MN–ITS Help Text – 837P – Claim Information

Field Description

Refer to the MN–ITS screen for values available

Specifies if the claim is an original, replacement or void

Payer Claim Control Number
(Loop: 2300, REF02)

Identifies the previously processed claim when the Claim Frequency Code is replacement or void

Place of Service
(Loop: 2300 CLM05-1)

Refer to the MN–ITS screen for values available

Identifies where the service or item was rendered

Patient Control Number
(Loop: 2300, CLM01)

A unique identifier, assigned by the provider, that will be reported on the remittance advice to help identify this claim for this patient

Assignment/Plan Participation
(Loop: 2300, CLM07)

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

Code indicating whether the provider accepts payment from MHCP

Default is Assigned

Benefits Assignment
(Loop: 2300, CLM08)

Yes - Benefits assigned to the provider

No - Benefits not assigned to the provider

Not Applicable - Patient refuses to assign benefits

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

Release of Information
(Loop: 2300, CLM09)

Yes - Signature collected or required

Informed Consent - Signature not collected and not required

The determination of whether the provider has on file a signed statement by the recipient authorizing the release of medical data to other organizations

Default is Yes

Provider Indicator
(Loop: 2300, CLM06)

Signature on File

Signature not on File

Identifies whether the provider’s signature is on file, certifying services were performed by the provider

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

ICD-9

ICD-10

Identifies 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)

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

Up to 12 diagnosis codes can be added to the claim.

Prior Authorization Number
(Loop: 2300, REF02)

The number assigned to the authorization that indicates MHCP has reviewed and determined medical necessity criteria has been met for the service(s) on this claim

Medical Record Number
(Loop: 2300, REF02)

A number to identify the actual medical record of the patient, assigned by the provider

Claim Note
(Loop: 2300, NTE02)

Free form description to provide additional information/clarification about this claim

Attachment Control Number
(Loop: 2300, PWK06)

Code/number assigned by the provider, identifying an attachment for this claim

MHCP uses only the first 30 characters when matching the attachments to the claim

Type
(Loop: 2300, PWK01)

Refer to the MN–ITS screen for values available for this field

Code indicating the type ID and description of the attachment

Contact Name
(Loop: 2010CA, PER02)

The name of the provider’s contact person who handles the property and casualty coverage related to this claim

Telephone Number
(Loop: 2010CA, PER04)

The telephone number of the provider’s contact person who handles the property and casualty coverage related to this claim

Extension
(Loop: 2010CA, PER06)

The telephone number extension of the provider’s contact person who handles the property and casualty coverage related to this claim

Related Causes
(Loop: 2300, CLM11-1)

AA - Auto Accident

EM - Employment

OA - Other Accident

Code identifying the type of accident that caused an illness or injury

Date of Accident
(Loop: 2300, DTP03)

MMDDCCYY

The date of the accident that caused an illness or injury

Certification Condition
(Loop: 2300, CRC02)

Yes - Condition code(s) apply

No - Condition code(s) do not apply

Code indicating whether a value in the Condition Code field applies to the Ambulance Transportation Service

Condition Code
(Loop: 2300, CRC03, CRC04, CRC05, CRC06, CRC07)

Refer to the MN–ITS screen for values available for this field

Code indicating the status or nature of the recipient’s condition for the Ambulance Transportation Service

Certification Condition
(Loop: 2300, CRC02)

Yes - A referral was made as a result of the C&TC screening

No - No referral was made

Code indicating whether or not the child needs further assessment, diagnosis or treatment which was identified during the C&TC screening

Condition Code
(Loop: 2300, CRC03, CRC04, CRC05)

Refer to the MN–ITS screen for values available for this field

Code used to define the status or nature of the referral as a result of the C&TC screening

Patient Weight
(Loop: 2300, CR102)

The weight of the patient.

Transport Distance
(Loop: 2300, CR106)

The distance traveled during the Ambulance Transportation Service

Transport Reason Code
(Loop: 2300, CR104)

Refer to the MN–ITS screen for values available for this field

Code indicating the reason for the Ambulance Transportation Service

Round Trip Purpose Description
(Loop: 2300, CR109)

Free form description to provide additional information about the round trip.

Stretcher Purpose Description
(Loop: 2300, CR110)

Free form description to provide additional information of why a stretcher was needed.

Pickup Address
(Loop: 2310E, N301)

Physical location address where the Ambulance Transportation Service began

Address {contd}
(Loop: 2310E, N302)

The second address line of the physical location address where the Ambulance Transportation Service began

City
(Loop: 2310E, N401)

The city name for the address where the Ambulance Transportation Service began

State
(Loop: 2310E, N402)

The state where the Ambulance Transportation Service began

Zip Code
(Loop: 2310E, N403)

The zip code for the address where the Ambulance Transportation Service began

Dropoff Address
(Loop: 2310F, N301)

Physical location address where the Ambulance Transportation Service ended

Address {contd}
(Loop: 2310F, N302)

The second address line of the physical location address where the Ambulance Transportation Service ended

City
(Loop: 2310F, N401)

The city name for the address where the Ambulance Transportation Service ended

State
(Loop: 2310F, N402)

The state where the Ambulance Transportation Service ended

Zip Code
(Loop: 2310F, N403)

The zip code for the address where the Ambulance Transportation Service ended

NPI/UMPI
(Loop: 2310B, NM109)

NPI/UMPI of the provider who performed the service

NPI/UMPI
(Loop: 2010AB, NM109)

NPI/UMPI of the provider to be paid when the address is different than that of the Billing Provider

NPI/UMPI
(Loop: 2310A, NM109)

NPI/UMPI of the provider who made the referral for the service

NPI/UMPI
(Loop: 2310C, NM109)

NPI/UMPI identifying one of the following:

• Where the services were actually provided
• The recipient’s or provider’s home/clinic location when the location of health care service is different than the billing provider