MN–ITS Interactive (837I) Outpatient claim form for Home Care
Contents
1. 7 8371 Home Care Outpatient Last updated 06 15 2012 MN ITS User Guide 8371 Home Care Outpatient Claim Private Duty Nursing LPN T1003 0552 Yes 15 Regular min Private Duty Nursing LPN T1003 0552 UC Yes 15 Regular Extended min Private Duty Nursing LPN T1003 0552 TT Y Yes 15 Shared 1 2 min Private Duty Nursing LPN T1003 0552 TT UC Y Yes 15 Shared 1 2 Ratio min Extended Private Duty Nursing LPN T1003 0552 TG Yes 15 Complex min Private Duty Nursing LPN T1003 0552 TG UC Yes 15 Complex Extended min Occupational Therapy 9129 0431 No Visit Visit Occupational Therapy 9129 0431 TF No Visit Assistant Visit Occupational Therapy 9129 0431 UC Yes Visit Extended Occupational Therapy 9129 0431 TF UC Yes Assistant Extended Physical Therapy Visit 9131 0421 No Visit Physical Therapy 9131 0421 TF No Visit Assistant Visit Physical Therapy 9131 0421 UC Yes Visit Extended Physical Therapy 9131 0421 TF UC Yes Assistant Extended Respiratory Therapy Visit 5181 0411 No Visit Respiratory Therapy Visit 5181 0411 UC Yes Extended Private Duty Nursing RN T1002 0552 Yes 15 Regular Private Duty min Regular Private Duty RN T1002 0552 UC Yes 15 Extended min Private Duty Nursing RN T1002 0552 TT Y Yes 15 Shared 1 2 min Private Duty Nursing RN T1002 0552 TT UC Y Yes 15 Shared 1 2 Extended min Private Duty Nursing2. are as follows e xx2 first claim in a series of continuous claims or interim billing When submitting the first claim the admission date field must be the same as the statement date e xx3 continuous claim or interim billing e xx4 the last claim or discharge claim e xX7 a replacement claim e xx8 void 2 Enter the start and end date of period being billed using the MMDDYYYY format in the Statement Dates field 3 Complete the following fields in the ADMISSION section a Click the down arrow in the Source field and select the appropriate source code Enter 41 for new or current patients b Click the down arrow in the Type field and select the appropriate response to identify the priority of the admission In most situations 3 elective is the most appropriate choice for a home care visit 4 Enter the Patient Account Number in the field of the same name The Patient Account Number is a unique alphanumeric code you assign which can be 1 38 characters in length This number will appear on your Remittance Advice 5 The following are required fields with generally accepted defaults Review each defaulted section for accuracy and adjust as needed a Medicare Assignment field indicates whether or not you accept assignment The default is Option A because MHCP requires you to accept assignment b Benefits Assignment field indicates whether or not you have a third party payer authorization on file allowing you to bill
3. you have a release of information on file from the recipient 8 The Payer Responsibility field identifies the insurance carrier s level of responsibility for payment of the claim Click the down arrow to select the appropriate response primary secondary or tertiary 9 Click the down arrow in the Claim Filing Indicator field to select the appropriate code for the type of insurance coverage being reported 10 Complete the remaining fields in this section if the information is available 11 Move to the top of the screen and review to ensure you have completed all required fields 12 Click the Save button located near the top of the COB tab to save the information that appears next to the blue dot Note If reporting more than one TPL or other insurance click on New and repeat steps When reporting Medicare Part B coverage in addition to MHCP 1 Enter the name of the Medicare or Medicare Advantage Plan in the Payer Name field 4 8371 Home Care Outpatient Last updated 06 15 2012 MN ITS User Guide 8371 Home Care Outpatient Claim Enter the NPI listed on the Explanation of Medicare Benefits EOMB used to submit the claim to Medicare in the Primary ID field Enter the Medicare ICN number in the Other Payer ICN field Scroll down to the PAYER AMOUNTS or Patient Liability section on the left hand side of the screen Click the drop down arrow in the Type field and select Allowed In the Amounts field enter the total am
4. RN T1002 0552 TG Yes 15 Complex min Private Duty Nursing RN T1002 0552 TG UC Yes 15 Complex Extended min Skilled Nurse Visit T1030 0551 Yes Visit Skilled Nurse Visit G0154 0552 Yes 15 AC Program only min Skilled Nurse Visit T1030 0551 GT Yes Visit Telehomecare Speech Therapy Visit 9128 0441 No Visit 8 8371 Home Care Outpatient Last updated 06 15 2012 MN ITS User Guide 8371 Home Care Outpatient Claim Speech Therapy Visit 9128 0441 UC Yes Visit Extended Authorization required if more than 9 skilled nurse visits per calendar year for regular state plan services Services always require authorization when the recipient is on a waiver or Alternative Care programs 3 Enter the appropriate HCPCS procedure code in the Procedure field Refer to MHCP Provider Manual Ch 24A Home Care Services Overview under Billing for further information 4 Enter the modifiers in the Modifiers field if appropriate Click the A button to added the modifier to the service line 5 Enter the number of units charged in the first Units field just below the field title Enter the type of units default is UN for units charged in the second Units field 6 Enter the dollar amount for the line item in the Charge field Multiply your usual and customary charge by the number of units if you are billing for multiple units The decimal point will right justify after the number you enter For example if you
5. enter 10 the charge would be 10 00 if you enter 1000 the charge would be 1 000 00 7 Click the Save button to save the line item Saved line information is visible next to the blue dot P1 You may enter a maximum of 999 lines of service per institutional claim transaction e To add additional lines click the New button to add an additional line P2 and clear the fields on the screen e To delete a line select the line to be deleted and click the Delete button e The line item next to the blue dot will delete 8 Repeat Steps 1 7 for each line item you wish to bill for on this claim When reporting line level payments by Medicare follow the procedure below 1 Click the underlined P1 to reach the Line Level Other Payer screen to enter Medicare Part B information a Complete the OTHER PAYER section 1 Click the down arrow in the Other Payer Primary ID field to select the identification number previously entered on the COB Primary ID field Enter the appropriate code in the Procedure Code field Enter the line amount paid by Medicare in dollars using the decimal point in the Line Paid Amount field Enter the units paid by Medicare in the Paid Units field Enter the appropriate revenue code in the Revenue Code field Enter modifiers in the Modifiers field if appropriate e Click the A button to add the modifier 7 Enter the date of the line adjudication in MMDDYYYY format in the Line Adjudication Date field b C
6. for the recipient The default is Yes c Provider Signature on File field indicates whether or not you have a signature on file acknowledging the performance of the service and authorizing you to bill for those services The default is Yes 6 8371 Home Care Outpatient Last updated 06 15 2012 MN ITS User Guide 8371 Home Care Outpatient Claim 6 d The EOB Indicator field identifies whether a paper EOB is requested The default is No e Release of Information field indicates whether or not you have a release of information on file from the recipient The default is A for appropriate release of information is on file Enter the highest level of specificity ICD CM 9 code in the Principal Diagnosis field The following are frequently used situational fields 7 10 11 12 Select the appropriate Patient Status for a home care claim The Patient Status field defaults to 01 The Occurrence field and associated Date field are used to indicate significant events that may affect payer processing A Enter the appropriate Occurrence Code in the first field Home care providers use e 24 to report the provider has documentation to support the TPL other insurance will not cover the service e 25 to report the provider has documentation to support Medicare will not cover the service B Enter the date the occurrence occurred in the MMDDYYYY format in the Date field C Click A to add and save the information in the t
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8. ains two main sections 1 Billing Provider MN ITS Interactive auto populates the required fields in the Billing Provider section with data on file The Address fields auto populate information in Line 1 Line 2 or both If you see the LOOK UP button refer to the 8371 Consolidated Provider user guide for further instructions 2 Other Provider Type Complete this section to identify the provider who performed ordered the product or service based on your provider type and the service provided If you are the billing and rendering provider and the service does not require that you enter an attending physician you do not need to complete this section Completing Other Provider Type Section Institutional providers are required to enter attending physician information on all claims Information from the OTHER PROVIDER TYPES section of the Providers tab is used to populate fields on the Claim Information and or Services tabs Scroll down to the OTHER PROVIDER TYPES section of the Providers tab 1 Enter the attending physician s NPI in the NPI field 2 Select Attending Physician from the Provider Type drop down menu 2 8371 Home Care Outpatient Last updated 06 15 2012 MN ITS User Guide 8371 Home Care Outpatient Claim 3 After you click out of the NPI field MN ITS auto populates the provider information for the entered NPI or UMPI The auto populated information in the Address field will appear in either Line 1 Line 2 or both fi
9. elds The provider information will immediately appear to the right of the blue dot 4 Verify the name and location of the other provider Note If the information in this section does not auto populate refer to the Other Provider Types Chart to verify which fields are required and enter the necessary information 5 Click the Save button located at the top of the OTHER PROVIDER TYPES section to save the rendering provider information If you do not save this information it will be lost Adding Additional Entries Click the New button to clear the fields and add additional other provider type information When you save the second entry the blue dot will move to the second line and an underlined P1 displays next to the first line of information If you enter a third other provider type the blue dot moves down and the second entry displays an underlined P2 next to the second line of information This process continues for each additional entry Deleting Entries Click on the number of the line you want to delete The blue dot will move to that line Verify this is the information you want to delete and then click the Delete button 2 Complete all other fields as needed and select the i tab Completing the COB Tab When no other payers including Medicare exist or it has been determined the other payers will not cover the services proceed to the Claim Information tab The COB tab requires information about third party liabi
10. elect Submit Interactive Claims 837 e Select Outpatient 8371 The MN ITS Interactive Outpatient claim contains the following five tabs e Subscriber e Providers e COB e Claim Information e Services 1 8371 Home Care Outpatient Last updated 06 15 2012 MN ITS User Guide 8371 Home Care Outpatient Claim Completing the Subscriber Tab Subscriber Enter recipient member information on the tab 1 Enter the member number from the recipients MHCP identification card in the Subscriber ID field 2 Enter the recipient s birth date in the Birth Date field The birth date must match the birth date on the MHCP file The format for entering the birth date is 2 digit month 2 digit day and 4 digit year MMDDYYYY Enter the recipient s last name in the Last Name field Enter the recipient s first name in the First Name field Click the down arrow in the Gender field to select appropriate option Enter the recipient s street address in the Address field Enter the city town where the recipient lives in the City field Enter the state where the recipient lives in the State field this should be MN oo NO aA Fw Enter the recipient s zip code in the Zip Code field The Address City State and Zip Code fields can be the recipient s current address last known address or Post Office box The zip code must be a valid zip code Select the _PZOvt4 FS J tab Completing the Providers Tab This tab cont
11. elect the type of claim you are filing 10 Complete the remaining fields in this section if the information is available Scroll down to the MEDICARE OUTPATIENT ADJUDICATION section 1 2 3 4 5 Enter the remark codes from the EOMB in the Remarks field Click A to add the code to the claim Repeat steps 1 and 2 until you enter and add all remark codes from the EMOB Click on the drop down arrow to review remark codes Move to the top of the screen and review this tab to ensure you have completed all required fields 5 8371 Home Care Outpatient Last updated 06 15 2012 MN ITS User Guide 8371 Home Care Outpatient Claim 6 Click the Save button located near the top of the COB screen to save the information that appears next to the blue dot Select the Claim Information 1 tab to continue Completing the Claim Information Tab The Claim Information tab contains claim level information Many of the required fields on this tab are defaulted to the most common responses The Total Submitted Charges field is displayed and cannot be altered This field will populate after the submitted charge is entered on the Services tab 1 Enter the Type of Bill The Type of Bill is a 3 digit code which defines the type of facility bill classification and frequency For homecare services use the 32X 34X series Critical Access Hospital providers billing home care use 34X series Numeric values for frequency third digit
12. hird field Add as many occurrence codes as necessary for this claim Enter the service agreement or authorization number in the Authorization Number field as appropriate Enter the 17 digit PCN number in the Original Reference Number field to identify a previously paid MHCP claim to be replaced as appropriate The Claim Notes field is situational Use this field only when required for claim adjudication to report claim information about the product or service provided for the entire claim up to 72 characters Adding a note causes the claim to become complex 90 days to process Click on the name of the Attending Physician from the drop down list to report one attending physician for all services on this claim Select the Services i tap Completing the Services Tab The Services tab contains line item information 1 Enter the actual date services were provided in the From Date field in MMDDYYYY format The To Date is only required if you are billing consecutive days You may bill only for services provided within the same calendar month 2 Enter the applicable revenue code for home care services in the Revenue Code field Home Care Service HCPCS Revenue Mod Mod Shared Auth Unit date of service Indicator Required Home Health Aide Visit T1021 0571 Yes Visit Home Health Aide Visit G0156 through 0572 Yes 15 Extended waivers 6 30 09 min Home Health Aide Visit T1004 7 1 09 and AC Program later
13. http mn its dhs state mn us Minnesota Health Care Programs MHCP N ITS MN ITS Interactive User Guide Completing a MN ITS Interactive 8371 Outpatient claim form for Home Objective Care services Performed by MN ITS Interactive users This User Guide lists which MN ITS Interactive fields you must complete when requesting MHCP reimbursement for skilled nurse visits SNV Home Health Aide visits homecare therapies and private duty nurse services Claim Form MN ITS Interactive Outpatient 8371 Background Using MN ITS Interactive e Complete all bolded required fields e Complete other non bolded situational fields as appropriate for your claim e Underlined items are linked to definitions and additional information including completing a field code definitions for fields or instructional information e Some fields are grouped together in boxes of associated information Field titles with an asterisk indicate the information is situational If you complete one asterisked field within a boxed section of a screen you must complete all asterisked fields in that section e When reporting Medicare coverage provided through a Medicare Advantage Health Plan or a private insurance recognized as a Medicare replacement policy complete the coordination of benefits COB tab as a Medicare claim Entering an Online Claim 1 Log in to MN ITS refer to the Login process if necessary 2 From the left menu e Select MN ITS e S
14. lity TPL or other insurance and Medicare You may need the EOB explanation of benefits from the TPL other payer or the EOMB explanation of medical benefits from Medicare to complete this tab When reporting TPL or other insurance coverage in addition to MHCP 1 Enter the name of the payer or other insurance in the Payer Name field 2 Enter the carrier ID of the TPL or other insurance in the Primary ID field This information is provided on the MN ITS Interactive Eligibility Response 270 271 transaction 3 Enter the total amount paid by the other payer in the Prior Payment Payer and Patient field even if the payer paid 0 00 4 Scroll down to the CLAIM ADJUSTMENTS AMOUNTS section on the right hand side of the screen Note If the EOB you received from the other insurance does not supply HIPAA compliant group or reason codes go to the Washington Publishing Company to determine the most appropriate codes to enter on this claim a Click the down arrow in the Group Code field to select the claim level adjustment type Claim level adjustment types include 3 8371 Home Care Outpatient Last updated 06 15 2012 MN ITS User Guide 8371 Home Care Outpatient Claim e CO Contractual obligation e CR Corrections and reversals e OA Other adjustments e PI Payer initiated reductions e PR Patient responsibility Refer to the Billing Policy section of the MHCP Provider Manual for different methods of submitti
15. ng contractual obligations or reduced rates b Enter the appropriate HIPAA compliant reason code in the Reason Code field c Enter the dollar amount of the adjustment using a decimal point in the Amount field d Click the A button to add the adjustment amount to the claim e Repeat steps A D until all adjustments are added Scroll down to the OTHER PAYER SUBSCRIBER section This section is specific to the person who actually holds the insurance policy Complete all asterisked fields in the OTHER PAYER SUBSCRIBER information 1 Enter the identification number of the policy holder for this insurance in the Insured ID field 2 Enter the policy holder s birth date in the Birth Date field The birth date must match the birth date on the MHCP file The format for entering the birth date is 2 digit month 2 digit day and 4 digit year MMDDYYYY Enter the policy holder s last name in the Last Name field Click the down arrow in the Insured Gender field to indicate the policy holder s gender 5 Click the down arrow in the Relationship field to select 18 for self or the correct code to indicate the relationship of the recipient of this service to the policyholder 6 Click the Benefits Assignment field to indicate a yes no response that a third party payer authorization is on file in your office allowing you to bill for the recipient 7 Enter the appropriate code in the Release of Information field to indicate whether or not
16. omplete the LINE ADJUSTMENT AMOUNTS section 9 8371 Home Care Outpatient Last updated 06 15 2012 MN ITS User Guide 8371 Home Care Outpatient Claim 1 Click the down arrow in the Group Code field to select the prior payers line level adjustment that caused the amount paid to differ from the amount originally charged Line level adjustment types include CO Contractual obligation CR Corrections and reversals OA Other adjustments PI Payer initiated reductions e PR Patient responsibility Enter the appropriate HIPAA compliant code in the Reason Code field Enter the dollar amount of the adjustment with the decimal point in the Amount field 4 Click the A button to add the line adjustment amounts into the fifth field c Click the Save button to save the line level information 2 Click the underlined L1 in the SERVICE LINE section to return to the Services tab 3 Repeat Steps 1 7 until all line items are entered Validating and Submitting Your Claim Validate your claim after completing the necessary tabs to e Ensure you have completed all required HIPAA compliant fields e Verify with DHS your claim information will be submitted and returned to you with the appropriate edits To Validate Your Claim 1 Click the Validate button 2 Review the validate response to ensure the claim information is correct Check the Claim Status Category Codes and Claim Status Codes for edits at the claim and
17. ount allowed by Medicare Click the A button to add the information which will appear in the third field Note Line Level Medicare payments will be entered on the second screen of the Services tab Scroll down to the OTHER PAYER SUBSCRIBER section Complete all asterisked fields in the OTHER PAYER SUBSCRIBER information 1 2 Enter the Medicare recipient s Medicare identification number in the Insured ID field Enter the Medicare recipient s birth date in the Birth Date field The birth date must match the birth date on the MHCP file The format for entering the birth date is 2 digit month 2 digit day and 4 digit year MMDDYYYY Enter the Medicare recipient s last name in the Last Name field Click the down arrow in the Insured Gender field to indicate the Medicare recipient s gender Click the down arrow in the Relationship field Click the Benefits Assignment field to indicate a yes no response that a third party payer authorization is on file in your office allowing you to bill for the recipient Enter the appropriate code in the Release of Information field to indicate whether or not you have a release of information on file from the recipient The Payer Responsibility field identifies the insurance carrier s level of responsibility for payment of the claim Click the down arrow to select the appropriate response primary secondary or tertiary Click the down arrow in the Claim Filing Indicator field to s
18. service line levels to determine if any corrections are needed 3 Close the validate response and make any necessary changes based on your validation response and click on Save 4 If you made changes click the Validate button again for your new validate response Repeat the above steps as necessary To Submit Your Claim to DHS 1 Close the validate response 2 Click the Submit button Within seconds you will receive a Claim Response similar to the Validate with the claims Payer Claim Control PCN number at the top Your claim is now complete You have the option of copying the claim beginning a new claim or logging out of MN ITS Copying a Claim After you submit a claim you may choose to copy a portion or an entire claim This can save you time if you have multiple claims for the same individual or the same claim for multiple recipients 10 8371 Home Care Outpatient Last updated 06 15 2012 MN ITS User Guide 8371 Home Care Outpatient Claim Click the Copy Claim button from the Claim Detail or Claim Response screen Select the appropriate button to choose the screens you want to copy You may choose all tab screens or individual tab screens to copy Click the Submit button at the bottom of the Copy Claim Options screen to return to the Subscriber tab to begin the next claim Complete all updates to the claim and complete the validate and submit processes 11 8371 Home Care Outpatient Last updated 06 15 20
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