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1. Page 71 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Loop Segment Data Element PROF COMP Loop 2100 CAS Claim Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 89 and Loop 2110 CAS Service Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 89 LNE ADJ AMT Loop 2110 CAS Service Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when CASO1 equals OA and Adjustment Code in CASQ2 05 08 11 14 17 equals A7 PER DIEM AMT Loop 2100 AMT Claim Supplemental Information AMTO2 Claim Supplemental Information Amount when AMTO1 equals DY Per Day Limit NPI Identification Code when N103 equals XX HIC CHG X Loop 2100 NM Corrected Patient Insured Name NM109 Corrected Insured Identification Indicator when NM108 equal C Insured s Changed Unique Identification Number TOB XXX Loop 2100 CLP Claim Payment Information CLP08 Facility Type Code in the first two positions of the XX and CLPO9 Claim Frequency Code in the third position last X CV LN Loop 2100 QTY Claim Supplemental Information QTY02 Claim Supplemental Information Quantity when QTYO1 equals CA Covered Actual COVD CHGS Loop 2100 AMT Claim Supplemental Information AMTO2 Claim Supplemental Information Amount
2. Covered Actual Page 76 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Loop Segment Data Element NCOVD VISITS Loop 2100 QTY Claim Supplemental Information Quantity QTY02 Claim Supplemental Information Quantity when QTY0O1 equals NE Non Covered Estimated PAYMENT DATA CLP11 Diagnosis Related Group DRG Code Information MIA04 Claim DRG Amount DRG OPER CAP Loop 2000 MIA Inpatient Adjudication Information MIA06 Claim Disproportionate Share Amount plus MIA08 Claim PPS Capital Amount plus MIA 18 Claim Indirect Teaching Amount LINE ADJ AMT Loop 2110 Service Line Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when CASO1 equals OA and Adjustment Code in CASQ2 05 08 11 14 17 equals A7 OUTLIER Loop 2100 AMT Claim Supplemental Information Amt02 when Amt01 is ZM Add on Outlier CAP OUTLIER Loop 2100 MIA Inpatient Adjudication Information MIA17 Claim PPS Capital Outlier Amount CASH DEDUCT Loop 2100 CAS Claim Adjustment CASO3 Adjustment Amount CASO06 Adjustment Amount CAS09 Adjustment Amount CAS12 Adjustment Amount CAS15 Adjustment Amount CAS18 Adjustment Amount when CAS02 is 1 BLOOD DEDUCT Loop 2100 CAS Claim Adjustment CAS03 Adjustment Amount CASO06 Adjustment Amount CAS09 Adjustment Amount CAS12 Adjustment Amount CASI5 Adjustme
3. Page 102 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Page 103 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 REVISION LOG REVISION LOG 06 13 13 D Skladnowski FISS Doc N A FISS documentation redesign Redesign 2 14 14 Terry Fenton Updates C2014200 Added ACO PIONEER information 03 31 14 Karen Bryan CR8140 and C2014200 Added Group CARC and RARC display and Jeanette CR8479 function GCR and related screen Walden prints Added headers per User Manual Template 04 30 14 D Angeloff FISS Doc N A Made 508 Compliant Redesign 04 24 14 Jeanette CR8479U1 C201422P Updated the SC Button SC Report Walden Service Line sections and replaced the Single Claim screen prints to depict the changes made to add the Group CARC and RARC information at the line level of the Single Claim screen view and report 10 06 14 Diane Floyd CR8479R1 C201441P Updated to add new Business Scenario button Bus Sce and related screen prints 11 18 14 Sandra R11565 C201513B Changed PC Print Version to 5 0 1 E ATES Sensis chamedrorinvesone sat Page 104 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003
4. SYSTEM LAYOUT MAPPING Loop Segment Data Element COVD VISITS NCOVD VISITS Loop 2100 QTY Claim Supplemental Information Quantity QTY02 Claim Supplemental Information Quantity when QTY01 equals CA Covered Actual Loop 2100 QTY Claim Supplemental Information Quantity QTY02 Claim Supplemental Information Quantity when QTY0O1 equals NE Non Covered Estimated REIM RATE Loop 2100 MOA Outpatient Adjudication Information MOAO1 Reimbursement Rate Loop 2110 SVC Service Payment Information when SVCOI 1 equals NU and SVCOI1 2 equals 55X this field value is equal to SVCOS5 Loop 2110 SVC Service Payment Information when SVCOI 1 equals NU and SVCOI 2 equals 42X this field value is equal to SVCO5 Loop 2110 SVC Service Payment Information when SVCOI 1 equals NU and SVCOI 2 equals 44X this field value is equal to SVCO5 Loop 2110 SVC Service Payment Information when SVCOI 1 equals NU and SVCOI 2 equals 43X 978 this field value is equal to SVCO5 Loop 2110 SVC Service Payment Information when SVCOI 1 equals NU and SVCOI1 2 equals 56X this field value is equal to SVCOS5 Loop 2110 SVC Service Payment Information when SVCOI 1 equals NU and SVCOI1 2 equals 57X this field value is equal to SVCOS5 Loop 2110 SVC Service Payment Information when SVCOI 1 equals NU and SVCOI 2 equals 651 this field value is equal to SVCO5 Loop 2110 SVC Service Payment Information when SVCOI 1 equals NU and
5. MENU BAR OPTIONS 1 PeP Pcp01 PC Print for Windows E S File Edit View Admin Help C ee ale 2 l f P oa x Intermediary Setu For Help press F1 Figure 8 Intermediary Setup Dialog Box Screen Layout INTERMEDIARY SETUP Based on changes made for the processing of a HIPAA 5010 835 X12 file this menu option is no longer required The application is mapping this information from the 835 X12 file 1 The Intermediary Setup dialog box is selected by clicking on Admin 2 Then select Intermediary and is used to set up the Intermediary data to be reflected on the screens and reports 3 When updating the dialog box to move from field to field press the TAB key 4 After entering all the requested information click OK to accept Page 19 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 MENU BAR OPTIONS Pe Pepo1 File Edit View Admin Help fw xej s gid e Bl ck Cancel v For Help press F1 Figure 9 Provider Setup Dialog Box Screen Layout Page 20 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016l Task Order HHSM 500 T0003 MENU BAR OPTIONS PROVIDER SETUP Based on changes made for the processing of a HIPAA 5010 835 X12 file this menu option is no longer required to be used The application i
6. 89 94 97 118 122 Loop 2110 SVC Service Payment Information when SVCOI 1 equals NU and SVCO1 2 equals 42X 58X 59X or 997 this field value is equal to SVCO05 Loop 2110 SVC Service Payment Information when SVCOI 1 equals NU and SVCO1 2 equals 57X this field value is equal to SVCOS5 Loop 2100 CAS Claim Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 23 and Loop 2110 CAS Service Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 23 Loop 2100 MOA Outpatient Adjudication Information MOAO02 Claim HCPC Payable Amount Page 91 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING PAT REFUND Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals AO and Loop 2110 CAS Service Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals AO CLAIM STATUS Loop 2100 CLP Claim Payment Information CLPO2 Claim Status Code MEDICAL REC NUMBER Loop 2100 REF Other Claim Related Identification REFO2 Other Claim Related Identifier when REFO1 is EA NCVDV Loop 2100 QTY Claim Supplemental Information Quantity QTY02 when QTYO1 equals NE
7. Aan Tra ona J1 nnn Usul Gis ya oul4ea 1 000 oo N a ATRA acna _4 afafa oud Us 4 das 1 00 nanan ac oann J3 Uslis Wij U4 gL 1 000 aom imj sais Senate anr Jis Way Us Plu Ei 1 00 e aigi Ei fo a n Fh 0450 07 04 99201 1 000 aag sare ean A nomen 30 O77 04 93005 0 1 000 iE fal CR Correctia ia Ll t Te 7 r Ee i CHARGES ALLOW REIM GC z4 co 24 n 4 21 39 1l iy Sa 479 44 7479 4 Li 32 fadi tal 1g 75 I p 16 Sot ee CH l iE Lo H co L 1 Deductible Amount 2 Coimsurance Amount 17 Requested information was not provided or was insufficient incomplete A 42 Charges exceed our fee schedule or maximum allowable amount Use CARC 45 Charge exceeds fee schedule maximum allowable or contracted legislated Figure 61 Mapping 5010 835 to Single Claim Report Layout ifs Pe bI Po Boo At least one Remark ar AMOUNT REMBRR CODES Car LD Bea oo oO oe le a Code must be provid ly with Group C th fu Page 95 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Field Loop Segment Data Element Name TS303 Fiscal Period Date Name PAYEE ADDRESS Loop 1000B N3 Payee Address N301 Payee Address Line PAID Header BPR Financial Information BPR16 Check EFT Date INTERMEDIARY ADDRESS Loop 1000A N3 Payer Address N301 Payer Address Line PROVIDER CITY ST ZIP Loop 10
8. CR Correction 2 Coinsurance Amount 45 Charge exceeds fee schedule maximum allowable or contracted legislated fee arrangement Use only with Group Codes PR or CO depending upon liability Figure 35 Single Claims Find Option Screen Layout 1 Access the single claim screen by clicking the SC button 2 Click on Edit then click on Find Page 49 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016l Task Order HHSM 500 T0003 FIND OPTIONS Fe 021016AAX12 PC Print for Windows A iT SSS Sela J File Edit View Admin Help Medicare National Standard Intermediary Remittance Advice FPE 09 30 01 HOSP PAID 08 26 02 PO BOX 1234 CLM 27 SAN JUAN PR 00919 NPI 9999999999 TOB 138 PATIENT BAZAN X x PCN 800507288 1 HIC 123456789B SVC FROM 09 18 01 MRN 0000028317 CLAIM STAT 22 THRU 09 18 01 ICN 20222808572504 CHARGES PAYMENT DATA P 52 00 REPORTED 0 00 DRG AMOUN 0 00 NCVD DENIED 0 00 DRG OPER 0 00 CLAIM ADJS 0 00 LINE ADJ 52 00 COVERED 0 00 OUTLIER Find What BETANCOURT DAYS VISITS 0 00 CAP OUTLI aa O COST REPT 0 00 CASH DEDU Cancel oo ee 0 00 BLOOD DEDI PatientLastName C Medical Record Number 0 NON COVERED 7 41 COINSURAN e E RR 0 COVD VISITS 0 00 PAT RE HIC Number aont amro neer O NCOV VISITS 0 00 ACO PIO ADJ REASON CODES CR 93 REMARK CODES Group CARC CODES CR Correction 93 No Claim level Ad
9. Ctrl N Find CARC RARC ctrisu 68 m DTM 020823 N1 HOSP N3 N3 N4 N4 Lx 000913 T53 400016 CLP 800182689 1 CAS CR NMT BARBERO MOA MADI REF 0001079178 DTM 000704 DTM 000704 AMT AU QTY CA SVC HC 800407 DTM 000704 CAS CR AMT B6 SVC HC 850317 DTM 000704 CAS CR AMT B6 SVC HC 81000 DTM 000704 CAS CR AMT B6 SVC HC 71020 DTM 000704 CAS CR REF R AMT B6 SYC HC 992017 DTM 000704 CAS CR AMT B6 Figure 44 CARC RARC Find Option Screen Layout 1 Access the single claim screen by clicking the SC button 2 Click on Edit then click on Find CARC RARC Page 58 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 FIND OPTIONS aks 4 pee BL CA de me s x 3 s Con tam Cote OE viit toe Oe a Comer hae 54 8 13 TETRI LL COP etetce Ameti wives Te pa pees Att L i ieee The peecegere opge is Lbeeeteietent with the eogifie used OF PeGeifed Godafier is siseing S p TER Tee peccegare coge Scll type ie inecesietest v ta the glece c service Goce Refer ta the 35 ieee The peocegere revenue GoGo Le beens etent Ath The pelieni e opt Bene Sefer te the 99 Beale 9 3 172 Pre The geccegare revrensee code if tecoeeietest with the geliert s gener Sote Sefer te the tno TET The peeee ere code is iheetelietent vith the prevrider type epetielty itennneny Bete Sef
10. Tool Bar Options 2220200022 n nnn e eee e nnn e nee 24 X12 Button 24 SL Button 28 PS Button 29 BS Button 30 AC Button 31 SC Button 33 Printer Button 34 GCR Button 35 BUS SCE Button 38 Chapter 6 2 2 2 2222 nee e ene e nen n nnn n nnn n nee n eee eee 41 Printing Options 2 20 2220220000 02 222 000 2225 41 Printing the Single Claim Report 41 Printing the All Claims Report 42 Page 2 Use or disclosure of the data contained on this sheet is subject to
11. click OK NOTE Clicking Next displays new provider fields same as Add When OK is clicked it stores the data MBB WN Re Page 22 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 MENU BAR OPTIONS HELP OPTION PeP PcpO1 PC Print for Windows File Edit View Admin lt jfa Index Using Help About Pcp01 Figure 11 Help Toolbar Option Screen Layout MENU OPTION HELP The Help menu option is currently NOT available for use as Help Upon selecting Help selecting About PCPO1 provides the version number of the PC Print in use 1 Depending on which Windows Platform is being used the following instructions may vary A Windows Platform prior to Vista processes as follows Upon clicking Help Index or Help Using Help a message box appears stating Cannot find the C Program Files FISS PCP01 HLP file Do you want to try to find this file yourself Always click NO 2 A second message box appears stating Cannot find the C Program files FISS PC Print PCPO1 HLP file Check that the files exist on the disk If it doesn t reinstall it Click OK No reinstall is required as a help file for PC Print as it does not exist at this time 3 When performing the help as stated above Windows Vista provides a dialog box that presents the message Failed to Launch Help
12. the View menu and as a keyboard sequence CTRL R NOTE The Status Bar at the bottom of the screen displays the total number of claims Page 65 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 PROCESSING PROCEDURES M nfo ajej ole amp Medicare National Standard intermediary Remittance Advice FRE 09 30 00 HOSP PAID 087 26 02 PO BOX 1234 r Cime 19 SAN JUAN PR 00919 NPI ssssssssss TOB 13 Sk ie renra renren renren nenen mn ja we SUBTOTAL TOTAL FOR DILL TYPE BESEBSBESBESSESSBSSSSESSSSESSESSSRSSRSCBSSSCSBSAESSSESSESSESSSESESESSSSRSESSSSESZSSSSESBSESSRSBESSEZSEE CHARGES PAYMENT DATA 0 GO08REIM RATE 1164 66 REPORTED 0 00 DRG AMOUNT 0 00 MSP PRIM PAYER 902 SL NCVD DENIED 0 00 0RG OPER CAP 0 00 PROF COMPONENT O 00 CLAIM ADJS O 008LINE ADJ 0 QU COVERED 0 OO OUTLIER 464 85 PROC CD AMOUNT DAYS VISITS O 00 CAP OUTLIER O COSsT REPT 0 00 CASH DEDUCT 0 008ACO PIONEER VeCOVD UTIL 0 00 BLOOD DEDUCT 0 OO INTEREST 0 NON COVERED 39 75 COINSURANCE 358 18 CONTRACT ADJ O covo Visits 0 00 PAT REFUND 0 00 PER DIEM AMT O NCOV VISITS 0 DO SEQUESTRATN 36 68 NET REIM AMT Figure 52 Bill Summary BS Screen Layout 8 Selecting the BS button brings up the Bill Summary screen The Bill Type Summary is available from the View menu and as a keyboard sequence CTRL B NOTE The Status Bar at the bottom o
13. 0 001 88 38 0 001 BETANCOURT X 1800200716 1 10008011 ol 441 001 l 0 001 0 5101 61 30 0 00 2022180006730XXXX 123456789A 10008011 ol 75 001 0 001 0 001 0 001 366 001 0 00 6 122 10001109082 l l ol 0 001 0 001 96 16 0 001 0 001 0 00 9999999999 HIC CHG HN TOB 13I 1l ol 366 001 0 001 0 001 0 001 208 54 61 30 0 001 Figure 40 All Claims AC Find Dialog Box Screen Layout In the Find dialog box there are options as to which data field to do a find on patient last name medical record number HIC number and the patient control number 1 In the Find What box key in the data to search on 2 Click on the appropriate search field then click OK The application searches for the selection and brings it to the screen for viewing or it brings up the message Search text not found Page 54 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 000161 Task Order HHSM 500 T0003 FIND OPTIONS PeP 021016AA X12 PC Print I Fite Edit View Admin Help el re losfer x alo S S PATIENT NAME PATIENT CNTRL NUMBER FRM DT COST REPTD CHGS DRG NBR Oa aaa OUTLIER AMT REIMB RATE ALLOW REIM INTEREST ICN NUMBER LAIM CLM STATUS NATIONAL PROVIDER ID HIC NUMBER MEDICAL REC NUMBER HIC CHG x TOB xxx l THR DT COVDV NCVD DENIED DRG AMOUNT l INCVDV CLAIM ADJS ICV IN NCV L COVD CHGS DRG O C DEDUCTIBLES COINS AMT NEW
14. 0301 07 04 80048 1 000 51 98 11 70 0305 07 04 85031 1 000 17 33 ce YY 0307 07 04 81000 1 000 16 75 4 37 0324 07 04 71020 R 1 000 43 18 11 62 Figure 29 Print Example A Screen Layout Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016l Task Order HHSM 500 T0003 Document Page Printer CR CR CR Port RSN Printing 021016AA X12 Page 1 Send To OneNote 2010 AMOUNT REMARK CODES 40 9 12 2 31 25 21 16 28 96 38 39 Page 43 PRINTING OPTIONS PRINT EXAMPLE B PeP 02 Af6AA X12 PC Print for Windows File Edit View Admin Help Print Ctrl P S Print Marked Items a fd Intermediary Remittance Advice Print All Items 09 30 01 HOSP Print Se 08 26 02 PO BOX 1234 A nes 27 SAN JUAN PR 00919 Print Preview 138 1 C Users Data 021016AA X12 x PCN 800507288 1 FROM 09 18 01 MRN 0000028317 THRU 09 18 01 ICN 20222808572504 Exit CHARGES PAYMENT DATA DRG 0 510 REIM RATE 52 00 REPORTED 0 00 DRG AMOUNT 0 00 MSP PRIM PAYER 0 00 NCVD DENIED 0 00 DRG OPER CAP 0 00 PROF COMPONENT 0 00 CLAIM ADJS 0 00 LINE ADJ AMT 0 00 ESRD AMOUNT 52 00 COVERED 0 00 OUTLIER 52 00 PROC CD AMOUNT DAYS VISITS 0 00 CAP OUTLIER 5 60 ALLOW REIM 0 COST REPT 0 00 CASH DEDUCT 0 00 SEQUESTRATN 1 COVD UTIL 0 00 BLOOD DEDUCT 0 00 INTEREST 0 NON COVERED 7 41 COINSURANCE 38 99 CONTRACT A
15. 07 04 TES 1 000 51 9 11 70 CR 42 40 29 305 07 04 5031 1 000 17 33 1 37 CE 4 4 95 ial 07 04 1000 1 000 16 75 4 37 CR 42 12 30 344 07 04 71020 F 1 00l 434 16 11 62 CE 2 27 39 4 AC 1 3l 2J 45 21 16 0450 07 04 99201 1 000 35 00 25 55 CR 2 5 25 1 68 7 4a 46 55 0730 07 04 93005 0 0 000 30 80 0 00 cE 17 30 60 CR Correction 1 Deductible Amount 2 Colnmsurance Amount 17 Requested information was not provided or was insufficient incomplete At least one Remark Code must be provid 42 Charges exceed our fee schedule or maximum allowable amount Use CARC 45 45 Charge exceeds fee schedule maximum allowable or contracted legislated fee arrangement Use only with Group C First Revenue Line Headings Loop Segment Data Element REV Loop 2110 SVC Service Payment Information SVCO1 2 when SVCOI 1 is NU National Uniform Billing Committee NUBC Codes DTMO1 is 472 Service HCPCS Loop 2110 SVC Service Payment Information SVCOI1 2 when SVCOI 1 is HC Health Care Common Procedural Coding System HCPCS APC HIPPS Loop 2110 REF Service Identification REFO2 when REFO1 is APC Ambulatory Payment Classification or REFO1 is 1S Ambulatory Patient Group APG Number And Loop 2110 SVC Service Payment Information SVCO1 2 when SVCO1 1 is HP Health Insurance Prospective Payment System HIPPS Skilled Nursing Facility Rate Code MODS Loop 2110 SVC Service Payment Info
16. 2007 00016I Task Order HHSM 500 T0003 PROCESSING PROCEDURES Medicare National Standard Intermediary Remittance Advice FPE 09 30 01 HOSP PAID 08 26 02 PO BOX 1234 CLM 27 SAN JUAN PR 00919 NPI 9999999999 TOB 138 PATIENT BAZAN X gt 4 PCN 800507288 1 HIC 123456789B SVC FROM 09 18 01 MRN 0000028317 CLAIM STAT 22 THRU 09 18 01 ICN 20222808572504 CHARGES PAYMENT DATA DRG 0 510 REIM RATE 52 00 REPORTED 0 00 DRG AMOUNT 0 00 MSP PRIM PAYER 0 00 NCVD DENIED 0 00 DRG OPER CAP 0 00 PROF COMPONENT 0 00 CLAIM ADJS 0 00 LINE ADJ AMT 0 00 ESRD AMOUNT 52 00 COVERED 0 00 OUTLIER 52 00 PROC CD AMOUNT DAYS VISITS 0 00 CAP OUTLIER 5 60 ALLOW REIM 0 COST REPT 0 00 CASH DEDUCT 0 00 SEQUESTRATN 1 COVD UTIL 0 00 BLOOD DEDUCT 0 00 INTEREST 0 NON COVERED 7 41 COINSURANCE 38 99 CONTRACT ADJ 0 COVD VISITS 0 00 PAT REFUND 0 00 PER DIEM AMT 0 NCOV VISITS 0 00 ACO PIONEER 5 60 NET REIM AMT ADJ REASON CODES CR 93 0 REMARK CODES MAO1 Group CARC CODES CR Correction 93 No Claim level Adjustments 4 REV DATE HCPCS APC HIPPS MODS QTY CHARGES ALLOW REIM GC RSN AMOUNT REMARK CODES LICN HCPI SVC Desc 0730 09 18 933005 900099 1 000 52 00 5 60 CR 2 7 41 45 38 99 CR Correction 2 Coinsurance Amount 45 Charge exceeds fee schedule maximum allowable or contracted legislated fee arrangement Use only with Group Codes PR or CO depending upon liability Figure 54 Single Claim SC Screen Layout m 10 Selecting
17. Claim Charge Amount NCVD DENIED Loop 2100 CAS Claim Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when CASO1 Group Code equals CO and CASO2 05 08 11 14 and 17 Reason Code does NOT equal 1 2 3 23 45 59 66 70 89 118 122 AO and A7 and Loop 2110 CAS Service Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when CASOI1 Group Code equals CO and CASO2 05 08 11 14 and 17 Reason Code does NOT equal 1 2 3 23 45 59 66 70 89 118 122 AO and A7 CLAIM ADJS Loop 2100 CAS Claim Adjustment CASO03 06 09 12 15 and 18 Adjustment Amount when CASO1 equals OA and Adjustment Code in CASQ2 05 08 11 14 17 equals A7 COVERED Loop 2100 AMT Claims Supplemental Information sum of AMTO2 when AMTO1 equals AU DAYS VISITS Loop Segment Data Element COST REPT Loop 2000 TS2 Provider Supplemental Summary Information TS212 Total Cost Report Day Count Information TS213 Total Covered Day Count Information TS214 Total Non Covered Day Count Page 83 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Loop Segment Data Element COVD VISITS Loop 2100 QTY Claim Supplemental Information Quantity QTY02 Claim Supplemental Information Quantity when QTYOI equals VS This is the sum of all claims in the LX loop NCOVD VISITS Loop 2100 QTY Claim Supplemental Information Quant
18. Identification REFO2 when REFO1 equals PQ N101 equal PE TS303 Fiscal Period Date Loop 1000A N1 Payer Identification N102 when N101 equals PR Header BPR Financial Information BPR16 Check EFT Date PC Print sets the page PATIENT NAME Loop 2100 NM1 Patient Name NM103 Last Name oe and NM104 First Name Initial PATIENT CNTRL NUMBER Loop 2100 CLP Claim Payment Information A CLPO1 Claim Submitter s Identifier FRM DT Loop 2100 DTM Statement From or To Date MPT lion Claim Date wen Dan eguas 233 Information MIA15 Cost Report Day Count Loop 2100 CLP Claim Payment Information CLPO3 Total Claim Charge Amount Page 69 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Loop 2100 CLP Claim Payment Information CLP11 Diagnosis Related Group DRG Code OUTLIER AMT Loop 2100 AMT Claim Supplemental Information AMT02 when AMTO1 equals ZM PIP Outlier Add on Information MOAOI1 Reimbursement Rate ALLOW REIM Loop 2110 SVC Service Payment Information SVCO03 Line Item Provider Payment Amount this is the sum of all revenue lines INTEREST Loop 2100 AMT Claim Supplemental Information AMTO2 Claim Supplemental Information Amount when AMTO1 equals I Interest Loop 2100 CLP Claim Payment Information CLPO7 Payer Claim Control Number Loop 2100 NM1 Patient Name NM109 Patient Identifier when NM108
19. LAYOUT MAPPING Loop Segment Data Element CLAIM STAT Loop 2100 CLP Claim Payment Information CLPO2 Claim Status Code THRU Loop 2100 DTM Statement From or To Date ee DTM02 when DTMO1 is 233 Claim Statement Period End CLPO7 Claim Payment Control Number CHARGES Loop Segment Data Element REPORTED Loop 2100 CLP Claim Payment Information CLP0O3 Total Claim Charge Amount NCVD DENIED Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 18 when CASO2 05 08 11 14 17 does not equal 1 2 3 23 45 66 70 89 94 118 122 and Loop 2110 CAS Claim Adjustment CASO3 06 09 12 15 18 when CASO2 05 08 11 14 17 does not equal 1 2 3 23 45 66 70 89 94 118 122 CLAIM ADJS Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when CASO1 equals OA and Adjustment Code in CASO2 05 08 11 14 17 equals A7 COVERED Loop 2100 AMT Claim Supplemental Information AMT02 when AMTO1 is AU Coverage Amount DAYS VISITS Loop Segment Data Element COST REPT Loop 2100 MIA Inpatient Adjudication Information MIA15 Total Cost Report Day Count COV UTIL Loop 2100 MIA Inpatient Adjudication Information MIAO1 Total Covered Days or Visits Count NON COVERED Loop 2100 QTY Claim Supplemental Information Quantity QTY02 when QTYO1 equals NE COVD VISITS Loop 2100 QTY Claim Supplemental Information Quantity QTY02 Claim Supplemental Information Quantity when QTY0O1 equals CA
20. N718 NONE M1 M127 M130 M131 M132 M135 M141 M142 M143 M19 M21 M23 M29 M30 M31 M42 M47 M60 MA04 MA27 MA64 MA75 MA76 MA81 MA88 MAS2 MA111 MA112 N3 N4 N26 N28 N29 N40 N42 N80 N102 N146 N170 N175 N178 N179 N186 N191 N197 N202 N204 N205 N206 N214 a od ees 56 N563 N590 N594 714 N715 N716 N717 Figure 28 Business Scenario Dialog Box Screen Layout Page 40 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHHSM 500 2007 00016I Task Order HHSM 500 T0003 PRINTING OPTIONS CHAPTER 6 PRINTING OPTIONS This section provides various options used to print each report PRINTING THE SINGLE CLAIM REPORT 1 The print button on the Tool Bar can be utilized when in the Single Claim format The arrow up and down buttons are available to parse through the claims Refer to example A 2 To print all of the claims in the data file in the single claim format from the menu bar click File then Print All Items All of the claims print in the single claim format Refer to example B 3 While in the single claim and parsing through certain claims can be selected to be printed This process is done by selecting Edit then Mark For Print Refer to example C When Mark For Print is selected a box displays that shows the number s of claim s that has have been selected Refer to example D Continue this process until all claims have been sele
21. NUMBER INCVDV CLAIM ADJS DRG O C COINS AMT PROF COMP LINE ADJ AMT PERDIEM AMT NATIONAL PROVIDER ID HIC CHG x TOB xxx CV LN NCV L COVD CHGS NEW TCH ECT SEQUESTRATN ESRD AMT CONT ADJ AMT NET REIMB l l l l l ACO PIONEER l l BARBERO x 800182689 1 1000704 ol 255 04 0 00 0 510 13 73 0 00 2001940001XxXxx 1123456789A 1000704 ol 139 97 0 00 100 00 0 00 224 24 0 00 i 122 10001079178 ol 0 00 0 00 7 64 0 00 0 00 0 00 9999999999 HIC CHG HN TOB 138 1 ol 224 24 0 00 0 00 0 00 21 16 pS ee 13 0 00 BARBERO x 800182689 1 1000 0 00 0 510 13273 0 00 20221800013 9XXXxXX 123456789A 1000 00 00 0 00 161 621 0 00 2 122 10001079178 7 64 0 00 0 00 0 00 9999999999 HIC CHG HN TOB i13I1 0 00 0 00 67 71 13 73 Find What BAZAN 0 DLIANLY 00 Cancel PatientLastName Medical Record Number C HIC Number C Patient Control Number 0 00 BETANCOURT X 800200716 1 0 510 97 98 0 00 2002230008XXXX 123456789A che 0 00 0 001 366 001 0 00 4 122 10001109082 l l Ol 0 001 0 001 135 91 0 00 0 001 0 00 9999999999 HIC CHG HN TOB 138 11 ol 366 001 0 001 0 001 0 001 132 111 97 98 0 001 BETANCOURT Xx 1800187158 1 10007111 ol 453 52 l 0 001 0 510 88 38 0 00 202218000672XXXXX 123456789A 10007111 ol 365 14 0 001 0 001 0 001 88 38 0 00 5 122 10000044544 l l ol 0 001 0 001 0 001 0 001 0 001 0 00 9999999999 HIC CHG HN TOB 13I 1l 0l 395 771 0 001 0 001 0 00
22. Order HHSM 500 T0003 FIND OPTIONS PeP 0210164843 PC Print for Window Edit View Admin Help Mark for Print Ctrl M EA Ctrl F CNTRL NUMBER FRM DT COST REPTD CHGS DRG NBR OUTLIER AMT REIMB RATE ALLOW REIM INTEREST THR DT COVDV NCVD DENIED DRG AMOUNT DEDUCTIBLES MSP PRI PAY PROC CD AMT PAT REFUND Find Next Ctrl N NCVDV CLAIM ADJS DRG O C COINS AMT PROF COMP LINE ADJ AMT PERDIEM AMT ICV LN NCV LICOVD CHGS NEW TCH ECT SEQUESTRATN ESRD AMT CONT ADJ AMT NET REIMB 8 amp Find CARC RARC Ctrl U BETANCOURT x Figure 39 All Claims Find AC Button Screen Layout ACO PIONEER 1 Access the all claims screen by clicking the AC button 2 Click on Edit in the pull down menu click on Find 0 00 NOTE If the Find returns more than one claim with the same search criteria then the Find Next is available Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHHSM 500 2007 00016I Task Order HHSM 500 T0003 Page 53 BARBERO x 800182689 1 10007041 ol 255 04 l 0 001 0 5101 13 73 0 00 2001940001xXxxx 123456789A 10007041 ol 139 97 0 001 100 001 0 001 224 24 0 00 1 122 10001079178 l l ol 0 00 0 00 7 64 0 00 0 001 0 00 9999999999 HIC CHG HN TOB 138 T ol 224 24 0 00 0 00 0 00 21 16 13 73 0 00 BARBERO xX 800182689 1 10007041 ol 255 04 l 0 001 0 5101 13 73 0 00 202218000139XXXXX 123456789A 1000704 ol
23. R AMT B6 SYC Ho 99201 DTM 000704 CAS CR AMT B6 SYC Ho 93005 DEES Tale nA 5 Figure 23 GCR Group CARC RARC Button Screen Layout The GCR GROUP CARC RARC button displays a listing of Group codes and CARC and RARC codes associated effective dates termination dates and descriptions Page 35 Use or disclosure of the data contained on this sheet is subject to restrictions of contract H HHSM 500 2007 00016I Task Order HHSM 500 T0003 TOOL BAR OPTIONS re gt CR8140 test X12 PC Print for Windows File Edit View Admin Help xj a Ps Bs ec feo a amp 1 1 1995 Term Date CARC Description Amount 1 1 1995 Coinsurance Amount 1 1 1995 Co payment Amount 1 1 1995 The procedure code is inconsistent with the modifier used or a required modifier is missing No 1 1 1995 The procedure code bill type is inconsistent with the place of service Note Refer to the 835 1 1 1995 The procedure revenue code is inconsistent with the patient s age Note Refer to the 835 Healt 1 1 1995 The procedure revenue code is inconsistent with the patient s gender Note Refer to the 835 He 1 1 1995 The procedure code is inconsistent with the provider type specialty taxonomy Note Refer to 1 1 1995 The diagnosis is inconsistent with the patient s age Note Refer to the 835 Healthcare Policy 1 1 1995 The diagnosis is inconsistent with the patient s gender Note Refer to the 835 Healthcare Poli 1 1 1995 The diagnosis is inconsistent with the
24. REFUND Loop 2100 CAS Claim Adjustment CAS03 Adjustment Amount CAS06 Adjustment Amount CASO9 Adjustment Amount CAS12 Adjustment Amount CAS15 Adjustment Amount CAS18 Adjustment Amount when CAS02 is AQ PROC CD AMOUNT Loop 2100 MOA Outpatient Adjudication Information MOAO02 Claim HCPCS Payable Amount ALLOW REIM Loop 2110 SVC Service Payment Information SVCO03 Line Item Provider Payment Amount this is the sum of all revenue lines SEQUESTRATN Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 118 and group code CO and CARC 223 and Loop 2110 CAS Service Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 118 and group code CO and CARC 223 INTEREST Loop 2100 AMT Claim Supplemental Information AMTO2 Claim Supplemental information Amount when AMTO1 equals I Page 99 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Loop Segment Data Element CONTRACT ADJ Loop 2100 CAS Claim Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 45 and Loop 2110 CAS Service Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 45 NET R
25. SVCO1 2 equals 652 this field value is equal to SVCO5 Loop 2110 SVC Service Payment Information when SVCOI 1 equals NU and SVCOI 2 equals 656 this field value is equal to SVCO5 Loop 2110 SVC Service Payment Information when SVCOI 1 equals NU and SVCOI 2 equals 655 this field value is equal to SVCO5 Loop 2110 SVC Service Payment Information when SVCOI 1 equals HC and SVCO1 2 equals 657 this field value is equal to SVCOS5 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 Page 98 SYSTEM LAYOUT MAPPING Loop Segment Data Element HSP OTH Loop 2110 SVC Service Payment Information when SVCOI 1 equals HC and SVCO1 2 equals 659 this field value is equal to SVCOS5 COINSURANCE Loop 2100 CAS Claim Adjustment CASO3 Adjustment Amount CASO06 Adjustment Amount CAS09 Adjustment Amount CAS12 Adjustment Amount CAS15 Adjustment Amount CAS18 Adjustment Amount when CAS02 is 2 3 and 122 MSP PRIM PAYER Loop 2100 CAS Claim Adjustment CASO3 Adjustment Amount CASO06 Adjustment Amount CAS09 Adjustment Amount CAS12 Adjustment Amount CAS15 Adjustment Amount CAS18 Adjustment Amount when CAS02 is 23 CASH DEDUCT Loop 2100 CAS Claim Adjustment CAS03 Adjustment Amount CASO06 Adjustment Amount CASO09 Adjustment Amount CAS12 Adjustment Amount CAS15 Adjustment Amount CAS18 Adjustment Amount when CASO is 1 PAT
26. Single Claim screens Each are addressed separately Page 48 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 FIND OPTIONS SINGLE CLAIM FIND Mark av Ctrl M tandard Intermediary Remittance Advice Find Ctrl F FPE 09 30 01 HOSP Find Next Ctrl N PAID 08 26 02 PO BOX 1234 Find CARC RARC Ctrl U CLM 30 SAN JUAN PR 00919 NPI TOB 138 PATIENT DE X NYDIA S PCN 800489324 1 HIC 123456789A SVC FROM 08 24 01 MRN 00000058 CLAIM STAT 22 THRU 08 24 01 ICN 20222808413904 CHARGES PAYMENT DATA DRG 0 510 REIM RATE 95 00 REPORTED 0 00 DRG AMOUNT 0 00 MSP PRIM PAYER 0 00 NCVD DENIED 0 00 DRG OPER CAP 0 00 PROF COMPONENT 0 00 CLAIM ADJS 0 00 LINE ADJ AMT 0 00 ESRD AMOUNT 95 00 COVERED 0 00 OUTLIER 95 00 PROC CD AMOUNT DAYS VISITS 0 00 CAP OUTLIER 26 84 ALLOW REIM 0 COST REPT 0 00 CASH DEDUCT 0 00 SEQUESTRATN 1 COVD UTIL 0 00 BLOOD DEDUCT 0 00 INTEREST 0 NON COVERED 6 71 COINSURANCE 61 45 CONTRACT ADJ 0 COVD VISITS 0 00 PAT REFUND 0 00 PER DIEM AMT 0 NCOV VISITS 0 00 ACO PIONEER 26 84 NET REIM AMT ADJ REASON CODES CR 93 0 E REMARK CODES MA01 Group CARC CODES CR Correction 93 No Claim level Adjustments 4 REV DATE HCPCS APC HIPPS MODS QTY CHARGES ALLOW REIM GC RSN AMOUNT REMARK CODES 4 LICN HCPI SVC Desc 0510 08 24 99201 00600 1 000 95 00 26 84 CR 2 6 71 45 61 45
27. TCH ECT SEQUESTRATN ESRD AMT ACO PIONEER PROF COMP IMSP PRI PAY PROC CD AMT LINE ADJ AMT PERDIEM AMT CONT ADJ AMT NET REIMB PAT REFUND 9999999999 Figure 41 All Claims AC Search Results Screen Layout ALVAREZ X x 800392183 1 1010420 0 127 70 l 0 00 0 510 0 00 0 00 20222800359902 123456789A 1010420 0 127 70 0 00 0 00 0 00 0 00 0 00 26 4 10001135440 l 0l 0 00 0 00 0 00 0 00 0 00 0 00 9999999999 HIC CHG HN TOB 130 0l 0l 0 00 0 00 0 00 0 00 0 00 0 00 0 00 BETANCOURT X A 800266970 1 10010311 ol 447 701 l 0 001 0 510 36 71 0 00 20219100215602 123456789A 10010311 ol 188 011 0 001 0 001 0 00 386 44 0 00 28 I2 10000596819 ol 0 001 0 001 0 001 0 001 0 001 0 00 9999999999 HIC CHG HN TOB 131 1 ol 447 701 0 001 0 001 0 00 222 98 36 71 0 001 CENTENO x 1800468835 1 10108021 ol 156 21 l 0 001 0 5101 28 92 0 00 20221800095802 123456789A 10108021 ol 127 29 0 00 0 001 0 001 28 92 0 00 29 11 10000022716 ol 0 001 0 001 0 001 0 001 0 001 0 00 9999999999 HIC CHG HN TOB 131 1 ol 156 21 0 00 0 001 0 001 0 001 28 92 0 001 DE X N S 800489324 1 1010824 ol 95 001 l 0 001 0 5101 26 84 0 00 20222808413904 123456789A 1010824 ol 0 00 0 00 0 00 0 00 95 001 0 00 30 122 10000005831 ol 0 001 0 001 6 711 0 001 0 001 0 00 9999999999 HIC CHG HN TOB 138 1 0l 95 001 0 001 0 001 0 001 61 45 26 84 0 001 DEJESUS X X 800454727 1 10107111 ol 287 18
28. YYMMDDX X12 example 981128A X12 remittance advice date 1 Copy or transfer from the system remittance advice mailbox an 835 X12 File then place it in a folder that can be accessed by the PC Print Application PeP Pcp01 PC Print for Windoys si mes File Edit View Admigr Help Pd el leeds ale 3 a For Hel ress Fl CAP Figure 46 Blank SL Segment List Screen Layout 2 Upon double clicking the PC Print icon this screen displays and the SL button is selected Before any claim information displays a data file needs to be selected Page 60 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 PROCESSING PROCEDURES Seg 0 Organize New folder ak Documents library eB ee Data Name Date modifi 3 12 2014 1 2 17 2014 9 CR8140 test X12 021016A X12 j File name v_ All Files z For Hel ress F1 Figure 47 X12 Button Open Dialog Box Screen Layout 1 of 2 3 Clicking on the X12 button brings up the Open dialog box Select the Data folder for viewing the data files then click Open Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016l Task Order HHSM 500 T0003 Page 61 PROCESSING PROCEDURES PeP Pcp01 PC Print for Windows Aamin Meip Qe 35 gt Libraries Documents
29. and denied charges and claim level adjustments as appropriate For outpatient claims all adjustments are at the line level with the exception of Outlier it is reported at claim level The 5010 version reflects the Provider Summary Report screen and report a new change for this screen report is that it includes the Payer Business and Technical Contact Information The 5010 version also has modified the Single Claim Report screen and report to reflect additional service line information the Line Item Control Number the Service Line Description for Not Otherwise Classified and the Health Care Policy Indicator The other changes that were implemented for these reports as well as the Bill Summary and the All Claims reports were minimal such as the removal of fields no longer being used Page 11 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 GETTING STARTED PRINTER SETUP Edit View Admin Help Print Ctrl P 4 ES op Print Marked Items A Print All Items Print Setup Print Preview Recent File Exit Change the printer and printing options CAP Figure 1 Printer Setup Toolbar Option Screen Layout 1 To set up for printing select File from the title bar 2 Then select Print Setup from the pull down menu Page 12 Use or disclosure of the data contained on this sheet is subject to restrictions of contra
30. equals HN Loop 2100 DTM Statement From or To Date DTM0O2 Claim Date when DTMO1 equals 233 Loop 2100 MIA Inpatient Adjudication Information MIAO1 Covered Days or Visits Count NCVD DENIED Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when adjustment code in CASO2 05 08 11 14 17 equals any adjustment code except 1 2 3 23 45 66 70 89 94 118 122 and Loop 2110 CAS Service Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CAS02 05 08 11 14 17 equals any adjustment code except 1 2 3 23 45 66 70 89 94 118 122 Information MIA04 Claim DRG Amount DEDUCTIBLE Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when adjustment code in CASO2 05 08 11 14 17 equals 1 and or 66 and Loop 2110 CAS Service Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals adjustment codes and 66 Page 70 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Loop Segment Data Element Loop 2100 CAS Claim Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 MSP PRI PAY equals 23 and Loop 2110 CAS Service Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Co
31. existing Question Problem process The PC Print environment has limitations on the size of a data file used It has been determined that a data file with greater than approximately 80 000 segments does not appropriately process in this PC Print Software FISS does not recommend using files greater than 80 000 segments Further in this document segments are covered Page 7 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 GLOSSARY CHAPTER 2 GLOSSARY This section provides a brief listing of acronyms used in the PC Print software This is presented at the beginning of the manual to assist in understanding TABLE OF ACRONYMS All Claims Report Screen ANSI American National Standards Institute Single Claim Report Screen Page 8 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 GETTING STARTED CHAPTER 3 GETTING STARTED This section provides instructions for getting started using PC Print INSTALLATION SOFTWARE PC Print has been packaged using Microsoft Visual Studio 2013 Windows Installer This software allows all files needed to install the application to be easily packaged and then installed on the user s machine Effective with PC Print version 4 3 0 released in April 2014 PC Print is not compatible with Microsoft Window
32. is available for parsing through the data file NOTE In the Status Bar at the bottom of the screen it states the total number of claims and total number of segments in the data file NOTE The PC Print environment has limitations on the size of a data file used It has been determined that a data file with greater than approximately 80 000 segments does not appropriately process in this PC Print Software FISS does not recommend using files greater than 80 000 segments Further in this document segments are covered Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 Page 64 PROCESSING PROCEDURES PcP 021016AA X12 PC Print for Wing File Edit View Admin Hey z e Ej eee alo S 2 Medicare National Standard Remittance Advice HOSP PO BOX 1234 r SAN JUAN PR 00919 NPI 9999999999 CHECK EFT NUMBER 0000026805 PAYMENT SUMMARY PAYMENT TOTAL 606551 42 BILLING CYCLE 08 26 02 TOTAL CLAIMS 2308 TOTAL PIP CLAIMS 0 Payer Business Contact Information Telephone Telephone Extension Facsimile Electronic Mail Payer Technical Contact Information Telephone Facsimile Electronic Mail Uniform Resource Locator URL Payer Web Site Uniform Resource Locator URL Figure 51 Provider Summary PS Screen Layout 7 Selecting the PS button brings up the Provider Summary screen The Provider Summary is available from
33. l 0 001 0 5101 72 881 0 00 20121300077402 123456789A 10107111 ol 62 62 0 001 0 001 0 001 266 93 0 00 31 122 10000531702 ol 0 001 0 001 36 48 0 001 0 001 0 00 HIC CHG HN TOB 138 1 ol 287 18 0 001 0 001 0 001 115 20 72 88 The search found the requested patient and highlighted the claim By clicking on the highlighted claim and then the SC button the application displays the single claim format of that claim Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016l Task Order HHSM 500 T0003 Page 55 FIND OPTIONS PeP 021016AA X12 PC Print fc dow s i File Edit View Admin Help xe sL PS Bs Ac sc Medicare National Standard Intermediary Remittance Advice FPE 09 30 01 HOSP PAID 08 26 02 PO BOX 1234 SAN JUAN PR 00919 NPT 9999999999 PATIENT BAZAN X PCN 800507288 1 HIC 123456789B SVC FROM 09 18 01 MRN 0000028317 CLAIM STAT 22 THRU 09 18 01 ICN 20222808572504 PAYMENT DATA 0 510 REIM RATE 00 MSP PRIM PAYER 00 PROF COMPONENT 00 ESRD AMOUNT 00 PROC CD AMOUNT 6 0 ALLOW REIM OO SEQUESTRATN 00O INTEREST 99 CONTRACT ADJ 00 PER DIEM AMT 60 NET REIM AMT 52 00 REPORTED 0 00 NCVD DENIED 0 00 CLAIM ADJS 52 00 COVERED DAYS VISITS 0 COST REPT 00 DRG OPER CAP 00 LINE ADJ AMT 0O OUTLIER 00 CAP OUTLIER 00 CASH DEDUCT 00 BLOOD DEDUCT 41 COINSURANCE 00 PAT REFUND 00 ACO PIO
34. on the Single Claim screen and report NOTE Up down arrow buttons are available to parse through the claims forward and backward The screen also has a split screen display The upper portion presents the claim level data and the lower portion displays the line item detail of the claim Both sections of the screen have up down and right left movement ability in order to view all data available Page 33 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 TOOL BAR OPTIONS PRINTER BUTTON PeP 021016AA X12 PC Print for Windows File Edit View Admin Help 7 22 a slsjafe ele amp cl Medicare National Standard Intermediary Remittance Advice FPE 09 30 00 HOSP PAID 08 26 02 PO BOX 1234 7 CLM 1 SAN JUAN PR 00919 NPI 9999999999 TOB 138 PATIENT BARBERO PCN 800182689 1 HIC 123456789A SVC FROM 07 04 00 MRN 0001079178 CLAIM STAT 22 THRU 07 04 00 ICN 2001940001XxXxx CHARGES PAYMENT DATA DE 255 04 REPORTED 0 00 DRG AMO 139 97 NCVD DENIED 0 00 DRG OPER 0 00 CLAIM ADJS 0 00 LINE ADJ A Printing 224 24 COVERED 0 00 OUTLIER DAYS VISITS 0 00 CAP OUTLIE Document 021016AA X12 O0 COST REPT 100 00 CASH DEDUG Page Pagel i covD UTIL 0 00 BLOOD DEDU Printer Send To OneNote 2010 0 NON COVERED 7 64 COINSURANG 0 COVD VISITS 0 00 PAT REFUND Port nul O NCOV VISITS 0 00 ACO PIONEE ADJ REASON CODE
35. p i Arrange by Folder 7 Data Name Date modifi Documents library CR8140 test X12 3 12 2014 1 021016A x12 2 17 2014 9 I b File name 021016A X12 v All Files z For Help press F1 CAP Figure 13 Data File Dialog Box Screen Layout 1 Select a data file and click Open 2 If the data file selected is not the correct one click the X12 button again and make another selection as stated above NOTE It automatically defaults to the data folder within PC Print Page 25 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016l Task Order HHSM 500 T0003 TOOL BAR OPTIONS Data File Segments Deblocked Segments mi x PeP 021016AA 112 PC Print for Window File Edit Viw Admin Help me E Ps BS ac sc al c GS AH GS 267 a ST 267001 BPR 020826 TRN 9000000468 REF 44 01 DTM 020823 N1 HOSP N3 N3 N4 N4 LX 000913 TS3 400016 CLP 800182689 1 CAS NM1 BARBERO MOA MADI REF 0001079178 DTM 000704 DTM 000704 AMT AU QTY CA SVC He s0046 DTM 000704 CAS CR AMT B6 SVC HC 85031 DTM 000704 CAS CR AMT B6 SVC HC 81000 DTM 000704 CAS CR AMT B6 SVC HC 71020 DTM 000704 CAS CR REF R AMT B6 SYC He 99201 DTM 000704 CAS CR AMT B6 z v Total claims 2308 Total seqments 78145 Figure 14 Data File Segments and Deblocked Segments Screen Layout Once the data fi
36. procedure code 1 1 1997 Alert THE YNDO TGode supmiccea Lor cnis Service was cCranslacea to a HCPCS code for processing but please 1 1 1997 Total payment reduced due to overlap of tests billed 1 1 1997 10 16 2003 Did not enter full 8 digit date MM DD CCYY 1 1 1997 The HPSA Physician Scarcity bonus can only be paid on the professional component of this service Rebill 1 1 1997 This service does not qualify for a HPSA Physician Scarcity bonus payment 1 1 1997 Multiple automated multichannel tests performed on the same day combined for payment RARC Code Search Display Full RARC Description Group Codes vr co Contractual Adjustment PI Payor Initiated Reductions CR Correction no longer used Figure 25 GCR Display Full CARC RARC Description Buttons Screen Layout The GCR button provides a Display Full CARC Description and Display Full RARC Description buttons to provide the full description of a given CARC RARC that is too long to display on the screen 1 Select the CARC or RARC code 2 Click on the Display Full CARC Description or Display Full RARC Description box A Description dialog box displays with the full description of the selected CARC or RARC code Page 37 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 TOOL BAR OPTIONS BUS SCE BUTTON E PeP PcpO1 PC Print for Windows oS ms File Edit Vie
37. restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 FISS PC Print User Guide Printing the Provider Summary Report 42 Printing the Bill Summary Report 42 Print Example A 43 Print Example C 45 Print Example D 46 Print Example E 47 Chapter 7 2 2222222 nner e nee e nnn n nnn n nnn n ene n ee eeee 48 Find Options 22 2 2 MMMM 48 Find Options General 48 Single Claim Find 49 All Claims Find 52 Find carc rarc 58 Chapter 8 2 22222222 eee e een n nnn n nnn n nnn n eee n eee e eee 60 Processing Procedures 22220222000000 60 Loading Ne
38. the SC Single Claim button accesses the single claim Single Claim is available from the View menu and as a keyboard sequence CTRL S NOTE The Status Bar at the bottom of the screen displays the total number of claims Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016l1 Task Order HHSM 500 T0003 Page 68 SYSTEM LAYOUT MAPPING CHAPTER 9 This section provides the information necessary to see and understand the mapping for each report PROVIDER NPI PROVIDER NAME FISCAL YEAR END FI MAC NAME PAID DATE PAGE PATIENT NAME PATIENT CNTRL NUMBER FRM DATE COST REPTD CHGS DRG NBR OUTLIER AMT REIMB RATE ALLOW REIM INTEREST ICN NUMBER HIC NUMBER THR DATE COVDV NCVD DENIED DRG AMOUNT DEDUCTABLE MSP PRI PAY PROC CD AMT PAT REFUND CLAIM CLAIM STATUS MEDICAL REC NUMBER NCVDV CLAIM ADJS DRG O C COIN AMT PROF COMP LINE ADJ AMT PER DIEM AMT NATIONAL PROVIDER ID HIC CHG X TOB XXX CV LN NCV1 COVD CHGS NEW TECH ECT SEQUESTRATN ESRD AMT CONT ADJ AMT NET REIMB ACO PIONEER Figure 55 Mapping 5010 835 to All Claims Report Header Layout Loop Segment Data Element PROVIDER NUMBER NPI Loop 1O00B N1 Payee Identification N104 when N103 equals XX else Loop 1OOOB REF Payee Additional
39. the claims in a 25 claim count increment within the transmission in an abbreviated format The All Claims display allows for left and right scrolling in order to view the entire Header and Detail of each claim displayed A Summary Subtotal Total Bill Type Bill Summary displays the sub totals for each payment category per provider fiscal year and the total remittance found within the Single Claim display accumulated and displayed by TOB Type of Bill A Payment Summary Provider Summary identifies the total paid to the Provider for this billing cycle transmission It also indicates the total claims within the billing cycle transmission Non claim payment adjustments are displayed when applicable These adjustments allow for Provider payments when claims are not present for example Periodic Interim Payments Cost Report Settlements etc The adjustments also allow for various other financial transactions required between Fiscal Intermediaries and Providers The PC Print program allows the end user to view or print all of the above displays These displays can be done selectively in all situations TECHNICAL SUPPORT Within the Standard System Maintainer Fiscal Intermediary community designated local Fiscal Intermediary support personnel should be contacted for technical support Updates are distributed through established channels COMMENTS The Standard System Maintainer receives requests for enhancements and corrections through the
40. then click OK Page 23 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 TOOL BAR OPTIONS CHAPTER 5 TOOL BAR OPTIONS This section focuses on explaining all the options that are available on the Tool Bar through PC Print and what they are used for X12 BUTTON File Edit View Admin Help Organize 7 New folder I e A ak Documents library Aane E Data Name Date oe CR8140 test X12 021016A X12 File name AII Files 4 roe ts ct For Hel ress F1 CAP Figure 12 X12 Button Open Data File Dialog Box Screen Layout Clicking on the X12 button brings up the Open dialog box Select Data file for viewing the data files select one then click the Open button 3 Another option to select a Data file is the File name Once a file has been viewed it is available to be selected from the Drop Down Box For Data files to show up in the Drop Down Box they must be named in the following format YMMDD X12 NO m Page 24 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 TOOL BAR OPTIONS PeP Pcp01 PC Print for Windows File Edit View Admin Help x xef fs Ps es ac sc Se lll SC Gad gt Libraries Documents gt Data Search Data p Organize v New folder
41. when AMTOI equals AU Coverage Amount NEW TECH ECT Loop 2100 AMT Claim Supplemental Information AMTO2 Claim Supplemental Information Amount when AMTO1 equals ZL New Tech Add On SEQUESTRATN Loop 2100 CAS Claim Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 118 and group code CO and CARC 223 and Loop 2110 CAS Service Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 118 and group code CO and CARC 223 Page 72 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Loop Segment Data Element ACO PIONEER Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 118 and group code CO and CARC 132 and Loop 2110 CAS Service Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 118 and group code CO and CARC 132 ESRD AMT Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 118 and Loop 2110 CAS Service Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO02 05 08 11 14 17 equals 118 CONT ADJ AMT Loop 2100 CAS Claim Adjustmen
42. 0 COVD VISITS O NCOV VISITS CLM 27 SAN JUAN PR 00919 SVC FROM 09 18 01 THRU 09 18 01 PAYMENT DATA DRS 0 00 DRG AMOUNT 0 00 DRG OPER CAP 0 00 LINE ADJ AMT 0 00 OUTLIER 0 00 CAP OUTLIER 0 00 CASH DEDUCT 0 00 BLOOD DEDUCT 7 41 COINSURANCE 0 00 PAT REFUND PCN 800507288 1 MRN 0000028317 ICN 20222808572504 A Claim marked to print gt Marked claims 27 m REMARK CODES MA01 Group CARC CODES CR Correction ADJ REASON CODES CR 93 0 93 No Claim level Adjustments 2 4 p REV DATE HCPCS APC HIPPS MODS QTY CHARGES ALLOW REIM GC RSN AMOUNT REMARK CODES 4 LICN HCPI SVC Desc 0730 09 18 93005 00099 1 000 52 00 5 60 CR 2 7 41 45 38 99 CR Correction 2 Coinsurance Amount 45 Charge exceeds fee schedule maximum allowable or contracted legislated fee arrangement Use only with Group Codes PR or CO depending upon liability Figure 32 Print Example D Page 46 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016l Task Order HHSM 500 T0003 PRINTING OPTIONS PRINT EXAMPLE E PC Print for Windows Edit View Admin Help Print 4 Ctrl P amp Print Marked Items d Intermediary Remittance Advice Print All Items 09 30 01 HOSP ae 7 08 26 02 PO BOX 1234 rint Setup 27 SAN JUAN PR 00919 Print Preview 138 1 CAUsers Data 021016AA X12 TT a O a ee Exit FROM 09 18 01 MRN 0000028317 THRU 09 18 01 ICN 2022
43. 0 NET REIM AMT ADJ REASON CODES CR 93 0 REMARK CODES MAOl Group CARC CODES CR Correction 93 No Claim level Adjustments RARC CODES MAOL MAO Alert If you do not agree with what we approved for these services ie our decision LO DE 1e eligi received this notice ABC HIPPS H REY DATE HCPCS MODS OTY LICH CPI S YC Desc 1730 03 18 93005 00055 1 000 2 Colnsurance Amount 45 Charge exceeds fee schedule maximum allowable To make sure that that did not process your initial claim to conduct the appeal for an appeal unless you have a good we are fair te we require anc ee Hot within 120 days n for being late you aE tH you must write to us ro on L ee CHARGES ALLOW REIM GC RSN AMOUNT REMARK CODES 52 00 5 60 CR 2 7 41 45 38 99 or contracted legislated fee arrangement Use only with Group C Figure 56 Mapping 5010 835 to Single Claim Report Layout Loop Segment Data Element Page 74 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Field PROVIDER NAME Loop Segment Data Element Loop 1000B N1 Payee Identification N102 Payee Name Loop 2000 TS3 Provider Summary Information T S303 Fiscal Period Date Loop 1000A N1 Payer Identification N102 Payer Name Loop 1000B N3 Payee Address N301 Payee Address Line Header BPR Financial Information BPR16 Check EFT Date Loop 1
44. 0 TOB 851 PATIENT HT oy d i E ETAT CLAIM THRU 07 04 00 T onni ozrgcona PCN dUULD4Z609 L LI RT gand ATIG HAN La Le 31 rm TCH 3900194 Ti LCN AUWLL 0 0 ULAR IARGES PAYMENT DATA DRG 255 04 REPORTED He UNTERE AMOUNT 135 97 NCVD DENIED 0 00 DRG OPER CAP O Q00 CLAIM ADJS 9 00 LINE ADJ AMT 224 24 COVERED 0 00 OUTLIER DAYS VISITS 0 00 CAP OUTLIER O CoO3ST REPT 100 00 CASH DEDUCT 1 CovD UTIL 0 00 BLOOD DEDUCT O NON COVERED T 64 COINSURANCE O CovVD VISITS 0 00 PAT REFUND U NHCOVY VISITS 0 00 AcO PIONEER ADJ REASON CODES CR 93 i REMARK CODES MAOL Group CARC CODES CR Correction 3 No Claim level Adjustments RARC CODES MAO 1 MAO Alert If you do not agree with what we approv our decision Te make sure that we are fair that did not process your initial claim to co to be eligible for an appeal you must write t received this notice unless you have a good O 5L0 REIM RATE 0 00 MSP PRIM PAYEI 0 00 PROF COMPONEN 0 00 ESRD AMOUNT 2724 24 PRoc CD AMOUN 13 73 ALLOW REIM B00 BE SUES TE aeN Tf L a LAE FAT CONTRACT PER DIEM HET REIM ADJ AMT AMT lt D tal ga Ca 2 For these services yo you We require another ct the appeal dHoweve me aay DER 7 50 E ef s within lzU days of t a on for being late Tr zr rane aoa oToo Lear rrr REY DATE HCPCS APC HIPPS DS Ld T TT Dany LICH HCPI T Th ovC Desc
45. 00 LINE ADJ AMT 0 00 ESRD AMOUNT 52 00 COVERED 0 00 OUTLIER 52 00 PROC CD AMOUNT DAYS VISITS 0 00 CAP OUTLIER 5 60 ALLOW REIM 0 COST REPT 0 00 CASH DEDUCT 0 00 SEQUESTRATN 1 COVD UTIL 0 00 BLOOD DEDUCT 0 00 INTEREST 0 NON COVERED 7 41 COINSURANCE 38 99 CONTRACT ADJ 0 COVD VISITS 0 00 PAT REFUND 0 00 PER DIEM AMT O0 NCOV VISITS 0 00 ACO PIONEER 5 60 NET REIM AMT ADJ REASON CODES CR 93 0 REMARK CODES MAOi Group CARC CODES CR Correction 93 No Claim level Adjustments 4 REV DATE HCPCS APC HIPPS MODS QTY CHARGES ALLOW REIM GC RSN AMOUNT REMARK CODES LICN HCPI SVC Desc 0730 09 18 93005 00099 1 000 52 00 5 60 CR 2 7 41 45 38 99 CR Correction 2 Coinsurance Amount 45 Charge exceeds fee schedule maximum allowable or contracted legislated fee arrangement Use only with Group Codes PR or CO depending upon liability 4 Figure 43 SC Single Claim Screen Layout In this application is the capability to toggle between the Single Claim screen and the All Claims screen Ifin the Single Claim view and the AC button is clicked when the All Claim screen comes up the Single Claim is highlighted in the All Claim view Use or disclosure of the data contained on this sheet is subject to restrictions of contract H HHSM 500 2007 00016I Task Order HHSM 500 T0003 Page 57 FIND OPTIONS FIND CARC RARC PeP 0210 File Edit View Admin Help Mark for Print Ctrl M al cal Find Ctrl F Find Next
46. 000A N3 Payer Address N301 Payer Address Line Loop 1000B N4 Payee City State Zip Code N401 City N402 State N403 Zip Code CLM INTERMEDIARY Loop 1O00A N4 Payer City State Zip Code N401 CITY ST ZIP City N401 State N403 Zip Code NPI Loop 1O00B N1 Payee Identification N104 Payee Identification Code when N103 equals XX else Loop 1000B REF Payee Additional Identification REFO2 when REFOI equals PQ TOB Loop 2100 CLP Claim Payment Information CLP08 Facility Type Code and CLP09 Claim Frequency Code Coordination of Benefits Carrier Name ID Code Loop 2100 NM1 Crossover Carrier Name NM109 Coordination of Benefits Carrier Identifier when NM108 is PP Payor Identification Last Name NM104 Patient First Name Initial PCN Loop 2100 CLP Claim Payment Information CLPO1 Patient Control Number HIC Loop 2100 NM1 Patient Name NM109 Patient identifier when NM108 is HN Health Insurance Claim HIC Number Loop 2100 DTM Statement From or To Date DTM02 when DTMO0O1 is 232 Claim Statement Period Start MRN Loop 2100 REF Other Claim Related Identification REF02 when REFO1 is EA Medical Record PT I 7 INTERMEDIARY NAME PAYEE ADDRESS PAID INTERMEDIARY ADDRESS PROVIDER CITY ST ZIP SVC FROM Identification Number Page 75 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM
47. 00B N4 Payee City State Zip Code N401 City N402 State N403 Zip Code CLM PC Print Assigned INTERMEDIARY Loop 10004A N4 Payer City State Zip Code N401 CITY ST ZIP City N401 State N403 Zip Code NPI Loop 1000B N1 Payee Identification N104 Payee Identification Code when N103 equals XX else Loop 1000B REF Payee Additional Identification REFO2 when REFOI equals PQ TOB Loop 2100 CLP Claim Payment Information CLP08 Facility Type Code and CLP09 Claim Frequency Code Coordination of Benefits Carrier Name ID CODE Loop 2100 NM1 Crossover Carrier Name NM109 Coordination of Benefits Carrier Identifier when NM108 is PP Payor Identification Loop 2100 NM1 Patient Name NM103 Patient Last Name NM104 Patient First Name and NM105 Patient Middle Name or Initial CLPO1 Patient Control Number HIC Loop 2100 NM1 Patient Name NM109 Patient identifier when NM 108 is HN Health Insurance Claim HIC Number PATIENT SVC FROM Loop 2100 DTM Statement From or To Date DTMO02 when DTMO01 is 232 Claim Statement Period Start Page 96 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Loop Segment Data Element Loop 2100 REF Other Claim Related Identification REFO2 when REFO1 is EA Medical Record Identification Number CLAIM STAT Loop 2100 CLP Claim Payment In
48. 02 is 118 PROC CD AMOUNT Loop 2100 MOA Outpatient Adjudication Information MOAO02 Claim HCPCS Payable Amount ALLOW REIM Loop 2110 SVC Service Payment Information SVC03 Line Item Provider Payment Amount this is the sum of all revenue lines SEQUESTRATN Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 118 and group code CO and CARC 223 and Loop 2110 CAS Service Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 118 and group code CO and CARC 223 INTEREST Loop 2100 AMT Claim Supplemental Information AMTO2 Claim Supplemental information Amount when AMTO1 equals I Page 78 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Loop Segment Data Element CONTRACT ADJ Loop 2100 CAS Claim Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 45 and 59 and Loop 2110 CAS Service Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CAS02 05 08 11 14 17 equals 45 and 59 PER DIEM AMT Loop 2100 AMT Claim Supplemental Information AMTO2 Claim Supplemental information Amount when AMTO1 equals DY NET REIM AMT Loop 2100 CLP Claim Payment Information C
49. 03 MENU BAR OPTIONS EDIT OPTION PeP Pcp01 PC Print for Window File Edit View Admin Help ma Mark for Print Ctrl M 8 c Find Ctrl F Find Next Ctrl N Find CARC RARC Ctrl U Figure 5 Edit Toolbar Option Screen Layout MENU OPTION EDIT 1 The Edit option offers a Mark for Print Find Find Next and Find CARC RARC e Mark for Print is available for use on the All Claims and Single Claims reports e The Find Next becomes available for use after the initial Find when viewing the claims e The Find CARC RARC is available for use in searching for a specific CARC or RARC the associated effective date termination date and the code description Page 16 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 MENU BAR OPTIONS VIEW OPTION Toolbar vV Status Bar Legend Segment List Ctrl L Provider Summary Ctrl R Billing Type Summary Ctrl B All Claims Ctrl A Single Claim Ctrl CARC RARC Ctrl U Display Business Scenarios Ctrl O Next Ctrl gt Prev Ctrl lt Figure 6 View Toolbar Option Screen Layout MENU OPTION VIEW 1 The View menu option allows for selection of the Tool Bar Status Bar and the Legend Screen Header for the All Claims format e View also identifies the keyboard commands necessary to navigate through the various screens that make up the PC Print A
50. 05 08 11 14 17 N Loop 2110 CAS Claim Adjustment Adjustment Amount CAS03 06 09 12 15 18 REMARK CODES Loop 2110 LQ Health Care Remark Codes LQO2 nl when LQO1 is HE Claim Payment Remark Codes Second Revenue Line Headings when REFO1 is equal 6R REFO2 when REFO 1 is OK Third Revenue Line Headings Loop Segment Data Element SVC DESC Loop 2110 SVC Service Payment Information when SVC06 7 is present and greater than spaces GROUP CARC CODES Adjustment Group Code Loop 2100 CAS Claim Adjustment Adjustment Reason CODES Codes CAS02 CAS05 CAS08 CAS11 CAS14 CAS17 RARC CODES Loop Segment Data Element REMITTANCE ADVICE Loop 2110 LQ Health Care Remark Codes LQO2 when REASON CODES LQO1 is HE Claim Payment Remark Codes Page 81 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING BILL TYPE SUMMARY REPORT PC PRINT BILL SUMMARY REPORT Medicare National Standard Intermediary Remittance Advice LR NPI Provider FPE 09 30 2008 PBSI FISS 9999 N Street PAID 22 0 1090 999 Road LRAR 99999 CLM 3 LR AR 99999 NPI 9999999999 TOB 11 CHANGES PAYMENT DATA 0 000 REIM RATE 6900 00 REPORTED 0 00 DRG AMOUNT 0 00 MSP PRIM PAYER 4600 00 NCVD DENIED 0 00 DRG OPER CAP 0 00 PROF CONFPONENT 0 00 CLAIM ADJS 0 00 LINE ADJ 0 00 COVERED 0 00 O0UTLIER 0 00 PROC CD AMOUN
51. 1 135 91 0 001 0 001 0 00 9999999999 HIC CHG HN TOB 138 1 0l 366 00 0 001 0 001 0 001 132 111 97 98 0 001 BETANCOURT X 1800187158 1 10007111 ol 453 52 0 001 0 5101 88 381 0 00 202218000672XXXXX 123456789A 10007111 0l 365 14 0 001 0 001 0 001 88 381 0 00 5 122 10000044544 ol 0 001 0 001 0 001 0 001 0 001 0 00 9999999999 HIC CHG HN TOB 13I 1l 0l 395 77 0 001 0 001 0 001 0 001 88 38 0 001 BETANCOURT X 1800200716 1 10008011 0l 441 001 0 001 0 5101 61 30 0 00 2022180006730XXXX 1123456789A 10008011 0l 75 001 0 001 0 001 0 001 366 00 0 00 6 122 10001109082 0l 0 001 0 001 96 16 0 00 0 001 0 00 4 HH p Figure 38 All Claims Find Feature Screen Layout In the all claims AC search find note a feature of this screen In the status bar at the bottom of the screen it states Displaying claims 1 through 10 of the total 10 claims If there are more claims click on the Arrow Down button to view the next set Then the status bar reflects Displaying claims xx through xx of the total xx claims Select Edit Find and input the search criteria and click OK Once the claim is found it is highlighted To view the claim in the single claim format click on the highlighted claim then click on the SC button and the application goes directly to the single claim format for that particular claim Page 52 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task
52. 14 NCVD DENIED 0 00 DRG OPER CAP 0 00 PROF COMPONENT 0 00 CLAIM ADJS 0 00 LINE ADJ AMT 0 00 ESRD AMOUNT 395 77 COVERED 0 00 OUTLIER 395 77 PROC CD AMOUNT DAYS VISITS 0 00 CAP OUTLIER 88 38 ALLOW REIM O COST REPT 0 00 CASH DEDUCT 0 00 SEQUESTRATN 1 COVD UTIL 0 00 BLOOD DEDUCT 0 00 INTEREST O0 NON COVERED 0 00 COINSURANCE 0 00 CONTRACT ADJ 0 COVD VISITS 0 00 PAT REFUND 0 00 PER DIEM AMT O NCOV VISITS 0 00 ACO PIONEER 88 38 NET REIM AMT ADJ REASON CODES CR 93 0 REMARK CODES MA01 Group CARC CODES CR Correction 93 No Claim level Adjustments 4 4 p REV DATE HCPCS APC HIPPS MODS QTY CHARGES ALLOW REIM GC RSN AMOUNT REMARK CODES 4 LICN HCPI F SVC Desc 0301 07 11 ATP20 1 000 66 00 3 92 CR 42 62 08 d 0301 07 11 ATP20 1 000 17 33 1 62 CR 42 15 71 0301 07 11 ATP20 1 000 28 88 2 42 CR 42 26 46 0301 07 11 82607 1 000 40 43 20 83 CR 42 19 60 0301 07 11 82784 1 000 34 65 12 85 CR 42 21 80 0301 07 11 83540 1 000 34 65 8 95 CR 42 25 70 itt gt Figure 37 Single Claim Screen Layout In this application is the capability to toggle between the single claim screen and the all claims screen If in the Single Claim view and the AC button is clicked when the All Claim screen comes up the single claim is highlighted in the all claim view Page 51 Use or disclosure of the data contained on this sheet is subject to restrictions of contract H HHSM 500 2007 00016I Task Order HHSM 500 T0003 FIND OPTIONS ALL CL
53. 2808572504 CHARGES PAYMENT DATA DRG 0 510 REIM RATE 52 00 REPORTED 0 00 DRG AMOUNT 0 00 MSP PRIM PAYER 0 00 NCVD DENIED 0 00 DRG OPER CAP 0 00 PROF COMPONENT 0 00 CLAIM ADJS 0 00 LINE ADJ AMT 0 00 ESRD AMOUNT 52 00 COVERED 0 00 OUTLIER 52 00 PROC CD AMOUNT DAYS VISITS 0 00 CAP OUTLIER 5 60 ALLOW REIM 0 COST REPT 0 00 CASH DEDUCT 0 00 SEQUESTRATN 1 COVD UTIL 0 00 BLOOD DEDUCT 0 00 INTEREST 0 NON COVERED 7 41 COINSURANCE 38 99 CONTRACT ADJ 0 COVD VISITS 0 00 PAT REFUND 0 00 PER DIEM AMT O0 NCOV VISITS 0 00 ACO PIONEER 5 60 NET REIM AMT ADJ REASON CODES CR 93 0 REMARK CODES MAO1 Group CARC CODES CR Correction 93 No Claim level Adjustments LICN HCPI SVC Desc 0730 09 18 93005 90099 1 000 52 00 5 60 CR 2 7 41 45 38 99 CR Correction 2 Coinsurance Amount Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016l Task Order HHSM 500 T0003 REV DATE HCPCS APC HIPPS MODS QTY CHARGES ALLOW REIM GC RSN AMOUNT REMARK CODES 45 Charge exceeds fee schedule maximum allowable or contracted legislated fee arrangement Use only with Group Codes PR or CO depending upon liability Figure 33 Print Example E Print Marked Items Screen Layout mm Page 47 FIND OPTIONS CHAPTER 7 FIND OPTIONS This chapter offers instructions on how to locate claims both All Claims and Single Claims and how to locate specific CARCs RARCs and Group codes FIND O
54. 3 27 REPORTED 0 00 DRG AMOUNT 0 00 MSP PRIM PAYER 33 27 NCVD DENIED 0 00 DRG OPER CAP 0 00 PROF COMPONENT 0 00 CLAIM ADJS 0 00 LINE ADJ AMT 0 00 ESRD AMOUNT 0 00 COVERED 0 00 OUTLIER 0 00 PROC CD AMOUNT DAYS VISITS 0 00 CAP OUTLIER 0 00 ALLOW REIM O0 COST REPT 0 00 CASH DEDUCT 0 00 SEQUESTRATN 0 COVD UTIL 0 00 BLOOD DEDUCT 0 00 INTEREST 0 NON COVERED 0 00 COINSURANCE 0 00 CONTRACT ADJ 0 COVD VISITS 0 00 PAT REFUND 0 00 PER DIEM AMT O0 NCOV VISITS 0 00 ACO PIONEER 0 00 NET REIM AMT ADJ REASON CODES OA 93 0 REMARK CODES MAOQi MAi3 Group CARC CODES OA Other Adjustment 93 No Claim level Adjustments REV DATE HCPCS APC HIPPS MODS QTY CHARGES ALLOW REIM GC RSN AMOUNT REMARK CODES LICN SVC Desc 0320 902 10 73600 0 000 33 27 0 00 CO 29 ni f ee CO Contractual Obligation Patient may not be billed for these 29 The time limit for filing has expired Figure 21 SC Single Claim Button Screen Layout The SC Single Claim button displays individual claims on the screen The Single Claim Report screen and report reflects the Coordination of Benefits COB data when there has been a COB transfer The name and number of the Trading Partner are reflected on the report In addition at the service line the line item control number health care policy indicator and the Not Otherwise Classified service line descriptions are reported The Group CARC and RARC codes and related descriptions are shown at the claim level and line level
55. 366 00 0 00 4 122 10001109082 l l 0l 0 00 0 00 A AE 0 00 0 00 0 00 9999999999 HIC CHG HN TOB 138 L 0l 366 00 0 00 0 00 0 00 132 11 97 98 0 00 BETANCOURT x 800187158 1 1000711 ol 453 521 0 00 0 510 88 38 0 00 202218000672XXXxXxX 123456789A 1000711 ol 365 14 0 00 0 00 0 00 88 38 0 00 5 22 10000044544 l 0l 0 00 0 00 0 00 0 00 0 00 0 00 9999999999 HIC CHG HN TOB 13I1 a Ol 395 771 0 00 0 00 0 00 0 00 88 38 0 00 BETANCOURT x 800200716 1 000801 0l 441 00 l 0 001 0 510 61 30 0 00 2022180006730XXxXxX 1123456789A 1000801 ol 75 00 0 00 0 00 0 00 366 00 0 00 6 122 10001109082 l l 0l 0 00 0 00 96 16 0 00 0 00 0 00 9999999999 HIC CHG HN TOB 13I L Ol 366 00 0 00 0 00 0 00 208 54 61 30 0 00 Figure 19 AC All Claims Button Screen Layout The AC All Claims button provides access to the All Claims display NOTE The up down arrow buttons allow for parsing forward and backward through the file The right left and up down scroll bars are available at the bottom and right of the screen respectively to move through the All Claims screen to view the data in its entirety Refer to the next screen to view the missing columns Page 31 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 000161 Task Order HHSM 500 T0003 TOOL BAR OPTIONS The below screen example does not accommodate a full screen view Therefore the far
56. 686 N706 N707 N708 N709 N710 N711 N712 N713 N714 N715 N716 N717 N718 Figure 27 Business Scenarios Code Combination Listing Screen Layout The BUS SCE Button provides a CARC Code Search option to locate the CARC code specific to a Business Scenario without having to go through each Business Scenario 1 In the CARC Code search box key in the code to search on The screen automatically goes to the Business Scenario for the CARC Code entered after pressing the Locate Business Scenario button If the entered code is not located in a Business Scenario a dialog box displays with the message The requested CARC was not found in any Business Scenario Page 39 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHHSM 500 2007 00016I Task Order HHSM 500 T0003 TOOL BAR OPTIONS Code Combinations For Business Scenario 1 Additional Information Required Missing Invalid Incomplete Documentation CARC RARC Codes Group Codes NONE N563 CO or PI TY M8 00 N29 N705 N706 N707 N708 N709 N710 N711 N712 N713 N714 N715 N716 CO or Pl NONE N678 N679 N680 N681 N682 N683 N685 N686 N706 N708 N710 N712 N714 N716 N718 164 00 CO NONE N678 N679 N680 N681 N682 N683 N685 N686 NONE N555 N556 N594 N595 N596 N667 N668 N678 N679 N680 N681 N682 N683 N685 N686 N705 N707 N708 N709 N710 N711 N712 N713 N714 N715 N716 N717
57. 6I Task Order HHSM 500 T0003 MENU BAR OPTIONS CHAPTER 4 MENU BAR OPTIONS This section focuses on explaining all the options on the Menu Bar that are available through PC Print and their purpose ACCESSING THE SCREEN PeP Pcp01 PC Print for Window File Edit View Admin Help Tl ila lolol ole SI ol For Help press F1 mae Figure 3 Accessing the Screen Screen Layout Upon double clicking on the PC Print Icon the system displays this screen Take notice that the SL button is always pre selected Before any claim information can be viewed a data file needs to be selected Page 14 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 MENU BAR OPTIONS FILE OPTION PeP Pcp01 PC Print for Window Edit View Admin Help Print Ctrl P Print Marked Items Print All Items Print Setup Print Preview Recent File Exit Figure 4 File Tool Bar Function Screen Layout MENU OPTION FILE 1 Select the FILE option from the title bar 2 When File is selected various choices display based on the particular format of PC Print In the above example PC Print has opened no data file has been selected and only certain options are available Page 15 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T00
58. 7 if DME orthotics and prosthetics must be billed to the DME carrier who services the patient s zip RARC Code Search Display Full RAF Group Codes co Contractual Adjustment PI Payor Initiated Reductions CR Correction no longer used OA Other Adjustment PR Patient Responsibility Figure 24 GCR Code Search Option Screen Layout The GCR button provides a CARC Code Search and RARC Code Search option to provide specific codes without having to page up and down the listing 1 In the CARC Code Search or RARC Code Search box key in the code to search on The screen automatically scrolls to the code entered or to the closest known code if the entered code is not located in the listing Note There is not a search option for the Group Codes all available Group Codes are visibly displayed at the bottom of the screen Page 36 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 TOOL BAR OPTIONS re gt CR8140 test X12 PC Print for Windows File Edit View Admin Help a slslefe ale S al SC Codd osco i i wee eee Term Date CARC Description EE E E E Eser EERS s patient s age N the 835 Healthcare Policy Identifig 1 1 1995 The diagnosis is inconsistent with the patient s gender Note Refer to the 835 Healthcare Policy Identi 1 1 1995 The diagnosis is inconsistent with the procedure Note Ref
59. 91 N392 N393 N394 N395 N396 N398 N399 N401 N402 N403 N404 N439 N440 N445 N446 N451 N452 N453 N454 N455 N456 N457 N458 N459 N460 N461 N462 N463 N464 N465 N466 N467 N468 N473 N474 N475 N476 N477 N478 N479 N480 N481 N482 N483 N484 N485 N486 N487 N488 N489 N490 N491 N493 N494 N495 N496 N497 N498 N499 N500 N542 N543 N555 N556 N563 N590 N594 N595 N596 N667 N668 N678 N679 N680 N681 N682 N683 N685 N686 N705 N706 N707 N708 N709 N710 N711 N712 N713 N714 N715 N716 N717 N718 M1 M19 M21 M23 M29 M30 M31 M42 M47 M60 M127 M130 M131 M132 M135 M141 M142 M143 MA04 MA27 MA64 MA75 MA76 MA81 MA88 MA92 MA111 MA130 N3 N4 N26 N28 N29 N40 N42 N50 N59 N80 N102 N146 N170 N175 N178 N186 N191 N197 N202 N204 N205 N206 N214 N221 N222 N223 N224 N225 N227 N228 N231 N232 N233 N234 N235 N236 N237 N238 N239 N240 N241 N242 N243 N244 N245 N286 N331 N350 N354 N366 N375 N391 N392 N393 N394 N395 N396 N398 N399 N401 N402 N403 N404 N439 N440 N445 N446 N451 N452 N453 N454 N455 N456 N457 N458 N459 N460 N461 N462 N463 N464 N465 N466 N467 N468 N473 N474 N475 N476 N477 N478 N479 N480 N481 N482 N483 N484 N485 N486 N487 N488 N489 N490 N491 N493 N494 N495 N496 N497 N498 N499 N500 N542 N543 N555 N556 N563 N590 N594 N595 N596 N667 N668 N678 N679 N680 N681 N682 N683 N685 N
60. 93 42 0 00 100 00 0 00 161 62 0 00 2 122 10001079178 l ol 0 00 0 00 7 64 0 00 0 001 0 00 9999999999 HIC CHG HN TOB 13I 1l ol 224 24 0 00 0 00 0 00 67 71 SENE 800200716 1 10008011 Ol 441 00 l 0 001 0 5101 97 98 0 00 2002230008XXXX 123456789A 10008011 0l 75 001 0 001 0 001 0 001 366 00 0 00 4 122 10001109082 Ol 0 001 0 001 135 91 0 001 0 001 0 00 9999999999 HIC CHG HN TOB 138 1 0l 366 00 0 001 0 001 0 001 132 111 97 98 0 001 BETANCOURT X 1800187158 1 10007111 Ol 453 52 0 001 0 5101 88 38 0 00 202218000672XXXXX 123456789A 10007111 0l 365 14 0 001 0 001 0 001 88 38 0 00 5 122 10000044544 ol 0 001 0 001 0 001 0 001 0 001 0 00 9999999999 HIC CHG HN TOB 13I 1l ol 395 77 0 001 0 001 0 001 0 001 88 38 0 001 BETANCOURT Xx 1800200716 1 10008011 0l 441 001 0 001 0 5101 61 30 0 00 2022180006730XXXX 123456789A 10008011 0l 75 001 0 001 0 001 0 001 366 001 0 00 6 122 10001109082 Ol 0 00 0 001 96 16 0 001 0 001 0 00 9999999999 HIC CHG HN TOB 13I 11 Ol 366 001 0 001 0 001 0 001 208 54 61 30 FIND OPTIONS PeP 021016AA X12 PC Print for Windows y File Edit View Admin Help fs a elTe ele E A PATIENT NAME ICN NUMBER PATIENT CNTRL NUMBER FRM DT COST REPTD CHGS DRG NBR HIC NUMBER OUTLIER AMT REIMB RATE ALLOW REIM INTEREST THR DT COVDV NCVD DENIED DRG AMOUNT DEDUCTIBLES MSP PRI PAY PROC CD AMT PAT REFUND CLAIM CLM STATUS MEDICAL REC
61. AIMS FIND Pe 021016AA X12 PC Print 021016AA X12 PC Print for Window File Edit View Admin Help _ m2 aj elefe s alo S al PATIENT NAME PATIENT CNTRL NUMBER FRM DT COST REPTD CHGS DRG NBR OUTLIER AMT REIMB RATE ALLOW REIM INTEREST ICN NUMBER HIC NUMBER ITHR DT COVDV NCVD DENIED DRG AMOUNT DEDUCTIBLES MSP PRI PAY PROC CD AMT PAT REFUND LAIM CLM STATUS MEDICAL REC NUMBER NCVDV CLAIM ADJS DRG O C COINS AMT PROF COMP LINE ADJ AMT PERDIEM AMT NATIONAL PROVIDER ID HIC CHG x TOB xxx CV LN NCV L COVD CHGS NEW TCH ECT SEQUESTRATN ESRD AMT CONT ADJ AMT NET REIMB ACO PIONEER BARBERO x 800182689 1 1000704 0 255 04 0 00 0 510 13 73 0 00 2001940001XXXxX 1123456789A 1000704 0 139 97 0 00 100 00 0 00 224 24 0 00 af 22 10001079178 ol 0 00 0 00 7 64 0 00 0 00 0 00 9999999999 HIC CHG HN TOB 138 1 ol 224 24 0 00 0 00 0 00 21 16 13 73 0 00 BARBERO xX 800182689 1 1000704 0l 255 04 0 00 0 510 13 73 0 00 20221800013 9XXxXxx 1123456789A 1000704 ol 93 42 0 00 100 00 0 00 161 62 0 00 2 122 10001079178 0 0 00 0 00 7 64 0 00 0 00 0 00 9999999999 HIC CHG HN TOB i13I1 1 0l 224 24 0 00 0 00 0 00 67 71 13 73 0 00 Ac ECS BETANCOURT x 800200716 1 1000801 0l 441 00 0 00 0 510 97 98 0 00 2002230008XXXX 123456789A o00801 ol 75 00 0 001 0 001 0 001 366 00 0 00 4 122 10001109082 0l 0 001 0 00
62. AS Claim Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when adjustment code in CASO2 05 08 11 14 17 equals 1 and or 66 and Loop 2110 CAS Service Adjustment CASO3 DEDUCTIBLES 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals adjustment codes and 66 NATIONAL PROVIDER ID Loop 1000B N1 Payee Identification N104 Payee Identification Code when N103 equals XX HIC CHG X TOB XXX CV LN Loop 2100 NM Corrected Patient Insured Name NM109 Corrected Insured Identification Indicator when NM108 equal C Insured s Changed Unique Identification Number Loop 2100 CLP Claim Payment Information CLP08 Facility Type Code in the first two positions of the XX and CLPO9 Claim Frequency Code in the third position last X Loop 2100 QTY Claim Supplemental Information QTY02 Claim Supplemental Information Quantity when QTYOI equals CA Covered Actual NCV L COVD CHGS OT DAYS SEQUESTRATN ESRD AMT Loop 2100 AMT Claim Supplemental Information AMTO2 Claim Supplemental Information Amount when AMTO1 equals AU Coverage Amount Loop 2110 SVC Service Payment Information when SVCOI 1 equals NU and SVCO1 2 equals 43X this field value is equal to SVCO5 Loop 2100 CAS Claim Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 118 and group code CO and CARC 223 and Loop 2110 CAS Service Adjustment C
63. ASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 118 and group code CO and CARC 223 Loop 2100 CAS Claim Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 118 and Loop 2110 CAS Service Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CAS02 05 08 11 14 17 equals 118 Page 93 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Loop Segment Data Element CONT ADJ AMT Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 45 and Loop 2110 CAS Service Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 45 NET REIMB Loop 2100 CLP Claim Payment Information CLP04 Claim Payment Amount Page 94 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING HOME HEALTH HOSPICE SINGLE CLAIM REPORT PC PRINT SINGLE CLAIM REPORT Medicare Na nal Standard Intermediary Remittance Advice HOSPITAL FPE 09 30 00 HOSP PO BOY 12345 PAID 08 26 02 PO BOX 1234 TAMPA r FL 336313240 CLM 1 SAN JUAN PR 00919 NPI 123456789
64. CLAIM ADJ ST DAYS COINS AMT PROF COMP LINE ADJ AMT Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 45 94 and 97 Loop 2110 CAS Service Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CAS02 05 08 11 14 17 equals 45 94 and 97 Loop 2110 SVC Service Payment Information when SVCOI 1 equals NU and SVCO1 2 equals 44X this field value is equal to SVCO5 Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 2 3 and 122 Loop 2110 CAS Service Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO02 05 08 11 14 17 equals 2 3 and 122 Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 89 and Loop 2110 CAS Service Adjustment CASO03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 89 Loop 2110 CAS Service Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 45 94 and 97 age 92 92 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Loop Segment Data Element Loop 2100 C
65. DJ 0 COVD VISITS 0 00 PAT REFUND 0 00 PER DIEM AMT O NCOV VISITS 0 00 ACO PIONEER 5 60 NET REIM AMT ADJ REASON CODES CR 93 0 REMARK CODES MAO1 Group CARC CODES CR Correction 93 No Claim level Adjustments 4 REV DATE HCPCS APC HIPPS MODS QTY CHARGES ALLOW REIM GC RSN AMOUNT REMARK CODES LICN HCPI SVC Desc 0730 09 18 93005 00099 1 000 52 00 5 60 CR 2 7 41 45 38 99 CR Correction 2 Coinsurance Amount 45 Charge exceeds fee schedule maximum allowable or contracted legislated fee arrangement Use only with Group Codes PR or CO depending upon liability Figure 30 Print Example B Print All Items Screen Layout Page 44 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016l Task Order HHSM 500 T0003 PRINTING OPTIONS PRINT EXAMPLE C iew Admi x PC Print for Windows Mark for Print Ctrl M e g c IL Ctrl F tandard Intermediary Remittance Advice i FPE 09 30 01 HOSP Find Next Ctrl N PAID 08 26 02 PO BOX 1234 Find CARC RARC Ctrl U CLM 27 SAN JUAN PR 00919 NPI TOB 138 PATIENT BAZAN X x PCN 800507288 i1 HIC 123456789B SVC FROM 09 18 01 MRN 0000028317 CLAIM STAT 22 THRU 09 18 01 ICN 20222808572504 CHARGES PAYMENT DATA DRG 0 510 REIM RATE 52 00 REPORTED 0 00 DRG AMOUNT 0 00 MSP PRIM PAYER 0 00 NCVD DENIED 0 00 DRG OPER CAP 0 00 PROF COMPONENT 0 00 CLAIM ADJS 0 00 LINE ADJ AMT 0 00 ESRD AMOUNT 52 00 C
66. Data Search Data pP Organize v New folder T 2 A Documents library Arrange by Folder v Data Name Date modifi CR8140 test X12 3 12 2014 1 021016A X12 2 17 2014 9 W i ia ia KEKEwKwvvnKO b 4 File name v All Files Z For Help press F1 CAP Figure 48 X12 Button Open Dialog Box 2 of 2 4 Select a data file and click on Open If the data file selected is not the correct one click the X12 button again and make another selection as stated above Page 62 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016l Task Order HHSM 500 T0003 PROCESSING PROCEDURES Data File Segments Deblocked Segments 267 r ST 267001 BPR 020826 TRN 9000000466 REF 4A 01 DTM 020823 N1 HOSP N3 N3 N4 N4 Lx 000913 TS3 4000 CLP 600162689 1 CAS NM1 BARBERO MOA MADI REF 0001079178 DTM 000704 DTM 000704 AMT AU QTY CA SVC HC a0040 DTM 000704 CAS CR AMT B6 SVC HC 85031 DTM 000704 CAS CR AMT B6 SVC Ho 81 000 DTM 000704 CAS CR AMT B6 SVC HO 1020 DTM 000704 CAS CR REF R AMT B6 SVC Hoe 99201 DTM 000704 CAS CR AMT B6 X v Total claims 2308 Total seqments 78145 Figure 49 Data File in Segment List SL Format Screen Layout 1 of 2 5 Once the data file is selected it appears on the screen in the segment list format Starting from the left the first column shows the GS segm
67. EIM AMT Loop 2100 CLP Claim Payment Information CLP04 Claim Payment Amount ADJ REASON CODES Loop Segment Data Element GROUP CODES Loop 2100 CAS Claim Adjustment CASO1 Claim Adjustment Group Code ADJUSTMENT REASON Loop 2100 CAS Claim Adjustment Adjustment CODES Reason Codes CAS02 CAS05 CAS08 CAS11 CAS 14 CAS17 ADJUSTMENT AMOUNT Loop 2100 CAS Claim Adjustment Adjustment Amount CAS03 CAS06 CASO9 CAS12 CASI5 CAS18 REMARK CODES Loop 2100 MIA Inpatient Adjudication Information Claim Payment Remark Codes MIAOS MIA20 MIA21 MIA22 MIA23 And Loop 2100 MOA Outpatient Adjudication Information Claim Payment Remark Code MOA03 MOA04 MOAOS MOA06 MOA07 GROUP CARC CODES Loop Segment Data Element GROUP CODES Loop 2100 CAS Claim Adjustment CASO1 Claim Adjustment Group Code ADJUSTMENT REASON Loop 2100 CAS Claim Adjustment Adjustment CODES Reason Codes CAS02 CAS05 CAS08 CAS11 CAS 14 CAS17 RARC CODES Loop Segment Data Element REMITTANCE ADVICE Loop 2110 LQ Health Care Remark Codes LQO2 REASON CODES when LQOI1 is HE Claim Payment Remark Codes Page 100 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING SINGLE CLAIM REPORT Service Lines REW DATE HCPCS APC HIPPS MODS JTY CHARGES ALLOW REIM GC ESH AMOUNT REMARE CODES e my rap LICH CEI SVC Desc 301
68. ERO MOA MADI REF 0001079178 DTM 000704 DTM 000704 AMT AU QTY CA SYC HC 80048 DTM 000704 CAS CR AMT B6 SYC Ho 85031 DTM 000704 CAS CR AMT B6 SYC HC 81000 DTM 000704 CAS CR AMT B6 SYC HC 1020 DTM 000704 CAS CR REF R AMT B6 SYC Hoe 99201 DTM 000704 CAS CR i AMT B6 X Total claims 2308 Total segments 78145 Figure 15 Data File Segments and Detail Data Elements Screen Layout Upon clicking on any segment the detail data elements for that segment displays on the right side of the screen This segment list is primarily a diagnostic tool Page 27 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016l Task Order HHSM 500 T0003 TOOL BAR OPTIONS SL BUTTON PeP 021016AA X12 PC Print fo File Edit View Admin Help xl xie si Ps es ac sc a amp l GS lt i GS GS 267 a a ST 267001 E BPR 020826 TRN 9000000468 REF 4A 01 DTM 020823 N1 HOSP N3 N3 N4 N4 LX 000913 TS3 400016 CLP 800182689 1 CAS CR NMI BARBERO MOA MAO1 REF 0001079178 DTM 000704 DTM 000704 AMT AU QTY CA SVC HC 80048 DTM 000704 CAS CR AMT B6 SYC Ho s5031 DTM 000704 CAS CR AMT B6 SYC HC 81 000 DTM 000704 CAS CR AMT B6 SVC HC 1020 DTM 000704 CAS CR REF R AMT B6 SYC Ho 99201 DTM 000704 CAS CR AMT B a Total claims 2308 Total segments 78145 Figure 16 SL Segment List Button Screen Layout The
69. FISS PC PRINT Fiscal Intermediary Standard System Version 5 0 1 October 2014 FISS PC Print User Guide Table of Contents Chapter 1 222222222 e nee n een n nnn n nnn n nnn e nee e eee 6 Introduction 0 20000002222 c enn e ee ee nnn e eee ene e eee 6 Description and Use 6 Benefits of the PC Print program 7 Technical Support 7 Comments 7 Chapter 2 2 222222 nner e enn n nnn n nnn n nnn n eee e eee 8 GIlOSSALY 222222 oon nnn nee n nnn nee nee n nnn nnn e enn n nee eeeen nnn n en eeeeeeee 8 Table of Acronyms 8 Chapter 3 2222222 n nner enn n nee n nnn n nnn n ene n eee e eee 9 Getting Started 22 20 2222 2222 200 nnn e nee e eee n nnn e ee eeeeeee e 9 Installation Software 9 Uninstall Process 9 Installatio
70. INFORMATION Loop Segment Data Element TELEPHONE Loop 1000A PER Payer Business Contact Information PERO4 when PERO3 is TE or PERO6 when PEROS is TE Page 88 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Loop Segment Data Element TELEPHONE EXTENSION Loop 1000A PER Payer Business Contact Information PERO6 when PEROS5 is EX or PERO8 when PERO7 is EX FACSIMILE Loop 1000A PER Payer Business Contact Information PERO4 when PERO3 is FX or PERO6 when PEROS is FX ELECTRONIC MAIL Loop 1000A PER Payer Business Contact Information PERO4 when PERO3 is EM or PERO6 when PEROS 1s EM PAYER TECHNICAL CONTACT INFORMATION Loop Segment Data Element TELEPHONE Loop 1000A PER Payer Technical Contact Information PERO4 when PERO3 is TE or PERO6 when PEROS is TE FACSIMILE Loop 1000A PER Payer Technical Contact Information PERO6 when PEROS5 is FX or PERO8 when PERO7 is FX ELECTRONIC MAIL Loop 1000A PER Payer Business Contact Information PERO4 when PERO3 is EM or PERO6 when PEROS is EM UNIFORM Loop 1000A PER Payer Technical RESOURCE Contact Information PERO4 when LOCATOR URL PERO3 is UR or PERO6 when PEROS is UR PAYER WEBSITE Loop 1000A PER Payer Web Site UNIFORM PERO4 when PERO3 is UR RESOURCE LOCATOR URL Page 89 Use or disclosure of the data contained on this sheet is su
71. LP04 Claim Payment Amount ACO PIONEER Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 118 and group code CO and CARC 132 and Loop 2110 CAS Service Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 118 and group code CO and CARC 132 ADJ REASON CODES Loop Segment Data Element GROUP CODES Loop 2100 CAS Claim Adjustment CASO1 Claim Adjustment Group Code ADJUSTMENT REASON Loop 2100 CAS Claim Adjustment Adjustment CODES Reason Codes CAS02 CAS05 CAS08 CAS11 CAS 14 CAS17 ADJUSTMENT AMOUNT Loop 2100 CAS Claim Adjustment Adjustment Amount CAS03 CAS06 CASO9 CAS12 CAS15 CAS18 REMARK CODES Loop 2100 MIA Inpatient Adjudication Information Claim Payment Remark Codes MIAO5 MIA20 MIA21 MIA22 MIA23 And Loop 2100 MOA Outpatient Adjudication Information Claim Payment Remark Code MOA03 MOA04 MOAOS MOA06 MOA07 Page 79 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING SINGLE CLAIM REPORT Service Lines REV DATE HCPCS APC HIPPS MODS OTY CHARGES ALLOW REIM GC RSN AMOUNT REMARK CODES LICH CPI SVC Desc 0730 09 18 93005 0009 1 000 52 00 5 60 CR 2 7 41 45 38 99 CR Correction 2 Coinsurance Amount 45 Charge exceeds fee schedule
72. NEER uw 1 COVD UTIL 0 NON COVERED 0 COVD VISITS O NCOV VISITS ADJ REASON CODES CR 93 oonoooo0ece WwW Momoonmnoncnd REMARK CODES Group CARC CODES CR Correction REV DATE HCPCS APC HIPPS MODS QTY CHARGES ALLOW REIM GC AMOUNT REMARK CODES LICN HCPI SVC Desc 0730 09 18 93005 00099 CR Correction 2 Coinsurance Amount 45 Charge exceeds fee schedule maximum allowable or contracted legislated fee arrangement Use only with Group Codes PR or CO depending upon liability 4 Figure 42 SC Single Claim Format Screen Layout This screen displayed from the previous application request From here SC click on the AC button and the application returns to the claim in the all claim format Page 56 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 FIND OPTIONS PeP 021016AA X12 PC Print fc File Edit View Admin Help Co e a elelee ale g ol Medicare National Standard Intermediary Remittance Advice FPE 09 30 01 HOSP PAID 08 26 02 PO BOX 1234 CLM 27 SAN JUAN PR 00919 NPI 9999999999 TOB 138 PATIENT BAZAN X x PCN 800507288 1 HIC 123456789B SVC FROM 09 18 01 MRN 0000028317 CLAIM STAT 22 THRU 09 18 01 ICN 20222808572504 CHARGES PAYMENT DATA DRG 0 510 REIM RATE 52 00 REPORTED 0 00 DRG AMOUNT 0 00 MSP PRIM PAYER 0 00 NCVD DENIED 0 00 DRG OPER CAP 0 00 PROF COMPONENT 0 00 CLAIM ADJS 0
73. OVERED 0 00 OUTLIER 52 00 PROC CD AMOUNT DAYS VISITS 0 00 CAP OUTLIER 5 60 ALLOW REIM 0 COST REPT 0 00 CASH DEDUCT 0 00 SEQUESTRATN 1 COVD UTIL 0 00 BLOOD DEDUCT 0 00 INTEREST 0 NON COVERED 7 41 COINSURANCE 38 99 CONTRACT ADJ 0 COVD VISITS 0 00 PAT REFUND 0 00 PER DIEM AMT O NCOV VISITS 0 00 ACO PIONEER 5 60 NET REIM AMT ADJ REASON CODES CR 93 0 REMARK CODES MAO1 Group CARC CODES CR Correction 93 No Cla 4 REV DATE HCPCS APC HIPPS LICN HCPI SVC Desc 0730 09 18 93005 00099 CR Correction 2 Coinsurance Amount 45 Charge exceeds fee schedule maximum allowable or contracted legislated fee arrangement im level Adjustments MODS QTY CHARGES ALLOW REIM GC RSN AMOUNT REMARK CODES 1 000 52 00 5 60 CR 2 7 41 45 38 99 Figure 31 Print Example C Screen Layout restrictions of contract HHSM 500 2007 00016l Task Order HHSM 500 T0003 Use or disclosure of the data contained on this sheet is subject to Use only with Group Codes PR or CO depending upon liability Page 45 PRINTING OPTIONS PRINT EXAMPLE D File Edit View Admin Help 7 x slsjefe ale 8 amp l Medicare National Standard Intermediary Remittance Advice FPE 09 30 01 HOSP PAID 08 26 02 PO BOX 1234 r NPI 9999999999 PATIENT BAZAN X HIC 123456789B CLAIM STAT 22 CHARGES 52 00 REPORTED 0 00 NCVD DENIED 0 00 CLAIM ADJS 52 00 COVERED DAYS VISITS 0 COST REPT 1 COVD UTIL 0 NON COVERED
74. OVIDER CITY ST ZIP Loop 1000B N4 Payee City State and Zip Code N401 City N402 State or Province Code N403 Postal Code Page 87 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Loop Segment Data Element INTERMEDIARY Loop 1O00A N4 Payer City State and Zip Code CITY ST ZIP N401 City N402 State or Province Code N403 Postal Code Loop 1000B N1 Payee Identification N104 Payee Identification Code when N103 equals XX else Loop 1000B REF Payee Additional Identification REFO2 when REFO equals PQ CHECK EFT NUMBER Header TRN Re association Trace Number TRNO2 Check or EFT Trace Number PAYMENT SUMMARY Field Loop Loop Segment Data Element _ _ _ Data Element Actual Provider Payment Amount Header BPR Financial Information BPR16 Check EFT Effective Date TS304 Total Claim Count TS323 Total PIP Claim Count FINANCIAL ADJUSTMENTS Loop Segment Data Element ADJUSTMENT REASON Summary PLB Provider Adjustment Adjustment CODE Reason Code PLBO03 1 PLBO5 1 PLBO7 1 PLBO9 1 PLB11 1 PLB13 1 PROVIDER ADJUSTMENT Summary PLB Provider Adjustment Provider IDENTIFIER Adjustment Identifier PLBO3 2 PLBO5 2 PLBO7 2 PLBO9 2 PLB11 2 PLB13 2 PROVIDER ADJUSTMENT Summary PLB Provider Adjustment Provider AMOUNT Adjustment Amount PLB04 PLB06 PLBO8 PLBO10 PLB12 PLB14 PAYER BUSINESS CONTACT
75. PTIONS GENERAL File View Admin Help r seit Ctrl M E amp tandard Intermediary Remittance Advice 4 Find Ctrl F a FPE 09 30 00 HOSP Find Next Ctrl N PAID 08 26 02 PO BOX 1234 Find CARC RARC Ctrl U CLM 19 SAN JUAN PR 00919 NP1 0999999999 TOB 130 PATIENT TRIGO wo E PCN 800082766 1 HIC 123456789A SVC FROM 02 10 00 MRN 0001101638 CLAIM STAT 4 THRU 02 10 00 ICN 20223300224102 CHARGES PAYMENT DATA DRG 0 510 REIM RATE 33 27 REPORTED 0 00 DRG AMOUNT 0 00 MSP PRIM PAYER 33 27 NCVD DENIED 0 00 DRG OPER CAP 0 00 PROF COMPONENT 0 00 CLAIM ADJS 0 00 LINE ADJ AMT 0 00 ESRD AMOUNT 0 00 COVERED 0 00 OUTLIER 0 00 PROC CD AMOUNT DAYS VISITS 0 00 CAP OUTLIER 0 00 ALLOW REIM O COST REPT 0 00 CASH DEDUCT 0 00 SEQUESTRATN 0 COVD UTIL 0 00 BLOOD DEDUCT 0 00 INTEREST 0 NON COVERED 0 0OO COINSURANCE 0 00 CONTRACT ADJ 0 COVD VISITS 0 00 PAT REFUND 0 00 PER DIEM AMT O NCOV VISITS 0 00 ACO PIONEER 0 00 NET REIM AMT ADJ REASON CODES OA 93 0 REMARK CODES MAOi MAi3 Group CARC CODES OA Other Adjustment 93 No Claim level Adjustments Al CHARGES ALLOW REIM GC AMOUNT REMARK CODES REV DATE HCPCS APC HIPPS MODS LICN HCPI SVC Desc 0320 02 10 73600 0 000 nE Pr 0 00 CO 29 33 27 CO Contractual Obligation Patient may not be billed for these 29 The time limit for filing has expired QTY Figure 34 Find Options General Screen Layout The Find option is available on the All Claims and the
76. RT Xx 800200716 1 000801 0l 441 00 l 0 00 0 510 97 98 0 00 2002230008XXXxX 123456789A 1000801 0l 75 00 0 00 0 00 0 00 366 00 0 00 4 10001109082 0l 0 00 0 00 135 91 0 00 0 00 0 00 9999999999 HIC CHG HN TOB 1i138 1 0l 366 00 0 00 0 00 0 00 1s2 50 97 98 0 00 BETANCOURT X 800187158 1 1000711 0l 453 52 l 0 00 0 510 88 38 0 00 202218000672XXXXX 123456789A 1000711 0l 365 14 0 00 0 00 0 00 688 38 0 00 5 122 10000044544 0l 0 00 0 00 0 00 0 00 0 00 0 00 9999999999 HIC CHG HN TOB 13I1 1 0l 395 77 0 00 0 00 0 00 0 00 88 38 0 00 BETANCOURT x 800200716 1 1000801 0l 441 00 l 0 00 0 510 61 30 0 00 2022180006730XXXxX 123456789A 1000801 0l 75 00 0 00 0 00 0 00 366 00 0 00 6 2 10001109082 0l 0 00 0 00 96 16 0 00 0 00 0 00 9999999999 HIC CHG HN TOB 13I 2i 0l 366 00 0 00 0 00 0 00 208 54 61 30 0 00 Figure 53 All Claims AC Screen Layout 9 Selecting the AC button brings up the All Claims screen The All Claims screen is available from the View menu and as a keyboard sequence CTRL A NOTE In the status bar at the bottom of the screen it states which claims are being displayed the total number of claims in the data file and which claim is currently selected highlighted To view a second set of claims click on the down arrow in the tool bar Page 67 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500
77. S CR 93 0 REMARK CODES CARC CODES CR Correction 93 No Claim level Adjustments RARC CODES MAO 4 REV DATE HCPCS APC HIPPS MODS QTY CHARGES ALLOW REIM GC RSN AMOUNT REMARK CODES LICN HCPI SVC Desc 0301 07 04 80048 1 000 51 98 11 70 CR 42 40 28 0305 07 04 85031 1 000 17 33 7 37 CR 42 9 96 0307 07 04 81000 1 000 16 75 4 37 CR 42 12 38 0324 07 04 71020 R 1 000 43 18 11 62 CR 2 2 39 1 31 25 45 21 16 Figure 22 Printer Button Screen Layout The Printer button prints the Current Single Claim the All Claims Report the Current Bill Summary and the Current Provider Summary The printer options are listed in the next chapter NOTE The arrow up and down buttons are available for parsing through to the next claim to be viewed printed Page 34 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 mm TOOL BAR OPTIONS GCR BUTTON PeP 021016AA X12 PC Print i File Edit View Admin Help Tv wm far lolol ale E ol aJ GS GS 267 a A ST 267001 Sy BPR 020626 TRN 9000000468 REF 44 01 DTM 020823 N1 HOSP N3 N3 N4 N4 000913 TS3 400016 CLP 600182689 1 CAS CR NMT BARBERO MOA MADI REF 0001079178 DTM 000704 DTM 000704 AMT AU QTY CA SYC HC 80048 DTM 000704 CAS CR AMT B6 SYC HC 850317 DTM 000704 CAS CR AMT B6 SYC Ho s1 000 DTM 000704 CAS CR AMT B6 SYC HC 71020 DTM 000704 CAS CR REF
78. SL Segment List button returns the display to the segment list format from any other location in the application Example If the current selection is AC for the All Claims screen selection of the SL button returns the user to the segment list display Page 28 Use or disclosure of the data contained on this sheet is subject to restrictions of contract H HHSM 500 2007 00016I Task Order HHSM 500 T0003 TOOL BAR OPTIONS PS BUTTON PeP 021016AA X12 PC Print for Window File Edit View Admin Help Cs el a fell ole Bl hl Medicare National Standard Remittance Advice HOSP PO BOX 1234 SAN JUAN PR 00919 NPI 9999999999 CHECK EFT NUMBER 0000026805 PAYMENT SUMMARY PAYMENT TOTAL 606551 42 BILLING CYCLE 08 26 02 TOTAL CLAIMS 2308 TOTAL PIP CLAIMS 0 Payer Business Contact Information Telephone Telephone Extension Facsimile Electronic Mail Payer Technical Contact Information Telephone Facsimile Electronic Mail Uniform Resource Locator URL Payer Web Site Uniform Resource Locator URL Figure 17 PS Provider Summary Button Screen Layout The PS Provider Summary button displays the Payment Summary screen format The Provider Summary Report screen and report now includes the Payer Business and Technical Contact information in addition to the PLB composite data when reporting provider level adjustments NOTE The up down arrows allow for the forward and backward parsing through the file If neces
79. T DAYS VISITS 0 00 CAP OUTLIER 12 COST REPT 0 00 CASH DEDUCT 12 COVD UTIL 0 00 BLOOD DEDUCT 0 00 INTEREST 0 NON COVERD 0 00 COINSURANCE 0 00 CONTRACT ADJ 0 COVD VISITS 0 00 PAT REFUND 0 00 PER DIEM AMT 0 NCOV VISITS 0 00 SEQUESTRATN 0 00 NET REIM AMT 0 00 ACO PIONEER Figure 58 Mapping 5010 835 to Bill Summary Report Layout Loop 1000B N1 Payee Identification N102 Payee Name when N101 equals PE Loop 2000 TS3 Provider Summary Information TS303 Fiscal Period Date Loop 1000A N1 Payer Identification N102 Payer Name when N101 equals PR Loop 1000B N3 Payee Address N301 Payee Address Line Header BPR Financial Information BPR16 Check EFT Date Loop 1000A N3 Payer Address N301 Payer Address Line PROVIDER CITY ST ZIP Loop 1000B N4 Payee City State and Zip Code N401 City N402 State or Province Code N403 Postal Code Page 82 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING TS304 Total Claim Count INTERMEDIARY Loop 10004A N4 Payer City State and Zip Code CITY ST ZIP N401 City N402 State or Province Code N403 Postal Code Loop 1000B N1 Payee Identification N104 Payee Identification Code when N103 equals XX else Loop 1000B REF Payee Additional Identification REFO2 when REFO equals PQ TOB Loop 2000 TS3 Provider Summary Information TS302 Facility Type Code CHARGES T305 Total
80. XxX 123456789A 10008011 Ol 75 001 0 00 0 00 0 00 366 00 4 22 10001109082 ol 0 00 0 00 135 91 0 00 0 00 9999999999 HIC CHG HN TOB 138 1 Ol 366 00 0 00 0 00 0 00 132 11 9 0 001 BETANCOURT X 800187158 1 10007111 Ol 453 52 0 00 0 510 88 38 202218000672XXXXX 123456789A 10007111 ol 365 14 0 00 0 00 0 00 88 38 5 122 10000044544 ol 0 00 0 00 0 00 0 00 0 00 9999999999 HIC CHG HN TOB 13I 1l 0l 395 77 0 00 0 00 0 00 0 00 8 0 00 BETANCOURT X 800200716 1 10008011 Ol 441 00 0 00 0 510 61 30 2022180006730XXXX 123456789A 10008011 ol 75 00 0 00 0 00 0 00 366 00 6 122 10001109082 ol 0 00 0 00 96 16 0 00 0 00 9999999999 HIC CHG HN TOB 131 11 Ol 366 001 0 001 0 001 0 001 208 54 6 4 Hl p Figure 20 Active Scroll Bar Screen Layout Page 32 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016l Task Order HHSM 500 T0003 gt TOOL BAR OPTIONS SC BUTTON PcP 021016AA X12 PC Print for Window TA x File Edit View Admin Help F ef af esiaslacfsc ee S sl Medicare National Standard Intermediary Remittance Advice FPE 09 30 00 HOSP PAID 08 26 02 PO BOX 1234 CLM 19 SAN JUAN PR 00919 NPI 9999999999 TOB 130 PATIENT TRIGO EX oc PCN 800082766 1 HIC 123456789A SVC FROM 02 10 00 MRN 0001101638 CLAIM STAT 4 THRU 02 10 00 ICN 20223300224102 CHARGES PAYMENT DATA DRG 0 510 REIM RATE 3
81. a File Segments and Detail Data Elements Screen Layout cccccccceeeeeeeeeees 27 SL S gment List Button Screen Gay Out ecirar E E S 28 PS Provider Summary Button Screen Layout 2 00 0 cccccccssssssesseseseeeeeceeeeeeeeeeeaas 29 BS Bill Summary Button Screen Layout cc ccccecssssseeeeeeeeceeeeeeeaaeeeeessssseeeseeeeess 30 AC CAMs Claims Button Screen May Out a7 nc Cie Mac stiatc ct acs a ctaeda 31 ACiiVe Scroll Bar Screech bay OU iszctastcian ates saa dca tasdaadesenda EN 32 SC Single Claim Button Screen Layout cc ccccccsssssssssesseeeeeeceeeeeeeeeeeeaeaaaaeeeeees 33 Printer Button Screen Ay OU das at asians Ea ET 34 GCR Group CARC RARC Button Screen Layout eeesssesssssssseseeeeeeresssssssssssssse 35 GCR Code Search Option Screen Layout cc cc cssssesssssseeeecceeeeeeeeeeeaaeaeessessseeeeeeeeees 36 GCR Display Full CARC RARC Description Buttons Screen Layout 08 37 BUS SCE Business Scenario Button Screen Layout cccccccsssssssssssseseeeseeeees 38 Business Scenarios Code Combination Listing Screen Layout ccccceeeeeeees 39 Business Scenario Dialog Box Screen Layout cccccccccccccceeceeeeeeaeeseeesessseeeeeeeeees 40 PrntvExample A Screen Layou tice aa a E a a N 43 Print Example B Print All Items Screen Layout seeeessssssoeeeeeeeenssssssssssssssesceeeeees 44 Print Bxample C Screen Layouleeriemini n a ia a a aa 45 Pint Exa
82. bject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING HOME HEALTH HOSPICE ALL CLAIMS REPORT Provider NPI Povder Name Fiscal Year End FIMMAC Name Faid Date Pare patient name patententl member frmdt cost pti ches an daya me days tamb rate allor reim interest icn umber hie number thr dt covly neviidemed ptdays na days mep pri pay po cdam pateni dam klam states medical rec number ncviy claim ads stdaye coin amt prof comp line adj amt deductibles mational provider id hic che x tob axx ev in ney 1 covd ches ot days sequestrain esd amt cont adj amt net reinb Figure 60 Mapping 5010 835 to All Claims Report Header Layout Loop Segment Data Element PROVIDER NPI Loop 1000B N1 Payee Identification N104 when N103 equals XX else Loop 1000B REF Payee Additional Identification REFO2 when REFO1 equals PQ N101 equal PE TS303 Fiscal Period Date Loop 1000A N1 Payer Identification N102 when N101 equals PR Header BPR Financial Information BPR16 Check EFT Date PC Print sets the page Loop 2100 NM1 Patient Name NM103 Last Name and NM104 First Name Initial CLPO1 Claim Submitter s Identifier DTM0O2 Claim Date when DTMOI equals 232 Information MIA15 Cost Report Day Count CLPO3 Total Claim Charge Amount SN DAYS Loop 2110 SVC Service Payment Information when SVCOI 1 equals NU and SVCO1 2 equals 55X this field value is equal to SVCOS5 MS DAYS Loop 2110 SVC Service Payment I
83. ct H HHSM 500 2007 00016I Task Order HHSM 500 T0003 GETTING STARTED her PeoOl PC Prira for Windows AES a For heto press PL Figure 2 Printer Setup Dialog Box Printer Drivers Screen Layout Along with the printer setup in the PC Print application being set up ensure that the Print Drivers are also set appropriately as one of the reports Single Claim uses two print fonts NOTE If the print drivers are not configured correctly the single claim does not print appropriately it prints as a single line PC Print does not print the report it turns over the print to Windows which communicates to a selected printer Therefore it is very important that the appropriate print drivers are loaded on any network printers or on the PC for any local printers If there is still an issue printing the reports it may be due to old hardware technology being used with new software technology thus an upgrade of printer and or operating system may be required GENERAL TEXT PRINT FILE If the user wants to generate a print file generate text file there should be a generic text print driver loaded To create the print file setup the dialog box by 1 Printer Name Generic Text Printer 2 Paper Size Ledger 3 Orientation Portrait Once the file is created it can be downloaded to a mainframe for viewing Page 13 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 0001
84. cted to print Select File then Print Marked Items and the claims that were marked are printed Refer to example E Page 41 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 PRINTING OPTIONS PRINTING THE ALL CLAIMS REPORT 1 When in the All Claims format printing the entire report can be done by clicking on the Printer button 2 When in the All Claims format and the user would like to print only selected claims but in the single claim format first select the claims to be printed by clicking on Edit then Mark For Print for all the claims to be printed Once the selection is complete click on the SC button This displays the single claims format then select File then Print Marked Items The claims selected from the AC format are printed in the SC format 3 Another way to print the entire All Claims report is to select File then Print or CTRL P PRINTING THE PROVIDER SUMMARY REPORT 1 When in the Provider Summary format click on the Printer button on the Tool Bar and the current summary prints To print additional summaries parse through using the up down arrows and use the Printer button 2 Another way to print the Provider Summary report s is to select File then Print or CTRL P PRINTING THE BILL SUMMARY REPORT 1 When in the Bill Summary format click on the Printer button on the Tool Bar and the current summary p
85. de in CASO2 05 08 11 14 17 equals 23 PROC CD AMT Loop 2100 MOA Outpatient Adjudication Information MOAO02 Claim HCPC Payable Amount PAT REFUND Loop 2100 CAS Claim Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals AO and Loop 2110 CAS Service Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals AO CLAIM PC Print Assigned CLAIM STATUS MEDICAL REC NUMBER NCVDV CLAIM ADJ DRG O C COIN AMT Loop 2100 CLP Claim Payment Information CLPO2 Claim Status Code Loop 2100 REF Other Claim Related Identification REFO2 Other Claim Related Identifier when REFO1 is EA Loop 2100 QTY Claim Supplemental Information Quantity QTY02 when QTYO1 equals NE Loop 2100 CAS Claim Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when CASO1 equals OA and Adjustment Code in CASQ2 05 08 11 14 17 equals A7 Loop 2100 MIA Inpatient Adjudication Information equals MIA06 Claim Disproportionate Share Amount MIAO08 Claim PPS Capital Amount MIA18 Claim Indirect Teaching Amount Loop 2100 CAS Claim Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 2 3 and 122 and Loop 2110 CAS Service Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO02 05 08 11 14 17 equals 2 3 and 122
86. ents the second column shows the segments within the GS and the third column reflects the data in each segment example follows NOTE On the bottom left of the screen it states the total number of claims and total number of segments in the data file Page 63 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 PROCESSING PROCEDURES Segments PeP 021016AA X12 PC Print for Window File Edit View Admin Help x ne su PS BS ac sc cr GS AT GS 267 ST 267001 BPR 020826 TRN 9000000468 REF 4A 01 DTM 020623 N1 HOSP N3 N3 N4 N4 Lx 000913 T53 400016 CLP 800182689 1 CAS CR NMT BARBERO MOA MAQT REF 0001079176 DTM 000704 DTM 000704 AMT AU QTY CA SVC HC 30048 DTM 000704 CAS CR AMT B6 SVC HC 85031 DTM 000704 CAS CR AMT B6 SYC HC 81 000 DTM 000704 CAS CR AMT B6 SVC HC 71020 DTM 000704 CAS CR REF R AMT B6 SVC Ho 9s9s201 DTM 000704 CAS CR AMT B6 Total claims 2308 Total segments 78145 m Data Elements a Functional Identifier Code gt Intermediary Number Provider Number File Creation Date File Creation Time Group Control Number Responsible Agency Code ANSI Version Code HP 00466 400016 020623 1914 267 x 003051 Figure 50 Data File in Segment List SL Format Screen Layout 2 of 2 6 This screen shows the data in each segment as selected A vertical scroll bar
87. er s p ive The Ghegeerie te Leeeneletent whi the politi e opts Bete Sefer te The 595 Beeliboere Poliny 6 TETEL LL The GLeGeeese Le LADOATLPTOnG WEEE She Petieet s Genter Sote Sefer be the 95 Besithoaere Peis j ETAS The GheGeeeie L LROORFLOTORE SESE She procer Trie Defer te the 95 Beeltbeere Peliey fee LJ L isiees The Giegeeeies i thecesietent with the preerider type Bote Sefer to the 855 Bealtbcere Policy is TETES LL The dete of Geath prececdes the date of service 134 LILL ppo The gete of Barth foellews the Gente of service pms TETAI Pene evtherieetios AGer bf S1001ee LOTOlLiG OF Gneo Set appiy FO The Dilig parrioeo Cf pimi CAAC Cale Seon CE or Come Mae So Ome PP lee ee wisi Step St Cotea SUTRAS the Peet 17 Sethe OF Seer ehOege FF the lert of Leeetment n TETESI D i peig eoperete y whee the petieet ie wn Lepetient TEES GL Equspeest ie the pne OF fbeb ler to egeigment sireety being ores 3 300 Alerts Thie be the beet Geethiy ineteliaest payment for tebe Gepeblie sections equiguent TATEN A Meethiy rettel polente cat Gottifue wetil the earlier ef the IMA Swett free the fijet festei TETAN D Alertt Tou Swot ferhieh eso service this itea for ety period of sedicel seed fer the temeieder g L71999 Bb feetel Peyronie efter the item ie peretered of efter the piel Of Leewed frentel peywente TATEN ze OF HOt mept ploca Gee Cepte fepulte whee Obe feet wes SGehertet by Getieel eupplier mtr ras ieee Alerte Thie be Ghee CeRRe PORES Mar
88. er to the 835 Healthcare Policy Identificati 1 1 1995 The diagnosis is inconsistent with the provider type Note Refer to the 835 Healthcare Policy Identific 1 1 1995 The date of death precedes the date of service 1 1 1995 The date of birth follows the date of service 1 1 1995 The authorization number is missing invalid or does not apply to the billed services or provider 1 1 1995 Claim service lacks information or has submission billing error s which is needed for adjudication Do 1 1 1995 7 1 2009 Requested information was not provided or was insufficient incomplete At least one Remark Code must be 1 1 1995 Exact duplicate claim service Use only with Group Code OA except where state workers compensation regi 1 1 1995 This i Description for CARC ID mae Worker s Compensation Carrier 1 1 1995 This ee EE 1 1 1995 This if 1 1 1995 This c Fa SENE 1 ES s 1 1 1995 The im The diagnosis is inconsistent with the patient s age Note Refer djustments Use only with Group Ce P to the 835 Healthcare Policy Identification Segment loop 2110 Service Payment Information REF if present 3 T Display Full CARC Description Effective Date 1 1 1995 RARC Code Effective Term Date RARC Descrip Term Date 1 1 1997 One inti rchased diagnostic test is indicat a 1 1 1997 Our re e limitations and the procedure coc__ 1 1 1997 Missing La 1 1 1997 6 2 2005 Missing G or referring physician identific 1 1 1997 Paid at y the modified
89. f the screen displays the total number of claims Page 66 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 PROCESSING PROCEDURES PeP 021016AA X12 P Print for Windows L k x File Edit View Admin Help l mef s PS sfe e S amp PATIENT NAME PATIENT CNTRL NUMBER FRM DT COST REPTD CHGS DRG NBR OUTLIER AMT REIMB RATE ALLOW REIM INTEREST ICN NUMBER HIC NUMBER THR DT COVDV NCVD DENIED DRG AMOUNT DEDUCTIBLES MSP PRI PAY PROC CD AMT PAT REFUND CLAIM CLM STATUS MEDICAL REC NUMBER INCVDV CLAIM ADJS DRG O C COINS AMT PROF COMP LINE ADJ AMT PERDIEM AMT NATIONAL PROVIDER ID HIC CHG x TOB xxx CV LN NCV L COVD CHGS NEW TCH ECT SEQUESTRATN ESRD AMT CONT ADJ AMT NET REIMB l l l l ACO PIONEER 00 0 510 13 73 BARBERO x 800182689 1 1000704 0l 255 04 l 0 0 00 20221800013 9XXXXxX J123456789A 1000704 0l 93 42 0 00 100 00 0 00 161 62 0 00 2 122 10001079178 0l 0 00 0 00 7 64 0 00 0 00 0 00 9999999999 HIC CHG HN TOB 13I 1 0 224 24 0 00 0 00 0 00 67 71 La ia 0 00 BETANCOURT Xx 800187158 1 1000711 0l 453 52 l 0 00 0 510 88 38 0 00 200216002 6XXXX 123456789A 1000711 0l 365 14 0 00 0 00 0 00 395 771 0 00 3 22 10000044544 0l 0 00 0 00 0 00 0 00 0 00 0 00 99999999993 HIC CHG HN TOB 138 1 0l 395 77 0 00 0 00 0 00 0 00 88 38 0 00 BETANCOU
90. formation CLP02 Claim Status Code Loop 2100 DTM Statement From or To Date DTMO02 when DTMO01 is 233 Claim Statement Period End ICN Loop 2100 CLP Claim Payment Information CLPO7 Claim Payment Control Number CHARGES CLP0O3 Total Claim Charge Amount NCVD DENIED Loop 2100 CAS Claim Adjustment CAS03 06 09 12 15 18 when CASO2 05 08 11 14 17 does not equal 1 2 3 23 45 66 70 89 94 97 118 122 and Loop 2110 CAS Claim Adjustment CASO3 06 09 12 15 18 when CASO2 05 08 11 14 17 does not equal 1 2 3 23 45 66 70 89 94 97 118 122 CLAIM ADJS Loop 2100 CAS Claim Adjustment CAS03 06 09 12 15 18 LINE ADJ AMT Loop 2110 CAS Claim Adjustment CASO3 Adjustment Amount CASO06 Adjustment Amount CAS09 Adjustment Amount CAS12 Adjustment Amount CAS15 Adjustment Amount CAS18 Adjustment Amount COVERED Loop 2100 AMT Claim Supplemental Information AMT02 when AMTO1 is AU Coverage Amount DAYS VISITS Loop Segment Data Element COST REPT Loop 2100 MIA Inpatient Adjudication Information MIA15 Total Cost Report Day Count COV UTIL Loop 2100 MIA Inpatient Adjudication Information MIAQ1 Total Covered Days or Visits Count NON COVERED Loop 2100 QTY Claim Supplemental Information Quantity QTY02 when QTYO1 equals NE Page 97 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003
91. he data contained on this sheet is subject to Page 30 qi TOOL BAR OPTIONS AC BUTTON PcP 021016AA X12 PC Print for Windows Ol X File Edit View Admin Help mef s PS sfe eje S amp PATIENT NAME PATIENT CNTRL NUMBER FRM DT COST REPTD CHGS DRG NBR OUTLIER AMT REIMB RATE ALLOW REIM INTEREST ICN NUMBER HIC NUMBER THR DT COVDV NCVD DENIED DRG AMOUNT DEDUCTIBLES MSP PRI PAY PROC CD AMT PAT REFUND CLAIM CLM STATUS MEDICAL REC NUMBER INCVDV CLAIM ADJS DRG O C COINS AMT PROF COMP LINE ADJ AMT PERDIEM AMT NATIONAL PROVIDER ID HIC CHG x TOB xxx CV LN NCV LICOVD CHGS NEW TCH ECT SEQUESTRATN ESRD AMT CONT ADJ AMT NET REIMB l l l l ACO PIONEER l 00 0 510 1 3 T31 BARBERO x 800182689 1 1000704 Ol 255 04 l 0 0 00 20221800013 9XXXXxX 123456789A 1000704 Ol 93 42 0 00 100 00 0 00 161 62 0 00 2 122 10001079178 l Ol 0 00 0 00 7 64 0 00 0 00 0 00 9999999999 HIC CHG HN TOB 13I 1 0l 224 24 0 00 0 00 0 00 67 71 13 73 0 00 BETANCOURT x 800187158 1 1000711 Ol 453 52 l 0 00 0 510 88 38 0 00 200216002 6XXxXxX 123456789A 1000711 ol 365 14 0 00 0 00 0 00 395 77 0 00 3 122 10000044544 l l 0l 0 00 0 00 0 00 0 00 0 00 0 00 9999999999 HIC CHG HN TOB 138 Ol 395 TT 0 00 0 00 0 00 0 00 88 38 0 00 BETANCOURT x 800200716 1 1000801 0l 441 00 l 0 00 0 510 97 98 0 00 2002230008XXxXx 123456789A 1000801 0l 75 00 0 00 0 00 0 00
92. hen Adjustment Code in CASO2 05 08 11 14 17 equals 118 and group code CO and CARC 132 Information MOAOI Reimbursement Rate TS313 Total MSP Payer Amount PROF COMPONENT Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when CASO1 Group Code equals CO and CASO2 05 08 11 14 and 17 Reason Code equals 89 Professional Fees removed from charges and Loop 2110 CAS Service Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when CASOI1 Group Code equals CO and CASO02 05 08 11 14 and 17 Reason Code equals 89 Professional Fees removed from charges Page 85 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Loop Segment Data Element LINE ADJ Loop 2110 Service Line Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when CASO1 equals OA and Adjustment Code in CASQ2 05 08 11 14 17 equals A7 PROC CD AMOUNT Loop 2000 TS3 Provider Summary Information TS318 Total HCPCS Payable Amount INTEREST Loop 2100 AMT Claim Supplemental Information AMTO2 Claim Supplemental Information Amount when AMTO1 equals I Interest This is the sum of all claims in the LX Loop CONTRACT ADJ Loop 2100 CAS Claim Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 45 and 59 and Loop 2110 CAS Service Adj
93. ity QTY02 Claim Supplemental Information Quantity when QTYOI equals NE This is the sum of all claims in the LX loop PAYMENT DATA Loop Segment Data Element fafonmation TS201 Total DRG Amount DRG OPER CAP Loop 2000 TS2 Provider Supplemental Summary Information TS202 Total Federal Specific Amount plus TS203 Total Hospital Specific Amount plus TS204 Total Disproportionate Share Amount plus T S206 Total Indirect medical Education Amount OUTLIER Loop 2000 TS2 Provider Supplemental Summary Information TS208 Total Day Outlier Amount plus TS209 Total Cost Outlier Amount CAP OUTLIER Loop 2100 MIA Inpatient Adjudication Information MIA17 Claim PPS Capital Outlier Amount This is the sum of all claims in the LX Loop CASH DEDUCT Loop 2100 CAS Claim Adjustment CASO03 06 09 12 15 and 18 Adjustment Amount when CASO1 Group Code equals PR and CASO02 05 08 11 14 and 17 Reason Code equals 1 Deductible and Loop 2110 CAS Service Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when CASO1 Group Code equals PR and CASO2 05 08 11 14 and 17 Reason Code equals 1 Deductible BLOOD DEDUCT Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when CASO1 Group Code equals PR and CAS02 05 08 11 14 and 17 Reason Code equals 66 Blood Deductible and Loop 2110 CAS Service Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when CASO1 Group Code equals PR and CASO2 05 08 11 14 a
94. justments REV DATE HCPCS APC HIPPS MODS QTY CHARGES ALLOW REIM GC RSN AMOUNT REMARK CODES LICN HCPI SVC Desc 0730 09 18 93005 90099 1 000 52 00 5 60 CR 2 7 41 45 38 99 CR Correction 2 Coinsurance Amount 45 Charge exceeds fee schedule maximum allowable or contracted legislated fee arrangement Use only with Group Codes PR or CO depending upon liability Figure 36 Find Dialog Box Screen Layout In the Find dialog box there are options as to which data field to do a find on patient last name medical record number HIC number and the patient control number 1 In the Find What box key in the data to search on 2 Click on the appropriate search field then click OK The application searches for the selection and brings it to the screen for viewing or it brings up the message Search text not found Page 50 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016l Task Order HHSM 500 T0003 FIND OPTIONS File Edit View Admin Help Medicare National Standard Intermediary Remittance Advice 4 FPE 09 30 00 HOSP J PAID 08 26 02 PO BOX 1234 CLM 3 SAN JUAN PR 00919 NPI 9999999999 TOB 138 PATIENT BETANCOURT x PCN 800187158 1 HIC 123456789A SVC FROM 07 11 00 MRN 0000044544 CLAIM STAT 22 THRU 07 11 00 ICN 200216002 6XXxXxX CHARGES PAYMENT DATA DRG 0 510 REIM RATE 453 52 REPORTED 0 00 DRG AMOUNT 0 00 MSP PRIM PAYER 365
95. le is opened the PC Print application displays on the left side of the screen the data file segment listing the GS segment s Also displayed on this screen in a deblocked segment format one segment per line is each segment of the transmitted X 12 835 file NOTE At the bottom of the screen there is a status bar that provides information about the 835 X12 data file It provides the total number of claims in the file and the total number of segments in the file If the total number of segments exceeds the file size limitation of approximately 80 000 segments and the user accesses the All Claims or Single Claims report and encounters the claim that exceeds the limitation an error message displays The user needs to shut down PC Print and restart the application Page 26 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 TOOL BAR OPTIONS Segments Data Elements PeP 021016AA 12 PC Print for Windov rrr File Edit View Admin Help ne sL PS BS ac LAC GS AT GS ej 267 a Functional Identifier Code HP ST 267001 Intermediary Number 00468 BPR 020826 Provider Number 400016 TRN 9000000468 File Creation Date 020823 REF 4A 01 File Creation Time 1914 DTM 020823 Group Control Number 267 NI HOSP Responsible Agency Code x N3 N3 ANSI Version Code 003051 N4 N4 LX 000913 T53 400016 CLP 800162689 1 CAS CR NMT BARB
96. maximum allowable or contracted legislated fee arrangement Use only with Group C First Revenue Line Headings Loop Segment Data Element REV Loop 2110 SVC Service Payment Information SVCO1 2 when SVCOI 1 is NU National Uniform Billing Committee NUBC Codes DTMO1 is 472 Service HCPCS Loop 2110 SVC Service Payment Information SVCOI1 2 when SVCOI 1 is HC Health Care Common Procedural Coding System HCPCS APC HIPPS Loop 2110 REF Service Identification REFO2 when REFO1 is APC Ambulatory Payment Classification or REFO1 is 1S Ambulatory Patient Group APG Number And Loop 2110 SVC Service Payment Information SVCO1 2 when SVCO1 1 is HP Health Insurance Prospective Payment System HIPPS Skilled Nursing Facility Rate Code MODS Loop 2110 SVC Service Payment Information Procedure Modifiers SVCO1 3 SVCO1 4 SVCO1 5 SVCOI1 6 QTY Loop 2110 SVC Service Payment Information SVCOS5 Units of Service Paid Count SVC02 Line Item Charge Amount Loop 2110 SVC Service Payment Information SVCO03 Line Item Provider Payment Amount Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 Page 80 SYSTEM LAYOUT MAPPING Loop Segment Data Element Loop 2110 CAS Claim Adjustment CASO1 Claim Adjustment Group Code RS Loop 2110 CAS Claim Adjustment Adjustment Reason Codes CAS02
97. me Dasein a 46 Print Example E Print Marked Items Screen Layout cc ceeseesssseeeeeeeeeeeeeeeeees 47 Find Options General Screen ay OU cso ticaertacentcarun Cidsatncearaadinediiatesaicereee leate tenant eseats 48 Single Claims Find Option Screen Layout 0000000000eneeeeeereerrsssssssnssneeceeereersssssssesssns 49 Fine Dialog BOX Sereen a yOu lancaster ieee E 50 Sinole Claim Screen eay OG esricaencshic inn nag lasses E saiutentvanaieersearemaenaneaes 51 All Claims Find Feature Screen Layout cccccccccecccceecceceeeceasseesseseseeeeeeeeeeeeeeeeaaas 32 All Claims Find AC Button Screen Layout eensssesssssssssseeeererersssssssssssssseseereeees 53 All Claims AC Search Results Screen Layout ccccccccccssssssssssseseeeeeccceeeeeeennaas 55 SC Single Claim Format Screen Layout 0 ccccccsssssssssessseeeeeceeeceeeeseeeeaaaaeeeeeeees 56 SC Sinsle Clam STE n LIN O gt cco scanside eater E a stances 57 CARC RARC Find Option Screen Layout cc cc cecsesssssseeeececeeeeeeeeeeaaaaasseseseseeeeeeeess 58 Find CARC RARC Dialog Box Screen Layout cccccccssssseesesseeeeeeeeeeeeeeseaaaas 59 Blank SL Segment List Screen Layout scccccicenciacoii cnn nis 60 X12 Button Open Dialog Box Screen Layout 1 Of 2 ceesseseseeeeeeeeeeeeeeeeeaes 61 X 2 Button Open Dialog Box 2 O82 Vaesed inan Sevvedca eaawont E denen 62 Page 4 Use or disclosure of the data contained on this sheet is subject
98. n 9 Running the PC Print Program 1 ERA Version Information 1 ERA Version 5010 11 Printer Setup 12 General Text Print File 13 Chapter 4 22222222 nee n nnn n ene n nnn n nnn n nee e eee eee 14 Menu Bar Options 2 0 2222220000002202200 14 Accessing the Screen 14 File Option 15 Edit Option 16 View Option 17 Admin Option 18 Help Option 23 Chapter 5 24
99. n Tee Geet Offer the PetLent the Saide Of Gheeging the Fe 1 3 7399 Spxuigeest Pereheses af Lisites to the Fiii Of the tenth Gets Of pethal Heteoeity 1 3 3997 a esthctics enc gpecethetice gust be billed to the DE certior whe services the getient s sip 3 Y Pah am at Oeria FA oeng Oe O9 Cent pertees Aateetenes ri Peper Sectieted Segurtieee GA Geepentees me Lispro Sood A other AT ee teen n Petiest Berpoari ba lity Figure 45 Find CARC RARC Dialog Box Screen Layout In the Find CARC RARC dialog box provides a code search option to locate specific codes without having to page up and down the listing 1 In the CARC Code Search or RARC Code Search box key in the code to search on The screen automatically scrolls to the code entered or the closest code if the entered code is not located in the listing Page 59 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHHSM 500 2007 00016I Task Order HHSM 500 T0003 PROCESSING PROCEDURES CHAPTER 8 PROCESSING PROCEDURES This section explains directions necessary to load a new data file and to process claims once the data file has been successfully loaded LOADING NEW DATA FILE AND PC PRINT PROCESS Each new 835 mailbox transmission received needs to be copied or transferred from the data set file into the PC Print data file before viewing and or printing in the PC Print application The recommended data file naming convention is
100. nd 17 Reason Code equals 66 Blood Deductible age 84 84 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Loop Segment Data Element COINSURANCE Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when CASO1 Group Code equals PR and CAS02 05 08 11 14 and 17 Reason Code equals 2 Coinsurance 3 Co Payment and 122 Psychiatric Reduction and Loop 2110 CAS Service Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when CASO1 Group Code equals PR and CASO2 05 08 11 14 and 17 Reason Code equals 2 Coinsurance 3 Co Payment and 122 Psychiatric Reduction PAT REFUND Loop 2000 TS3 Provider Summary Information TS322 Total Patient Reimbursement Amount SEQUESTRATN Loop 2100 CAS Claim Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 118 and group code CO and CARC 223 and Loop 2110 CAS Service Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 118 and group code CO and CARC 223 ACO PIONEER Loop 2100 CAS Claim Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 118 and group code CO and CARC 132 and Loop 2110 CAS Service Adjustment CASO3 06 09 12 15 and 18 Adjustment Amount w
101. nformation when SVCOI 1 equals NU and SVCO1 2 equals 56X this field value is equal to SVCOS5 Information MOAOI1 Reimbursement Rate Page 90 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Field ALLOW REIM INTEREST ICN NUMBER HIC NUMBER THR DT COVDV NCVD DENIED PT DAYS NA DAYS MSP PRI PAY PROC CD AMT Loop Segment Data Element Loop 2110 SVC Service Payment Information SVCO03 Line Item Provider Payment Amount this is the sum of all revenue lines Loop 2100 AMT Claim Supplemental Information AMTO2 Claim Supplemental Information Amount when AMTOI1 equals I Interest Loop 2100 CLP Claim Payment Information CLPO7 Payer Claim Control Number Loop 2100 NM1 Patient Name NM109 Patient Identifier when NM108 equals HN Loop 2100 DTM Statement From or To Date DTM0O2 Claim Date when DTMOI1 equals 233 Loop 2100 MIA Inpatient Adjudication Information MIAQ1 Covered Days or Visits Count Loop 2100 CAS Claim Adjustment CASO03 06 09 12 15 and 18 Adjustment Amount when adjustment code in CASO2 05 08 11 14 17 equals any adjustment code except 1 2 3 23 45 66 70 89 94 97 118 122 and Loop 2110 CAS Service Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CAS02 05 08 11 14 17 equals any adjustment code except 1 2 3 23 45 66 70
102. nt Amount CAS18 Adjustment Amount when CAS02 is 66 COINSURANCE Loop 2100 CAS Claim Adjustment CAS03 Adjustment Amount CASO06 Adjustment Amount CAS09 Adjustment Amount CAS12 Adjustment Amount CAS15 Adjustment Amount CASI8 Adjustment Amount when CAS02 is 2 3 and 122 Page 77 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Loop Segment Data Element PAT REFUND Loop 2100 CAS Claim Adjustment CASO3 Adjustment Amount CAS06 Adjustment Amount CAS09 Adjustment Amount CAS12 Adjustment Amount CAS15 Adjustment Amount CAS18 Adjustment Amount when CAS02 is AQ REIM RATE Loop 2100 MOA Outpatient Adjudication Information MOAOI1 Reimbursement Rate MSP PRIM PAYER Loop 2100 CAS Claim Adjustment CASO3 Adjustment Amount CASO06 Adjustment Amount CAS09 Adjustment Amount CAS12 Adjustment Amount CAS15 Adjustment Amount CASI8 Adjustment Amount when CAS02 is 23 PROF COMPONENT Loop 2100 CAS Claim Adjustment CASO3 Adjustment Amount CAS06 Adjustment Amount CAS09 Adjustment Amount CAS12 Adjustment Amount CAS15 Adjustment Amount CAS18 Adjustment Amount when CAS02 is 89 ESRD AMOUNT Loop 2100 CAS Claim Adjustment CASO3 Adjustment Amount CASO06 Adjustment Amount CASO9 Adjustment Amount CAS12 Adjustment Amount CAS15 Adjustment Amount CAS18 Adjustment Amount when CAS
103. ntract HHSM 500 2007 00016I Task Order HHSM 500 T0003 INTRODUCTION CHAPTER 1 INTRODUCTION This section provides knowledge on PC Print as well as explains the benefits of using this system DESCRIPTION AND USE The PC based ANSI ASC X12 835 translator program PC Print is an interactive program written for the IBM PC and compatibles It allows the viewing and printing of the Medicare Part A Electronic Remittance Advice received by the Provider in the form of an ANSI ASC X12 835 Electronic Remittance Advice The primary purpose of the program is to produce a paper remittance advice containing all of the data residing within the ANSI ASC X12 835 Electronic Remittance Advice transmission The intent of the paper remittance advice is to facilitate Accounts Receivable processing for the end user a Provider who does not have access to sophisticated data processing facilities Also to produce a paper remittance advice acceptable for subsequent payers processing when electronic links capable of ANSI ASC X12 835 transmission do not exist Page 6 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 INTRODUCTION BENEFITS OF THE PC PRINT PROGRAM Viewing facilities exist to display a Single Claim Compressed font is incorporated in order to display the detail line item activity of a claim The All Claims display allows the operator to view all of
104. pplication e Available for use is the Next and Prev options These can be used to parse forward and backward through the different formats e Provides the ability to view CARC RARC codes the associated effective dates termination dates and the descriptions The CARC RARC option also depicts Group codes e Provides the ability to view the four Business Scenarios with the associated CARC RARC and group codes Page 17 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 MENU BAR OPTIONS ADMIN OPTION PeP Pep01 PC Print for Window File Edit View Help o CYC Intermediary 8 A Providers Figure 7 Admin Toolbar Option Screen Layout MENU OPTION ADMIN Based on changes made for the processing of a HIPAA 5010 835 X12 file this menu option is no longer required to be used The application is mapping this information from the 835 X12 file 1 The Admin menu has two options e The Intermediary option is where the user can add the Intermediary name and address so that it is printed out on the reports and screens e The Provider option is where the user can add the Provider s number name and address information so it appears on the reports and screens Page 18 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003
105. procedure Note Refer to the 835 Healthcare Policy Ide 1 1 1995 The diagnosis is inconsistent with the provider type Note Refer to the 835 Healthcare Policy 1 1 1995 The date of death precedes the date of service 1 1 1995 WA The date of birth follows the date of service owrnwn bp WD bb 1 1 1995 The authorization number is missing invalid or does not apply to the billed services or provi CARC Code Search RARC Code Effective Term Date RARC Description Mi 1 1 1997 X ray not taken within the past 12 months or near enough to the start of treatment M2 1 1 1997 Not paid separately when the patient is an inpatient M3 1 1 1997 Equipment is the same or similar to equipment already being used M4 1 1 1997 Alert This is the last monthly installment payment for this durable medical equipment MS 1 1 1997 Monthly rental payments can continue until the earlier of the 15th month from the first rental m M6 1 1 1997 Alert You must furnish and service this item for any period of medical need for the remainder q M7 1 1 1997 No rental payments after the item is purchased or after the total of issued rental payments eq M8 1 1 1997 We do not accept blood gas tests results when the test was conducted by a medical supplier or ta M9 1 1 1997 Alert This is the tenth rental month You must offer the patient the choice of changing the ren 1 1 1997 Equipment purchases are limited to the first or the tenth month of medical necessity M11 1 1 199
106. re 28 Figure 29 Figure 30 Figure 31 Figure 32 Figure 33 Figure 34 Figure 35 Figure 36 Figure 38 Figure 39 Figure 40 Figure 41 Figure 42 Figure 43 Figure 44 Figure 45 Printer Setup Toolbar Option Screen Layout cccccccccccccccsssssssssessseeseceeeeeeeeeeeaaas 12 Printer Setup Dialog Box Printer Drivers Screen Layout ccccceeeeeeeeeeeeeeeeeeees 13 Accessin th Screen Screen Lay Out isi theses cet adivurels eile air e 14 File Tool Bar Function Screen Layout cccccccccccccccceccececeeeaaseeeesesseseeeeeeeeeeeeeeeaaas 15 Edit T oolbar Option screen Layout sires seca aesece es sasanieovng bade R 16 View Toolbar Option Screen Layout ess inince a setae iain 17 Admin Toolbar Option Screen Layout ccccccceeeecccccceecececeeesssesseeeeeceeceeeeeeeeaaas 18 Intermediary Setup Dialog Box Screen Layout cccccccccccccceccceceeeeaeaeeessseeseeeeeeeeees 19 Provider Setup Dialog Box Screen Layout cccccccccccccccceeececeseeeeesseseeeeeeeeeeeeeeeeeaaas 20 Provider Setup Dialog Box Example Screen Layout esssseseseseeeeeeeeeeeeeeeenaas 22 Help Toolbar Option Screen Layout siisi na a E a 29 X12 Button Open Data File Dialog Box Screen Layout cccccecseeeeeceeeeeeeeeeees 24 Data File Dialog Box Screen Layout senl rruen i E ESAE 25 Data File Segments and Deblocked Segments Screen Layout cccccceeeeeeeeeeeeees 26 Dat
107. right column Interest does not display fully The right left and up down scroll bars are available to move left and right and up and down through the All Claims screen to view the data in its entirety E PeP 021016AA X12 PC Print for Window lo amp amp File Edit View Admin Help a relesfac s ole S al PATIENT NAME PATIENT CNTRL NUMBER FRM DT COST REPTD CHGS DRG NBR OUTLIER AMT REIMB RATE ALLOW REIM INTEREST ICN NUMBER HIC NUMBER THR DT COVDV NCVD DENIED DRG AMOUNT DEDUCTIBLES MSP PRI PAY PROC CD AMT PAT REFU CLAIM CLM STATUS MEDICAL REC NUMBER NCVDV CLAIM ADJS DRG O c COINS AMT PROF COMP LINE ADJ AMT PERDIEM NATIONAL PROVIDER ID HIC CHG x TOB xxx CV LN NCV L ICOVD CHGS NEW TCH ECT SEQUESTRATN ESRD AMT CONT ADJ AMT NET REI l l ACO PIONEER l l BARBERO X 800182689 1 1000704 Ol 255 04 0 00 0 510 13 73 202218000139XXXXX 123456789A 1000704 Ol 93 42 0 00 100 00 0 00 161 62 2 122 10001079178 0l 0 001 0 001 7 64 0 001 0 001 9999999999 HIC CHG HN TOB 13I 1l Ol 224 24 0 00 0 00 0 00 67 71 1 0 001 BETANCOURT X 800187158 1 10007111 0l 453 52 0 00 0 510 88 38 200216002 6XXxXxX 123456789A 10007111 Ol 365 14 0 00 0 00 0 00 395 77 3 122 10000044544 Ol 0 00 0 00 0 00 0 00 0 00 9999999999 HIC CHG HN TOB 138 1 ol 395 77 0 00 0 00 0 00 0 00 8 0 00 BETANCOURT X 800200716 1 10008011 Ol 441 00 0 00 0 510 97 98 2002230008XXx
108. rints To print additional summaries parse through using the up down arrows and use the Printer button 2 Another way to print the Bill Summary report s is to select File then Print or CTRL P NOTE It is not necessary to go to File Print if using the CTRL P sequence Page 42 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 PRINTING OPTIONS PRINT EXAMPLE A PeP 021016AA X12 PC Print for Windor File Edit View Admin Help xl xe sL ps es ac sc a S amp l NPI 9999999999 PATIENT BARBERO Medicare National Standard Intermediary Remittance Advice HIC 123456789A FPE 09 30 00 HOSP PAID 08 26 02 PO BOX 1234 CLM 1 SAN JUAN PR 00919 TOB 138 X PCN 800182689 1 SVC FROM 07 04 00 MRN 0001079178 THRU 07 04 00 ICN 2001940001XXXX CLAIM STAT 22 CHARGES PAYMENT DATA 255 04 REPORTED 0 00 DRG AMO 139 97 NCVD DENIED 0 00 DRG OPER 0 00 CLAIM ADJS 0 00 LINE ADJ 2 224 24 COVERED 0 00 OUTLIER DAYS VISITS 0 00 CAP OUTLIE 0 COST REPT 100 00 CASH DEDUG 1 COVD UTIL 0 00 BLOOD DEDU O0 NON COVERED 7 64 COINSURANC 0 COVD VISITS 0 00 PAT REFUNY 0 NCOV VISITS 0 00 ACO PIONEE ADJ REASON CODES CR 93 0 REMARK CODES CARC CODES CR Correction 93 No Claim level Adjustments RARC CODES MAO 4 REV DATE HCPCS APC HIPPS MODS QTY CHARGES ALLOW REIM LICN HCPI SVC Desc
109. rmation Procedure Modifiers SVCO1 3 SVCO1 4 SVCO1 5 SVCOI1 6 Page 101 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING Loop 2110 SVC Service Payment Information SVCO5 Units of Service Paid Count Loop 2110 SVC Service Payment Information SVC02 Line Item Charge Amount Loop 2110 SVC Service Payment Information SVCO03 Line Item Provider Payment Amount Loop 2110 CAS Claim Adjustment CASO1 Claim GC Adjustment Group Code Loop 2110 CAS Claim Adjustment Adjustment Reason Codes CAS02 05 08 11 14 17 Loop 2110 CAS Claim Adjustment Adjustment Amount CAS03 06 09 12 15 18 REMARK CODES Loop 2110 LQ Health Care Remark Codes LQO2 a when LQO1 is HE Claim Payment Remark Codes Second Revenue Line Headings when REFO1 is equal 6R REFO2 when REFO 1 is OK Third Revenue Line Headings Loop Segment Data Element SVC Desc Loop 2110 SVC Service Payment Information when SVC06 7 is present and greater than spaces GROUP CARC CODES Loop 2100 CAS Claim Adjustment CASO1 Claim Adjustment Group Code Loop 2100 CAS Claim Adjustment Adjustment Reason CODES Codes CAS02 CAS05 CAS08 CAS11 CAS14 CAS17 RARC CODES Loop Segment Data Element REMITTANCE ADVICE Loop 2110 LQ Health Care Remark Codes LQ02 when REASON CODES LQO1 is HE Claim Payment Remark Codes
110. s XP If Windows XP is being used continue to use PC Print version 4 2 6 UNINSTALL PROCESS Before loading a new version of PC Print it is imperative that the old version is uninstalled 1 Click Start 2 Click Control Panel 3 Click Add Remove Programs 4 Select PCP or PC Print whichever is applicable 5 Click Add Remove 6 Click Remove INSTALLATION 1 Go to the following website https www medicaremaintainer com login asp mess Please login tot access the MSC application 2E 2 Login e Click on Fiscal Intermediary Shared System FISS e Click on Supporting Applications e Click or scroll down to PC Print GETTING STARTED e Click FISS PC Print 5 0 1 e Follow the down load instructions provided in the FISS PC Print Download Directions Page 10 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 GETTING STARTED RUNNING THE PC PRINT PROGRAM To run the program simply double click on the Icon The PC Print program runs over a network identically to how it runs locally Ensure that when saving or archiving transmissions that the appropriate directory is chosen ERA VERSION INFORMATION ERA Version 5010 The 5010 Version 4 0 and greater of PC Print allows the end user to load and view a 5010 835 X12 ERA data file As in the previous PC Print version for Inpatient claims there are line level adjustments for non covered
111. s mapping this information from the 835 X12 file 1 The Provider Setup is used to set up the Provider s data to be reflected on the screens and reports 2 The Provider Setup dialog box is selected by clicking on Admin Then select Provider Dialog Box Buttons Go back and view prior provider information Go to the next provider in the file Add a new provider s information To get a blank screen click Add then OK Delete a provider record from this file bring the provider record to the screen and click Delete then OK Page 21 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 MENU BAR OPTIONS BP PC Pint fr Wind lll i File Edit View Admin Help Pad eE lolol ole E e Number 123456 Name FISS HOSPITAL Cancel Address 123 ANYWHERE STREET GAGKSONVILE eae 555 5555 Delete For Hel ress Fl Figure 10 Provider Setup Dialog Box Example Screen Layout Based on changes made for the processing of a HIPAA 5010 835 X12 file this menu option is no longer required The application is mapping this information from the 835 X12 file Example of adding a Provider to the Provider Setup File Click on the Add button in the Provider Setup Dialog box Complete the provider information To add the next provider click Add and complete the provider information If finished
112. sary a vertical scroll bar is available for parsing through the screen Page 29 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 TOOL BAR OPTIONS BS BUTTON PeP 021016 AA X12 PC Print fo File Edit View Admin Help vl el for cel ole S e Medicare National Standard Intermediary Remittance Advice NPI 9999999999 CHARGES 1184 66 REPORTED 02 91 NCVD DENIED 0 00 CLAIM ADJS 0 00 COVERED DAYS VISITS 0 COST REPT 0 COVD UTIL 0 NON COVERED 0 COVD VISITS O NCOV VISITS FPE 09 30 00 HOSP PAID 08 26 02 PO BOX 1234 CLM 19 SAN JUAN PR 00919 PAYMENT DATA 0 000 REIM RATE 0 00 DRG AMOUNT 0 00 MSP PRIM PAYER 0 00 DRG OPER CAP 0 00 PROF COMPONENT 0 00 LINE ADJ 0 00 OUTLIER 464 85 PROC CD AMOUNT 0 00 CAP OUTLIER 0 00 CASH DEDUCT 0 00 ACO PIONEER 0 00 BLOOD DEDUCT 0 00 INTEREST 39 75 COINSURANCE 358 18 CONTRACT ADJ 0 00 PAT REFUND 0 00 PER DIEM AMT 0 00 SEQUESTRATN 36 68 NET REIM AMT Figure 18 BS Bill Summary Button Screen Layout The BS Bill Summary button allows access to view the Type of Bill summary records generated per provider NOTE The up down arrows allow for the forward and backward parsing through the file If necessary a vertical scroll bar is available for parsing through the screen restrictions of contract HHHSM 500 2007 00016I Task Order HHSM 500 T0003 Use or disclosure of t
113. t CASO3 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CASO2 05 08 11 14 17 equals 45 and 59 and Loop 2110 CAS Service Adjustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CAS02 05 08 11 14 17 equals 45 and 59 NEW REIMB Loop 2100 CLP Claim Payment Information CLP04 Claim Payment Amount Page 73 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING SINGLE CLAIM REPORT PC PRINT SINGLE CLAIM REPORT Medicare National Standard Intermediary Remittance Advice HOSPITAL FP 09 30 0 HOSP PO BOX 12345 PAID 08 26 02 PO BOX 1234 TAMPA FL 336313240 CLM 27 SAN JUAN PR 00919 NPI 1234567890 TOB 138 PATIENT BAZAN X k PCN 800507288 1 HIC 123456789B SVC FROM 09 18 01 MRN 0000028317 CLAIM STAT 22 THRU 09 18 01 IC 20222808572504 CHARGES PAYMENT DATA DRG Q 510 REIM RATE 52 00 REPORTED 0 00 DRG AMOUNT 0 00 MSE PRIM PAYEI 0 00 NCVD DENIED 0 00 DRG OPER CAP 0 Q00 PROF COMPONENT O 00 CLAIM ADJS 0 O00 LINE ADJ AMT Q0 Q00 ESRD AMOUNT b2 00 COVERED 0 Q00 OUTLIER 52 00 PROC CD AMOUN DAYS VISITS 0 Q00 CAP OUTLIER 5 60 ALLOW REIM V COST REPT 0 00 CASH DEDUCT 0 OO SEQUESTRATN eo UTTE 0 00 BLOO0D DEDUCT 0 00 INTEREST 0 NON COVERED 7 41 COINSURANCE 38 99 CONTRACT ADJ Ec VISITS 0 Q00 PAT REFUND Q0 00 PER DIEM AMT O NCOV VISITS 0 00 AC0 PIONEER 5 6
114. to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 Figure 46 Figure 47 Figure 48 Figure 49 Figure 50 Figure 51 Figure 52 Figure 53 Figure 54 Figure 56 Figure 57 Figure 58 Figure 59 FISS PC Print User Guide Data File in Segment List SL Format Screen Layout 1 of 2 ccccceeeeeeeeeeees 63 Data File in Segment List SL Format Screen Layout 2 of 2 cccccccccceeeeeeeeeeees 64 Provider summary PS Screen Layo bias rn EAN RANS 65 Bill Summary Bs Screem Layout synene ie det detaeedaianineae 66 ANCAM AC Screen Tay OU trsiistsh ie iadciteaee hs iee ta tuielee aetna ielal iets helde deletes 67 Smelle ClaimCS Screen Layou ei cnt crea ase eat cea ee 68 Mapping 5010 835 to All Claims Report Header Layout ccccccceececeeeeeeeeeeeeees 69 Mapping 5010 835 to Single Claim Report Layout cc cccsssssesseeeseeeeecceeeeeeeeeaaas 74 Mapping 5010 835 to Single Claim Report Layout Service Lines 00008 80 Mapping 5010 835 to Provider Payment Summary Report Layout eee 87 Mapping 5010 835 to All Claims Report Header Layout ccceccceeeeeeeeeeeeeeeeeees 90 Mapping 5010 835 to Single Claim Report Layout 0ssssssesooeeeeeeneessssssssssssssseererees 95 Mapping 5010 835 to Single Claim Report Layout Service Lines 0006 101 Page 5 Use or disclosure of the data contained on this sheet is subject to restrictions of co
115. ustment CAS03 06 09 12 15 and 18 Adjustment Amount when Adjustment Code in CAS02 05 08 11 14 17 equals 45 and 59 PER DIEM AMT Loop 2100 AMT Claim Supplemental Information AMTO2 Claim Supplemental information Amount when AMTO1 equals DY This is the sum of all claims in the LX Loop NET REIM AMT Loop 2100 CLP Claim Payment Information CLP04 Claim Payment Amount This is the sum of all claims in the LX Loop Page 86 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 SYSTEM LAYOUT MAPPING PROVIDER PAYMENT SUMMARY REPORT PC PRINT PAYEE SUMMARY REPORT Medicare National Standard Remittance Advice Provider Summary Hospital PBSI FISS 789 River Rd 123 River Rd LR FL 32206 LR AR 72207 NPI 1821186313 CHECK EFT NUMBER 0000459988 PAYMENT SUMMARY PAYMENT TOTAL 2421 43 BILLING CYCLE 12 03 2009 TOTAL CLAIMS 4 TOTAL PIP CLAIMS 0 FINANCIAL ADJUSMENTS L3 SW 1000 00 L6 IN 105 13 AP AW 150 00 Payer Business Contact Information Telephone Telephone Extension Facsimile Electronic Mail Payer Technical Contact Information Telephone Facsimile Electronic Mail Uniform Resource Locator URL Payer Web Site Uniform Resource Locator URL Figure 59 Mapping 5010 835 to Provider Payment Summary Report Layout Name when N101 equals PE Name when N101 equals PR Address Line Address Line PR
116. w Admin Help For Help press F1 INUM h Figure 26 BUS SCE Business Scenario Button Screen Layout The BUS SCE Business Scenario button displays a listing of CARC codes with associated RARC and Group codes that are associated with the Business Scenario Each of the Business Scenario s 1 through 4 are accessible for viewing Page 38 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016l Task Order HHSM 500 T0003 TOOL BAR OPTIONS CARC RARC Codes NONE N563 CO or PI rs 48 0 N29 N705 N706 N707 N708 N709 N710 N711 N712 N713 N714 N715 N716 16300 NONE N678 N679 N680 N681 N682 N683 N685 N686 N706 N708 N710 N712 N714 N716 N718 La NONE N678 N679 N680 N681 N682 N683 N685 N686 250 NONE N555 N556 N594 N595 N596 N667 N668 N678 N679 N680 N681 N682 N683 N685 N686 N705 N707 N708 N709 N710 N711 N712 N713 CO or PI N714 N715 N716 N717 N718 251 NONE M1 M127 M130 M131 M132 M135 M141 M142 M143 M19 M21 M23 M29 M30 M31 M42 M47 M60 MAO4 MA27 MA64 MA75 MA76 MA81 MA88 MA92 MA111 MA112 N3 N4 N26 N28 N29 N40 N42 N80 N102 N146 N170 N175 N178 N179 N186 N191 N197 N202 N204 N205 N206 N214 N221 N222 N223 N224 N225 N227 N228 N231 N232 N233 N234 N235 N236 N237 N238 N239 N240 N241 N242 N243 N244 N245 N286 N331 N350 N354 N366 N375 N3
117. w Data File and PC Print Process 60 Chapter 9 2 22 222222 nnn e enn n nnn n nnn n nnn e eee eee 69 System Layout Mapping 220 222 0 69 All Claims Report 69 Single Claim Report 74 Bill Type Summary Report 82 Provider Payment Summary Report 87 Home Health Hospice All Claims Report 90 Home Health Hospice Single Claim Report 95 Revision Log 2222222220000 nnn n nnn n nnn n nee 104 Page 3 Use or disclosure of the data contained on this sheet is subject to restrictions of contract HHSM 500 2007 00016I Task Order HHSM 500 T0003 FISS PC Print User Guide Table of Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Figure 16 Figure 17 Figure 18 Figure 19 Figure 20 Figure 21 Figure 22 Figure 23 Figure 24 Figure 25 Figure 26 Figure 27 Figure 28 Figure 26 Figure 27 Figu

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