admission (POA)
    (Loop: 2300, HI01-9)

    This field is not used for the outpatient services identified in this guide.

    An indicator used to report if the Principal Diagnosis Code was POA.

    Admitting Diagnosis Code
    (Loop: 2300, HI01-1)

    This field is not used for the outpatient services identified in this guide.

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

    Patient Reason for Visit
    (Loop: 2300, HI01-2)

    This field is not used for the outpatient services identified in this guide.

    The diagnosis code describing the recipient’s reason for the visit at the time of the outpatient registration.

    External Cause of Injury
    (Loop: 2300, HI01-2)

    This field is not used for the outpatient services identified in this guide.

    The ICD diagnosis code used to describe the external cause of injury, poisoning or adverse effect that was the cause for seeking medical treatment or occurred during medical treatment.

    Present on Admission (POA)

    This field is not used for the outpatient services identified in this guide.

    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).

    Select Add. Repeat this process to add all other diagnosis codes related to this service.

    Select Delete to remove the entry.

    Present on Admission (POA)
    (Loop: 2300, HI01-1)

    An indicator used to report if the Other Diagnosis Code was POA.

    Situational Claim Information- Select this accordion panel to report situational information when required

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

    This field is not used for the outpatient services identified in this guide.

    The ICD code that identifies the principal procedure performed during the period covered by this bill.

    Date
    (Loop: 2300, HI01-4)

    This field is not used for the outpatient services identified in this guide.

    The date the Principal Procedure was performed.

    Code
    (Loop: 2300 HI01-2)

    Other Procedure:
    This field is not used for the outpatient services identified in this guide.

    The ICD code(s) identifying all significant procedures other than the principal procedure.

    Date
    (Loop: 2300, HI01-3)

    This field is not used for the outpatient services identified in this guide.

    The date the Other Procedure(s) were performed.

    Prior Authorization Number
    (Loop: 2300, REF02)

    This field is not used for the outpatient services identified in this guide.

    When appropriate, enter the service agreement or authorization number.

    Reference
    (Loop: 2300, NTE01)

    Claim Notes:
    This field should only be used when required to support adding claim note text information about the medical treatment or home health service not supported elsewhere on the claim.

    A code used to identifying the functional area or purpose for which the claim note text entered on the claim applies.

    Text
    (Loop: 2300, NTE02)

    This field should only be used when required to add information about the medical treatment or home health service not supported elsewhere on the claim.

    Adding note causes the claim to become complex and allows 90 days to process.

    Free form text related to the Reference code selected to support/clarify information relating to the entire claim about the treatment/product or service provided.

    Attachment Control Number
    (Loop: 2400, PWK06)

    Attachments:
    If an attachment is required, 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)

    If an attachment control number has been entered, from the drop down 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.

    Select Delete to remove the entry.

    Situational (Continued) Claim Information - Select this accordion panel to report situational information

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

    Occurrence:
    This field is not used for the outpatient services identified in this guide.

    The Occurrence Code defining a significant event relating to this claim.

    Date
    (Loop: 2300, HI01-4)

    This field is not used for the outpatient services identified in this guide.

    The date associated with the Occurrence Code.

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

    Occurrence Span:
    This field is not used for the outpatient services identified in this guide.

    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)

    This field is not used for the outpatient services identified in this guide.

    The beginning date associated with the Occurrence Span.

    To Date
    (Loop: 2300, HI01-4)

    This field is not used for the outpatient services identified in this guide.

    The end date associated with the Occurrence Span.

    Value Code
    (Loop: 2300, HI01-2)

    Value:
    This field is not used for the outpatient services identified in this guide.

    The Value Code identifies data necessary for processing this claim.

    Amount
    (Loop: 2300, HI101-1)

    This field is not used for the outpatient services identified in this guide.

    The value or amount associated with the Value Code.

    Condition Code
    (Loop: 2300 HI01-2)

    Condition:
    This field is not used for the outpatient services identified in this guide.

    The Condition Code identifies a condition/event related to this claim.

    Patient Responsibility Amt
    (Loop: 2300, AMT02)

    This field is not used for the services identified in this guide.

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

    Auto Accident State or Province
    (Loop: 2300, REF01)

    This field is not used for the outpatient services identified in this guide.

    State or Province where auto accident occurred.

    Delay Reason
    (Loop: 2300, CLM20)

    This field is not used for the outpatient services identified in this guide.

    Code indicating the reason why an auto accident request was delayed.

    Other Providers (Claim Level) – Select this accordion panel to report other providers associated with this claim as required

    Rendering Provider - This accordion panel is optional, and may be used to report the actively enrolled MHCP provider who performed the service

    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
  • Select Delete removes an entry.

    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
  • Select Delete removes an entry.

    Referring Provider – This accordion panel is used to report the provider who referred the subscriber for the service

    NPI/UMPI
    (Loop: 2310A, NM109)

    If different than the Attending/Ordering 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
  • Select Delete removes an entry.

    Attending Provider – This accordion panel is used to report the provider who is responsible for the overall care of the subscriber, or ordered the service

    NPI/UMPI
    (Loop: 2310A, NM101)

  • • Enter the NPI/UMPI of the provider of the attending or ordering provider
  • • Select Add to add the Attending Provider NPI
  • • Select the radio button to add the Attending Provider to the claim
  • Select Delete removes an entry.

    Operating Provider – This accordion panel is not used for outpatient OT,PT and SLP

    NPI/UMPI
    (Loop: 2330D, REF02)

    Enter the NPI/UMPI of the provider who performed the operation

  • • Select Add to add the Operating Provider NPI
  • • Select the radio button to add the Operating Provider to the claim
  • Select Delete remove an entry

    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
  • • Select Delete remove an entry
  • Screen Action Button

    Select Back to go back to the previous screen.

    Screen Action Button

    Select Cancel to cancel the claim entry.

    Screen Action Button

    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)

    Other Payer:
    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, 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)

    Other Payer Subscriber:
    From the drop down, 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, Select the relationship of the MHCP subscriber (recipient) to the policy holder.

    Payer Paid Amount

    Other Payer Amounts:
    This field is not used for the outpatient services identified in this guide. Medicare is reported at the line level.

    This field is used to report TPL adjustments at the claim (header level),

    Non-Covered Charge Amount

    This field is not used for the outpatient services identified in this guide. Medicare is reported at the line level.

    This field is used to report TPL adjustments at the claim (header level),

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

    Enter the claim number reported on the Medicare EOMB.
    The claim will deny if the ICN from Medicare is not reported

    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 authorizing the release of medical data to other organizations on file.

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

    Inpatient Adjudication Information (MIA) This field is not used for the services identified in this guide.

    Outpatient Adjudication Information (MOA) Select this to report the Medicare Remark Codes(s) when if the code is reported on the Medicare EOMB,

    Remark Code
    (Loop: 2320, MOA03-MOA07)

    Claim Payment Remarks Code(s):
    Enter
    the Medicare remark code(s) from the Medicare EOMB.

    Select Add to add the code to the claim. Select Delete removes an entry.

    After all Remark Code(s) are entered and saved:

    Section Action Button

    Select one of the following:

  • • Delete to remove the payer information from the claim
  • • Save to add the payer information to the claim
  • 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
  • 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)

    Other Payer:
    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, 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)

    Other Payer Subscriber:
    From the drop down, 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, 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.
    OR

    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)

    This field is not used when reporting TPL information.

    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 Button

    Select one of the following:

  • • Delete to remove the payer information from the claim
  • • Save to add the payer information to the claim
  • 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
  • • 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 service if the service was provided over a span of the consecutive dates.

    If the service was not part of a consecutive date range, do not complete this field.

    Revenue Code
    (Loop: 2400,SV201)

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

    Line Item Charge Amount
    (Loop: 2400, SV102)

    Enter the total line item charge for the service.

    Unit Code
    (Loop: 2400, SV204)

    Default is UN-Unit.
    Select the correct response from the drop down if different than the default.

    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)

    This field is not used for the outpatient services identified in this guide.

    The National Drug Unit Count (NDC) – A numeric value used to identify a specific drug.

    CODE Qualifier
    (Loop: 2410, CTP05-1)

    This field is not used for the outpatient services identified in this guide.

    A 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.

    Select Add to add the specific adjustment to this line.

    Select Delete to remove that specific entry.

    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.
    Delete:
    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 Button

    Select Save once all entries are complete.

    Each time you select save/view line, 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
  • 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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