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Minnesota Department of Human Services MN–ITS User Manual
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Early Intensive Developmental Behavioral Intervention (EIDBI) Claims

Revised: 02-23-2017

Review MHCP Billing Policy for general billing requirements and guidance when submitting claims.

Refer to additional billing requirements in the EIDBI Billing Grid section of the MHCP Provider Manual before you submit the claim for services.

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)”
  • 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) (complete only when the recipient has other or private insurance)
  • Services
  • Billing Provider

    The billing provider screen auto-populates with the information in the enrollment profile for the NPI or 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 field auto-populates with the name of the service provider.

    Taxonomy
    (Loop: 2000A, PRV03)

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

    Consolidated NPI record: A table will display showing both the location and taxonomy code for each record on file with MHCP. Select the radio button to identify the appropriate location for this claim.

    Address 1
    (Loop: 2010AA, N301)

    This field auto-populates with the first line of your address in your provider file.

    Address 2
    (Loop: 2010AA, N302)

    This field auto-populates with the second line of your address in your provider file.

    City
    (Loop: 2010AA, N401)

    This field auto-populates with the city listed in the address of your provider file.

    State
    (Loop: 2010AA, N402)

    This field auto-populates with the state listed in the address of your provider file.

    ZIP
    (Loop: 2010AA, N403)

    This field auto-populates with the ZIP code listed in the address of your provider file.

    Telephone
    (Loop: 2010AA, PER04)

    This field auto-populates with the telephone number reported on the provider file.

    Screen Action Button

    Select:

  • Continue to proceed to the next screen
  • Cancel to cancel the claim entry
  • Subscriber

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

    Refer to the table below for instruction and information about fields to complete on this screen.

    Field Name*
    (X12 loop & element)

    Field Instruction

    Subscriber ID
    (Loop: 2010BA, NM109)

    Enter the eight 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 the Search action button in this section 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 the incorrect recipient.

    Screen Action Button

    Select :

  • Continue to proceed to the next screen.
  • Back to go back to the previous screen
  • Cancel to cancel the claim entry
  • Claim Information

    Use the Claim Information screen(s) to report header (claim) level information that will identify the type of claim and details about the service(s). Information entered on the claim information screen will apply to all lines of the claim.

    Refer to the table below for instruction and information about each field on this screen.

    Field Name*
    (X12 Loop & element)

    Field Instruction

    Claim Frequency Code
    (Loop: 2300, CLM05-3)

    The default is Original. Leave original if not submitting a Replacement or Void claim.

    Select replacement if you are replacing a claim that MHCP previously paid for this recipient.

    Select void if you are voiding a claim that MHCP previously paid for this recipient.

    Payer Claim Control Number
    (Loop: 2300, REF02)

    Enter the claim number of the claim you want to replace or void. This field only displays if you selected the replacement or void claim frequency code.

    Place of Service
    (Loop: 2300 CLM05-1)

    Select from the drop down menu the code that identifies where the service was performed.

    Patient Control Number
    (Loop: 2300, CLM01)

    Enter a unique identifier of words, numbers, letters or a combination to report a claim for this recipient in your records. This can be anything you want. MHCP will report this back to you on the remittance advice (RA).

    Assignment/ Plan Participation
    (Loop: 2300, CLM07)

    Select the code to report whether the provider accepts payment from MHCP if different than the default. The default is Assigned.

    The options are:

  • • Assigned - provider has a participation agreement with MHCP
  • • Assignment Accepted - provider accepts assignment only for clinical lab services
  • • Not Assigned - neither assigned nor assignment accepted apply
  • Benefits Assignment
    (Loop: 2300, CLM08)

    Select the benefit assignment to report the policy holder or person authorized to act on behalf of the policy holder. Gives MHCP permission to pay the provider directly if different than the default. The default is Yes.

    The options are:

  • • Yes - Benefits assigned to the provider
  • • No - Benefits not assigned to the provider
  • • Not Applicable - Patient refuses to assign benefits
  • 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. The default is Yes. Select the correct response if different than the default.
    The options are:

  • • Yes - Signature collected or required
  • • Informed Consent - Signature not collected and not required
  • Provider Indicator
    (Loop: 2300, CLM06)

    Select the correct response if different than the default to report whether the provider’s signature is on file, certifying services were performed by the provider. The default is Signature on File.

    Diagnosis Code Type
    (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.

    ICD-10 became effective 10.01.2015

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

    Enter the diagnosis code (ICD) that is listed on your service authorization (SA) or Assesment and Service Plan document that coordinates with the dates of services for this claim.

    Select the Add action button in this section to include on the claim.

    Once a diagnosis code is entered, it will display in the table below.

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

    Prior Authorization Number
    (Loop: 2300, REF02)

    When authorization is required, enter the service agreement number from your service authorization (SA) letter.

    Medical Record Number
    (Loop: 2300, REF02)

    This field is not required for this service.

    Claim Note
    (Loop: 230, REF02)

    Use only when additional information is required.

    Enter a free form description to provde additional information about this claim.

    Attachment Control Number
    (Loop: 2400, PWK06)

    Use only when submitting a claim with attachment.

    Enter the code or number, assigned by the provider, identifying an attachment for this claim.

    Review the Electronic Claim Attachments page for MHCP Attachment Criteria and additional information.

    Attachment Type
    (Loop: 2400, PWK01)

    Use only when an attachment is required. From the drop down, select the code indicating the attachment type ID and the description of the attachment.

    Select the Add action button in this section to include the attachment information on the claim.

    Screen Action Button

    Select Continue to proceed to the next screen.

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

    Rendering Provider

    NPI/UMPI
    (Loop: 2310B, NM109)

    EIDBI providers are required to enter rendering provider information on all claims:

  • • Enter the NPI or UMPI of the provider who provided the service
  • • Leave the rendering provider blank for any services delivered by a Level III provider prior to January 1, 2018
  • • 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
  • Pay-To Provider:

    NPI/UMPI
    (Loop: 2010AB, NM109)

    If different than the billing provider:

  • • Enter the NPI or UMPI of the provider who should be paid for 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
  • Supervising Provider

    NPI/UMPI
    (Loop: 2310D, NM109)

    If reporting a supervising provider:

  • • Enter the NPI or UMPI of the qualified supervising provider (QSP) who supervised the service
  • • For more information on services that require the supervision of a QSP, refer to the EIDBI Billing Grid
  • • Select the Add action button in this section to add the supervising provider information
  • Select the radio button to add the supervising provider to 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
  • Coordination of Benefits (COB)

    Use the COB screen only if reporting payments or denials by another payer source. 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 header (claim) level, use the tables below.

    TPL or Private Insurance (non-Medicare)
    Complete the following fields to report adjustment, payments and denials from the private insurance (non-Medicare) carrier.

    Field Name*
    (X12 Loop & Element)

    Field Instruction

    Other Payer Name
    (Loop: 2330B, NM103)

    Enter the full name of the insurance carrier or other insurance.

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

    Enter the Identifier of the insurance carrier (this is available on the eligibility response for this recipient). Do not use symbols such as slashes, dashes, periods or plus signs.

    Claim Filing Indicator
    (Loop: 2320, SBR09)

    Select from the drop down menu, the code identifying the type of insurance.

    The type of insurance is usually reported in the Other Insurance section of the eligibility response for this recipient.

    Once the claim filing indicator is selected, additional fields will display to report payments made by the TPL or other insurance.

    Payer Responsibility
    (Loop: 2320, SBR01)

    Select from the drop down menu, 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)

    Select from the drop down menu, the relationship of the MHCP subscriber (recipient) to the policy holder.

    Example: Recipient is the child to the person who holds this other insurance policy.

    Complete the following fields only if reporting adjustments at the claim (header) level.

    If reporting adjustment at the service line, select the Save action button in this section and then scroll down to the Other Insurance Information section of this screen.

    Claim Adjustment Group Code
    (Loop: 2320, CAS01)

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

    Select the adjustment code from the drop down menu to report the type of adjustment reported by the other insurance.

    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 or 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.

    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 or 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 or 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.

    Action Button

    Select the Add action button in this section to include the adjustment entries on the claim.

    To remove an adjustment from the claim, select the Delete action button next to an adjustment.

    Repeat the Claim Adjustment entries to report all adjustments as noted on the EOB from the TPL or private insurance.

    Payer Paid Amount
    (Loop: 2320, AMT02)

    This field is used only when reporting TPL or 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 behalf of the policy holder, 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: :

  • Save to save the entry to include the TPL or private insurance information on the claim
  • Delete to remove this payer from the claim level
  • Add to enter additional payers on this claim. Repeat the COB entry process to report all payers for the claim
  • Screen Action Button

    After you save the entry, select one of the following:

  • • Continue to proceed to the next screen
  • Back to return to the previous screen
  • Cancel to cancel the claim entry
  • Services

    Use the Services screen to describe the details for each EIDBI 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 (MMDDYYYY).

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

    Enter the last date of consecutive date range the service was provided, only when required (MMDDYYYY). Bill only for services provided within the same calendar month.

    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 procedure code from your service authorization letter identifying the service provided.

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

    Enter the modifier(s) that clarifies the level of the provider who delivered the service and further identifies the service indicated in the procedure code field.

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

    Review to ensure the diagnosis code is displaying in the first field.

    EIDBI service claims only require the most current, most specific diagnosis code for the service provided on this claim line.

    If the code is not visible, use the drop down menu to select the correct diagnosis code for this line of the claim.

    Line Item Charge
    (Loop: 2400, SV102)

    Enter your total charge for all units on this line.

    To determine the total charge, multiply the number of units for this line to your usual and customary charge for this service.

    If you report other payers in the COB or line COB sections, your total charge must be the same as the amount you submitted or would have submitted to the other payer.

    Service Unit Count
    (Loop: 2400, SV104)

    Enter the number of units for this service line.

    Other Payer – Use this section only if reporting other payer (TPL) COB payments or denials at the service (line) level. To complete this section, select the Other Payer accordion panel and complete the fields. If the recipient does not have other or private insurance to report, skip this accordion section.

    Other Payer Primary Identifier
    (Loop: 2430, SVD01)

    From the drop down menu, select the identifier of the TPL or private insurance carrier, HMO Medicare Risk or the NPI of the Medicare contractor.

    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 or private insurance reporting.

    Paid Unit Count
    (Loop: 2430,SVD05)

    Enter the number of units identified as being paid from the other payer’s EOB or EOMB for this service line.

    Claim Adjustment Group Code
    (Loop: 2430, CAS01)

    From the drop down menu, select the adjustment code identifying the general category of payment adjustment for this service line.

    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.

    Adjustment Reason Code
    (Loop: 2430, CAS02)

    Enter the code identifying the reason the other payer adjusted the payment for this service line.

    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.

    Adjustment Amount
    (Loop: 2430, CAS03)

    Enter the dollar amount of the specific adjustment for this service line.

    Adjustment Quantity
    (Loop: 2430, CAS04)

    Enter the number of units not paid when the units paid are different than the number of units submitted for this service line.

    Action Button

    Select the Add action button in this section to include the adjustment entries on the service line.

    Repeat the Other Payer COB Line Adjustment Entries to report all adjustments for this service line as noted on the EOB or EOMB.
    To remove an adjustment, select the Delete action button next to the adjustment.

    To remove the entire COB line entry, select the delete action button afer adding the information.

    Section Action Button

    Select the Save action button in this section, below the display of adjustments, to save the COB information for the payer to this service line.

    Once saved, the COB Line Payments/Adjustments screen will appear with the following information:

  • • Other Payer Primary identifier
  • • Line Paid Amount
  • • Total Adjustment for the service line
  • Section Action Button as needed

    Select the Edit action button next to a payer to change the adjustment entries for the payer (the totals on this screen should equal the charge you sent to the primary payer).

    Section Action Button as needed

    Select the Add action button in this section, below the display of payers, to report another payer to this service line. Repeat the same steps to add additional payer information for this service line.

    Situational Services –Select the Situational Services accordion panel to report additional information about the service line.

    Prior Authorization
    (Loop: 2400, REF02)

    Enter the approved authorization number for the service line, when different than the authorization number reported on the claim information screen.

    Situational Ambulance Information

    Not required for this service

    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.

    Rendering Provider

    NPI or UMPI

    EIDBI providers are required to enter rendering provider information on all service lines:

  • • Enter the NPI or UMPI of the provider who provided the service
  • • *Leave the rendering provider field blank only if services were delivered by a level III before January 1, 2018.
  • • Select Add to add the individual providers information
  • • Select the radio button to add the provider to the claim
  • Supervising Provider

    NPI or UMPI

    If reporting a supervising provider:

  • • Enter the NPI or UMPI of the qualified supervising provider (QSP) who supervised the service
  • • For more information on services that require the supervision of a QSP, refer to the EIDBI Billing Grid
  • • Select the Add action button in this section to add the supervising provider information
  • • Select the radio button to add the supervising provider to the claim
  • Section Action Button

    Select :

  • Save/ View Line(s): To save the line item and view summary table, displaying information for each line on the claim.
  • 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.
  • Select Save/View Line(s) once all entries are complete.

    Service Line Recap Table

    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
  • • Units
  • Select:

  • Edit button next to the line item to change the information for that service line.
  • Add button below the service line summary table to create a new service line that is blank.
  • Finish the claim

    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 submit the claim for adjudication. The submit response will identify if the claim will be paid, denied or suspended for review at the claim level and the line level of the claim.

  • 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 User Guide for step-by-step instructions when completing these transactions.

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    © 2017 Minnesota Department of Human Services Updated: 2/23/17 9:35 AM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 2/23/17 9:35 AM