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.

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.

The first address line reported on the provider file.

The second address line reported on the provider file.

The city name for the address in address fields 1 and 2.

The state name for the address in address fields 1 and 2.

The ZIP Code for the address in address fields 1 and 2.

Telephone number reported on the provider file.

When using a consolidated NPI, a table will display showing the locations and taxonomy codes information on file with MHCP.

Select the radio button next to the location where the services were provided.

Screen Action Button

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.

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.

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.

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 recipient. 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.

Defaulted 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.

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 appropriate code indicating the disposition or discharge status of the recipient on the date entered in the statement Date (To) field.

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 highest level of ICD or other industry accepted codes that best describe the condition or reason the recipient needed the services.

Other Diagnosis Code
(Loop: 2300, HI01-2)

Enter the ICD or other industry accepted codes that best describes the additional condition or reason the recipient needed the services and select Add. Repeat this process to add all other diagnosis codes.

To delete the entered codes, select Delete.

Prior Authorization Number
(Loop: 2300, REF02)

When appropriate, enter the service agreement or authorization number.

Reference
(Loop: 2300, NTE01)

Select the code identifying the functional area or purpose for which the claim note applies.

Text
(Loop: 2300, NTE02)

Use this field only when required for claim adjudication to report claim information or clarification about the product or service provided for the entire claim relating to the Reference Code. Adding note causes the claim to become complex and allows 90 days to process.

Select Add to add the claim notes to the claim. To delete, select the Delete button.

Attachment Control Number
(Loop: 2400, PWK06)

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

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

Attachment Type
(Loop: 2400, PWK01)

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.

Occurrence Code
(Loop: 2300, HI02-2- HI12)

When appropriate, enter the Occurrence Code defining a significant event relating to this claim.

Date
(Loop: 2300, HI01-4)

Enter the date associated with the Occurrence Code.

Select Add to add the Occurrence Code and Date. To delete entry, select Delete.

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

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)

When appropriate, enter the Value Code that identifies data necessary for processing this claim.

Amount
(Loop: 2300, HI101-1)

Enter the value or amount associated with the Value Code.

Select Add to add the Value Code and Amount. To delete entry, select Delete.

Condition Code
(Loop: 2300 HI01-2)

When appropriate, enter the Condition Code to identify a condition or event related to this claim.

Select Add to add the condition code. To delete entry, select Delete.

Select:

Field Name*
(X12 Loop & Element)

Enter the name of the Medicare or Medicare Advantage Plan.

Enter the NPI listed on the Explanation of Medicare Benefits (EOMB) used to submit the claim to Medicare.

From the dropdown menu options, select the code identifying the type of insurance. After the claim filing indicator is selected, additional fields will display for reporting Medicare information.

From the dropdown menu options, select the code identifying the payer’s level of responsibility for payment of a claim.

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.

From the dropdown menu options, select the relationship of the MHCP subscriber (member) to the policy holder.

Enter the claim number reported on the Medicare EOMB.

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.

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

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

Enter the Medicare remark codes from the Medicare EOMB.

Select Add to add the code to the claim.

Select:

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 recipient’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. After the claim filing indicator is selected, additional fields will display for reporting TPL/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 subscriber (recipient) 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 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 Buttons

Select:

Field Name*
(X12 Loop and element)

Field Instruction

CODE Qualifier
(Loop: 2410, CTP05-1)

Enter the code specifying the units in which a value is being expressed, or manner in which a measurement has been taken.

When no other payer information is required for this line, skip to the Screen Action Button section.

Other Payer Primary Identifier
(Loop: 2430, SVD01)

From the dropdown menu options select the identifier of other payer entered on the COB screen.

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.

Claim Adjustment Group Code
(Loop: 2430, CAS01)

Enter the code identifying the general category of the payment adjustment for this line.

Adjustment Reason Code
(Loop: 2430, CAS02)

Enter the code identifying the reason the adjustment was made.

Adjustment Amount
(Loop: 2430, CAS03)

Enter the total dollar amount of the specific adjustment for the reason code entered on this service line.

Adjustment Quantity
(Loop: 2430, CAS04)

Use this field to enter the number of units not paid when the units paid are different than the number of units submitted on the claim sent to the other payer.

Section Action Buttons

Select:

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

Screen Action Button

Select: