Minnesota Minnesota

MN–ITS User Manual

MN–ITS User Manual

Billing for Medication Therapy Management Service

Revised: October 6, 2026

Review Billing Policy Overview section under Provider Basics in the Minnesota Health Care Programs (MHCP) Provider Manual for general billing requirements and guidance when submitting claims. Refer to additional billing requirements in the item or service specific section of the MHCP Provider Manual before you submit the claim for services.

Log in to MN–ITS

  • 1. Use LoginMN to access MN–ITS
  • 2. From the left menu of the MN–ITS homepage:
  • a. Select MN–ITS
  • b. Select Claim Transactions
  • c. Select Professional (837P)

    • Submit the Claim

    Follow the instructions in the following tables for each of the following claim screens to submit the claim:

    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 log in to MN–ITS. If changes are needed, follow the information in Changes to Enrollment to notify MHCP Provider Enrollment.

    Refer to the following table for instructions and information about each field on this screen.

    Field Name*
    (X12 Loop and 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 log in 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 Code
    (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 Button

    Select:

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

    • Subscriber

    Use the Subscriber (member) screen to report the member who received the services reported on this claim.

    Refer to the following table for instructions and information about each field on this screen.

    Field Name*
    (X12 loop and element)

    Field Instruction

    Subscriber ID
    (Loop: 2010BA, NM109)

    Enter the 8-digit MHCP ID for the subscriber (member) 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 remaining subscriber fields will 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 action button in this section to remove the subscriber information if not correct.

    Screen Action Button

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

    Refer to the following table for instructions and information about each field on this screen.

    Field Name*
    (X12 Loop and element)

    Field Instruction

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

    Specifies if the claim is an original, replacement or void.

    The 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 from a submit response or from the request status feature, the claim will display with the 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 the replacement or void radio button is selected. After selected, enter the payer claim control number to be replaced or voided.

    If the claim has been retrieved from a submit response or the request status feature, the payer claim number will display.

    Place of Service
    (Loop: 2300, CLM05-1)

    Select the code from the drop-down menu that identifies where the service was performed or where the item will be used by the subscriber (member).

    Patient Control Number
    (Loop: 2300, CLM01)

    Enter a unique identifier to help identify this claim for this subscriber (member). Enter numbers, letters or a combination.

    MHCP will report the patient control number on your remittance advice.

    Assignment/Plan Participation
    (Loop: 2300, CLM07)

    Code indicating whether the provider accepts payment from MHCP.

    Default is Assigned. Select the correct response if different that 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 that the default.

    Release of Information
    (Loop: 2300, CLM09)

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

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

    Provider Indicator
    (Loop: 2300, CLM06)

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

    Default is Signature on File. Select the correct response if different that the default.

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

    Select from the drop-down menu 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)

    Enter the ICD or other industry accepted codes that best describes the condition or reason the member needs the service or item.

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

    Repeat this step to add additional codes. When entering multiple codes, enter the codes in order of priority to identify the primary reason the service or item is needed.

    After a diagnosis code is added, a delete action button will display next to that entry in the display field below.

    Select Delete to remove an entry if incorrect.

    Situational Claim Information - Select this accordion panel to report additional information at the claim level when required.

    Prior Authorization Number
    (Loop: 2300, REF02)

    When authorization is required, enter the approved authorization number for the item or service. Or if there are multiple authorizations to report, enter the authorization numbers at the service line.

    You may report multiple authorizations on a claim, but after one authorization is entered all lines must either be on that authorization or have a service line specific authorization.

    Medical Record Number
    (Loop: 2300, REF02)

    This field is not required for the items and service types identified in this guide.

    Claim Note
    (Loop: 2300, NTE02)

    Enter a free-form description to provide additional information about this claim when required.

    Attachment Control Number
    (Loop: 2300, PWK06)

    Use only when Electronic claim attachments are required. Enter a code or 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. This must match the number entered in MN-ITS under Attachment Control Number on the Claim Information tab under Situational.

    Type
    (Loop: 2300, PWK01)

    Use only when sending an attachment with the claim. Select the code indicating the attachment type ID and description from the drop-down menu.

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

    Contact Name
    (Loop: 2010CA, PER02)

    This field is not required for the items and service types identified in this guide.

    Telephone Number
    (Loop: 2010CA, PER04)

    This field is not required for the items and service types identified in this guide.

    Extension
    (Loop: 2010CA, PER06)

    This field is not required for the items and service types identified in this guide.

    Related Causes
    (Loop: 2300, CLM11-1)

    This field is not required for the items and service types identified in this guide.

    Date of Accident
    (Loop: 2300, DTP03)

    This field is not required for the items and service types identified in this guide.

    Certification Condition
    (Loop: 2300, CRC02)

    This field is not required for the items and service types identified in this guide.

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

    This field is not required for the items and service types identified in this guide.

    Situational Ambulance Information - Select the Situational Ambulance Services accordion panel to report ambulance services information on the service line, if different than what was reported at the claim level.

    Certification Condition
    (Loop: 2400, CRC02)  

    This field is not required for the items and service types identified in this guide.

    Condition Code
    (Loop: 2400, CRC03, CRC04, CRC05, CRC06, CRC07)

    This field is not required for the items and service types identified in this guide.

    Patient Weight
    (Loop: 2400, CR102)

    This field is not required for the items and service types identified in this guide.

    Transport Distance
    (Loop: 2300, CR106)

    This field is not required for the items and service types identified in this guide.

    Transport Reason Code
    (Loop: 2400, CR104)

    This field is not required for the items and service types identified in this guide.

    Round Trip Purpose Description
    (Loop: 2400, CR109)

    This field is not required for the items and service types identified in this guide.

    Stretcher Purpose Description
    (Loop: 2400, CR110)

    This field is not required for the items and service types identified in this guide.

    Pickup Address
    (Loop: 2310E, N301)

    This field is not required for the items and service types identified in this guide.

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

    This field is not required for the items and service types identified in this guide.

    City
    (Loop: 2310E, N401)

    This field is not required for the items and service types identified in this guide.

    State
    (Loop: 2310E, N402)

    This field is not required for the items and service types identified in this guide.

    Zip Code
    (Loop: 2310E, N403)

    This field is not required for the items and service types identified in this guide.

    Dropoff Address
    (Loop: 2310F, N301)

    This field is not required for the items and service types identified in this guide.

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

    This field is not required for the items and service types identified in this guide.

    City
    (Loop: 2310F, N401)

    This field is not required for the items and service types identified in this guide.

    State
    (Loop: 2310F, N402)

    This field is not required for the items and service types identified in this guide.

    Zip Code
    (Loop: 2310F, N403)

    This field is not required for the items and service types identified in this guide.

    Other Providers (Claim Level) – Select this accordion panel to report other providers when required.

    Rendering Provider

    NPI/UMPI
    (Loop: 2310B, NM109)

    If different than the billing or rendering provider:

  • · Enter the National Provider Identifier (NPI) of the Medication Therapy Management Services pharmacist 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

    • 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 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

    • Referring Provider

    NPI/UMPI
    (Loop: 2310A, NM109)

    This field is not required for the items and service types identified in this guide.

    Service Facility Location

    NPI/UMPI
    (Loop: 2310C, NM109)

    This field is not required for the items and service types identified in this guide.

    If different than the billing provider:

  • · Enter the NPI of the provider who should be paid for the item or 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)

    This field is not required for the items and service types identified in this guide.

    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 to report other payers, third party liability (private insurance) or Medicare’s financial responsibility for all or a portion of the claim. If no other payers are involved with this claim, select the Contiuebutton at the bottom of this screen to proceed to the next screen.

    Use the following tables to report each type of other payer information at the claim or header level:

  • · Third Party Liability (TPL) - Other Insurance (non-Medicare)
  • · Medicare and HMO Medicare Risk
  • · Use for reporting MB-Medicare Part B or 16-Health Maintenance Organization and HMO Medicare Risk insurance.

    • Third Party Liability (TPL) - Other Insurance (non-Medicare)
    Complete the following fields to report adjustment, payments and denials from the private insurance (Non-Medicare) carrier.

    Field Name*
    (X12 Loop and element)

    Field Instruction

    Other Payer Name
    (Loop: 2330B, NM103)

    Other Payer:
    Enter the full name of the insurance carrier. Do not use symbols such as slashes, dashes, periods or plus signs.

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

    Enter Payer Identifier for the TPL or other insurance.

    This information is available on the MN–ITS Eligibility Response screen for this member. Do not use symbols such as slashes, dashes, periods or plus signs.

    Claim Filing Indicator
    (Loop: 2320, SBR09)

    Select the code identifying the type of insurance from the drop-down.

    After the claim filing indicator is selected, additional fields will display for reporting TPL or private insurance.

    Payer Responsibility
    (Loop: 2320, SBR01)

    Other Payer Subscriber:
    Select the code from the drop-down menu identifying the insurance carrier’s level of responsibility for this claim.

    Insured ID
    (Loop: 2330A, NM109)

    Enter the policy holder’s identification number as assigned by the payer.

    For Medicare this would be the Medicare health insurance claim number (HICN) or the Medicare beneficiary identifier (MBI) number.

    Relationship Code
    (Loop: 2320, SBR02)

    Select the code from the drop-down menu identifying the relationship of the MHCP subscriber (member) to the policy holder.

    If reporting adjustments at the claim (header) level for TPL complete the remaining Claim Level Adjustments.

    Or:

    If reporting adjustments at the line level, scroll to down to the Other Insurance Information section.

    Claim Adjustment Group Code
    (Loop: 2320, CAS01)

    Claim Level Adjustments:
    This field is used only when reporting TPL or private insurance at the claim (header) level. When reporting adjustments at the line level, do not complete the claim level adjustment fields.

    If reporting at the claim level:

    Select the adjustment code from the drop-down menu as reported on the other payer’s EOB identifying the general category of payment adjustment and complete the claim level adjustments.

    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.

    Enter the code identifying the reason the claim paid differently than originally billed to the other payer.

    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.

    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.

    Enter the number of not units paid when the units paid different than the number of units submitted on the claim.

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

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

    After an adjustment entry is entered and added, a delete button will display next to the entry. Select the Delete action button to remove the entry from the claim.

    Payer Paid Amount
    (Loop: 2320, AMT02)

    Other Payer Amounts:
    This field is used only when reporting TPL or private insurance at the claim (header) level.

    The total dollar amount paid by the other payer.

    Non-Covered Charge Amount
    (Loop: 2320, AMT02)

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

    The total dollar amount the other payer did not pay.

    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 member 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 the Delete action button at the bottom of this section to remove the payer that is displayed on the screen.

    Section Action Button

    Select the Save action button at the bottom of this section to save this payer information on the claim.

    Screen Action Button

    After the Other Payer Information is saved, an ADD button will display below this section.

    Select the ADD action button to enter additional payers.

    Repeat the same Other Payer and Claim Adjustments step for additional payers.

    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

    • Medicare and HMO Medicare Risk

    Members eligible for Medicare Part D are not eligible for this service through Medical Assistance or Minnesota Care.

    Complete the following fields to report adjustments, payments and denials from Medicare or an HMO Medicare Risk plan.

    Field Name*
    (X12 Loop and element)

    Field Instruction

    Other Payer Name
    (Loop: 2330B, NM103)

    Other Payer:
    Enter the full name of the insurance carrier.

    Do not use symbols, such as slashes, dashes, and so on.

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

    Enter the Payer ID of the Medicare contractor or Medicare Risk (Advantage) health plan.

  • · For Medicare: Refer to the Review Contractor Directory - Interactive Map for contractor contact information in your area.
  • · For HMO/Medicare Risk/Advantage (Coverage Type: 07): Refer to the member’s MN–ITS Eligibility Response. The Payer ID is displayed in the Carrier ID field.

    • Claim Filing Indicator
    (Loop: 2320, SBR09)

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

    After the claim filing indicator is selected, additional fields will display for reporting Medicare information.

    Payer Responsibility
    (Loop: 2320, SBR01)

    Other Payer Subscriber:
    Select the code identifying the payer’s level of responsibility for payment of this claim from the drop-down menu.

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

    Enter the policy holder’s identification number as assigned by the payer.

    Relationship Code
    (Loop: 2320, SBR02)

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

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

    Medicare:
    Enter the claim number reported on the Medicare EOMB.

    Payment Remark Code
    (Loop: 2320, MOA03-MOA07)

    Claim Payment Remark Code(s):
    When reported on the Medicare EOMB, enter the payment remark codes as reported.

    Select the Add action button that is displayed next to the entry to add the remark code to the claim.

    Repeat the remark code entries until all remark codes are entered. After a remark code is entered, a Delete action button will display.

    Select the Delete action button in this section to remove that entry.

    Payer Paid Amount
    (Loop: 2320, AMT02)

    Other Payer Amounts:
    This field is not used when reporting Medicare or HMO Medicare risk insurance.

    The total dollar amount paid by the other payer.

    Non-Covered Charge Amount
    (Loop: 2320, AMT02)

    This field is not used when reporting Medicare or HMO Medicare risk insurance.

    The total dollar amount the other payer did not pay.

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

    Default is Yes.

    Select the correct response if different than the default

    Section Action Button

    Select the Delete action button in this section to remove the payer that is displayed on the screen.

    Section Action Button

    Select the Save action button in this section to save this payer information on the claim.

    Screen Action Button

    After the Other Payer Information is saved, an ADD button will display below this section.

    Select the ADD action button to enter additional payers.

    Repeat the same Other Payer and Claim Adjustments step for additional payers.

    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

    • 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 following table 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 (MMDDCCYY) the item or service was provided, dispensed or delivered to the member.

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

    Enter the last date (MMDDCCYY) of a consecutive date range, the service was provided only when required.

    Place of Service
    (Loop: 2400, SV105)

    Select the place from the drop-down menu where the service was provided or where the member will use the service or item when different than what was reported on the Claim Information screen.

    Procedure Code
    (Loop: 2400, SV101-2)

    Enter the Current Procedural Technology (CPT) code or Healthcare Common Procedure Coding System (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.

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

    Select the diagnosis codes from the drop-down menu in the order of importance that best describe the need for this service.

    Line Item Charge
    (Loop: 2400, SV102)

    Enter your usual and customary charge for this line item or service.

    If other payers were involved with the determination of this claim/service line item, enter the charge that was submitted on the claim to the other payer.

    Service Unit Count
    (Loop: 2400, SV104)

    Enter the number of units for this line item or service.

    Select one or more of the collapsed accordion panels to report:

  • · Other Payer - when reporting other payers (Medicare or TPL) payments or denials for the line level item or service
  • · Situational Services – to report additional information or if the service line information is different than reported at the claim level
  • · Other Providers – if reporting a provider different than who was reported at the claim level

    • Other Payer – Select this accordion panel when reporting other payers (Medicare and/or TPL) payments or denials for the line level item or service.

    Other Payer Primary Identifier
    (Loop: 2430, SVD01)

    Select the identifier from the drop-down of the TPL/private insurance carrier, HMO Medicare Risk Insurance or the NPI of the Medicare contractor.

    Service Line Paid Amount
    (Loop: 2430, SVD02)

    Enter the total dollar amount paid by the other payer for this service line.

    Adjudication - Payment Date
    (Loop: 2430, DTP03)

    Enter the determination date of payment or denial 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 explanation of benefits (EOB) or explanation of medical benefits (EOMB).

    Claim Adjustment Group Code
    (Loop: 2430, CAS01)

    COB Line Adjustments Entry:
    Select the adjustment code from the drop down as reported on the other payer. EOB/EMOB identifying the general category of payment adjustment.

    Adjustment Reason Code
    (Loop: 2430, CAS02)

    Enter the code identifying the reason the adjustment was made as reported on the other payer EOB or EOMB.

    Adjustment Amount
    (Loop: 2430, CAS03)

    Enter the total dollar amount of the adjustment for this service line as reported on the other payer EOB or EOMB.

    Adjustment Quantity
    (Loop: 2430, CAS04)

    Enter the number of not units paid, if different than the number of units submitted on the claim sent to the other payer as reported on the other payer EOB or EOMB.

    Section Action Button

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

    Repeat the Other Payer COB Line Adjustment Entries to report all adjustments for this line as noted on the EOB /EOMB.

    Section Action Button

    After the line-item adjustment entry is added to the claim, a Delete button will display next to each entry.

    Select the Delete action button to remove that specific entry.

    Section Action Button

    Select the Delete action button that is displayed under the adjustments table to remove the COB information about this payer from this service line.

    Section Action Button

    Select the Save action button that is displayed under the adjustments table to save the COB information about this payer to this service line.

    After saved, the COB Line Payments/Adjustments screen will appear with a line edit action button for the following information:

  • · Other Payer Primary identifier
  • · Line Paid Amount
  • · Total Adjustment for the service line

    • Section Action Button

    Select Edit to go back and change your adjustment entries if corrections are needed.

    The totals on this screen should equal the total charge you sent to the primary payer for this service line.

    Section Action Button

    Select the Add action button that is displayed right under the COB Line.
    Payments/Adjustments in this section to report additional payers if additional payers were entered on the COB screen.

    Repeat the same steps used to report the primary payer service line adjustments to report the secondary or additional payer information for this service line.

    Situational Services – Select this accordion panel to report additional information or if the service line information is different than reported at the claim level.

    Prior Authorization
    (Loop: 2400, REF02)

    Enter the approved authorization number for the service line when different than the authorization number reported at the claim level.

    Certification Condition Indicator
    (Loop: 2400, SV111)

    Not used by MHCP.

    Ambulance Patient Count
    (Loop: 2400, QTY02)

    This field is not required for the items and service types identified in this guide.

    Line Note
    (Loop: 2400, NTE02)

    When required, enter a free-form description to provide additional information about this line item or service.

    Qualifier
    (Loop: 2400, K301)

    This field is not required for the items and service types identified in this guide.

    Value
    (Loop: 2400, K301)

    This field is not required for the items and service types identified in this guide.

    Tooth number(s) or oral cavity designation(s) for the service.

    Description
    (Loop: 2400, SV101-7)

    Enter the model number of the item as noted on the approved authorization.

    NDC
    (Loop: 2410, LIN03)

    This field is not required for the items and service types identified in this guide.

    NDC Count
    (Loop: 2410, CPT04)

    This field is not required for the items and service types identified in this guide.

    CODE Qualifier
    (Loop: 2410, CTP05-1)

    This field is not required for the items and service types identified in this guide.

    Situational Ambulance Information - Select the Situational Ambulance Services accordion panel to report ambulance services information on the service line, if different than what was reported at the claim level.

    Certification Condition
    (Loop: 2400, CRC02)

    This field is not required for the items and service types identified in this guide.

    Condition Code
    (Loop: 2400, CRC03, CRC04, CRC05, CRC06, CRC07)

    This field is not required for the items and service types identified in this guide.

    Patient Weight
    (Loop: 2400, CR102)

    This field is not required for the items and service types identified in this guide.

    Transport Distance
    (Loop: 2400, CR106)

    This field is not required for the items and service types identified in this guide.

    Transport Reason Code
    (Loop: 2400, CR104)

    This field is not required for the items and service types identified in this guide.

    Round Trip Purpose Description
    (Loop: 2400, CR109)

    This field is not required for the items and service types identified in this guide.

    Stretcher Purpose Description
    (Loop: 2400, CR110)

    This field is not required for the items and service types identified in this guide.

    Pickup Address
    (Loop: 2420G, N301)

    This field is not required for the items and service types identified in this guide.

    Address (contd)
    (Loop: 2420G, N302)

    This field is not required for the items and service types identified in this guide.

    City
    (Loop: 2420G, N401)

    This field is not required for the items and service types identified in this guide.

    State
    (Loop: 2420G, N402)

    This field is not required for the items and service types identified in this guide.

    Zip Code
    (Loop: 2420G, N403)

    This field is not required for the items and service types identified in this guide.

    Dropoff Address
    (Loop: 2420H, N301)

    This field is not required for the items and service types identified in this guide.

    Address (contd)
    (Loop: 2420H, N302)

    This field is not required for the items and service types identified in this guide.

    City
    (Loop: 2420H, N401)

    This field is not required for the items and service types identified in this guide.

    State
    (Loop: 2420H, N402)

    This field is not required for the items and service types identified in this guide.

    Zip Code
    (Loop: 2420H, N403)

    This field is not required for the items and service types identified in this guide.

    Other Providers – Select this accordion panel if reporting a provider different than who was reported at the claim level.

    Rendering Provider

    NPI/UMPI
    (Loop: 2420A, NM109)

    This field is required:

  • · Enter the NPI of the provider who provided the service
  • · Select the action button in this section to add the other provider information
  • · Select the radio button to add the other provider to the claim

    • Referring Provider

    NPI/UMPI
    (Loop: 2420F, NM109)

    This field is not required for the items and service types identified in this guide.

    Service Facility Location

    NPI/UMPI
    (Loop: 2420C, NM109)

    This field is not required for the items and service types identified in this guide.

    Ordering Provider

    NPI/UMPI
    (Loop: 2420E, NM109)

    This field is not required for the items and service types identified in this guide.

    Supervising Provider

    NPI/UMPI
    (Loop: 2420D, NM109)

    This field is not required for the items and service types identified in this guide.

    Section Action Button

    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

    • Section Action Button

    Select Save once all entries are complete.

    Each time you select save/view line, a service line table will display 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 table to add additional service line(s).

    Screen Action Button

    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 X12 (formerly known as Washington Publishing Company) 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 X12 health care codes lists to identify the claim status category and claim status codes displayed on the claim response.

    • Copy, Replace or Void (take back) 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 (take back) - If the claim was submitted in error. This reverses the claim and takes the payment back.

    Review the Copy, Replace, Void (take back), or Reverse a Claim user guides for step-by-step instructions when completing these transactions.

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