Psychiatric Residential Treatment Facility (PRTF)

Revised: March 13, 2024

Review MHCP Billing Policy for general billing requirements and the Psychiatric Residential Treatment Facility (PRTF) section in the MHCP Provider Manual when submitting claims.

Log in to MN–ITS

1. Log in to MN–ITS

2. From the left menu options:

a. Select MN–ITS

b. Select Submit DDE Claims (837)

c. Select Institutional (837I)

Submit an 837I Inpatient Claim

To submit an 837I Inpatient 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 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 (Loop: 2010AA, N403)	The ZIP code for the address in address fields 1 and 2.
Telephone (Loop: 2010AA, PER04)	Telephone number reported on the provider file.
Select Locations	When using a consolidated NPI, a table will display showing the locations and taxonomy code(s) information on file with MHCP. Select the radio button next to the location where the service(s) was provided.
Screen Action Button	Select: · Cancel to cancel the claim entry · Continue to proceed to the next screen

Subscriber

Use the Subscriber screen to report the member 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 (member) indicated on the MHCP member identification card.
Birth Date (Loop: 2010BA, DMG02)	Enter the birth date of the subscriber. Select Search to have MN–ITS find and display the subscriber associated with the subscriber ID and date of birth entered.
The following fields auto-populate based on the information entered in the Subscriber ID and Birth Date fields:
Subscriber First Name (Loop: 2010BA, NM104)	The first name of the subscriber.
Middle Initial (Loop: 2010BA, NM105)	The middle initial of the subscriber.
Last Name (Loop: 2010BA, NM103)	The last name of the subscriber.
Gender (Loop: 2010BA, DMG03)	The gender of the subscriber. Select Delete to remove the subscriber information if incorrect.
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 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
TOB (Loop: 2300, CLM05)	Enter the appropriate Type of Bill (TOB). The TOB is a 3-digit code which defines the type of facility, bill classification and frequency. Enter Type of Bill: · 86X for the treatment and room and board components of PRTF residential services. · Numeric values for frequency (third digit) are as follows: · XX1 – admit through discharge claim · XX2 – first claim in a series of continuous claims or interim billing · XX3 – continuous claim or interim billing · XX4 – the last claim or discharge claim · XX7 – a replacement claim · XX8 – a void claim
Payer Claim Control Number (Loop: 2300, REF02)	The Payer Claim Control Number (PCN) field will display when the TOB frequency code 7 (Replacement) or 8 (Void), is entered. Enter the 17-digit PCN to identify the previously paid claim to be replaced or void. If the claim has been retrieved from a submit response, or the request status feature, the payer claim number will display.
Statement Date (From) (Loop: 2300, DTP03)	Enter the service start date.
Statement Date (To) (Loop 2300, DTP03)	Enter the service end date.
Patient Control Number (Loop: 2300, CLM01)	Enter a unique identifier assigned by you, to help identify the claim for this member. The patient control number will be reported 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 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 member on file, authorizing the release of medical data to other organizations. Default is Yes. Select the correct response if different than the default.
Admission Type (Loop: 2300, CL101)	From the dropdown menu options, select the appropriate response to identify the priority of the admission or visit.
Admission Source (Loop: 2300, CL102)	From the dropdown menu options, select the appropriate source code indicating the point of location or origin for this admission or visit.
Patient Status (Loop: 2300, CL103)	From the dropdown menu options, select the code indicating the disposition or discharge status of the member on the date entered in the Statement Date (To) field.
Admission Date (Loop: 2300, DTP02)	Enter the date the episode of care began or the admission date to the facility. **Must be the true admission date to the PRTF and match the admission date reported on the members PRTF Inpatient Hospital Authorization (IHA).
Admission Time (Loop: 2300, DTP03)	Enter the time the episode of care began or admission to the facility.
Discharge Time (Loop: 2300, DTP03)	Enter the time the member was discharged from the inpatient care, if applicable. If the patient status is discharged, transferred, or expired, the discharge time is required.
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.
Principal Diagnosis Code (Loop: 2300, HI01-2)	Enter the appropriate diagnosis code as specified on the member’s Inpatient Hospital Authorization. **Must match to the principal diagnosis code reported on the members PRTF Inpatient Hospital Authorization (IHA).
POA (Loop: 2300, HI01-9)	From the dropdown menu options, select the appropriate indicator to identify whether or not the Principal Diagnosis Code was present on admission.
Admitting Diagnosis Code (Loop: 2300, HI01-1)	Enter the ICD or other industry accepted code(s) that best describes the condition or reason the member needed the service(s).
Patient Reason For Visit (Loop: 2300, HI01-2)	This field is not required for this service.
External Cause of Injury Code (Loop: 2300, HI01-2)	This field is not required for this service.
POA (Loop: 2300, HI101-9)	This field is not required for this service.
Other Diagnosis Code (Loop: 2300, HI01-2)	Enter the ICD or other industry accepted code(s) that best describes the additional condition or reason the member needed the service(s) and select Add. Repeat this process to add all other diagnosis codes. To delete the entered code(s), select Delete.
POA (Loop: 2300, HI01-1)	From the dropdown menu options, select the appropriate indicator to identify whether or not the Other Diagnosis Code was present at time of admission.
Situational Claim Information - Select the situational claim information accordion screen to report situational information when required.
Principal Procedure Code (Loop: 2300, HI01-2)	This field is not required for this service.
Date (Loop: 2300, HI01-4)	This field is not required for this service.
Other Procedure Code (Loop: 2300, HI01-2)	This field is not required for this service.
Date (Loop: 2300, HI01-3)	This field is not required for this service.
Prior Authorization Number (Loop: 2300, REF02)	Enter the members PRTF Inpatient Hospital Authorization (IHA) number.
Reference (Loop: 2300, NTE01)	This field is not required for these services.
Text (Loop: 2300, NTE02)	This field is not required for these services.
Attachment Control Number (Loop: 2400, PWK06)	Enter the Code or number assigned by the provider, identifying an attachment for this claim, if applicable. Extended leave days from a PRTF facility must receive prior authorization by the DHS Behavioral Health Division. See the Psychiatric Residential Treatment Facility (PRTF) section of the MHCP Provider Manual for more information. When submitting a claim with extended leave days, you are required to fax approval documentation with the claim according to the Electronic claim attachments procedure. Review the Electronic claim attachments webpage for MHCP Attachment Criteria and additional information.
Attachment Type (Loop: 2400, PWK01)	From the dropdown menu options, select the code indicating the Type ID and description of the attachment. Select Add to add the attachment Control Number and Type ID to the entire claim. To delete entry, select Delete.
Situational (Continued) Claim Information
Occurrence Code (Loop: 2300, HI02-2- HI12)	This field is not required for this service.
Date (Loop: 2300, HI01-4)	This field is not required for this service.
Occurrence Span Code (Loop: 2300, HI01-2)	When appropriate, enter the Occurrence Span Code that identifies an event, occurring over a span of days, that relates to this claim. Bill for therapeutic and hospital leave days using the Occurrence Span Code 74 (non-level of care absence days)
From Date (Loop: 2300, HI01-3)	Enter the beginning date associated with the Occurrence Span.
To Date (Loop: 2300, HI01-4)	Enter the end date associated with the Occurrence Span. Select Add to add the Occurrence Span Code and Dates. To delete entry, select Delete.
Value Code (Loop: 2300, HI01-2)	Enter the Value Code that identifies data necessary for processing this claim. Enter Value code 80 for covered days. Enter Value code 81 for noncovered days.
Amount (Loop: 2300, HI101-1)	Enter the value or amount associated with the Value Code. **Amount must equal to the combined units from all claim service lines.
Condition Code (Loop: 2300, HI01-2)	This field is not required for this service.
Patient Responsibility Amt (Loop: 2300, AMT02)	This field is not required for this service.
Other Providers (Claim Level) – Select the Other Providers accordion screen when required to report other provider information.
Rendering Provider
NPI/UMPI (Loop: 2310B, NM109)	If different than the Attending Provider: · Enter the NPI of the Rendering Provider who provided the service · Select Add to add the Rendering Provider NPI · Select the radio button to add the Rendering Provider to the claim · To delete, select Delete
Pay-To Provider
NPI/UMPI (Loop: 2010AB, NM109)	If different than the Billing Provider: · Enter the NPI of the provider who should be paid for the item or service · Select Add to add the other Pay-to Provider NPI · Select the radio button to add the Pay-to Provider to the claim · To delete, select Delete
Referring Provider
NPI/UMPI (Loop: 2310A, NM109)	If different than the Attending Provider: · Enter the NPI of the provider who referred the member for the item or service · Select Add to add the Referring Provider NPI · Select the radio button to add the Referring Provider to the claim · To delete, select Delete
Attending provider
NPI/UMPI (Loop: 2310A, NM101)	Required, enter the NPI/UMPI of the provider who is attending the service: · Select Add to add the Attending Provider NPI · Select the radio button to add the Attending Provider to the claim · To delete, select Delete OR If NPI entered is Consolidated: · Select Add to add the Attending Provider · Select the location for the Attending Provider · Select the radio button to add the Attending Provider to the claim · To delete, select Delete
Operating Provider
NPI/UMPI (Loop: 2330D, REF02)	This field is not required for this service
Service Facility Location
NPI/UMPI (Loop: 2310E, NM101)	If different than the Billing Provider: · Enter the NPI of the provider where the services were actually provided · Select Add to add the Service Facility Location NPI · Select the radio button to add Service Facility Location to the claim · To delete, select Delete
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, private insurance (TPL) or Medicare’s financial responsibility for all or a portion of the claim. If no other payers are involved with this claim, select the action button at the bottom of this screen to proceed to the next screen and skip to the Claim Services section of this user guide.

To report each type of other payer information at the header (claim) level, use the tables below.

Medicare Part A

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

Medicare Part A
Complete the following fields to report adjustment, payments and denials from Medicare Part A.

Field Name* (X12 Loop & Element)	Field Instruction
Other Payer Name (Loop: 2330B, NM103)	Enter the name of the Medicare or Medicare Advantage Plan.
Other Payer Primary ID (Loop: 2330B, NM109)	Enter the NPI listed on the Explanation of Medicare Benefits (EOMB) used to submit the claim to Medicare.
Claim Filing Indicator (Loop: 2320, SBR09)	From the dropdown menu options, select the code identifying the type of insurance. Once the claim filing indicator is selected, additional fields will display for reporting Medicare information.
Payer Responsibility (Loop: 2320, SBR01)	From the dropdown menu options, select the code identifying the payer’s level of responsibility for payment of a claim.
Insured ID (Loop: 2330A, NM109)	Enter the policy holder’s identification number as assigned by the payer. 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 dropdown menu options, select the relationship of the MHCP member to the policy holder.
Claim Adjustment Group Code (Loop: 2320, CAS01)	For header (claim) level adjustment, select the code identifying the general category of the payment adjustment for this line from the dropdown menu options.
Adj Reason Code (Loop: 2320, CAS03)	Enter the code identifying the reason the adjustment was made.
Adj Amount (Loop: 2320, CAS03)	Enter the total adjusted dollar amount for this line.
Payer Paid Amount (Loop: 2320, AMT02)	Enter the prior payer paid amount.
Non-Covered Charge Amount (Loop: 2320, AMT02)	Enter the non-covered charge amount.
Other Payers Claim Control Number (Loop: 2330B, REF02)	Enter the claim number reported on the Medicare EOMB.
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 member authorizing the release of medical data to other organizations on file. Default is Yes. Select the correct response if different than the default.
Inpatient Adjudication Information (MIA)
Remark Code (Loop: 2320, MIA20-MIA23)	Enter the Medicare remark code(s) from the Medicare EOMB. Select Add to add the code to the claim.
Section Action Buttons	Select: · Delete to remove the Medicare’s information from the claim level · Save to save the entered Medicare information · Add to add additional prior payer on this claim
Screen Action Buttons	Select: · Back to return to the previous screen · Cancel to the entire claim entry · Continue to proceed to the next screen

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

Field Name* (X12 Loop & Element)	Field Instruction
Other Payer Name (Loop: 2330B, NM103)	Enter the name of the TPL insurance payer. Do not use symbols such as slashes, dashes, periods or plus signs.
Other Payer Primary ID (Loop: 2330B, NM109)	Enter the Identifier of the insurance carrier. (This is available on the member’s eligibility response). Do not use symbols such as slashes, dashes, periods or plus signs.
Claim Filing Indicator (Loop: 2320, SBR09)	From the dropdown menu options, select the code identifying type of insurance. Once the claim filing indicator is selected, additional fields will display for reporting TPL or private insurance.
Payer Responsibility (Loop: 2320, SBR01)	From the dropdown menu options, select the code identifying the insurance carrier’s level of responsibility for payment.
Insured ID (Loop: 2330A, NM109)	Enter the policy holder’s identification number as assigned by the payer.
Relationship Code (Loop: 2320, SBR02)	From the dropdown menu options, select the relationship of the MHCP member to the policy holder. If reporting adjustments at the claim (header) level for TPL, complete the remaining Claim Level Adjustments. If reporting adjustment at the line level, select the Save action button in this section and then scroll to down to the Other Insurance Information section of this screen.
Claim Adjustment Group Code (Loop: 2320, CAS01)	For header (claim) level adjustment, select the code identifying the general category of the payment adjustment for this line from the dropdown menu options.
Adj Reason Code (Loop: 2320, CAS03)	Enter the code identifying the reason the adjustment was made.
Adj Amount (Loop: 2320, CAS03)	Enter the total adjusted dollar amount for this line.
Payer Paid Amount (Loop: 2320, AMT02)	When reporting TPL adjustments at the claim (header level), enter the prior payer paid amount.
Non-Covered Charge Amount (Loop: 2320, AMT02)	When reporting TPL at the claim (header level), enter the non-covered charge amount.
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 Buttons	· Select Delete to remove this payer from the claim level. · Select Save to include this TPL or private insurance information on the claim. · Select Add to add additional prior payer on this claim.
Screen Action Buttons	· Select Back to return to the previous screen. · Select Cancel to cancel the entire claim entry. · Select Continue to proceed to the next screen.

Claim 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
Revenue Code (Loop: 2400,SV201)	Enter the appropriate revenue code used to specify the service line item detail for a health care institution. Rev Code 0101: All-inclusive room and board Rev Code 0180: Hospital leave days Rev Code 0183: Therapeutic leave days
Line Item Charge Amount (Loop: 2400, SV102)	Enter the total charge for the service.
Unit Code (Loop: 2400, SV204)	Enter the unit(s) or manner in which a measurement has been taken.
Service Unit Count (Loop: 2400, SV104)	Enter the quantity of units, time, days, visits, services or treatments for the service.
Other Payer – Medicare A and TPL for inpatient claims should be reported on the header (claim) level for appropriate claim processing.
Other Providers – This section is not required for this service.
Screen Action Button	Select: · Save/View Line(s) to save and view all entered lines in the service line table · Copy to save and copy the entire line information to an additional service line · Deleted to remove the entered service line information · From the summary table, select Edit to return and edit a particular line · Add to add a new blank service line
Claim Action Button	Select: · Save once all entries are completed · Validate to determine if the claim has met the HIPAA-compliant and certain basic requirements at both the claim and service line level information · Submit to identify if the claim will be paid, denied or suspended for review at the claim and service 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 validate and submit claim response.

Monthly Interim Billing

The PRTF inpatient hospital authorization (IHA) permits for a single paid claim per authorization. To complete billing monthly, providers must submit replacement claims for each subsequent month after the initially paid claim. Interim billing must include Patient Discharge Status Code 30 and the Payer Claim Control Number (PCN) of the previously paid claim to be replaced must be included in the Payer Claim Control Number field in the Claim Information tab (REF02 Loop 2300)

Copy, Replace or Void (take back) Claims

After submitting the claim and receiving a claim response, the Copy, Replace or Void action buttons will appear at the bottom of the claim response screen. Use each of these features to do the following:

Copy – Copy this exact claim. You may want to do this if you have to resubmit your claim with corrections.

Replace – If the claim is paid incorrectly (including zero pay) and you want to resubmit to replace the previously paid claim. The original paid claim will be taken back and replaced with the new claim submission.

Void (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 webpage for step-by-step instructions when completing these transactions.