Long Term Care Claims - Connecticut Medical Assistance Program
Contents
1. 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 LONG TERM CARE 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 Facility Type Qualifier is 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 fille 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 15 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 Code Enter the 9 digit zip code of the provider being referenced The address is required for providers clients and policyholders HP PRO2. SITUATIONAL S ALPHANUMERIC X OCCURRENCE CODES 2 O N OCCURRENCE CODE DATES 8 O N OCCURRENCE SPAN CODES 2 O N OCCURRENCE SPAN DATES 8 O N CONIDITON CODES 2 S X HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 28 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS HEADER FOUR ENTRY INSTRUCTIONS Occurrence Code 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 lIllness 21 Administratively Necessary Days 42 Date of discharge NOTE This field is required with value 42 if RCC 185 hospital reserve is billed The date entered is the date the hospital reserve began Remarks Optional Format NN Occurrence Code Date Enter the date associated with the code listed Remarks Optional Format MM DD CCYY Occurrence Span Codes 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 Enter the appropriate condition codes to identify conditions that determine eligibility and establish primary and or secondary responsibility The following codes a
3. s condition which prompted admission to the hospital Remarks Optional Format XXXXX 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 Delay Reason Enter one of the reason codes listed below to explain why the claim was delayed ode 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 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 Q HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 26 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS Remarks Optional Format NN 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 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 default Remarks Situational Format A Crossover Indicator This field should only be used when the intent is to obtain coinsurance and
4. Report Code Last Org SKILLED NURSING Account 0201 14 First Name IDOE Attachment Ctl FIELD REQUIRED R ALPHA A LENGTH OPTIONAL N 13 10 35 16 38 35 25 Sunee n SITUATIONAL S NOOAAOCHOAAAAAAAAA ALPHANUMERIC X gt X gt gt X Z gt gt gt X gt x Z Z Z HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 15 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS HEADER ONE ENTRY INSTRUCTIONS Special Note All data entry will default to capital letters Header Field Definition 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 2 Description Skilled Nursing Second Digit indicates the Bill Classification Code O O Description Inpatient including Medicare Part A Inpatient Medicare Part B only Outpatient Other for hospital referenced diagnostic services or home health not under a plan of treatment Intermediate Care Level I Intermediate Care Level II Sub acute Inpatient revenue code 19x required Swing Beds Reserved for national use Third Digit indicates the Frequency Code 3 Description Non payment Zero Claim Admit through discharge date F
5. SPECIAL FEATURE Edit All Command Button The Edit All feature allows Nursing Home providers to copy select claims from a previous submission and update the From DOS To DOS and Total Days for all selected claims simultaneously Providers can then submit claims for the current month without the need to re key claim information To learn more about this feature select the Help menu select Contents and Index select the Help Topics button select the Index tab type in Edit All and press the Enter key on your keyboard This will display the functions of and instructions for the Edit All feature HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 42
6. INSURANCE SCREEN Total Charge 01 Amount Billed Amount Services Header 1 Header 2 Header 3 Header 4 Header5 OI crossover Service Release of Medical Data Benefits Assignment ICN Claim Filing Ind Code Adjustment Group Cd Payer Responsibility Reason Codes Amts 1 000 2 O Paid Date Amount 00 00 0000 0703 m Policy Holder I Group CTMEDJDOE Group Name FEDMEDICARE Carrier Code Last Name DOE First Name JOHN Add GroupName Last Name 1 MPA CTMEDJDOE FEDMEDICARE DOE Copy Delete FIELD REQUIRED R ALPHA A DESCRIPTION LENGTH OPTIONAL O NUMERIC N SITUATIONAL S ALPHANUMERIC X 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 5 R X REASON AMTS 9 R N PAID DATE 8 R N PAID AMOUNT 9 R N POLICY HOLDER GROUP 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 35 LONG TERM CARE 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 Me
7. 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 is entered and contains the name of the other insurance company listed for the client HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 12 LONG TERM CARE 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 insura
8. Results CB Chiropractic Justification CK Consent Form s CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits HC Health Certificate HR Health Clinic Records I5 Immunization Record IR State School Immunization Records LA Laboratory Results MI Medical Record Attachment MT Models NN Nursing Notes OB Operative Notes OC Oxygen Content Averaging Report OD Orders and Treatment Document OE Objective Physical Examination 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 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 20 LONG TERM CARE CLAIMS BI
9. coinsurance and deductible payments form a claim paid by 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 that identifies a specific accommodation or ancillary service Code Description 100 Per diem rate 183 Home reserve 185 Inpatient hospital reserve 189 Non covered reserve 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 cc Units Enter the number of days being billed for the Revenue Center Code Note For each RCC billed the number of days must be entered The total of all detail service units must equal the number of covered days plus the number of non covered days If the patient status billed is a value other than 30 40 41 or 42 the detail with the oldest service date must be reduced by 1 day Remarks Required Format NNNN 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 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 34 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS NURSING HOME OTHER INSURANCE OTHER
10. deductible payments from a claim already paid by Medicare This field is defaulted to N for no When this is changed to a Y for yes the Crossover Tab is added to the claim form for entry Use this field for the following situations e Claims that do not crossover from Medicare can be submitted electronically with Provider Electronic Solutions software e After claims have 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 Y Yes N No default Remarks Situational Format A HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 27 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS NURSING HOME HEADER FOUR HEADER FOUR SCREEN Total Charge Ti 01 Amount Billed Amount NT Services Header 1 Header 2 Header3 Header 4 Header 5 or Crossover Service Occurrence Codes Dates 1 42 06710 2011 2 00 00 0000 3 00 00 0000 4 00 00 0000 5 00 00 0000 6 00 00 0000 07 00 0000 8 00 00 0000 Occurence Span Codes Dates 1 42 05 10 2011 05 13 2011 2 00 00 0000 00 00 0000 Condition Codes gt 5 Th Hi FIELD REQUIRED R ALPHA A DESCRIPTION LENGTH OPTIONAL NUMERIC N
11. 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 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 LONG TERM CARE 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 types of bill and admission sources and types 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 cer
12. 67890 SSN 7 Tax ID Qualifier 24 v _ Undo A Provider Address Line 1 100 EAST STREET Line2 City BRIDGEPORT State CT Zip 060601234 Find Print Provider ID Taxonomy Last Org Name Type Qualifier 1000000000 314000000 TEST FACILITY 2 1000000001 3140000004 GENERIC FACILITY 2 1 1000000002 314000000 LONG TERM CARE 2 1000000003 314000000K EXTENDED CARE 2 1000000004 314000000 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 t
13. E ENTRY INSTRUCTIONS E S eR E S 26 NURSING HOME HEADER FOUR 28 HEADER FOUR ENTRY INSTRUCTIONS ernst asrori raser EE Eor Ee TETE E E rE EE Si 29 NURSING HOME HEADER FIVE seene eroarea r r EES aeo E EE ETT ES E EE E oi 31 HEADER FIVE ENTRY INSTRUCTIONS aor EE E ET E EEE SEE 32 NURSING HOME SERVICE ana a riera VE o rE E T EEE EE E ETETE TEE E TE 33 SERVICE ENTRY INSTRUCTIONS aee 34 OTHER INSURANCE EEE E EES ETET ET 35 OTHER INSURANCE ENTRY INSTRUCTIONS 36 CROSSOVER SEREEN 39 55 8 50 0 40 EDIT ALL SPECIAEEFEATUREBE 42 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 2 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS INTRODUCTION Now that you have installed and become familiar
14. HP Provider Electronic Solutions Billing Instructions Long Term Care Claims LONG TERM CARE CLAIMS BILLING INSTRUCTIONS TABLE OF CONTENTS INTRODUCTION E Ad eI GAG OAM Puas oh a 3 CEIENT SCREEN ua a n eh BR sais oldie ee So tee Sin a aa ees 5 CLIENT ENTRY INSTRUCTIONS D a Q A eo h u aa uhun ace 5 BILLING PROVIDER SCREEN 7 BILLING PROVIDER ENTRY 7 OTHER PROVIDER SCREEN ies sci a nspa aa inasa ia hua 9 OTHER PROVIDER ENTRY INSTRUCTIONS 9 TAXONOMY SCREEN aasan A SS eto 11 TAXONOMY ENTRY INSTRUCTIONS A s su l Sau 11 POLICY HOLDER SCREEN L p satus a usu asa 12 POLICY HOLDER ENTRY INSTRUCTIONS 12 CLAIMCENTRY INSTRUCTIONS S suu su o nunana Santas tetas qhasuy 13 NURSING HOMES HEADER ONB S S ia pie 15 HEADER ONE ENTRY INSTRUCTIONS 5 E 16 NURSING HOMES HEADER ab DDOS SSS uu Sasu 22 HEADER TWO ENTRY INSTRUCTIONS Suay asuamanta ences 23 NURSING HOMES HEADER THREE a E S 25 HEADER THRE
15. IC SOLUTIONS USER S MANUAL 4 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS CLIENT SCREEN 5 Client Client ID 001 000002 ID Qualifier Y Issue Date 00 00 0000 Account Client SSN 345 67 8901 Delete Last Hame ROBERT First Name SMITH Client 12 01 1975 Gender gt Undo Subscriber Address Save Line 1 150 EAST STREET Line 2 3 Find 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 Client list requires you to collect detailed information about your clients which 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
16. LLING INSTRUCTIONS BM By mail EL Electronically only EM E mail FT File Transfer FX By fax Note If the values BM EL EM 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 EL EM or Enter the control number of the attachment Remarks Situational Format HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 21 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS NURSING HOMES HEADER TWO HEADER TWO SCREEN Total Charge 01 Amount Ti Billed Amount SMM Services Header1 Header 2 Header 3 Header 4 Header 5 Service Admission Date 0271 Z22011 Hour 10 v Type From DOS 06 01 22011 005 05 30 2011 Attending Provider ID 111122223 Taxonomy Code 2080000009 Last Org Name SMITH First Name ROBERT FIELD REQUIRED R ALPHA A DESCRIPTION LENGTH OPTIONAL O NUMERIC N SITUATIONAL S ALPHANUMERIC X ADMISSION DATE 8 R N ADMISSION HOUR 2 O N ADMISSION TYPE 1 R x FROM DOS 8 R N TO DOS 8 R N ATTENDING PROVIDER ID 10 R N ATTENDING TAXONOMY CODE 10 R x ATTENDING LAST ORG NAME 35 R A ATTENDING FIRST NAME 25 R A HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 22 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS HEADER TWO ENTRY INSTRUCTIONS Admission Date Enter the date that the client was a
17. RM CARE CLAIMS BILLING INSTRUCTIONS NURSING HOMES HEADER THREE HEADER THREE SCREEN Total Charge 01 Amount Billed Amount ENT Services Header 1 Header2 Header 3 Header 4 Header 5 or Crossover Service Diagnosis Codes Primary 4589 22 Admit xi 7 s Facility ID 000000004 Delay Reason Y Other Insurance Indicator Y Crossover Indicator Y v FIELD REQUIRED R ALPHA A DESCRIPTION LENGTH OPTIONAL O NUMERIC N SITUATIONAL S ALPHANUMERIC X DIAGNOSIS CODE PRIMARY 5 R X DIAGNOSIS CODE OTHER 1 8 5 O X DIAGNOSIS CODE ADMIT 5 O X FACILITY ID 10 O N DELAY REASON 2 O N OTHER INSURANCE INDICATOR 1 5 CROSSOVER INDICATOR 1 S A HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 25 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS HEADER THREE ENTRY INSTRUCTIONS Diagnosis Code Primary Enter the primary diagnosis code from the International Classification of Diseases 9 Revision Clinical Modification ICD 9 CM manual Note DO NOT key the decimal point It is already assumed Remarks Required Format XXXXX 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 already assumed Remarks Optional Format XXXXX Diagnosis Codes Admit Enter the ICD 9 CM diagnosis code corresponding to the diagnosis of the client
18. 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 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 is an individual performer or corporation
19. VIDER ELECTRONIC SOLUTIONS USER S MANUAL 10 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS TAXONOMY SCREEN gt Taxonomy Taxonomy Code 314000000 lt Description Skilled Nursing Facility Delete Undo All Save Taxonomy Code Description Find 282 00000 lt Long Term Care Hospital Print 313 00000 lt Nursing Facility Intermediate Care Facility 31400000 Skilled Nursing Facility Close The Taxonomy list allows you to list the taxonomy code which is then automatically entered into the Provider List 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 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS POLICY HOLDER SCREEN 5 Policy Holder Client ID 001 000001 Group 0001 230 Carrier Code 801 Y Add Carrier BEST PLAN Other Insurance Group Name CCORPORATION Delete Relationship to Insured 18 Y In
20. ast date of service on which services were provided for this claim Remarks Required Format MM DD CCYY Attending Provider ID Select the Connecticut Medical Assistance Program billing 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 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 Attending Last Org Name This field will be auto plugged once you enter the attending provider number 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 Situatlonal Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA Attending First Name This field will be auto plugged once you enter the attending provider number and contains the first name of the provider when they are an individual Remarks Situatlonal Format AAAAAAAAAAAAAAAAAAAAAAAAA HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 24 LONG TE
21. ation number This field contains the first character of the client s middle name Example Jy 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 outpatient services as specified by the discharge plan of care HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 18 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS Remarks Required Format Medical Record Enter the number assigned to the patient s record Remarks Optional Format XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Release of Medical Data This code indicates whether the provider has on file a signed statement by the client author
22. ct 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 40 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS Remarks Required Format XXXXXXXXXXXXXX Paid Amount Enter the dollar amount paid by Medicare for the service or claim Remarks Required Format cc 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 cc Policy Holder Carrier Code Select the carrier code that corresponds to the policyholder for this claim Remarks Required Format XXX Policy Holder Last Name This field is auto plugged once you select the carrier code Remarks Required Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA Policy Holder First Name This field is auto plugged once you select the carrier code Remarks Required Format AAAAAAAAAAAAAAAAAAAAAAAAA HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 41 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS EDIT ALL
23. dicare 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 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 ICN Enter the claim number from the claim processed by the other insurance Remarks Optional Format XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Claim Filing Ind Code Select the appropriate value from the drop down box that identifies the type of other insurance claim that is being submitted Select MA or 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 Res
24. dmitted into the facility Note This software will not accept dates of service prior to 1976 Therefore if the client s admission date is prior to 1976 please enter the admission date as 01 01 1976 Remarks Required Format MM DD CCYY Admission Hour Select the appropriate value for the national code which corresponds to the hour during which the client was admitted for inpatient care Note 99 is not acceptable Code Description Code Description 00 12 00 12 59AM Midnight 12 12 00 12 59PM Noon 01 1 00 1 59 13 1 00 1 59PM 02 2 00 2 59AM 14 2 00 2 59 03 3 00 3 59AM 15 3 00 3 59PM 04 4 00 4 59AM 16 4 00 4 59PM 05 5 00 5 59AM 17 5 00 5 59PM 06 6 00 6 59AM 18 6 00 6 59PM 07 7 00 7 59AM 19 7 00 7 59PM 08 8 00 8 59AM 20 8 00 8 59PM 09 9 00 9 59AM 21 9 00 9 59PM 10 10 00 10 59AM 22 10 00 10 59PM 11 11 00 11 59AM 23 11 00 11 59PM Remarks Optional Format NN Admission 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 x From Date of Service Enter the first date of service on which services were provided for this claim Remarks Required HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 23 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS Format MM DD CCY Y To Date of Service Enter the l
25. do All Policy Holder Information Last Name pe c First Hame DANE 7 ID Code 20000123 ID Qualifier MI Find Date Of Birth 01 01 1965 Gender F Policy Holder Address Line 1 N00 MAIN STREET Line 2 5UITE 24 City SPRINGFIELD 5 Zip 06000 1234 Patient Information Patient ID 00100000 7 ID Qualifier 23 Close Client ID Code First N s 001000001 00001230 901 DOE JANE 001000000 CTMEDJDOE MDCR 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
26. e 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 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 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 17 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS Example THOMPSON or Remarks Required Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA or AA First 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 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 s identific
27. e 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 Claim Filing Ind Code Select the appropriate code from the drop down box that identifies the type of other insurance claim that is being submitted 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 sele
28. ghlighted 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 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 14 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS NURSING HOMES HEADER ONE HEADER ONE SCREEN Type Of Bill 213 Provider ID 000000004 Client ID 001 000000 Patient Status 30 Report Transmission Code DESCRIPTION TYPE OF BILL ORIGINAL CLAIM PROVIDER ID TAXONOMY CODE LAST ORG NAME CLIENT ID ACCOUNT LAST NAME FIRST NAME MI PATIENT STATUS MEDICAL RECORD RELEASE OF MEDICAL DATA BENEFITS ASSIGNMENT REPORT TYPE CODE REPORT TRANSMISSION CODE ATTACHMENT CTL Total Charge 01 Amount Billed Amount SENT Services JN Header 1 Header 2 Header 3 Header 4 Header 5 Service Original Claim Taxonomy Code 31 4000000 Last Name OHN Medical Record 000001 234 Release of Medical Data Y Benefits Assignment
29. harge 01 Amount SICJ IIUOIId lli Billed Amount EFT Services J Header 1 Header 2 Header 3 Header 4 Header 5 OI Crossover Service Release of Medical Data Benefits Assignment ly Claim Filing Ind Code MB Medicare Providers Rendering ID 000000000 Last Org Name TEST FACILITY Medicare ICN PaidAmount 00 Paid Date 00 00 0000 Amounts Deductible 00 Coinsurance 000 Policy Holder Code MPa Last Name DOE First Name JOHN FIELD REQUIRED R ALPHA A DESCRIPTION LENGTH OPTIONAL O 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 O 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 39 LONG TERM CARE CLAIMS 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 th
30. hat 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 Assistance 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 Last Org Name HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 7 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS Enter the last name of an individual provider or the business name of a group or facility when the Entity Type Qualifier is 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 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 Li
31. irst interim claim Continuing Interim claim Last interim claim Replacement of prior claim designates electronic adjustment Void Cancel of prior claim designates electronic adjustment Note If the third digit is a Z or 8 the Original Claim field will be required Remarks Format Required NNN HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 16 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS 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 Remarks Situational Format NNNNNNNNNNNNN Provider ID Enter the NPI or Connecticut Medical Assistance Program s Provider 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 th
32. izing 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 default 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 default 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 the two digit value that corresponds to the report type 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 HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 19 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results BS Baseline BT Blanket Test
33. mber 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 37 LONG TERM CARE 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 Program s identification number Remarks Required Format 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 38 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS NURSING HOME CROSSOVER CROSSOVER SCREEN Total C
34. nce 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 information 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 CLAIM ENTRY INSTRUCTIONS HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 13 LONG TERM CARE CLAIMS BILLING 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 hi
35. ne 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 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 8 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS OTHER PROVIDER SCREEN Other Provider Provider ID 1111122223 Provider ID Code Qualifier lt gt Add Taxonomy Code 208000000 Entity Type Qualifier Y Delete Last Org Name SMITH First Name ROBERT SSN Z Tax ID 234567890 SSN Tax ID Qualifier 34 v Provider Address Save Line 1 250 PARK PLACE Line 2 City State Zip 06240 1 234 Find YY SP COS 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
36. ponsibility 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 36 LONG TERM CARE 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 Click on Claim Adjustment Reason Codes Use this list of codes to indicate if a payment was made by OI or denied by OI Remarks Required Format XXXXX Reason Amounts Enter the amount associated with the reason code Remarks Required Format cc Paid Date Enter the date on the other insurance voucher or explanation of benefits Use this field to enter the date Medicare denied the claim Remarks Required Format MM DD CCYY Paid Amount Enter the amount paid by the other insurance carrier 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 nu
37. re applicable 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 A4 Family Planning HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 29 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS Remarks Situatlonal Format HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 30 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS NURSING HOME HEADER FIVE HEADER FIVE SCREEN Total Charge 01 Amount ENT Billed Amount SENT Services Header 1 Header 2 Header 3 Header4 Header 5 Service Value Codes Amounts iT 52 s 0O 4 FkII IKITF lt ICI C IIIXE E 00 7 9 O 10 i m 12 FIELD REQUIRED R ALPHA A DESCRIPTION LENGTH OPTIONAL O N SITUATIONAL 5 ALPHANUMERIC X VALUE CODES 2 O x VALUE CODE AMOUNTS 9 O N HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 31 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS HEADER FIVE ENTRY INSTRUCTIONS Value Codes Enter the National Uniform Billing Committee NUBC code to relate amounts or values to identify data elements necessary to process this claim as qualified by the payer organization Value Codes are used to report Covered Days Value Code 80 and Non Covered Days Value Code 81 Enter the number of days for each of the
38. se value codes in the Amount field The format of the Amount field appears as a whole number with a decimal point followed by two zeros and is adjusted during claims processing Covered Days are required for processing both Long Term Care and Inpatient claims Remarks Optional Format XX Value Code Amounts Enter the corresponding Value Code amount Remarks Optional Format cc HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 32 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS NURSING HOME SERVICE SERVICE INFORMATION SCREEN Total Charge AT 01 Amount Billed Amount TM Services Header 1 Header 2 Header 3 Header 4 Header 5 or Crossover Service Date Of Service 065 1 4 2011 Revenue Code 00 Billed Amount 6 800 00 Units 17 0 Basis of Measurement DA v Add Srv f Date Df Service Revenue Code nits Billed Amount 1 9 0 3 600 00 06 01 2011 100 Copy Srv 2 06 10 2011 185 40 1 600 00 3 06 14 2011 100 170 6 800 00 Delete Srv FIELD REQUIRED R ALPHA A DESCRIPTION LENGTH OPTIONAL O NUMERIC N SITUATIONAL 5 ALPHANUMERIC X DATE OF SERVICE 8 R N REVENUE CODE 3 R N BILLED AMOUNT 9 R N UNITS 4 R N BASIS OFMEASUREMENT 2 R A HP PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 33 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS SERVICE ENTRY INSTRUCTIONS Complete this section as though you were submitting this claim to Medicare Ifthe intent for this claim is to obtain
39. tain 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 contain preloaded information that is available for auto plugging as soon as you install Provider Electronic Solutions Other lists require you to enter the information you will use for auto plugging You should enter your data in these lists soon after you set up Provider Electronic Solutions to take advantage of the auto plug feature To create or edit a list select List from the Main Menu and then select the appropriate item Working with Lists From the Lists option on the menu bar select the list you want to work with Perform one of the following To add a new entry select Add To edit an existing entry select the entry and then enter your changes The command buttons for Delete Undo All Find Print and Close work as titled Note The Select Command button is not visible on the List window unless it has been invoked by double clicking an 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 ELECTRON
40. 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 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS Client DOB Enter the date the client was born Gender Select the appropriate value from the drop down list to enter the client s gender Code Description F Female M Male U Unknown Subscriber Address Line 1 Enter the street address 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 LONG TERM CARE CLAIMS BILLING INSTRUCTIONS BILLING PROVIDER SCREEN Billing Provider Provider ID 1000000002 Provider ID Code Qualifier xx Y Add Taxonomy Code 4000000 Entity Qualifier 2 Y Delete Last Org Name LONG TERM CARE First Name SSN 7 Tax ID 2345
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