Inpatient - Connecticut Medical Assistance Program
Contents
1. 15 INPATIENT HEADER IW Osis chon cnet ie a hp e RE er N UN 21 HEADER TWO ENTRY INSTRUCTIONS Sheeno E 22 INPATIENT HEADER THREE is ons gto he ph tete ee E eae erroe 24 HEADER THREE ENTRY INSTRUCTIONS ooa E E 24 INPATIENT HEADBRJEQUR ay E e C eee e ia ei derit y ee erret 26 HEADER FOUR ENTRY INSTRUCTIONS 27 INPATIENT Ud to eeepc dere tea tiet er ty tete ires 28 HEADER FIVE ENTRY INSTRUCTIONS 29 INPATIENT SERVICE tor etra eig eve trate cie emet 32 SERVICE ENTRY INSTRUCTIONS tetuer epa a eR E REPRE Eee Seen SR 33 OTHERJINSURANCGBE eiii ter vetet npe aeter ree Ee rele ep ee beh tede elec 34 OTHER INSURANCE ENTRY INSTRUCTIONS eese nenne nennen trennen rennen ene 35 CROSSOVER 5 e et eh vestrae cie eee che 37 CROSSOVER ENTRY A nennen EEE KEE A EEEE TENE enne ene 38 HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 2 INPATIENT CLAIMS BILLING INSTRUCTIONS INTRODUCTION Now that you have installed and become familiar with the functionality of the Hewlett Packard Enterprise PROVIDER ELECTRONIC SOLUTIONS software it s time to begin claims data entry The claim entry screen consists of eight sections Five2. Ciy Zp Find Print Help 4564564565 00000 lt PROVIDER 0987654321 123456000 PROVIDER2 Select 1234567830 5 00000 PROVIDER 0087654321 ATYPICALPROY Close Taxonomy Last Org Name Type Qualifier The Provider list requires you to collect information about service providers which is then automatically entered into forms These can be individual providers or organizations Use this list to enter all billing provider and Medicare rendering provider numbers All fields are required except Provider Address Line 2 and First Name when the Entity Type Qualifier is a 2 Facility BILLING PROVIDER ENTRY INSTRUCTIONS Provider ID Enter the National Provider Identifier NPI or the Connecticut Medical Assistance Program billing provider number with two leading zeros if the provider is a Non Covered Entity NCE An NCE is a Medicaid service provider who is not included in the National Provider Identifier requirement Provider ID Code Qualifier Enter the code that identifies if the Provider ID submitted is the Connecticut Medical Assistance Provider number or the Health Care Financial Administration HCFA National Provider Identifier NPI Taxonomy Code An alphanumeric code that consists of a combination of the provider type classification area of specialization and education training requirements Only numeric characters 0 9 and alphabetic characters A Z are accepted Lower case le
3. Attachment CTL HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 20 INPATIENT CLAIMS BILLING INSTRUCTIONS This field is enabled when the Report Transmission Code is a BM EL EM FT or FX Enter the control number of the attachment Remarks Situational Format XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX INPATIENT HEADER TWO 12 2 837 Institutional Inpatient Total Charge Amount Billed Amount ENT Services Header1 Header 2 Header 3 Header 4 Header 5 Service Diagnosis Codes Present On Admission Add 2 a 48 1 Admit J Ado lH i ECode 2 3 Delete Surgical Qualifiers Codes Dates Undo All 1 4 00 00 0000 2 z 00 00 0000 Copy 3 zj 00 00 0000 4 00 00 0000 Save 5 00 00 0000 M Attending Provider ID Taxonomy Code Last rg Name First Name Last Name First Name Billed Amount Last Submit Dt 111111111 JONES 2 500 00 HEADER TWO INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL O NUMERIC SITUATIONAL S DIAGNOSIS CODES PRIMARY 3 R X PRESENT ON ADMISSION 1 R A DIAGNOSIS CODES OTHER 1 8 5 R X DIAGNOSIS CODES ADMIT 3 R X DIAGNOSIS CODES E CODE 1 3 5 O X SURGICAL QUALIFIERS 1 5 2 S A SURGICAL CODES 1 5 5 S X SURGICAL DATES 1 5 8 S N ATTENDING PROVIDER ID 10 R N ATTENDING TAXONOMY CODE 10 R X ATTENDING LAST ORG NAME 35 R A ATTEND
4. Last Name First Name Billed amp mount Last Submit Dt 111111111 JONES 2 500 00 e Dmae EE mom Sa SERVICE INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL O NUMERIC SITUATIONAL S REVENUE CODE 3 R N BASIS OF MEASUREMENT 2 R A UNITS 5 R N BILLED AMOUNT 9 R N ALPHA N NUMERIC X ALPHANUMERIC HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 32 INPATIENT CLAIMS BILLING INSTRUCTIONS SERVICE ENTRY INSTRUCTIONS Please NOTE If the intent for this claim is to obtain coinsurance and deductible payments form a claim paid by Medicare please complete this section as though you were submitting this claim to Medicare Revenue Code Enter the revenue center code RCC for the appropriate accommodation and ancillary services provided NOTE See the Connecticut Uniform Billing Committee CUBC manual for all possible codes Inpatient hospital claims must be billed with the accommodation RCCs for which DSS has assigned rates Remarks Required Format NNN Basis of Measurement Enter the code specifying the units in which a value is being expressed or the manner in which a measurement has been taken This field defaults to UN Code Description DA Days Institutional UN Unit Institutional and Professional Remarks Required Format XX Units Enter the number of days being billed for the Revenue Center Code RCC NOTE For accommodation days the sum of all th
5. 36 47 58 04 15 26 37 48 59 05 16 27 38 49 06 17 28 39 50 07 18 29 40 51 08 19 30 41 52 09 20 31 42 53 10 21 32 43 54 Remarks Required Format NN HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 29 INPATIENT CLAIMS BILLING INSTRUCTIONS Admission Type Select the appropriate value that corresponds to the primary admission reason a ode Description Emergency Urgent Elective Newborn Transfer Re admission Information not available Remarks Required Format N Discharge Hour Select the appropriate value that corresponds to the hour during which the client was discharged for inpatient care Code Description Code Description 00 12 00 12 59AM Midnight 12 12 00 12 59PM Noon 01 1 00 1 59AM 13 1 00 1 59PM 02 2 00 2 59AM 14 2 00 2 59PM 03 3 00 3 59AM 15 3 00 3 59PM 04 4 00 4 59AM 16 4 00 4 59PM 05 5 00 5 59AM 17 5 00 5 59PM 06 6 00 6 59AM 18 6 00 6 59PM 07 7 00 7 59AM 19 7 00 7 59PM 08 8 00 8 59AM 20 8 00 8 59PM 09 9 00 9 59AM 21 9 00 9 59PM 10 10 00 10 59AM 22 10 00 10 59PM 11 11 00 11 59AM 23 11 00 11 59PM Remarks Situational Format NN Admit Source Select the appropriate value that corresponds to the source of admission Code Description 1 Physician referral 2 Clinic referral 3 HMO 4 Transfer from hospital 5 Transfer from SNF 6 Transfer from another health facility 7 Emergency room 8 Court Law A Transfer from a critical
6. FIELD REQUIRED ALPHA DESCRIPTION LENGTH OPTIONAL NUMERIC SITUATIONAL RELEASE OF MEDICAL DATA 1 R A BENEFITS ASSIGNMENT 1 R A CLAIM FILING IND CODE 2 R X HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 37 INPATIENT CLAIMS BILLING INSTRUCTIONS MEDICARE PROVIDER RENDERING ID 10 R MEDICARE PROVIDER LAST ORG NAME 35 R MEDICARE ICN 14 R PAID AMOUNT 9 R PAID DATE 8 R AMOUNTS DEDUCTIBLE 9 R AMOUNTS COINSURANCE 9 R POLICY HOLDER CARRIER CODE 5 R POLICY HOLDER LAST NAME 35 R POLICY HOLDER FIRST NAME 25 R A ALPHA N NUMERIC X ALPHANUMERIC CROSSOVER ENTRY INSTRUCTIONS The following fields are required when a Y is indicated in the Crossover Indicator field on the Header Five Screen These fields should only be used when the intent is to obtain coinsurance and deductible payments from a claim already paid by Medicare Please see the instructions on the Other Insurance tab if Medicare did not pay any portion of the claim Use these fields for the following situations e Claims that do not crossover from Medicare can be submitted electronically with Provider Electronic Solutions software e After claims have been submitted to other insurance providers can submit the Connecticut Medical Assistance claim electronically with Provider Electronic Solutions software NOTE DSS conducts monthly Electronic Claims Submission ECS audits therefore providers must retain the Explanation of Medicare Benefits EOMB for auditing purposes
7. Header One Service Other Insurance and Crossover screens The following instructions detail requirements and general information for each section of your claim In the following sections each data entry field is defined with the appropriate requirements Edits have been built into the software to assist you in correct data entry however READ THESE SECTIONS CAREFULLY Payment or denial of your claims depends on the data you supply to Hewlett Packard Enterprise Please reference your billing manual for detailed Connecticut Medical Assistance Program billing requirements unique to your provider type Important Update This software will not be supported after October 1 2015 Current PES users are encouraged to transition to an alternative method of claim submission by October 1 2015 to avoid a disruption in electronic claims processing HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 3 INPATIENT CLAIMS BILLING INSTRUCTIONS Provider Electronic Solutions contains reference lists of information that you commonly use when you enter and edit screens For example you can enter lists of common diagnosis codes procedure codes type of bill and admission source and type AII of the lists are available from the data entry section as a drop down list where you can select previously entered data to speed the data entry process and help ensure accuracy of the form There are several lists that you are required to complete prior to entering a tr
8. Release of Medical Data Select the appropriate value from the drop down box that indicates whether the provider has on file a signed statement by the client authorizing the release of medical data to other organizations This field defaults to a Y Remarks Required Format A Benefits Assignment Select the appropriate value from the drop down box that identifies that the client or authorized person authorizes benefits to be assigned to the provider This field defaults to a Y Remarks Required Format A HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 38 gt gt 2222224 gt 2 INPATIENT CLAIMS BILLING INSTRUCTIONS Claim Filing Ind Code Select the appropriate code from the drop down box that identifies the type of other insurance claim that is being submitted This field defaults to MA Remarks Required Format XX Medicare Provider Rendering ID Select the appropriate identification number of the Medicare rendering provider from the billing provider list Remarks Optional Format NNNNNNNNN Medicare Provider Last Org Name This field is auto plugged once you select the rendering provider identification number Remarks Optional Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA Medicare ICN Enter the claim number assigned to the claim by Medicare Remarks Required Format XXXXXXXXXXXXXX Paid Amount Enter the dollar amount paid by Medicare for the service or claim Remarks Required Forma
9. to populate the claim screen with the selected List entry INPATIENT HEADER ONE Ag HP Provider Electronic Solutions HIPAA NCPDP File Edit View Forms Tools Window Help OBX9HX SLUR 0 sisi 837 Institutional Inpatient DE Total Charge Amount SET Billed Amount Services Header 1 Header 2 Header 3 Header 4 Header 5 Service Type Of Bill v Original Claim Ad Provider ID Taxonomy Code _ Cow Last rg Name Delete Undo All 00 Patient Status Medical Record Txn Type Code CH v From DOS 00 00 0000 DOS 00 00 0000 Release of Medical Data v v Benefits ssignment v v Report Type Code v Report Transmission Code Attachment Ctl Last Name Billed Amount Last Submit Dt 111111111 JONES JANE 2 500 00 HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 14 INPATIENT CLAIMS BILLING INSTRUCTIONS HEADER ONE INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL O NUMERIC SITUATIONAL S TYPE OF BILL 3 R N ORIGINAL CLAIM 13 5 PROVIDER ID 10 R N TAXONOMY CODE 10 R X LAST ORG NAME 35 R A CLIENT ID 16 R X ACCOUNT NUMBER 38 R X LAST NAME 35 R A FIRST NAME 25 R A MI 1 O A PATIENT STATUS 2 R N MEDICAL RECORD 30 O X TXN TYPE CODE 2 R A FROM DOS 8 R N TO DOS 8 R N RELEASE OF MEDICAL DATA 1 R A BENEFITS ASSIGNMENT 1 R A REPORT TYPE CODE 2 O X REPORT TRANSMISSION CODE 2 O A ATT
10. 2 5 X ALPHA N NUMERIC X ALPHANUMERIC HEADER THREE ENTRY INSTRUCTIONS Occurrence Codes 1 8 Enter the applicable code that identifies a significant event relating to this stay Up to eight occurrence codes can be entered with a corresponding date Code Description 01 Auto Accident out of state accident 02 Auto Accident used for no fault 03 Accident Tort Liability if known 04 Accident Employment Related 05 Type of Accident Other than 01 04 06 Crime Victim HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 24 INPATIENT CLAIMS BILLING INSTRUCTIONS 11 Onset of Symptoms IlIness 21 Administratively Necessary Days Remarks Situational Format NN Occurrence Code Dates 1 8 Enter the date associated with the code listed Remarks Situational Format MM DD CCYY Occurrence Span Codes 1 2 Enter the Occurrence span code Remarks Optional Format NN Occurrence Span Dates 1 2 Enter the date associated with the code listed Remarks Optional Format MM DD CCYY Condition Codes 1 7 Enter the appropriate condition codes to identify conditions that determine eligibility and establish primary and or secondary responsibility The following codes are applicable to the Connecticut Medical Assistance Program Code Description 01 Military Service Related 02 Condition is Employment Related 03 Patient Covered by Insurance Not Shown on Claim 05 Lien Has Been Filed Al EPSDT A4 Family Planning NOTE The condi
11. ACHMENT CTL 30 5 X ALPHA NUMERIC X ALPHANUMERIC HEADER ONE ENTRY INSTRUCTIONS Special Note All data entry will default to capital letters Header Field Definition Dollars cc Cents Alpha N Numeric X Alphanumeric Type of Bill Enter the 3 digit code that identifies the type of bill The code identifies the type of facility and the bill classification First digit indicates facility Code Description 1 Hospital Second Digit indicates the Bill Classification HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 15 INPATIENT CLAIMS BILLING INSTRUCTIONS Code Description Inpatient including Medicare Part A Inpatient Medicare Part B only Outpatient Other for hospital referenced diagnostic services or home health not under a plan of treatment AUN Third Digit indicates the Frequency Code Description Non payment Zero Claim Admit through discharge date First interim claim Continuing Interim claim Last interim claim Replacement of prior claim designates electronic adjustment Void Cancel of prior claim designates electronic adjustment 3 gt Note If the third digit is a 7 or 8 the Original Claim field will be required Remarks Required Format NNN Original Claim This field is populated when the last digit on the Type of Bill is a 7 or 8 When a claim is replaced or voided indicate the original Internal Control Number as it appear
12. ALPHA N NUMERIC X ALPHANUMERIC HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 28 INPATIENT CLAIMS BILLING INSTRUCTIONS HEADER FIVE ENTRY INSTRUCTIONS Admission Date Enter the admission date associated with the period being submitted This date cannot be greater than the From DOS on the Header 1 tab NOTE This software will not accept dates of service prior to 1976 Therefore if the client s admission date is prior to 1976 please enter the admission date as 01 01 1976 Remarks Required Format MM DD CCY Y Admission Hour Select the appropriate value that corresponds to the hour during which the client was admitted for inpatient care Field defaults to 00 Code Description Code Description 00 12 00 12 59AM Midnight 12 12 00 12 59PM Noon 01 1 00 1 59AM 13 1 00 1 59PM 02 2 00 2 59AM 14 2 00 2 59PM 03 3 00 3 59AM 15 3 00 3 59PM 04 4 00 4 59AM 16 4 00 4 59PM 05 5 00 5 59AM 17 5 00 5 59PM 06 6 00 6 59AM 18 6 00 6 59PM 07 7 00 7 59AM 19 7 00 7 59PM 08 8 00 8 59AM 20 8 00 8 59PM 09 9 00 9 59AM 21 9 00 9 59PM 10 10 00 10 59AM 22 10 00 10 59PM 11 11 00 11 59AM 23 11 00 11 59PM Remarks Optional Format NN Admission Minute Select the appropriate value that corresponds to the minute during which the client was admitted for inpatient care Field defaults to 007 Code Code Code Code Code Code 00 11 22 33 44 55 01 12 23 34 45 56 02 13 24 35 46 57 03 14 25
13. Amount Enter the amount paid by the other insurance carrier An amount of zero 0 may be entered This field is required if a value is entered in the Reason Code field on the other insurance screen and a payment has been received towards the claim from a third party This field is also used to indicate the Medicare Part B allowed amount when Medicare Part A coverage is exhausted or not applicable Enter the sum of the Medicare paid amount the coinsurance amount and the deductible amount located on the Medicare Explanation of Benefits Remarks Required Format Policy Holder Group Select the group number from the drop down list If a group number is not applicable please enter the policy number of the client For Medicare clients please enter the client s Health Insurance Claim HIC number Remarks Optional Format XXXXXXXXXXXXXXXXX Policy Holder Group Name This field is auto plugged when a group number is entered and contains the name of the group that the other insurance is listed under and coincides with Group number Remarks Required Format AAAAAAAAAAAAAA Policy Holder Carrier Code This field is auto plugged when a group number is entered and contains the carrier code identifying the Other Insurance carrier from the drop down list Remarks Required Format XXX HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 36 INPATIENT CLAIMS BILLING INSTRUCTIONS Policy Holder Last Name This field is auto plu
14. Format XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Claim Filing Ind Code Select the appropriate value from the drop down box that identifies the type of other insurance claim that is being submitted Select MA or MB when the denial is from Medicare Remarks Required Format XX Adjustment Group Cd Select the appropriate value from the drop down box that identifies the general category of payment adjustment by the other insurance company Remarks Required Format XX Reason Codes Enter the code identifying the reason the adjustment was made by the other insurance carrier At least one reason code and amount is required or use this field to indicate the reason Medicare denied the claim The reason code can be found in the Implementation Guide by clicking on the following site http www wpc edi com Follow the instructions below to retrieve the reason codes e Click on Code Lists HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 35 INPATIENT CLAIMS BILLING INSTRUCTIONS e Click on Claim Adjustment Reason Codes Use this list of codes to indicate if a payment was made by OI or denied by OI Remarks Required Format XXXXX Reason Amounts Enter the amount associated with the reason code Remarks Required Format 555555 Paid Date Enter the date that the other insurance carrier paid the claim remittance advice date Use this field to enter the date Medicare denied the claim Remarks Required Format MM DD CCY Y Paid
15. IC SOLUTIONS USER S MANUAL 26 INPATIENT CLAIMS BILLING INSTRUCTIONS HEADER FOUR ENTRY INSTRUCTIONS Value Codes 1 12 Enter the applicable code that identifies a significant event relating to this stay Up to twelve value codes can be entered with a corresponding date Remarks Situational Format XX Value Code Amounts 1 12 Enter the corresponding value code amount Remarks Situational Format Operating Physician Provider ID Enter the NPI or Connecticut Medical Assistance Program Provider number with two leading zeros of the party being referenced Use the List from the menu to enter the information before submitting your claim Note Once you have entered the Operating Provider ID the Taxonomy Code Last Org Name and First Name will be populated automatically Remarks Required Format NNNNNNNNNN Operating Physician Taxonomy Code This field will be auto plugged once you enter the Operating Provider ID and contains an alphanumeric code that consists of a combination of the provider type classification area of specialization and education training requirements Note The health care provider taxonomy code list is available on the Washington Publishing Company web site http www wpc edi com Remarks Situational Format NNNANNNNNA Operating Physician Last Org Name This field will be auto plugged once you enter the Operating Provider ID and contains the last name of an individual provider or t
16. ING FIRST NAME 25 R A A ALPHA N NUMERIC X ALPHANUMERIC HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 21 INPATIENT CLAIMS BILLING INSTRUCTIONS HEADER TWO ENTRY INSTRUCTIONS Diagnosis Codes Primary Enter the primary diagnosis code from the International Classification of Diseases 9 Revision Clinical Modification ICD 9 CM manual Note DO NOT key the decimal point It is already assumed Remarks Required Format XXXXX Present on Admission Select the appropriate indicator from the drop down list to indicate whether the diagnosis was present at the time the patient was admitted Required for each diagnosis reported Y Yes N No U Unknown W Clinically undetermined Remarks Required Format A Diagnosis Codes Other 1 8 Enter up to eight ICD 9 CM three four or five digit diagnosis codes for a diagnosis other than the principal diagnosis Note DO NOT key the decimal point It is already assumed Remarks Optional Format XXXXX Diagnosis Codes Admit Enter the ICD 9 CM diagnosis code corresponding to the diagnosis of the client s condition which prompted admission to the hospital Remarks Required Format XXXXX Diagnosis Codes E Code 1 3 Enter the appropriate diagnosis code beginning with E whenever there is a diagnosis of an injury poisoning or adverse effect Remarks Optional Format XXXXX Surgical Qualifiers 1 5 When a surgical procedure code is billed select the appropriat
17. INPATIENT CLAIMS BILLING INSTRUCTIONS HPE Provider Electronic Solutions Billing Instructions LI Hewlett Packard Enterprise Provider Electronic Solutions Inpatient Claims Important Update This software will not be supported after October 1 2015 Current PES users are encouraged to transition to an alternative method of claim submission by October 1 2015 to avoid a disruption in electronic claims processing HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 1 INPATIENT CLAIMS BILLING INSTRUCTIONS TABLE OF CONTENTS INTRODUCTION 5 pr enn teer RO ORE ER p te e theta 3 CLIENT SCREEN os oma ete eet te 5 BILEING PROVIDER SCREEN 2 trn RR RE DE e OE sabes ce betreibt etre ipod 7 BILLING PROVIDER ENTRY INSTRUCTIONS essere nennen trennen teen 7 OTHER PROVIDER SCREEN 2 0 epe e rr o eed EO p ce Debet re 9 OTHER PROVIDER ENTRY INSTRUCTIONS 000000000005 eene enne ennt tenen 9 TAXONOMY SCRBEN 5 er to ri o e ie t epar 11 TAXONOMY BILLING INSTRUCTIONS 22 11 POLICY HOLDER SCREEN 2 ettet rete PR TR a eR e OON Et EN 12 POLICY HOLDER ENTRY 8 20 20222 24 0 0 enne 12 CLAIM ENTRY INSTRUCTIONS ipee e hop ehe Eee ase Ree 14 INPATIENT HEADER ONE reete io ie I E iss ee te ee 14 HEADER ONE ENTRY 5
18. IONS Enter the name of the group that the other insurance is listed under and coincides with group number Insurance Type Code Select the appropriate value from the drop down box that identifies the type of insurance listed Relationship to Insured Select the appropriate value from the drop down box that identifies the client s relationship to the policy holder for the other insurance or Medicare listed If the client is the policyholder self will be selected Last Name Enter the last name of the policyholder of the other insurance or Medicare First Name Enter the first name of the policyholder of the other insurance or Medicare ID Code Enter the policyholder s identification number assigned by the other insurance company or Medicare ID Qualifier Select the appropriate value from the drop down box that identifies the ID that is being used Date of Birth Enter the date the policyholder was born Gender Select the appropriate value from the drop down box that identifies the sex of the individual Policy Holder Address Line 1 Enter the street address of the party being referenced The address is required for providers subscribers and policyholders Line 2 Enter additional address information of the party being referenced such as suite or apartment number if applicable City Enter the city of the party being referenced The address is required for providers clients and policyholders State Enter the state
19. OLICY HOLDER GROUP NAME 14 R A POLICY HOLDER CARRIER CODE 3 R X POLICY HOLDER LAST NAME 35 R A POLICY HOLDER FIRST NAME 25 R A ALPHA N NUMERIC X ALPHANUMERIC HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 34 INPATIENT CLAIMS BILLING INSTRUCTIONS OTHER INSURANCE ENTRY INSTRUCTIONS Providers are required to submit other insurance information when another payer is known to potentially be involved in paying or denying a claim This tab should also be used when Medicare does not pay any portion of the claim and all dollar fields below will contain zero amounts Please use the crossover tab when the intent is to obtain coinsurance and deductible payments from a claim already paid by Medicare The following fields are required when a Y is indicated in the other insurance indicator field on the Header Five Screen Release of Medical Data Select the appropriate value from the drop down box that indicates whether the provider has on file a signed statement by the client authorizing the release of medical data to other organizations This field defaults to Y Remarks Required Format A Benefits Assignment Select the appropriate value from the drop down box that identifies that the client or authorized person authorizes benefits to be assigned to the provider This field defaults to Y Remarks Required Format A ICN Enter the original claim number as assigned by the other insurance Remarks Optional
20. PATIENT CLAIMS BILLING INSTRUCTIONS 06 Discharged transferred to home under care of organized home health service organization 07 Left against medical advice 08 Discharged transferred to home under the care of home IV provider 09 Admitted as an inpatient to this hospital 20 Expired or did not recover 30 Still a patient 40 Expired at home 41 Expired in medical facility 42 Expired place unknown 50 Hospice home 51 Hospice medical facility 61 Discharge transferred within this institution to hospital based Medicare approved swing bed Remarks Required Format NN Medical Record Enter the number assigned to the patient s record Remarks Optional Format XXXXXXXXXXXXXXXXX Transaction Type Code Select the appropriate code from the drop down list indicating the type of transaction being sent Code Description CH Chargeable RP Reporting Remarks Required Format AA From DOS Enter the first date of service on which services were provided for this claim Remarks Required Format MM DD CCYY To DOS Enter the last date of service on which services were provided for this claim Remarks Required Format MM DD CCYY Release of Medical Data HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 18 This code indicates whether the provider has on file a signed statement by the client authorizing the release of medical data to other organizations Enter the value that corresponds to the release of the medic
21. STRUCTIONS DG Diagnostic report DJ Discharge monitoring report DS Discharge summary EB Explanation of benefits HC Health certificate HR Health clinic records I5 Immunization record IR State school Immunization records LA Laboratory results MI Medical record attachment MT Models NN Nursing notes OB Operative Notes OC Oxygen content averaging report OD Orders and treatments document OE Objective physical examination including vital signs document OX Oxygen therapy certification OZ Support data for claim P4 Pathology report P5 Patient medical history document PE Parenteral or enteral certification PN Physical therapy notes PO Prosthetics or orthotic certification PQ Paramedical results PY Physician s report PZ Physical therapy certification RB Radiology films RR Radiology reports RT Report of tests and analysis report RX Renewable oxygen content averaging report SG Symptoms document V5 Death notification XP Photographs Remarks Optional Format XX Report Transmission Code Code defining timing transmission method or format by which reports are to be sent Enter the two digit value that defines the transmission method reports will be sent Code Description AA Available on Request at Providers Site BM By mail EL Electronically only EM E mail FT File Transfer FX By fax Note If the values BM EL EM FT or FX are used the Attachment Control field will be required Remarks Optional Format AA
22. al data INPATIENT CLAIMS BILLING INSTRUCTIONS Code Description I Informed consent to release medical information For conditions or diagnoses regulated by federal statutes Yes provider has a signed statement permitting release of medical billing data related to a claim Remarks Required Format A Benefits Assignment Code identifying that the client or authorized person authorizes benefits to be assigned to the provider Enter one of the values below to indicate assignment of benefits Y Yes N No Remarks Required Format A Report Type Code Code indicating the title or contents of a document report or supporting item for this claim Enter the two digit value that corresponds to the report type Code 03 04 Description Report justifying treatment beyond utilization guidelines Drugs Administered Treatment diagnosis Initial assessment Functional goals Plan of treatment Progress report Continued treatment Chemical analysis Certified test report Justification for admission Recovery plan Allergies sensitivities document Autopsy report Ambulance certification Admission summary Prescription Physician order Referral form Benchmark testing results Baseline Blanket test results Chiropractic justification Consent form s Certification Drug profile document Dental models Durable medical equipment prescription HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 19 INPATIENT CLAIMS BILLING IN
23. ansaction Because this software uses the HIPAA compliant transaction format there is certain information which is required for each transaction To assist you in making sure that all required information is included and to save time entering your information some of the lists are required These lists are Client Billing Provider Other Provider Taxonomy Policy Holder If these lists are not completed prior to keying your transaction the list will open in the transaction form Some of the lists contain preloaded information that is available for auto plugging as soon as you install Provider Electronic Solutions Other lists require you to enter the information you will use for auto plugging You should enter your data in these lists soon after you set up Provider Electronic Solutions to take advantage of the auto plug feature To create or edit a list select List from the Main Menu and then select the appropriate item Working with Lists From the Lists option on the menu bar select the list you want to work with Perform one of the following To add a new entry select Add To edit an existing entry select the entry and then enter your changes The command buttons for Delete Undo All Find Print and Close work as titled Note The Select command button is not visible on the List window unless it has been invoked by double clicking an auto plug field from a claim screen Once a List entry has been either added or edited the S
24. d once you enter the Attending Provider ID and contains the last name of an individual provider or the business name of a group or facility when the Entity Type Qualifier is a 2 Remarks Required Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA Attending First Name This field will be auto plugged once you enter the Attending Provider ID and contains the first name of the provider when they are an individual Required when the Entity Type Qualifier is a 1 Field is not available when the Entity Type Qualifier is a 2 Remarks Required Format AAAAAAAAAAAAAAAAAAAAAAAAA HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 23 INPATIENT CLAIMS BILLING INSTRUCTIONS INPATIENT HEADER THREE 837 Institutional Inpatient Total Charge Amount SET Billed Amount DS Services Header 1 Header2 Header3 Header 4 Header 5 Service ccurrence Codes Dates 1 1 00 00 0000 2 00 00 0000 3 00 00 0000 4 00 00 0000 5 00 00 0000 6 00 00 0000 7 00 00 0000 8 00 00 0000 M Condition Codes Delete Undo All Occurrence Span Codes Dates 1 00 00 0000 00 00 0000 2 00 00 0000 00 00 0000 Save 111111111 JONES JANE 2 500 00 er n HEADER THREE INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL O NUMERIC SITUATIONAL S OCCURRENCE CODES 1 8 2 5 N OCCURRENCE CODE DATES 1 8 8 5 N OCCURRENCE SPAN CODES 1 2 2 5 OCCURRENCE SPAN DATES 1 2 8 5 CONDITION CODES 1 7
25. e detail days must equal the days indicated Remarks Required Format NNNNN Billed Amount Enter the total amount for the services performed for this procedure This should include the charge for all units listed Remarks Required Format cc HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 33 INPATIENT CLAIMS BILLING INSTRUCTIONS OTHER INSURANCE 837 Institutional Inpatient Total Charge Amount Billed Amount Services Header 1 Header 2 Header 3 Header 4 Header5 OI Service Release of Medical Data v x Benefits Assignment Y xl ICN Claim Filing Ind Code Adjustment Group Cd Payer Responsibility Copy Reason Codes Amts 1 5 00 Paid Date Amount 0070070000 00 apo 00 __ Delete Policy Holder Undo All Group Group Carrier _Undo AM LastName I Save Add 01 Srv Carrier Code Group Group Name Last Name Copy 01 Delete 01 Last Name First Name Billed Amount Last Submit Dt 111111111 JONES 2 500 00 OTHER INSURANCE INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL O NUMERIC SITUATIONAL S RELEASE OF MEDICAL DATA 1 R A BENEFITS ASSIGNMENT 1 R A ICN 30 5 CLAIM FILING IND CODE 2 R X ADJUSTMENT GROUP CD 2 R X PAYER RESPONSIBILITY 1 R A REASON CODES 1 3 5 R X REASON AMTS 1 3 9 R N PAID DATE 8 R N PAID AMOUNT 9 R N POLICY HOLDER GROUP 17 O X P
26. e procedure code qualifier from the drop down list Code Description BR Principle procedure ICD 9 BQ Other Procedure ICD 9 Remarks Situational Format AA HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 22 INPATIENT CLAIMS BILLING INSTRUCTIONS Surgical Codes 1 5 Once the qualifier is selected enter the ICD 9 surgical procedure code Then enter the date that the procedure was performed Remarks Situational Format XXXXX Surgical Dates 1 5 Enter the date that the procedure was performed Remarks Situational Format MM DD CCYY Attending Provider ID Enter the NPI or Connecticut Medical Assistance Program Provider number with two leading zeros of the party being referenced Use the List from the menu to enter the information before submitting your claim Note Once you have entered the Attending Provider ID the Taxonomy Code Last Org Name and First Name will be populated automatically Remarks Required Format NNNNNNNNNN Attending Taxonomy Code This field will be auto plugged once you enter the Attending Provider ID and contains an alphanumeric code that consists of a combination of the provider type classification area of specialization and education training requirements Note The health care provider taxonomy code list is available on the Washington Publishing Company web site http www wpc edi com Remarks Required Format NNNANNNNNA Attending Last Org Name This field will be auto plugge
27. elect button must be clicked in order for the data to populate the claim screen with the selected List entry HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 4 INPATIENT CLAIMS BILLING INSTRUCTIONS CLIENT SCREEN n Client ClientiD ID Qualifier MI Issue Date 00 00 0000 Account ClentSSN Delete Last Name FrstNam MI Client DOB 00 00 0000 Gende m Subscriber Address Save 0055 Find Ciy z n Print Client ID Last Name First Name 111111111 JONES 123456789 NAMELAST 987654321 SMITH Select Close The Client list requires you to collect detailed information about your clients which is then automatically entered into forms All of the fields are required except Account Number Middle Initial Issue Date and Subscriber Address Line 2 CLIENT ENTRY INSTRUCTIONS Client ID Enter the Client Identification Number assigned by the Connecticut Medical Assistance Program ID Qualifier This field has been preloaded with the information which identifies the type of client This field will be by passed Issue Date Enter the issue date found on the patient s Medical Assistance Program Identification Card Account Enter the unique number assigned by your facility to identify a client Client SSN Enter the client s social security number Last Name Enter the last name of the client who received services First Name En
28. entered into the Provider List All fields are required TAXONOMY BILLING INSTRUCTIONS Taxonomy Code An alphanumeric code that consists of a combination of the provider type classification area of specialization and education training requirements Only numeric characters 0 9 and alphabetic characters A Z are accepted Lower case letters are automatically converted to upper case Note The health care provider taxonomy code list is available on the Washington Publishing Company web site http www wpc edi com Description Enter the description of the code listed HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 11 INPATIENT CLAIMS BILLING INSTRUCTIONS POLICY HOLDER SCREEN 4 Policy Holder Client ID v Group tt Carrier Code Add Carrier Name Other Insurance Group Name Delete Insurance Type Code v Relationship to Insured Policy Holder Information FistNamel o ooo Save ID Coe ID Qualifier Find Date Of Birth 00 00 0000 Gender v Policy Holder Address Stef 0 Zp Patient Information Patient ID ID Qualifier v Undo All Print Client ID Group Carrier Code Last Name First Name 111111111 664 JONES 123456789 001 LAST 387654321 MPB SMITH The Policy Holder list requires you to enter the information for the policyholder of the other insurance policies and Medicare policies As with the provider and client lists this
29. erenced SSN Tax ID Qualifier Select the appropriate code from the drop down box that identifies what value is being submitted in the SSN Tax ID field Provider Address Line 1 Enter the street address of the party being referenced The address is required for providers subscribers and policyholders Line 2 Enter additional address information of the party being referenced such as suite or apartment number if applicable City Enter the city of the party being referenced The address is required for providers clients and policyholders State Enter the state of the address of the party being referenced The address is required for providers clients and policyholders Zip Code Enter the 9 digit zip code of the party being referenced The address is required for providers clients and policyholders HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 10 INPATIENT CLAIMS BILLING INSTRUCTIONS TAXONOMY SCREEN 4 Taxonomy Code Description Delete Indo All ik Save Taxonomy Code Description Find 111 00000 lt Chiropractor 163 00000 lt Registered Nurse 207K 00000 Physician Allergy amp Immunology 2072ZF0201 Physician Pathology Forensic Pathology Help 20811000005 Physician Clinical Pharmacology 5 000005 test taxonomy Print Select me mcm E He Em a Close The Taxonomy list requires you to enter the taxonomy code which is then automatically
30. gged when a group number is entered and contains the last name of the policyholder of the other insurance Remarks Required Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA Policy Holder First Name This field is auto plugged when a group number is entered and contains the first name of the policyholder of the other insurance Remarks Required Format AAAAAAAAAAAAAAAAAAAAAAAAA CROSSOVER SCREEN js 837 Institutional Inpatient Total Charge Amount Billed Amount SENT Services Header 1 Header 2 Header 3 Header 4 Header5 Crossover service Add Release of Medical Data v Benefits Assignment v Claim Filing Ind Code MA Medicare Provider Copy Rendering ID Last Org Name Delete Medicare ICN Il Paid mount 00 Paid Date 00 00 0000 Undo All Amounts S Deductible 00 Coinsurance 00 Policy Holder Carrier Code Last Name First Name Last Name First Name Billed Amount Last Submit Dt 111111111 JONES This tab should only be used when the intent is to obtain coinsurance and deductible payments from a claim already paid by Medicare Please see the instructions on the Other Insurance tab if Medicare did not pay any portion of the claim The Crossover Indicator on the Header 5 screen is defaulted to N for no When this is changed to a Y for yes the Crossover Tab is added to the claim form for entry CROSSOVER INFORMATION
31. he business name of a group or facility when the Entity Type Qualifier is a 2 Remarks Situational Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA Operating Physician First Name This field will be auto plugged once you enter the Operating Provider ID and contains the first name of the provider when they are an individual Required when the Entity Type Qualifier is a 1 Field is not available when the Entity Type Qualifier is a 2 Remarks Situational Format AAAAAAAAAAAAAAAAAAAAAAAAA HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 27 INPATIENT CLAIMS BILLING INSTRUCTIONS INPATIENT HEADER FIVE jz 837 Institutional Inpatient Total Charge M Amount Billed Amount Services Header 1 Header 2 Header 3 Header4 Header 5 Service Add Admission Date 00 00 0000 Hour 00 Minute 00 Type Copy Delete Discharge Hour v Admit Source Facility ID Undo All Other Insurance Indicator N v Crossover Indicator N Delay Reason Code Save Last Name First Name Billed Amount Last Submit Dt 111111111 JONES 2 500 00 HEADER FIVE INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL O NUMERIC SITUATIONAL S ADMISSION DATE 8 R N ADMISSION HOUR 2 R N ADMISSION MINUTE 2 R N ADMISSION TYPE 1 R N DISCHARGE HOUR 2 5 ADMIT SOURCE 1 R X FACILITY ID 10 R N OTHER INSURANCE INDICATOR 1 5 CROSSOVER INDICATOR 1 5 DELAY REASON CODE 1 O N
32. hospital HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 30 INPATIENT CLAIMS BILLING INSTRUCTIONS Admit Source continued Select the appropriate value that corresponds to the source of admission New Born If the admission type has a value of 4 Code Description 1 Normal delivery 2 Premature delivery 3 Sick baby 4 Extramural birth 5 Born inside hospital 6 Born outside hospital Remarks Required Format X Facility ID Select the Connecticut Medical Assistance Program provider number from the drop down box that identifies the facility where services were performed Remarks Optional Format NNNNNNNNNN Other Insurance Indicator This field indicates whether the client has other insurance or when Medicare does not pay any portion of the claim This field is defaulted to N for no When this is changed to a Y for yes the Other Insurance Tab is added to the claim form for entry Y Yes N No Remarks Situational Format A Crossover Indicator This field should only be used when the intent is to obtain coinsurance and deductible payments from a claim already paid by Medicare This field is defaulted to N for no When this is changed to a Y for yes the Crossover Tab is added to the claim form for entry Use this field for the following situations e Claims that do not crossover from Medicare can be submitted electronically with Provider Electronic Solutions software e After claims have bee
33. list must be completed before entering a claim with other insurance or Medicare Complete a separate list for each policy when a client has both other insurance and Medicare Like the other lists once the code is entered into the list it may be accessed by the drop down window and will automatically populate into the claim All fields are required except Policy Holder Address Line 2 POLICY HOLDER ENTRY INSTRUCTIONS The information on this screen must be entered before you enter the Group Number located on the Other Insurance screen Client ID Enter the Client identification number assigned by the Connecticut Medical Assistance Program Group Number Enter group number for other insurance or Medicare If a group number is not applicable please enter the policy number of the client For Medicare clients please enter the client s Health Insurance Claim HIC number Carrier Code Select the 3 digit other insurance carrier code from the drop down box This field is required if an indicator of Y is entered in the other insurance indicator field on the Header Five screen Note Provider must maintain an Explanation of Benefit EOB on file for audit purposes Carrier Name This field is auto plugged by the system once the carrier code is entered and contains the name of the other insurance company listed for the client Other Insurance Group Name HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 12 INPATIENT CLAIMS BILLING INSTRUCT
34. n NCE is a Medicaid service provider who is not included in the National Provider Identifier requirement Provider ID Code Qualifier Enter the code that identifies if the Provider ID submitted is the Connecticut Medical Assistance Provider number or the Health Care Financial Administration HCFA National Provider Identifier NPI Taxonomy Code An alphanumeric code that consists of a combination of the provider type classification area of specialization and education training requirements Only numeric characters 0 9 and alphabetic characters A Z are accepted Lower case letters are automatically converted to upper case Note The health care provider taxonomy code list is available on the Washington Publishing Company web site http www wpc edi com Entity Type Qualifier Select the appropriate value to indicate if the provider is an individual performer or corporation Last Org Name Enter the last name of an individual provider or the business name of a group or facility when the Entity Type Qualifier is a 2 First Name Enter the first name of the provider when the provider is an individual Required when the Entity Type Qualifier is a 1 Field will not be available when the Entity Type Qualifier is a 2 HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 9 INPATIENT CLAIMS BILLING INSTRUCTIONS SSN Tax ID Enter the Social Security Number SSN or Federal Employee Identification Number FEIN of the provider being ref
35. n submitted to other insurance providers can submit the Connecticut Medical Assistance claim electronically with Provider Electronic Solutions software NOTE DSS conducts monthly Electronic Claims Submission ECS audits therefore providers must retain the Explanation of Medicare Benefits EOMB for auditing purposes Remarks Situational Format A Delay Reason Code Select the appropriate code from the drop down list that identifies the reason for delay in submitting the claim HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 31 INPATIENT CLAIMS BILLING INSTRUCTIONS Code Description 1 Proof of eligibility unknown or unavailable 2 Litigation 3 Authorization delays 4 Delay in certifying provider 5 Delay in supplying billing forms 6 Delay in delivery of custom made appliances 7 Third party processing delay 8 Delay in eligibility determination 9 Original claim rejected or denied due to a reason unrelated to the billing limitation rules 10 Administration delay in the prior approval process 11 Other 15 Natural Disaster Remarks Optional Format N INPATIENT SERVICE 1 837 Institutional Inpatient Total Charge 01 Amount Billed Amount SENT Services Header 1 Header 2 Header 3 Header 4 Header5 Service Revenue Code Units 0 Basis of Measurement UN Billed Amount 00 Add Copy Delete Undo All Save Add Srv Revenue Code Billed amp mount Copy Srv i Delete Sry
36. of the address of the party being referenced The address is required for providers clients and policyholders Zip Code Enter the 9 digit zip code of the party being referenced The address is required for providers clients and policyholders Patient ID Enter the other insurance identification number of the Connecticut Medical Assistance Program client for whom services are being billed ID Qualifier Select the appropriate value from the drop down box that identifies the ID that is being used HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 13 INPATIENT CLAIMS BILLING INSTRUCTIONS CLAIM ENTRY INSTRUCTIONS Use the following instructions to complete the claim screens When data entry is complete click SAVE The saved claim will appear in the list below the data entry screen If the claim data hits edits a message window will appear with error messages Click SELECT to move to the highlighted error and correct the data Once all error messages have been resolved you can save the claim Newly saved claims are in Status R Ready Status R claims can be edited and saved multiple times prior to submission Be sure to click ADD before beginning to enter the data for each new claim Note The Select command button is not visible on the List window unless it has been invoked by double clicking an auto plug field from a claim screen Once a List entry has been either added or edited the Select button must be clicked in order for the data
37. quired Format NNNNNNNNN Account Enter the patient s account number Provider assigned this field may be alphabetic or numeric and is used for the provider s own accounting purposes Remarks Required Format XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Last Name This field is auto plugged when the client ID is entered and contains the client s last name or the first two characters of the client s last name Example THOMPSON or Remarks Required Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA or AA First Name This field is auto plugged when the client ID is entered and contains the client s first name or the first character of the client s first name There are no spaces allowed in this field Example JOHN or J Remarks Required Format AAAAAAAAAAAAAAAAAAAAAAAAA or A MI This field is auto plugged when the client ID is entered and contains the first character of the client s middle name Example Remarks Optional Format A Patient Status Enter the appropriate patient status code as of the through date from the table below Code Description 01 Discharged to home or self care routine discharge 02 Discharged transferred to another short term general hospital 03 Discharged transferred to a skilled nursing facility 04 Discharged transferred to an intermediate care facility 05 Discharged transferred to another type of institution HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 17 IN
38. s on the remittance advice Remarks Situational Format NNNNNNNNNNNNN Provider ID Enter your NPI or Connecticut Medical Assistance Program Provider number with two leading zeros Remarks Required Format NNNNNNNNNN Taxonomy Code This field will be auto plugged once you enter your provider number and contains an alphanumeric code that consists of a combination of the provider type classification area of specialization and education training requirements Only numeric characters 0 9 and alphabetic characters A Z are accepted Lower case letters are automatically converted to upper case This field is entered when entering your provider number under the lists menu This field will be auto plugged once you enter your provider number Note The health care provider taxonomy code list is available on the Washington Publishing Company web site http www wpc edi com Remarks Required Format NNNANNNNNA Last Org Name This field will be auto plugged once you enter your provider number and contains the provider s name or the first two letters of the provider s last name as enrolled in the Connecticut Medical Assistance Programs Example THOMPSON or Remarks Required HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 16 INPATIENT CLAIMS BILLING INSTRUCTIONS Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA or AA Client ID Enter the client s 9 digit Connecticut Medical Assistance Program identification number Remarks Re
39. t Paid Date Enter the date of the Medicare remittance advice on which these services are listed Remarks Required Format MM DD CCYY Amounts Deductible Enter the amount of the deductible that applies to the claim or detail identified by Medicare Remarks Optional Format ec Amounts Coinsurance Enter the amount of coinsurance applied to the claim or detail identified by Medicare Remarks Optional Format cec Policy Holder Carrier Code Select the carrier code that corresponds to the policyholder for this claim HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 39 INPATIENT CLAIMS BILLING INSTRUCTIONS Remarks Required Format XXX Policy Holder Last Name This field is auto plugged once you select the carrier code Remarks Required Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA Policy Holder First Name This field is auto plugged once you select the carrier code Remarks Required Format AAAAAAAAAAAAAAAAAAAAAAAAA HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 40
40. ter the first name of the client who received services MI Enter the middle initial of the client who received services HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 5 INPATIENT CLAIMS BILLING INSTRUCTIONS Client DOB Enter the date the client was born Gender Select the appropriate value from the drop down list to enter the client s gender Code Description F Female M Male U Unknown Subscriber Address Line 1 Enter the street address of the party being referenced The address is required for providers clients and policyholders Line 2 Enter additional address information of the party being referenced such as suite or apartment number if applicable City Enter the city of the party being referenced The address is required for providers clients and policyholders State Enter the state of the address of the party being referenced The address is required for providers clients and policyholders Zip Enter the 9 digit zip code of the party being referenced The address is required for providers clients and policyholders HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 6 INPATIENT CLAIMS BILLING INSTRUCTIONS BILLING PROVIDER SCREEN Billing Provider Provider ID Provider ID Code Qualifier xx Add Taxonomy Code 2 Entity Type Qualifier Delete Last rg Name I First Name p 7 077 SSN TaxID SSN Tax ID Qualifier _ Provider Address Save Line 1 Line 2
41. the state of the address of the party being referenced The address is required for providers clients and policyholders Zip Code Enter the 9 digit zip code of the party being referenced The address is required for providers clients and policyholders HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 8 INPATIENT CLAIMS BILLING INSTRUCTIONS OTHER PROVIDER SCREEN 4 Other Provider Provider ID Provider ID Code Qualifier Xx Taxonomy Code Entity Type Qualifier Delete Last Org Name FirstName SSN Tax ID SSN Tax ID Qualifier Undo Provider Address Line 1 P Line 2 City State Zip Print 0112233445 111N00000 DOE Help 1111111111 207K00000 PHYSICIAN 5566778899 163w 00000 BROWN Select Provider ID Taxonomy Last Org Name Type Qualifier The Other Provider list requires you to collect information about non billing providers which is then automatically entered into forms Enter the attending operating and other Medical Assistance provider numbers in this list All fields are required except Provider Address Line 2 and First Name when the Entity Type Qualifier is a 2 Facility OTHER PROVIDER ENTRY INSTRUCTIONS Provider ID Enter the National Provider Identifier NPI or the Connecticut Medical Assistance Program billing provider number with two leading zeros if the provider is a Non Covered Entity NCE A
42. tion codes listed below should only be used if an abortion was performed due to rape incest or life endangerment Code Description AA Abortion performed due to rape AB Abortion performed due to incest AD Abortion performed due to a life endangering physical condition caused by or arising from pregnancy itself 7 Induced abortion endangerment to life A8 Induced abortion victim of rape incest Remarks Situational Format XX HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 25 INPATIENT CLAIMS BILLING INSTRUCTIONS INPATIENT HEADER FOUR 152 837 Institutional Inpatient Total Charge Amount SET Billed Amount SENT Services Header 1 Header 2 Header3 Header 4 Header 5 Service Value Codes Amounts 10 00 i 1 5 5 00 00 lt Delete Undo All Save Operating Physician Provider ID Taxonomy Code LasV 0rg Name First Name Client ID Billed Amount Last Submit Dt 111111111 JONES 2 500 00 r HEADER FOUR INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL O NUMERIC SITUATIONAL S VALUE CODES 1 12 2 5 X VALUE CODE AMOUNTS 1 12 9 5 OPERATING PHYSICIAN PROVIDER ID 10 5 X OPERATING PHYSICIAN TAXONOMY CODE 10 5 X OPERATING PHYSICIAN LAST ORG NAME 35 5 OPERATING PHYSICIAN FIRST NAME 25 5 N NUMERIC X ALPHANUMERIC HPE PROVIDER ELECTRON
43. tters are automatically converted to upper case Note The health care provider taxonomy code list is available on the Washington Publishing Company web site http www wpc edi com Entity Type Qualifier Select the appropriate value to indicate if you are an individual performer or corporation Last Org Name Enter the last name of an individual provider or the business name of a group or facility when the Entity Type Qualifier is a 2 HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 7 INPATIENT CLAIMS BILLING INSTRUCTIONS First Name Enter the first name of the provider when they are an individual Required when the Entity Type Qualifier isa 1 This field will not be available when the Entity Type Qualifier is a 2 SSN Tax ID Enter the Social Security Number or Tax Identification number of the party being referenced SSN Tax ID Qualifier Select the appropriate code from the drop down box that identifies what value is being submitted in the SSN Tax ID field Provider Address Line 1 Enter the street address of the party being referenced The address is required for providers subscribers and policyholders Line 2 Enter additional address information of the party being referenced such as suite or apartment number The address is required for providers subscribers and policyholders City Enter the city of the party being referenced The address is required for providers clients and policyholders State Enter
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