Minnesota Minnesota

MN–ITS User Manual

MN–ITS User Manual

Rehabilitative Services, OT, PT and SLP

Revised: March 12, 2024

Review MHCP Billing Policy for general billing requirements and guidance when submitting claims.
Refer to additional billing requirements in the service specific 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 Claim Transactions
  • 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)
    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 the 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

    Screen Action Button

    Select:

  • · Cancel to cancel the claim entry
  • · 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 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 not correct

    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

    • 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)

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

    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 replacement or void is selected. Once 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 claim number will auto-populate.

    Place of Service
    (Loop: 2300 CLM05-1)

    From the drop down menu, select the code that identifies where the service was performed.

    Default is 11 (office).

    Patient Control Number
    (Loop: 2300, CLM01)

    Enter a unique identifier to help identify this claim for this recipient. This will be reported on the 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 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.

    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 than the default.

    Diagnosis Type Code
    (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.

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

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

    Once 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 the situational claim information accordion panel to report situational information when required.

    Prior Authorization Number
    (Loop: 2300, REF02)

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

    When authorization is required, enter the approved authorization number.

    Medical Record Number
    (Loop: 2300, REF02)

    When required, enter a number to identify the actual medical record of the patient, assigned by the provider.

    Claim Note
    (Loop: 2300, NTE02)

    Use only when additional information is required.

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

    Attachment Control Number
    (Loop: 2300, PWK06)

    Use only when an attachment is required.

    Enter a 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)

    Use only when an attachment is required.

    rom 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.

    Contact Name
    (Loop: 2010CA, PER02)

    When required, enter the name of the provider’s contact person who handles the property and casualty coverage related to this claim.

    Telephone Number
    (Loop: 2010CA, PER04)

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

    Extension
    (Loop: 2010CA, PER06)

    Enter 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)

    When required, select the code identifying the type of accident that caused an illness or injury.

    Date of Accident
    (Loop: 2300, DTP03)

    Enter the date of the accident that caused an illness or injury.

    Certification Condition
    (Loop: 2300, CRC02)

    When required, select the 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,)

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

    Situational Ambulance Information - Select the situational claim information accordion panel to report situational information for ambulance when required.

    Certification Condition
    (Loop: 2300, CRC02)

    When required, select the 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)

    Select the code indicating the status or nature of the recipient’s condition for the Ambulance Transportation Service.

    Patient Weight
    (Loop: 2300, CR102)

    Enter the weight of the patient.

    Transport Distance
    (Loop: 2300, CR106)

    Enter the distance traveled during the Ambulance Transportation Service.

    Transport Reason Code
    (Loop:2300 CR104)

    Select the transport reason from the drop down menu.

    Round Trip Purpose Description
    (Loop: 2300, CR109)

    When required enter a free form description to provider additional information about the round trip.

    Stretcher Purpose Description
    (Loop: 2300, CR110)

    When required enter a free form description to provide additional information of why a stretcher was needed.

    Pickup Address
    (Loop: 2310E, N301)

    Enter the physical location address where the Ambulance Transportation Service began.

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

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

    City
    (Loop: 2310E, N401)

    Enter the city name for the address where the Ambulance Transportation Service began.

    State
    (Loop: 2310E, N402)

    Enter the state where the Ambulance Transportation Service began.

    Zip Code
    (Loop: 2310E, N403)

    Enter the zip code for the address where the Ambulance Transportation Service began.

    Dropoff Address
    (Loop: 2310F, N301)

    Enter the physical location address where the Ambulance Transportation Service ended.

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

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

    City
    (Loop: 2310F, N401)

    Enter the city name for the address where the Ambulance Transportation Service ended.

    State
    (Loop: 2310F, N402)

    Enter the state where the Ambulance Transportation Service ended.

    Zip Code
    (Loop: 2310F, N403)

    Enter the zip code for the address where the Ambulance Transportation Service ended.

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

    Rendering Provider

    NPI/UMPI
    (Loop: 2310B, NM109)

    * Rehabilitative agencies and nursing homes are not required to report rendering provider. Refer to Rehabilitative Services in the MHCP Provider Manual for details.

    If different than the billing provider:

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

    • 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 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,NM101, NM109)

    If different than the billing provider:

  • · Enter the NPI of the provider who referred the recipient 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


    • This service requires an order or referral. Enter the referring provider here. If an order was written, report the ordering provider on the services screen

    Service Facility Location

    NPI/UMPI
    (Loop: 2310C, NM109)

    If different than the billing provider:

  • · Enter the NPI of the location where the service was performed
  • · 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 different than the billing provider:

  • · Enter the NPI of the provider who supervised 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

    • 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

    • 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 Continue button at the bottom of this screen to proceed to the next screen.

    To report each type of other payer information at the claim/header level use the tables below:

    Third Party Liability (TPL)/Other insurance (non-Medicare)
    Medicare/HMO Medicare Risk

    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 use the instructions in the Medicare/HMO Medicare Risk table below.

    Field Name*
    (X12 Loop & 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 the Identifier of the insurance carrier (this is available on the eligibility response for this recipient).

    Claim Filing Indicator
    (Loop: 2320, SBR09)

    Select from the drop down menu, the code identifying the 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 menu, select 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.

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

    Relationship Code
    (Loop: 2320, SBR02)

    From the drop down menu, select the relationship of the MHCP subscriber (recipient) to the policy holder

    Claim Adjustment Group Code
    (Loop: 2320, CAS01)

    Claim Level Adjustments:
    This field is used only when reporting TPL/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 from the drop down, the adjustment code as reported on the other payers EOB identifying the general category of payment adjustment and complete all of the claim level adjustment fields

    Adj Reason Code
    (Loop: 2320, CAS02, CAS05, CAS08, CAS11, CAS14, CAS17)

    This field is used only when reporting TPL/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.

    Adj Amount
    (Loop: 2320, CAS03, CAS06, CAS09, CAS12, CAS15 CAS18)

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

    Enter the number of not units paid, if different than the number of units submitted on the claim sent to the other payer.

    Select the Add action button that is displayed next to the filed to add the adjustment entry claim.

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

    Once and 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/private insurance at the claim (header) level rather than at the service line.

    Enter the total dollar amount paid by the other payer.

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

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

    Enter the total dollar amount the other payer did not pay.

    Benefits Assignment
    (Loop: 2320, O103)

    The determination of the policy holder, or person authorized to act on their behalf, to give the other payer permission to pay the provider directly.

    Default is Yes.

    Select the correct response if different than the default.

    Release of Information
    (Loop 2320, O106)

    The determination of whether the provider has a signed statement by the recipient 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 in this section to remove this payer from the claim level and at the line level.

    Section Action Button

    Select the Save action button in this section to include the TPL/private insurance information on the claim.

    Section Action Button

    Once 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 Button

    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

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

  • · For Medicare: Refer to the CMS Provider Compliance Group Map for contractor contact information in your area.
  • · For HMO/Medicare Risk/Advantage (Coverage Type: 07): Refer to the recipient’s MN–ITS Eligibility Response. The Payer ID is displayed in the Carrier ID field

    • Claim Filing Indicator
    (Loop: 2320, SBR09)

    From the drop down menu, select the code identifying the type of insurance.

    Once the claim filing indicator is selected, additional fields will display for reporting Medicare payments.

    Payer Responsibility
    (Loop: 2320, SBR01)

    Other Payer Subscriber:
    From the drop down menu, select 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)

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

    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 code(s) 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. Once 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 COB. This information should be reported at the service line.

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

    This field is not used when reporting Medicare or HMO Medicare risk insurance COB. This information should be reported at the service line.

    Benefits Assignment
    (Loop: 2320, O103)

    The determination of the policy holder, or person authorized to act on their behalf, to give the other payer permission to pay the provider directly.

    Default is Yes.

    Select the correct response if different than the default.

    Release of Information
    (Loop 2320, O106)

    The determination of whether the provider has a signed statement by the recipient 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 in this section to remove this payer from the claim level and at the line level.

    Section Action Button

    Select the Save action button in this section to include the Medicare information on the claim.

    Section Action Button

    Once 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 Button

    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 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 a consecutive date range, the service was provided only when required.

    Place of Service
    (Loop: 2400, SV105)

    Select from, the drop down, 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 CPT or HCPCS code identifying the service.

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

    Enter the modifier(s) 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)

    From the drop down menu, select the diagnosis code(s), in the order of importance, that best describes the need for this service.

    Line Item Charge
    (Loop: 2400, SV102)

    Enter your usual and customary charge for this 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 the service.

    Select one or more of the collapsed accordion panel(s) to report:

  • · Other Payer - when reporting other payers (Medicare and/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 the Other Payer accordion panel when reporting other payer (Medicare and/or TPL) payments or denials at the service (line) level.

    Other Payer Primary Identifier
    (Loop: 2430, SVD01)

    Select from the drop down, the identifier of the TPL/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/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 for this service line.

    Claim Adjustment Group Code
    (Loop: 2430, CAS01)

    COB Line Adjustments Entry:
    Select from the drop down, menu, select the adjustment code identifying the general category of payment adjustment for this service line.

    Adjustment Reason Code
    (Loop: 2430, CAS02)

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

    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/EOMB.

    Action Button

    Select the Delete action button next to an adjustment to remove it from the service line.

    Section Action Button

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

    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

    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

    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)

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

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

    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 services types identified in this guide.

    The number of patients, when more than one is transported in the same ambulance or non-emergency transportation service.

    Line Note
    (Loop: 2400, NTE02)

    Enter a free form description to provide additional information about this service line, when required.

    Qualifier
    (Loop: 2400, K301)

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

    CDT code indicating type of value entered for the service.

    Value
    (Loop: 2400, K301)

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

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

    Description
    (Loop: 2400, SV101-7)

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

    When required, enter the model number of an item as noted on the approved authorization or the hearing aid model number exactly as written in the hearing aid volume purchase contract for this service line.

    NDC
    (Loop: 2410, LIN03)

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

    The National Drug Code (NDC) that further specifies the HCPCS code used for the service.

    NDC Count
    (Loop: 2410, CPT04)

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

    Number specifying the drug quantity.

    CODE Qualifier
    (Loop: 2410, CTP05-1)

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

    Code indicating type of measurement for the NDC count.

    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)

    When required, select the code indicating whether a value in the Condition Code field applies to the Ambulance Transportation Service.

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

    Select the code indicating the status or nature of the recipient’s condition for the Ambulance Transportation Service.

    Patient Weight
    (Loop 2400, CR102)

    Enter the weight of the patient.

    Transport Distance
    (Loop 2400, CR106)

    Enter the distance traveled during the Ambulance Transportation Service.

    Transport Reason Code
    (Loop 2400, CR104)

    Select the transport reason from the drop down menu.

    Round Trip Purpose Description
    (Loop: 2400, CR109)

    When required enter a free form description to provider additional information about the round trip.

    Stretcher Purpose Description
    (Loop: 2400, CR110)

    When required enter a free form description to provide additional information of why a stretcher was needed.

    Pickup Address
    (Loop 2420G, N301)

    Enter the physical location address where the Ambulance Transportation Service began.

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

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

    City
    (Loop: 2420G, N401)

    Enter the city name for the address where the Ambulance Transportation Service began.

    State
    (Loop: 2420G, N402)

    Enter the state where the Ambulance Transportation Service began.

    Zip Code
    (Loop: 2420G, N403)

    Enter the zip code for the address where the Ambulance Transportation Service began.

    Dropoff Address
    (Loop: 2420H, N301)

    Enter the physical location address where the Ambulance Transportation Service ended.

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

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

    City
    (Loop: 2420H, N401)

    Enter the city name for the address where the Ambulance Transportation Service ended.

    State
    (Loop: 2420H, N402)

    Enter the state where the Ambulance Transportation Service ended.

    Zip Code
    (Loop: 2420H, N403)

    Enter the zip code for the address where the Ambulance Transportation Service ended.

    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/UMPI
    (Loop: 2420A, NM109)

    * Rehabilitative agencies and nursing homes are not required to report rendering provider. Refer to Rehabilitative Services in the MHCP Provider Manual for details.

    If different than the provider reported on the claim information screen:

  • · 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)

    If different than the provider reported on the claim information screen:

  • · Enter the NPI of the provider who referred the recipient for this 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

    • Service Facility Location

    NPI/UMPI
    (Loop: 2420C, NM109)

    If different than the location reported on the claim information screen:

  • · Enter the NPI of the location where the service was performed
  • · Select the action button in this section to add the location information
  • · Select the radio button to add the location to the claim

    • Ordering Provider

    NPI/UMPI
    (Loop: 2420E, NM109)

    If reporting an ordering/prescribing provider:

  • · Enter the NPI of the provider who wrote the order/prescription for 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

    • Supervising Provider

    NPI/UMPI
    (Loop: 2420D, NM109)

    If reporting a supervising provider:

  • · Enter the NPI of the provider who is doing the supervising service
  • · 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 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, service line 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 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.
  • · 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.


    • Use the Washington Publishing Company (WPC) 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 Guide for step-by-step instructions when completing these transactions.

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