EDS Provider Electronic Solutions - Connecticut Medical Assistance
Contents
1. Subscriber Address Line 1 Enter the street address that is on file with CT Medicaid of the client being referenced The address is required for providers clients and policyholders Line 2 Enter additional address information of the client being referenced such as suite or apartment number if applicable City Enter the city of the client being referenced The address is required for providers clients and policyholders State Enter the state of the address of the client being referenced The address is required for providers clients and policyholders Zip Enter the 9 digit zip code of the client being referenced The address is required for providers clients and policyholders HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 6 OUTPATIENT CLAIMS BILLING INSTRUCTIONS BILLING PROVIDER SCREEN Billing Provider Provider ID 000000002 Provider ID Code Qualifier lt Taxonomy Code 31 4000000 Entity Qualifier 2 2 Delete Last Org Name LONG TERM CARE First Name SSN 7 Tax ID 2 234567890 SSN 7 Tax ID Qualifier ier 24 zi Provider Address Gave Line 1 100 EAST STREET Line 2 City B RIDGEPORT State CT Zip 0 06060 1234 Find E Print Provider ID Taxonomy Last Org Name Type Qualifier la 1000000000 314000000 TEST FACILITY 2 1000000001 314000000 GENERIC FACILITY 2 1000000002 314000000 LONG TERM 2 1002. 1 5 When a surgical procedure code is billed select the appropriate procedure code qualifier from the drop down list Code Description BR Principle procedure ICD 9 BQ Other Procedure ICD 9 Remarks Situational Format AA Surgical Codes 1 5 Once the qualifier is selected enter the ICD 9 or HCPC 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 CCY Y HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 24 OUTPATIENT CLAIMS BILLING INSTRUCTIONS OUTPATIENT HEADER THREE HEADER THREE SCREEN Total Charge 01 Amount Billed Amount SENT Services J Header 1 Header2 Header 3 Header 4 Header5 Service Occurrence Codes Dates 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 M Occurrence Span Codes Dates if 1 00 00 0000 00 00 0000 4 E 5 i E 2 00 00 0000 00 00 0000 7 FIELD REQUIRED R ALPHA A DESCRIPTION LENGTH OPTIONAL NUMERIC N SITUATIONAL S ALPHANUMERIC X OCCURRENCE CODES 1 8 2 5 N OCCURRENCE CODE DATES 8 5 OCCURRENCE SPAN CODES 1 2 2 N OCCURRENCE SPAN DATES 8 O N 2 5 X CONIDITON CODES 1 7 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 25 OUTPATIENT
3. CLAIMS BILLING INSTRUCTIONS 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 11 Onset of Symptoms IlIness 21 Administratively Necessary Days 42 Discharge date Remarks Situational Format NN Occurrence Code Date 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 Date 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 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 26 OUTPATIENT CLAIMS BILLING INSTRUCTIONS Note The conditio
4. City GRANBY State Zip 06050 6451 Print Client ID Last Name First Name 001000000 JOHN DOE 001000001 JANE DOE 001000002 ROBERT SMITH 001000003 JENNIFER JOHNSON Close e Hr The Client list requires you to collect detailed information about your clients which are then automatically entered into forms All of the fields are required except Issue Date Account 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 that 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 Enter the first name of the client who received services MI Enter the middle initial of the client who received services HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 5 OUTPATIENT 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
5. 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 HP Please reference your billing manual for detailed Connecticut Medical Assistance Program billing requirements unique to your provider type HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 3 OUTPATIENT CLAIMS BILLING INSTRUCTIONS Provider Electronic Solutions contains reference lists of information that you commonly use when you enter and edit forms For example you can enter lists of common diagnosis codes procedure codes types of bill and admission sources and types All 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 is required for each transaction To assist you in making sure that all required information is included 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 co
6. number with two leading zeros Remarks Required Format NNNNNNNNN 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 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 Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA or AA Client ID Enter the client s nine digit Connecticut Medical Assistance Program s identification number Remarks Required 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 AAAAAAAAAAAAAAAAAAAAAAAAA
7. 0 00 0000 4 il 00 00 0000 5 00 00 0000 FIELD REQUIRED R ALPHA A HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 21 OUTPATIENT CLAIMS BILLING INSTRUCTIONS DESCRIPTION LENGTH OPTIONAL 0 NUMERIC N SITUATIONAL S ALPHANUMERIC X DIAGNOSIS CODES PRIMARY 5 R X DIAGNOSIS CODES OTHER 1 8 5 O X DIAGNOSIS CODES E CODE 1 3 5 O X PATIENT REASON 1 3 5 O X ATTENDING PROVIDER ID 9 R X ATTENDING TAXONOMY CODE 10 R X ATTENDING LAST ORG NAME 33 R A ATTENDING FIRST NAME 25 R A SURGICAL QUALIFIERS 1 5 2 5 X SURGICAL CODES 1 5 5 5 SURGICAL DATES 1 5 8 5 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 22 OUTPATIENT 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 assumed Remarks Required Format XXXXX Diagnosis Codes Other 1 8 Enter up to 8 ICD 9 CM three four or five digit diagnosis code for a diagnosis other than the principal diagnosis Note DO NOT key the decimal point It is assumed Remarks Optional 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 Patient Reason 1 3 Enter the ICD 9 diagnosis code that identif
8. 0000003 314000000K EXTENDED CARE 2 1000000004 31400000065 SKILLED NURSING 2 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 Medical Assistance 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 The taxonomy code entered in this field must be among the list of taxonomy codes submitted to the Connecticut Medical As
9. AAAAAAAAAA or AA HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 17 OUTPATIENT CLAIMS BILLING INSTRUCTIONS 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 06 Discharged transferred to home under care of organized home health service organization 07 Left against medical advice 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 72 Discharged transferred referred to this institution for outpat
10. AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA Policy Holder First Name This field is auto plugged when a group number is entered and contains the client s Connecticut Medical Assistance Program s identification number Remarks Required Format AAAAAAAAAAAAAAAAAAAAAAAAAAA HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 40 OUTPATIENT CLAIMS BILLING INSTRUCTIONS OUTPATIENT CROSSOVER CROSSOVER SCREEN Medicare Providers Rendering ID 000000000 Total Charge 01 Amount 7777777 Billed Amount Services iS Header 1 Header 2 Header 3 Header 4 Header 5 01 Crossover service Release of Medical Data v Benefits Assignment Y Claim Filing Ind Code MB Last Org TEST FACILITY Medicare ICN Paid Amount 010 Paid Date 00 00 0000 Amounts Deductible 00 Coinsurance mM Policy Holder Carrier Code Last Name DOE First Name JOHN FIELD REQUIRED R ALPHA A DESCRIPTION LENGTH OPTIONAL NUMERIC N SITUATIONAL S ALPHANUMERIC X RELEASE OF MEDICAL DATA 1 R A BENEFITS ASSIGNMENT 1 R A CLAIM FILING IND CODE 2 R X MEDICARE PROVIDERS 9 N RENDERING ID MEDICARE PROVIDERS 16 O A LAST ORG NAME MEDICARE ICN 14 R X PAID AMOUNT 9 R N PAID DATE 8 R N AMOUNTS DEDUCTIBLE 9 R N AMOUNTS COINSURANCE 9 R N POLICY HOLDER CARRIER 3 R X CODE POLICY HOLDER LAST NAME 35 R A POLICY HOLDER FIRST NAME 25 R A HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 41 OUTPATIENT CLA
11. DOE JOHN 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 All fields are required except Policy Holder Address Line 2 POLICY HOLDER ENTRY INSTRUCTIONS This list 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 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 three digit other insurance carrier code from the drop down box 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 i
12. ESCRIPTION LENGTH OPTIONAL NUMERIC N SITUATIONAL S ALPHANUMERIC X ADMISSION TYPE 1 R X ADMIT SOURCE 1 R X FACILITY ID 10 O N OTHER INSURANCE INDICATOR 1 5 CROSSOVER INDICATOR 1 5 DELAY REASON CODE 1 O N HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 31 OUTPATIENT CLAIMS BILLING INSTRUCTIONS HEADER FIVE ENTRY INSTRUCTIONS Admission Type Enter the corresponding code from the primary admission reason list below Code Description 1 Emergency 2 Urgent 3 Elective 5 Trauma Center 6 Re Admission 9 Information Not Available Remarks Required Format 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 hospital 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 pa
13. HP Provider Electronic Solutions Billing Instructions Outpatient Claims OUTPATIENT CLAIMS BILLING INSTRUCTIONS TABLE OF CONTENTS INTRODUCTION bids Savarese dowd ie dee RR Sata T AU E UO E E Gehl elo De SERIES da 3 CLIENT SCREEN oc Itt oie enter e IM age 5 CLIENT ENTRY INSTRUCTIONS ts heed cine especie 5 BIEEING PROVIDER SCREEN tine avis beer cii ce Hobs re nere recte iuge ib e deo Eee Eee ded 7 BILLING PROVIDER ENTRY INSTRUCTIONS enne 7 OTHER PROVIDER SCREEN ette de sp casa bea eases RA EE VAY AR ny dbus EAD Tee de EN De pei 9 OTHER PROVIDER ENTRY INSTRUCTIONS eee eene enne 9 TAXONOMY SCREEN tA ptu tt tdm o etus 11 TAXONOMY ENTRY INSTRUCTIONS re e Ete RR De ae 11 POLICY HOLDER SCRBEEN etit eR nere Ue e n at Lees t oie eoe nites 12 POLICY HOLDER ENTRY 12 CLAIM ENTRY INSTRUCTIONS tte ne oet Ratte t ots puree tuns 14 OUTPATIENT HEADER ONE ee oen Dn ine eU it e RR tae ito 15 HEADER ONE ENTRY INSTRUCTIONS nnne nennen trennen eene entente trennen tree 16 OUTPATIENT HEADER isso tiet cused ern ge o 21 HEADER TWO ENTRY INSTRUCTIONS Heo trem rote mem te ue
14. IMS BILLING INSTRUCTIONS CROSSOVER ENTRY INSTRUCTIONS The following fields are required when a Y is indicated in the Crossover Indicator field on the Header Three 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 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 Cl
15. P 17 O X POLICY 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 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 37 OUTPATIENT 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 claim number from the claim processed by the other insurance Remarks Optional Format XXXXXXXXXXXXXXXXXXXXXXX
16. XXXXXXX 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 M 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 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 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 38 OUTPATIENT CLAIMS BILLING INSTRUCTIONS Reason Codes Enter the code identifying the reason the adjustment was made by the other insurance carrier 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 these instructions to retrieve the reason codes e Click on HIPAA e Click on Code Lists e Clickon 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 Paid Date Enter the date on the other insurance voucher or explanation of benefits Use this field to ent
17. aim Filing Ind Code Select the appropriate code from the drop down box that identifies the type of other insurance claim that is being submitted Remarks Required Format XX Medicare Providers Rendering ID Select the appropriate identification number of the Medicare attending provider from the billing provider list Remarks Optional Format NNNNNNNNN Medicare Providers 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 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 42 OUTPATIENT CLAIMS BILLING INSTRUCTIONS Remarks Required Format XXXXXXXXXXXXXX Paid Amount Enter the dollar amount paid by Medicare for the service or claim Remarks Required Format Paid Date Enter the date on the Explanation of Medicare Benefits EOMB 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 Required Format Amounts Coinsurance Enter the amount of coinsurance applied to the claim or detail identified by Medicare Remarks Required Format Policy Holder Carrier Code Select the carrier code that corresponds to the policyholder for this claim Rem
18. arks 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 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 43
19. e The Taxonomy list allows you to list the taxonomy code which is then automatically entered into the Provider List All fields are required TAXONOMY ENTRY 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 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 11 OUTPATIENT CLAIMS BILLING INSTRUCTIONS POLICY HOLDER SCREEN 0 Policy Holder Client ID 001 000001 Group ABC0000123D Carrier Code 301 BEST PLAN Other Insurance Group Name CCORPORATION Delete Relationship to Insured 18 Policy Holder Information Last Name DOE First Name ID Code 200001 23 ID Qualifier MI Date Of Birth 01 011965 Gender Policy Holder Address Line 1 00 MAIN STREET Line 2 SUITE 2 City SPRINGFIELD State CT Zip 05000 1234 Patient Information Patient ID 001000001 ID Qualifier 23 v Close Client ID Carrier Code Last Name First Name 001000001 0001230 901 DOE JANE 001000000 CTMEDJDOE MDCR
20. ect 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 This field defaults to UN Code Description GR Grams ME Milligram ML Milliliters UN Units default Remarks Situational required if NDC present Format AA HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 36 OUTPATIENT CLAIMS BILLING INSTRUCTIONS OUTPATIENT OTHER INSURANCE OTHER INSURANCE SCREEN Total Charge AMM 01 Amount Fi Billed Amount Services Header 1 Header 2 Header 3 Header 4 Header5 OI Crossover Service Release of Medical Data v x Benefits Assignment ly ICN o Claim Filing Ind Code Adjustment Group Cd Responsibility x Reason Codes Amts 1 000 2 Es Po Paid Date Amount 00 00 0000 0 070 Policy Holder Group CTMEDJDOE Group Name FEDMEDICARE Carrier Code MPA ast Name DOE First Name JOHN Add 01 Carrier Code 1 MPA CTMEDJDOE Copy Ol Delete 01 FIELD REQUIRED R ALPHA A DESCRIPTION LENGTH OPTIONAL 0 NUMERIC N SITUATIONAL S ALPHANUMERIC X Group Group Name Last Name FEDMEDICARE DOE RELEASE OF MEDICAL DATA 1 R A BENEFITS ASSIGNMENT 1 R A ICN 30 O X 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 GROU
21. efinition Dollars cc Cents A 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 3 Home Health 8 Hospice Second Digit indicates the Bill Classification Code Description 1 Inpatient including Medicare Part A 2 Inpatient Medicare Part B only 3 Outpatient 4 Other for hospital referenced diagnostic services or home health not under a plan of treatment Third Digit indicates the Frequency Code Description 0 Non payment Zero Claim 1 Admit through discharge date 2 First interim claim 3 Continuing Interim claim 4 Last interim claim 7 Replacement of prior claim designates electronic adjustment 8 Void Cancel of prior claim designates electronic adjustment 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 appears on the remittance advice HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 16 OUTPATIENT CLAIMS BILLING INSTRUCTIONS Remarks Situational Format NNNNNNNNNNNNN Provider ID Enter the NPI or Connecticut Medical Assistance Program s Provider
22. er the date Medicare denied the claim Remarks Required Format MM DD CCYY Paid 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 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 entered and contains the name of the group that the other insurance is listed under and coincides with the Group number Remarks Required Format AAAAAAAAAAAAAA HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 39 OUTPATIENT CLAIMS BILLING INSTRUCTIONS 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 Policy Holder Last Name This field is auto plugged when a group number is entered and contains the client s Connecticut Medical Assistance Programs identification number Remarks Required Format
23. g 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 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 33 OUTPATIENT CLAIMS BILLING INSTRUCTIONS OUTPATIENT SERVICE SERVICE SCREEN Total Charge 01 Amount DAT Billed Amount SENT Services I Header 1 Header 2 Header 3 Header 4 Header5 o1 Crossover Service Date Of Service 00 00 0000 Revenue Code Billed Amount 00 Units 0 Basis of Measurement JUN Procedure Modifiers 1 2 3 4 Pharmaceutical NDC Units 000 Basis for Measurement 777 Add Srv EXER Copy Srv Delete Srv Billed Amount ate Of Service Revenue Code FIELD REQUIRED R ALPHA A DESCRIPTION LENGTH OPTIONAL NUMERIC N SITUATIONAL S ALPHANUMERIC X DATE OF SERVICE 8 R N REVENUE CODE 3 R N BILLED AMOUNT 9 R N UNITS 5 R N BASIS OF MEASUREMENT 2 R A PROCEDURE 5 S X MODIFIERS 1 4 2 S X PHARMACEUTICAL NDC 11 S N PHARMACEUTICAL UNITS 8 S N PHARMACEUTICAL BASIS FOR 2 S A MEASUREMENT HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 34 OUTPATIENT CLAIMS BILLING INSTRUCTIONS SERVICE ENTRY INSTRUCTIONS Please NOTE If the intent for this claim is t
24. he two digit value that corresponds to the report type Code Description 03 Report Justifying Treatment beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 19 OUTPATIENT CLAIMS BILLING INSTRUCTIONS 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 Treatment Document Objective Physical Examination Oxygen Therapy Certification Support Data for Claim Pathology Report Patient Medical History Document Parenteral or Enteral Certification Physical Therapy Notes Prosthetics or Orthotic Certification Paramedical Results Physician s Report Physical Therapy Certification Radiology Films Radiology Reports Report
25. his stay Up to twelve value codes can be entered with a corresponding amount Institutional Part A Deductible Code Description Al Deductible payer A Bl Deductible payer B Cl Deductible payer C Institutional Part A Coinsurance Code Description A2 Coinsurance payer A B2 Coinsurance payer B C2 Coinsurance payer C 08 Medicare lifetime reserve coinsurance amount in first calendar year 09 Medicare coinsurance amount in first calendar year 10 Medicare lifetime reserve coinsurance amount in second calendar year 11 Medicare coinsurance amount in second calendar year Professional Part B Deductible Code Description Al Deductible payer A Bl Deductible payer B Cl Deductible payer C Professional Part B Coinsurance Code Description A2 Coinsurance payer A B2 Coinsurance payer B C2 Coinsurance payer C Covered Days Code Description 80 Covered Days Newborn Birth Weight Code Description 54 Newborn Birth Weight in Grams Remarks Situational Format XX Value Code Amounts 1 12 Enter the corresponding value code amount Remarks Situational Format Other Physician Provider ID HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 29 OUTPATIENT CLAIMS BILLING INSTRUCTIONS Select the Connecticut Medical Assistance Program provider number or the HIPAA NPI from the drop down window Note Once you have entered the Provider ID number the Taxonomy Code Last Org Name and First Name will be populated automatica
26. ient services as specified by the discharge plan of care Remarks Required Format NN Medical Record Enter the number assigned to the patient s record HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 18 OUTPATIENT CLAIMS BILLING INSTRUCTIONS Remarks Optional Format XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 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 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 assigned to the provider Enter one of the values below to indicate assignment of benefits Y Yes N No W 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 t
27. ies the reason for the patient visit Remarks Optional Format XXXXX Attending Provider ID Select the Connecticut Medical Assistance Program attending provider number or the HIPAA NPI from the drop down window Note Once you have entered the Provider ID number the Taxonomy Code Last Org Name and First Name will be populated automatically Remarks Required Format XXXXXXXXX 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 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 23 OUTPATIENT CLAIMS BILLING INSTRUCTIONS Remarks Required Format NNNANNNNNA Attending Last Org Name This field will be auto plugged 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 Remarks Required Format AAAAAAAAAAAAAAAAAAAAAAAAA Surgical Qualifiers
28. ity 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 that is on file with CT Medicaid of the provider being referenced The address is required for providers subscribers and policyholders Line 2 Enter additional address information of the provider being referenced such as suite or apartment number if applicable City Enter the city of the provider being referenced The address is required for providers clients and policyholders State Enter the state of the address of the provider being referenced The address is required for providers clients and policyholders Zip Code Enter the 9 digit zip code of the provider being referenced The address is required for providers clients and policyholders HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 10 OUTPATIENT CLAIMS BILLING INSTRUCTIONS TAXONOMY SCREEN amp gt Taxonomy Taxonomy Code 314000000 lt Add Description Skilled Nursing Facility Delete Undo Save Taxonomy Code Description Find 282E 00000 Long Term Care Hospital Print 313M00000 Nursing Facility Intermediate Care Facility abas er 314000000 Skilled Nursing Facility m Clos
29. lly Remarks Required Format XXXXXXXXX Other Physician Taxonomy Code This field will be auto plugged once you enter the other physician 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 Other Physician Last Org Name This field will be auto plugged once you enter the other physician provider ID and contains the last name of an individual provider or the business name of a group or facility Remarks Situational Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA Other Physician First Name This field will be auto plugged once you enter the other physician provider ID and contains the first name of the provider when they are an individual Remarks Situational Format AAAAAAAAAAAAAAAAAAAAAAAAA HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 30 OUTPATIENT CLAIMS BILLING INSTRUCTIONS OUTPATIENT HEADER FIVE HEADER FIVE SCREEN Total Charge Za Ol Amount HIT Billed Amount Hail Services Header 1 Header 2 Header 3 4 Header5 service Admission Type Admit Source mE Facility ID 1000000000 Other Insurance Indicator N v Crossover Indicator IN Delay Reason Code FIELD REQUIRED R ALPHA A D
30. n codes listed below should only be used ifan 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 Induced abortion endangerment to life A8 Induced abortion victim of rape incest Remarks Situational Format XX HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 27 OUTPATIENT CLAIMS BILLING INSTRUCTIONS OUTPATIENT HEADER FOUR HEADER FOUR SCREEN Total Charge 0I Amount ENT Billed Amount SENT Services J Header 1 Header 2 Header3 Header 4 Headers Service Value Codes Amounts i sl diz EN Tora spo Tra mh o NS NE 12 gt va 5 12 0 Other Physician Si 8 Provider ID Taxonomy Code Last Org First FIELD REQUIRED R ALPHA A DESCRIPTION LENGTH OPTIONAL NUMERIC N SITUATIONAL S ALPHANUMERIC X VALUE CODES 1 12 2 5 X VALUE CODE AMOUNTS 1 12 9 5 N OTHER PHYSICIAN PROVIDER ID 9 5 X OTHER PHYSICIAN TAXONOMY 10 5 X CODE OTHER PHYSICIAN LAST ORG 35 5 NAME OTHER PHYSICIAN FIRST NAME 25 5 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 28 OUTPATIENT CLAIMS BILLING INSTRUCTIONS HEADER FOUR ENTRY INSTRUCTIONS Value Codes 1 12 Enter the applicable code that identifies a significant event relating to t
31. ntain 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 autoplug 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 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 4 OUTPATIENT CLAIMS BILLING INSTRUCTIONS CLIENT SCREEN 5 Client Client ID 001 000002 ID Qualifier MI Issue Date 00 00 0000 Add Account Client SSN 345 67 8901 Delete Last Name ROBERT First Name SMITH MI B Client DOB 12 01 1975 Gender Undo All Subscriber Address Save Line 1 150 EAST STREET Line 2 3 Find
32. o obtain coinsurance and deductible payments form a claim paid by Medicare please complete this section as though you were submitting this claim to Medicare Date of Service Enter the date on which service s were provided for this claim in MM DD CCYY format Remarks Required Format MM DD CCYY Revenue Code Enter the revenue code for the appropriate accommodation and or ancillary services provided Each specific revenue center code for outpatient services must have a single date of service Span dating is not permitted in the detail section for outpatient claim submission Outpatient Revenue center codes 300 309 must be accompanied by the corresponding HCPCS code for laboratory services Outpatient Revenue center codes 250 253 258 260 273 and 634 637 must be accompanied by the corresponding HCPCS code for physician administered pharmaceuticals Home Health Revenue center codes 500 599 must be accompanied by the corresponding HCPCS code for home health claims Revenue center codes 657 and 659 must be accompanied by the corresponding HCPCS code for hospice claims Outpatient and Home Health claims must be billed with the RCCs for which DSS has assigned rates Remarks Required Format NNN 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 Units Enter the number of days or units of service for
33. of Tests and Analysis Report Renewable Oxygen Content Averaging Report Symptoms Document Death Notification Photographs HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 20 OUTPATIENT CLAIMS BILLING INSTRUCTIONS 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 Attachment CTL This field is enabled when the Report Transmission Code is a BM EL EM or FX Enter the control number of the attachment Remarks Situational Format XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX OUTPATIENT HEADER TWO HEADER TWO SCREEN Total Charge 01 Amount ENT Billed Amount SENT Services J Header1 Header 2 Header 3 Header 4 Header5 Service M Diagnosis Codes Primary o Other 1 2 EA 3 ____ 4 7 o _____ 2 3 EE Patient Reason 1 2 Es 3 EJ Attending Provider ID Taxonomy Code Last Org First M Surgical Procedure Qualifiers Codes D ates 1 00 00 0000 2 00 00 0000 3 0
34. ovider 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 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 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 9 OUTPATIENT CLAIMS BILLING INSTRUCTIONS First Name Enter the first name of the provider when the provider is an individual Required when the Entity Type Qualifier isa 1 Field will not be available when the Facil
35. s and policyholders State Enter the state of the address of the provider being referenced The address is required for providers clients and policyholders Zip Code Enter the 9 digit zip code of the provider being referenced The address is required for providers clients and policyholders HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 8 OUTPATIENT CLAIMS BILLING INSTRUCTIONS OTHER PROVIDER SCREEN Other Provider Provider ID 1111122223 Provider ID Code Qualifier XxX v Add Taxonomy Code 208000000 Entity Type Qualifier 1 Delete Last Org Name SMITH First Name ROBERT SSN 7 Tax ID 234567890 SSN Tax ID Qualifier 34 Provider Address Save Line 1 250 PARK PLACE Line 2 City NETHERSFIELD State CT Zip 06240 1 234 Find ET a Provider ID Taxonomy Last Org Name Type Qualifier la 1000000001 207NO0000 GENERIC 1 1111122222 204 00000 lt DOE 1 1111122223 208000000 5 1 1111122224 207NO0000 JOHNSON 1 1111122225 2084P0800 MARTINEZ 1 The Other Provider list requires you to collect information about non billing providers which are 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 Pr
36. s entered and contains the name of the other insurance company listed for the client HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 12 OUTPATIENT CLAIMS BILLING INSTRUCTIONS Other Insurance Group Name Enter the name of the group that the other insurance is listed under and coincides with group number 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 listed Last Name Enter the last name of the policyholder of the other insurance or Medicare Only numeric characters 0 9 and alphabetic characters A Z are accepted Lower case letters are automatically converted to upper case 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 type of 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 policy holder being referenced The address is required for providers clients and policyholders Line 2 Enter additional address informa
37. sistance Program by the provider via the provider enrollment application 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 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 7 OUTPATIENT 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 isa 1 Field will not be available when the Facility 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 that is on file of the provider being referenced The address is required for providers subscribers and policyholders Line 2 Enter additional address information of the provider being referenced such as suite or apartment number if applicable City Enter the city of the provider being referenced The address is required for providers client
38. te Paten e e espe 23 OUTPATIENT HEADER THREE IRE eer Ore 24 HEADER THREE ENTRY INSTRUCTIONS dirt ree t Hee ren tet eerte eee ee cogunt 26 OUTPATIENT HEADER nn et pere ree ertet orbe eriperet rete ip b rie 28 HEADER FOUR ENTRY INSTRUCTIONS e eE etre ener 29 OUTPATIENT HEADER FIVE neret rrr RR Ea ie E EEEE EEr een 31 HEADER FIVE ENTRY INSTRUCTIONS ertet ete re eee riter torre dp bere 32 OUTPATIENT SERVICE tn rae et ed rs Rte ied Rp hee p in 34 SERVICE ENTRY INSTRUCTIONS terret teet he i Trete rip Yo ee pri ie Ha eii pH ette 35 OUTPATIENT OTHER INSUR ANCE itte prre rt eret eere eget rb e E ptite eere be 37 OTHER INSURANCE ENTRY INSTRUCTIONS 38 OUTPATIENT CROSSOVER one e He Re n eH RERO ERR OR oa 41 CROSSOVER ENTRY INSTRUCTIONS 42 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 2 OUTPATIENT CLAIMS BILLING INSTRUCTIONS INTRODUCTION Now that you have installed and become familiar with the functionality of the HP PROVIDER ELECTRONIC SOLUTIONS software it s time to begin claims data entry The claim entry screen consists of eight sections Five 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
39. tion of the policy holder being referenced such as suite or apartment number if applicable City Enter the city of the policy holder being referenced State Enter the state of the address of the policy holder being referenced Zip Code Enter the 9 digit zip code of the policy holder being referenced Patient ID Enter the other insurance identification number of the Medical Assistance Program client being billed ID Qualifier Select the appropriate value from the drop down box that identifies the type of ID that is being used HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 13 OUTPATIENT 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 autoplug field from a claim screen Once a List entry has been either added or edited the Select b
40. utton must be clicked in order for the data to populate the claim screen with the selected List entry HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 14 OUTPATIENT CLAIMS BILLING INSTRUCTIONS OUTPATIENT HEADER ONE HEADER ONE SCREEN Total Charge 01 Amount Billed Amount DT Services J Header 1 Header 2 Header 3 Header 4 Header5 Service Of Bill fl riginal Claim t Provider ID Taxonomy Code Last Org Name ClientID Accutt LastNam Fist Name 7 Patient Status Medical Record From DOS 00 00 0000 To DOS 00 00 0000 Release of Medical Data v v Benefits ssignment Y Report Type Code Report Transmission Code Attachment cul FIELD REQUIRED R ALPHA A DESCRIPTION LENGTH OPTIONAL NUMERIC N SITUATIONAL S ALPHANUMERIC X TYPE OF BILL 3 R N ORIGINAL CLAIM 13 5 PROVIDER ID 9 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 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 X REPORT TRANSMISSION CODE 2 O A ATTACHMENT CTL 30 5 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 15 OUTPATIENT CLAIMS BILLING INSTRUCTIONS HEADER ONE ENTRY INSTRUCTIONS Special Note All data entry will default to capital letters Header Field D
41. which services were provided Note For accommodation days the sum of all the detail days must equal the days indicated Remarks Required Format NNNNN HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 35 OUTPATIENT CLAIMS BILLING INSTRUCTIONS 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 UN Units default Remarks Required Format AA Procedure Enter the appropriate procedure code when submitting revenue center codes for Laboratory Physician Administered Pharmaceutical Home Health or Hospice services Please refer to the relevant Connecticut Medicaid Provider Billing Manual Chapter 8 for provider specific claims submission instructions Remarks Situational Format XXXXX Modifiers 1 4 Enter the modifier if applicable Up to four 4 modifiers may be entered for each detail Remarks Situational Format XX Note When physician administered drugs are being billed the Pharmaceutical section should also be used Pharmaceutical NDC Enter the 11 digit National Drug Code NDC Remarks Situational required if physician administered drug is billed Format NNNNNNNNNNN Pharmaceutical Units Enter the number of units for the drug that was dispensed Remarks Situational required if NDC present Format NNNNNNNN Pharmaceutical Basis for Measurement Sel
42. y any portion of the claim This field is defaulted to for no When this is changed to a Y for yes the Other Insurance Tab is added to the claim form for entry HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 32 Y Yes OUTPATIENT CLAIMS BILLING INSTRUCTIONS N No default 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 Claims that do not crossover from Medicare can be submitted electronically with Provider Electronic Solutions software 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 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 Code Description 1 Proof of eligibility unknown or unavailable 2 Litigation 3 Authorization delays 4 Delay in certifying provider 5 Delay in supplyin
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