Professional/Transportation - Connecticut Medical Assistance Program
Contents
1. HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 29 ZK PROFESSIONAL CLAIMS BILLING INSTRUCTIONS PROFESSIONAL SERVICE ONE SCREEN 837 Professional BR Total Charge Amount ETT Billed Amount Services Header 1 Header 2 Header 3 Header4 Service 1 service 2 Service 3 Diagnosis Codes 119 2 0 4 Add From 005 00 00 0000 DOS 00 00 0000 Emergency Ind IN gt Place Of Service cae Procedure Modifiers 1 2 3 ism 4 _ DiagPu CLIA Number Unts Delete Family Planning vj Billed Amount 00 Basis of Measurement UN Undo All Add Srv Srv From DOS 205 Procedure Billed amp mount 00 Copy Srv Delete Srv Last Name First Name Billed Amount 987654321 SMITH JOHN 123456789 NAMELAST FIRST PROFESSIONAL SERVICE ONE INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL NUMERIC SITUATIONAL S DIAGNOSIS CODES 1 4 3 O X FROM DOS 8 R N TO DOS 8 R N EMERENGY INDICATOR 1 R A PLACE OF SERVICE 2 R N PROCEDURE 2 R X MODIFIERS 1 4 2 O X EPSDT 1 R A DIAG PTR 2 O N CLIA NUMBER 10 5 X UNITS 3 R N FAMILY PLANNING IND 1 R A BILLED AMOUNT 9 R N BASIS OF MEASUREMENT 2 R A ALPHA N NUMERIC X ALPHANUMERIC PROFESSIONAL SERVICE ONE 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 sect2. fields are required except Policy Holder Address Line 2 POLICY HOLDER ENTRY INSTRUCTIONS This tab is required if an indicator of Y is entered in the other insurance indicator field on the Header Three screen The information on this screen must be entered before you enter the Group Number from the Other Insurance screen Client ID Enter the Client identification number assigned by the Connecticut Medical Assistance Program Group Number Enter group number for the 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 three digit other insurance carrier code from the drop down box Note Provider must maintain an Explanation of Benefits 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 Enter the name of the group that the other insurance is listed under and coincides with Group number HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 12 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS 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
3. Patient transferred to rehabilitation facility Remarks Situational Format A Transport Distance Enter the number of miles the client was transported by ambulance This field is required for all Ambulance claims when billing mileage Remarks Situational Format NNNN Condition Codes 1 5 Select the code used to identify conditions relating to this bill that may affect Payer processing List on Header 3 if this condition applies to the entire claim or on Service 2 if it applies to a particular detail This field is required for all Ambulance claims Code Description 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair Remarks Situational Format NN HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 34 gt gt gt PROFESSIONAL CLAIMS BILLING INSTRUCTIONS Rendering Provider Provider ID Select the NPI or Connecticut Medical Assistance Program rendering provider from the drop down window The other provider information will be populated once you select enter Used only when the provider rendering services is different from the billing provider on the Header One tab Remarks Situational Format NNNNNNNN Rendering Provider Taxonomy Code Enter
4. DEME Last Org Name First Name SSN TaxID 5 SSN Tax ID Qualifier Undo Aii Provider Address Save Line 1 Line 2 Print Cty Sae Find Provider ID 5566778899 163w 00000x BROWN 0112233445 111 00000 DOE 1111111111 20 00000 PHYSICIAN1 The Other Provider list requires you to collect information about non billing providers which is then automatically entered into forms Enter the performing attending operating and other Medical Assistance provider numbers in this list fields are required except Provider Address Line 2 and First Name when the Entity Type Qualifier is a 2 Facility OTHER PROVIDER ENTRY INSTUCTIONS 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 NOTE Acquired Brain Injury ABI and Personal Care Assistance PCA providers enter the Social Security Number SSN or Federal Employee Identification Number FEIN in this field Provider ID Code Qualifier Enter the code that identifies if the Provider ID submitted is the Medical Assistance Provider number or the Health Care Financial Administration HCFA National Provider Identifier NPI Taxonomy Code An alphanumeric code that consists of a combinatio
5. Transport Reason Cod v Transport Distance 0 Rendering Provider Provider ID Last Org Name First Name Undo All Delete Bee Service Adjustment Ind N Save Srv From DOS DOS Last Name First Name Find 387654321 SMITH JOHN 123456783 NAMELAST FIRST Print PROFESSIONAL SERVICE TWO INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL O NUMERIC SITUATIONAL 5 AMBULANCE TRANSPORT REASON CODE 1 5 AMBULANCE TRANSPORT DISTANCE 4 5 N AMBULANCE CONDITION CODES 1 5 2 5 N RENDERING PROVIDER PROVIDER ID 10 5 N RENDERING PROVIDER TAXONOMY CODE 10 5 X HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 33 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS RENDERING PROVIDER LAST ORG NAME 35 5 RENDERING PROVIDER FIRST NAME 25 5 SERVICE ADJUSTMENT IND 1 5 ALPHA N NUMERIC X ALPHANUMERIC PROFESSIONAL SERVICE TWO ENTRY INSTRUCTIONS Ambulance Transport Reason Code Enter the code indicating the reason for ambulance transport This field is required for all Ambulance claims Code Description A Patient was transported to nearest facility for care of symptoms complaints or both Patient was transported for the benefit of a preferred physician Patient was transported for the nearness of family members Patient was transported for the care of a specialist or for availability of specialized equipment
6. 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 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 for auditing purposes Remarks Required Format A PROFESSIONAL HEADER FOUR 837 Professional Total Charge SS 0I Amount Billed Amount SENT Services Header 1 2 Header3 Header 4 Service 1 Service 2 3 Ambulance Pickup Location Address Line 1 Address Line 2 Copy City State Zip BE Delete Ambulance Dropoff Location Address Line 1 Address 1 Undo Ciy Ste Zp Save Last Name First Name Billed Amount Last Submit Dt 987654321 SMITH JOHN 123456789 NAMELAST FIRST PROFESSIONAL HEADER FOUR INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL O NUMERIC SITUATIONAL S AMBULANCE PICKUP LOCATION 33 5 X ADDRESS LINE 1 ADDRESS LINE 2 55 5 X CITY 30 S A STATE 2 5 ZIP 9 5 N AMBULANCE DROPOFF LOCATION 55 5 X HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 28 PROFESSIONAL CLAI
7. 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 Enter the nine 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 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS BILLING PROVIDER SCREEN n HP Provider Electronic Solutions HIPAA NCPDP File Edit Forms 5 ools Window Help OY QU SOK St Ba SHS 4p Billing Provider Provider ID Provider ID Code Qualifier x Add Taxonomy Code Entity Type Qualifier Delete Last Org Name First Name SSN 7 Tax ID SSN ID Qualifier 9 Provider Address cme2 7 Ciy TN Print 4564564565 TESTOOOOOX PROVIDER 0987654321 123456000 Select 1234567830 5 0000 lt PROVIDER 0087654321 ATYPICALPROV Close Provider ID Taxonomy ast Org Name Type Qualifier The Provider list requires you to collect information
8. about service providers which are then automatically entered into forms These can be individual providers or organizations Use this list to enter all billing referring rendering facility identification Medicare rendering and Medicare referring 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 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 i
9. an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair Remarks Situational Format NN EPSDT Referral Certification Condition Ind Enter a Y or to indicate if an Early and Periodic Screening Diagnosis and Treatment EPSDT referral was given to the patient Note If a is used the condition indicator of NU Not Used should be used Remarks Situational Format A EPSDT Referral Condition Ind 1 3 Select the appropriate condition indicator from the drop down list Code Description AV Available not used NU Not used 52 Under treatment ST New services requested Remarks Situational Format XX 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 Required Format A HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 27 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS 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 When this is changed to a Y for yes the
10. and contains the first name of the policyholder of the other insurance Remarks Required Format AAAAAAAAAAAAAAAAAAAAAA CROSSOVER SCREEN 837 Professional Total Charge TT 01 Amount Billed Amount ET Services Header 2 Header 3 Header4 Crossover Service 1 2 3 41 Release of Medical Data v Benefits Assignment Y Medicare Providers Referring ID Last Org Name Rendering ID Last rg Name I Delete Medicare ICN Paid Date 00 00 0000 Undo All Policy Holder Carrier Code Save Last Name First Last Name First Name Billed Amount Last Submit Dt 987654321 SMITH JOHN 123456789 NAMELAST FIRST er n CROSSOVER INFORMATION FIELD REQUIRED ALPHA DESCRIPTION LENGTH OPTIONAL NUMERIC SITUATIONAL HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 41 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS RELEASE of MEDICAL DATA 1 R BENEFITS ASSIGNMENT 1 R MEDICARE PROVIDER REFERRING ID 10 5 MEDICARE PROVIDER LAST ORG NAME 35 5 MEDICARE PROVIDER RENDERING ID 10 R MEDICARE PROVIDER LAST ORG NAME 35 R MEDICARE ICN 14 R PAID DATE 8 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 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
11. assigned to the provider Enter one of the values below to indicate assignment of benefits HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 18 Y Yes N No PROFESSIONAL CLAIMS BILLING INSTRUCTIONS Not Applicable 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 Diagnostic report Discharge monitoring report Discharge summary Explanation of benefits Health certificate Health clinic records Immunization record State school Immunization records Laboratory results Medical record attachment Models Nursing notes Operative Notes Oxygen content averaging report Orders and treatments document Objective physical examinati
12. box that identifies the ID that is being used HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 13 PROFESSIONAL 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 to populate the claim screen with the selected List entry HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 14 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS PROFESSIONAL HEADER ONE 837 Professional Total Charge 0I Amount Billed Amount SENT Services Header 1 Header 2 Header 3 Header 4 Service 1 Service 2 Service 3 Claim Frequency Original Claim Provider ID Taxonomy Code Copy La
13. 2 v 3 Other Insurance Indicator N v Crossover Indicator N Last Name First Name Billed Amount Last Submit Dt 987654321 SMITH JOHN 123456789 NAMELAST FIRST PROFESSIONAL HEADER THREE INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL O NUMERIC SITUATIONAL S ACCIDENT RELATED 2 5 CAUSES 1 2 DATE 8 5 N STATE 2 5 COUNTRY 3 5 AMBULANCE TRANSPORT 1 5 REASON CODE TRANSPORT DISTANCE 4 5 N CONDITION CODES 1 5 2 5 N EPSDT REFERRAL 1 5 CERTIFICATION CONDITION IND EPSDT REFERRAL 2 5 X CONDITION IND 1 3 OTHER INSURANCE 1 R A INDICATOR CROSSOVER INDICATOR 1 R A ALPHA N NUMERIC X ALPHANUMERIC PROFESSIONAL HEADER THREE ENTRY INSTRUCTIONS HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 25 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS Accident Related Causes 1 2 Select the appropriate value from the drop down box to indicate the type of accident This field is required for all accident related claims Code Description AA Auto Accident EM Employment OA Other Accident Remarks Situational Format AA Date Indicate the date of the accident Remarks Situational Format MM DD CCYY State Enter the state where the auto accident occurred Use state postal codes CT Connecticut etc Required if Accident Related Causes value 15 Remarks Situational Format AA Country Enter the country in which the auto accident occurred when outside of the Unit
14. AAAA Medicare Providers Rendering ID Select the appropriate identification number of the Medicare rendering provider from the billing provider list Remarks Situational Format NNNNNNNNNN Medicare Providers Last Org Name This field is auto plugged once you select the Rendering provider identification number Remarks Situational Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA Medicare ICN Enter the claim number assigned to the claim by Medicare Remarks Required Format XXXXXXXXXXXXXX Paid Date Enter the date of the Medicare remittance advice on which these services are listed Remarks Required Format MM DD CCY Y Policy Holder Carrier Code Select the carrier code that corresponds to the policyholder for this claim Remarks Required Format XXXXX 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 43
15. DER ELECTRONIC SOLUTIONS USER S MANUAL 8 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS TAXONOMY SCREEN 4 Description Delete Undo Save Taxonomy Code Description Find 101 MO80 0 Counselor Mental Health 103TCO700 Psychologist Clinical 111N00000 Chiropractor 163w 00000 Registered Nurse Help 207K 000000 Physician Allergy amp Immunology 2072ZF0201 Physician Pathology Forensic Pathology 208U 00000 Physician Clinical Pharmacology Close Print Select The Taxonomy list requires you to list the taxonomy code which is then automatically entered into the Provider List All fields are required TAXONOMY BILLING INSTRUCTIONS Taxonomy Code Enter the 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 9 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS OTHER PROVIDER SCREEN p Other Provider Provider iD Provider ID Code Qualifier Xx Add I Entity Type Qualifier
16. First Name This field will be auto plugged once you enter your provider number and contains the provider s first name or the first letter of the provider s first name as enrolled in the Connecticut Medical Assistance Program Required when the Entity Type Qualifier is a 1 There are no spaces allowed in this field Example THOMPSON T Remarks Situational Format AAAAAAAAAAAAAAAAAAAAAAAAA Or A Client ID Enter the client s nine digit Connecticut Medical Assistance Program s identification number Remarks Required Format XXXXXXXXXXXXXXXX Account This field will be auto plugged once you enter the client s Connecticut Medical Assistance Program identification number and contains 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 Optional Format XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Last Name This field will be auto plugged once you enter the client s Connecticut Medical Assistance Program s identification number This field contains the client s last name or the first two characters of the client s last name Example THOMPSON or TH Remarks Required Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA or AA HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 17 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS First Name This field will be auto plugged once you enter the client s Connecticut Medical Ass
17. MS BILLING INSTRUCTIONS ADDRESS LINE 1 ADDRESS LINE 2 55 5 CITY 30 5 STATE 2 5 ZIP 9 5 lt N NUMERIC X ALPHANUMERIC PROFESSIONAL HEADER FOUR ENTRY INSTRUCTIONS Ambulance Pickup Location Address Line 1 Enter the street address of the location being referenced This field is required for all Ambulance claims Line 2 Enter additional address information of the location being referenced such as suite or apartment number if applicable City Enter the city of the location being referenced The address is required for all Ambulance claims State Enter the state of the address of the location being referenced The address is required for all Ambulance claims Zip Code Enter the nine digit zip code of the location being referenced The address is required for all Ambulance claims Ambulance Dropoff Location Address Line 1 Enter the street address of the location being referenced This field is required for all Ambulance claims Line 2 Enter additional address information of the location being referenced such as suite or apartment number if applicable City Enter the city of the location being referenced The address is required for all Ambulance claims State Enter the state of the address of the location being referenced The address is required for all Ambulance claims Zip Code Enter the nine digit zip code of the location being referenced The address is required for all Ambulance claims
18. PROFESSIONAL CLAIMS BILLING INSTRUCTIONS HPE Provider Electronic Solutions Billing Instructions du Hewlett Packard Enterprise Provider Electronic Solutions Professional 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 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS TABLE OF CONTENTS Ii OO CLIENT ENTRY INSTRUCTIONS eee eese eese esses BILLING PROVIDER SCREEN cscsssssssssssssessessssessessssessessssessessssessessesessessssessessssessessssessesessessessesesees BILLING PROVIDER ENTRY INSTRUCTIONG ccsssssssssssssssessessssessessssessessssessessssessessssessessesesees TAXONOMY SCREEN cccssssssssssessessssessessssessessssessessssessessesessessssessessssessessesessesessessessesessessesessessessssesees TAXONOMY BILLING INSTRUCTION G ccsssssssssesssssssessessssesscsssssssessessssesessessessessssessessssessesessesees 9 OTHER PROVIDER SCREEN i 10 OTHER PROVIDER ENTRY INSTUCTIONS cccssssssssssssessessesessersesessersesessersesessessesessessesessesseess 10 POLICY HOLDER SCREEN eese ee ee
19. S PROFESSIONAL HEADER TWO 837 Professional Total Charge Amount ETT Billed Amount Services Header1 Header 2 Header 3 Header 4 Service 1 Service 2 Service 3 Diagnosis Codes Delete Referring Provider Provider ID Undo All Last Org Name First Name Save Place Of Service Onset of Current Illness Date 00 00 0000 Delay Reason Code Facility ID Rendering ID Admission Date 00 00 0000 Initial Treatment Date 00 00 0000 Client ID Last Name First Name Billed Amount Last Submit Dt 987654321 SMITH JOHN 123456789 NAMELAST FIRST HEADER TWO INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL O NUMERIC SITUATIONAL S DIAGNOSIS CODES 1 12 5 O X REFERRING PROVIDER ID 10 O N REFERRING LAST ORG NAME 35 O A REFERRING FIRST NAME 25 O A PLACE OF SERVICE 2 R N ONSET OF CURRENT ILLNESS DATE 8 O N DELAY REASON CODE 2 O N FACILITY ID 10 O N RENDERING ID 10 O N ADMISSION DATE 8 5 N INITIAL TREATMENT DATE 8 O N A ALPHA N NUMERIC X ALPHANUMERIC PROFESSIONAL HEADER TWO ENTRY INSTRUCTIONS Diagnosis Codes 1 12 Enter the 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 Optional HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 21 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS Format XXXXX Referring Provider ID Sel
20. 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 NOTE DSS conducts monthly Electronic Claims Submission ECS audits therefore providers must retain the Explanation of Medicare Benefits EOMB for auditing purposes 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 yes 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 yes Remarks Required Format A Medicare Providers Referring ID Select the appropriate identification number of the Medicare referring provider from the billing provider list Remarks Required Format NNNNNNNNNN Medicare Providers Last Org Name This field is auto plugged once you select the referring provider identification number Remarks Required HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 42 gt gt gt gt gt gt PROFESSIONAL CLAIMS BILLING INSTRUCTIONS Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
21. an alphanumeric code that consists of a combination of the provider type classification area of specialization and education training requirements This field will be populated once you select a rendering provider provider ID 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 Rendering Provider Last Org Name Enter provider s name or the first two letters of the provider s last name as enrolled in the Connecticut Medical Assistance Program This field will be populated once you select a rendering provider provider ID Example THOMPSON or TH Remarks Situational Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA or AA Rendering Provider First Name Enter the first name of the provider when they are an individual Required when the entity type qualifier is a1 Cannot be used when the Entity Type Qualifier is a 2 This field will be populated once you select a rendering provider provider ID Example THOMPSON or TH Remarks Situational Format AAAAAAAAAAAAAAAAAAAAAAAAA or AA Service Adjustment Ind Choose the best value to indicate if the service is being adjusted Remarks Situational Format A HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 35 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS PROFESSIONAL SERVICE THREE SCREEN 837 Professional Total Charge WII Amount Billed Amount S
22. bmitted Select 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 ICN Enter the original claim number as assigned by the other insurance Remarks Optional Format XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 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 HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 39 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS 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 Click on Code Lists 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 At least one reason code and amount is required Remarks Required Format 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 Pai
23. d 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 Remarks Required Format cc Policy Holder Group Select the group number for the other insurance 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 selected 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 HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 40 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS This field is auto plugged when a group number is selected and contains the carrier code identifying the Other Insurance carrier from the drop down list Remarks Required Format XXXXX Policy Holder Last Name This field is auto plugged when a group number is selected and contains the last name of the policyholder of the other insurance Remarks Required Format AAAAAAAAAAAAAAAAAAAAAA Policy Holder First Name This field is auto plugged when a group number is selected
24. ductible 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 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 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 Medicare Amount Paid Enter the dollar amount that Medicare paid for the service provided Required if the crossover indicator on the Header Three tab is a Y Remarks Situational Format Medicare Amount Deductible Enter the amount of the deductible that applies to the claim or detail identified by Medicare Required if the crossover indicator on the Header Three tab is a Y Remarks Situational Format Medicare Amount Coinsurance Enter the amount of coinsurance applied to the claim or detail identified by Medicare Required if the crossover indicator on the Header Three tab is a Y Remarks Situational Format NOTE DSS conducts monthly Electronic Claims Submission audits therefore providers must re
25. e 1 Line 2 Find Print Ciy z n _ Print Last Name Fist Name Help 111111111 JONES 123456789 NAMELAST Select 987654321 SMITH Close The Client list requires you to collect detailed information about your clients which are then automatically entered into forms of the fields are required except Issue Date Middle Initial 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 HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 5 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS Enter the first name of the client who received services MI Enter the middle initial of the client who received services 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
26. e eese enata snas tatus tasto suse ense n sens ta ense n statuo 12 POLICY HOLDER ENTRY INSTRUCTIONS esee eese enses tatu snas 12 CLAIM ENTRY INSTRUCTIONS eere eee esent entn 14 PROFESSIONAL HEADER ONE eese eee tatus tns n status sie iei 15 PROFESSIONAL HEADER ONE ENTRY INSTUCTIONS eese 16 PROFESSIONAL HEADER 21 PROFESSIONAL HEADER TWO ENTRY INSTRUCTIONS ccccsssssssssssssssessesessersesesserseseesersesees 21 PROFESSIONAL HEADER THREE eeeeeeee reete eee tn enata suat n statu stas tatu sons ta snae n statu sene 25 PROFESSIONAL HEADER THREE ENTRY INSTRUCTIONS eese esee este tn aenea tna on statuo 25 PROFESSIONAL HEADER FOUR eere eee estne tnn 257 PROFESSIONAL HEADER FOUR ENTRY INSTRUCTIONS eee entente 257 PROFESSIONAL SERVICE ONE SCREEN eere eee ee enitn enne tatu 30 PROFESSIONAL SERVICE ONE ENTRY INSTRUCTION G ccssssssssssssssssssessessessesesserseseesersesees 30 PROFESSIONAL SERVICE TWO SCREEN eres 33 PROFESSIONAL SERVICE TWO ENTRY INSTRUCTION cccccsssssssssssssessesesserse
27. ect the NPI or Connecticut Medical Assistance identification number from the drop down list of the referring physician Remarks Optional Format NNNNNNNNNN Last Org Name This field will be auto plugged once you enter the provider number This field 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 Optional Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA First Name This field will be auto plugged once you enter the provider number This field contains the first name of the provider when they are an individual Required when the Entity Type Qualifier is a 1 Cannot be used when the Entity Type Qualifier is a 2 Remarks Optional Format AAAAAAAAAAAAAAAAAAAAAAAAA Place of Service Enter the appropriate code from the drop down list that reflects where the services for this claim were performed Refer to your Connecticut Medical Assistance Program Provider Manual for the valid codes HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 22 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS Code Description Code Description 03 School 33 Custodial care facility 04 Homeless Shelter 34 Hospice 05 Indian health service free 41 Ambulance land standing facility 42 Ambulance 06 Indian health service 50 Federally qualified health center provider based facility 51 Inpatient psychiatric facility 07 Tribal 638 free standing facility 52 Psychiatric facility pa
28. ed States Required if the auto accident occurred outside of the United States Remarks Situational Format AAA Ambulance Transport Reason Code Select the appropriate value from the drop down box to indicate the type of Ambulance transport This field is required for all Ambulance claims Code Description A Patient was transported to nearest facility for care of symptoms complaints or both Patient was transported for the benefit of a preferred physician Patient was transported for the nearness of family members Patient was transported for the care of a specialist or for the availability of specialized equipment Jaw E Patient transferred to rehabilitation facility Remarks Situational Format A Transport Distance Enter the number of miles the client was transported by ambulance This field is required for all Ambulance claims when billing mileage HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 26 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS Remarks Situational Format NNNN Condition Codes 1 5 Select the code used to identify conditions relating to this bill that may affect Payer processing List on Header 3 if this condition applies to the entire claim or on Service 2 if it applies to a particular detail This field is required for all Ambulance claims Code Description 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in
29. equired 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 HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 38 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS 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 Three 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 Payer Responsibility Select the code that describes the order of insurance carrier s level of responsibility for a payment of a claim Remarks Required Format A Claim Filing Ind Code Select the appropriate value from the drop down box that identifies the type of other insurance claim that is being su
30. ervices Header 1 Header 2 Header 3 Header 4 Service 1 Service 2 Service 3 Pharmaceutical NDCCode vj Unis 000 Basis for Measurement i m Medicare Amount 00 Deductible 00 Coinsurance 00 Last Name First Name 987654321 SMITH JOHN 123456789 NAMELAST FIRST PROFESSIONAL SERVICE THREE INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL O NUMERIC SITUATIONAL S PHARMACEUTICAL NDC CODE 11 O N PHARMACEUTICAL UNITS 8 O N PHARMACEUTICAL BASIS FOR MEASUREMENT 2 O X MEDICARE AMOUNT PAID 9 5 N MEDICARE AMOUNT DEDUCTIBLE 9 S N MEDICARE AMOUNT COINSURANCE 9 S N A ALPHA N NUMERIC X ALPHANUMERIC PROFESSIONAL SERVICE THREE ENTRY INSTRUCTIONS Pharmaceutical NDC Code Enter the National Drug Code NDC Remarks Optional Format NNNNNNNNNNN Pharmaceutical Units Enter the number of units for the drug that was dispensed Remarks Optional Format NNNNNNNN HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 36 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS Pharmaceutical Basis for Measurement Select the appropriate value from the drop down lists that specifies the units in which a value is being expressed or the manner in which a measurement has been taken Code Description F2 International Unit GR Gram ME Milligram ML Milliliters UN Unit Remarks Optional Format XX The Medicare section should only be used when the intent is to obtain coinsurance and de
31. ion as though you were submitting this claim to Medicare HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 30 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS Diagnosis Codes 1 4 The diagnosis codes entered in Header 2 positions 1 4 will display in these fields From DOS Enter the first date of service on which services were provided for this claim in MM DD CCY Y format Remarks Required Format MM DD CCYY To DOS Enter the last date of service on which services were provided for this claim in MM DD CCYY format Remarks Required Format MM DD CCYY Emergency Ind Indicate N or Y if service provided was emergency related The field is defaulted to an N Remarks Required Format A Place of Service Select the appropriate code that reflects where the services for this claim were performed This field is required if a place of service code is not entered on Header Two Code Description Code Description 03 School 33 Custodial care facility 04 Homeless Shelter 34 Hospice 05 Indian health service free 41 Ambulance land standing facility 42 Ambulance 06 Indian health service 50 Federally qualified health center provider based facility 51 Inpatient psychiatric facility 07 Tribal 638 free standing facility 52 Psychiatric facility partial hospital 08 Tribal 638 provider based facility 53 Community mental health center 11 Office 54 Intermediate care facility mentally retarded 12 Home 55 Psychiatric substance ab
32. istance 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 PROFESSIONAL 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 and modifiers 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 transaction Because this software uses the HIPAA compliant transaction format there is certain information which 15 required for each transaction assist you in making sure that all required information is included and save time entering your information some of the lists are required These lists are Client 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 soo
33. istance Program identification number This field 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 will be auto plugged once you enter the client s Connecticut Medical Assistance Program identification number This field contains the first character of the client s middle name Example JOHN or J Remarks Optional Format A Medical Record Enter the number assigned to the patient s record Remarks Optional Format XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 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 Release of Medical Data 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 medical data Code Description I Informed consent to release medical information For conditions or diagnoses regulated by federal statutes Y 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
34. limitation rules Administration delay in the prior approval process Other Natural Disaster Remarks Optional Format N HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 23 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS Facility ID Select the appropriate provider identification number from the drop down list Required when the Place of Service value is 21 22 31 or 35 Remarks Optional Format NNNNNNNNNN Rendering ID Select the NPI or Connecticut Medical Assistance identification number from the drop down list of the rendering physician Remarks Optional Format NNNNNNNNNN Admission Date Enter the date of admission if applicable Remarks Situational Format MM DD CCYY Initial Treatment Date Enter the initial date treatment was provided Remarks Optional Format MM DD CCY Y HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 24 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS PROFESSIONAL HEADER THREE Y 837 Professional Total Charge SII Amount Billed Amount SENT Services Header 1 Header2 gt 3 Header 4 Service 1 2 Service 3 Accident Related Causes 1 2 Date 0070070000 State Country c Delete gt a ro n d Ambulance Transport Reason Code 7 Transport Distance 0 Undo All Condition Codes 1 2 3 aj 5 x E EPSDT Referal Certification Condition Ind N v Condition Ind 1 NU
35. n 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 access 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 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 Select 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 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS CLIENT SCREEN HP Provider Electronic Solutions HIPAA NCPDP File Edit View Forms Tools Window Help OYA DOAR 6 4p Client Client ID ID Qualifier v Issue Date 00 00 0000 Add Account it Client SSN D Delete Last Name First Name MI Client DOB 00 00 0000 Uis Subscriber Address Save Lin
36. n 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 a 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 10 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS 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 SSN Tax ID Enter the Social Security Number SSN or Federal Employee Identification Number FEIN of the provider 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 sui
37. of prior claim 8 Void Void Cancel of prior claim Note If the claim frequency value is a 7 or 8 the Original Claim field will be required Remarks Required Format N Original Claim This field is populated when the claim frequency value is a 7 or 8 When a claim is replaced or voided indicate the original Internal Control Number as it appears on the remittance advice Remarks Situational Format NNNNNNNNNNNNN Provider ID Enter your NPI or Connecticut Medical Assistance Program s 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 Note The health care provider taxonomy code list is available on the Washington Publishing Company web site http www wpc edi com Remarks Required HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 16 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS 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 TH Remarks Required Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA or AA
38. on including vital signs document HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 19 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS 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 Attachment Ctl This field is enabled when the Report Transmission Code is a BM FT or Enter the control number of the attachment Remarks Situational Format XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 20 PROFESSIONAL CLAIMS BILLING INSTRUCTION
39. pplicable Remarks Optional Format NN CLIA Number Enter the number assigned to all certified facilities performing CLIA covered laboratory services Required field for any laboratory or physician performing tests covered by the CLIA act Remarks Situational Format XXXXXXXXXX Units Enter the number of units performed for the service being billed NOTE For Ambulance providers if a mileage HCPC is billed the number of units is equal to the number of miles Remarks Required Format NNNNN Family Planning Ind Select a N or Y if the procedure is due to family planning Remarks Required Format A HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 32 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS 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 Basis of Measurement Select the code from the drop down list that specifies the units in which a value is being expressed or the manner in which a measurement has been taken This fields defaults to UN Code Description MJ Minutes Professional UN Unit Institutional and Professional Remarks Required Format XX PROFESSIONAL SERVICE TWO SCREEN 837 Professional Total Charge Amount Billed Amount Services Header 1 2 Header 3 Header 4 Service 1 Service 2 service 3 Ambulance
40. rtial hospital 08 Tribal 638 provider based facility 53 Community mental health center 11 Office 54 Intermediate care facility mentally retarded 12 Home 55 Psychiatric substance abuse treatment facility 13 Assisted Living Services 56 Psychiatric residential treatment center 15 Mobile unit 60 Mass immunization center 16 Temporary lodging 61 Comprehensive inpatient rehabilitation 20 Urgent care facility 62 Comprehensive outpatient rehabilitation 21 Inpatient 65 End stage renal disease treatment facility 22 Outpatient 71 State or local public health clinic 23 Emergency room 72 Rural health clinic 24 Ambulatory surgical center 81 Independent laboratory 25 Birthing center 99 Other unlisted Facility 26 Military treatment facility 31 Skilled nursing facility Remarks Required Format XX Onset of Current Illness Date Enter the date of onset of illness or symptoms when different from the date of service if applicable Remarks Optional Format MM DD CCYY Delay Reason Code Select the appropriate code from the drop down list that identifies the reason for delay in submitting the claim SO ON AV E Code Description Proof of eligibility unknown or unavailable Litigation Authorization delays Delay in certifying provider Delay in supplying billing forms Delay in delivery of custom made appliances Third party processing delay Delay in eligibility determination Original claim rejected denied due to reason unrelated to the billing
41. s an individual performer or a corporation HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 7 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS 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 SSN Tax ID Enter the Social Security Number SSN or Federal Employee Identification Number FEIN of the provider 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 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 nine digit zip code of the party being referenced The address is required for providers clients and policyholders HPE PROVI
42. sessevseseesevseeees 34 PROFESSIONAL SERVICE THREE SCREEN eese eee 36 PROFESSIONAL SERVICE THREE ENTRY INSTRUCTIONS scsscsssssssessssessessesessersesessersesees 36 OTHER INSURANCE 38 OTHER INSURANCE ENTRY INSTRUCTION G cccsssssssssssssessersevsssessessesessessesessessssessesseseeserseeees 38 IU n 41 CROSSOVER ENTRY INSTRUCTIONS eere eee tatus tas tatu sons tatu sine ta sns en sensu ao 42 HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 2 PROFESSIONAL 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 nine sections Four Header Three Service Other Insurance and Crossover screens The following instructions detail requirements and general information for each of these sections 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 Ass
43. st OrgName Delete Client ID 7 Account Undo LastNam FirstName MI Medical Record v Release of Medical Data Y Benefits Assignment v Report Type Code Report Transmission Code Attachment Ct Last Name First Name Billed Amount Last Submit Dt 987654321 SMITH JOHN 123456789 NAMELAST FIRST PROFESSIONAL HEADER ONE INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL O NUMERIC SITUATIONAL S CLAIM FREQUENCY 1 R N ORIGINAL CLAIM 13 5 N PROVIDER ID 10 R N TAXONOMY CODE 10 R X LAST ORG NAME 35 R A FIRST NAME 25 R A CLIENT ID 16 R X ACCOUNT 38 R X LAST NAME 33 R A FIRST NAME 25 5 MI 1 O A MEDICAL RECORD 30 O X TRANSACTION TYPE CODE 2 R A RELEASE OF MEDICAL DATA 1 R A BENEFITS ASSIGNMENT 1 R A REPORT TYPE CODE 2 O X REPORT TRANSMISSION CODE 2 O A ATTACHMENT CTL 30 5 X ALPHA N NUMERIC X ALPHANUMERIC HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 15 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS PROFESSIONAL HEADER ONE ENTRY INSTRUCTIONS Special Note data entry will default to capital letters Header Field Definition Dollars cc Cents Alpha Numeric X Alphanumeric Claim Frequency Select the appropriate code specifying the frequency of the claim to identify original adjustment or void Code Description 1 Original Admit thru discharge claim 7 Replacement Replacement
44. tain the Explanation of Medicare Benefits EOMB for auditing purposes HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 37 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS OTHER INSURANCE 837 Professional Total Charge Amount Billed Amount SENT Services Header 2 Header 3 Header4 OI Service 1 Service 2 Service 3 Release of Medical Data Y 7 Benefits ssignment v v Payer Responsibility Claim Filing Ind Code v Adjustment Group Cd 7 ICN f Reason Codes Amts 1 00 2 00 Paid Date Amount 00 00 0000 00 3 00 Policy Holder Group I Group Name Carrier Name 1 Add 01 Srv Carrier Code Group Group Name Last Name Copy 01 Delete 01 Last First Name Billed amp mount Last Submit Dt 387654321 SMITH JOHN 123456789 NAMELAST FIRST OTHER INSURANCE INFORMATION FIELD REQUIRED DESCRIPTION LENGTH OPTIONAL SITUATIONAL RELEASE of MEDICAL DATA 1 R BENEFITS ASSIGNMENT 1 R PAYER RESPONSIBILITY 1 R CLAIM FILING IND CODE 2 R ADJUSTMENT GROUP CD 2 R ICN 30 O REASON CODES 1 3 5 R REASON AMTS 1 3 9 R PAID DATE 1 3 8 R PAID AMOUNT 1 3 9 R POLICY HOLDER GROUP 17 O POLICY HOLDER GROUP NAME 14 R POLICY HOLDER CARRIER CODE 3 R POLICY HOLDER LAST NAME 35 R POLICY HOLDER FIRST NAME 25 R A ALPHA N NUMERIC X ALPHANUMERIC OTHER INSURANCE ENTRY INSTRUCTIONS ALPHA NUMERIC gt gt gt gt gt gt Providers are r
45. te 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 nine digit zip code of the party being referenced The address is required for providers clients and policyholders HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 11 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS POLICY HOLDER SCREEN 2 Policy Holder Client ID v Group it Carrier Code Carrier Name Other Insurance Group Name Relationship to Insured hd Policy Holder Information Undo Last Name First Name ID Code ID Qualifier MI Find Date Of Birth 00 00 0000 Gender v mU Print Policy Holder Address Line 1 Line 2 City State 5 Zip Patient Information Patient ID ID Qualifier Close The Policy Holder list requires you to list the information for the policyholder of the other insurance policies and Medicare policies As with the Provider and Client lists this list must be completed before completing 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
46. the policyholder self will be listed 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 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 of the address of the party being referenced The address is required for providers clients and policyholders Zip Code Enter the nine 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 being billed ID Qualifier Select the appropriate value from the drop down
47. use treatment facility 15 Mobile unit 56 Psychiatric residential treatment center 20 Urgent care facility 60 Mass immunization center 21 Inpatient 61 Comprehensive inpatient rehabilitation 22 Outpatient 62 Comprehensive outpatient rehabilitation 23 Emergency room 65 End stage renal disease treatment facility 24 Ambulatory surgical center 71 State or local public health clinic 25 Birthing center 72 Rural health clinic 26 Military treatment facility 81 Independent laboratory 31 Skilled nursing facility 99 Other unlisted facility 32 Nursing facility Remarks Required Format NN Procedure Enter the five 5 digit HCPCS or locally assigned non health service procedure code which best describes the services rendered HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 31 PROFESSIONAL CLAIMS BILLING INSTRUCTIONS Remarks Required Format XXXXX Modifiers Enter the modifier if applicable Up to four 4 modifiers may be entered for each detail Remarks Required Format XX EPSDT Select a or Y if the patient is part of the Early Periodic Screening Diagnosis and Treatment EPSDT program Remarks Required Format A Diag Ptr Enter the detail diagnosis number that references the diagnosis that relates to this service Valid values are one 1 through eight 8 to refer to the header diagnosis codes This field must be populated to report a diagnosis for the claim service line Leave blank if no diagnosis code is a
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