The date of service will auto-populate with the date the claim is created. If the date of service is different from the date the prescription was dispensed, delete the auto-populated date and Enter the date the prescription was dispensed in the 8-digit MMDDCCYY format.

Enter the 10 digit NPI of the health care provider who prescribed this medication.

Enter the prescription number for this medication.

Enter the date the prescription was written in the 8 digit MMDDCCYY format.

From the drop down, Select the appropriate option for this claim.

* If Compound code 2 is selected, a collapsed accordion screen identified as Compound Claim Information will display. You must complete the compound information screen when submitting a compound drug claim to MHCP.

Enter the NDC that identifies this drug.

* For compound drugs, if code 2 was selected for compound code, then this field will be shaded and you will enter in all NDC numbers on the compound screen.

Enter the number that identifies the number of “fills” this prescription is (i.e.: 1 = first fill, 2 = second fill).

From the drop down, Select the appropriate code that indicates whether you followed the prescriber’s instructions regarding generic substitutions.

Enter the number of units dispensed. A decimal point must be placed at the fourth digit from the end followed by three remaining numbers

*For compound drugs enter the number of finished bags, vials, etc.

Enter the number of days that this dispensing should last.

Enter the cost of the ingredient for this prescription. Must use a decimal.

Enter the total of all costs associated with this claim. Must use a decimal.

From the drop down, Select the appropriate qualifier that identifies how the cost or submitted charge was determined.

Enter your usual and customary charge for this medication.

When other insurance is available this is a required field.

From the drop down, Select the appropriate code to identify if the other insurance accepted or denied the claim and what was determined to be the patient responsibility.

Select 0 or 1 if it is unknown or if other insurance is not available.

* At the bottom of the screen a collapsed COB Information screen will display if other coverage code 2, 3 or 4 is selected. The COB screen must be completed when other insurance is identified.

Select the appropriate Action Button from the bottom of this screen if no other information needs to be reported on the collapsed accordion screens.

This field in not required, but the provider can use this field to identify the place where a drug or service is dispensed or administered.

This field in not required unless billing criteria requires a compound type on this claim.

If reporting a compound type, from the drop down Select the appropriate compound type.

This field in not required unless a pharmacist intervention is needed when a conflict code is identified.

If reporting a professional service code, from the drop down Select the appropriate professional service code.

This field is required when reporting a compound drug claim.

Enter the SNOMED value that corresponds with the route the compounded prescription is being administered.

This field in not required unless billing criteria requires the unit of measure to be identified.

If reporting a unit of measure, Select the appropriate unit of measure from the drop down.

This field in not required unless billing criteria requires a special packaging ID on this claim.

If reporting a special packaging ID, from the drop down Select the appropriate unit of measure.

When required Enter the 11- digit prior authorization number assigned for this prescription.

This field is not required unless drug utilization review is necessary.

Select the appropriate code from the drop down.

When required enter the number of refills that have been authorized for this prescription.

Enter the appropriate refill count using a 2-digit format.

This field in not required unless billing criteria requires an explanation of why this prescription is being filled for one of these reasons: Select either of these two reasons from the drop down

Action Buttons
Select Add to add the submission clarification code to the claim.

When the submission clarification code is added, that code will display in the Submission Clarification Description field.

A Delete button will display next to the submission code entry. Select Delete to remove that entry if the wrong code was selected.

When required, Enter the diagnosis code that describes the medical condition that requires the use of this medication.

Select Add to add the diagnosis code to the claim.

The diagnosis code will display below the field in the display table.

Repeat this step to add additional codes. When entering multiple codes enter their codes in order of priority to identify the primary reason the prescription was filled.

I would just indicate that there can be up to five occurrences. Then add the part of the priority.

A Delete button will display next to the diagnosis code. Select Delete to remove the entry if the wrong diagnosis code was entered.

Refer to the Compound Drugs section of the MHCP Provider Manual to review billing criteria for billing compound drug claims.

From the drop down, Select the indicator that describes the type of compound.

Enter the 11-digit NDC for each ingredient of the compound. Enter the main ingredient first, even if it has been entered on the claim information screen.

Enter the total quantity of units used of the NDC that was reported in the product ID field. A decimal point must be placed at the fourth digit from the end followed by three remaining numbers.

Enter the total cost of the NDC reported in the Product ID field for this drug.

From the drop down, Select the appropriate qualifier that identifies how the cost or submitted charge was determined.

This field will auto-fill for each line entry of the compound.

*Maximum count is 25

Refer to the Billing Coordination of Benefits (COB) section of the MHCP Provider Manual to review billing criteria and the Minnesota Medicaid Version of the D.0) NCPDP Payer Sheets

From the drop down, Select the other payer’s level of responsibility for this cardholder (i.e., primary, secondary).

Enter ID of the payer.

*This ID is often called the “Carrier ID” and can be found on the eligibility response in MN–ITS.

From the drop down, Select the qualifier that was indicated by the other payer that describes the benefit or additional cost that was paid by the other payer.

Enter the amount that was paid by the other payer for the paid amount qualifier.

Enter the reject code(s) that were indicted by the other payer, describing the reason the claim was denied.

From the drop down, Select the qualifier that was indicated by the other payer that describes the amount being applied as patient responsibility.

Enter the dollar amount that was applied to the patient responsibility.

This field will populate the numeric count for each qualifier and dollar amount entered as patient responsibility.