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Provider Electronic Solutions Software User`s Manual

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1. O0 Paid Date Amount 00 00 0000 ii 3 0 Delete Policy Holder Carrier Code Group it Group Name lt CS wt Undo All Last Name FirstName tst S Gave Add Ol Carrier Code Group Group Name Last Name Copy Ol Delete Ol 7 z Find Recipient ID Last Name First Hame Billed Amount Last Submit Print Close Release of Select the release code from the drop down list or enter an Medical Data appropriate value as specified as described below Select I Informed Consent to Release Medical Info For Conditions or Diagnoses Regulated by Federal Statutes Select Y Yes Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Use if the provider has a signed statement on file from the recipient that authorizes the release of medical data to other organizations Benefits Select the assignment code from the drop down list or enter an Assignment appropriate value as specified as described below Select Y Yes if the recipient or authorized person has authorized that benefits be assigned to the provider RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 162 PA PROMISe Provider Electronic Solutions Software User Manual Claim Filing Indicator Code Adjustment Group Cd Version 4 00 Select N No if the recipient or authorized person has not authorized that benefits be assigned to the provider Select W f
2. File Forms Lists Reports Tools Window Help 37 hd OK S Oh 4 270 Eligibility Request Detail Report Batch Number Recipiem Cardholdar IDE Fom Status Submit Date aoto Reconds selected E Arok a140 270 Eligibility Request Detail Report ALL CLAIMS Infomation Recarei Name Provider ID Location Code 000i OOM Provider ID MP Jaari Lasing Hame Furl Name RICHARD Recipient Name Aecem ID 1234473 Card lztue Humber D0 ID Qualifier MI Recipient SSH Recpient DOB OOO 0000 Medical Aero Last Name First Hamit Procedure NOC Procedure Code Qualdrer From DOS OFAN Ta DOS 07 10 2013 Trace Assigning Additional IO Trace 8 Transection Reference 6715 Step 7 Click Erint to print the 270 Eligibility Request Detail Report Step 8 Click Close to exit the 270 Eligibility Request Detail Report screen 11 2 270 Eligibility Request Summary Report You can generate a summary report for 270 Eligibility Request s using the Provider Electronic Solutions software This summary report contains only the key fields on the 270 Eligibility Request form To generate a 270 Eligibility Request Summary Report perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select the 270 Eligibility Request option from the Summary Forms drop down menu The 270 Eligibility Request Summary Report screen is displayed Step 2 Click M OK to include all the requests in the s
3. Note Fee For Service Providers who are billing directly to Medical Assistance do not use this field For Consolidated Community Reporting for OMHSAS CCR If submitting a managed care claim where there is a sub capitation arrangement choose the contract version from the pull down list The contract version is the month of the contract that was in force at the time of the service Note Fee For Service Providers who are billing directly to Medical Assistance do not use this field For Consolidated Community Reporting for OMHSAS CCR Note This is an adjustment made to the billed amount by an insurance carrier other than MA For example a service adjustment would be completed if a third party insurance carrier paid a monetary amount towards the claim or denied the claim prior to the claim being submitted to MA Note Each service line is linked to a separate Service Adjustment screen Therefore it 1s necessary to complete the Service Adjustment screen for each service line that has received partial payment from a third party insurance carrier RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 137 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 The Service Adjustment screen is added to the claim if you selected Y in the Service Adjustment Indicator field on the Service 2 screen Access the Service Adjustment screen by clicking the Service Adj tab The software displays the
4. Provider s organization name or the group name This field is automatically populated after you select or enter an MPI number in the Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form The recipient s 10 digit recipient number For additional information on the Recipient ID field refer to Recipient Reference List in section 8 3 of this manual R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 200 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Medical Record Last Name First Name Middle Initial From DOS To DOS Account Number Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Medical record number assigned to the recipient by your facility This field 1s automatically populated after you select or enter a recipient ID Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form Recipient s last name This field 1s automatically populated after you select or enter a recipient ID Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form Recipient s first name This field is automatically populated after you
5. Provider ID Provider ID Filesize Creation Date Creation Time 07 30 2015 15 29 42 07 29 2015 12 08 46 0770242015 08 20 07 Batch Response L FO RMA TT ON TAr CROZER CHESTER MEDICAL CTR 1237163674 P O BOX 8500 5205 PHILADELPHIA PA 19178 1007605830079 231637191 SERRE PAY EH R INFORMATION x Payer Name Payer Address 1 Payer Address 2 Payer City Name Payer State Code Payer Zip Code Payer Contact Name DEPARTMENT OF HUMAN SERVICES OFFICE OF MEDICAL ASSISTANCE PROGRAMS SUPPORT SERVICES SECTION ENROLLMENT PO BOX 69022 HARRISBURG PA 171069022 PROVIDER ASSISTANCE CENTER PAC Note In addition the information above the following will also be on the 835 ERA response mE For complete CARC RARC Descriptions please visit the following web site Washington Publishing Company _ http www wpc edi com CAQH CORE website http www cagh org Step 5 Click Erint to print the 271 Eligibility Response or 835 ERA The entire report will print not just an individual response Step 6 Click Close to exit the View Batch Response screen 10 5 View Bulletins You can view and print the bulletins that have been posted to the Pennsylvania MA bulletin board Bulletins are important messages and should be accessed regularly A sample bulletin is shown below Sample Bulletin RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 309 August 31 2015
6. 201 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Admit Source Admit Type Prior Authorization Enter the code that identifies the source of admission to the facility or choose the appropriate code from the field s preloaded drop down list or enter an appropriate value as specified 1 Physician Referral 2 Clinic Referral 3 HMO Referral 4 Transfer from a Hospital 5 Transfer from a Skilled Nursing Facility 6 Transfer from Another Healthcare Facility 7 Emergency Room 8 Court Law 9 Information Not Available A Transfer from a Rural Primary Care Hospital Admit Type Code Enter the code that identifies the type of admission to the facility or choose the appropriate code from the field s pull down list or enter an appropriate value as specified 1 Emergency Admission An emergency admission is defined as the patient s condition requires immediate medical attention and any time delay would be harmful to the patient 2 Urgent Admission An urgent admission is defined as the patient s condition while not immediately essential should have medical attention provided very early to prevent possible loss or impairment of life limb or body function 3 Elective Admission An elective admission is defined as a scheduled or planned admissions 4 Newborn Admission of a newborn baby 5 Trauma Center Admission to a trauma c
7. 999 Acknowledgment Report which indicates that the file sent for processing failed initial HIPAA edits and needs to be resubmitted Exception 270 submissions can receive a 999 that does not indicate a failure TXN A Transaction Status Report which lists those transactions within a batch that were approved and or rejected For eligibility inquires the report contains a list of individuals who are approved and or rejected for MA services For claims the report lists the transactions that passed and or failed the HIPAA checks Failed transactions need to be corrected and then resubmitted Note Payment is not guaranteed for claims that are accepted on this report NCP Response to a NCPDP pharmacy claim that was submitted for processing which indicates whether the claim was accepted and processed or rejected ZZZ Unrecognizable File Format Report which indicates that the associated transmission was garbled or corrupted Step 3 Click Erint to print the reports Step 4 Click Glose to exit the Submit Reports Screen 10 7 View Communication Logs The Communication Logs list the batch files submitted to HP Enterprise Services and include their file size creation date creation time and submission information To view the communications logs perform the following steps Step 1 Select the View Communication Log option from the Communication menu to access the Communication Log screen RAPA MMIS CMcElhe
8. Copy Provider ID Location Code HPI Delete Last Org Name First Name Hl H Recipient ID Hedical Rec it DOB 00 00 0000 Last Name First Name Hl Release of Medical Data x Account P Benefits Assignment Y Patient Signature Report Type Code x Report Transmission Code Attachment Ctl Po Recipient ID LastName FirstName Billed Amount J Last Submit Dt Undo All Care Claim Frequency in which the claim is was submitted Frequency Select the appropriate frequency code from the drop down list or enter an appropriate value as specified 0 No Pay Claim Use this code when a bill is submitted to a payer but the provider does not anticipate a payment as a result of submitting the bill for example the patient pay is equal to or exceeds the amount billed 1 Original Admit Used when billing MA for new or thru Discharge claim previously unpaid service s This code is Rebill also used to resubmit a specific bill that has been previously rejected 7 Replacement Used to adjust a previously paid claim as Replacement of necessary Prior Claim 8 Void Void Cancel Reflects the cancellation or voiding of a of Prior Claim previously paid bill RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 235 Provider Electronic Solutions Software User Manual Original Claim Provider Role Provider ID Location Code NPI Last Org Name First Name
9. Location Code The 4 digit code for the location where the rendering provider Rendering performed the service Provider NPI Enter the NPI National Provider Identifier Numeric 10 digit Rendering identifier consisting of 9 numbers plus a check digit in the 10 Provider position Last Org Name Rendering provider s last name This field is automatically Rendering populated after you select or enter a medical license number in the Provider Provider ID Rendering Provider field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form First Name Rendering provider s first name This field is automatically Rendering populated after you select or enter a medical license number in the Provider Provider ID Rendering Provider field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form MI Rendering Rendering provider s middle initial This field is automatically Provider populated after you select or enter a medical license number in the Provider ID Rendering Provider field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 182 PA PROMISe Provider Electronic Solutions Software User Manual Versi
10. PASSWORD RULES May not be the same as the Logon ID May not be the same as the current password Must contain only alphanumeric characters A Z a z or 0 9 Must contain at least one alphabetic character A Z or a z Must contain at least one numeric character 0 9 Must not have the same character appear more than twice Must be 5 9 alphanumeric characters in length In the ReKey New Password field re enter your new password Click the OK button The Web Password Status screen displays Web Password SUCCESSFULLY Updated To continue click the OK button 5 5 What if I can t remember my Web password Step 1 From the Main menu select Tools Step 2 From the Tools sub menu select Options Step 3 From the Options screen select the Batch Tab Your Old password will display in the password field Interactive The Interactive screen contains information related to submitting interactive files Step 1 To access the Interactive screen click the Interactive tab in the Tools Options box RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 20 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Modem web Batch Interactive Carrier Faper Processor Retention Hodem Init String Note Data for this screen populates automatically after the modem type is selected on the Modem screen This also includes a Web BBS submission method if you receive the message
11. Service Code DUR PPS Version 4 00 Select the service code from the drop down list or enter an appropriate value as specified This code identifies pharmacist intervention when a conflict code has been identified 00 No Intervention AS Patient Assessment CC Coordination Of Care DE Dosing Evaluation Determination DP Dosage Evaluated FE Formulary Enforcement GP Generic Product Selection MO Prescriber Consulted MA Medication Administration MB Overriding Benefit MP Patient Will Be Monitored MR Medication Review PO Patient Consulted PA Previous Patient Tolerance PE Patient Education Instruction PH Patient Medication History PM Patient Monitoring RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 282 PT Perform Laboratory Test RO Pharmacist Consulted Other Source RT Recommended Laboratory Test SC Self Care Consultation SW Literature Search Review TC Payer Processor Consulted TH Therapeutic Product Interchange August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Result Of Service DUR PPS Version 4 00 Select the result code from the drop down list or enter an appropriate value as specified The result code identifies the action taken by a pharmacist in response to a conflict If multiple prescription detail lines were entered on the Claim 1 screen these detail lin
12. The Options box records the information necessary to transmit forms and receive responses It is important that each tab in the Options box be completed accurately 5 1 Web Internet ONLY OPTION AVAILABLE The Web screen contains your system s Web information Select the appropriate settings for connection to the Web Note You can use regular internet connections installed on your computer to use the software to send files You need to manually complete the fields for this screen You can use the following steps to set up the software in order to send and receive files using the PES software Step 1 Select Tools then Options On the Web tab you can choose the settings that apply to the type of internet connection that you have Step 2 The Use Microsoft Internet Explorer Pre config Settings is a checkbox that allows you to elect to use the Microsoft Internet Explorer configuration settings Checking this box indicates that the Provider Electronic Solutions application will use the same registry settings as the Microsoft browser to connect to the internet It defaults to checked or the pre config settings Note It is recommended to leave this box checked as the default setting Note PES provides a Web based Interactive communication method In order to use the Web BBS for Interactive claims choose W for Web B for BBS is no longer applicable RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 15
13. os Professorial Rejected Submit Report s NCPDP Pharmacy Bulletin MCPOP Pharmacy Eligibility Submission Transaction Aeport s Step 8 Click Close to exit the Batch Submission screen 10 2 Batch Resubmission The Batch Resubmission function is used to resubmit previously transmitted forms to DHS to identify the forms that were sent with each batch or to copy a form for revision purposes Please note that resubmitted claims are sent with exactly the same information as they contained when they were originally transmitted If you have changed information and need to transmit the new information you will perform a submission not a resubmission RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 304 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 To resubmit previously transmitted forms to DHS perform the following steps Step 1 Select the Resubmission option from the Communication drop down menu located on the main screen of the Provider Electronic Solutions software Aig HP Provider Electronic Solutions File Forms Communication Lists Reports Tools Security Window Help cM Wl Submission Resubmission View Batch Response 835 ERA View Bulletin View Submit Reports View Communication Log The Resubmission screen appears with a list of previously submitted batches at the top of the screen Step 2 Select the batch file by clicking on any of the bat
14. 118 ESRD Network Support Adjustment119 Benefit Maximum for this time period has been reached 2 Coinsurance Amount 23 Payment adjusted because charges were paid by another payer 3 Copayment Amount 35 Lifetime Benefits Maximum has been reached 45 Charge exceeds fee schedule maximum allowable or contracted legislated fee arrangement 50 Non covered services Enter the amount of the adjustment in the right segment of the field using a decimal point For example enter 105 50 if the adjustment amount was 105 50 Paid Field is divided into two segments Date Amount In the left segment of the field enter the 2 digit month 2 digit day and 4 digit year on which the recipient s third party insurance carrier paid the claim For example enter 10012015 if the date was October 1 2015 Enter the amount paid by the other insurance carrier in the right segment of the field using a decimal point For example enter 105 50 if the paid amount was 105 50 An amount of 0 may be entered If the third party insurance carrier paid 0 00 complete the Paid Date Amount field with the date of third party insurance explanation of benefits EOB denial and the amount of 0 00 If Medicare is the third party insurance carrier complete this field using the Medicare Approved amount Code Select the carrier code from the drop down list or enter an Carrier appropriate value as specified The carrier code identifies the
15. 336 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Use the scroll bars located on the right side and bottom of the screen to view the entire report CY HP Provider Electronic Solutions _ File Forms Lists Reports Tools Window Help OY UbhadDOK lk G 837 Professional Detail Report Batch Number Recipient Cardholder IDE Form Stus Submit Date 0 00 0000 Recods selected Fy 837 Professional Detail Report Asot 08182015 ALL CLAIMS Claim Frequency 1 Onginal Claim Provider Role 2 Provider ID 007442730001 Location Code 0001 Last Ong Name MPI 1665411401 First Name Hi Step 6 Click Print to print the 837 Professional Detail Report Step 7 Click _ Close to exit the 837 Professional Detail Report screen 11 12 837 Professional Summary Report You can generate a summary report for a Professional Claim s using the Provider Electronic Solutions software This summary report contains only the key fields on the 837 Professional Form To generate an 837 Professional Summary Report perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select the 837 Professional option from the Summary Forms drop down menu The 837 Professional Summary Report screen is displayed Step 2 Click OK to include all the Professional Claims in the summary report Step 3 Click OK when prompted by the box that advises you that a
16. Delay in Supplying Billing Forms 6 Delay in Delivery of Custom Made 7 Third Party Processing Delay 8 Delay in Eligibility Determination 9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules Appli aca 10 Administration Delay in the Prior Authorization Process 11 Other Billing Used to record visit codes necessary to adjudicate MA claims This field Note is optional If the provider is a qualified small business enter QSB in the Billing Note field You may enter more than one code if applicable Example VCO9QSB for a claim filed by a qualified small business dental provider for services rendered to a pregnant woman If the visit code Which means IS 09 10 11 QSB EPSDT Then enter Services rendered to a pregnant VC09 woman Dental only Services rendered to an LTC ora VC10 state mental hospital resident Provider attempted but was vcll unsuccessful in collecting a co payment If the provider is a qualified small QSB business If the claim involved EPSDT referral information any or all of the following that apply must be entered RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 213 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 EPSDT Dental Referral YD EPSDT Vision Referral YV EPSDT Hearing Referral YH EPSDT Medical Referral Y
17. Enter the 5 digit ZIP code and 4 digit 4 Code for the policyholder s street address The 4 Code is not required to process a claim Step 3 Click o Save when all of the data entry fields are completed Step 4 Click o Ad and repeat steps 2 3 and 4 to add another policyholder to the Policy Holder reference list Llase Step 5 Click Z to exit the Policy Holder screen RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 84 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 8 18 Procedure HCPCS Reference List To complete the data entry fields needed to add or edit a Procedure HCPCS reference list selection perform the following steps Step 1 Click Lists Procedure HCPCS to access the Procedure HCPCS reference list fg HP Provider Electronic Solutions ley File Edit View Forms Lists Tools Window Help DX 2 Hle Ba sr AHM 79 Procedure HCPCS Procedure HCPCS Delete Description Undo All Save Frocedure HCPCS Description Find Print RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 85 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 2 Enter the data requested for each field as described below Procedure HCPCS Enter the HCPCS code that describes the service rendered as indicated Code in the MA Progr
18. Insurance Type Code Find Recipient ID Last Hame First Marne Billed Amount Last Submit Dt Print Close The Crossover screen is added to the claim if you selected Y in the Crossover Ind field on the Header 3 screen RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 192 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 8 1 To access the Crossover screen click the Crossover tab The Crossover screen is displayed Release of Medical Data Benefits Assignment Claim Filing Indicator Code Select the appropriate release code from the drop down list or enter an appropriate value as specified Select I Informed Consent to Release Medical Information Select Y Yes Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Use if the provider has a signed statement on file permitting the release of medical data to other organizations Select the appropriate assignment code from the drop down list or enter an appropriate value as specified Select Y Yes if the recipient or authorized person has authorized that benefits be assigned to the provider Select N No if the recipient or authorized person has not authorized that benefits be assigned to the provider Select W for Not Applicable Not applicable for this claim Select the appropriate claim code from the drop down list or enter
19. Limits the summary report to requests in a specific batch Enter the appropriate batch ID number in this field You can locate the batch numbers under the Resubmission option of the View Communication Log menu Limits the summary report being requested to return information only for the specified recipient Enter the appropriate recipient ID in this field Limits the summary report being requested to include only the claims with the specified form status Select the appropriate form status from this drop down list Limits the summary report to requests transmitted on the specified date Enter the appropriate date in this field Step 4 After you enter the report criteria click OF The summary report is generated and displayed on your screen R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 323 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Use the scroll bars located on the right side and bottom of the screen to view the entire report File Forms Lists Reports Tools Window Help jen a 5S Ol mx Oh Ip 276 Claim Status Request Summary Report Batch Number Recipient Cardholder IDE 2 2 Fom Status Submit Date H0000 Records selected 2 276 Claim Status Request Summary Report 8 14 2015 ALL CLAIMS Last Name First Name It Billed Amount D Recipient ID 0303578405 SOPHLE Last Submit Dt 1006 2013 First
20. Original Claim Rejected or 4 Delay in Certifying Denied Due to a Reason Unrelated to Provider the Billing Limitation Rules 5 Delay in Supplying 10 Administration Delay in the Billing Forms Prior Approval Process RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 118 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Encounter Ind Special Program Code Referral Code Prior Authorization EPSDT Patient Pay Amount 6 Delay in Delivery of 11 Other Custom Made Appliances Enter the correct Encounter Indicator information RP Reporting Used only when the claim is submitted as an encounter by a managed care organization MCO CH Chargeable Used when billing for payment Note Consolidated Community Reporting for OMHSAS CCR encounter submissions are indicated using the Encounter Ind To submit an encounter select RP from the field s drop down list The special program code indicates the claim was submitted under one of the circumstances programs or projects listed Select the appropriate value from the drop down list or enter an appropriate value as specified 02 Physically Handicapped Children s Program 03 Special Federal Funding 05 Disability Enter the 2 digit Primary Care Case Manager Referral code For claims that have a referring provider but do not have a Referral code enter the referring provider s
21. PA PROMISe Version 4 00 Provider Electronic Solutions Software User Manual Payer Responsibility Claim Filing Indicator Code Select N for No if the recipient or authorized person has not authorized benefits to be assigned to the provider Select W for Not Applicable Not applicable for this claim Payer responsible for the recipient s other insurance Select the appropriate code from the drop down list or enter an appropriate value as specified as described below P Payer 1 S Payer 2 T Payer 3 A Payer 4 B Payer 5 C Payer 6 D Payer 7 E Payer 8 F Payer 9 G Payer 10 H Payer 11 U Unknown Select the appropriate claim code from the drop down list or enter an appropriate value as specified The claim code identifies the type of other insurance claim that is being submitted MC Medicaid 09 Self Pay 11 Other Non Federal Program 12 Preferred Provider Organization PPO 13 Point of Sale POS 14 Exclusive Provider Organization 15 Indemnity Insurance 16 Health Maintenance Organization HMO Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical BL Blue Cross Blue Shield CH CHAMPUS RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 130 CI Commercial Insurance Co DS Disability F1 Federal Employees Program HM Health Maintenance Organization LM Liabilit
22. RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx PA PROMISe Version 4 00 Note Dispensing Providers must use the Claim Frequency 8 to Void claims Claim Frequency Code 7 Adjustments is not supported If resubmitting a previously rejected claim or a claim for adjustment enter the 13 digit ICN as printed on the RA statement If resubmitting a claim or an adjustment that was processed prior to the implementation of PROMISe enter the 10 digit CRN followed by the 2 digit line number as it is printed on the RA statement Select the provider role code from the drop down list or enter the appropriate value as described below Select 1 Group if the MA number entered is for a group practice Select 2 Non Group if the MA number entered is for an individual provider If for a group practice individual rendering provider information is required Select the 9 digit MPI number from the drop down list for the provider under whom the claim will be paid or double click on the data entry portion of the field to add a reference list selection Provider s 4 digit service location code associated with the MPI number selected in the Provider ID field This field is automatically populated when an MPI number is chosen Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Enter the NPI National Provider Identifier Numeric 10 digit
23. Renal Residential Psychiatric Treatment Transitional Care Transitional Nursery Care Urgent Care RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 377 Version 4 00 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 17 Appendix C Glossary of Terms Acronym Description Word ACCESS Medical Assistance plastic ID card issued to recipients ID Card Access Plus Enhanced primary care case management and disease management program Program Refer to Bulletin 99 06 11 for instructions CAO County Assistance Office these offices administer all DHS benefit programs at the local level CARC Claim Adjustment Reason Codes Carrier Number assigned to a specific insurance company Code CCR Consolidated Community Reporting for OMHSAS CIS Client Information System CRN Claim Reference Number Diagnosis Identity of a condition cause or disease DOB Date of Birth DOD Date of Death DOI Department of Insurance DOS Date of Service DHS Department of Human Services sometimes called the department Drop down Also known as a reference list list EOMB Explanation of Medical Benefits ERA Electronic Remittance Advice EFT Electronic Funds Transfer HCSIS Home and Community Services Information System HIPAA Health Insurance Portability and Accountability Act of 1996 ICD 9 CM_ International Classification of Diseases 9 Revision Clinical Modification ICD 10 In
24. Step 3 Click Close to close the reference list box 7 2 Create or Build a Reference List Prior to Accessing a Form Step 1 Access the reference list Step 2 Enter the data requested for each field Each reference list has unique data entry fields See Section 8 for instructions on completing data entry fields for a specific reference list RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 47 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Provider ID fLicense Facility ID Location Code Ad ID Code Qualifier E Entity Type Qualifier Delete Last Org Name First Hame Hil E Undo All Taxonomy Code Provider Address Line 1 Line 2 Gy i See rovider ID Taxonomy LastOrg Name 111111111 0001 eeeeeeeeel TESTER 1 555555555 0005 2011111111 BILLING Step 3 When the data entry fields have been completed click __ ave j After the selection has been saved you can choose this selection from a drop down list to automatically populate the information above in the appropriate fields Step 4 To add another selection to the same reference list click Si and repeat steps 1 2 and 3 as shown above RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 48 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 To create or add to a reference list as you go while completing a form perform the following
25. Step 5 Complete Header 4 G HP Provider Electronic Solutions File Edit View Forms Tools Window Help D al S Pe w PA 837 Institutional Inpatient Total Charge ET 0 Amount ET Billed Amount ST Services Hdr 1 Hdr2 Hdr3 Hdr4 Har 5 Har6 Hdr7 Hare sm1 Value Codes Amounts 0 ee a Lm sf fm s a eff 00 A wf Ett fo e an 00 Undo All Save Recipient ID Last Mame First Mame Billed Amount Wf Last Submit Dt Value Each field is divided into two segments Codes Amounts Fields 1 12 In the left segment of the field enter the value code or select the value code from the segment s drop down list or enter an appropriate value as specified The value code identifies data of a monetary nature that is necessary for processing the form as required by the payer organization 06 Medicare Blood Deductible 35 Offset to Patient Payment 14 No Fault Auto Other Amount Health Insurance Premium 15 Workman s Compensation RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 150 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 16 PHS or Other Federal Agency 38 Medicare Blood Deductible 25 Drug Deduction Pints Furnished 31 Patient Liability Amount 39 Medicare Blood Deductible Pints Replaced 34 Offset to Patient Payment Amount Other Medical Expense 47 Any Liability Insurance 66 Patient Paid
26. Verify that you are using a valid and open PROMISe provider number and service location for the inquiry Inappropriate Error only applies to inquiries that include a procedure code Product Service ID or NDC The inquiry failed to find the procedure code or NDC submitted Verify that you are using a valid procedure code or NDC Invalid Missing Date s Range of dates of service submitted exceeds a 31 day of Service period Maximum number of days is 30 me Invalid Missing Date of Birth Date of Birth Follows Date of service submitted is before the date of birth on the Date s of Service recipient s eligibility file 61 Date of Death Precedes Date of service submitted is after the date of death on the Date s of Service recipient s eligibility file R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 369 52 Service Dates Not The inquiry made covers a range of dates and the provider is Within Provider Plan not eligible part or all of the period of eligibility being Enrollment requested PROMISe will still return eligibility for the period when the provider is eligible however you will not Date of birth is required when performing a name or SSN inquiry PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Error 271 X12 Error Status code Code Description Why the Error Set Date of Service not within Allowable Inquiry Period Date Of Service In past more than 10 year
27. and 4 digit year on which the recipient s third party insurance carrier adjudicated the claim For example enter 10012015 if the date was October 1 2015 Enter the amount paid by the other insurance carrier in the right segment of the field using a decimal point For example enter 100 75 if the paid amount was 100 75 The MCO ICN field contains the internal claim number assigned to the claim when the managed care organization processed the claim from a provider Consolidated Community Reporting for OMHSAS CCR submitters must enter a MCO ICN Note The MCO ICN field is activated when RP is indicated on Hdr 2 AND has a payer on the OI tab with Claim RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 295 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Filing Indicator code HM Without these conditions being met the MCO ICN field will remain disabled Carrier Code Resource code that identifies the third party insurance carrier This Group field is automatically populated after you select a Group Number from the Group field Select the group number for the third party insurance from the drop down list or double click on the data entry portion of the field to add a reference list selection Group Name Name of the group or business that makes the insurance available to the insured person This is not the third party insurance group number from the Group
28. s 9 e 10 CG 11 BOTTI peee OS OS 3 OS jave Send Last Hame First Hame led Amt Find Print Close Enter the Patient Amount and Qualifier when the recipient owes for any of the reasons listed RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 295 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Patient Enter a value from the drop down list or enter an appropriate Amount Qualifier value as specified Not Specified 01 Amount Applied Periodic Deductible 02 Amount Attributed Product Selection 03 Amount Attributed to Sales Tax 04 Amount Exceeding Periodic Benefit 05 Amount of Copay 06 Patient Pay Amount 07 Amount of Coinsurance 08 Non Preferred Formulary Selection 09 Amount Attributed to Health Plan 10 Amount Attributed Provider Network 11 Brand Non Preferred Formulary 12 Amount Attributed to Coverage Gap 13 Amount Attributed to Processor Fee Step 12 Click _ ave to save the NCPDP Pharmacy claim Step 13 Click Close to exit the NCPDP Pharmacy Form 9 10 Complete an NCPDP Pharmacy Eligibility Form The NCPDP Pharmacy Eligibility Form is used by Pharmacies to request verification of a recipient s eligibility status The NCPDP Pharmacy Eligibility Form consists of only the Header screen The Header screen contains the provider and recipient information For additional
29. 09 Nonary Ninth Select the qualifier from the drop down list or enter an appropriate value as specified 01 National Payer ID 02 Health Industry Number 03 Bank Information Number 04 National Association of Insurance 05 Medicare Carrier Number 99 Other Date Enter the 2 digit month 2 digit day and 4 digit year For example enter 01012015 if the date was January 1 2015 ICN Internal Control Number unique claim number that distinguishes claims within PROMISe and appears on a Remittance Advice statement Paid Enter the amount received from other payers associated with the Amount Qualifier Qualifier selected Use a decimal point For example enter 100 23 if the adjustment amount was 100 23 Enter the paid amount Select the qualifier from the drop down list or enter an appropriate value as specified 01 Delivery 02 Shipping 03 Postage 04 Administrative 05 Incentive 06 Cognitive Service RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 294 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 07 Drug Benefit 09 Compound Preparation Cost 10 Sales Tax Reject Code Enter a value from the drop down list or enter an appropriate value as specified Step 11 Complete COB 2 Pharmacy Es Gees Total Charge Amt Paid it Details Patient Amount ual if oof x 2 oy 3 o Add nwo ee SO 6 fel Comm
30. 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 BM Lymphatic BN Gastrointestinal BP Endocrine BQ Neurology BR Eye BS Invasive Procedures BT Gynecological BU Obstetrical BV Obstetrical Gynecological BW Mail Order Prescription Drug Brand Name BX Mail Order Prescription Drug Generic BY _ Physician Visit Office Sick BZ Physician Visit Office Well Cl Coronary Care CA Private Duty Nursing Inpatient CB Private Duty Nursing Home CC Surgical Benefits Professional Physician CD Surgical Benefits Facility CE Mental Health Provider Inpatient CF Mental Health Provider Outpatient CG Mental Health Facility Inpatient CH Mental Health Facility Outpatient CI Substance Abuse Facility Inpatient CJ Substance Abuse Facility Outpatient CK Screening X ray CL Screening laboratory CM Mammogram High Risk Patient CN Mammogram Low Risk Patient CO Flu Vaccination CP Eyewear and Eyewear Accessories CQ Case Management DG Dermatology RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 376 PA PROMISe Provider Electronic Solutions Software User Manual DM DS GF GN GY IC MH NI ON PT PU RN RT TC TN UC Durable Medical Equipment Diabetic Supplies Generic Prescription Drug Formulary Generic Prescription Drug Non Formulary Allergy Intensive Care Mental Health Neonatal Intensive Care Oncology Physical Therapy Pulmonary
31. 2015 102 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 ig Batch Submission Submission Method Web Server Diskette Drive Vat b JEME BES Batch Select Diskette Select All Deselect All Files To Send al Files To Receive ArU Eligibility Request E 2r 1 Eligibility Response s ef Claim Status Request ef Claim Status Response s oo Dental NCPOP Pharmacy Response s oa Institutional Inpatient 035 Electronic Remittance Advice odr Institutional Nursing Facility 7 999 Acknowledgenent s of Institutional Outpatient Accepted Submit Reports oo Professional Rejected Submit Reports NCPDP Pharmacy Bulletin WNCPDF Pharmacy Eligibility B Submission Transaction Reporta Step 1 Select the method Web Server to send the file s for Processing in the Method drop down box This must be the same method you listed in the Tools and Options of the PES software Note BBS Batch and Diskette are no longer available Step 2 Select the forms you want to submit from the Files to Send column Step 3 Click Submit Submitting forms by batch lets you submit several form types at the same time However only the 270 Eligibility Request is processed for the next day of service The system accepts the 270 Eligibility Request files you sent and on the next day of service processes them and places a 271 Eligibility Response s on the bulletin board For example if you submit a batch of 270
32. Date the date was October 1 2015 Step 7 1 To add another dental service line click dd S8 l R PA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 135 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 A new blank service line 1s added to the screen Click on the new service line and then enter the dental service data in the data fields as described previously Step 7 2 To copy the data from an existing dental service line to a new service line click on the existing service line you want to copy and then click apy Srv A new service line is added to the screen The new service line has the same data as the existing service line that you previously selected You can edit the data in the new service line Simply click on the new service line and enter the changes to the appropriate fields Step 7 3 To delete an existing dental service line click on the service line you want to delete and then click Delete Srv The selected service line is deleted Step 8 Complete Service 2 ig HP Provider Electronic Solutions File Edit View Forms Tools Window Help DRX VHa ol Ba B74 E F fe 837 Dental Apphance Placement Date jon 00 0000 Service Adjustment Ind N Copy Delete Contract Type Contract Code Undo All Contract Version Save Cow Bm oa 5 Procedure Billed Amount Wz i D0 Recipient ID FirstName Billed Arnount Last Submit
33. H Payer 11 U Unknown MCO ICN The MCO ICN field contains the internal claim number assigned to the claim when the managed care organization processed the claim from a provider Consolidated Community Reporting for OMHSAS CCR submitters must enter a MCO ICN RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 164 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Paid Date Amount Carrier Code Policy Holder Group Policy Holder Group Name Policy Holder Last Name Policy Holder Note The MCO ICN field is activated when RP is indicated on Hdr 2 AND has a payer on the OI tab with Claim Filing Indicator code HM Without these conditions being met the MCO ICN field will remain disabled This field 1s divided into two segments In the left segment of the field enter the 2 digit month 2 digit day and 4 digit year that the recipient s third party insurance carrier paid the claim For example enter 10012015 if the date was October 1 2015 Enter the amount paid by the other insurance carrier in the right segment of the field using a decimal point For example enter 100 50 if the paid amount was 100 50 An amount of 0 zero may be entered If a third party insurance carrier paid 0 00 you still should complete the Paid Date Amount field with the date of the third party insurance carrier s explanation of benefits EOB denial and the amount o
34. HIPAA permits 16 3 Service Type Codes CODE DEFINITION Medical Care Surgical Consultation Diagnostic X Ray Diagnostic Lab Radiation Therapy Anesthesia Surgical Assistance Other Medical Blood Charges O WHA Q OA BP U N e pb pd O Used Durable Medical Equipment 12 Durable Medical Equipment Purchase R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 371 PA PROMISe Provider Electronic Solutions Software User Manual 13 Ambulatory Service Center Facility 14 Renal Supplies in the Home 15 Alternate Method Dialysis 16 Chronic Renal Disease CRD Equipment 17 Pre Admission Testing 18 Durable Medical Equipment Rental 19 Pneumonia Vaccine 20 Second Surgical Opinion 21 Third Surgical Opinion 22 Social Work 23 Diagnostic Dental 24 Periodontics 25 Restorative 26 Endodontics 21 Maxillofacial Prosthetics 28 Adjunctive Dental Services Version 4 00 30 Health Benefit Plan Coverage If only a single category of inquiry can be supported use this code 32 Plan Waiting Period 33 Chiropractic 34 Chiropractic Office Visits 35 Dental Care 36 Dental Crowns 37 Dental Accident 38 Orthodontics 39 Prosthodontics 40 Oral Surgery 41 Routine Preventive Dental 42 Home Health Care 43 Home Health Prescriptions 44 Home Health Visits 45 Hospice RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 372 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual 4
35. Indicator Code Version 4 00 Level of payer responsibility for the recipient s other insurance Select the appropriate code from the drop down list or enter an appropriate value as specified P Payer 1 S Payer 2 T Payer 3 A Payer 4 B Payer 5 C Payer 6 D Payer 7 E Payer 8 F Payer 9 G Payer 10 H Payer 11 U Unknown Select the claim code from the drop down list or enter an appropriate value as specified The claim code identifies the type of other insurance claim that is being submitted MC Medicaid 11 Other Non Federal Program 12 Preferred Provider Organization PPO 13 Point of Sale POS 14 Exclusive Provider Organization EPO 15 Indemnity Insurance 16 Health Maintenance Organization HMO Medicare Risk 17 Dental Maintenance Organization AM Automotive Medical BL Blue Cross Blue Shield RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 254 CH CHAMPUS CI Commercial Insurance Co DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MA Medicare A MB Medicare B OF Other Federal Program TV Title V VA Veterans Administration Plan WC Worker s Compensation Health Claim ZZ Mutually Defined August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Pa
36. PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 334 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Use the scroll bars located on the right side and bottom of the screen to view the entire report GY HP Provider Electronic Solutions File Forms Lists Reports Tools Window Help OV UHAaDOK lk D 837 Institutional Nursing Facility Summary Report Batch Number Recipient Cardholder ID Form Status Submit Date OO000000 Record selected K 837 Institutional Nursing Facility Summary Report set 08717 2015 Heconendt O Last Hame Fost Hame Date of Sevice Filled Amount Last Submit Dt Status 12rd Fels b000 00 0371624 a aa E M ee a M i M a M a a M M ee Billed Amgyunt Total Charge 6 000 00 Ol Amount 0D me Step 6 Click Print to print the 837 Institutional Nursing Home Summary Report Step 7 Click Close to exit the 837 Institutional Nursing Home Summary Report screen 11 11 837 Professional Detail Report You can generate a detail report for Professional Claims using the Provider Electronic Solutions software The detail report contains all the fields on the 837 Professional Form To generate an 837 Professional Detail Report perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select the 837 Professional Option from the Detail Forms drop down menu The 837 Professional Detail
37. Recipient ID f First Name Billed Amount E A Dt Find Print Close Claim Frequency in which the claim is was submitted Select the appropriate Frequency frequency code from the drop down list as described below or enter an appropriate value as specified This code should be used when a bill is submitted to a payer but the provider does not anticipate a payment as a result of submitting the bill 1 Original Code is used to bill new or previously unpaid service to Admit thru MA You may also use this code to resubmit a bill that Discharge was rejected on a RA Claim 7 Replacement Code is used when a specific bill was paid and needs to Replacement of be replaced or adjusted Prior Claim 8 Void Code reflects the elimination or the backing out in its Void Cancel of entirety of a previously submitted bill for a specific Prior Claim provider patient payer insured and statement covers period dates RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 114 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Original Claim Enter the Original ICN as printed on the RA If you are resubmitting or adjusting a claim processed prior to the implementation of PA PROMISe enter the 10 digit claim reference number CRN followed by the 2 digit line number Provider Role Provider ID Location Code NPI Last Org Name
38. automatically populated with the correct information after an MPI number is selected in the Rendering Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Rendering provider s first name This field is automatically populated with the correct information after an MPI number is selected in the Rendering Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Rendering provider s middle initial This field is automatically populated with the correct information after an MPI number is selected in the Rendering Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Indicator that the claim is being submitted for recipient s newborn Select the appropriate response from the drop down list Y Yes Recipient is a newborn N No Recipient is not a newborn Used to activate the O I screen which is used to record a recipient s other insurance information Select the other insurance code from the drop down list or enter an appropriate value as specified Y Yes Recipient has other insurance N No Recipient does not have other insurance August 31 2015 209 PA PROMISe Provider Electronic Solutions Software User Manual
39. enter 01012015 if the date was January 1 2015 Select the Cardholder ID number from the drop down list or double click on the data entry portion of the field to add a reference list selection Cardholder ID numbers are issued to recipients who are authorized to receive Pennsylvania Medicaid services Cardholder IDs consist of the 10 digit recipient ID number and the 2 digit card issue number Cardholder s recipient s last name Use this field only if you enter the data when you enter the cardholder ID number Recipient s first name The date the Policy Holder was born Field is in the format MM DD CCYY Select from the drop down box 0 Not Specified 1 Male 2 Female Select the pregnancy code from the drop down list or enter an appropriate value as specified R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 271 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Not Specified Select 1 if the recipient is not pregnant Select 2 if the recipient is pregnant Patient Select the code from the drop down list or enter an appropriate Relationship value as specified Code 0 Not Specified 1 Cardholder 2 Spouse 3 Child 4 Other Patient Select the patient location code from the drop down list or enter an Residence appropriate value as specified This code identifies the location of the recipient when receiving pharmacy
40. field Last Name Policyholder s last name This field is automatically populated after you select a group number from the Group field First Name Policyholder s first name This field is automatically populated after you select a group number from the Group field Each professional claim can have as many other insurance lines as needed Each other insurance line contains the data fields described in this step Step 9 1 Click _ dd Ql to add another other insurance line A new blank service line is added to the screen Step 9 2 Click on the new line and then enter the other insurance data in the appropriate data fields Step 9 3 Click on the existing line of other insurance information you want to copy to a new line Step 9 4 Click Copy Ol A new insurance line is added to the screen The new line has the same data as the existing line that you previously selected You can edit the data in the new line Step 9 5 Click on the new line to edit the data or make changes to the appropriate fields Step 9 6 Click Delete Ol to delete an existing other insurance line RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 256 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 10 Complete Service 1 Total Charge 999i Ol Amount Billed Amount J Services Diag Codes 1 ME 3 5 c ns 7 ss a 5 ES 10 1 2 a Copy From pos 0 0000 0000 To DOS 0 00000000 Emergency
41. identifier consisting of 9 numbers plus a check digit in the 10 position Provider s last name or the name of the group This field is automatically populated when an MPI number is chosen Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Provider s first name This field is automatically populated when an MPI number is chosen Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form August 31 2015 236 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 MI Recipient ID Medical Record DOB Last Name First Name MI Release of Medical Data Provider s middle initial This field 1s automatically populated when an MPI number 1s chosen Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form The recipient s 10 digit recipient number For additional information on the Recipient ID field refer to Recipient Reference List in section 8 3 of this manual Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Medical record number assigned by your office to the recipient This field is automatically populated after you select a Recipient number from the Recipi
42. it assists in reconciling claims and RA statements Recipient Enter the recipient s 9 digit social security number in the following SSN format 123456789 Do not use hyphens slashes dashes or spaces when completing this field Last Enter the recipient s last name Name RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 64 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 First Enter the recipient s first name Name MI Enter the recipient s middle initial This field accepts one alphanumeric character Recipient Enter the recipient s date of birth using a 2 digit month 2 digit day and DOB 4 digit year 00 00 0000 Gender Choose the appropriate gender selection from the drop down list or enter an appropriate value as specified F Female M Male U Unknown Address Enter the recipient s street address Line 1 Address Enter additional address information such apartment number Line 2 City Enter the recipient s city State Enter the abbreviation for the recipient s state This field accepts a maximum of two characters e g PA MD Zip Enter the recipient s ZIP code This field accepts a maximum of 9 digits ZIP Plus 4 Step 3 Click __ Save when all of the data entry fields are completed Step 4 Click o Aid and repeat steps 2 3 and 4 to add another recipient ID to the Recipient reference list Step 5 Click Cose t
43. recipient s third party insurance carrier The list consists of the NEIC codes for insurance carriers RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 267 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Name Name of the recipient s third party insurance carrier This field Carrier automatically populates after you select a carrier code in the Code field Each professional claim can have unlimited adjustment lines Each claim line contains the data fields described in this step Step 13 3 Click Add Srv Adi to add another claim adjustment line A new blank claim line is added to the screen Step 13 4 Click on the new claim line and then enter the claim adjustment data in the appropriate data fields Step 13 5 Click on the existing line you want to copy and then click Copy St Adj to copy the data from an existing claim adjustment line to a new adjustment line A new line is added to the screen This new line has the same data as the existing adjustment line previously selected Edit the data in the new line Step 13 6 Click on the new adjustment line and make changes to the appropriate fields Step 13 7 Click Delete srv Adi to delete an existing claim adjustment line The selected line is deleted Service adjustment lines are linked to the claim line that is highlighted when you access the service adjustment screen Make sure you highlight the correct service line
44. reference list you can choose that selection when you create a form and the information contained within that selection will automatically populate the form fields References lists speed the data entry process and help ensure the accuracy of information used to complete the forms Reference lists can be built or edited by anyone using the software Reference lists can be built or used four different ways You can choose one of the following options for building your Reference lists 1 Build your reference lists prior to accessing a form which is helpful for lists that are used often and contain information within the selections that rarely changes such as the Provider reference list 2 Build a reference list as you go while completing a form which is helpful for lists that contain information within selections that may not be used often such as the Recipient reference list 3 Complete some of the data entry fields manually rather than saving selections to a reference lists Temporarily entering the information in a data entry field and not saving it to areference list 1s beneficial when you are familiar with the data needed to complete the field or in cases where the data changes often Some of the reference lists that you may want to complete temporarily are the Diagnosis Diagnosis ICD and Procedure HCPCS and Procedure HCPCS ICD 10 reference list 4 Use the reference lists 1 e Place of Service and Patient Status refer
45. 10 screen 19 Revenue Reference List To complete the data entry fields needed to add or edit a Revenue reference list selection complete the following steps Step 1 Click Lists Revenue to access the Revenue reference list Ag HP Provider Electronic Solutions Ses File Edit View Forms Lists Tools Window Help ax volel Bea s74 a h Fa ag Revenue Add Revenue Code Description Delete Undo All Save Revenue Lode Description Find Facility Days Leave Days Hospital Days Print Step 2 Enter the data requested for each field as described below Revenue Enter the code that identifies a specific accommodation or ancillary Code service RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 87 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 The software is pre populated with revenue codes used for Long Term Care billing Additional revenue codes for other billing types can be added as needed Enter a description of the revenue code Step 3 Click __ Save when all of the data entry fields are completed Step 4 Click o Add and repeat steps 2 3 and 4 to add another revenue code to the revenue reference list Step 5 Click Cose to exit the Revenue screen 8 20 Type of Bill Reference List To complete the data entry fields needed to add or edit a Type of Bill reference list selection perform the following steps Step 1 Clic
46. 10012015 if the date was October 1 2015 Time Enter the hour that the resident was admitted to the facility The Admission hour codes are in military twenty four hour time For example 12 00 12 59 Midnight 00 00 00 59 12 00 12 59 Noon 12 00 12 59 6 00 6 59 p m 6 00 p m 18 00 18 59 Type Enter the code that identifies the type of admission to the facility or Admission choose the appropriate code from the field s preloaded drop down list or enter an appropriate value as specified RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 179 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 1 Emergency Admission An emergency admission is defined as the patient s condition requires immediate medical attention and any time delay would be harmful to the patient 2 Urgent Admission An urgent admission is defined when the resident s condition while not immediately essential should have medical attention provided very early to prevent possible loss or impairment of life limb or body function 3 Elective Admission An elective admission is defined as a scheduled or planned admission 4 Newborn 5 Trauma Center Admit Source Enter the code that identifies the source of admission to the facility Admission or choose the appropriate code from the field s preloaded drop down list or enter an appropriate value as specif
47. 112 Interim First Claim 117 Replacement of Prior Claim 118 Void Cancel of Prior Claim Note Types of Bills 113 and 114 and not valid values for PA MA County Nursing Facilities General Nursing Facilities State Mental Facilities use a type of bill code that starts with 26 260 Nursing Home Zero No Pay Claim 261 Nursing Home Admit Through Discharge Claim 262 Nursing Home Interim First Claim 263 Nursing Home Interim Continuing Claim 264 Nursing Home Interim Last Claim 267 Nursing Home Replacement of Prior Claim 268 Nursing Home Void Cancel of Prior Claim 131 Outpatient Hospital Original Claim 137 Outpatient Hospital replacement of Prior Claim 138 Outpatient Hospital Void Cancel of Prior Claim 141 Hospital Referenced Diagnostics Original Claim 147 Hospital Referenced Diagnostics Replacement of Prior Claim 148 Hospital Referenced Diagnostics Void Cancel of Prior Claim 830 Ambulatory Surgical Center Zero No Pay Claim 831 Ambulatory Surgical Center Original Claim 837 Ambulatory Surgical Center Replacement of Prior Claim 838 Ambulatory Surgical Center Void Cancel of Prior Claim RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 89 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Intermediate Care Facilities 650 ICF MR Zero No Pay Claim State Mental Retardation 651 ICF MR Admit
48. 16 NCPDP Pharmacy Eligibility Summary Report You can generate a summary report for the NCPDP Pharmacy Eligibility Inquiries using the Provider Electronic Solutions software This summary report contains only the key fields on the NCPDP Pharmacy Eligibility Form To generate an NCPDP Pharmacy Eligibility Summary Report perform the following steps Step 1 Step 2 Step 3 From the main screen of the Provider Electronic Solutions software select the NCPDP Pharmacy Eligibility Option from the Summary Forms drop down menu The NCPDP Pharmacy Eligibility Summary Report screen is displayed Click OK to include all the Pharmacy Eligibility Inquires in the summary report Click oK when prompted by the box that advises you that all records will be selected A detail report is generated and displayed on your screen RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 345 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 To limit the type of Pharmacy Eligibility Inquires in the summary report enter the appropriate report criteria into one or more of the following fields Batch Limits the summary report to Pharmacy Eligibility Inquires in a specific Number batch Enter the appropriate Batch ID number in this field You can locate the Batch Numbers under the Resubmission option of the View Communication Log menu Recipient Limits the summary report to Pharmacy Elig
49. 4 Enter the user s password in the Password field Passwords must be longer than five characters long and are case sensitive Step 5 Select the Authorization Level you wish to assign to the user from the Authorization Level drop down box Each level allows the user the type of access described in the table below User Allows access to enter the system and send claims but cannot make changes to software Administrator Allows complete access to the software including all settings Step 6 Click zave to save your added User ID Click J Step 7 to add a new User ID 13 2 Edit Existing Users To edit Security Information in the Provider Electronic Solutions software perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select Security Maintenance from the Security Menu The Security Maintenance screen is displayed ig HP Provider Electronic Solutions Application User ID Password Authorization Level User ID Password Authorization Level Last Used 08711715 05 29 16 oo 0m0 00 00 00 Step 2 Select a user ID in the User ID field Step 3 Change the information you wish to change for that User ID Step 4 Click zave to save your updated User ID RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 365 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 14Contact Information For additional inf
50. Amount In the right segment of the field enter the dollar amount for each code using a decimal point Step 6 Complete Header 5 F HP Provider Sena aiae File Edit View Forms Tools Window Help DBREXxJ maj r e A aya a 837 Institutional Inpatient Total Charge 99 0l Amount T Billed Amount I Services Hdr 1 Hdr2 Hdr3 Hdr4 Hdr5 Har 6 Hdr7 Harg Srv Admission Date IMM Time E Type Discharge Time Admit Souce Delay Reason ed Emergency Ind Billing Note ind Newborn Ind N Encounter Ind CH _ cane Other Insurance Ind N Crossover Ind N gt File Information FO Contract Type a Contract Code OO Contract Version DAG a Find Last Name First Mame Last Submit Dt Print Close Date Enter the 2 digit month 2 digit day and 4 digit year the recipient was Admission admitted to the facility For example enter 10012015 if the date was October 1 2015 Time Enter the hour during which the patient was admitted Enter the hour in military Admission twenty four hour time For example 12 00 12 59 Midnight 00 00 12 00 12 59 Noon 12 00 6 00 6 59pm 6 00p m 18 00 RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 151 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Type Enter the code that identifies the type of admission to the facility as specified Admission or choose the appropriat
51. Attending Provider Location Code hour in military twenty four hour time For example 12 00 12 59 Midnight 00 00 00 59 12 00 12 59 Noon 12 00 12 59 6 00 6 59 6 00p m 18 00 18 59 Enter the number of days covered by MA The discharge day should not be counted as a covered day This field accepts up to three numeric characters This field should equal Facility Days Hospital Reserved Bed Days Therapeutic Leave Days Enter the total number of days during the service month that were not covered by Medicare or MA Days that should be counted as non covered days are e Therapeutic leave days that exceed 30 days per calendar year e The number of hospital reserved bed days that are greater than 15 consecutive days and or e The number of days paid in full by a third party liability Co insurance days are NOT accounted for in the Covered or Non Covered fields These days are recorded on the Crossover Screen Enter the number of Medicare coinsurance days that apply to this service month This field accepts up to three numeric characters Days that should be counted as co insurance days are any Medicare co insurance days that occur between days 21 and 100 of the resident s stay Provider who attends to the resident Select the attending provider s 8 or 9 character medical license number The 4 digit code for the location where the attending provider Attending performed the servic
52. Birth 00 00 0000 Gender Code o Send Pregnancy Ind Patient Relationship Code 1 Patient Residence E Eligibility Clarification Code E Cardholder ID Last Name First Name Billed Amt Last Submit Dt Status Find Print Close Trans Code Select the Trans Code from the drop down list or enter an appropriate value as specified R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 270 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Provider ID Location Code NPI Date Of Service Cardholder ID Last Name First Name Date of Birth Gender Code Pregnancy Indicator Select B1 for a new billing Select B3 for a rebill Select the 9 digit MPI number for the payee from the drop down list or double click on the data entry portion of the field to add a reference list selection This is the provider MPI number under which the claim will be paid The 4 digit location code associated with the selected 9 digit MPI number This field automatically populates after you select a provider ID Pharmacists who qualify as a Qualified Small Business QSB should add a Q as the fifth character in the Location Code Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Enter the 2 digit month 2 digit day and 4 digit year on which the service was provided For example
53. Charge 999i OF Amount ik Billed Amount M Services Ambulance Pick Up Location Ambulance Drop Off Location Street Street Street Street City City State ip State ip Recipient IO Ji Last Name First Mame Billed Arioaunt Last Submit Dt Condition Code 1 Choose the appropriate code from the drop down list or enter 12 an appropriate value as specified that identifies conditions relating to a bill that may affect payer processing 02 Condition is Employment Related 03 Patient Covered by Insurance Not Reflected Here 05 Lien Has Been Filed 77 Payment was accepted as payment in full A1 EPSDT CHAP A3 Special Federal Funding A4 Family Planning RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 250 Provider Electronic Solutions Software User Manual Street 1 Ambulance Pick Up Location Street 2 Ambulance Pick Up Location City Ambulance Pick Up Location State Ambulance Pick Up Location Zip Ambulance Pick Up Location Street 1 Ambulance Drop Off Location Street 2 Ambulance Drop Off Location City Ambulance Drop Off Location State Ambulance Drop Off Location Zip Ambulance Drop Off Location RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx PA PROMISe A7 Induced Abortion Danger to Life A8 Inducted Abortion Victim Rape incest AI Sterilization B3 Pr
54. Code Amount fields Each field is divided into Codes Amts two segments In the left segment of the field select the appropriate reason code from the segment s drop down list or enter an appropriate value as specified The reason code identifies the reason the adjustment is being made to the claim line as described below 1 Deductible Amount 35 Lifetime Benefits Maximum has 118 ESRD Network Support been reached Including Medicare adjustment 45 Charge exceeds fee 119 Benefit Maximum for schedule maximum allowable this time period has been 50 Non covered services reached 2 Coinsurance Amount 23 Payment adjusted because charges were paid by another payer 3 Copayment Amount Enter the amount of the adjustment in the right segment of the field using a decimal point For example enter 100 75 if the adjustment amount was 100 75 Paid This field 1s divided into two segments Date Amount In the left segment of the field enter the 2 digit month 2 digit day and 4 digit year that the recipient s third party insurance carrier adjudicated the claim For example enter 10012015 if the date was October 1 2015 Enter the amount paid by the other insurance carrier in the right segment of the field using a decimal point For example enter 100 75 if the paid amount was 100 75 Code Select the carrier code from the drop down list or enter an appropriate Carrier value as specified This fi
55. Codes Amounts enter an appropriate value as specified if applicable 1 Deductible Amount 118 ESRD Network Support Adjustment 119 Benefit Maximum for this time period has been reached 2 Coinsurance Amount 23 Payment adjusted because charges were paid by another payer 3 Copayment Amount 35 Lifetime Benefits Maximum has been reached 45 Charge exceeds fee schedule maximum allowable or contracted legislated fee arrangement 50 Non covered services Medicare ICN Enter the Medicare ICN found on the Medicare EOMB for the service being billed Full Medicare Enter the total number of days during the service month that were Days fully covered by Medicare Days 1 20 of the resident s stay Paid Date Enter the 2 digit month 2 digit day and 4 digit year the Medicare coinsurance was paid This information can be found on the Medicare EOMB RAPA MMIS CMcElheny PES Manual_50104 00_ICD10 docx 2 August31 2015 194 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Paid Amount Payer Responsibility Carrier Code Policy Holder Last Name Policy Holder First Name Policy Holder Insurance Type Enter the total amount that Medicare paid for the coinsurance days during the service month using a decimal point This information can be found on the Medicare EOMB A zero 0 amount may be entered Level of payer responsibility for the resident s other insurance Select the appro
56. Delete Undo All Save Diagnosis Code Description Find Print Step 2 Enter the data requested for each field as described below Enter the most specific diagnosis ICD 9 CM ICD 10 CM PCS Diagnosis Code code that relates to the recipient s visit Description Enter a description of the diagnosis code Step 3 Click Save when all data entry fields are completed Step 4 Click o d and repeat steps 2 3 and 4 to add another diagnosis code to the diagnosis reference list Step 5 Click Cose to exit the Diagnosis screen RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 73 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 The following list will be used for the Diagnosis ICD 10 codes Follow the instructions below Step 1 Click Lists Diagnosis ICD to access the Diagnosis reference list for Diagnosis ICD 10 reference list File Edit View Forms Lists Tools Window Help Dx Vel Sl 4 Ba 274 8 F 69 Diagnosis ICD 10 Diagnosis Code j Description Delete Undo All Save Description Find Print Step 2 Enter the data requested for each field as described below Diagnosis Enter the most specific diagnosis ICD 10 CM PCS code that relates Code to the recipient s visit Description Enter a description of the diagnosis
57. Dt d If multiple dental service lines were entered on the Service 1 screen these service lines also appear on the Service 2 screen Each service line contains the data fields described in this step Step 8 1 Click on a service line to access its data fields RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 136 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Appliance Placement Date Service Adjustment Indicator Contract Type Contract Code Contract Version Enter the 2 digit month 2 digit day and 4 digit year the recipient received orthodontic appliances For example enter 10012015 if the date was October 1 2015 Select the adjustment code from the drop down list or enter an appropriate value as specified Select Y if a third party insurance carrier has made a payment towards the claim Selecting Y will add the Service Adjustment screen to the form for this claim line Select N if a third party insurance carrier has not made a payment towards the claim The indicator represents the contract between the provider and the managed care or sub capitation subcontractor Choose a value from the drop down list Note Fee For Service Providers who are billing directly to Medical Assistance do not use this field For Consolidated Community Reporting for OMHSAS CCR The contract number between the provider and the managed care or sub capitation subcontractor
58. First Name MI Recipient ID Select the provider role code from the drop down list or enter an appropriate value as specified as described below Select 1 if the provider number entered is for a group practice Select 2 if the provider number entered is for an individual provider Select the 9 digit Master Provider Index MPI number PROMISe Legacy Numbers for the provider that the claim is paid under from the drop down list or double click on the data entry portion of the field to add a reference list selection If assigning payment to a group select the 9 digit group MPI number Field automatically completes once a provider ID number is selected or entered Information cannot be entered directly into these fields to add or change information in these fields access the Provider List Form Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Provider s last name or the group name This field 1s automatically populated after you select or enter an MPI number in the Provider ID field Information cannot be entered directly into these fields to add or change information in these fields access the Provider List Form Provider s first name This field is automatically populated after you select or enter an MPI number in the Provider ID field Information cannot be entered directly into these fields to add or change information
59. ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Referring provider s middle initial This field 1s automatically populated with the correct information after an MPI number is selected in the Referring Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Select the appropriate Emergency Indicator code from the drop down list or enter an appropriate value as specified Select 3 if the service provided was in response to an emergency Enter the two letter abbreviation for the state where the accident occurred For example enter PA for Pennsylvania Enter the amount the recipient has paid towards his her medical bills as determined by the local CAO Patient pay is only applicable if notification is received from the local CAO on a PA 162RM For example enter 25 50 if the amount was 25 50 Use a decimal point Do not enter copay in this field August 31 2015 212 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Delay Select the appropriate code to indicate why a claim is being submitted Reason outside of the 180 day initial submission window This field is optional 1 Proof of Eligibility Unknown or Unavailable 2 Litigation 3 Authorization Delays 4 Delay in Certifying Provider 5
60. Manual Version 4 00 9 Form Overview The Provider Electronic Solutions software provides several HIPAA ready forms These forms are used to complete and edit Pennsylvania MA claims and eligibility requests Instead of completing a claim on paper you can complete a claim on your computer using the Provider Electronic Solutions software After you complete a form save it to process other claims The Provider Electronic Solutions software lets you submit a group or batch of forms at one time as well as submitting certain forms individually The Provider Electronic Solutions software features the following form types e 270 271 Eligibility Inquiry and Response e 276 277 Claim Status Request and Response e 837 Dental e 837 Institutional Inpatient e 837 Institutional Nursing Facility e 837 Institutional Outpatient e 837 Professional e NCPDP Pharmacy e NCPDP Eligibility e NCPDP Pharmacy Reversal You can access these forms from the Forms drop down menu located on the Provider Electronic Solutions software main menu as shown below or via the Toolbar shortcut icons ie HP Provider Electronic Solutions File Communication Lists Reports Tools Security Window Help 2 0 Eligibility Request 2 6 Claim Status Request 837 Dental 63 7 Institutional Inpatient 837 Institutional Nursing Facility 837 Institutional Outpatient 837 Professional NCPDP Pharmacy NCPDP Pharmacy Eligibility NCPOP Pharmacy Reve
61. PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Retention Connection Type C LAN C Modem C Use Proxy Server Dialup Network Proxy Information Address HTTP Port HTTPS Port Proxy Bypass Environment Ind F Interactive Ind Y e Connection Type is an indication of the Internet connection that is established through the LAN Modem is no longer available If Use Microsoft Internet Explorer Pre config Settings is unchecked Connection Type will default to LAN This is selected when using a proxy setting for the PES application The Connection Type indicates the Internet connection is established through a LAN o LAN office network broad band DSL cable modem o Modem analog is no longer available o Dialup Network is no longer available RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 16 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Connection Type f LAN C Modem Use Proxy Server Dialup Network Proxy Information Address HTTP Port HTTPS Port Proxy Bypass Environment Ind P Interactive Ind W Step 3 Step 4 Step 5 Step 6 Step 7 Step 8 Step 9 Step 10 Use Proxy Server should be checked when a proxy server is used to connect to the internet It is most commonly used with a LAN connection If checked the P
62. PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 kee MESSAGE OF THE DAY From EMCS SYSOP The following time limits apply to all files on the BBS Mail 5 Days News bulletins Libs Not automatically purged Files for download 10 Days Archives Upld Dnld 1 Day Operations Logs 3 Days Files that are older than the indicated date will be deleted during the nightly batch cycle Prior to viewing a bulletin you must retrieve the file using the Submission option of the Communications menu found on the Main Menu of the Provider Electronic Solutions software To view the bulletins perform the following steps Step 1 Download the bulletin by following the instructions in section 10 1 Batch Submission that discuss how to submit and receive files Step 2 Select the View Bulletin option from the Communication menu to access the Bulletin screen Ag HP Provider Electronic Solutions File Forms Communication Lists Reports Tools Security Window Help Submission Resubmission View Batch Response 835 ERA View Bulletin View Submit Reports View Communication Log The Bulletin screen 1s displayed Step 3 Click Ernt to print the bulletins Step 4 Click Glose to exit the Bulletin screen 10 6 View Submit Reports The View Submit Reports option lets you see if the forms in a particular batch have made it through the first level of system edits and to receive transmission infor
63. Provider field RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 126 Provider Electronic Solutions Software User Manual NPI Referring Provider Last Org Name Referring Provider First Name Referring Provider MI Referring Provider Provider ID Supervising Provider Location Code Supervising Provider RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx PA PROMISe Version 4 00 Information cannot be entered directly into these fields to add or change information in these fields access the Provider List Form Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Referring provider s last name This field is automatically populated after you select or enter an MPI number in the Provider ID Referring Provider field Information cannot be entered directly into these fields to add or change information in these fields access the Provider List Form Referring provider s first name This field is automatically populated after you select or enter an MPI number in the Provider ID Referring Provider field Information cannot be entered directly into these fields to add or change information in these fields access the Provider List Form Referring provider s middle initial This field is automatically populated after you select or enter an MPI number in the Provider ID Referring P
64. Renal Disease Treatment Facility 71 State or Local Public Health Clinic 72 Rural Health Clinic 81 Independent Laboratory 99 Other Unlisted Facility Note If the Place of Service is used in Hdr 2 do not use a Place of Service in Srv 1 unless it is a different Place of Service RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 121 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Billing Note Use this field to record visit codes necessary to adjudicate MA Claims as follows If the visit This means Then code is Enter 09 Services rendered to a pregnant VC09 woman Dental only 10 Services rendered to an LTC ora VC10 state mental hospital resident 11 Provider attempted but was vcll unsuccessful in collecting a co payment QSB If the provider is a Qualified QSB Small Business EPSDT If the claim involved EPSDT referral information any of the following that apply must be entered EPSDT Dental Referral YD EPSDT Vision Referral YV EPSDT Hearing Referral YH EPSDT Medical Referral YM EPSDT Behavioral Health YB Referral EPSDT Other Referral YO Note If entering more than one code enter them in one complete string e g VCIIQSBYO Required field when claims meet the above criteria If the provider is a qualified small business enter QSB in the Billing Note field You may enter more than one code if applicable
65. Report a Seen ALL CLAIMS Trant Code 61 Proveder ID 001116075 Location Code OMH NPI 1633867563 Date OF Sennce OF 0 2014 Cadholder ID LastName FustName Step 6 Click Print to print the NCPDP Pharmacy Detail Report Step 7 Click Close to exit the NCPDP Pharmacy Detail Report screen 11 14 NCPDP Pharmacy Summary Report You can generate a summary report for the Pharmacy Claim using the Provider Electronic Solutions software This summary report contains all the fields on the NCPDP Pharmacy form To generate an NCPDP Pharmacy Summary Report perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select the NCPDP Pharmacy Option from the Summary Forms drop down menu The NCPDP Pharmacy Summary Report screen is displayed Step 2 Click M QK to include all the Pharmacy Claims in the summary report Step 3 Click M 0K when prompted by the box that advises you that all records will be selected A summary report is generated and displayed on your screen RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 341 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 To limit the type of Pharmacy Claims in the summary report enter the appropriate report criteria into one or more of the following fields Batch Limits the summary report to Pharmacy Claims in a specific batch Number Enter the appropriate Batch ID
66. Report screen is displayed Step 2 Click OK to include all the Professional Claims in the detail report Step 3 Click OK when prompted by the box that advises you that all records will be selected The detailed report is generated and displayed on your screen RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 335 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 To limit the type of Professional Claims in the detail report enter the appropriate report criteria into one or more of the following fields Batch Number Recipient Cardholder ID Form Status Submit Date Limits the summary report to Professional Claims in a specific batch Enter the appropriate batch ID number in this field You can locate the Batch Numbers under the Resubmission option of the View Communication Log menu Limits the summary report to Professional Claims for the specified recipient Enter the appropriate recipient ID in this field Limits the summary report to Professional Claims with the specified form status Select the appropriate form status from this drop down list Limits the summary report to Professional Claims transmitted on the specified date Enter the appropriate date in this field Step 4 After you enter the report criteria click 0K The detailed report is generated and displayed on your screen R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015
67. Reporta NCPDF Pharmacy Bulletin MCPOP Pharmacy Eligibility i Submission Transaction Report s To receive responses perform the following steps Step 1 Select the Submission option from the Communication option in the Main Menu of the Provider Electronic Solutions software Step 2 Select appropriate submission method from the Method drop down list Default is the Web Server Only option available Note BBS Batch and Diskette are no longer available Select the type of responses you want to receive under the Files to Receive list Select the response type by clicking on it Multiple responses can be requested at the same time Note Always select the Submission Transaction Report s Accepted Submit Report s and the Rejected Submit Report s for the files to receive You should also select 999 Acknowledgement s for any files that may have rejected for HIPAA errors Step 3 Step 4 Click _Select All to select all the batch responses for receipt 10 4 View and Print Batch Response 835 Electronic Remittance Advice The View Batch Response 835 ERA option allow you to view and print a 271 Eligibility Responses or an 835 Electronic Remittance Advices ERA Note CARC Claim Adjustment Reason Codes RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 307 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 RARC Remittance Advice Remark Codes Additional information is located
68. Service Adjustment screen as shown below Step 9 Complete Service Adjustment ED 1 Provider tectonic Sl rr ee File Edit View Forms Tools Window Help JD RX CHAS ae e7ts ae 837 Dental Total Charge PTI DI Amount ii Billed Amount ro Services Hdr1 Hdr2 Hara Hdr4 or svi Srv2 Srv Adj Adjustment Group Cd B Remaining Patient Liability O10 apih Reason Codes Amts 1 oo 2 00 Copy Paid Date Amount oo 00 0000 OO 3 0 Delete Carrier Undo All Save Add Srv Adj Sry arrier Code Carrier Hame Group Paid Amount Copy Srv Ad Delete Srv Adil Recipient ID Last Hame First Hame Billed Amount Last Subrnit Dt Adjustment Identifies the general category of the adjustment made to the claim Group Cd line Select the adjustment group code from the drop down list or enter an appropriate value as specified as described below CO Contractual Obligations PI Payer Initiated Reductions CR Correction and PR Patient Responsibility Do not Reversals Enter Patient Pay or Co pay in the OA Other Adjustments PR field Remaining In the judgment of the provider this is the remaining amount to be Patient paid after adjudication by the Other Payer Liability RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 138 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Reason There are three Reason
69. The summary report is generated and displayed on your screen R PA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 330 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Use the scroll bars located on the right side and bottom of the screen to view the entire report I EE m 1 HP Provider Electronic Solutions File Forms Lists Reports Tools Window Help VV had Ok Slk ND 837 Institutional Inpatient Summary Report Batch Number RecipemACadholder ID Form Status Submit Date 0 00 0000 Records selected 837 Institutional Inpatient Summary Report 0613 2015 PALL CLAMS Reciprent ID Last Name Fost Hame Billed Amount Last Subm Di Status a Step 6 Click Print to print the 837 Institutional Inpatient Summary Report Step 7 Click Close to exit the 837 Institutional Inpatient Summary Report screen 11 9 837 Institutional Nursing Home Detail Report You can generate a detail report for Institutional Nursing Home Claims using the Provider Electronic Solutions software This detail report contains all the fields on the 837 Institutional Nursing Home Form To generate an 837 Institutional Nursing Home Detail Report perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select the 837 Institutional Nursing Home option from the Detail Forms drop down menu Batch Number Limits the summary rep
70. Using MS Internet Explorer settings to connect to internet Uploading files to Web Server Uploading 270 Eligibility Bequest File THE NUMBER OF BYTES TO BE TRANSFERRED IS 724 a H R PA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 314 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 3 Click Erint to print the Communication Log Step 4 Click 1498 to exit the Communication Log screen R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 315 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 11 Accessing and Using Reports The Provider Electronic Solutions software lets you create and print reports as well as view and print all the selections contained in a reference list The table below describes the type of information that can be viewed from the options in the Reports menu Detail Form This type of report retrieves and displays the form information from the Form Report screens so you can view all the information that has been entered for the selected form Summary This type of report displays basic recipient information the billed amount Form Report the date the form was last submitted status and service lines Reports Menu This option allows you to access a Reference list and view and print a master list of the selections for that reference list You can access these reports from the Reports
71. Version 4 00 entered directly into this field If you need to add or edit information in this field access the Provider Form Other provider s middle initial This field is automatically populated after you select or enter an MPI number in the Provider ID Other field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Select the 8 or 9 character Medical License Number of the attending provider from the drop down list or double click on the data entry portion of the field to add a reference list selection 4 digit location code associated with the MPI number selected in the Provider ID field This field is automatically populated after you select or enter an MPI number in the Provider ID Attending field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Attending provider s last name This field 1s automatically populated after you select or enter an MPI number in the Provider ID Attending field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Attending provider s first name This field is automatically populated after you selec
72. Y Yes Recipient or authorized person has authorized that benefits be assigned to the provider N No Recipient or authorized person has not authorized that benefits be assigned to the provider W for Not Applicable Not applicable for this claim Payer responsibility for the recipient s other insurance Select the appropriate code from the drop down list or enter an appropriate value as specified P Payer 1 S Payer 2 T Payer 3 A Payer 4 B Payer 5 C Payer 6 D Payer 7 E Payer 8 F Payer 9 G Payer 10 H Payer 11 U Unknown Select the appropriate claim code from the drop down list or enter an appropriate value as specified The claim code identifies the type of other insurance claim that is being submitted MC Medicaid 11 Other Non Federal Program 12 Preferred Provider Organization PPO 13 Point of Sale POS 14 Exclusive Provider Organization EOP 15 Indemnity Insurance 16 Health Maintenance Organization HMO Medicare Risk 17 Dental Maintenance Organization RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 218 CI Commercial Insurance Co DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B OF Other Federal Program TV Title V August 31 2015 PA PROMISe Prov
73. You can select a file type by clicking on it Multiple files can be sent at the same time Step 4 Click _ 3elect All to select all the files listed If you try to send a file type that does not currently have any files attached to it you will receive the error message No records in ready status Step 5 When submitting by Web Internet you can send and receive files simultaneously To receive files select the type of files you want to receive back from DHS from the Files To Receive list You can select a file type by on clicking it Note This is required in order to verify that all of the claims submitted were accepted Step 6 Click _ select All lto select all the files listed RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 303 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 7 Click Submit to send and receive the files you have selected in Steps 3 and 4 Aig Batch Submission Method Web Sever Diskette Drive Select All Deselect All Select All Deselect All Files To Send A Files To Receive 2 FU Eligibility Request iW 2 1 Eligibility Response s Submit fb Claim Status Request f Claim Status Response s os Dental NCPOF Fharmacy Response s Os Institutional Inpatient 0359 E lectronic Remittance Advice os Institutional Nursing Facility 7 999 Acknowledgenent s os Institutional Outpatient Accepted Submit Reports
74. a value from the drop down list or enter an appropriate value as specified Not Specified 01 Inches 02 Centimeters 03 pounds 04 Kilograms 05 Celsius 06 Fahrenheit 07 Meters Squared 08 Milligrams 09 Units per Milliliter 10 Millimeters of Mercury 11 Centimeters 12 Milliliters Per Minute 13 Percent 14 Milliquivalents Per Milliliter 15 International Units Per Liter 16 Micrograms Per Milliliter 17 Nanograms Per Milliliter 18 Milligrams Per Milliliter 19 Ratio 20 SI Units 21 Millimoles Liter 22 Seconds 23 Grams 24 Cells Per Cubic Millimeter 25 1 000 000 Cells Cubic Millimeter 26 Standard Deviation 27 Beats Per Minute Value Required if Measurement Dimension and Measurement Unit are used RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 289 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 9 Complete Compound Pharmacy Eee Total Charge 0 Amt Paid Os Billed Amt T Details T 4 t k Add Dosage Form Dispensing Unit Ind 1 Compound Ingredients Copy Product ID Product ID Qualifier 03 Delete Ingredient Quantity 000 Inqredient Cost OU Basis OF Cost Determination Undo All Save Add Ingredient Ingredient Quantity Ingredient Cost O00 D0 Send Copy Ingredient Delete Ingredient Last Name I First
75. another field or software program Copy Copies the highlighted data to the clipboard so that it can be pasted into another field or software program Paste Inserts data from the clipboard to the selected data fields or another software program Filter Lets you define which forms are displayed at the bottom of the form screen by status date submitted name amount billed etc Find Lets you search for a claim by recipient ID last name first name and billed amount 4 Sort Lets you sort the claims that are displayed at the bottom of the form screen by recipient ID last name first name billed amount status and submit date Lets you view errors that have been detected on the current form Calculator Calls up the calculator Closes the form GJ miy RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 38 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 6 3 10 Command Buttons Command buttons are navigation shortcuts that appear on the various Provider Electronic Solutions software screens You can activate command buttons by clicking on them with a mouse or using the hot key associated with that button The hot key is identified on a menu by an underlined letter which works simultaneously with the Alt key on your keyboard The major command buttons are Button Button Description Name Adds a new claim or a selection to a reference list Copy Copy Cop
76. as specified Select Y if the resident or authorized person has authorized that benefits be assigned to the provider Select N if the resident or authorized person has not authorized that benefits be assigned to the provider Select W for Not Applicable Not applicable for this claim RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 188 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Claim Filing Indicator Code Adjustment Group Cd Select the appropriate claim code from the drop down list or enter an appropriate value as specified The claim code identifies the type of other insurance claim that is being submitted Note Consolidated Community Reporting for OMHSAS CCR submitters must use the Claim Filing Indicator Code HM Using HM activates the MCO ICN field MC Medicaid 09 Self Pay 10 Central Certification 11 Other Non Federal Program 12 Preferred Provider Organization PPO 13 Point of Sale POS 14 Exclusive Provider Organization EPO 15 Indemnity Insurance 16 Health Maintenance Organization HMO Medicare Risk AM Automotive Medical BL Blue Cross Blue Shield CH CHAMPUS CI Commercial Insurance Co DS Disability HM Health Maintenance Organization LI Liability LM Liability Medical MA Medicare Part A MB Medicare Part B OF Other Federal Program T
77. at the following links ma For complete CARC RARC Descriptions please visit the following web site Washington Publishing Company http www wpc edi com CAQH CORE website http www cagh org The View Batch Response 835 ERA option lets you view and print a Batch of 271 Eligibility Responses or an 835 ERA To view a 271 Eligibility Response or the 835 ERA perform the following steps Step 1 Download the reports using the instructions provided in section 10 3 Batch Responses Step 2 Select the View Batch Response 835 ERA option from the Communication menu located on the Main Menu of the Provider Electronic Solutions software Submission Resubmission View Batch Response 835 ERA View Bulletin View Submit Reports View Communication Log The 835 ERA screen is displayed Step 3 Select the file you would like to view The contents of the file appear below the list of files Step 4 Use the scroll bars on the left side and at the bottom of the 271 Eligibility Response or 835 ERA to view the entire report R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 308 PA PROMISe Version 4 00 Provider Electronic Solutions Software User Manual lip View Batch Response Filename E10 39C6 2100NE91 271 FIL 10139CC 2100NE5A277 FIL R03D000451 BCONB3F 635 FIV eee ew i Ke R Provider Name Provider Tax ID NPT Provider Address 1 Provider City Name Provider State Code Provider Zip Code
78. availability of specialized equipment E Patient Transferred to Rehabilitation Facility Enter the number of miles the recipient was transported by ambulance This field accepts up to four numeric characters Enter the weight of the recipient in pounds at the time of transport by ambulance This field accepts up to four numeric characters Each field identifies a condition relating to the bill that may affect payer processing Select the appropriate code from the drop down list or enter an appropriate value as specified 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair Enter the 2 digit month 2 digit day and 4 digit year on which the recipient was admitted to a facility For example enter 10012015 if the date was October 1 2015 Enter the 2 digit month 2 digit day and 4 digit year on which the recipient was discharged from a facility For example enter 1001215 if the date was October 1 2015 If the recipient has not yet been discharged when the claim is filed enter eight zeros in this field The special program code indicates the claim was submitted under one of the circumstances programs or proje
79. because the value is Case sensitive ATT Menu Enter 3 Production Choose P for Production from the drop down box Test Indicator Step 6 1 Choose Batch Transmit screen under Transaction Type to configure the Batch Transaction Carrier Use this particular transaction type to submit a batch of claims or requests Modem web Batch Interactive Carrier PayerProcessor Retention Trans Desc BATCHITRANS MIT E Dr 28800 Carner ID ETCH _TOLL_FREE Phone Number 8666270015 Het ID PAMP Het Password pamopds ATT Menu Production Test Ind F r INTACT TRANSMIT BATCH TRANSMIT BITCH TOLL FREE FAME DTR Do not change this Value Will automatically populate Carrier ID Select BTCH_TOLL_FREE from the drop down list Phone Automatically populates when the Carrier ID is selected If you Number need to dial an access code prior to accessing an outside line enter that number followed by a comma prior to the phone number Ex 9 18666270015 Net Id Automatically populates with PAMP Do not change this value unless directed by HP Enterprise Services It is case sensitive Net Password Enter the value pamopds Enter this value exactly as shown because the value is case sensitive ATT Menu Enter 2 in this field when testing Not required when using the Provider Electronic Solutions PES software After you RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 23 PA PROMISe P
80. code that indicates the method by which Ingredient Cost Submitted was calculated 00 Default 08 340B 01 AWP Average Wholesale Price 09 Other 02 Local Wholesaler 10 ASP 03 Direct 11 AMP Average 04 EAC Estimated Acquisition Cost Manufacturer Price 05 Acquisition 12 WAC 06 MAC Maximum Allowable Cost 13 Special Patient 07 Usual amp Customary Pricing Required if its value has an effect on the Submitted Gross Amount Patient Paid Select Yes if co pay was required and the Required recipient did not pay the co pay R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 279 Provider Electronic Solutions Software User Manual Patient Paid Amount Unit Of Measure Gross Amount Due Prescription Origin Code Ingredient Cost Submitted Prior Authorization PA Type RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx PA PROMISe Version 4 00 If Yes was selected in the Patient Paid Required field enter 0 zero to indicate that the recipient did not pay the copay Select the unit of measure code from the drop down list or enter an appropriate value as specified Enter the appropriate standard product billing code EA Each GM Grams ML Milliliters Predetermination Of Benefits Select the prescription origin code from the field s pull down list or enter an appropriate value as specified This prescription origin code i
81. consent to release medical information for conditions or diagnosis regulated by federal statutes Select Y Yes Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Use if the provider has a signed statement on file permitting the release of medical data to other organizations Benefits Select the assignment code from the drop down list or enter an Assignment appropriate value as specified Y The recipient or authorized person has authorized that benefits be assigned to the provider N The recipient or authorized person has not authorized that benefits be assigned to the provider W for Not Applicable Not applicable for this claim RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 221 Provider Electronic Solutions Software User Manual Reason Codes Amts Claim Filing Indicator Code PA PROMISe Version 4 00 There are three Reason Code Amount fields Each field is divided into two segments In the left segment of the field select the appropriate reason code from the segment s drop down list or enter an appropriate value as specified The reason code identifies the reason the adjustment is being made to the claim line 1 Deductible Amount 118 ESRD Network Support Adjustment119 Benefit Maximum for this time period has been reached 2 Coinsurance Amount 23 Payment adjusted because charges were paid by another paye
82. displayed on your screen To limit the type of Pharmacy Claims in the detail report enter the appropriate report criteria into one or more of the following fields Batch Number Recipient Client ID Form Status Submit Date Limits the summary report to Pharmacy Claims in a specific batch Enter the appropriate batch ID number in this field You can locate the batch numbers under the Resubmission option of the View Communication Log menu Limits the summary report to Pharmacy Claims for the specified recipient Enter the appropriate recipient ID in this field Limits the summary report to Pharmacy Claims with the specified form status Select the appropriate form status from this drop down list Limits the summary report to Pharmacy Claims transmitted on the specified date Enter the appropriate date in this field Step 4 After you enter the report criteria click 0K i The detailed report is generated and displayed on your screen R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 340 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Use the scroll bars located on the right side and bottom of the screen to view the entire report File Forms Lists Reports Toots Window Help a Wma DO ik 9 NCPDP Pharmacy Detail Report Batch Number Recipient Cardholder IDE Form Statws Submit Date D00000 Records selected LP Pharmacy Claim Detail
83. field Step 4 Re enter your new password in the Rekey New Password field Step 5 Select a hint question from the Question field drop down list Step 6 Enter the answer to your hint question in the Answer field Step 7 Re enter your answer to the hint question in the Rekey Answer field Step 8 Click OF to save your new password 12 2 Compact the Database You can compact your database to make the database files smaller and better organized Whenever you delete a form empty space is created in the database where that form existed Compacting the database releases all empty space and makes it available again Note You may want to compact your database if it is running slowly or after archiving a number of claims To compact your database perform the following steps Step 1 From the main menu of the Provider Electronic Solutions software select the Compact option from the Database Recovery drop down menu A Compacting Database message is displayed while the database is being compacted Step 2 After the database is successfully compacted the Application box is displayed with a message that indicates if the action was successful RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 354 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Application Step 3 Click OF to clear the message from your screen 12 3 Repair the Database You should repair your databa
84. for the service adjustment you are entering Step 14 Click ave to save the professional claim Step 15 Click Glose to exit the 837 Professional Form 9 9 Complete an NCPDP Pharmacy Claim Form Note The valid values listed are using the External Code List ECL published March 2010 The valid values will be updated annually in October and will include any ECL published in the prior calendar year The NCPDP Pharmacy Form is used to submit drug claims by Retail Pharmacies The NCPDP Pharmacy Form is divided into six screens Each screen contains Header Screen contains information related to the pharmacy that dispensed the medication and the recipient to whom the prescription is provided Patient Screen contains information related to the Patient Claim 1 Screen contains the prescription information RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 268 Provider Electronic Solutions Software User Manual Claim 2 Prescriber Coupon Clinical 1 Clinical 2 Compound COB 1 Coordination of Benefits COB 2 Coordination of Benefits PA PROMISe Version 4 00 Screen contains additional prescription information including responses to any drug therapy issues that have been identified when the claim was previously submitted Screen contains Prescriber Information Screen contains Coupon information Screen contains clinical information related to the claim Screen contains clinical info
85. hospitalization began In the right segment enter the 2 digit month 2 digit day and 4 digit year the period of hospitalization ended Condition Each field identifies a condition relating to the invoice that may affect Codes payer processing Enter the appropriate 2 character condition code or Fields 1 7 select the appropriate code from the drop down list or enter an appropriate value as specified 02 Condition is Employment Related 03 Patient Covered by Insurance Not Reflected Here 05 Lien Has Been Filed 60 Day Outlier 77 Payment was accepted payment in full Al EPSDT CHAP A3 Special Federal Funding A4 Family Planning A7 Induced Abortion Danger to Life A8 Induced Abortion Victim Rape Incest AI Sterilization B3 Pregnancy DR Disaster Related Covered Enter the number of days covered by MA for the period of Days hospitalization The discharge day should not be counted as a covered day R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 149 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Non Enter the number of days not covered by MA for the period of Covered hospitalization Days The discharge day should not be counted as a non covered day Coinsurance Enter the number of coinsurance days that apply to this period of hospitalization Lifetime Enter the number of lifetime reserve days Reserve
86. if the recipient or authorized person does not have authorized benefits to be assigned to the provider RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 116 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Report Type Code Report Transmission Code Attachment Control Select W for Not Applicable Not applicable for this claim Enter the appropriate code for the type of attachment submitted from the drop down or enter an appropriate value as specified B4 Referral Form OB Operative Notes DA Dental Models OZ Support Data for Claim DG Diagnostic Report P6 Periodontal Charts EB Explanation of Benefits RB Radiology Films RR Radiology Reports Enter the appropriate code for the method of attachment transmission from the drop down or enter an appropriate value as specified AA Available on Request at Provider Site BM By Mail EL Electronically Only EM E Mail FX By Fax Enter the up to 10 digit number obtained from the PROMISe web site This number is used when a paper attachment is required by MA to cross reference the paper attachment with the electronic claim This number also must be written on the cover letter sent to MA R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 117 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 3 Complete Header
87. in this field access the Policy Holder Form Step 7 1 To add another other insurance line click Add Ol A new blank service line is added to the screen Step 7 2 Click on the new service line and then enter the other insurance data in the appropriate data fields as described in this step Step 7 3 To copy the data from an existing other insurance line to a new service line click on the existing service line you want to copy and then click Copy Ul A new service line is added to the screen that has the same data as the existing service line that you previously selected Edit the data in the new service line by clicking on the line and then change the appropriate fields Step 7 4 To delete an existing other insurance line click on the service line that you want to delete then click Delete DI The selected other insurance line is deleted Step 8 Complete Crossover G HP Provider Electronic Solutions a File Edit View Forms Tools D RXV Bale BA Term fi 837 Institutional Nursing Facility Total Charge ii OF Amount ii Billed Amount P Services Reason Codes Amts Add Release of Medical Data Benefits Assignment Y 1 g Claim Filing Ind Code MA Adjustment Group Ca 2 00 __ Copy Medicare ICN Full Medicare Days al 00 Delete Paid Date 00 00 0000 Paid Amount OO Payer Responsibility Undo All Policy Holder Carner Code jare Last N First H ast Name st Name Edit All
88. install HP Provider Electronic Solutions on your computer To continue click Mert Cancel Step 7 When the Setup Type screen is displayed click either Typical or Workstation and then click Next gt Note This section applies to full install for the DHS WEB site download or the CD ROM Installs A Typical installation installs all files including the database Use this installation to install the software to a stand alone PC or to initially install the software to a network server Most installations are typical installations A Workstation installation is used to add the software to additional PCs that are connected to a network server where all users share a database This installation type does not load the database files to the PC however it does allow for sharing the database files that were installed to the network Note Use of software for purposes other than intended or any altering of software such as files being loaded into the software are not supported by the EDI Department RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 H P Provider Electronic Solutions Setup Type Select the setup type that best suits pour needs Click the type of setup you preter Description Workstation This ts the default setup type The HE Provider Electronic Solutions application and an Initialized database will be Install
89. license number Not currently used Enter the appropriate 10 digit certification or authorization number as described below Enter the 10 digit Prior Authorization number if the service requires and has received prior authorization Enter the 10 digit Prior Authorization number for approved 1150 Administrative Waiver services Select the EPSDT code from the drop down list or enter an appropriate value as specified as described below Select Y if the recipient participates in the Early Periodic Screening Diagnosis and Treatment EPSDT program Select N if the recipient does not participate in the Early Periodic Screening Diagnosis and Treatment EPSDT program Enter the amount use a decimal point that the recipient has paid toward his her medical bills as determined by the local County Assistance Office CAO Patient pay is only applicable if notification is received from the local CAO on a PA 162RM For RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 119 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Orthodontic Treatment Total Months Orthodontic Treatment Months Remaining Place of Service example enter 25 50 if the amount was 25 50 Do not enter copay in this field Enter the total number of months the recipient has received orthodontic treatment Enter the total number of orthodontic treatment months remaining for the transfer recipi
90. must be used must be used CD ROM Drive Printer with MS Sans Serif font installed Printer with MS San Serif font installed Notice The information contained in this software should be guarded in accordance with the Health Insurance Portability and Accountability Act of 1996 Privacy Rule 45 CFR Part 164 It is the responsibility of the Covered Entity as well as its Business Associates to comply with HIPAA Privacy and Security standards in order to safeguard individually identifiable information and protected health information R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 3 Installation Overview The Provider Electronic Solutions software can be installed on either your local hard disk drive Typical Installation or a network Workstation Installation This software can be installed on as many PCs as needed Upon completion store the original Provider Electronic Solutions software CD ROM and or download files in a safe place In the event the program and files are damaged or deleted the original files are needed to re install the Provider Electronic Solutions software Note Use of software for purposes other than intended or any altering of software such as files being loaded into the software are not supported by the EDI Department Note Please disable all Anti Virus software before proceeding with the installation or upg
91. nursing Facility Dischrgd transtird to an intermediate care Facility Dischrgdtranstird to another type of institution Lett against medical advice or discontinued care Expired Print Step 2 Enter the data requested for each field as described below Patient Choose the code from the drop down box that identifies the patient s Status status or enter an appropriate value as specified 01 Dischrgd to home or self care 05 Dischrgd transfrrd to routine discharge another type of institution 02 Dischrgd trnsfrrd to another 07 Left against medical advice hospital for inpatient care or discontinued care 03 Dischrgd transfrrd to skilled 20 Expired nursing facility 30 Still a patient 04 Dischrgd transfrrd to an intermediate care facility Description Enter a description of the patient status code being added These patient status values are preloaded and are HIPAA compliant If any changes or modifications need to be made to these values you will be notified by DHS or HP Enterprise Services Step 3 Click Sawe when all data entry fields are completed RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 80 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 4 Click Add and repeat steps 2 3 and 4 to add another patient status code to the Patient Status reference list Step 5 Click Close to exit th
92. or Other Federal Agency 25 Drug Deduction 31 Patient Liability Amount 34 Offset to Patient Payment Amount Other Medical Expense 35 Offset to Patient payment Amount Health Insurance Premium 38 Medicare Blood Deductible Pints Furnished 39 Medicare Blood Deductible Pints Replaced 47 Any Liability Insurance 66 Patient Paid Amount In the right segment of this field enter the dollar amount for each code using a decimal point Patient Estimated Enter the gross patient pay amount for the claim Amount Due RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 186 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 6 Complete Hdr 5 G HP Provider Electronic Solutions File Edit View Forms Tools Window Help DRX 9eel el ea a74 m i di 837 Institutional Nursing Facility Total Charge PI 1 Amount ii Billed Amount Ni Services Hdr1 Hdr2 Hdr3 Hdr4 Hdr5 srva Additional Diagnosis Codes Delete Undo All Last Hame Billed Amount Last Submit Dt E Code Diagnosis code that describes the external cause of the recipient s Additional injury Select the external diagnosis code from the drop down list or Diagnosis enter an appropriate value as specified Codes 2 12 Step 7 Complete Other Insurance RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 187 PA PROMISe Provider Electr
93. or by double clicking on a data entry field that is linked to a reference list R PA MMIS CMcElheny PES_Manual_ 5010 4 00 _ICD10 docx August 31 2015 31 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 AU row Lists Reports Tools Security Window Help O Cha DO Provider Recipient Taxonomy Admission Type Admit Source Carrier Condition Code Diagnosis Diagnosis ICD Modifier NDC Occurrence Other Insurance Reason Patient Status Place Of Service Policy Holder Procedure HCPCS Procedure HCPCS ICD10 Revenue Type Of Bill Value Code R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 32 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 6 3 5 Reports The Reports option lets you create and print summary or detail reports of the forms or reference lists HP Provider Electronic File Forms Communication Lists Reports Tools Security Window Help Chea DORS Summary Forms NCPDP Provider Recipient Taxonomy Admission Type Admit Source Carrier Condition Code Diagnosis Diagnosis ICD 10 Modifier NDC Occurrence OI Reason Patient Status Place of Service Policy Holder Procedure HCPCS Procedure HCPCS ICD 10 Revenue Type of Bill Value Code R PA MMIS CMcElheny PES_Manual_ 5010 4 00 _ICD10 docx August 31 2015 33 PA PROMISe Provider Electronic Solutions Software User Manual Version
94. responses from the PROMISe system The Submission option lets you send and receive multiple form types at the same time Each form type is equal to a batch For example if you are sending a 270 Eligibility Request file and an 837 Professional file you are sending two batches Keep in mind that although you may be sending several forms in the same batch file those forms may be returned with other batches of the same form type There is no guarantee that all batches will be processed together RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 302 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 To submit and receive files perform the following Step 1 Select the Submission option from the Communication menu ig HP Provider Electronic Solutions leyni Submission Resubmission View Batch Response 35 ERA View Bulletin View Submit Reports View Communication Log Step 2 Select the appropriate submission method from the Method drop down list To submit via Web Internet Modem or diskette are no longer available The default is Web Server The default is Web Server if it is not selected Select the Web Server option to submit by Web Internet The BBS Batch option to submit by modem is no longer available Step 3 Note Diskette and BBS Batch are no longer available Select the type of files you want to send to HP Enterprise Services from the Files To Send list
95. screen contains the following claim data Hdr 1 Hdr 2 Hdr 3 Hdr 4 Hdr 5 O I Crossover Srv 1 Accesses the screen that contains the provider and resident information Accesses the screen that contains the admission days Attending Provider and Rendering provider Accesses the screen that contains any diagnosis information Accesses the screen that contains any occurrence condition and value code information Access the screen that contains Additional Diagnosis Codes 2 12 Accesses the screen that contains any other insurance carrier information Accesses the screen that contains Medicare information It can be accessed by selecting Y in the Crossover Ind field located under the Header 3 Accesses the screen that contains billing information For additional information on a particular field highlight the field with your mouse and press F1 To create an institutional nursing facility claim perform the following steps RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 172 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 1 From the main screen of the Provider Electronic Solutions software access the 837 Institutional Nursing Facility Form either in one of two ways Click 837 Institutional Nursing Facility Shortcut icon on the Toolbar or Select the 837 Institutional Nursing Facility Option from the Forms drop down menu nag HP Provi
96. select or enter a recipient ID Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form Recipient s middle initial This field 1s automatically populated after you select or enter a recipient ID Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form Enter the 2 digit month 2 digit day and 4 digit year on which the recipient first received service under this claim For example enter 10012015 if the date was October 1 2015 If the same service was provided on a single day enter the date of service in both the From DOS and To DOS fields Enter the 2 digit month 2 digit day and 4 digit year on which the recipient last received service under this claim For example enter 10012015 if the date was October 1 2015 Provider s own reference number for the recipient Enter the 30 character account number assigned to the recipient by your facility This data appears in the first column of the RA statement when the claim is adjudicated A unique account number is required for each claim submitted to be able to obtain claim status information If the same account number is used for each claim submitted when a claim status request is sent the claim status 1s reported on all claims with that account number RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015
97. sensitive Retype your new password in the Rekey New Password field cik _ RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 13 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Enter all fields to change a user password on the HP Provider Electronic Solutions Application Cancel User ID pes admir Old Password Hew Password E Rekey New Password Tr Question In what city were you bom Answer femme Rekey Answer fren Step 5 When the Logon Status box is displayed and you see that your password was successfully updated click ue A User Password SUCCESSFULLY Updated Step 6 When the Application box is displayed and prompts you to establish your personal options click ua Need to add this r 1 Since itis the first time you have run the application You will have to set up pour personal options OF R PA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 5 Complete Transmission Options The first time you log on to the application and change your password you are required to set up your Transmission Options and the Options box is automatically displayed If you have logged on to the software previously and would like to update your Transmission Options access the Tools menu from the main screen and click the Options selection
98. services The only Patient Location codes that are accepted by MA are 00 Not Specified 1 Home 2 Skilled Nursing Facility 3 Nursing Facility 4 Assisted Living Facility 5 Custodial Care facility 6 Group Home 7 Inpatient Psychiatric Facility 8 Psychiatric Facility 9 Intermediate Care Facility ICFMR 10 Residential 11 Hospice 12 Psychiatric Residential Facility 13 Comprehensive Inpatient Facility 14 Homeless Shelter 15 Correctional Institution RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 272 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Eligibility Select the eligibility clarification code from the drop down list or Clarification enter an appropriate value as specified This code indicates that the Code pharmacy 1s clarifying eligibility based on the receipt of a denial 0 Not specified 1 No Override 2 Override 3 Full Time Student 4 Disabled Dependent 5 Dependent Parent 6 Significant Other Step 2 1 If Patient Relationship Code is anything other than 0 Not Specified the Patient tab will be required Pharmacy Baba Total Charge Mi Amt Paid Tf Billed Amt Wii Details P E I Coupon Clinical 1 Clinical 2 Patient Add s Patient ID ID Code Qualifier x Copy Last Namel First Name gt Street
99. steps Step 1 Double click the data entry section of the field for which you would like to add a selection or create a reference list 6 HP Provider Electronic Solutions File Edit View Forms Tools Window Help D3 RXJ Eal e B ES H E k EJ 837 Professional Total Charge TT 0I Amount EET Billed Amount Services Hdr 1 Hdr 2 Hdr3 Hdr4 Hars svi sw2 swa Claim Frequency fix Original Claim Add Provider Role Copy Provider ID See Location Code NPI Delete Last Org Name First Name hil e a a Undo All Recipient ID Medical Rec tt DOB 00 00 0000 F ave Last Name First Name Hl Release of Medical Data o Account H o Benefits Assignment Y x Patient Signature Report Type Code ee Report Transmission Code ee Attachment Ctl nnn Billed Amount Last Submit Dt Step 2 Enter the data requested for each field Provider ID fLicense Facilty ID Location Code Ad ID Code Qualifier EEE Entity Type Qualifier v Delete Last Org Hame First Hame Wil E Undo All Taxonomy Code Provider Address Line 1 Line 2 Gy i See Provider ID Taxonomy LastOrg Name 111111111 0001 eeeeeeeeel TESTER 1 555555555 0005 2011111111 BILLING RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 49 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 3 When the data entry fields are completed click Step
100. that a modem needs to be selected but will not be used Note If using the Web BBS this does not need to be completed This is no longer available Initialization string of modem commands used to select a modem type Note Change the string in this field only under the direction of a representative from the HP Enterprise Services Provider Assistance Center PAC 1 800 248 2152 or 717 975 4100 5 6 Carrier The Carrier screen contains information related to transmitting your files To access the Carrier screen Step 1 Click the Carrier tab in the Tools Options box The software comes preloaded with Interactive Transmit and Batch Transmit options at the bottom of the screen Fields populate with the associated data These two transaction types are submitted through the Provider Electronic Solutions software RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 21 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Modem web Batch Interactive Carrier PayerProcessor Retention Trans Desc ESE Dtr 9600 Carrier ID INT_TOLL_FREE v Phone Number 8666270017 Het ID FAMF Het Password pamopds ATT Menu B Production Test Ind F Trangaction Type Het id Phone Number INTACT TRANSMIT INT TOLLUFREE PAMP gegi BATCH TRANSMIT BTCH_TOLL_FREE PAMP 16666270015 20000 Step 2 Enter the data requested for each transaction type listed below Inte
101. that apply must be entered EPSDT Dental Referral YD EPSDT Vision Referral YV RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 153 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 EPSDT Hearing Referral YH EPSDT Medical Referral YM EPSDT Behavioral Health YB Referral EPSDT Other Referral YO If the provider is a qualified small business enter QSB in the Billing Note field You may enter more than one code if applicable Example VCO9QSB for a claim filed by a qualified small business dental provider for services rendered to a pregnant woman Newborn Select the newborn indicator code from the drop down list or enter the Indicator appropriate value as described below or enter an appropriate value as specified Select Y Yes if the recipient is a newborn Select N No if the recipient 1s not a newborn Encounter Select the encounter indicator from the field s pull down list Ind o Select RP if the claim is an encounter record Consolidated Community Reporting Use Only o Select CH if the claim is a Fee for Service claim The default value for this field is CH Other Select the other insurance code from the drop down list or enter an Insurance appropriate value as specified as described below Indicator Select Y Yes if the recipient has other insurance Select N No if the recipient does not have other insurance Crossover The Crossover
102. the NDC Service ID must be 0 If the compound indicator field contains the value 0 or 1 then the 11 digit NDC for the drug dispensed must be entered Qualifier code for the NDC The qualifier code must always be 03 for claims Enter the quantity being dispensed expressed in metric decimal units Enter a number to indicate whether the prescription is the original prescription or a refill Enter 0 to indicate that this is the first time the prescription is filled Enter the number of days the dispensed quantity should last Select the compound code from the drop down list or enter an appropriate value as specified This compound code identifies if the prescription is a compound 1 Not a Compound 2 Compound Enter the appropriate code or enter an appropriate value as specified that indicates whether the prescriber s instructions regarding generic substitution have been followed 0 No Product Selection Indicated 1 Substitution Not Allowed by Prescriber 2 Substitution Allowed Patient Requested Product Dispensed 3 Substitution Allowed Pharmacist Selected Product Dispensed 4 Substitution Allowed Generic Drug Not in Stock 5 Substitution Allowed Brand Drug Dispensed as Generic August 31 2015 276 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 6 Override 7 Substitution Not Allowed Brand Drug Mandated by Law 8 Substitution Allowed Gene
103. the detail report to information for the specified recipient Cardholder ID Enter the appropriate recipient ID in this field Form Status Limits the summary report to include only the claims with the specified form status Select the appropriate form status from this drop down list Submit Date Limits the summary report to Dental Claims transmitted on a specified date Enter the appropriate date in this field Step 4 Click OF after you enter the report criteria A detailed report is generated and displayed on your screen R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 325 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Use the scroll bars located on the right side and bottom of the screen to view the entire report Gh HP Provider Electronic Solutions File Forms Lits Reports Tools Window Help jarvis a 5 O amp el lt C9 837 Dental Detail Report Batch Number RtecipietMCardholder ID 2 Form Statue Submit Date HOO ION Recods selected 837 Dental Detail Report Asof 08M S015 ALL CLAMS Claim Frequency 1 Original Claim tt Provider Role 7 Provider ID 00503472 Lasti0rg Hame AMOUROSO HPI 174692731 Location Code 0001 Fost Name JOHN HI H Recipient IDL Medical Record LastMame _ Fuit Name LESTER Ml Bendi Attignanent Y Reput Type Code Report Transmssion Code Allachment Cil Aelerring Proveder Provides D Location C
104. the menu o Select RP if the claim is an encounter record Consolidated Community Reporting Use Only o Select CH if the claim is a Fee for Service claim The default value for this field 1s CH Note Consolidated Community Reporting for OMHSAS CCR submissions are indicated using the Encounter Ind value of RP The default value for this field is CH RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 242 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Complete Header 3 EJ 837 Professional Total Charge 999i Ol Amount S99 Billed Amount Services Accident Add Related Cause 1 2 hai Date 0070070000 Copy State Country Transport Reason Code Transport Distance 0 Undo All Patient Weight 0 Condition Codes 1 2 3l Gave L 4 5 zj Admission Date 00700 0000 Discharge Date 00700 0000 Special Program Code Pregnancy Ind N Date of Last Henstruation 0070070000 EPSDT Referral Hewbor Ind N Delay Reason Other Insurance Ind N Ambulance LastName FirstName Billed Amount Last Submit Dt lute Print Close Recipient ID Related 1 2 Select the value from the drop down list or enter an appropriate Cause value as specified Accident AA Auto Accident EM Employment OA Other Accident Date Enter the 2 digit month 2 digit day and 4 digit year on
105. the place of service on Claim Header 2 the place of service displayed on Service Header 1 is used in the adjudication process Procedure Service that was rendered to the recipient Enter the procedure code as listed in the MA Program Fee Schedule or Select the procedure code from the drop down list that was created or Enter the appropriate procedure code value as specified Modifiers Enter the 2 digit modifier for the procedure code that was entered in the Procedure field Only enter a modifier if the procedure code requires a modifier as indicated by the MA Program Fee Schedule Tooth Enter the 2 character code for the tooth on which the service was performed in the range 00 to 32 for permanent teeth and A through T for primary teeth R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 134 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Surfaces Each field identifies a tooth surface on which services were performed Select Fields 1 5 the appropriate code from the drop down list or enter an appropriate value as specified as described here B Buccal D Distal F Facial I Incisal L Lingual M Mesial O Occlusal Quadrants Each field identifies a mouth quadrant on which services were performed Select Fields 1 5 the appropriate code from the fields drop down lists or enter an appropriate value as specified 00 Entire Oral Cavity 20 Upper L
106. these fields access the Recipient List Form Recipient s middle initial This field 1s automatically populated after you select or enter a recipient number in the Recipient ID field Information cannot be entered directly into these fields to add or change information in these fields access the Recipient List Form Select the appropriate release code from the drop down list or enter an appropriate value as specified Select I if the provider has Informed Consent to Release Medical Information Select Y if the provider has a signed statement on file permitting the release of medical data to other organizations Enter the patient s alpha numeric or alphanumeric number assigned by the provider You may enter up to 30 characters MA captures and returns 30 characters When this field is completed the patient s account number appears on the RA statement and makes it easier to identify those invoices where the recipient number is not recognized Note An account number is required for each claim to be able to obtain claim status information If the same account number is used for each claim submitted when a claim status request is sent the claim status is reported on all claims with that account number Select the appropriate assignment code from the drop down list or enter an appropriate value as specified Select Y if the recipient or authorized person has authorized benefits to be assigned to the provider Select N
107. upgrade shortcut in the Provider Electronic Solutions area of your Windows Start Menu 12 6 Create Archive You should archive your database to keep the number of claims for a particular form manageable and to maintain historical records of the forms you have entered It is also a good practice to archive your claims on a regular basis to protect them in case of a system failure To archive your database perform the following steps Step 1 From the main menu of the Provider Electronic Solutions software select the Create option from the Archive drop down menu Step 2 The following message is displayed Fh Asa reminder all other users MUST be out of the application SL before the forms can be archived successfully Note Make sure all other users are logged off the system and all claims are not in a Ready status Step 3 Click OF to clear the message from your screen This is only necessary if your system is shared across a network Step 4 The message below is then displayed not been modified in the past 100 days will be deleted Continue RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 357 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Note All forms with an T status Incomplete that have not been modified in the past 30 days are deleted when you archive your database Step 5 Click No to cancel the archive procedure or Click
108. you will be notified by DHS or HP Enterprise Services Step 3 Click __ Save when all data entry fields are completed Step 4 Click o Ada and repeat steps 2 3 and 4 to add another carrier code to the Carrier reference list Step 5 Click Close to exit the Carrier screen 8 9 Condition Code Reference List To complete the data entry fields needed to add or edit a Condition Code reference list selection complete the following steps R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 71 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 1 Click Lists Condition Code to access the Condition Code reference list Up HP Provider Electronic Solutions O Fe E p Sel File Edit View Forms Lists Tools Window Help D xo ale Blas A Eh Ag Condition Code Add Condition Code Description Delete Undo All Gave Description Find Condition i Employment Related Patient Covered by Insurance Not Reflected Here Lien Has Been Filed Payment was accepted payment in full EPSOT CHAP Special Federal Funding Family Planning Print Step 2 Enter the data requested for each field as described below Condition Choose the appropriate code from the drop down list that identifies Code conditions relating to a bill that may affect payer processing or enter an appropriate value as specified 02 Condition
109. 003113 Step 4 Click Close to exit the View Batch Response box 9 3 Complete the 276 Claim Status Request Version 4 00 The 276 Claim Status Inquiry Request form is used to create a request to determine claim status and is submitted in either an interactive mode or a batch mode These modes are described in this section The 276 Form is divided into two screens Each screen contains the following claim data RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 106 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Header 1 This tab contains the provider and recipient information Header 2 This tab contains the specific claim information For additional information on a particular field highlight the field with your mouse and press F1 To create a claim status request perform the following steps Step 1 From the Provider Electronic Solutions software main screen access the 276 Claim Status Inquiry Request in one of the following two ways Click M 276 Claim Status Inquiry Request Shortcut Button on the Toolbar or Select the 276 Claim Status Inquiry Option from the Forms drop down menu as shown below _ Lig HP Provider Electronic Solutions Forms Communication Lists Reports Tools Security Window Help 270 Eligibility Request 2 6 Claim Status Request 837 Dental 837 Institutional Inpatient 837 Institutional Nursing Facility 837 Institutional Out
110. 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Required when the rendering provider is supervised by a physician or dentist Supervising Provider s last name or the name of the group or facility This field is automatically populated after you select or enter an MPI number in the Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Required when the rendering provider is supervised by a physician or dentist Supervising provider s first name This field is automatically populated after you select or enter an MPI number in the Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Required when the rendering provider is supervised by a physician or dentist August 31 2015 249 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 MI Supervising Supervising provider s middle initial This field is automatically Provider populated after you select or enter an MPI number in the Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Required when the rendering provider is supervised by a physician or dentist Step 7 Complete Header 5 J 837 Professional Total
111. 2 GD HP Provider Electronic Solutions SS File Edit View Forms Tools Window Help RX VB 8 8 Beles mle at 837 Dental oE Total pas a a OI Amount 999i Billed Amount PT Services ICD Version JICDiO JICDiO Codes i T i __ Cony Emergency T Delay Reason yy Delete Encounter Ind Special Program Codef Referal Code p HRA Undo All Prior Authorization EPSDT N Patient Pay Amount Orthodontic Treatment Save Total Months Months Remaining Place OF Service Billing Note Contract Type Contract Code Contract Version Find Recipient ID Last Name First Marne Billed Amount Last Submit Dt Find Print Close Enter the most specific diagnosis ICD 9 CM ICD 10 CM PCS Diagnosis Codes code that relates to the recipient s visit ICD Version Use the ICD 9 ICD10 Version for the code being submitted Emergency Select the appropriate Emergency Indicator code from the drop down Indicator list or enter an appropriate value as specified Select 3 if the service provided was in response to an emergency Delay Reason Select the appropriate code to indicate why a claim is being submitted outside of the 180 day initial submission window field is optional or enter an appropriate value as specified 1 Proof of Eligibility 7 Third Party Processing Delay Unknown or Unavailable 8 Delay in Eligibility 2 Litigation Determination 3 Authorization Delays 9
112. 4 To add another selection to the same reference list click steps 1 2 and 3 above and repeat 7 3 Edit Delete a Reference List To edit or delete a reference list selection prior to accessing a form complete the following steps Step 1 Access the Main screen of the Provider Electronic Solutions software Step 2 Click the Lists Menu and then click on the type of list you need to edit or delete The reference list box is displayed The selections for the reference list you have accessed are displayed at the bottom of the reference list box Click the selection that you need to edit or delete NCPDP Provider Recipient Taxonomy Admission Type Admit Source Carrier Condition Code Diagnosis Diagnosis ICD Modifier NDC Occurrence Other Insurance Reason Patient Status Place Of Service Policy Holder Procedure HCPCS Procedure HCPCS ICD10 Revenue Type Of Bill Value Code R PA MMIS CMcElheny PES_Manual_ 5010 4 00 _ICD10 docx August 31 2015 50 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 51 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 The software then fills the data fields on the screen with the information for the selection D HP Provider Electronic Solutions NN File Edit View Forms Lists Tools Window Help Dx JE S BA TSM kne Provider ID License Facili
113. 4 00 6 3 6 Tools The Tools option lets you create and work with archives perform database maintenance retrieve upgrades set up communications options and determine retention settings Archive Database Recovery Get Upgrades Change Password Options 6 3 7 Window The Window option lets you access the standard options available for most Windows compatible applications These options help you to configure the appearance of your work area s HP Provider Electronic Solution File Forms Communication Lists Reports Tools Security Window Help Cascade Tile Horizontal Tile Vertical Layer R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 34 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 6 3 8 Help The Help option lets you access the help file and basic information about the Provider Electronic Solutions software such as copyright details and version information if HP Provider Electronic Solutio Forms Communication Lists Reports Tools Security Window Help Contents and Index FL About 6 3 9 Toolbar Shortcut Buttons Toolbars are designed to work as shortcuts for frequently used menu commands and to reduce the time and steps needed to activate a function A toolbar consists of small pictures or shortcut icons that represent different menu commands To execute a command using the toolbar simply click on the appropriate shortcut icon with t
114. 6 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 7 73 74 75 76 a Respite Care Hospital Hospital Inpatient Hospital Room and Board Hospital Outpatient Hospital Emergency Accident Hospital Emergency Medical Hospital Ambulatory Surgical Long Term Care Major Medical Medically Related Transportation Air Transportation Cabulance Licensed Ambulance General Benefits In vitro Fertilization MRI CAT Scan Donor Procedures Acupuncture Newborn Care Pathology Smoking Cessation Well Baby Care Maternity Transplants Audiology Exam Inhalation Therapy Diagnostic Medical Private Duty Nursing Prosthetic Device Dialysis Otological Exam RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 373 Version 4 00 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 AO Al A2 A3 A4 A5 A6 A7 A8 A9 Chemotherapy Allergy Testing Immunizations Routine Physical Family Planning Infertility Abortion AIDS Emergency Services Cancer Pharmacy Free Standing Prescription Drug Mail Order Prescription Drug Brand Name Prescription Drug Generic Prescription Drug Podiatry Podiatry Office Visits Podiatry Nursing Home Visits Professional Physician Anesthesiologist Professional Physician Visit Office Profession
115. 8 ICF MR Void Cancel of Prior Claim Note The last digit should be selected based on the definitions below 0 Non Payment Zero Claim This code should be used when a bill is submitted to a payer but the provider does not anticipate a payment as a result of submitting the bill 1 Admit Through Discharge Claim This code should be used for a bill that is expected to be the only bill received for a course of treatment or confinement 2 Interim First Claim This code is to be used for the first of a series of bills to the same payer for the same confinement 3 Interim Continuing Claim This code is to be used for when a bill for the same confinement or course of treatment will be submitted 4 Interim Last Claim This code is to be used when a bill for the same confinement or course of treatment has previously been submitted and it is expected that no further bills for the same confinement or course of treatment will be submitted 7 Replacement of a Prior Claim This code is to be used when a bill has been submitted and paid and needs to be adjusted 8 Void Cancel of Prior Claim This code reflects the elimination of a previously submitted bill August 31 2015 175 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Original Claim Enter the 13 digit original ICN jj When submitting a previously rejected claim or a claim adjustment that was a
116. 837 Institutional Inpatient Form To generate an 837 Institutional Inpatient Summary Report perform the following steps Step 1 From the main menu of the Provider Electronic Solutions software select the 837 Institutional Inpatient Option from the Summary Forms drop down menu The 837 Institutional Inpatient Summary Report screen is displayed Step 2 Click OK to include all the Inpatient Claims in the summary report Step 3 Click OK when prompted by the box that advises you that all records will be selected A summary report is generated and displayed on your screen To limit the type of Inpatient Claims in the summary report enter the appropriate report criteria into one or more of the following fields Batch Limits the summary report to Inpatient Claims in a specific batch Number Enter the appropriate Batch ID number in this field You can locate the Batch Numbers under the Resubmission option of the View Communication Log menu Recipient Limits the summary report to Inpatient Claims for the specified Client ID recipient Enter the appropriate recipient ID in this field Form Status Limits the summary report to Inpatient Claims with the specified form Status Select the appropriate form status from this drop down list Submit Date Limits the summary report to Inpatient Claims transmitted on the specified date Enter the appropriate date in this field Step 4 After you enter the report criteria click 0K
117. AN FI 06713 2015 12 52 45 C2 2250NGa TSM FIV 06713 2015 12 52 44 C251 S556 2250N GWT TAN FIY 09 13 2015 12 07 18 C251 3980 2250N GWU TAN Fly 08 13 2015 12 07 17 C238 2250N GW TAN FIV 06713 2015 11 45 43 FILE C25I39YN 2250NGZJ TXN FIV 08 13 204 SHEE HEHEHE HEHEHE TRANSACTION SUMMARY BY STATUS TOTAL TKHS 1 TOTAL CHARGES TOTAL REJECT TXN 0 TOTAL R gect carces FILE NAME EXTENSION TOTAL ACCEPT TXN 1 TOTAL ACCEPT CHARGES 50 00 F TRANSACTION STATUS REPORT MODEL OFFICE PAGE 1 Ent SUBNITITER NAHE LOSER SUBMITTER ID 1441171521 SUBNISSION ID C sr33 tN PROCESSING DATE AND TIME 08713 2015 13 35i42 FROVIDER NAME FROVIDER ID RECEIVER NAME DEPARIMENT OF HUMAN SERVIC RECEIVER ID 236003113 TAN FORMAT VEASION ELIGIBILITY REQUEST Alg 2010 I The extension in the file name indicates what is contained in the file The chart that follows provides explanations of each file name extension Filename Extensions Extension Description Response to a 270 Eligibility Benefit Inquiry transaction that indicates whether the individual is entitled to receive MA benefits payment details for your claims submissions Payment Advice also referred to as a Remittance Advice which shows the RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 312 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Filename Extensions Extension Description
118. Additional information is located at the following links mE For complete CARC RARC Descriptions please visit the following web site Washington Publishing Company _ http www wpc edi com CAQH CORE website http www cagh org Step 1 Step 2 Step 3 Select the Communication View Batch Response 835 ERA option from the main screen Click the corresponding filename listed under the Filename column to view a particular batch Use the scroll bar to view the batch response or Press Print to print the 271 Eligibility Responses Each form is assigned a transaction reference number which indicates the beginning of a new 271 Eligibility Response RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 105 PA PROMISe Provider Electronic Solutions Software User Manual ig View Batch Response Filename 311139G1 211O0NEFW 2 FIV E10IS9CB 2100NE91 271 FIv 510139CC 2100NE54A 27 7 FIV Creation Date Creation Time 07730 2015 15 29 43 07730 2015 07729 2015 12 08 46 Eligibility Batch Response Date of Response Transaction Reference Number 07 29 2015 1001 Eligibility Batch Response Date of Response Transaction Reference Number submitter Transaction ID RECEIVED DATE ax N FORMATION SOURCE Information Source Last Org Mame Information Source Primary ID OF 29 2015 1001 QOOO0010e5 07 30 2015 FENNSyLYANIA DEPT OF HUMAN SERVICES 36
119. Amount Last Submit Dt Print Close Provider ID Enter the 8 or 9 digit medical license number or 9 digit MPI Attending number for the attending physician in this field Location Code The 4 digit location code associated with the attending MPI number Attending This field 1s automatically populated when a value is selected in the Attending Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form NPI Enter the NPI National Provider Identifier Numeric 10 digit Attending identifier consisting of 9 numbers plus a check digit in the 10 position Last Org Last name or organization name for the attending provider This Name field is automatically populated when a value is selected in the Attending Attending Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 207 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 First Name First name for the attending provider This field is automatically Attending populated when a value is selected in the Attending Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form MI Middle initi
120. August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 12Using the Tool Functions The Provider Electronic Solutions software provides several tool functions These functions include the following e Archive files e Database recovery e Get software upgrades e Change password e Change communication options You can access these functions from the Tools drop down menu on the main screen of the Provider Electronic Solutions software ig HP Provider Electronic Solutions File Forms Communication Lists Reports Tools Security Window Help Database Recovery Get Upgrades Change Password Options 12 1 Change Your Password To change your Provider Electronic Solutions software password perform the following Steps Step 1 From the main screen of the Provider Electronic Solutions software select the Change Password option from the Tools drop down menu R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 353 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 The Logon screen is displayed Enter all fields to change a user password on the HP Provider Electronic Solutions Application Cancel User ID pes admin Old Password Hew Password Rekey New Password Question In what city were you born Step 2 Enter your old password in the Old Password field Step 3 Enter your new password in the New Password
121. Bill Enter the code that identifies the type of bill or choose the appropriate code Code from the drop down list as described below Select the appropriate Type of Bill codes for the transaction type from the table below or enter an appropriate value as specified 837 Institutional County Nursing Facilities General Nursing Nursing Facility Facilities State Mental Facilities use a type of County and General bill code that starts with 26 pulse Pee ae 260 Nursing Home Zero No Pay Claim Mental Hospitals oe 261 Nursing Home Admit Through Discharge Claim 262 Nursing Home Interim First Claim 263 Nursing Home Interim Continuing Claim 264 Nursing Home Interim Last Claim 267 Nursing Home Replacement of Prior Claim RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 174 PA PROMISe Provider Electronic Solutions Software User Manual Intermediate Care Facilities State Mental Retardation Centers ICF MR Facilities ICF ORC Facilities RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx Version 4 00 268 Nursing Home Void Cancel of Prior Claim Intermediate Care Facilities State Mental Retardation Centers ICF MR Centers and ICF ORC Centers 650 ICF MR Zero No Pay Claim 651 ICF MR Admit Through Discharge Claim 652 ICF MR Interim First Claim 653 ICF MR Interim Continuing Claim 654 ICF MR Interim Last Claim 657 ICF MR Replacement of Prior Claim 65
122. CD10 docx August 31 2015 28 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 6 System Navigation Navigating through the Provider Electronic Solutions software is similar to other Windows applications The navigation options available are Menus Toolbar icons and Command buttons Use your mouse and keyboard to access these options On the keyboard you have Hot Keys such as the Ctrl C combination used to copy text and Function Keys such as the F5 key to refresh data in addition to normal navigation keys such as Enter and Backspace The following sections describe these navigational features in greater detail 6 1 Using the Mouse Using a mouse in the Provider Electronic Solutions software is the same as in most other software applications Just move the mouse pointer to the position on the screen where you want to work or select an option Click the left mouse button once to position your cursor at that location or to select an option To double click on a feature press the left mouse button twice very quickly For Windows users use the right mouse button to display a menu of options such as Cut Copy Paste and Select All To use the right mouse button position the cursor on a data entry field then click and hold the right mouse button This displays a list of options next to the field Drag the arrow down the list until the desired option is highlighted then release the mouse button to activat
123. CPDP pharmacy claim can have a maximum of twenty five ingredient lines Each ingredient line contains the data fields described in this step 00 Default 01 AWP Average Wholesale Price 02 Local Wholesaler 03 Direct 04 EAC Estimated Acquisition Cost 05 Acquisition 06 MAC Maximum Allowable Cost 07 Usual amp Customary 08 3408 Disproportionate Share 09 Other 10 ASP Average Sales Price 11 AMP Average Manufacturer Price 12 WAC Wholesale Acquisition Cost 13 Special Patient Pricing Step 9 3 Click dd Ingredient to add another ingredient line A new blank ingredient line is added to the screen RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 292 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 9 4 Click on the new ingredient line and then enter the ingredient data in the appropriate data fields Step 9 5 Click on the existing ingredient line information you want to copy to a new ingredient line Step 9 6 Click Copy Ingredient The new ingredient information is copied to the new line The new ingredient line has the same data as the existing ingredient line you previously selected You can edit the data in the new ingredient line Step 9 7 Click on the new ingredient line to make changes to the appropriate fields Step 9 8 Click on the ingredient line you want to delete and then click Delete I
124. Claim Filing Ind Code Paid DatefAmount 00 00 0000 00 Copy Policy Holder Carrier Code Group Group Name Delete Last Name First Name Undo All Remaining Patent Liability OO Won Covered Amount OO 5 Save Insurance Type Code Add Ol eee Group Manne Last Mame Copy Ol Delete DI Find Recipient ID Last Marre Billed Amount Last Submit Dt Find Print Close The Other Insurance screen is added to the claim when you select Y in the Other Insurance Indicator field on the Header 3 screen Step 6 1 Click the OI tab to access the Other Insurance screen The Other Insurance screen 1s displayed The Other Insurance screen contains the recipient s other insurance information for the new form Step 6 2 Perform the following steps to complete the OI screen Release of Select the release code from the drop down list or enter an Medical Data appropriate value as specified as described below Select I Informed consent to release Medical Information Select Y Yes Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Benefits Select the assignment code from the drop down list or enter an Assignment appropriate value as specified as described below Select Y for Yes if the recipient or authorized person has authorized benefits to be assigned to the provider RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 129
125. Elheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 45 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 837 Professional Ese Total Charge ii Ol Amount ii Billed Amount Services Hdr 1 Hdr 2 Hdr3 Har 4 Hdr5 svi srv2 sra Claim Frequency Provider Role Provider ID Location Code HPI Last Org Name First Name hil Recipient ID Medical Rec H DOB 00 00 0000 Care Last Name First Name Hl Release of Medical Data gt Account H o Benefits Assignment Y x Patient Signature z Report Type Code gt Report Transmission Code Attachment Ctl Fa Last Submit Dk The Provider list box is displayed RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 46 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 GY HP Provider Electronic Solutions File Edit View Forms Tools Window Help DEX 2OA el Balen r m k cS 837 Professional Total Charge PTI 0l Amount il Billed Amount Tl Services Hdr 1 Hdr 2 Hdr3 Hdr4 Hdr5 svi srv2 srv3 Claim Frequency E Original Claim Add Prg ider Role G Provider Provider ID License Facility ID Location Code Add ID Code Qualifier G2 Entity Type Qualifier Delete Last Org Name First Name MI SSN Tax ID Undo a Taxonomy Code HPI Save Provider Address A A_AAMAAHJp AAHA Find
126. Eligibility Request forms on January 2 the system processes your request and has a 271 Eligibility Response available for you to access on January 3 Step 4 When you receive an Application box that identifies the status of your transmission read the message and click If the transmission was unsuccessful read the message or communication log make the necessary changes and resubmit the files RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 103 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 The following day Step 5 Select the Communication Submission option from the main screen i HP Browder Electronic Solutions File Forms Communication Lists Reports Tools Security Window Help Submission Resubmission View Batch Response 35 ERA View Bulletin View Submit Reports View Communication Log Step 6 Select the form files you want to receive located under the Files to Receive column Note Always select the Submission Transaction Report s 999 Acknowledgment s Accepted Submit Report s and Rejected Submit Report s for the files to receive along with the 271 Eligibility Response s Review all the Reports to make sure all submissions were processed Submission Method Web Serve Diskette Drive Select All Deselect All Select All Deselect All Files To Send a i l ArU Eligibility Request 2f Eligibility Responzefs Submi
127. Eligibility Responses that assist you in matching the 271 Eligibility Responses to the department person or group in your office who made the eligibility request Trace Transaction Reference Used by the software to match the 270 Eligibility Request with the 271 Eligibility Response This value automatically increases by 1 each time a new 271 Eligibility Response is generated Step 7 Complete Service ag HP Provider Electronic Cet E A al File Edit View Forms Tools Window Help D RXV Ba olt BAES 3 T al a 270 Eligibility Request Hdr1 Hdr2 Service Service Type Code TE Delete Undo All Save Add Dtl Service Type Code Copy Du Delete Dtl Recipient ID Last Hame First Marre From DOS To DOS Last Submit Dt Status eke EERE Service contains the Service Type Code To complete the Service screen Service Type Health Benefit Plan Coverage Required if utilizing a Service Type Code Code inquiry list of codes supported is in Appendix B Values may be repeated 99 times Step 8 Click Add Dti to add another detail line RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 99 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 9 A new blank detail line is added to the screen Step 10 Click on the new detail line and then enter the data in the appropriate data fields Step 11 Click Copy DU to copy the data
128. Emergency Room Hospital 24 Ambulatory Surgical Center 25 Birthing Center 26 Military Treatment Center 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 35 Adult Living Care Facility 41 Ambulance Land 42 Ambulance Air or Water 50 Federally Qualified Health Center Version 4 00 53 Community Mental Health Care 54 Intermediate Care Facility Mentally Retarded 55 Residential Substance Abuse Treatment Facility 56 Psychiatric Residential Treatment Center 60 Mass Immunization Center 61 Comprehensive Inpatient Rehabilitation Facility 62 Comprehensive Outpatient Rehabilitation Facility 65 End Stage Renal Disease Treatment Facility 71 State or Local Public Health Clinic 72 Rural Health Clinic 81 Independent Laboratory 99 Other Unlisted Facility Description Enter a description of the place of service code being added Click __ Save when all data entry fields are completed Step 3 Step 4 Click o Ad and repeat steps 2 3 and 4 to add another place of service code to the Place of Service reference list Step 5 Click Cose to exit the Place of Service screen 8 17 Policy Holder Reference List To complete the data entry fields needed to add or edit a Policy Holder reference list selection perform the following steps RAPA MMIS CMcElheny PES_Manual_5010 4 00
129. Example VCO9QSB for a claim filed by a qualified small business dental provider for services rendered to a pregnant woman Step 4 Complete Header 3 RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 122 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 ig HP Provider Electronic Solutions Sa File Edit View Forms Tools Window Help al 837 Dental Total Charge 999i 0l Amount 9 Billed Amount o Services Accident Add Related Causes D ate 007000000 State Country Copy Delete Undo All Service Facility Location Facility ID Location Code Facility Hame Other Insurance Ind N Recipient ID Last Hame First Marne Billed Amount Last Submit Dt Accident Related Select accident code from the drop down list or enter an Causes appropriate value as specified as described below Select AA Auto Accident 1f this claim is the result of an auto accident Select EM Employment if the claim is the result of an employment accident Select OA Other Accident if the claim is the result of an accident other than employment or auto Enter the 2 digit month 2 digit day and 4 digit year when the accident occurred that is related to the charges or to the recipient s current condition diagnosis or treatment For example enter 10012015 if the date of the accident was October 1 2015 State Enter the 2 letter abbreviation for
130. FO Delte City State Zip Undo All Email Address Phone a Cave Send Cardholder ID Last Name First Name Billed Amt Last Submit Dt Find Print Close Patient Enter the identification number issued to recipients who are authorized to ID receive Pennsylvania Medicaid services ID This field identifies the type of number used in the Patient ID field 1 e Qualifier Medicaid ID Number Client ID Number Member ID Number Insurance Policy Number or Social Security Number Select the appropriate code For NCPDP claims this value should always be blank RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 273 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Select a value from the drop down box or enter an appropriate value as specified 01 Social Security Number 02 Driver s License Number 03 US Military ID 04 Non SSN Based Patient Identifier 05 SSN Based Patient Identifier 06 Medicaid ID 07 State Issued ID 08 Passport ID 09 Medicare HIC 10 Employer Assigned ID 11 Payer PBM Assigned ID 12 Alien Number 13 Government Student Visa Number 14 Indian Tribal ID 1J Facility ID Number 99 Other EA Medical Record Identification Num Last Patient s last name Name First Patient s last name Name Street Address of the Patient Street City City where the Patient resides State State where the Patient resides Zip Pat
131. Federal Program 12 Preferred Provider Organization PPO 13 Point of Sale POS 14 Exclusive Provider Organization EPO 15 Indemnity Insurance 16 Health Maintenance Organization HMO Medicare Risk 17 Dental Maintenance Organization AM Automotive Medical BL Blue Cross Blue Shield CH CHAMPUS CI Commercial Insurance Co DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B OF Other Federal Program TV Title V VA Veteran Administration Plan WC Worker s Compensation Health Claim ZZ Mutually Defined Identifies the general category of the adjustment being made to the claim Select the adjustment group code from the drop down list or enter an appropriate value as specified CO Contractual Obligations CR Correction and Reversals OA Other Adjustments PI Payer Initiated Reductions PR Patient Responsibility R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 168 PA PROMISe Payer Payer responsible for the recipient s other insurance Select the Responsibility appropriate code from the drop down list or enter an appropriate value as specified P Payer 1 S Payer 2 T Payer 3 A Payer 4 B Payer 5 C Payer 6 D Payer 7 E Payer 8 F Payer 9 G Payer 10 H Payer 11
132. For additional information on a particular field highlight the field with your mouse and press F1 To create a Professional claim perform the following steps RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 233 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 1 From the Provider Electronic Solutions software main window access the 837 Professional Form on one of the other Click 837 Professional Shortcut Button on the Toolbar or Select the 837 Professional option from the Forms drop down menu 10 Eligibility Request 2 6 Claim Status Request a37 Dental 63 7 Institutional Inpatient 83 Institutional Nursing Facility 83 Institutional Outpatient 63 Professional NCPDP Pharmacy NCPOP Pharmacy Eligibility NCPDP Pharmacy Reversal Note When you choose a selection from a drop down list many fields are populated A drop down list is also known as a reference list For additional information on reference lists refer to the List options under Section 6 Step 2 The 837 Professional Form appears with the Header 1 screen displayed R PA MMIS CMcElheny PES_Manual_ 5010 4 00 _ICD10 docx August 31 2015 234 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 3 Complete Header 1 EJ 837 Professional Total Charge i OF Amount Sa Billed Amount Ut Services Claim Frequency 1 Original Claim Add Provider Role
133. Has Been Filed 60 Day Outlier 77 Payment was accepted payment in full A1 EPSDT CHAP A3 Special Federal Funding A4 Family Planning A7 Induced Abortion Danger to Life A8 Induced Abortion Victim Rape Incest AI Sterilization B3 Pregnancy Indicator DR Disaster Related If the provider is a qualified small business enter QSB in the Billing Note field You may enter more than one code if applicable Example VCO9QSB for a claim filed by a qualified small business dental provider for services rendered to a pregnant woman Step 4 Complete Header 3 R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 206 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 ig HP Provider Electronic Solutions File Edit View Forms Tools Window Help tl DECA EAL Ey 837 Institutional Outpatient laoa Total Charge PT 0I Amount D Billed Amount MT Services Hdr1 Hdr2 Hdr3 Hdr 4 pat o1 crossover swa srv2 srv3 swadi Attending Provider Add Provider ID ie Location Code NPIL Copy Last Org Hame TO First Name o Hl Operating Provider Delete Provider ID tS Location Code NPI Undo All Last Org Hame PO First Name o Hl Save Rendering Provider Provider ID o Location Codel NPI Last Org Hame First Name o Hi C Newborn Ind Y Other Insurance Ind Y Crossover Ind Y Find Last Hame First Marne Billed
134. Help jax valolta Alas 4m k Ag Occurrence Occurrence Code Description Delete Undo All Save Occurence Code Description Find Auto Accident No Fault Insurance lnvolyved lncluiding Auto Accident Other Accident T ort Liability Accident Employment Related Other Accident Crime Wictim Date Insurance Denied Print Step 2 Enter the data requested for each field Occurrence Enter the code that defines significant events relating to the service or Code enter an appropriate value as specified 01 Auto Accident 24 Date Insurance Denied 02 No Fault Insurance Involved 25 Date Benefits Terminated Including Auto Accident Other By Primary Payer 03 Accident Tort Liability 71 Prior Stay Dates 04 Accident Employment Related 74 Noncovered Level of 05 Other Accident Care Leave of Absence 06 Crime Victim DR Disaster Related _MR Disaster Related Description Enter a description of the occurrence These occurrence code values are preloaded and are HIPAA compliant If any changes or modifications need to be made to these values you will be notified by DHS or HP Enterprise Services Step 3 Click Save when all data entry fields are completed RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 77 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 4 Click Add and repeat steps 2 3 and 4 t
135. I Org Name Recipient ID Select a type of bill code from the drop down list or enter the appropriate value based on your facility and bill type Outpatient Hospitals use a type of bill code that begins with 13 When billing for a hospital special treatment room use a type of bill code that begins with 14 Select the last digit of the type of bill code based on the definitions listed below 0 Non Payment Zero Claim 1 Admit Through Discharge Claim 7 Replacement of a Prior Claim 8 Void Cancel of Prior Claim Enter the 13 digit original ICN When submitting a previously rejected claim or a claim adjustment that was adjudicated prior to the implementation of PROMISe enter the 10 digit CRN followed by the 2 digit line number as printed on the RA statement Select the 9 digit MPI number of the provider for whom the claim will be paid from the drop down list or double click on the data entry portion of the field to add a reference list selection If assigning payment to a group select the 9 digit group MPI number Field is automatically populated with the location code associated with the MPI number selected in the Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position
136. IT Services Attending Provider Add Provider ID Location Code HPI c opy Last Org Name First Hame Hi Operating Provider Delete Provider ID Location Code HPI Undo All Last Org Name First Name hii jare EE ee E Find Recipient ID LastName jf First Name l Billed Amount f Last Submit Dt Print Close Provider ID Select the 9 digit MPI number or 8 or 9 digit medical license Attending number for the attending provider ONLY IF the attending provider Provider on the service line is different from the attending provider for the claim itself Location Code Attending provider s 4 digit location code This field is Attending automatically populated when an attending provider ID number is Provider chosen Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form NPI Enter the NPI National Provider Identifier Numeric 10 digit Attending identifier consisting of 9 numbers plus a check digit in the 10 Provider position Last Org Name Attending provider s last name or organization name associated Attending with the number selected in the Attending Provider ID field This Provider field is automatically populated when an attending provider ID number is chosen RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 228 Provider Electronic Solutions Software User Manual First
137. Ind Place Of Service Delete Procedure Modifiers 1 2 3 4 Units 0 EPSDT DiagPu 1 2 af 4f Undoan Basis of Measurement UN Billed Amount 0 CLIA Humber Po Cave Prescription Number Refill Number 0 Prescription Date 00 00 0000 HDC a Drug Units 000 0 Drug Unit of sali Add Srv FromDOS ToDOS POS Procedure Units Billed Amount_ I 00 Copy Srv Delete Srv Recipient ID LastName f First Name Billed Amount Last Submit Dt Enter the 2 digit month 2 digit day and 4 digit year on which the recipient first received service under this claim For example enter 10012015 if the date was October 1 2015 If the same service was provided on consecutive days enter the first day of the service in this field and the last day of service in the To DOS field If you are billing for a service that was provided on only one day complete the From DOS with the date of service and press the Tab key The same date will populate automatically in the To DOS field Note The From DOS and To DOS fields are used to determine the Days Supply if being used by a Dispensing Provider Enter the 2 digit month 2 digit day and 4 digit year on which the recipient last received service under this claim For example enter 10012015 if the date was October 1 2015 Emergency Select the emergency code from the drop down list or enter an Indicator appropriate value as specified Select Y if the service provi
138. Indicate where it was installed in the above step RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 4 Access the Application Step 1 To access the application perform the following Double click the PA HP Provider Electronic Solutions folder from the desktop and then select HP Provider Electronic Solutions or Select the Start button in the bottom left hand corner of the screen select the Program option and then select PA HP Provider Electronic Solutions Step 2 When the Logon screen is displayed use pes admin as the default User ID DO NOT CHANGE Type the default password hp pes and click o Enter a User ID and password to log onto the HP Provider Electronic Solutions Application Cancel User ID lpesadmin Forgat Password Password Note The User ID is always pes admin unless additional User IDs are set in the security menu Step 3 The first time you log on a Password Expired box is displayed cik _ Password Expired ae Select OK to change your password now E orselect CANCEL to discontinue LogOn Step 4 The Logon screen prompts you to change your password Type the old password hp pes in the Old Password field Type your new password in the New Password field Your new password must be a minimum of five 5 and a maximum of ten 10 alphanumeric characters This password is case
139. Indicator is used to determine the recipient s Medicare Indicator information Select the crossover code from the drop down list or enter an appropriate value as specified as described below Select Y Yes if the recipient has Medicare coverage Select N No if the recipient does not have Medicare coverage File Must start with POA must end with Z Only characters allowed are Y N U Information W 1 Total count of characters between POA and Z must be equal to the primary diagnosis code plus the number of other diagnosis codes RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 154 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Contract Type Contract Code Contract Version DRG Diagnosis Related Group The indicator represents the contract between the provider and the managed care or sub capitation subcontractor Choose a value from the drop down list Note Fee For Service Providers who are billing directly to Medical Assistance do not use this field For Consolidated Community Reporting for OMHSAS CCR The contract number between the provider and the managed care or sub capitation subcontractor Note Fee For Service Providers who are billing directly to Medical Assistance do not use this field For Consolidated Community Reporting for OMHSAS CCR If submitting a managed care claim where there is a sub capitation arrangement choose the contrac
140. M EPSDT Behavioral Health YB Referral EPSDT Other Referral YO If the provider is a qualified small business enter QSB in the Billing Note field You may enter more than one code if applicable Example VCO9QSB for a claim filed by a qualified small business dental provider for services rendered to a pregnant woman Contract Type Contract Code Contract Version Encounter Ind The indicator represents the contract between the provider and the managed care or sub capitation subcontractor Choose a value from the drop down list Note Fee For Service Providers who are billing directly to Medical Assistance do not use this field For Consolidated Community Reporting for OMHSAS CCR The contract number between the provider and the managed care or sub capitation subcontractor Note Fee For Service Providers who are billing directly to Medical Assistance do not use this field For Consolidated Community Reporting for OMHSAS CCR If submitting a managed care claim where there is a sub capitation arrangement choose the contract version from the pull down list The contract version is the month of the contract that was in force at the time of the service Note Fee For Service Providers who are billing directly to Medical Assistance do not use this field For Consolidated Community Reporting for OMHSAS CCR Select the encounter indicator from the field s pull down list o Select RP if the claim is an e
141. MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Table of Contents 1 INTRODUCTION TO PROVIDER ELECTRONIC SOLUTIONS 1 2 SYSTEM REQUIREMENTS 2 3 INSTALLATION OVERVIEW 3 3 1 INSTALLATION FROM A DOWNLOADED FILE 4 3 2 INSTALLATION FROM A CD ROM 7 3 3 INSTALL THE SOFTWARE TO A NETWORK 12 4 ACCESS THE APPLICATION 13 5 COMPLETE TRANSMISSION OPTIONS 15 5 1 WEB INTERNET ONLY OPTION AVAILABLE 15 5 2 MODEM IS NO LONGER AVAILABLE 18 5 3 BATCH SCREEN 18 5 4 HOW DO I RESET MY WEB PASSWORD 19 5 5 WHAT IF I CAN T REMEMBER MY WEB PASSWORD 20 5 6 CARRIER 21 5 7 PAYER PROCESSOR 24 5 8 RETENTION 26 6 SYSTEM NAVIGATION 29 6 1 USING THE MOUSE 29 6 2 USING THE KEYBOARD 29 6 3 MENU OPTIONS 29 6 3 1 File 30 6 3 2 Forms 30 6 3 3 Communication 31 6 3 4 Lists 31 6 3 5 Reports 33 6 3 6 Tools 34 6 3 7 Window 34 6 3 8 Help 35 6 3 9 Toolbar Shortcut Buttons 35 6 3 10 Command Buttons 39 7 REFERENCE LISTS 41 7 1 ACCESSING A REFERENCE LIST 43 7 2 CREATE OR BUILD A REFERENCE LIST PRIOR TO ACCESSING A FORM 47 7 3 EDIT DELETE A REFERENCE LIST 50 8 COMPLETE A SPECIFIC REFERENCE LIST 57 8 1 837 NCPDP CARDHOLDER REFERENCE LIST 57 8 2 NCPDP PROVIDER REFERENCE LIST 58 8 3 837 PROVIDER REFERENCE LIST 59 8 4 RECIPIENT REFERENCE LIST 63 8 5 TAXONOMY REFERENCE LIST 65 8 6 ADMISSION TYPE REFERENCE LIST SELECTION 67 8 7 ADMIT SOURCE REFERENCE LIST
142. NDC code The qualifier code must always be 03 for NCPDP forms Enter a number to indicate whether the prescription is the original prescription or a refill Enter 0 to indicate that this is the first time the prescription is filled Step 4 Click _ ave to save the pharmacy reversal request Step 5 Click Clase to exit the NCPDP Pharmacy Reversal Form RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 301 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 10Communication Tools and Functions The Provider Electronic Solutions software provides several functions related to communicating with DHS These functions include the following e Submit forms through Web Internet Dial up or diskette submission is no longer available e Resubmit batch forms through Web Internet submission e View and print transaction responses e View and print communication logs Access these functions from the Communication menu on the main screen of the Provider Electronic Solutions software ig HP Provider Electronic Solutions File Forms Communication Lists Reports Tools Security Window Help ry Me i Submission Resubmission View Batch Response 635 ERA View Bulletin View Submit Reports View Communication Log 10 1 Batch Submission Use the Batch Submission function to transmit forms and inquiries for processing in the PROMISe system This function also lets you receive
143. Name ELLEN Last Name Billed Amount Last Submit Dt 256 0U 10082013 Status Step 6 Click Print to print the 276 Claim Status Request Summary Report Step 7 Click Cose to close the Summary Report screen 11 5 837 Dental Detail Report You can generate a detail report for a Dental Claim using the Provider Electronic Solutions software This detail report contains all the fields on the 837 Dental form To generate an 837 Dental Detail Report perform the following steps Step 1 From the main screen of Provider Electronic Solutions software select the 837 Dental option from the Detail Forms drop down menu a 837 Dental Detail Report screen is displayed Step 2 Click OK to include all the Dental Claims in the detail report Step 3 Click a when prompted by the box that advises you that all records will be selected A detailed report is generated and displayed on your screen RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 324 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 To limit the type of Dental Claims in the detail report enter the appropriate report criteria into one or more of the following fields Batch Number Limits the detail report to Dental Claims in a specific batch Enter the appropriate batch ID number in this field You can locate the Batch Numbers under the Resubmission option of the View Communication Log menu Recipient Limits
144. Name Attending Provider MI Attending Provider Operating Provider Operating Provider Location Code Operating Provider NPI Operating Provider Last Org Name Operating Provider First Name Operating Provider MI Operating Provider RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx PA PROMISe Version 4 00 Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Attending provider s first name This field is automatically populated when an attending provider ID number is chosen Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Attending provider s middle initial This field 1s automatically populated when an attending provider ID number is chosen Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Select the 9 digit MPI number or 8 or 9 digit medical license number for the operating provider ONLY IF the operating provider on the service line is different from the operating provider for the claim itself Operating provider s 4 digit location code associated with the number selected in the Operating Provider ID field This field is automatically populated when an operating provider ID number is chosen Information cannot be entered
145. Name lled Amt Last Submit Dt Step 9 1 Select 02 in the Compound Ind field on the Claim 1 screen to display the Compound screen Step 9 2 Click the Compound tab to access the Compound screen by Dosage Form Select the form in which the dosage of the prescription is dispensed from the drop down list or enter an appropriate value as specified Examples tablet powder capsule liquid etc Not Specified 01 Capsule 02 Ointment 03 Cream 04 Suppository 05 Powder 06 Emulsion 07 Liquid 10 Tablet 11 Solution 12 Suspension RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 290 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 13 Lotion 14 Shampoo 15 Elixir 16 Syrup 17 Lozenge 18 Enema Dispensing Unit Ind Select the unit of dosage in which the prescription is dispensed from the drop down list or enter an appropriate value as specified Examples each gram milliliters etc 1 Each 2 Grams 3 Milliliters Product ID Select the product ID number for the ingredient from the drop Compound down list or enter an appropriate value as specified This field Ingredients is required if the compound indicator field contains the value 2 which indicates that the claim is for a compound Product ID Qualifier code for the product ID number This field is required Qualifier if the compound indicator field co
146. OF to clear the message from your screen 12 7 Restore Archive You can restore forms from archive files to your database Forms that have been archived and then restored have a status of A You cannot change these forms however you can view them to confirm information print them in a report and copy them to create a new form To restore forms from an archive file perform the following steps Step 1 Step 2 From the main screen of the Provider Electronic Solutions software select the Restore option from the Archive drop down menu The Restore Forms screen is displayed Enter the name and location of the archive file in the data entry field or Click Browse and select the location for the archive file Note Archive files have an extension of ach RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 359 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Type the archive file name you want to use to restore the forme FT Browse Cancel lt Back Hext gt Finish Step 3 Click Next gt after you select the archive file A list of all the form types is displayed Step 4 Select the form type you want to restore and then click Mext gt Chose the form type you wish to restore fb Claim status Request Cancel lt Back Next gt Finish RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 360 PA
147. Os f 837 Dental Total Charge EET 01 Amount ET Billed Amount ENT Services Hdr 1 Hdr2 Hara Hdr4 stv 1 srv2 From DOS fil To DOS 00 00 0000 Referring Provider Provider ID a Location Code HPI Last Org Name First Name MI Supervising Provider Undo All Provider ID o Location Code HFI o Last Org Hame Po First Namel sits M Save Find Recipient ID Last Mame First Mame Billed Amount Last Submit Dt Fid Print Close From DOS Enter the 2 digit month 2 digit day and 4 digit year the first day of service on which services were provided for this claim in MM DD CCYY format For example enter 10012015 if the admission date was October 1 2015 Enter the 2 digit month 2 digit day and 4 digit year the recipient last received service under this claim For example enter 10012015 if the date was October Ist 2015 Provider ID Provider who referred the recipient for the service performed Select the 8 or 9 digit Medical License Number the 9 digit MPI number from the drop down list or double click on the data entry portion of the field to add a reference list selection Referring Provider For Access Plus Referred Services select the 13 digit MAID number for the referring provider from the field s pull down list Location Code Referring provider s 4 digit service code This field is automatically populated after you select or enter an MPI Referring Provid a number in the Provider ID Referring
148. PA PROMISe Project Workbook Provider Electronic Solutions software Documentation PA PROMISe User Manual PA PROMISe Provider Electronic Solutions Sottware User Manual PROVIDER ELECTRONIC SOLUTIONS SOFTWARE DOCUMENTATION LIBRARY REFERENCE NUMBER 00000147 REVISION DATE 08 31 2015 VERSION 4 00 RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Library Reference Number 00000147 This document contains confidential and proprietary information of the Pennsylvania PROMISe account of HP Enterprise Services and may not be disclosed to others than those to whom it was originally distributed It must not be duplicated published or used for any other purpose than originally intended without the prior written permission of Pennsylvania PROMISe Information described in this document is believed to be accurate and reliable and much care has been taken in its preparation However no responsibility financial or otherwise is accepted for any consequences arising out of the use or misuse of this material Address any comments concerning the contents of this manual to HP Enterprise Services Attention Documentation Unit PA MMIS 225 Grandview Ave MS A20 Camp Hill PA 17011 HP is an equal opportunity employer and values the diversity of its people 2015 Hewlett Packard Development Company LP R PA
149. PHS or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran s Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan LGHP 47 Medicare Secondary Other Liability Insurance is Primary RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 224 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 9 Complete Service 1 6 9 HP Provider Electronic Solutions File Edit View Forms Tools Window Help DRX CH2 8l Ba 874 E 7 837 Institutional Outpatient EAr Total Charge T 0 Amount MTT Billed Amount EN Services i Hdr1 Hdr2 Hdr3 Hdr4 Pat or Crossover Srv1 srv2 sw3 From DOS WWW To DOS loovoov0000 Revenue Code Billed Amount O Units 0 Procedure py Basis of Measurement UN _ Modifiers 1 2 3 4 a Delete Prescnuption Number Refill Number Prescription Date L Undo All NDE Drug Units 000 Drug Unit of Measure Add Srv Te Li Units Billed Amount Copy Srv a Delete Srv Save FirstName ff BiledAmount Last SubmitDt Status 300 00 07 23 2015 SO0 00 06 26 2075 s0000 067 1872015 From DOS Enter the 2 digit month 2 digit day and 4 digit year on which the recipient first received service under this claim If you bill for a service that was provided on only one day complete the From DOS with the date of service and press tab
150. PONSES VIEW AND PRINT BATCH RESPONSE 835 ELECTRONIC REMITTANCE ADVICE VIEW BULLETINS VIEW SUBMIT REPORTS VIEW COMMUNICATION LOGS ACCESSING AND USING REPORTS 270 ELIGIBILITY REQUEST DETAIL REPORT 270 ELIGIBILITY REQUEST SUMMARY REPORT 276 CLAIM STATUS DETAIL REPORT 276 CLAIM STATUS SUMMARY REPORT 837 DENTAL DETAIL REPORT 837 DENTAL SUMMARY REPORT RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx Version 4 00 71 73 74 75 76 78 79 81 82 85 86 87 88 91 94 95 100 100 102 106 111 112 140 172 198 232 268 296 298 302 302 304 306 307 309 310 313 316 317 319 321 322 324 326 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual i Bee 11 8 11 9 11 10 11 11 11 12 11 13 11 14 11 15 11 16 11 17 11 18 11 19 12 12 1 12 2 12 3 12 4 12 5 12 6 127 12 8 13 13 1 13 2 14 15 16 16 1 16 2 16 3 17 837 INSTITUTIONAL INPATIENT DETAIL REPORT 837 INSTITUTIONAL INPATIENT SUMMARY REPORT 837 INSTITUTIONAL NURSING HOME DETAIL REPORT 837 INSTITUTIONAL NURSING HOME SUMMARY REPORT 837 PROFESSIONAL DETAIL REPORT 837 PROFESSIONAL SUMMARY REPORT NCPDP PHARMACY DETAIL REPORT NCPDP PHARMACY SUMMARY REPORT NCPDP PHARMACY ELIGIBILITY DETAIL REPORT NCPDP PHARMACY ELIGIBILITY SUMMARY REPORT NCPDP PHARMACY REVERSAL DETAIL REPORT NCPDP PHARMACY REVERSAL SUMMARY REPORT MASTER LIST OF SELECTIONS FOR A REFERENCE LIST USING THE TOOL FUNCTIONS CHANGE YOU
151. PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 2 Complete Header 1 ag HP Provider Electronic Solutions File Edit View Forms Tools Window He DExX Voalel ealares a h a 270 Eligibility Request Hdr 1 Har 2 Service information Receiver Hame DOH Provider ID Location Code NPI Eae Last Org Name l First Hame Delete Recipient Hame ID Qualifier H Last Hame Header One Provider ID Location Code OON Provider ID NPI Recipient DOB 00 00 0000 Recipient ID Last Hame Undo All Recipient ID Card Issue Se Recipient 55H Save Medical Record i 7 Send First Name Hl Procedure NDC Modifiers 1 2 3 sf Procedure Code Qualifier From DOS 07 20 2015 To DOS 07 20 2015 First Mame From DOS To DOS Last Submit Contains the provider and recipient information required to submit a 270 Eligibility Request To complete the Header One screen perform the following steps Choosing a selection from a drop down list automatically populates several fields Select the 9 digit provider number from the drop down list or enter an appropriate value as specified required field Field is automatically populated with the appropriate data after you select a provider number from the Provider ID field required field Out Of Network Provider ID number enter the appropriate value MA provides t
152. PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Select the Restore all forms radio button to restore all the forms on the list or Select the Restore only selected forms radio button to restore only selected forms and then click on an item to select it Step 6 Click Einish after you have selected the items that you want to restore C Restore all forms Restore only selected forms re os Recipient ID Last Hame Bree eee ee Form type H selected restored 0 00 Step 7 After the selected forms are successfully restored the following message is displayed Step 8 Click 0K to clear the message from your screen The item s that you have restored is are placed back into the corresponding Form option You can access an item when you select the Forms menu or a Form short cut which are located on the main screen RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 361 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 12 8 Modify Options Settings Use the Options form to update your system s logon software settings and transmission information The Options form is divided into six screens Each screen contains the following data Modem System modem information Web System Web information Batch l System batch information Interactive System interactive information Ca
153. PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Use the scroll bars located on the right side and bottom of the screen to view the entire report GY HP Provider Electronic Solutions Fue Form Letts Reports Tools Window Help Ov VhaDOK e Slk 5 837 Institutional Nursing Facility Detail Report Batch Number Recipient Cardholder ID Form Status Submit Date O00 0000 Records selected Ly 837 Institutional Nursing F j all Report Senreots ALL Cleuma Type Of Bill 267 Oiginal Clam amp 20140770000 Provider ID 001928408 Location Code 0001 Org Nome ALTOONA CTR FOR HURSII HPI 1237970029 Recipient ID Medical Record EVS TESTING Lait Name _ Fast Nome Palbent Status 30 A cmon Oooo Step 6 Click Print to print the 837 Institutional Nursing Home Detail Report Step 7 Click Close to exit the 837 Institutional Nursing Home Detail Report screen 11 10 837 Institutional Nursing Home Summary Report You can generate a summary report for Institutional Nursing Home Claims using the Provider Electronic Solutions software This summary report contains only the key fields on the 837 Institutional Nursing Home form To generate an 837 Institutional Nursing Home Summary Report perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select the 837 Institutional Nursing Home option from the Summar
154. R PASSWORD COMPACT THE DATABASE REPAIR THE DATABASE UNLOCK YOUR DATABASE GET UPGRADES CREATE ARCHIVE RESTORE ARCHIVE MODIFY OPTIONS SETTINGS SECURITY FUNCTIONS ADD ADDITIONAL USERS EDIT EXISTING USERS CONTACT INFORMATION APPENDIX A FREQUENTLY ASKED QUESTIONS APPENDIX B ELIGIBILITY RESPONSE CODE TABLES ELIGIBILITY OR BENEFIT INFORMATION CODES REJECT REASON CODES SERVICE TYPE CODES APPENDIX C GLOSSARY OF TERMS RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx Version 4 00 328 330 331 333 335 337 339 341 343 345 347 349 351 353 353 354 355 355 356 357 359 362 364 364 365 366 367 368 368 369 371 378 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 VI PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 1 Introduction to Provider Electronic Solutions The Provider Electronic Solutions software supports the processing of Health Insurance Portability and Accountability Act HIPAA ready transactions The HIPAA ready form types available for the Pennsylvania Office of Medical Assistance Programs OMAP include the following e 837 Dental e 837 Institutional Inpatient e 837 Institutional Nursing Home e 837 Institutional Outpatient e 837 Professional e NCPDP Pharmacy e Pharmacy Eligibility e NCPDP Pharmacy Reversal e 276 Cla
155. Release of Medical Data Benefits Assignment Y Payer Responsibility Add Claim Filing Ind Code Patient Signature Insurance Type Code Copy Paid Date Amount 00700 0000 00 MCU ICH Folicy Holder Delete Carrier Code Group it Group Name Undo All Last Name First Hame jave Group Mame Last Hame Copy Ol Delete Ol Last Submit Dt Release of Select the appropriate release code from the drop down list or enter Medical Data an appropriate value as specified Select I Informed Consent to Release Medical Information Use for conditions or diagnosis regulated by Federal statutes Select Y Yes Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Use if the provider has a signed statement on file that permits the release of medical data to other organizations Benefits Select the assignment code from the drop down list or enter an Assignment appropriate value as specified Select Y Yes Recipient or authorized person has authorized that benefits be assigned to the provider Select N No Recipient or authorized person has authorized that benefits be assigned to the provider Select W for Not Applicable Not applicable for this claim RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 253 PA PROMISe Provider Electronic Solutions Software User Manual Payer Responsibility Claim Filing
156. Retention Hame DEPARTMENT OF HUMAN SERVICES ETIN 445314156 Identifier Code Qualifier Fi Identifier Code 236003113 ne e NCPDP Certification ID P4N01500 HCPOP Submitter ID 5456571 F oer Eligibility Submitter ID 5456541 F Print Eligibility Batch Eligibility Interactive Tee RE FABDI 001 Terminal ID Jraxooo02 Transmission Type BOTH Close Note This ETIN number 445314156 above is used only if you choose to certify and should not be altered unless directed by HP Enterprise Services or DHS RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 25 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 5 8 Retention The Retention screen contains settings for the length of various software functions To access the Retention screen Step 1 Click the Retention tab in the Tools Options box Archive Days 100 4 Max Batch 100 Max Verify 1004 Max Log 1004 Max Submit Reports 100 Max Bulletin Liia Password Expiration Days 30 Recommended settings for the fields listed below are populated automatically However any setting can be changed at your discretion Archive Number of days finalized forms are retained After the selected number Days of days occurs you are prompted to archive your invoices All claims older than the specified number of days are archived Invoices can be archived at any time by selecting the Tools menu from the
157. S CMcElheny PES_Manual_5010 4 00_ICD10 docx PA PROMISe Code designating the provider type classification and specialty This field is automatically populated after you select an MPI number from the Facility ID Field Information cannot be entered directly into these fields to add or change information in these fields access the Provider List Form Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Name of the facility if the services are being rendered in an inpatient hospital emergency room hospital special treatment room hospital short procedure unit ambulatory surgical center or renal dialysis center This field is automatically populated after you select and or enter an MPI number in the Facility ID field Information cannot be entered directly into these fields to add or change information in these fields access the Provider List Form Select the other insurance code from the drop down list or enter an appropriate value as specified as described below Select Y if the recipient has other insurance Select N if the recipient does not have other insurance 125 Version 4 00 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Complete Header 4 HP Provider Electronic Solutions Filens EditmeViews FormsmeToolsmeWindowre Help D RXV ma S B 7 1 3
158. SELECTION 68 8 8 CARRIER REFERENCE LIST 70 R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual 8 9 8 10 8 11 8 12 8 13 8 14 8 15 8 16 8 17 8 18 CONDITION CODE REFERENCE LIST DIAGNOSIS REFERENCE LIST DIAGNOSIS ICD LIST MODIFIER REFERENCE LIST NDC REFERENCE LIST OCCURRENCE REFERENCE LIST OTHER INSURANCE REASON REFERENCE LIST PATIENT STATUS REFERENCE LIST PLACE OF SERVICE REFERENCE LIST POLICY HOLDER REFERENCE LIST PROCEDURE HCPCS REFERENCE LIST PROCEDURE HCPCS ICD 10 CM PCS REFERENCE LIST 8 19 8 20 8 21 9 1 9 2 REVENUE REFERENCE LIST TYPE OF BILL REFERENCE LIST VALUE CODE REFERENCE LIST FORM OVERVIEW COMPLETE A 270 ELIGIBILITY REQUEST SUBMIT A 270 ELIGIBILITY REQUEST 9 2 1 Interactive Submission 9 2 2 Batch Submission 9 3 COMPLETE THE 276 CLAIM STATUS REQUEST 9 3 1 Interactive Submission 9 4 9 5 9 6 9 7 9 8 9 9 9 10 9 11 10 10 1 10 2 10 3 10 4 10 5 10 6 10 7 11 11 1 11 2 11 3 11 4 11 5 11 6 COMPLETE THE 837 DENTAL FORM COMPLETE THE 837 INSTITUTIONAL INPATIENT FORM COMPLETE AN 837 INSTITUTIONAL NURSING FACILITY FORM COMPLETE AN 837 INSTITUTIONAL OUTPATIENT FORM COMPLETE A 837 PROFESSIONAL FORM COMPLETE AN NCPDP PHARMACY CLAIM FORM COMPLETE AN NCPDP PHARMACY ELIGIBILITY FORM COMPLETE AN NCPDP PHARMACY REVERSAL FORM COMMUNICATION TOOLS AND FUNCTIONS BATCH SUBMISSION BATCH RESUBMISSION BATCH RES
159. S_Manual_ 5010 4 00_ICD10 docx August 31 2015 237 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Account Benefits Assignment Patient Signature Report Type Code Select Y Yes Provider has a signed Statement Permitting Release of Medical Billing Data Related to a Claim Provider has a signed statement on file that permits the release of medical data to other organizations Enter the account number assigned to the recipient by the provider for the service that was performed This information is returned on the RA statement A unique account number is required for each claim submitted to be able to obtain claim status information If the same account number is used for each claim submitted when a claim status request is sent the claim status is reported on all claims with that account number Select the appropriate assignment code from the drop down list or enter an appropriate value as specified Select Y 1f the recipient or authorized person has authorized that benefits be assigned to the provider Select N 1f the recipient or authorized person has not authorized that benefits be assigned to the provider Select W for Not Applicable Not applicable for this claim The signature code identifies how the recipient or authorized person s signature was obtained and how the provider retains it Select the appropriate signature code from the drop down list or enter an a
160. Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End Stage Renal Disease in the Mandated Coordination Period with an Employer s Group Health Plan 14 Medicare Secondary No fault Insurance including Auto is Primary 15 Medicare Secondary Worker s Compensation 16 Medicare Secondary Public Health Service PHS or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran s Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan LGHP 47 Medicare Secondary Other Liability Insurance is Primary Step 9 Complete Service 1 GP HP Provider Electronic Solutions So File Edit View Forms Tools Window Help METERA TEEL fi 837 Institutional Nursing Facility Total Charge PTI 0I Amount iii Billed Amount Ii Services Billed Amount OO Revenue Code Basis of Measurement DA Units 0 Copy Delete Undo All care Add Srv Srv Revenue Code Units Billed Amount Copy Srv l Delete Srv D0 Edit All Recipient ID Last Name First Marne Billed Amount Last Submit Dt Billed Amount Enter the billed amount for the revenue code indicated RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 196 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 ICF MR and ICF ORC facilities should use the full per diem rate for
161. Service codes accepted on an 837 Dental claim are 03 School 04 Homeless Shelter 11 Office Outpatient Clinic Independent Clinic 12 Patient s Home or Community 15 Mobile Unit 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room Hospital 24 Ambulatory Surgical Center 25 Birthing Center 26 Military Treatment Center RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 133 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 35 Adult Living Care Facility 41 Ambulance Land 42 Ambulance Air or Water 50 Federally Qualified Health Center 51 Inpatient Psychiatric Facility 52 Psychiatric Facility Partial Hospitalization 53 Community Mental Health Center 54 Intermediate Care Facility Mentally Retarded 55 Residential Substance Abuse Treatment Facility 56 Psychiatric Residential Treatment Center 60 Mass Immunization Center 61 Comprehensive Inpatient Rehabilitation Facility 62 Comprehensive Outpatient Rehabilitation Facility 65 End Stage Renal Disease Treatment Facility 71 State or Local Public Health Clinic 72 Rural Health Clinic 81 Independent Laboratory 99 Other Unlisted Facility If the place of service on Service Header 1 is different from
162. The same date is automatically populated in the To DOS field To DOS Enter the 2 digit month 2 digit day and 4 digit year on which the recipient last received service under this claim Revenue Code Enter the code that identifies a specific accommodation or ancillary service This field accepts a maximum of four numeric characters 0100 Facility Days 0183 Leave Days 0185 Hospital Days Billed Amount Enter the usual charge to the self paying public for the service provided using a decimal point If billing for multiple units multiply the usual charge by the number of units billed and enter that amount A zero billed amount is an appropriate value RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 225 Provider Electronic Solutions Software User Manual Units Procedure Basis of Measurement Modifiers Prescription Number Refill Number Prescription Date NDC Drug Units RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx PA PROMISe Version 4 00 Enter the number of units provided to the recipient for the service billed Zero units is an appropriate value Enter the appropriate procedure code as listed in the MA Program Fee Schedule or select the procedure code from the drop down list or enter an appropriate value as specified The procedure code identifies the service that was rendered to the recipient Select the basis code from the drop down list or enter an appropr
163. Through Discharge Claim Centers ICF MR Facilities 652 ICF MR Interim First Claim ICF ORC Facilities 653 ICF MR Interim Continuing Claim 654 ICF MR Interim Last Claim 657 ICF MR Replacement of Prior Claim 658 ICF MR Void Cancel of Prior Claim Note The last digit should be selected based on the definitions below 0 Non Payment Zero Claim This code should be used when a bill is submitted to a payer but the provider does not anticipate a payment as a result of submitting the bill 1 Admit Through Discharge Claim This code should be used for a bill that 1s expected to be the only bill received for a course of treatment or confinement 2 Interim First Claim This code is to be used for the first of a series of bills to the same payer for the same confinement 3 Interim Continuing Claim This code is to be used for when a bill for the same confinement or course of treatment will be submitted 4 Interim Last Claim This code is to be used when a bill for the same confinement or course of treatment has previously been submitted and it 1s expected that no further bills for the same confinement or course of treatment will be submitted 7 Replacement of a Prior Claim This code is to be used when a bill has been submitted and paid and needs to be adjusted Void Cancel of Prior Claim This code reflects the elimination of a previously submitted bill Description Enter
164. Total Charge 999i 0I Amount TT Billed Amount il Services Adjustment Group Cd i Add Reason Codes Amts 1 i IL 2 Copy Delete Undo All Delete Srv v Adi See ene Last Name First Name T Billed Tau Last Submit Dt TS Step 13 1 Select the service line you want to adjust from the Service 1 screen This accesses the Service Adjustment screen for a particular service line Step 13 2 Select Y in the Service Adjustment Ind field on the Service 3 screen The Service Adjustment screen populates for the service line previously selected from the Service 1 screen Adjustment General category of the adjustment being made to the claim Group Cd Select the adjustment group code from the drop down list or enter an appropriate value as specified CO Contractual Obligations PI Payer Initiated Reductions CR Correction and Reversals PR Patient Responsibility OA Other Adjustments RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 266 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Reason Each field is divided into two segments Codes Amts Fields 1 3 In the left segment of the field select the appropriate reason code from the segment s drop down list or enter an appropriate value as specified The reason code identifies the reason the adjustment is being made to the claim 1 Deductible Amount
165. U Unknown Full Medicare Enter the total number of days during the service month that were Days fully covered by Medicare This field is not currently used on the Institutional Inpatient claim Please leave it blank Medicare Enter the Medicare ICN from the Medicare explanation of medical ICN benefits EOMB for the service being billed Paid Date Enter the 2 digit month 2 digit day and 4 digit year the Medicare coinsurance was paid This information can be found on the Medicare EOMB Paid Amount Enter the Medicare coinsurance amount using a decimal point This information can be found on the Medicare EOMB For example enter 5 00 if the paid amount was 5 00 An amount of 0 zero may be entered Carrier Code Select the carrier code from the drop down list or enter an appropriate value as specified The carrier code identifies the Policy a he Holder recipient s third party insurance carrier Note Carrier Codes can be added or deleted as Required from the Lists as described in Section 7 REFERENCE LISTS on page 40 Last Name Policyholder s last name This field is automatically populated after Policy you select or enter a carrier code in the Group field Holder RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 169 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 First Name Policy Holder Insurance Type Code Policy Holder Information ca
166. Undo All Save This code represents the external cause of injury Enter the external diagnosis code or select the external code from the field s pull down list or enter an appropriate value as specified Required on Institutional claims whenever a diagnosis is needed to describe an injury poisoning or adverse effect In the second part of this enter the value from the drop down or enter an appropriate value as specified N No U Unknown W Not Applicable Y Yes Enter the two letter abbreviation for the state where the accident occurred For example enter PA for Pennsylvania RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 157 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 DAX BA ei ease EE Total Charge o Ol Amount PT Billed Amount PTT Services Rendering Provider ID Location Code HPI Last Org Name First Name Hi Delete Attending Provider ID Location Code HPI Undo Last Org Name First Name MI jave Operating Provider ID Location Code HPI Last Org Namel First Name HI Find Recipient ID Last Mame First Hame Billed Amount ast Submit Dt Status Find Print Close Provider ID Select the 9 digit MPI number for the provider that the claim will be paid under Rendering billing provider from the drop down list or double click on the data entry portion of the field to add a reference list se
167. V Title V VA Veteran Administration Plan WC Worker s Compensation Health Claim ZZ Mutually Defined General category of the adjustment being made to the claim Select the adjustment group code from the drop down list or enter an appropriate value as specified CO Contractual Obligations CR Correction and Reversals OA Other Adjustments PI Payer Initiated Reductions RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 189 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 PR Patient Responsibility Payer Level of payer responsibility for the resident s other insurance Responsibility Select the appropriate code from the drop down list or enter an appropriate value as specified P Payer 1 S Payer 2 T Payer 3 A Payer 4 B Payer 5 C Payer 6 D Payer 7 E Payer 8 F Payer 9 G Payer 10 H Payer 11 U Unknown Reason There are three Reason Code Amount fields Each field is divided Codes Amts into two segments Fields 1 3 In the left segment of the field select the appropriate reason code from the segment s drop down list or enter an appropriate value as specified The reason code identifies the reason the adjustment is being made to the claim line as described below 1 Deductible Amount 118 ESRD Network Support Adjustment119 Benefit Maximum for this time period has been
168. Version 4 00 Crossover Used to activate the Crossover screen which is used to record a Indicator recipient s Medicare information Select the crossover code from the drop down list or enter the appropriate value as described below Y Yes Recipient has Medicare N No Recipient does not have Medicare R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 210 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 File Edit View Forms Tools aE Help Py Bal Institutional Outpatient a mes E Charge Ol Amount 999i Billed Amount i Services Referring Provider Add Provider ID Location Code HPI Copy Last Org Name First Name MI Delete Emergency Ind Auto Accident State Undo All Patient Paid Amount Delay Reason ave Billing Notel Contract T Contract Code Contract Version Encounter Ind Yalue e J z af o aj Find Last Name First Hame Billed Amount Last Submit Dt Print Close Provider Enter the 8 or 9 digit medical license number or MPI number for the ID physician who referred the recipient for the service performed or double Referring click in the data entry portion of the field to add a reference list selection Provider Note For Access Plus Referred Services select the 13 digit MAID number for the referring provider from the field s pull down list Location Referring provider s 4 di
169. _ 5010 4 00_ICD10 docx August 31 2015 143 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Recipient ID Medical Record Number Last Name First Name Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Select the recipient s 10 digit recipient number For additional information on the Recipient ID field refer to the Complete a Recipient reference list heading found in Section 8 of the Provider Electronic Solutions Software User s Guide Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form Your own reference number for the recipient This field is automatically populated after you select or enter a Recipient number This data appears in the first column of the RA statement when the claim is adjudicated Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form Recipient s last name This field is automatically populated after you select or enter a Recipient number Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form Recipient s first name This field is automatically populated after you select or enter a Recipient number Information cannot be entered direc
170. _ 5010 4 00_ICD10 docx August 31 2015 241 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Contract Type Contract Code Contract Version Encounter Indicator EPSDT Vision Referral YV EPSDT Hearing Referral YH EPSDT Medical Referral YM EPSDT Behavioral Health YB Referral EPSDT Other Referral YO The indicator represents the contract between the provider and the managed care or sub capitation subcontractor Choose a value from the drop down list Note Fee For Service Providers who are billing directly to Medical Assistance do not use this field For Consolidated Community Reporting for OMHSAS CCR The contract number between the provider and the managed care or sub capitation subcontractor Note Fee For Service Providers who are billing directly to Medical Assistance do not use this field For Consolidated Community Reporting for OMHSAS CCR Enter the contract number held with DHS This field is used only by Consolidated Community Reporting for OMHSAS CCR submitter The contract version is the month of the contract that was in force at the time of the service Note Fee For Service Providers who are billing directly to Medical Assistance do not use this field For Consolidated Community Reporting for OMHSAS CCR Values 01 thru 12 Use the Encounter Indicator drop down menu to enter the appropriate value To submit an encounter select RP for
171. _ICD10 docx 82 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 1 Click Lists Policy Holder to access the Policy Holder reference list Gp 1 Provider Eecroic So File Edit View Forms Lists Tools Window Help 3x e mle l elas almir ig Policy Halder Recipient ID 112345671 Group 561234567791 23456 Carer Code Mon r Add Carner Hame MEDICARE PART B Other Insurance Group Hame Delete Relationship to Insured E Undo All Policy Holder Information Undo Last Name TESTER First Name FIRST Save ID Code ii 2345678993 ID Qualifier hal Policy Holder Address Line 1 i 23 ANY STREET Line 2 Print City ANY TOW State IPA ip fi 1111 1111 s eE Recipient ID Group EERE Last Marnie First Hame W12345671 SB12S4567 79123456 100 TESTER FIRST Step 2 Enter the data requested for each field as described below Recipient ID Select the appropriate recipient ID number from the drop down list or double click on the data entry portion of the field to add a reference list selection This code identifies the recipient Group Enter the group ID number assigned by the other insurance company Carrier Code Select the appropriate carrier code from the drop down list or enter an appropriate value as specified The carrier code identifies the other insurance carrier Carrier Name Populates automatically when the carrier code is selected Contains the name
172. a description of the type of bill code Step 3 Click __ Save when of the data entry fields are completed Step 4 Click o Add and repeat steps 2 3 and 4 to add another type of bill code to the Type of Bill reference list Step 5 Click e exit the Type of Bill screen RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 90 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 21 Value Code Reference List To complete the data entry fields needed to add or edit a Value Code reference list selection perform the following steps R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 91 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 1 Click Lists Value Code to access the Value Code reference list F HP Provider Electronic Solutions _ KS Se j File Edit View Forms Lists Tools Window Help ax g el Bealaral el F Ag Value Code Value Code Description Value Code Delete Undo All Save Description Find Medicare Blood Deductible No Fault Auto Other Workman s Compensation PHS or Other Federal Agency Drug Deduction Patient Liability Amount Offset to Patient Fayment Amount Other Medical Expenses Print Step 2 Enter the data requested for each field Value Code Enter the National Uniform Billing Committee NUBC code that relates amounts or val
173. access the Policy Holder Form Group name associated with the other insurance coverage This field is automatically populated when a carrier code is selected Information cannot be entered directly into this field If you need to add or edit information in this field access the Policy Holder Form Last name of the person who carries the other insurance policy This field 1s automatically populated when a carrier code is selected Information cannot be entered directly into this field If you need to add or edit information in this field access the Policy Holder Form RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 219 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 First Name First name of the person who carries the other insurance policy Policy Holder This field is automatically populated when a carrier code is Step 7 2 Step 7 3 Step 7 4 Step 7 5 selected Information cannot be entered directly into this field If you need to add or edit information in this field access the Policy Holder Form To add another insurance line click Add OI A new blank service line is added to the screen Click on the new service line and then enter the other insurance data in the appropriate data fields To copy the data from an existing other insurance line to a new service line click on the existing service line you want to copy and then click Copy OI A new b
174. al Physician Visit Inpatient Professional Physician Visit Outpatient Professional Physician Visit Nursing Home Professional Physician Visit Skilled Nursing Facility Professional Physician Visit Home Psychiatric Psychiatric Room and Board Psychotherapy Psychiatric Inpatient Psychiatric Outpatient Rehabilitation RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 374 Version 4 00 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual AA AB AC AD AE AF AG AH Al AJ AK AL AM AN AO AQ AR Bl B2 B3 BA BB BC BD BE BF BG BH BI BJ BK BL Rehabilitation Room and Board Rehabilitation Inpatient Rehabilitation Outpatient Occupational Therapy Physical Medicine Speech Therapy Skilled Nursing Care Skilled Nursing Care Room and Board Substance Abuse Alcoholism Drug Addiction Vision Optometry Frames Routine Exam Use for Routine Vision Exam only Lenses Nonmedically Necessary Physical Experimental Drug Therapy Burn Care Brand Name Prescription Drug Formulary Brand Name Prescription Drug Non Formulary Independent Medical Evaluation Partial Hospitalization Psychiatric Day Care Psychiatric Cognitive Therapy Massage Therapy Pulmonary Rehabilitation Cardiac Rehabilitation Pediatric Nursery Skin Orthopedic Cardiac RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 375 Version 4 00 August 31
175. al Inpatient Total Charge PI Ol Amount ET Billed Amount NT Services Hdr 1 Hdr2 Hdr3 Hdr4 Hdr5 Hare Hdr7 Hars sra Type OF Bill Provider ID Org Hame Recipient ID a Medical Record Report Transmission Code Last Hame Patient Status Account From DOS 00 00 0000 To DOS foo 00 0000 Prior Authorization Release of Medical Data Benefits Assignment Y Report Type Code Attachment Cu Recipient ID Last Marne First Marne Billed Amount Last Submit Dt R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx 142 Add Location Code HPI Copy Delete Undo All First Name o HI Referral Code Find Print Close August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Type Of Bill Original Claim Provider ID Location Code NPI Org Name Enter the code that describes the type of bill submitted Select the appropriate type of bill code from the drop down list or enter an appropriate value as specified Form Name Type of Bill Codes 837 110 Inpatient Zero No Pay Claim Institutional 111 Inpatient Admit Through Discharge Claim Inpatient 112 Inpatient Interim First Claim 117 Inpatient Replacement of Prior Claim 118 Inpatient Void Cancel of Prior Claim Note Types of Bills 113 and 114 and not valid values for PA MA Enter the original ICN by f
176. al for the attending provider ID This field is Attending automatically populated when a value is selected in the Attending Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Provider ID Enter the 8 or 9 digit medical license number or 9 digit MPI Operating number for the physician performing a surgical procedure in this field NPI Enter the NPI National Provider Identifier Numeric 10 digit Operating identifier consisting of 9 numbers plus a check digit in the 10 position Last Org Last name or organization name for the operating provider This Name field is automatically populated when a value is selected in the Operating Operating Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form First Name First name for the operating provider This field is automatically Operating populated when a value is selected in the Operating Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form MI Middle initial for the operating provider ID This field is Operating automatically populated when a value is selected in the Operating Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this
177. all claims with that account number when a claim status request is sent Referral The status code indicates the PCCM Referral number If there is a referral Code from a Primary Care Case Manager PCCM enter the referral number into this field Not currently used From DOS Enter the 2 digit month 2 digit day and 4 digit year on which the recipient first received service under this claim For example enter 10012015 if the date was October 1 2015 If the same service was provided on a single day enter the date of service in both the From DOS and To DOS fields To DOS Enter the 2 digit month 2 digit day and 4 digit year on which the recipient last received service under this claim For example enter 10012015 if the date was October 1 2015 Prior Enter the 10 digit CHR DRG PSR admission certification number Authorization Eater the 10 di git Prior Authorization number if the service requires and has received prior authorization Enter the 10 digit PSR number if the admission is elective to an acute care hospital a hospital short procedure unit SPU or an ambulatory surgical center ASC Enter the 10 digit admission certification number for urgent or emergency admission to an acute care hospital a SPU an ASC or specialty hospital Release of Select the appropriate release code from the drop down list or enter an Medical Data appropriate value as specified Select I Informed Consent to Release Medical Informati
178. am Fee Schedule Enter a description of the procedure HCPCS code Step 3 Click __ Save when all data entry fields are completed Step 4 Click __ Add and repeat steps 2 3 and 4 to add another procedure HCPCS code to the procedure HCPCS reference list Step 5 Click Close to exit the Procedure HCPCS screen Procedure HCPCS ICD 10 Reference List To complete the data entry fields needed to add or edit a Procedure HCPCS ICD 10 reference list selection perform the following steps Step 1 Click Lists Procedure HCPCS ICD 10 to access the Procedure HCPCS ICD 10 reference list DLL Provides Seca File Edit View Forms Lists Tools Window Help VACHS ta TIE EA ALL G Procedure HCPCS ICD 10 Procedure HCPCS Description Description Step 2 Enter the data requested for each field as described below RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 86 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Procedure HCPCS Enter the HCPCS ICD 10 code that describes the service rendered ICD 10 Code as indicated in the MA Program Fee Schedule Enter a description of the procedure HCPCS ICD 10 codes Step 3 Click __ Save when all data entry fields are completed Step 4 Click Add and repeat steps 2 3 and 4 to add another Procedure HCPCS ICD 10 code to the procedure HCPCS ICD 10 reference list Step 5 Click Close to exit the Procedure HCPCS ICD
179. an appropriate value as specified The claim code identifies the type of other insurance claim that is being submitted MC Medicaid 09 Self Pay 10 Central Certification 11 Other Non Federal Program 12 Preferred Provider Organization PPO 13 Point of Sale POS 14 Exclusive Provider Organization EPO 15 Indemnity Insurance 16 Health Maintenance Organization HMO Medicare Risk AM Automotive Medical BL Blue Cross Blue Shield CH CHAMPUS CI Commercial Insurance Co DS Disability HM Health Maintenance Organization LI Liability LM Liability Medical RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 193 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 MA Medicare Part A MB Medicare Part B OF Other Federal Program TV Title V VA Veteran Administration Plan WC Worker s Compensation Health Claim ZZ Mutually Defined Adjustment General category of the adjustment being made to the claim Group Code Select the adjustment group code from the drop down list or enter an appropriate value as specified This field can be left blank if no reason code is being used CO Contractual Obligations CR Correction and Reversals OA Other Adjustments PI Payer Initiated Reductions PR Patient Responsibility Reason Select the appropriate Reason Code from the drop down list or
180. angement 23 Payment adjusted because charges were paid by another 50 Non covered services payer 118 ESRD network support 23 Payment adjusted because adjustment charges were paid by another 119 Benefit Maximum for this payer time period has been reached 35 Lifetime Benefits Maximum has been reached Description Enter a description of the other insurance reason being added Step 3 Click __ Save when all data fields are completed Step 4 Click o Add and repeat steps 2 3 and 4 to add another other insurance reason code to the Other Insurance Reason reference list Step 5 Click Close to exit the Other Insurance Reason screen 8 15 Patient Status Reference List To complete the data entry fields needed to add or edit a Patient Status reference list selection perform the following steps R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 79 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 1 Click Lists Patient Status to access the Patient Status reference list i HP Provider Electronic soutions 5 SS File Edit View Forms Lists Tools Window Help ax gl e6l ealare e F bi Patient Status Patient Status Description Delete Undo All Save Patient Status Description Find Dischrgd to home or self care routine discharge Dischrgdtrastrd to another hospital for inpatient care Dischrgdtranstird to skilled
181. ar a o oroa 2j pona ooa ODO e CS OO Find Last Name First Mame Billed Amount Last Submit Dt Print Close Surgical Each field is divided into two segments Codes Dates In the left segment of the field enter the procedure code or select the 1 24 procedure code from the field s pull down list as indicated in the MA Program Fee Schedule The procedure code identifies I ICD 9 CM ICD 10 CM PCS for Inpatient or CPT for Outpatient the procedure that was performed during the billing period as shown in the recipient s medical record Enter the date the 2 digit month 2 digit day and 4 digit year the procedure was performed in the right segment of the field For example enter 10012015 if the date was October Ist 2015 RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 156 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Sten OMn Lele ECL S aa ig HP Provider Electronic Solutions eee File Edit View Forms Tools Window Help D EXxC Raet BA SeH ah 837 Institutional Inpatient Total Charge PI Ol Amount iT Billed Amount IT Services J Diagnosis Codes Present On Admission E Code a Copy Auto Accident State Recipient ID Last Hame Billed Amount Last Submit Dt E Code Diagnosis Codes Present on Admission Auto Accident State Diagnosis Codes Present on Admission aa ee IE en ee ee
182. armacy Reversal option from the Forms drop down menu 2 0 Eligibility Request 2 6 Claim Status Request 637 Dental 63 7 Institutional Inpatient 83 Institutional Nursing Facility 83 Institutional Outpatient 637 Professional NCPDP Pharmacy NCPDP Pharmacy Eligibility NCPDP Pharmacy Reversal The NCPDP Pharmacy Reversal Form appears with the Header Reversal screen displayed R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 299 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Pharmacy Reversal Provider ID Location Code HPI Provider ID Code Qualifier ps Date Of Service 00 00 0000 Delete Undo All Send Last Submit Dt Eee aa Copy _ Bde Erea Save Gerd m a Step 2 Complete Header Reversal Provider ID Location Code NPI Provider ID Qualifier Date Of Service Select the 9 digit MPI for the payee from the drop down list or double click on the data entry portion of the field to add a reference list selection This is the number under which the claim was paid The 4 digit location code associated with the 9 digit MPI selected This field is automatically populated after you select a Provider ID Pharmacists who qualify as a QSB should add a Q as the fifth character in the location code Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting
183. ason Code Amount fields Each field is divided Codes Amts into two segments In the left segment of the field select the appropriate reason code from the segment s drop down list or enter an appropriate value as specified The reason code identifies the reason the adjustment is being made to the claim line 1 Deductible Amount 118 ESRD Network Support Adjustment RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 231 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 9 8 Paid Date Amount Carrier Code Name 119 Benefit Maximum for this time period has been reached 2 Coinsurance Amount 23 Payment adjusted because charges were paid by another payer 3 Copayment Amount 35 Lifetime Benefits Maximum has been reached 45 Charge exceeds fee schedule maximum allowable or contracted legislated fee arrangement 50 Non covered services In the right segment of this field enter the amount of the adjustment using a decimal point In the left segment of this field enter the date on which the other insurance carrier paid an amount toward the claim Use a 2 digit month 2 digit day and 4 digit year format In the right segment of this field enter the amount the other insurance carrier paid toward the claim Use a decimal point Select the carrier code for the insurance company that paid toward the claim from the drop down list or enter an appro
184. at matches the code you entered into the procedure NDC code Enter the first date of a range of dates to check recipient eligibility If you only check for a single date enter the same date in both the From DOS and the To DOS fields Enter the last date of a range of dates to check recipient eligibility If you only check for a single date enter the same date in both the From DOS and the To DOS fields Step 3 Click __ Save to save the 270 Eligibility Request Step 4 Click Add to start another 270 Eligibility Request or Step 5 Click Close to exit the 270 Eligibility Request form Step 6 Complete Header 2 ag HP Provider Electronic Solutions oo A ZE File Edit View Forms Tools Window Help DEX HEa e t BARSA r m k K 270 Eligibility Request Hdr1 Hdr Service Trace Assigning Additional ID d j Copy Trace Transaction Reference 62 Last Hame Delete Undo All Save Send First Mame From DOS To DOS RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 98 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Header Two contains the data being verified for eligibility To complete the Header 2 screen Trace Assigning Enter the Trace Assigning Additional ID of the department _ Additional ID person or group in your office that is sending the 270 Eligibility Request Information placed in this field is included on the 271
185. atus Inquiry form 9 3 1 Interactive Submission An interactive submission is when a single request is entered and a response is received back within a few minutes after the request is submitted Note PES provides a Web based Interactive communication method In order to use the Web BBS for Interactive claims choose W for Web B for BBS is no longer available on the Tools Options Web screen For instructions go to Section 5 1 Web Internet in the Provider Electronic Solutions Software User s Manual To submit an interactive 276 Claim Status Inquiry Request perform the following steps Step 1 Complete the 276 Claim Status Inquiry Request as directed in Section 9 3 1 Step 2 Click e Step 3 Click Sed The system responds to your 276 Claim Status Inquiry Request by sending a 277 Claim Status Response within a few minutes of receiving your request Note If the transmission was unsuccessful read the message or communication log make the necessary changes and resubmit the files Step 4 Select the 999 Acknowledgment s Accepted Submit Report s Rejected Submit Report s and Submission Transaction Report s and access the system again if no file is found and the submission was successful At this time you can also click on the 277 Claim Status Response s Note These reports help determine what errors were encountered in processing the submitted file RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx Augus
186. ay If you do not see this message the Upgrade file was not saved to the correct location y Solutions software is running Please exit all applications prior to continuing with the upgrade Do you wish to apply upgrades now 6 Click on vs The upgrade process will launch and indicate the upgrade version that will be applied Click Yes The following screens will display RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 UPGRADE Only 1 upgrade is available to apply to this workstation The upgrade is for upgrading to version 400 Select OK to proceed with upgrade 7 Click OK and the following screens will display Provider Electronic Solutions Upgrade Welcome to the Provider Electronic Solutions Upgrade Setup program Tha progam veal upgrade PA Provider Electrons Sclutons bo vernon 400 8 Click L S The upgrade process will complete Once the process is finished the following screen will display R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Provider Electronic Solutions Upgrade InstallShield Wizard Complete Setup has finished installing UPGRADE on your computer ance 9 Click Fresh The upgrade has been successfully added to your installation of the Provider Electronic Soluti
187. b to access the Newborn screen Patient Enter the recipient ID of the newborn If the newborn recipient does not ID have an ID number leave this field blank When the claim is submitted this field automatically populates with the mother s recipient ID number Last Enter the newborn s last name Name First Enter the newborn s first name Name Enter the newborn s middle initial Date of Enter the newborn s date of birth The format is the 2 digit month 2 digit Birth day and 4 digit year Gender Select the appropriate gender from the drop down box or enter an appropriate value as specified as described below F Female RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 161 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 M Male U Unknown The Other Insurance screen 1s added to the form if you selected Y in the Other Insurance Indicator field on the Header 5 screen Access the Other Insurance screen by clicking the OI tab The Other Insurance screen is displayed Step 11 Complete Other Insurance HP Provider Electronic Solutions 837 Institutional Inpatient Str File Edit View Forms Tools Window Help D RXV AA S B2 elk Total Charge o 0I Amount 999i Billed Amount i Services Release of Medical Data v Benefits Assignment Y o Add i 00 Claim Filing Ind Code Adjustment Group Cd Payer Responsibility HCO ICH
188. bility DL Drug Lab Conflict DM Apparent Drug Misuse DS Tobacco Use ED Patient Education Instruction ER Overuse EX Excessive Quantity HD High Dose IC Iatrogenic Condition ID Ingredient Duplication LD Low Dose LK Lock In Recipient LR Underuse MC Drug Disease Reported MN Insufficient Duration MS Missing Information Clarification RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 281 PP Plan Protocol PR Prior Adverse Reaction PS Product Selection Opportunity RE Suspected Environmental Risk RF Health Provider Referral SC Suboptimal Compliance SD Suboptimal Drug Indication SE Side Effect SF Suboptimal Dosage Form SR Suboptimal Regimen SX Drug Gender TD Therapeutic Duplication TN Laboratory Test Needed TP Payer Processor Question UD Duplicate Drug August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual MX Excessive Duration NA Drug Not Available NC Non Covered Drug Purchase ND New Disease Diagnosis NF Non Formulary Drug NN Unnecessary Drug NP New Patient Processing NR Lactation Nursing Interaction NS Insufficient Quantity OH Alcohol Conflict PA Drug Age PC Patient Question Concern PG Drug Pregnancy PH Preventive Health Care PN Prescriber Consultation
189. cal Center 60 Mass Immunization ASC SPU Center 25 Birthing Center 61 Comprehensive 26 Military Treatment Center Inpatient Rehabilitation 31 Skilled Nursing Facility Facility 32 Nursing Facility a T p l 7 i oe omprehensive Outpatient E O Rehabilitation Facility ASOP n 7 65 End Stage Renal 35 Adult Living Care Facility Disease Treatment Facility 41 Ambulance Land 71 State or Local Public 42 Ambulance Air or Water Health Clinic 50 Federally Qualified Health Center 72 Rural Health Clinic 51 Inpatient Psychiatric Facility 81 Independent 52 Psychiatric Facility Partial Laboratory Hospitalization 99 Other Unlisted Facility Prior Enter the 10 digit CHR DRG PSR admission certification number Authorization Enter the 10 digit Prior Authorization number if the service requires and has received prior authorization Enter the 10 digit PSR Number if admission to an acute care hospital a hospital SPU or an ASC 1s elective Enter the 10 digit Admission Certification number for urgent or emergency admission to an acute care hospital a SPU an ASC or specialty hospital Enter the 10 digit GA Voucher Exception for approved GA voucher exception requests RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 240 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Enter the 10 digit authorization number for approved 1150 A
190. changes to the appropriate fields Step 3 5 Click Delete Du to delete an existing detail line The selected detail line is deleted Step 3 6 Click the Claim 2 tab to access the Claim 2 screen The software displays the Claim 2 screen R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 21 1 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 4 Complete Claim 2 Pharmacy Submission Clarification 1 l 2 3 Level OF Service 0 Basis Of Cost Determination Dispensing Fee Submitted 00 Patent Paid Required IN Patient Paid Amount 0 Unit OF Measure EA Gross Amount Due 0 Presciption Origin Code gt ingredient Cost Submitted e PA Type O PA Number DUR Z PPS Heason For Service Service Code Result Of Service Copy Delete Undo All Cave NOC Decimal G ty D000 send Last Hame First Name Last Submit Dt Submission Clarification Select the submission clarification code from the drop down list or enter an appropriate value as specified This code indicates that the pharmacist is clarifying the submission Default 1 No Override 10 Meets Plan Limitations 11 Certification on File 12 DME Replacement Indicator 13 Payer Recognized Emergency Disaster 14 Long Term Care Of Absence 15 Long Term Care Replacement 16 Long Term Care Emergency Box 17 Long Term Care Emergency Supply 18 L
191. ches in the Batch Resubmission box Claims sent in that batch file appear at the bottom of the screen In the example below three claims were sent with the batch file that was selected Step 3 Click the batch file you would like to resubmit to resubmit a batch Step 4 Click _ Select All to select all the batch files forms for resubmission Step 5 Click Deselect All if you want to deselect all the files for resubmission Step 6 Select the batch the claim was sent with to copy a file for revision Step 7 Select the claim and then click __ topy to copy a claim The copied claim is placed in the appropriate Form option in Ready R status which can be accessed from the Forms Menu or Form short cut icon from the main screen of the Provider Electronic Solutions software For example if you copied an 837 Professional Form you would access the 837 Professional Form screen through the Forms Menu or by clicking on the appropriate short cut icon After you have accessed the 837 Professional Form screen you will see that the copied claim appears in the list at the bottom of the screen RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 305 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 J Batch Resubmissio Resubmission Ext Batch Description Datesent Timezsent C25 SoH 2 FO Eligibility Request 08713 2015 EAEE MEPOP Pharmacy Eligibility Oey s 2015 C25 S
192. chment transmission n AA Available by request at Provider site BM By Mail EL Electronically Only EM E mail FT File Transfer FX By Fax Attachment Enter the 10 digit ACN obtained from the PROMISe web site This Control number is used when a paper attachment is required by MA to cross Number reference the paper attachment with the electronic claim This number must also be written on the cover letter sent to MA R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 146 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 3 Complete Header 2 ig HP Provider Electronic Solutions File Edit View Forms Tools Window Help DEXJSA 4 lt B 2SH mT A 837 Institutional Inpatient Total Charge 9 0l Amount ii Billed Amount DT Services ICD Version ficb10 Diagnosis Codes Present On Admission Principal Aadi o o Other Diagnosis 7 POA Recipient ID Last Name ICD Version Use the ICD 9 ICD10 Version for the code being submitted Principal primary diagnosis code is the most specific ICD 9 CM ICD 10 CM PCS diagnosis code that relates to a recipient s Codes stay Select the principal diagnosis code from the drop down list or enter an appropriate value as specified Principal Diagnosis Other Fields 1 Each of these fields can identify an additional diagnosis code for 24 Diagnosis the form Select the additional diagnosis code s f
193. cipient s status on the last date of service billed on this claim Enter the appropriate 2 digit status code or select the status code from the drop down list or enter an appropriate value as specified 01 Dischrgd to home or self care routine discharge 02 Dischrgd trnsfrrd to another hospital for inpatient care 03 Dischrgd transfrrd to skilled nursing facility 04 Dischrgd transfrrd to an intermediate care facility 05 Dischrgd transfrrd to another type of institution 07 Left against medical advice or discontinued care 20 Expired 30 Still a patient Enter the patient s alpha numeric or alphanumeric number assigned by the provider You may enter up to 30 characters MA captures and returns 30 characters When this field is completed the patient s account number appears on the RA statement and makes it easier to identify those invoices where the recipient number is not recognized Note An account number is required for each claim to be able to obtain claim status information If the same account number is used for each claim submitted when a claim status request is sent the claim status is reported on all claims with that account number Select the appropriate release code from the drop down list or enter an appropriate value as specified Select I Informed Consent to Release Medical Information Select Y Yes Provider has a Signed Statement Permitting Release of Medical Billing Data R
194. code Step 3 Click __ Save when all data entry fields are completed Step 4 Click Add and repeat steps 2 3 and 4 to add another diagnosis code to the diagnosis reference list Step 5 Click __ Close to exit the Diagnosis CD 10 screen 11 Modifier Reference List To complete the data entry fields needed to add or edit a modifier reference list selection perform the following steps Step 1 Click Lists Modifier to access the Modifier reference list RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 74 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Ag HP Provider Electronic Solutions File Edit View Forms Lists Tools Window Help x vale CEAAL Ag Modifier Modifier Code Delete Description Undo All Save Modifier Code Description Find Step 2 Enter the data requested for each field as described below Modifier Enter the 2 digit modifier for the procedure code that was entered in the Code Procedure field Only enter a modifier if the procedure code requires a modifier as indicated by the MA Program Fee Schedule Description Enter a description of the modifier being added Step 3 Click o Save when all data entry fields are completed Step 4 Click o d and repeat steps 2 3 and 4 to add another modifier code to the Modifier reference list Step 5 Click Cose to exit the Modifier screen 8 12 NDC Reference Li
195. ctronic Solutions Forms Communication Lists Reports Tools Security Window Help 10 Eligibility Request 2 6 Claim Status Request a3 Dental 63 7 Institutional Inpatient 83 Institutional Nursing Facility 83 Institutional Outpatient 63 Professional NCPDP Pharmacy NCPDP Pharmacy Eligibility NCPDP Pharmacy Reversal Choosing a selection from a drop down list as indicated in the field completion instructions below completes many of the fields A drop down list is also known as a reference list For additional information on reference lists refer to the List options under Section 6 The 837 Dental Form appears with the Header 1 screen displayed as shown R PA MMIS CMcElheny PES_Manual_ 5010 4 00 _ICD10 docx August 31 2015 113 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 2 Complete Header 1 File Edit View Forms Tools Window Help DRX GBA S Ba 42925 8 F i ai 837 Dental co E1 fee Total Charge ET 01 Amount ET Billed Amount ENT Services Hdr 1 Hr 2 Hara Hars o1 swi Srv2 Srv adj Claim Frequency x Original Clam o Add Provider Role Copy Provider ID Location Code HPI Delete Last Org Name First Name Hl T a a Undo All Recipient ID Last Hame First Hame HI __ Sae Releaze of Medical Data Account it Benefits Assignment Iv Report Type Code Report Transmission Code Attachment Ctl tt Find
196. cts listed Enter the appropriate value from the drop down box or enter an appropriate value as specified August 31 2015 244 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 02 Physically Handicapped Children s Program 03 Special Federal Funding 05 Disability Pregnancy Select the pregnancy code from the drop down list or enter the Indicator appropriate value Select Y Yes if the recipient was pregnant at the time of service Select N No if the recipient was not pregnant at the time of service Date of Last Enter the 2 digit month 2 digit day and 4 digit year of the mother s Menstruation last menstruation If the date is unknown enter the first date that you saw the recipient EPSDT Enter the appropriate value from the drop down list or enter an Referral appropriate value as specified AV Availability not used NU Not used S2 Under treatment ST New service Newborn Select Y Yes from the drop down list if services were rendered to a Indicator newborn Select N No from the drop down list Delay Reason Select the appropriate code to indicate why a claim is being submitted outside of the 180 day initial submission window This field is optional 1 Proof of Eligibility 7 Third Party Processing Delay Unknown or Unavailable 8 Delay in Eligibility 2 Litigation Determination 3 Authorization Delays 9 Original Claim Rej
197. cx August 31 2015 215 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 6 Complete PAT 3 3 Institutional Outpatient Total Charge aa Ol Amount P Billed Amount i Services J Hdr 1 Hdr 2 Hdr3 Har 4 Pat Srv 1 srv 2 Srv 3 Patient ID Last Name First Name Ml B Copy Date of Birth Delete Gender Undo All Save J i a Last Mame FirstName _ Coy w m _ r _ a e _ Step 6 1 To access the Pat tab select Y in the Newborn Indicator field Access this tab when the claim is for a newborn or maternity care Patient ID Enter the Recipient ID of the newborn If the newborn recipient does not have an ID number leave this field blank When the claim is submitted this field automatically populates with the mother s recipient ID number Last Name Enter the last name of the newborn First Name Enter the first name of the newborn MI Enter the middle initial of the newborn Date of Enter the date of birth of the newborn The format is the 2 digit month Birth 2 digit day and 4 digit year RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 216 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Gender Select the appropriate gender from the drop down box or enter the appropriate value F Female M Male U Unknown Step 7 Complete Other Insurance Ey 837 Institutiona
198. d and repeat steps 2 3 and 4 to add another taxonomy code to the Taxonomy Code reference list Step 5 Click Cose to exit the Taxonomy screen RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 66 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 8 6 Admission Type Reference List Selection To complete the data entry fields needed to add or edit an Admission Type reference list selection perform the following steps Step 1 Click the Lists Admission Type to access the Admission Type reference list J HP Provider Electronic Solutions iit File Edit View Forms Lists Tools Window Help ax vBleal Bal a73 8 lio Admission Type Admission Type Code F Description Trauma Center Delete Undo All Save Admission Type Code Description Find E mergency Urgent Print Elective Newborn Trauma Center Step 2 Enter the data requested for each field as described below Admission Enter the code that identifies the type of admission to the facility or Type Code choose the appropriate code from the field s preloaded drop down list as described below or enter an appropriate value as specified 1 Emergency Patient s condition requires immediate medical Admission attention and any time delay would be harmful to the patient 2 Urgent Patient s condition while not immediately essential Admission should have medical atte
199. d 1s automatically populated after you select or enter an MPI number in the Provider ID Rendering Provider field Information cannot be entered directly into these fields to add or change information in these fields access the Provider List Form Rendering Provider s first name This field is automatically populated after you select or enter an MPI number in the Provider ID Rendering Provider field Information cannot be entered directly into these fields to add or change information in these fields access the Provider List Form Rendering Provider s middle initial This field is automatically populated after you select or enter an MPI number in the Provider ID Rendering Provider field Information cannot be entered directly into these fields to add or change information in these fields access the Provider List Form If the services are being rendered in an inpatient hospital emergency room hospital special treatment room hospital short procedure unit ambulatory surgical center or renal dialysis center select the 9 digit MPI number for the Service Facility Location from the drop down list or double click on the data entry portion of the field to add a reference list selection August 31 2015 124 Provider Electronic Solutions Software User Manual Location Code Service Facility Location NPI Service Facility Location Facility Name Service Facility Location Other Insurance Indicator RAPA MMI
200. d and displayed on your screen R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 317 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 To limit the type of requests in the detail report enter the appropriate report criteria into one or more of the following fields Batch Limits the detail report to requests in a specific batch Number Enter the appropriate batch ID number in this field You can locate the batch numbers under the Resubmission or the Communication Log options of the View Communication Log menu Recipient Limits the detail report being requested to return information only for Cardholder the specified recipient ID Enter the appropriate recipient ID in this field Form Status Limits the detail report being requested to include only the claims with the specified form status Select the appropriate form status from this drop down list Submit Date Limits the detail report to requests transmitted on the specified date Enter the appropriate date in this field Step 5 After you enter the report criteria click 0K i The detail report is generated and is displayed on your screen R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 318 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 6 Use the scroll bars located on the right side and bottom of the screen to view the entire report EEEE OOOO N
201. d and enter that amount A zero 0 00 billed amount is a permitted value RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 171 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 13 1 To add additional service lines with revenue codes click Add Srv l A new blank service line is added to the screen Step 13 2 Click on the new service line and then enter the service data in the appropriate data fields as described in this step Step 13 3 To copy the data from an existing service line to a new service line click on the existing service line you want to copy and then click _ Copy 9m A new service line is added to the screen The new service line has the same data as the existing service line you previously selected Edit the data in the new service line by clicking on the new service line and then enter changes to the appropriate fields Step 13 4 To delete an existing service line click on the service line you want to delete and then click Delete stv The selected service line is deleted Step 14 Click ave to save the institutional inpatient form Step 15 Click amp dd to start another institutional inpatient claim 9 6 Complete an 837 Institutional Nursing Facility Form Use the 837 Institutional Nursing Facility form to create claims for institutional nursing home services The 837 Institutional Nursing Facility form is divided into seven screens Each
202. d in the Provider ID field This field is automatically populated when an MPI number is selected Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form First name of the provider indicated in the Provider ID field This field is automatically populated when an MPI number is selected Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Middle initial of the provider indicated in the Provider ID field This field is automatically populated when an MPI number is selected Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form If the services are being ONLY rendered in an inpatient hospital emergency room a hospital special treatment room a hospital short procedure unit an ambulatory surgical center or a renal dialysis center select the 9 digit ID Number for the Service Facility Location from the field s pull down list Enter the 4 digit Service Location Code that corresponds to the Service Provider Specialty and Address Facility Location NPI Enter the NPI National Provider Identifier Numeric 10 digit Service identifier consisting of 9 numbers plus a check digit in the 10 Facility position Location Facility Name Enter the last name of an individual provider when the Enti
203. d services The cardholder ID consists of the 10 digit Recipient ID number and 2 digit Card Issue Number as printed on the recipient s card Recipient s last name This filed 1s automatically populated after you select a Cardholder ID from the Cardholder ID field Recipient s first name This filed 1s automatically populated after you select a Cardholder ID from the Cardholder ID field Step 3 Click ave to save the pharmacy eligibility inquiry Step 4 Click Close to exit the NCPDP Pharmacy Eligibility form 9 11 Complete an NCPDP Pharmacy Reversal Form The NCPDP Pharmacy Reversal form is used by Pharmacies to create reversal requests for pharmacy claims This form consists of the Header Reversal screen and the Claim Reversal screen The Header Reversal screen contains the provider information and the Date of Service The Claim Reversal screen contains the prescription information For additional information on a particular field highlight the field with your mouse and press F1 To create a pharmacy reversal request perform the following steps R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 298 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 1 From the main screen of the Provider Electronic Solutions software access the NCPDP Pharmacy Reversal Form in one of two ways NCPDP Pharmacy Reversal Shortcut icon on the Toolbar or Select the NCPDP Ph
204. de Step 8 Complete Pat ks 6a Professional Total Charge ii O1 Amount ii Billed Amount li Services Patrent ID atien Copy Last Name TFT First Name o Hl Date of Birth 00 00 0000 Date of Death 00 00 0000 Delete Undo All Garve Last Submit Dit Find Print Close Patient ID Enter the 10 digit recipient ID for the newborn If the recipient ID is not known leave this field blank this value will automatically populate with the mother s recipient ID number when the claim is submitted Last Name Enter the last name for the recipient First Name Enter the first name for the recipient MI Enter the recipient s middle initial Date of Enter the date of birth of the newborn using the 2 digit month 2 digit Birth day and 4 digit year format MMDDYYYY Date of Enter the date of death of the newborn if applicable Use the 2 digit Death month 2 digit day and 4 digit year format MMDDYYYY Gender Select the gender of the recipient from the drop down list or enter an appropriate value as specified RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 252 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 M Male F Female U Unknown Step 9 Complete Other Insurance EJ 837 Professional Total Charge ii OF Amount ili Billed Amount ill Services
205. ded was emergency related RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 257 PA PROMISe Provider Electronic Solutions Software User Manual Place Of Service Procedure Modifiers Version 4 00 Select the place of service code from the drop down list or enter an appropriate value as specified This field identifies the location where the service was performed The only place of service codes accepted on an 837 Professional are 03 School 04 Homeless Shelter 11 Office 12 Patient s Home 15 Mobile Unit 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room Hospital 24 Ambulatory Surgical Center ASC SPU 25 Birthing Center 26 Military Treatment Center 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 35 Adult Living Care Facility 41 Ambulance Land 42 Ambulance Air or Water 50 Federally Qualified Health Center 51 Inpatient Psychiatric Facility 52 Psychiatric Facility Partial Hospitalization 53 Community Mental Health Care 54 Intermediate Care Facility Mentally Retarded ICF MR 55 Residential Substance Abuse Treatment Facility 56 Psychiatric Residential Treatment Center Non JCHAO 60 Mass Immunization Center 61 Comprehensive Inpatient Rehabilitation Facility 62 CORF Comprehensive Outpatient R
206. dentifies whether the prescription was sent in writing electronically by phone or by facsimile 0 Not Known 1 Written 2 Telephone 3 Electronic 4 Facsimile 5 Pharmacy Enter the product component cost of the dispensed prescription Select the prior authorization code from the drop down list or enter an appropriate value as specified Enter the appropriate code that clarifies the prior authorization number 0 Not Specified 6 Family Planning 1 Prior Authorization Indicator 2 Medical Certification 7 TANF 3 EPSDT 8 Payer Defined Exemption 4 Exemption from Copay 5 Exemption from RX August 31 2015 280 PA PROMISe Provider Electronic Solutions Software User Manual Prior Authorization PA Number Reason For Service DUR PPS Version 4 00 9 Emergency Preparedness Enter the prior authorization number provided by the DHS for the prescription Select the reason code from the drop down list or enter an appropriate value as specified This code identifies the type of conflict detected AD Additional Drug Needed AN Prescription Authentication AR Adverse Drug Reaction AT Additive Toxicity CD Chronic Disease Management CH Call Help Desk CS Patient Complaint Symptom DA Drug Allergy DC Drug Disease Inferred DD Drug Drug Interaction DF Drug Food Interaction DI Drug Incompati
207. der Electronic Solutions Communication Lists Reports Tools Security Window Help 10 Eligibility Request 16 Claim Status Request 63 Dental 63 7 Institutional Inpatient 83 Institutional Nursing Facility 83 Institutional Outpatient 83 Professional NCPDP Pharmacy NCPDP Pharmacy Eligibility NCPOP Pharmacy Reversal Note When you choose a selection from a drop down list as indicated in the field completion instructions below many of the fields are completed A drop down list is also known as a reference list For additional information on reference lists refer to the List options under Section 6 R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 173 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 2 Complete Header 1 7 HP Provider Electronic Solutions mmm File Edit View Forms Tools Window Help D2 RXV H4 S4 BATS fi 837 Institutional Nursing Facility Total Charge ii OF Amount ii Billed Amount ih Services Hdr 1 Hdr 2 Hdr 3 Hdr4 Hars Srv Type OF Bill Add Provider ID Location Code Copy Org Name NPI Delete Recipient ID Medical Record it Undo All Last Name First Hame Hl Patient Status Account it Edit All Release of Medical Data Benefits Assignment Y Report Type Code Report Transmission Code Attachment Ctl it Last Mame First Name Billed Amount Last Submit Dt Save Type of
208. directly into this field If you need to add or edit information in this field access the Provider Form Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Operating provider s last name or organization name associated with the number selected in the Operating Provider ID field This field is automatically populated when an operating provider ID number is chosen Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Operating provider s first name This field is automatically populated when an operating provider ID number is chosen Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Operating provider s middle initial This field is automatically populated when an operating provider ID number is chosen August 31 2015 229 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Step 11 Complete Service 3 Total Charge PO DI Amount 9999 Billed Amount Si Services Service Adjustment Ind N Copy Delete Undo All Tare Billed Amount Find Recipient ID Last Name FirstName Billed Amo
209. djudicated prior to the implementation of PROMISe enter the 10 digit CRN followed by the 2 digit line number as printed on the RA Statement Provider ID Select the 8 or 9 character Medical License Number of the other provider from the drop down list or double click on the data entry portion of the field to add a reference list selection Note For Access Plus Referred Services select the 13 digit MAID number for the referring provider from the field s pull down list Location Code 4 digit location code associated with the MPI number selected in the Provider ID field This field is automatically populated after you select or enter an MPI number in the Provider ID Other field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Org Name Provider s organization name or the group name This field is automatically populated after you select or enter an MPI number in the Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form NPI Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Recipient ID The recipient s 10 digit recipient number For additional information on the Recipient ID field refer to Recipient Reference List in section 8 3 of this manual I
210. dministrative Waiver services Patient Pay Enter the amount using a decimal point the recipient has paid toward Amount this claim as determined by the local CAO Patient pay is only applicable if notification is received from the local CAO on a PA 162RM For example enter 25 50 if the amount was 25 50 Do not enter copay in this field Referral Enter a 2 digit alphanumeric code that identifies the Primary Care Code Case Manager if applicable Not currently used Billing Note This field pertains to information related to visit codes and additional information required to adjudicate MA claims Enter the following codes 1f they apply Multiple codes should be entered in one string ex VCO9QSB If the provider is a qualified small business enter QSB in the Billing Note field You may enter more than one code if applicable Example VCO9QSB for a claim filed by a qualified small business dental provider for services rendered to a pregnant woman If the visit This means Then Enter code Is 09 Services rendered to a VC09 pregnant woman Dental only 10 Services rendered toan LTC VC10 or a state mental hospital resident 11 Provider attempted but was vcll unsuccessful in collecting a co payment QSB If the provider is a Qualified QSB Small Business EPSDT If the claim involved EPSDT referral information any of the following that apply must be entered EPSDT Dental Referral YD RAPA MMIS CMcElheny PES_Manual
211. drop down menu located on the main menu of the Provider Electronic Solutions software R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 316 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 ig HP Provider Electronic mifare File Forms Communication Lists Reports Tools Security Window Help a a oe EJ Re a Detail Forms summary Forms NCPDP Provider Recipient Taxonomy Admission Type Admit Source Carrier Condition Code Diagnosis Diagnosis ICD 10 Modifier NOC Occurrence Ol Reason Patient Status Place of Service Policy Holder Procedure HCPCS Procedure HCPCS ICD 10 Revenue Type of Bill Value Code 11 1 270 Eligibility Request Detail Report You can generate a detail report for the 270 Eligibility Request s using the Provider Electronic Solutions software This detail report contains only the key fields on the 270 Eligibility Request Form To generate a 270 Eligibility Request Detail Report perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select the 270 Eligibility Request option from the Detail Forms drop down menu Step 2 The 270 Eligibility Request Detail Report screen is displayed Step 3 to include all the requests in the detail report Step 4 Click ok When you see the box advising you that all records will be selected A detailed report is generate
212. dure HCPCS Procedure HCPCS ICD10 Diagnosis Diagnosis ICD Procedure HCPCS Procedure HCPCS ICD10 Diagnosis Diagnosis ICD Procedure HCPCS Procedure HCPCS ICD10 Diagnosis Diagnosis ICD Procedure HCPCS Procedure HCPCS ICD10 Diagnosis Diagnosis ICD Place of Service Type of Bill Patient Status Occurrence Condition Code Value Code Admission Type Admission Source Type of Bill Patient Status Occurrence Condition Code Value Code Admission Source Admission Type Type of Bill Patient Status Occurrence Condition Code Value Code Admission Source Admission Type Place of Service Carrier August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Form Reference List NCPDP NCPDP Provider NCPDP Pharmacy Recipient Eligibility NCPDP NCPDP Provider Pharmacy Reversal 7 1 Accessing a Reference List Reference lists are accessed by using the Lists option or by double clicking on a data entry field that is linked to a reference list To access a reference list from the Provider Electronic Solutions software main menu perform the following steps Step 1 Access the Provider Electronic Solutions software main menu Step 2 Select the Lists option and select the reference list you need RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 43 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 S Smit J Reports T
213. e Provider NPI Enter the NPI National Provider Identifier Numeric 10 digit Attending identifier consisting of 9 numbers plus a check digit in the 10 Provider position Last Org Name Attending provider s last name This field is automatically Attending populated after you select or enter a medical license number in the Provider Provider ID Attending Provider field R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 181 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form First Name Attending provider s first name This field is automatically Attending populated after you select or enter a medical license number in the Provider Provider ID Attending Provider field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form MI Attending provider s middle initial This field 1s automatically Attending populated after you select or enter a medical license number in the Provider Provider ID Attending Provider field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Provider ID Select the rendering provider s 8 or 9 character medical license Rendering number Provider
214. e Clinical 1 i a Pharmacy Total Charge Amt Paid gt WW Biled m gt 0 Details Delete Undo All cave Send Last Name First Hame Copy Bde rte Eee s m ee Gas Select the code from the drop down list that identifies the diagnosis code or enter the ICD 9 CM ICD 10 CM PCS diagnosis code that relates to a recipient s diagnosis as specified Qualifier 00 Not Specified 01 ICD9 02 ICD10 03 National Criteria Care Institute 04 SNOMED 05 Common Dental Terminology 06 Medi Span Product Line 07 DSM IV 08 FDBDX 09 FDB DXID 99 Other Diagnosis Code Qualifier RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 286 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 8 Complete Clinical 2 Pharmacy Total Charge Amt Paid Measurement Date Time Dimension Unt alue 1 fama FT el PT gt ono dP C dP A 3 00700 0000 4 00700 0000 5 00700 0000 Cardholder Io LastName FirstName BilledAmt jf Last Submit Dt _ ex Bak wan Sr sena Ti Ra me Measurement Enter the 2 digit month 2 digit day and 4 digit year For example enter Date 01012015 if the date was January 1 2015 Time Required if Time is known or has impact on measurement RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 287 PA PROMISe Provider El
215. e Fa Zip fi 7111 1111 Print ovider ID Tasonomy Last Org Name 111111111 0001 O TESTER 1 n5555SRSS O0OS 2011111111 BILLING Step 4 Click _ Swe to save your changes To delete a selection prior to accessing a form perform the following steps Step 1 Complete steps 1 2 and 3 as directed above Step 2 Click E Step 3 A box appears to ask if you are sure you want to delete the record Delete current record l Are you sure you want to delete this record eT Step 4 Clik RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 53 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 To edit or delete a selection as you go while completing a claim perform the following Step 1 Access the claim Step 2 Double click on the data entry section of the field for the reference list you would like to change 7 HP Provider Electronic Solutions 837 Professional File Edit View Forms Tools Window Help E RXxXJHa elt B SS M k Total Charge ME 0 Amount EET Billed Amount III Services M Hdr 1 Har 2 Hdr3 Hdr4 Hors Swi srv2 swa Claim Frequency 1 Original Clam its s Provider Role Copy Provider ID paa Location Code NPI Delete Last Org Name First Name Hi Recipient ID Medical Rec tt DOB 00700 0000 Last Name First Name Hl Helease of Medical Data gt Account H P Benefit
216. e First Name Insurance Type Code Find Recipient ID Last Hame First Name Billed Amount Last Submit Print Close RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 166 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 The Crossover screen is added to the claim if you selected Y in the Crossover Ind field on the Header 3 screen Access the Crossover screen by clicking the Crossover tab The Crossover screen is displayed Release of Medical Data Benefits Assignment Reason Codes Amts Fields 1 3 Select the appropriate release code from the drop down list or enter an appropriate value as specified Select I Informed Consent to Release Medical Information for conditions or diagnosis regulated by Federal statutes Select Y Yes Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim The provider has a signed statement on file permitting the release of medical data to other organizations Select the appropriate assignment code from the drop down list or enter an appropriate value as specified Select Y Yes if the recipient or authorized person has authorized that benefits be assigned to the provider Select N No if the recipient or authorized person has not authorized that benefits be assigned to the provider Select W for Not Applicable Not applicable for this claim There a
217. e Patient Status screen 16 Place of Service Reference List To complete the data entry fields needed to add or edit a Place of Service reference list selection perform the following steps Step 1 Click Lists Place of Service to access the Place of Service reference list F HF Provider Electronic Soiton Qa File Edit View Forms Lists Tools Window Help 53 xv mle Blas Alm G Place Of Service Place Of Service Code Description Delete Undo All Save Place Of Service Code Description Find Schaal Homeless Shelter Office Home Mobile Unit Inpatient Hospital Outpatient Hospital Print Step 2 Enter the data requested for each field as described below Place of Enter the code for where the claim services were performed from the Service preloaded list or enter an appropriate value as specified Code These values are preloaded and are HIPAA compliant If any changes or modifications need to be made to these values you will be notified by DHS or HP Enterprise Services 03 School 51 Inpatient Psychiatric Facility 04 Homeless Shelter 52 Psychiatric Facility Partial 11 Office Hospitalization 12 Home RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 81 PA PROMISe Provider Electronic Solutions Software User Manual 15 Mobile Unit 21 Inpatient Hospital 22 Outpatient Hospital 23
218. e an existing claim adjustment line click on the claim line that you want to delete and then click Delete Sry Adil The selected claim line is deleted from the screen Click Save to save the dental claim Click 4d to start another dental claim or Click Close to exit the 837 Dental Form The claim adjustment lines are linked to the claim line that is highlighted when you access the Service Adjustment screen Make sure that you have the correct service line highlighted for the adjustment you are entering 9 5 Complete the 837 Institutional Inpatient Form The 837 Institutional Inpatient form is used to create claims for inpatient services normally billed on a UB 04 paper claim form The 837 Institutional Inpatient form is divided into seven screens Note Consolidated Community Reporting for OMHSAS CCR submissions can now be performed starting with PES software Version 3 57 Each screen contains the following claim data Hdr 1 Accesses the screen that contains the provider and recipient information Har 2 Access the screen that contains all diagnosis for ICD 9 CM ICD 10 CM PCS Hdr 3 Accesses the screen that contains any occurrence condition and coverage information Hdr 4 Accesses the screen that contains any value code RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 140 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Hdr 5 Hdr 6 Hdr 7 Hd
219. e carrier code from the drop down list or enter an appropriate value as specified The carrier code identifies the recipient s third party insurance carrier Policyholder s last name This field 1s automatically populated after you select a carrier code from the Carrier Code field Information cannot be entered directly into this field If you need to add or edit information in this field access the Policy Holder Form Policyholder s first name This field is automatically populated after you select a carrier code from the Carrier Code field Information cannot be entered directly into this field If you need to add or edit information in this field access the Policy Holder Form The window is only active if the payer is Medicare with Claim filing code of MB and the Payer Responsibility is not P Primary Select the appropriate value from the dropdown box or enter an appropriate value as specified that identifies the type of insurance listed Insurance Type Code is a Do Not Use field in the 837 Institutional Implementation Guide 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End Stage Renal Disease in the Mandated Coordination Period with an Employer s Group Health Plan 14 Medicare Secondary No fault Insurance including Auto is Primary 15 Medicare Secondary Worker s Compensation 16 Medicare Secondary Public Health Service
220. e code from the field s preloaded drop down list 1 Emergency Admission Patient s condition requires immediate medical attention and any time delay would be harmful to the patient 2 Urgent Admission Patient s condition while not immediately essential should have medical attention provided very early to prevent possible loss or impairment of life limb or bodily function 3 Elective Admission Scheduled or planned admission 4 Newborn Admission of a newborn baby 5 Trauma Center Admission to a trauma center Discharge Enter the hour during which the patient was discharged Enter the hour in Time military twenty four hour time For example 12 00 12 59 Midnight 00 00 12 00 12 59 Noon 12 00 6 00 6 59 6 00p m 18 00 Admit Enter the code that identifies the source of admission to the facility as Source specified or choose the appropriate code from the field s preloaded drop down list as described below 1 Physician Referral 2 Clinic Referral 3 HMO Referral 4 Transfer from a Hospital 5 Transfer from a Skilled Nursing Facility 6 Transfer from Another 7 Emergency Room 8 Court Law 9 Information Not Available A Transfer from a Rural Primary Care Hospital Delay Enter the appropriate code to indicate why a claim is being submitted outside Reason of the 180 day initial submission window This is an optional field 1 Proof of Elig
221. e hyphens slashes dashes or spaces when completing this field Note If this value is not known enter 999999999 Taxonomy Required field Lists the code designating the provider type Code classification and specialty Enter the appropriate Taxonomy code View the most recent list of approved Taxonomy codes at http www wpc edi com codes Codes asp If you have questions about which Taxonomy code you should use for your provider type please contact Provider Inquiry or the Provider Assistance Center Note The Taxonomy code is crucial to using the NPI National Provider Identifier If entering an NPI as the primary identifier you must use the correct Taxonomy code that you coordinated with Provider Enrollment for your legacy ID Nine Digit Provider ID plus Four Digit Service Location Code Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Provider Enter the individual provider s or facility s street address Address Line 1 Provider Enter additional address information such as suite or apartment Address number for the individual provider or facility being referenced Line 2 Enter the City that corresponds with the street address State Enter the two letter abbreviation for the state that corresponds with the city listed in the City field Enter the required 9 digit zip code corresponding to the city and state listed in the Ci
222. e specified form status Select the appropriate form status from this drop down list Submit Date Limits the summary report to Inpatient Claims transmitted on the Step 4 Step 5 specified date Enter the appropriate date in this field After you enter the report criteria click OF The detailed report is generated and displayed on your screen Use the scroll bars located on the right side and bottom of the screen to view the entire report 7 837 Institutional Inpatient Detail Report Batch Number Recipient Cardholder ID Form Status Submit Date 00 00 0000 Records selected 837 Institutional Inpatient Detail Report As of 08 26 2015 ALL CLAIMS Type Of Bill 111 Original Claim Provider ID 100760553 Location Code 0079 NPI 1237163674 Org Name CROZERCHESTER Recipient ID l ont Klomn Step 6 Step 7 RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx KMdedical Record Firrt Klomo Click Print to print the 837 Institutional Inpatient Detail Report Click Close to exit the 837 Institutional Inpatient Detail Report screen 329 Version 4 00 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 11 8 837 Institutional Inpatient Summary Report You can generate a summary report for the Institutional Inpatient Claims using the Provider Electronic Solutions software This summary report contains only the key fields on the
223. e that option 6 2 Using the Keyboard Use the following keys to navigate through a screen using just the keyboard Tab or Enter Go to the next field Shift Tab Go to the previous field Left Arrow Move backward within a field Right Arrow Move forward within a field Up Arrow Scroll up through a list Down Arrow Scroll down through a list F1 Open on line help when the cursor is on a data entry field 6 3 Menu Options The Provider Electronic Solutions software uses drop down menus to navigate through the application and to complete data entry fields The menu options change depending on what you are doing When you first open the Provider Electronic Solutions software the Main Menu is displayed Use these menus by clicking on them with the mouse or by activating a menu option with a hot key R PA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 29 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 A hot key is usually a two key combination that is pressed at the same time For example to view the File drop down menu from the Main Menu hold the Alt key and then press the F key on your keyboard A hot key is identified on a menu by an underlined letter for example the F in File That underlined letter is pressed in combination with the Alt key to access the menu option The options on the Main Menu bar are described below 6 3 1 File The File option lets you exit the a
224. e the Service Adjustment screen for each service line that has received partial payment from a third party insurance carrier To access the Service Adjustment screen for a particular service line follow the steps below e Select the service line you are adjusting from the Service 1 Screen e Select Y in the Service Adjustment Ind field on the Service 3 screen The Service Adjustment screen is displayed Step 12 1 Click Add S1 to add another service line A new blank service line 1s added to the screen Step 12 2 Click on the new service line and then enter the service data in the appropriate data fields Step 12 3 To copy the data from an existing service line to a new service line click on the existing service line that contains information you want to copy Step 12 4 Click Copy stv to add a new service line to the screen R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 265 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 The new service line has the same data as the existing service line you previously selected You can edit the data in the new service line Simply click on the new service line and make changes to the appropriate fields Step 12 5 To delete an existing service line click on the service line you want to delete and then click Delete Srv The selected service line 1s deleted Step 13 Complete Service Adjustment EJ 837 Professional
225. e to edit or delete Step 4 The data fields on the screen are filled with the information from the selection RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 55 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 ig HP Provider Electronic Solutions 837 Professional EP File Edit View Forms Tools Window Help DRX Ha S Ba 872 Mk Total Charge ET 01 Amount ETT Billed Amount IIE Services Hdr 1 Hdr 2 Hdr3 Hdr4 Hdr5 svi srv2 srv3 Claim Frequency Original Claim Add Provider Role Copy Provider ID 111111111 Location Code 0071 NPI 3333333333 Delete Last Org Name TESTER 1 First Name TEST Mil Recipient ID Eien cee Medical Rec it DOB 00 00 0000 Last Name First Name Hl Release of Medical Data gt Account H o Benefits Assignment Y Patient Signature Report Type Code gt Report Transmission Code xl Attachment Ctl Le Recipient ID ff Last Name FirstName f Billed Amount f Last Submit Dt 1112345671 TESTER Undo All Save Cw B CA __Seve_ FRR Step 5 Tab to or click on the data entry field to be edited and make the appropriate changes by typing over the already populated information Step 6 Click Swe to save your changes To delete a selection as you go while accessing a claim perform the following steps Step 1 Complete steps 1 through 4 as directed above Step 2 C
226. ected or 4 Delay in Certifying Provider Denied Due to a Reason Unrelated 5 Delay in Supplying Billing to the Billing Limitation Rules Forms 10 Administration Delay in the 6 Delay in Delivery of Prior Authorization Process Custom Made Appliances 11 Other Other Select the other insurance code from the drop down list or enter an Insurance appropriate value as specified met Select Y Yes if the recipient has other insurance If you select Y the other insurance screen will be added to the claim Select N No if the recipient does not have other insurance RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 245 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 6 Complete Header 4 EJ 837 Professional Total Charge 999i Dl Amount S99 Billed Amount M Services Referring Provider Add Provider ID Location Code HPI Last Org Name First Name Hl Copy Rendering Provider Delete Provider ID Location Code HPI Undo All Last Org Name First Hame hil Service Facility Location cave Facility ID Location Code NPI Facility Hame Supervising Provider Provider ID Location Code NPI Last Org Name First Name hil Recipient ID E f FirstName Billed Amount E Provider ID Enter the 8 or 9 digit medical license number or MPI number for Referring the physician who referred the recipient for the service perfo
227. ection 9 1 Step 2 Click Step 3 Click __ Send The Eligibility Verification System EVS responds to your 270 Eligibility Request by sending a 271 Eligibility Response within a few minutes of receiving your request Interpret the 271 Eligibility Response The 271 Eligibility Responses identifies the recipient s eligibility for MA Use the scroll bars located on the right side and bottom of the 271 Eligibility Response box to view the 271 Eligibility Responses RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 100 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 An explanation of Indicated 271 Response Report Areas is listed here Information Source Last Org Name Service Provider Number Recipient Information Eligibility Benefit Information Indicates who has returned the 271 Eligibility responses In this case it is always the Pennsylvania DHS Provider and service location number is used to request recipient eligibility information Indicates recipient demographic information First and last name recipient ID number date of birth and gender are returned with the recipient information in PROMISe Eligibility benefit information on record for the recipient Information not listed indicates that the recipient does not currently have that particular benefit information on their record MCO TPL Lock In etc Benefit Information a
228. ectronic Solutions Software User Manual Version 4 00 Dimension Required if Measurement Unit and Measurement Value are used Enter using the drop down list or enter an appropriate value as specified Not Specified 01 Blood Pressure BP 02 Blood Glucose 03 Temperature 04 Serum Creatinine SCR 05 Glycosylated Hemoglobin HBA1C 06 Sodium NA 07 Potassium K 08 Calcium CA 09 Serum Glutamic Oxaloacetic Tran 10 Serum Glutamic Pyruvic Trans 11 Alkaline Phosphatase 12 Theophylline 13 Digoxin 14 Weight 15 Body Surface Area BSA 16 Height 17 Creatinine Clearance CRCL 18 Cholesterol 19 Low Density Lipoprotein LDL 20 High Density Lipoprotein HDL 21 Triglycerides TG 22 Bone Mineral Density BMD T Score 23 Prothrombin Time PT 24 Hemoglobin HB HGB 25 Hematocrit HCT 26 White Blood Cell Count WBC 27 Red Blood Cell Count RBC 28 Heart Rate 29 Absolute Neutrophil Count ANC 30 Activated Partial Thromboplastin 31 CD4 Count 32 Partial Thromboplastin Time PTT 33 T Cell Count RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 288 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 34 INR International Normalized Ratio 99 Other Unit Required if Measurement Dimension and Measurement Value are used Enter
229. ed on your machine Installshield Back Cancel Step 8 When the Choose Destination Location screen is displayed click __Next gt to install at C papromise which becomes the default directory If the software is to run from a network rather than the PC hard drive select the appropriate destination drive and click Next gt RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 H P Provider Electronic Solutions Choose Destination Location Select folder where setup wall install files Setup will install H P Provider Electronic Solutions in the following folder To install to thie folder click Mest To install to a different folder click Browse and select another folder Destination Folder cc papromise Browse InstallShield Cancel Step 9 When the Choose Database Destination Location screen is displayed a second time click _ Next gt to install at C papromise where the database files are loaded and become a default directory If installing the software to a network select the appropriate destination drive and click Next gt RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 10 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 H P Provider Electronic Solutions Choose Database Destination Location Setup will install H P Provider Elect
230. ed person this is not the third party insurance carrier This field is automatically populated after you select a group number from the Group field Information cannot be entered directly into these fields to add or change information in these fields access the Policy Holder List Form Last Name Policyholder s last name This field 1s automatically populated after Policy Holder you select a group number from the Group field Information cannot be entered directly into these fields to add or change information in these fields access the Policy Holder List Form First Name Policyholder s first name This field is automatically populated after Policy Holder you select a group number from the Group field Information cannot be entered directly into these fields to add or change information in these fields access the Policy Holder List Form Remaining In the judgment of the provider this is the remaining amount to be Patient paid after adjudication by the Other Payer Liability RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 131 Provider Electronic PA PROMISe Solutions Software User Manual Version 4 00 Non Covered Required when the destination payer s cost avoidance policy allows Amount providers to bypass claim submission to the otherwise prior payer Insurance Type The window is only active if the payer is Medicare with Claim Code Step 6 3 Step 6 4 Step 6 5 fil
231. eferring provider it is necessary to create a separate 7 digit entry for that provider Referring Providers are generally identified by their 8 or 9 character state license number The format for a license number is either 2 alpha RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 60 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 6 numeric OR 2 alpha 6 numeric alpha Service Facilities are identified by their 9 digit MPI If using the Medical License Number in conjunction with the G2 qualifier OB enter the referring provider s 8 or 9 digit medical license number The license number should be entered with two alpha characters six numeric characters and one alpha character e g MD011234L If the practitioner s license number was issued after June 29 2001 enter the number in the new format e g MD123456 Note For Access Plus Referred Services select the 13 digit MAID number for the referring provider from the field s pull down list Location Enter the 4 digit location code that is applicable for the provider If a Code provider has multiple location codes assigned complete multiple entries with the same MPI and each different location code assigned to the provider G2 Code Qualifier Value submitted in the Provider G2 field The format of this field consists of a preloaded dropdown box with two selections The selections are as follows G2 Medica
232. eft Quadrant 01 Maxillary Area 30 Lower Left Quadrant 02 Mandibular Area 40 Lower Right Quadrant 09 Other Area of Oral Cavity L Left 10 Upper Right Quadrant R Right Placement Select the placement code from the drop down list or enter an appropriate value Indicator as specified Select I Initial Placement if the service requires an initial placement of a prosthetic Select R Replacement if the service requires a replacement of an existing prosthetic Diag Ptr Enter the field number of the Diagnosis Codes field on the Header 2 Screen that contains the detail diagnosis number that references the diagnosis that relates to this service This field will accept one numeric character Valid values are one 1 through eight 8 to refer to the header diagnosis codes Billed Enter the amount using a decimal point usually charged to the self paying public Amount for the service s provided If billing for multiple units multiply the usual charge by the number of units billed and enter that amount Zero 0 billed amount is a permitted value Units Enter the number of units provided to the recipient for the service being billed For example enter 1 1f one unit was provided to the recipient Zero 0 units is a permitted value Prior Enter the 2 digit month 2 digit day and 4 digit year the prosthetic being Placement replaced was originally placed on the recipient For example enter 10012015 if
233. egment enter the 2 digit month 2 digit day and 4 digit year in which the period of hospitalization began In the right segment enter the 2 digit month 2 digit day and 4 digit year in which the period of hospitalization ended Break the period of hospitalization out by month if the hospitalization overlaps two consecutive months If a claim for the month following the service month was previously approved for payment by MA and contained RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 185 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 periods of hospitalization include these dates of hospitalization in the hospitalization items The date of return to the facility is considered a facility day not a hospital day Condition Codes Condition codes are not used in Long Term Care billing Fields 1 4 Please leave this field blank Value Value codes are used to report drug deductions insurance Codes Amounts premiums and other medical expenses Value codes identify Fields 1 4 data of a monetary nature that is necessary for processing the form as required by the payer organization Each field is divided into two segments In the left segment of this field enter the value code as specified or select the value code from the segment s drop down list as described below 06 Medicare Blood Deductible 14 No Fault Auto Other 15 Workman s Compensation 16 PHS
234. egnancy Indicator DR Disaster Related Enter the street address Enter additional address information such as suite or apartment number Enter the City that corresponds with the street address Enter the two letter abbreviation for the state that corresponds with the city listed in the City field Enter the 9 digit zip code corresponding to the city and state listed in the City and State fields This field holds a maximum of 9 numeric characters Note If entering an NPI as the primary identifier you must use the correct Nine Digit Zip Code that you coordinated with Provider Enrollment for your legacy ID Nine Digit Provider ID plus Four Digit Service Location Code Enter the street address Enter additional address information such as suite or apartment number Enter the City that corresponds with the street address Enter the two letter abbreviation for the state that corresponds with the city listed in the City field Enter the 9 digit zip code corresponding to the city and state listed in the City and State fields This field holds a maximum of 9 numeric characters Note If entering an NPI as the primary identifier you must use the correct Nine Digit Zip Code that you coordinated with Provider Enrollment for your legacy August 31 2015 251 Version 4 00 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 ID Nine Digit Provider ID plus Four Di git Service Location Co
235. ehabilitation Facility 65 End Stage Renal Disease Treatment Facility 71 State of Local Public Health Clinic 72 Rural Health Clinic 81 Independent Laboratory 99 Other Unlisted Facility Select the procedure code from the drop down list or enter an appropriate value as specified The procedure code identifies the service that was rendered to the recipient Enter the 2 digit modifier for the procedure code entered in the Procedure field if the MA Program Fee Schedule indicates that the procedure code requires a modifier RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 258 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Units Enter the number of units provided to the recipient for the service being billed For example enter 1 if one unit was provided to the recipient Zero units is an appropriate value EPSDT Select the EPSDT code from the drop down list or enter an appropriate value as specified Select Y 1f the recipient is part of the Early Periodic Screening Diagnosis and Treatment EPSDT program Diag Ptr The field number of the Diagnosis Codes field on the Header 2 screen contains the detailed diagnosis number for the diagnosis that relates to this service Enter that field number here using one numeric character Basis of Select the basis code from the drop down list or enter an appropriate Measurement value as specified The basis code
236. elated to a Claim Use if the provider has a signed statement on file permitting the release of medical data to other organizations Select the appropriate assignment code from the drop down list or enter an appropriate value as specified RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 177 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Select Y Yes if the recipient or authorized person has authorized benefits to be assigned to the provider Select N No if the recipient or authorized person does not have authorized benefits to be assigned to the provider Select W for Not Applicable Not applicable for this claim Report Type Enter the appropriate code for the type of attachment submitted from the drop Code down list or enter an appropriate value as specified AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form CT Certification DA Dental Models DG Diagnostic Report DS Discharge Summary EB Explanation of Benefits MT Models NN Nursing Notes OB Operative Notes OZ Support Data for Claim PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PZ Physical Therpy Certification RB Radiology Films RR Radiology Reports RT Reports of Tests and Analysis Report Report Enter the appropriate code for the method of attachment transmission fro
237. eld Operating Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form First Name Operating physician s first name This field 1s automatically populated after you Operating select or enter an MPI number in the Provider ID Operating field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form MI Operating Operating physician s middle initial This field 1s automatically populated after you select or enter an MPI number in the Provider ID Operating field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 160 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 10 Complete PAT ig HP Provider Electronic Solutions 837 Institutional Inpatient a File Edit View Forms Tools Window Help DEXSHH0 l4 B SH Hk Total Charge P 0l Amount T Billed Amount IMT Services Patient ID Last Name First Name HI Date of Birth 00 00 0000 Delete Gender v Undo All Dare Recipient ID Last Mame First Hame Billed Amount Last Submit ree eie The Pat screen is added to the form 1f you selected Y in the Newborn Indicator field on the Header 5 screen Step 10 1 Click the Pat ta
238. eld identifies the recipient s third party insurance carrier This code must match the carrier code selected on the Other Insurance screen The list consists of the National Electronic Insurance Clearinghouse NEIC codes for insurance carrier Note If the third party insurance carrier paid 0 00 complete the Paid Date Amount field with the date of the third party insurance explanation of benefits EOB denial and the amount of 0 00 RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 139 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Name Step 9 1 Step 9 2 Step 10 Step 11 Step 12 Name of the recipient s third party insurance carrier This field is automatically populated after you select a carrier code in the Code field To add another claim adjustment line click Add sr Adj A new blank claim line is added to the screen Click on the new claim line and then enter the claim adjustment data in the appropriate data fields as described previously To copy the data from an existing claim adjustment line to a new claim line click on the existing claim line you want to copy and then click Copy Sry Adj A new claim line is added to the screen The new claim line has the same data as the existing claim line that you previously selected Edit the data in the new claim line Simply click on the new claim line and enter the changes in the appropriate fields To delet
239. elp leypa Slk ig 10 Eligibility Request Summary Report Batch Number Ooo Recipient Cardholder Doo Form Status O Submit Date 0070070000 Records selected 270 Eligibility Request Summary Report s 08 13 2015 ALL CLAIMS Recipient ID Last Name First Name 123456709 From DOS To BOS Last Submit Dt Status 0710 2013 071072013 1070872013 F LLL RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 320 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 7 Click Print to print the 270 Eligibility Request Summary Report Step 8 Click Glose to exit the 270 Eligibility Request Summary Report screen 11 3 276 Claim Status Detail Report You can generate a detail report for a Claim Status Request using the Provider Electronic Solutions software The detail report contains all the fields on the 276 Claim Status Request Form To generate a 276 Claim Status Request Detail Report perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select the 276 Claim Status option from the Detail Forms menu The 276 Claim Status Request Detail Report screen is displayed Step 2 Click OR to include all the requests in the summary report Step 3 Click OF when prompted by the box that advises you that all records will be selected A detail report is then generated and displayed on your screen To limit the type of request in the d
240. ence lists which are already built for you and preloaded during the installation process These pre loaded selection lists can still be edited and additional selections added Accessing building and editing reference lists is discussed in more detail later in this section This chart helps to determine when and how to build your reference lists for the forms you need to complete Although the chart provides suggestions on when to build a reference list keep in mind you need to choose the method for building reference lists that best suits your needs R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 41 PA PROMISe Provider Electronic Solutions Software User Manual Form us Request 37 Dental 37 Institutional Inpatient 837 Institutional Nursing Facility 37 Institutional Outpatient 37 Professional NCPDP Pharmacy Reference List Taxonomy 270 Provider Provider Location Code Provider Location Code Provider Location Code Provider Location Code Provider Location Code NCPDP Provider Version 4 00 o Pf Recipient ID Policy Holder Modifiers Recipient ID Revenue Policy Holder Recipient ID Revenue Policy Holder Recipient ID Revenue Policy Holder Recipient ID Policy Holder Modifiers NCPDP Recipient NDC RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 42 Procedure HCPCS Procedure HCPCS ICD10 Diagnosis Diagnosis ICD Proce
241. ent Select the Place Of Service code from the drop down list or enter an appropriate value as specified The Place Of Service code identifies the location where the service was performed The only Place Of Service fields accepted on an 837 Dental Claim are listed below 03 School 04 Homeless Shelter 11 Office Outpatient Clinic Independent Clinic 12 Patient s Home or Community 15 Mobile Unit 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room Hospital 24 Ambulatory Surgical Center SPU 25 Birthing Center 26 Military Treatment Center 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 35 Adult Living Care Facility 41 Ambulance Land 42 Ambulance Air or Water 50 Federally Qualified Health Center 51 Inpatient Psychiatric Facility 52 Psychiatric Facility Partial Hospitalization 53 Community Mental Health Center 54 Intermediate Care Facility Mentally Retarded 55 Residential Substance Abuse Treatment Facility R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 120 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 56 Psychiatric Residential Treatment Center 60 Mass Immunization Center 61 Comprehensive Inpatient Rehabilitation Facility 62 Comprehensive Outpatient Rehabilitation Facility 65 End Stage
242. ent ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form Recipient s date of birth This field 1s automatically populated after you select a Recipient number from the Recipient ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form Recipient s last name This field is automatically populated after you select a recipient number from the Recipient ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form Recipient s first name This field 1s automatically populated after you select a recipient number from the Recipient ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form Recipient s middle initial This field is automatically populated after you select a recipient number from the Recipient ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form Select the appropriate release code from the drop down list or enter an appropriate value as specified Select I Informed Consent to Release Medical Information Informed consent to release medical information for billing RAPA MMIS CMcElheny PE
243. enter Enter the 10 digit CHR DRG PSR admission certification number Enter the 10 digit Prior Authorization number if the service requires and has received a prior authorization Enter the 10 digit PSR number if admission to an acute care hospital a hospital SPU or an ambulatory surgical center ASC is elective Enter the 10 digit Admission Certification number for urgent or emergency admission to an acute care hospital SPU ASC or specialty hospital Enter the 10 digit authorization number for approved 1150 Administrative Waiver Services RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 202 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Patient Status Recipient s status on the last date of service billed on this claim Enter the appropriate 2 digit status code or select the status code from the drop down list or enter the appropriate value or enter an appropriate value as specified 01 Dischrgd to home or self care routine discharge 02 Dischrgd trnsfrrd to another hospital for inpatient care 03 Dischrgd transfrrd to skilled nursing facility 04 Dischrgd transfrrd to an intermediate care facility 05 Dischrgd transfrrd to another type of institution for inpatient care 07 Left against medical advice or discontinued care 20 Expired 30 Still a patient Referral Code Enter the referral number provided by a primary care case mana
244. eport 837 Institutional Inpatient Claims using the Provider Electronic Solutions software This detail report contains all the fields on the 837 Institutional Inpatient form To generate an 837 Institutional Inpatient Detail Report perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select the 837 Institutional Inpatient option from the Detail Forms drop down menu The 837 Institutional Inpatient Detail Report screen is displayed Step 2 Click OK to include all the Inpatient Claims in the detail report Step 3 Click OK when prompted by the box that advises you that all records will be selected A detailed report is generated and displayed on your screen To limit the type of Inpatient Claims in the detail report enter the appropriate report criteria into one or more of the following fields RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 328 Provider Electronic Solutions Software User Manual PA PROMISe Batch Number Limits the summary report to Inpatient Claims in a specific batch Enter the appropriate batch ID number in this field You can locate the Batch Numbers under the Resubmission option of the View Communication Log menu Recipient Limits the summary report to Inpatient Claims for the specified Cardholder ID recipient Enter the appropriate recipient ID in this field Form Status Limits the summary report to Inpatient Claims with th
245. equested for each field as described below RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 68 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Admit Source Enter the code that identifies the source of admission to the facility or Code choose the appropriate code from the drop down list as described below or enter an appropriate value as specified 1 Physician Referral 6 Transfer from Another 2 Clinic Referral 7 Emergency Room 3 HMO Referral 8 Court Law 4 Transfer from a Hospital 9 Information Not Available 5 Transfer from a Skilled A Transfer from a Rural Primary Nursing Facility Care Hospital These values are preloaded and are HIPAA compliant If any changes or modifications are required you are notified by DHS or HP Enterprise Services Description Enter the description of the Admit Source code Step 3 Click __ Save when all data entry fields are completed Step 4 Click __ Add and repeat steps 2 3 and 4 to add another Admit Source Code to the Admit Source reference list Step 5 Click __ Close to exit the Admit Source screen RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 69 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 8 8 Carrier Reference List The Carrier Reference List has been updated for this version of PES To complete the data entry fields needed to add
246. er letter sent to MA Step 4 Complete Header 2 Services ICD Version ICD10 Add Diagnosis Codes Copy Delete Undo All 5 Place Of Service Prior Authorization ar Patient Pay Amount Referral Code Billing Hote Contract Type Contract Code Contract Version Encounter Ind CH RecipientID LastName FirstName ff Billed Amount Last Submit Dt ICD Version Use the ICD 9 ICD10 Version for the code being submitted Each field can contain a specific ICD 9 CM ICD 10 CM PCS Codes Fields diagnosis code that relates to the recipient s visit The primary ICD 9 Diagnosis 1 12 CM ICD 10 CM PCS code must be entered in the first field RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 239 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Place of Select the appropriate place of service code from the drop down list Service or enter an appropriate value as specified This field identifies the location where the service was performed 03 School 53 Community Mental 04 Homeless Shelter Health Care 11 Office 54 Intermediate Care i2 Parents Home Facility Mentally Retarded i 55 Residential Substance 15 Mobile Unit H j i tal Abuse Treatment Facility isa Ga ospi j 56 Psychiatric Residential 22 Outpatient Hospital Treatment Center Non 23 Emergency Room Hospital JCHAO 24 Ambulatory Sur gi
247. es will also appear on the Claim 2 screen Each detail line contains the data fields described in this step Click on a detail line to access its data fields 00 Not Specified 1A Filled As is False Positive 1B Filled Prescription As is 1C Filled With Different Dose 1D Filled With Different Directions 1E Filled With Different Drug 1F Filled With Different Quantity 1G Filled With Prescriber Approval 1H Brand to Generic Change 1J Rx to OTC Change 1K Filled with Different Dosage Form 2A Prescription Not Filled 2B Not Filled Directions Clarified 3A Recommendation Accepted 3B Recommendation Not Accepted 3C Discontinued Drug 3D Regimen Changed 3E Therapy Changed 3F Cost Increased Acknowledged 3G Drug Therapy Unchanged 3H Follow Up Report 3J Patient Referral 3K Instructions Understood 3M Compliance Aid Provided 3N Medication Administered 4A Prescribed with ACK RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 283 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Complete Prescriber Total Charge Ot Amt Paid 00 BiledAmt M Details Prescriber Last Name FO First Name FO Address Phone Number Copy Ciy o ef l Cpl Delete Undo All Save Prescription Decimal Oty 000 Send First Name Billed Amt Last Submit Dt Las
248. etail report enter the appropriate report criteria into one or more of the following fields Batch Number Limits the detail report to requests in a specific batch Enter the appropriate batch ID number in this field You can locate the batch numbers under the Resubmission option of the View Communications Log menu Recipient Limits the detail report being requested to return information only Cardholder ID for the specified recipient Enter the appropriate recipient ID in this field Form Status Limits the detail report being requested to include only the claims with the specified form status Select the appropriate form status from this drop down list Submit Date Limits the detail report to requests transmitted on the specified date Enter the appropriate date in this field Step 4 Click OR after you enter the report criteria A summary report is generated and displayed on your screen RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 321 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Use the scroll bars located on the right side and bottom of the screen to view the entire report 5 276 Claim Status Request Detail Report Balch Number Recipient Cardholder I0 Form Status Submit Date pi roni Recods selected 276 Claim Status Request Detail Report Asot GohMdre015 ALL CLAIMS Provide IO Location Code 0001 Provider ID Code Qualifier 1 NPI 1609091 39 La
249. f 0 00 Resource code that identifies the third party insurance carrier This field is automatically populated after you select or enter a group number Information cannot be entered directly into this field If you need to add or edit information in this field access the Policy Holder Form Select the group number for the third party insurance from the drop down list or double click on the data entry portion of the field to add a reference list selection Name of the group or business that makes the insurance available to the insured person this is not the third party insurance carrier This field 1s automatically populated after you select or enter a Group Number Information cannot be entered directly into this field If you need to add or edit information in this field access the Policy Holder Form Policyholder s last name This field is automatically populated after you select or enter a group number Information cannot be entered directly into this field If you need to add or edit information in this field access the Policy Holder Form RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 165 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 First Name Policyholder s first name This field 1s automatically populated Policy Holder after you select or enter a group number Information cannot be entered directly into this field If you need to add or edit i
250. field This field is automatically populated with the correct information after an MPI number is selected in the Rendering Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Rendering provider s last name or organization name This field 1s automatically populated with the correct information after an MPI number is selected in the Rendering Provider ID field August 31 2015 247 Provider Electronic Solutions Software User Manual First Name Rendering Provider MI Rendering Provider Facility ID Service Facility Location Location Code Service Facility Location NPI Service Facility Location Facility Name Service Facility Location RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx PA PROMISe Version 4 00 Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Rendering provider s first name This field is automatically populated with the correct information after an MPI number is selected in the Rendering Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Rendering p
251. field access the Provider Form Provider ID Provider who rendered the service Select the 9 digit MPI number Rendering for the provider of service s from the drop down list or double Provider click on the data entry portion of the field to add a reference list selection Complete this field if a group s MA ID was entered on R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 208 Provider Electronic Solutions Software User Manual Location Code Rendering Provider NPI Rendering Provider Last Org Name Rendering Provider First Name Rendering Provider MI Rendering Provider Newborn Ind Other Insurance Indicator RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx PA PROMISe Version 4 00 Header 1 indicates that a group receives the payment instead of an individual provider Rendering provider s 4 digit service facility location number for the MPI number selected in the Referring Provider ID field This field 1s automatically populated with the correct information after an MPI number is selected in the Rendering Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Rendering provider s last name or organization name This field 1s
252. fies your logon password Use this password to verify the Password Web BBS Logon ID that you use to log on to submit claims HP Enterprise Services provides you with a Web BBS Password prior to submitting claims after you have registered using the PROMISe Transaction Certification Registration Form Note For security purposes when you use the Web method option your password expires every 30 days PES will prompt you to update your Web login password when it expires See Instructions for changing the Web Password below RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 18 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Submitter ID If you have a Master Provider Index MPI number PROMISe Legacy Numbers assigned by DHS enter that value in this field If you are a billing service or other entity that does not have an MPI number enter the same value that you entered in the BBS Logon ID field into this field Service Enter the 4 digit Service Location number associated with the MPI Location number in this field If you entered the BBS Logon ID value in the Submitter ID field enter XX XX in the Service Location field Submitter Identifies whether the user is a person or non person A person is Entity Type defined as an individual Pennsylvania Medical Assistance MA Qualifier provider A non person is defined as a group facility or billing Service Submitter Last name
253. from an existing detail line to a new detail line Step 12 A new detail line is added to the screen Step 13 The new detail line has the same data as the existing detail line you previously selected You can edit the data in the new detail line Step 14 Click on the new detail line to make changes to the appropriate fields Step 15 Click Delete Du to delete an existing detail line Step 16 The selected detail line is deleted Step 17 Click o Save to save the 270 Eligibility Request Step 18 Click Add to start another 270 Eligibility Request or Click Close to exit the 270 Eligibility Request form 9 2 Submit a 270 Eligibility Request The 270 Eligibility Request is submitted in either an interactive mode or a batch mode These modes are described in this section 9 2 1 Interactive Submission An interactive submission is when a single request is entered and a response is received back within a few minutes after the request is submitted Note PES provides a Web based Interactive communication method In order to use the Web BBS for Interactive claims choose W for Web B for BBS is no longer available on the Tools Options Web screen For instructions go to Section 5 1 Web Internet in the Provider Electronic Solutions Software User s Manual To submit an interactive 270 Eligibility Request perform the following steps Step 1 Complete the 270 Eligibility Request as directed in S
254. ftware User Manual Version 4 00 1G HP Provider Elecromeselenionen File Edit View Forms Tools Window Help DRX 9Ba Sl BA TSt Hm P 837 Institutional Inpatient Total Charge DT O Amount BT Billed Amount EEN Services Hdr 1 Hdr2 Hara Hdr4 Hdr5 Hare Hdr7 Hare Srv Revenue Code Units 0 Copy Basis of Measurement UN Billed Amount 00 Delete Undo All Save Add Srv Smt Revenue Code Billed Amount I Copy Srv Delete Srv Recipient ID Last Mame First Marne Billed Amount Last Submit Dt Revenue Code Enter the code that identifies a specific accommodation or ancillary service This field accepts a maximum of four numeric characters 0100 Facility Days 0183 Leave Days 0185 Hospital Days Units Enter the number of units provided to the recipient for the service being billed For example enter 1 if one unit was provided to the recipient Zero 0 units is a permitted value Basis of Select the basis code from the drop down list or enter an Measurement appropriate value as specified This field identifies the units in which a value is being expressed or the manner in which a measurement has been taken DA Days Institutional UN Unit Institutional and Professional Billed Amount Enter the usual charge to the self paying public for the service s provided using a decimal point If billing for multiple units multiply the usual charge by the number of units bille
255. g Provider s last name or the group name This field is automatically Name populated after you select or enter an MPI number in the Provider ID field Information cannot be entered directly into these fields to add or change information in these fields access the Provider List Form First Name Provider s first name This field is automatically populated after you select or enter an MPI number in the Provider ID field Provider ID Information cannot be entered directly into these fields to add or change information in these fields access the Provider List Form MI Recipient s middle initial This field is automatically populated after you select or enter a recipient number RAPA MMIS CMcElheny PES_ Manual_5010 4 00_ICD10 docx August 31 2015 108 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Recipient ID Medical Record Last Name First Name MI Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form Select the 10 digit recipient ID number from the drop down list or enter an appropriate value as specified Field is automatically populated once a recipient ID is selected Recipient s last name This field is automatically populated after you select or enter a Recipient number in the Recipient ID field Information cannot be entered directly into these fields to add or change information in t
256. ger Release of Select the appropriate release code from the drop down list or enter Medical Data an appropriate value as specified I Informed Consent to release Medical Information Informed consent to release medical information for conditions or diagnosis regulated by Federal statutes Y Yes Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Provider has a signed statement on file that permits the release of medical data to other organizations Benefits Select the appropriate assignment code from the drop down list or Assignment enter an appropriate value as specified Y Recipient or authorized person has authorized that benefits be assigned to the provider N Recipient or authorized person has not authorized that benefits be assigned to the provider W Not Applicable Report Type Enter the appropriate code for the type of attachment submitted or Code enter an appropriate value as specified AS Admission Summary NN Nursing Notes B2 Prescription OB Operative Notes B3 Physician Order OZ Support Data for Claim B4 Referral Form PN Physical Therapy Notes CT Certification RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 203 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 DA Dental Models PO Prosthetics or Orthotics DG Diagnostic Report Notes DS Discharge Summary PZ Phys
257. git service facility location number for the MPI Code number selected in the Referring Provider ID field This field is Referring automatically populated with the correct information after an MPI Provider number is selected in the Referring Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form NPI Enter the NPI National Provider Identifier Numeric 10 digit identifier Referring consisting of 9 numbers plus a check digit in the 10 position Provider RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 211 Provider Electronic Solutions Software User Manual Last Org Name Referring Provider First Name Referring Provider Middle Initial Referring Provider Emergenc y Indicator Auto Accident State Patient Paid Amount RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx PA PROMISe Version 4 00 Referring provider s last name or organization name This field is automatically populated with the correct information after an MPI number is selected in the Referring Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Referring provider s first name This field is automatically populated with the correct information after an MPI number is selected in the Referring Provider
258. h 2 digit day and 4 digit year on which the recipient last received service under this claim For example enter 10012015 if the date was October 1 2015 Type Of Enter the type of bill code or enter the appropriate value based on your Bill facility and bill type Billed Enter the amount using a decimal point usually charged to the self Amount paying public for the service s provided If billing for multiple units multiply the usual charge by the number of units billed and enter that amount Zero 0 billed amount is a permitted value Claim Enter the Original ICN as printed on the RA RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 110 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Account Enter the account number assigned to the recipient by the provider for the service that was performed This information is returned on the RA Statement A unique account number is required for each claim submitted to be able to obtain claim status information If the same account number is used for each claim submitted when a claim status request is sent the claim status is reported on all claims with that account number Claim status can only be obtained for claims submitted after the implementation of PA PROMISe Step 4 Click Save zave to save the form Step 5 Click Add _ d to start another claim status inquiry or Step 6 Click Close AEE to exit the 276 Claim St
259. harmacy Summary Report screen 11 15 NCPDP Pharmacy Eligibility Detail Report You can generate a detail report for the NCPDP Pharmacy Eligibility Inquiries using the Provider Electronic Solutions software This detail report contains all the fields on the NCPDP Pharmacy Eligibility Form To generate an NCPDP Pharmacy Eligibility Detail Report perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select the NCPDP Pharmacy Eligibility option from the Detail Forms drop down menu The NCPDP Pharmacy Eligibility Detail Report screen is displayed Step 2 Click OK to include all the Pharmacy Eligibility Inquires in the detail report Step 3 Click OK when prompted by the box that advises you that all records will be selected A detailed report is generated and displayed on your screen RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 343 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 To limit the type of Pharmacy Eligibility Inquires in the detail report enter the appropriate report criteria into one or more of the following fields Batch Limits the summary report to Pharmacy Eligibility Inquires in a specific Number batch Enter the appropriate batch ID number in this field You can locate the batch numbers under the Resubmission option of the View Communication Log menu Recipient Limits the summary report to Pharmacy E
260. he OON provider ID for providers that operate outside of Pennsylvania s MA network Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 96 Provider Electronic Solutions Software User Manual Last Org Name First Name Recipient ID Card Issue Number ID Qualifier Recipient SSN Recipient DOB Medical Record Account Last Name First Name MI Procedure NDC RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx PA PROMISe Version 4 00 Provider s last name This field is automatically populated after you select a provider number from the Provider ID field Provider s first name This field 1s automatically populated after you select a provider number from the Provider ID field Select the 10 digit recipient number from the drop down list or enter an appropriate value as specified This field is found on the recipient s Pennsylvania ACCESS card Enter the recipient s 2 digit card issue number which is located on the recipient s Pennsylvania ACCESS card Required if using recipient ID for eligibility This field contains the qualifier code for the ID Number assigned to the policy holder by the carrier The default 1s MI for Medicaid recipients ID Contains the recipient s 9 digit social security number This field is a
261. he Resubmission option of the View Communication Log menu Limits the summary report of Dental Claims being requested for the specified recipient Enter the appropriate recipient ID in this field Limits the summary report to Dental Claims with the specified form Status Select the appropriate form status from this drop down list Limits the summary report of Dental Claims transmitted on the specified date Enter the appropriate date in this field Step 4 After you enter the report criteria click OF k The summary report is generated and displayed on your screen R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 327 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Use the scroll bars located on the right side and bottom of the screen to view the entire report ap HP Previder Electron Solutions E vouthons my File Forns Lists Reports Tools Tools Window Help jo Vb a 5 OK ia 69 837 Dental Summary Report Batch Number Recipient Cardholder Ip Fom Status Submit Date Puriri Reco selected EP Summ ary Re port ALL CLAMS Recipient ID Lact Hame Fasi Name LESTER Billed Amount Lact Submit Dt Rv aS Procedure porz l 20 00 200 Step 6 Click Print to print the 837 Dental Summary Reports Step 7 Click _ Close to exit the 837 Dental Summary Report screen 11 7 837 Institutional Inpatient Detail Report You can generate a detail r
262. he Upgrade using the following steps 1 On the Website Do not use the links below Click on one of the following Download the software upgrade 4 00 Download the software upgrade 3 61 Download the software upgrade 3 60 2 You will be prompted to save the file to a location on your computer similarly to the picture below Click on the sme button F Ue Download Do you want to open or save this file Name eagQ0HC0 ap 2 Type Wrzo Fie 11 0MB Frome peomise dow state paus Deen sw i lV Awa atk before opening this type of fle While files from the Internet can be usebul some fles can poterhaly harm your computer If you do not trust the source do not open or save this fle What s the risk RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 3 Browse to the location you wish to save the file You need to save the file to the upgrades folder where you installed your database file similar to the picture below ex C papromise upgrades Click _ sve to download the file and save it to the location you indicated 4 Once the file successfully downloads you will need to apply the upgrade To do this go to the Start Menu Programs PA PROMISe Provider Electronic Solutions Software and click on the Upgrades folder This will launch the upgrade program similar to the picture below 5 The following message will displ
263. he mouse To see a name or brief description of each shortcut icon move the mouse arrow over the icon hover but do not click the mouse The description will appear just below the shortcut icon at which you are pointing The Toolbar on the Provider Electronic Solutions software Main Screen is shown below below Lists Reports Tools Security Window Help R PA MMIS CMcElheny PES_Manual_ 5010 4 00 _ICD10 docx August 31 2015 35 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 The shortcut icons on the Provider Electronic Solutions software main screen toolbar are described here Calls the 270 Eligibility Request Form Calls the 276 Claim Status Inquiry Form Calls the 837 Dental Form Calls the 837 Institutional Inpatient Form Calls the 837 Institutional Nursing Home Form 837 Institutional Outpatient Calls the 837 Institutional Outpatient Form 837 Professional Calls the 837 Professional Form NCPDP Pharmacy Calls the NCPDP Pharmacy Form NCPDP Pharmacy Calls the NCPDP Pharmacy Eligibility Form Eligibility NCPDP Pharmacy Reversal Calls the NCPDP Pharmacy Reversal Form Closes the Provider Electronic Solutions software RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 36 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Note The toolbar on the various forms is different from the toolbar on the Provider Electron
264. he referring Provider emergency indicator patient paid value codes and contract information Accesses the screen that contains patient information used for newborns and is accessed by selecting Y in the Newborn Indicator on Hdr 3 Accesses the screen that contains information about other insurance coverage It is accessed by selecting Y in the OI Indicator on Hdr 3 Accesses the screen that contains information about Medicare coverage It is accessed by selecting Y in the Crossover Indicator on Hdr 3 Accesses the screen that contains service information Accesses the screen that contains additional attending and operating provider information Accesses the screen that contains service adjustment indicator Accesses the screen that contains service adjustment information For additional information on a particular field highlight the field with your mouse and press F1 To create an Institutional Outpatient Claim perform the following steps Step 1 From the Provider Electronic Solutions software main screen access the 837 Institutional Outpatient Form in one of two ways Click 837 Institutional Outpatient Shortcut icon on the Toolbar or Select the 837 Institutional Outpatient Option from the Forms drop down menu RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 198 PA PROMISe Provider Electronic Solutions Software User Manual 2 HP Provider Electronic Solutions Forms Communicati
265. hese fields access the Recipient List Form Recipient s first name This field is automatically populated after you select or enter a recipient number in the Recipient ID field Information cannot be entered directly into these fields to add or change information in these fields access the Recipient List Form Recipient s middle initial This field is automatically populated after you select or enter a recipient number Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 109 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 3 Complete Header 2 Ag HP Provider Electronic Solutions DY a mamme File Edit View Forms Tools Window Help DEX Balel ealervens Er LLM 16 Claim Status Inquiry Request gt o E ese Hdri Hdr2 From DOS 00 00 0000 To DOS 00 00 0000 Copy Type OF Bill Billed Amount sD __Delete _ Cam l oo 2 OOC S _ Undo All All Account Save Send From Enter the 2 digit month 2 digit day and 4 digit year on which the DOS recipient first received service under this claim For example enter 10012015 if the date was October 1 2015 If the same service was provided on a single day enter the date of service in both the From DOS and To DOS fields To DOS Enter the 2 digit mont
266. iate value as specified This field identifies the units in which a value is being expressed or the manner in which a measurement was taken DA Days Institutional UN Unit Institutional and Professional Enter the 2 digit modifier for the procedure code entered in the Procedure field if the MA Program Fee Schedule indicates that the procedure code requires a modifier Enter the prescription number that identifies the prescription If the prescription number is less than 12 numeric characters add zeroes to the beginning of the prescription number to make it equal to 12 characters ex 000000001234 Note Required if being used by Dispensing Provider Enter the refill number if a prescription is refilled This field accepts one numeric character Note Required if being used by Dispensing Provider Date Expressed in Format CCY YMMDD Required when a drug is billed for this line and a prescription was written Note Required if being used by Dispensing Provider If dispensing medication enter the NDC number in this field using the 5 4 2 format Zero fill to complete the 5 4 2 format Enter the zeroes in the beginning of the segment Ex 00123 0123 01 Dashes are not required in the field but are shown for clarity If you are dispensing medication you will need to create a separate claim for the administration procedure Note Required if being used by Dispensing Provider The actual count of Milliliters Grams or Unit
267. ibility 8 Delay in Eligibility Determination Unknown or Unavailable 9 Original Claim Rejected or Denied due 2 Litigation to a Reason Unrelated to the Billing 3 Authorization Delays Limitation Rules RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 152 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 4 Delay in Certifying 10 Administration Delay in the Prior Provider Authorization Process 5 Delay in Supplying Billing 11 Other Forms 6 Delay in Delivery of Custom Made Appliances 7 Third Party Processing Delay Emergency Select the appropriate Emergency Indicator code from the drop down list or Indicator enter an appropriate value as specified Select 3 if the service provided was in response to an emergency Billing Note This field pertains to information related to visit codes and additional information required to adjudicate MA claims Enter the following codes if they apply Multiple codes should be entered in one string for example VCO9QSB If the This means Then Enter visit code S 09 Services rendered to a VCO09 pregnant woman Dental only 10 Services rendered to an LTC VC10 or a state mental hospital resident 11 Provider attempted but was vcll unsuccessful in collecting a co payment QSB If the provider is a Qualified QSB Small Business EPSDT If the claim involved EPSDT referral information any of the following
268. ibility Inquires for the ID specified recipient Enter the appropriate recipient ID in this field Form Limits the summary report to Pharmacy Eligibility Inquires with the Status specified form status Select the appropriate form status from this drop down list Submit Limits the summary report to Pharmacy Eligibility Inquires transmitted Date on the specified date Enter the appropriate date in this field Step 4 After you enter the report criteria click 0K The summary report is generated and displayed on your screen R PA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 346 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Use the scroll bars located on the right side and bottom of the screen to view the entire report 6 HP Provider Electronic Solutions File Forms lists Reports Tools Window Help ever mh ado kK S G MCPDP Pharmacy Eligibility Summary Report Batch Number Recipient Cardholder IDE Form Status Submit Date Dowo Records sclecied Dy AS Or 08 19 2015 ALL CLAIMS Cardholder ID Last Name First Hame Dale Of Service Last Subm Dt Slatus TESTERS BAAS Step 6 Click Print to print the NCPDP Pharmacy Eligibility Summary Report Step 7 Click Close to exit the NCPDP Pharmacy Eligibility Summary Report screen 11 17 NCPDP Pharmacy Reversal Detail Report You can generate a detail report for the NCPDP Pharmacy Reversal Req
269. ic Solutions software main screen The toolbar on the various form windows 1s Shown here and on the next screen shot DRX JHE Eb E47 Blk G HF Provider Electronic Solutions File Edit View Forms Tools Window Help JDBX VHA e ealsrRs ley LLM 2 6 Claim Status Inquiry Request Hdr 1 Hdr2 Provider ID cama Location Code HPI Delete Last Org Name First Name bil Undo All Recipient ID Hedical Record it Cave Last Name First Name Send Shortcut icons on the forms toolbar are explained here Icon Shortcut Description Form Name Add Form Saves the existing form and calls up a new blank form I Delete Form Deletes the existing form Undo All Reverses all of the changes done to the existing form since the form was last saved Saves the existing form RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 37 Copy Form Makes a copy of the existing form PA PROMISe Provider Electronic Solutions Software User Manual ii Version4 00 Electronic Solutions Software User Manual Version 4 00 Shortcut Description Form Name Transmits the existing form for processing Print Form Can only be accessed from one of the various form screens Selecting the print icon will automatically create a report and lets you print the report that was automatically created Cut Deletes the highlighted data and places a copy of the data on the clipboard so that it can be pasted into
270. ical Therapy Certification EB Explanation of Benefits MT Models RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report Enter the appropriate code for the method of attachment Transmission transmission Code AA Available by request at Provider site BM By Mail EL Electronically Only EM E Mail FT File Transfer FX By Fax Attachment Enter the up to 10 digit attachment control number obtained from Control the PROMISe web site This number is used when a paper Number attachment is required by MA to cross reference the paper attachment with the electronic claim This number must also be written on the cover letter sent to MA RAPA MMIS CMcElheny PES_Manual_50104 00_ICD10 docx i asi tst lt OW August 81 2015 204 Provider Electronic Solutions Software User Manual Step 3 PA PROMISe Version 4 00 Complete Header 2 ig HP Provider Electronic Solutions File Edit View Forms Tools Window Help DRX GBala 4 ea 804 8 h Ta 837 Institutional Outpatient oe ee Total Charge 999i O1 Amount NT Billed Amount MT Services ICD Yersion a i pein modes A Sa F a I Reason for Visit Diagnosis Codes Principal Diagnosis Codes Other Diagnosis Codes E Code Diagnosis Codes RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx CD Version Add Copy Delete Undo All JAYE Diagnosi
271. ical center or a renal dialysis center This field 1s automatically populated with the correct August 31 2015 248 Provider Electronic Solutions Software User Manual Provider ID Supervising Provider Location Code Supervising Provider NPI Supervising Provider Last Org Name Supervising Provider First Name Supervising Provider RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx PA PROMISe Version 4 00 information after an MPI number is selected in the Facility ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Select the 9 digit MPI number for the provider that the claim will be paid under billing provider from the drop down list or double click on the data entry portion of the field to add a reference list selection Required when the rendering provider is supervised by a physician or dentist Individual last name or organizational name 4 digit location code associated with the MPI number selected in the Provider ID field This field is automatically populated after you select or enter an MPI number in the Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Required when the rendering provider is supervised by a physician or dentist Enter the NPI National Provider Identifier Numeric
272. id Provider Number 0B Medical License Number If you select Medical License Number OB as the G2 Code Qualifier no Service Location code is required Entity Type Qualifier Identifies whether the information entered in this reference list selection represents a group facility or individual To complete this field choose one of the two selections listed in the preloaded dropdown box The selections are as follows 1 Person Indicates that the information entered for this reference list selection relates to an individual provider 2 Non Person Indicates that the information being entered for this reference list selection relates to a group or facility Last Org Name Enter the individual provider s last name or the business name of a group facility in this field First Name Enter the individual provider s first name This field is only completed when the Entity Type Qualifier field has been populated with a selection of 1 Person MI Enter the individual provider s middle initial This field is only completed when the Entity Type Qualifier field has been populated RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 61 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 with a selection of 1 Person This field holds a maximum of 1 alpha character SSN Tax Enter the individual provider s 9 digit social security number or Tax ID ID number Do not us
273. identifies the units in which a value is being expressed or the manner in which a measurement has been taken MJ Minutes Professional UN Unit Institutional and Professional Billed Enter the usual charge to the self paying public for the service s Amount provided using a decimal point If billing for multiple units multiply the usual charge by the number of units billed and enter that amount A zero billed amount is an appropriate value CLIA Enter the CLIA Number that identifies the certified facility that Number performed the CLIA covered laboratory services This field is required for any laboratory that performs tests covered by the CLIA Act Prescription Enter the prescription number that identifies the prescription If the Number prescription number is less than 12 numeric characters add zeroes to the beginning of the prescription number to make it equal to 12 characters ex 000000001234 Note Required if being used by Dispensing Provider Refill Enter the refill number if a prescription is refilled This field accepts Number one numeric character Note Required if being used by Dispensing Provider Prescription Date Expressed in Format CCY YMMDD Required when a drug is Date billed for this line and a prescription was written Note Required if being used by Dispensing Provider R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 259 PA PROMISe Provider Electronic Solutions Sof
274. ider Electronic Solutions Software User Manual Version 4 00 AM Automotive Medical VA Veteran Administration BL Blue Cross Blue Shield Plan CH CHAMPUS WC Workers Paid Date Amount MCO ICN Carrier Code Policy Holder Group Number Policy Holder Group Name Policy Holder Last Name Policy Holder Compensation Health Claim ZZ Mutually Defined Enter the date on which the other insurance company paid against the claim Enter the date in a 2 digit month 2 digit date and 4 digit year format Enter the amount paid by the Other Insurance carrier An amount of zero 0 may be entered Negative amounts are not allowed on 837 claims The MCO ICN field contains the internal claim number assigned to the claim when the managed care organization processed the claim from a provider Consolidated Community Reporting for OMHSAS CCR submitters must enter a MCO ICN Note The MCO ICN field is activated when RP is indicated on Hdr 2 AND has a payer on the OI tab with Claim Filing Indicator code HM Without these conditions being met the MCO ICN field will remain disabled Select the carrier code associated with the other insurance coverage from the drop down list Group number associated with the other insurance coverage This field is automatically populated when a carrier code 1s selected Information cannot be entered directly into this field If you need to add or edit information in this field
275. ied 1 Physician Referral 2 Clinic Referral 3 HMO Referral 4 Transfer from a Hospital 5 Transfer from a Skilled Nursing Facility 6 Transfer from Another Healthcare Facility 7 Emergency Room 8 Court Law 9 Information Not Available A Transfer from a Rural Primary Care Hospital From DOS Enter the 2 digit month 2 digit day and 4 digit year on which the resident first received service under this claim For example enter 10012015 if the date was October 1 2015 If the same service was provided on consecutive days enter the first day of the service in this field and the last day of service in the To DOS field If you bill for a service that was provided on only one day complete the From DOS field with the date of service and press the Tab key The same date is populated automatically in the To DOS field To DOS Enter the 2 digit month 2 digit day and 4 digit year on which the resident last received service under this claim For example enter 10312015 if the date was October 31 2015 The From DOS and To DOS should equal Covered Days Non covered Days Co insurance Days Full Medicare Days RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 180 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Discharge Time Enter the hour during which the patient was discharged Enter the Covered Non Covered Co insurance Provider ID
276. ient s zip code Enter all 9 digits Email Patient s Email address Address Phone Patient s phone number include the area code Step 2 2 Click the Claim 1 tab to access the Claim 1 screen The Claim 1 screen is displayed Step 3 Complete Claim 1 R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 274 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Pharmacy ecu Total Charge Amt Paid Billed Amt Details Header Patient Prescriber Coupon Clinical 1 Clinical 2 Prescriber ID Prescrber ID Qualifier o Pharmacy Type 1 Add Ax Service it Rx 7 Service Qualifier E Authorized Refills D Copy HDC Service ID HDC 7 Service Qualifier 03 Delet Quantity Dispensed OU Hew Refill D Days Supply ans Compound Ind i Dispense As Written Date Prescribed 00 00 0000 Undo All Other Coverage Code jo Usual and Customary Charge OU Add Dtl Jays Prescription Decimal Oty O00 Send Copy Du Delete Dtl Cardholder ID Dare EENE ERINETE Billed Amt Print Close Prescriber ID Enter the 8 or 9 character prescriber s license number The formats for medical license numbers are AAXXXXXXA AAXXXXXX or AAAXXXXXX where A is an alpha character and X is a numeric character Prescriber ID Qualifier code for the prescriber ID number The qualifier code must Qualifier always be 08 to indicate that the state license number has been en
277. ies the current claim Copied information appears in the data entry screen Note The original claim is not altered by any changes made to the copy Delete Delete Deletes the current claim or reference list selection You are prompted to confirm the deletion Click the Yes Button to delete the claim or reference list selection Undo All Undo Reverses all changes made to the current claim or reference list All selection since the last time you saved the claim or reference list selection Save Save Saves data entered in the current claim or reference list selection When saving a claim or reference list selection the data is evaluated or edited for completeness If the data is determined to be incorrect a list of errors is presented for correction After you save a claim or reference list selection the claim or reference list selection status is updated and displayed in the lookup window located at the bottom of the form window Send Send Send button utilizes the Interactive Submission functionality An interactive submission is when a single request is entered and a response is received back within a few minutes after the request is submitted Find Locates specific claims or a reference list selection from the list in the lookup window R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 39 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Print Print Creates a report of
278. im Status Request e 277 Claim Status Response e 270 Eligibility Request e 271 Eligibility Request Response This version of the Provider Electronic Solutions software was released for PA PROMISe August 2015 Please take a few moments and read the portions of this user manual that pertain to your type of billing A number of changes have been made to the billing procedures forms and fields These changes are explained in the form completion sections Also please note that the completion information given in this manual does not guarantee a claim s payment during adjudication Please obtain completion instructions from the Pennsylvania Medical Assistance Provider Inquiry units Contact information can be found in Section 14 R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 2 System Requirements The Provider Electronic Solutions software requires the following system requirements before it can be installed on a PC System Requirements for PES Provider Electronic Solutions Intel Core 13 2100 or AMD Phenom II X4 980 Pentium II BE Microsoft Windows 2000 or Windows XP Microsoft Internet Explorer 8 0 or higher 100 Megabytes Free Hard Drive Space 800 X 600 Resolution Using the WEB Option LAN Office Using the WEB Option LAN Office Network Broadband DSL cable modem or Network Broadband DSL cable modem or T1 T1
279. in these fields access the Provider List Form Provider s middle initial This field 1s automatically populated after you select or enter an MPI number in the Provider ID field Information cannot be entered directly into these fields to add or change information in these fields access the Provider List Form Select the recipient s 10 digit recipient number For additional information on the Recipient ID field refer to the Complete a Recipient reference list heading found in Section 8 of the Provider Electronic Solutions software RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 115 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Last Name First Name MI Release of Medical Data Account Number Benefits Assignment User s Guide Information cannot be entered directly into these fields to add or change information in these fields access the Recipient List Form Recipient s last name This field 1s automatically populated after you select or enter a Recipient number in the Recipient ID field Information cannot be entered directly into these fields to add or change information in these fields access the Recipient List Form Recipient s first name This field is automatically populated after you select or enter a recipient number in the Recipient ID field Information cannot be entered directly into these fields to add or change information in
280. information on a particular field highlight the field with your mouse and press F1 To create a pharmacy eligibility inquiry perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software access the NCPDP Pharmacy Eligibility Form one of these two ways a Rx Eligibility Shortcut icon on the Toolbar or Select the NCPDP Pharmacy Eligibility option from the Forms drop down menu or enter an appropriate value as specified RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 296 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 g HP Provider Electronic Solutions Forms Communication Lists Reports Tools Security Window Help 10 Eligibility Request 16 Claim Status Request 63 Dental 63 7 Institutional Inpatient amp 37 Institutional Nursing Facility 63 Institutional Outpatient 63 Professional NCPDP Pharmacy NCPDP Pharmacy Eligibility NCPDP Pharmacy Reversal Step 2 Complete Pharmacy Eligibility T a a Provider IB Location Code HPI Date Of Service Jon 00 0000 Provider ID Code Qualifier jos Copy Delete CardHolder ID Last Name First Hame ae Undo All care Send Cardholder ID LastName FirstName Date Of Service Last Submit Dt cw __ ba DA S s T Ra _ me When you choose a selection from a drop down list or enter an appropriate value as specified many of the field
281. ing code of MB and the Payer Responsibility is not P Primary Select the appropriate value from the dropdown box or enter an appropriate value as specified that identifies the type of insurance listed 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End Stage Renal Disease in the Mandated Coordination Period with an Employer s Group Health Plan 14 Medicare Secondary No fault Insurance including Auto is Primary 15 Medicare Secondary Worker s Compensation 16 Medicare Secondary Public Health Service PHS or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran s Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan LGHP 47 Medicare Secondary Other Liability Insurance is Primary To add an additional other insurance line click AddOL The software adds a new blank service line to the screen Click on the new Service line and then enter the other insurance data in the appropriate data fields To copy data from an existing other insurance line to a new service line click the existing service line that you want to copy and then click Copy Ul The software adds a new service line to the screen The new service line has the same data as the existing service line that you previously selected Edit the data in the new service line Click the new service line and e
282. ing service line Step 11 8 The selected service line is deleted Step 12 Complete Service 3 EJ 837 Professional Total Charge ii 0l Amount Sil Billed Amount ill Services Add Copy Service Facility Location Delete Facility ID Location Code ei Undo All Facility Hame i Recipient D Last Marne Provider ID If the rendering provider is different on the service line than the Rendering rendering provider on the claim Provider Select the 9 digit MPI number from the drop down box You can also double click in the data entry area in the field to add a reference list selection RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 263 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Location Code Rendering Provider NPI Rendering Provider Last Org Name First Name Middle Initial Facility ID Service Facility Location Location Code Provider s 4 digit service location code associated with the MPI number selected in the Provider ID field This field is automatically populated when an MPI number is selected Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Last name of the provider indicate
283. ions Software you will need to register at the PROMISe Transaction Certification Registration Form link below However you will not need to submit testing for HIPAA PROMISe certification RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 with HP Enterprise Services http www dhs state pa us provider promise certification index htm 5 2 Modem is no longer available 5 3 Batch Screen The Batch screen contains information related to submitting batch files To access the Batch screen Step 1 Click the Batch tab in the Options box Comon _ i Modem Web Batch Interactive Carrier Faer Processor Retention Logon ID Password Submitter ID Location Code Submitter Entity Type Qualifier Submitter Last Org Hame Submitter First Name Contact Hame Contact Phone Step 2 Enter the data requested for each field as described here Web BBS ID code assigned to you This code is required for batch submission Logon ID HP Enterprise Services provides you with a Production Web BBS Logon ID prior to submission of a file After obtaining the Provider Electronic Solutions Software you will need to register using the PROMISe Transaction Certification Registration Form However you will not need to submit testing for HIPAA PROMISe certification with HP Enterprise Services Web BBS Identi
284. is Employment A4 Family Planning Related A7 Induced Abortion 03 Patient Covered by Danger to Life Insurance Not Reflected Here A8 Inducted Abortion 05 Lien Has Been Filed Victim Rape incest 77 Payment was accepted AI Sterilization as payment in full B3 Pregnancy Indicator Al EPSDT CHAP DR Disaster Related A3 Special Federal Funding Description Enter the description of the condition code These values are preloaded and are HIPAA compliant If any changes or modifications need to be made to these values you will be notified by DHS or HP Enterprise Services Step 3 Click Save when all data entry fields are completed RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 72 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 4 Click o Add and repeat steps 2 3 and 4 to add another condition code to the condition code reference list Step 5 Click Cose to exit the Condition Code screen 8 10 Diagnosis Reference List Diagnosis List To complete the data entry fields needed to add or edit a Diagnosis reference list selection perform the following steps Step 1 Click Lists Diagnosis to access the Diagnosis reference list ig HP Provider Electronic Solutions F Sas a _ File Edit View Forms Lists Tools Window Help 3 xe mlel B SA14 E T Gi Diagnosis Add Diagnosis Code Description
285. ity function that allows an administrator to do the following e Create Multiple User IDs for the software e Assign Passwords to the User IDs e Assign Authorization or Access to users e Monitor User ID access to the system It is strongly recommended that all users add at least one additional Administrator level ID and password to the software Adding an administrator level ID ensures that if there is a problem with accessing the software a known User ID and password value can be used to access the system Note The default User ID pes admin and default password hp pes should only be used for the initial set up of the program and for technical support if needed 13 1 Add Additional Users To add another user to the Provider Electronic Solutions software perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select Security Maintenance from the Security Menu Step 2 The Security Maintenance screen is displayed Ag HP Provider Electronic Solutions Application User ID Password Authorization Level User ID Password Authorization Level Last Used 08711715 05 29 16 000 00 00 00 00 Step 3 Enter a user ID in the User ID field User IDs must be longer than five characters and are case sensitive RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 364 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step
286. k Cose to exit the Provider screen 8 4 Recipient Reference List To complete the data entry fields needed to add or edit a Recipient reference list perform the following steps RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 63 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 1 Click Lists Recipient to access the Recipient reference list IY HP Provider Electronic Solutions _ Sa File Edit View Forms Lists Tools Window Help _ Ux VHl el Ba s72 a T Recipient ID ID Qualifier MI Recipient SSN Medical Record Delete Last Name First Name Ml E Recipient DOB 00 00 0000 Gender Umo dell Recipient Address AAA a_i Save Line 1 Line 2 Find Print 1112345671 TESTER fade 23 TESTER Close Step 2 Enter the data requested for each field as described below Recipient Enter the recipient s 10 digit MA number which is found on their ID Pennsylvania ACCESS card D I Choose the appropriate selection from the drop down box or enter an Qualifier appropriate value as specified MI Member ID Indicates the recipient s MA number was placed in the Recipient ID field Medical Enter the recipient s medical record number as assigned by the provider s Record office This information does not appear on the claim or RA statement Number however
287. k Lists Type of Bill to access the Type of Bill reference list Ap HF Provider Electronic Solutions File Edit View Forms Lists Tools Window Help 5 x valel 4 Basa mk 6 Type Of Bill Type Of Bill Description Add Delete Undo All Dare Type OF Bill Description Find Inpatient Zeroo Pay Claim Inpatient Admit Through Discharge Claim Inpatient Interim First Claim Inpatient Interim Continuing Claim Inpatient Interim Last Claim Inpatient Replacement of Prior Claim Inpatient Yod Cancel Prior Claim Print RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 88 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 2 Enter the data requested for each field as described below Type of Bill Code Form Name 837 Institutional Inpatient 837 Institutional Nursing Facility County and General Nursing Facilities State Mental Hospitals 837 Institutional Outpatient Outpatient Hospital 837 Institutional Outpatient Hospital Special Treatment Room 837 Institutional Outpatient Ambulatory Surgical Center Enter the code that identifies the type of bill or choose the appropriate code from the drop down list as described below or enter an appropriate value as specified Type of Bill Codes 110 Zero Payment Zero Claim 111 Admit Through Discharge Claim
288. l Outpatient o ee Total Charge 9 O1 Amount FT Billed Amount NINN Services Add Release of Medical Data Benefits Assignment Y Payer Responsibility _________ Claim Filing Ind Code Copy Paid Date Amount 00 00 0000 D0 HCO ICN Policy Holder Carrier Code Group it Group Name Undo All Last Name First Name Gaye Add Ol Carer Code Group GroupName Last Name Copy Ol Delete Ol Recipient ID f Last Name Io FirstName Billed Amount Last Submit Dt Delete Step 7 1 To access the OI tab select Y in the Other Insurance field Access this tab when the recipient has Other Insurance information Release of Select the release code from the drop down list or enter an Medical Data appropriate value as specified Select I Informed Consent to Release Medical Information conditions or diagnosis regulated by federal statutes Select Y Yes Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a claim If the provider has a signed statement on file permitting the release of medical data to other organizations RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 217 PA PROMISe Provider Electronic Solutions Software User Manual Benefits Assignment Payer Responsibility Claim Filing Indicator Code Version 4 00 Select the assignment code from the drop down list or enter an appropriate value as specified
289. lank service line is added to the screen that has the same data as the previously selected line Edit the data in the new service line by clicking on the new line then make changes to the appropriate fields To delete an existing other insurance line click on the service line you want to delete and then click Delete OI The selected service line is deleted R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 220 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 8 Complete Crossover Tp 837 Institutional Outpatient o te Total Charge PI Ol Amount DT Billed Amount II Services Add M Reason Codes Amts Release of Medical Data 7 Benefits Assignment E 7 1 Hi Claim Filing Ind Code MB Adjustment Group Cd 2 mmm Ls Delete Paper Responsibility Full Medicare Days 3 00 Medicare ICN Paid Amount lo O00 Paid Date 00 00 0000 Undo All Policy Holder coe Carrier Code Last N iiai Name i s R Type Code m Copy LastName FirstName Billed Amount Last Submit Ot Status Step 8 1 To access the Crossover tab select Y in the Crossover Ind field on Header 3 Release of Select the release code from the drop down list or enter an Medical Data appropriate value as specified Select I Select I Informed Consent to Release Medical Information Informed
290. lection Location Code 4 digit location code associated with the MPI number selected in the Provider ID Rendering field This field is automatically populated after you select or enter an MPI number in the Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form NPI Enter the NPI National Provider Identifier Numeric 10 digit identifier Rendering consisting of 9 numbers plus a check digit in the 10 position Last Org Provider s last name or the name of the group or facility This field is Name automatically populated after you select or enter an MPI number in the Provider Rendering ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form First Name Other provider s first name This field is automatically populated after you select Rendering or enter an MPI number in the Provider ID Other field Information cannot be RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 158 Provider Electronic Solutions Software User Manual MI Rendering Provider ID Attending Location Code Attending NPI Attending Last Org Name Attending First Name Attending MI Attending Provider ID Operating Location Code Operating RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx PA PROMISe
291. lectronic Solutions software This summary report contains all the fields on the NCPDP Pharmacy Reversal Form To generate an NCPDP Pharmacy Reversal Summary Report perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select the NCPDP Pharmacy Reversal option from the Summary Forms drop down menu The NCPDP Pharmacy Reversal Summary Report screen is displayed Step 2 Click OK to include all the Pharmacy Reversal Requests in the summary report Step 3 Click OK when prompted by the box that advises you that all records will be selected RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 349 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 A summary report is generated and displayed on your screen To limit the type of Pharmacy Reversal Requests in the summary report enter the appropriate report criteria into one or more of the following fields Batch Number Recipient ID Form Status Submit Date Limits the summary report to Pharmacy Reversal Requests in a specific batch Enter the appropriate batch ID number in this field You can locate the batch numbers under the Resubmission option of the View Communication Log menu Limits the summary report to Pharmacy Reversal Requests for the specified recipient Enter the appropriate recipient ID in this field Limits the summary report to Pharmacy Reversal Request
292. lick E Step 3 A box appears and asks you if you are sure you want to delete the record Delete current record Are you sure you want to delete this record ow Step 4 Click RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 56 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 8 Complete a Specific Reference List The Provider reference list is linked to the Provider ID Referring Provider Rendering Provider ID and Facility ID fields Therefore the selections added to the 837 Provider reference list can be accessed from any of the fields mentioned above If a provider renders services in multiple locations or is a provider with multiple provider types add multiple selections for that provider so that each selection properly reflects the location code for the rendered services 8 1 837 NCPDP Cardholder Reference List To complete the data entry fields needed to add or edit an NCPDP Cardholder reference list selection perform the following Step 1 Click Lists NCPDP NCPDP Cardholder to access the NCPDP Cardholder reference list File Edit View Forms Lists Tools Window Help ax gal l eea 204 8 F 69 NCPDP Cardholder Cardholder fi 23456789000 First Hame ANT Last Hame ONE Cardholder Last Hame First Name ANY Step 2 Enter the data requested for each field as described below NCPDP Enter the recipient ACCESS ID and card issue number in the Ca
293. ligibility Inquires for the ID specified recipient Enter the appropriate recipient ID in this field Form Limits the summary report to Pharmacy Eligibility Inquires with the Status specified form status Select the appropriate form status from this drop down list Submit Limits the summary report to Pharmacy Eligibility Inquires transmitted Date on the specified date Enter the appropriate date in this field Step 4 After you enter the report criteria click 0K The detailed report is generated and displayed on your screen Step 5 Use the scroll bars located on the right side and bottom of the screen to view the entire report R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 344 PA PROMISe Provider Electronic Solutions Software User Manual p z 2 HP Provider Electronic Solutions lt 5 File Fors Lists Reports Tools Window Help eo a e a p gt oA 2 WO NCPDP Pharmacy Eligabality Detail Report Batch Number Recipient Caadholder ID Form Siatus Submit Dade mio Records selected 2 Pharmacy Eligibility Detail Report AS of 08 19 2015 ALL CLAIMS Provider ID 111111111 Lec sation Code UOI HPI TIYSA Date Of Senvice 0A132015 Provides ID Qualifier 0 CandholdediD ery Lact Name TESTERS Fas Hame TEST Version 4 00 Step 6 Click Print to print the NCPDP Pharmacy Eligibility Detail Report Step 7 Click _blase to exit the NCPDP Pharmacy Eligibility Detail Report screen 11
294. ll records will be selected The summary report is generated and displayed on your screen To limit the type of Professional Claims in the summary report enter the appropriate report criteria into one or more of the following fields RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 337 Form Status Submit Date PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Batch Limits the summary report to Professional Claims in a specific batch Number Enter the appropriate batch ID number in this field You can locate the Batch Numbers under the Resubmission option of the View Communication Log menu Recipient Limits the summary report to Professional Claims for the specified Client ID recipient Enter the appropriate recipient ID in this field Limits the summary report to Professional Claims with the specified form status Select the appropriate form status from this drop down list Limits the summary report to Professional Claims transmitted on the specified date Enter the appropriate date in this field Step 4 After you enter the report criteria click OF i The summary report is generated and displayed on your screen R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 338 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Use the scroll bars located on the right side and bottom of the screen to view the entire re
295. ltiple location codes are assigned to a single provider number complete multiple entries in the NCPDP Provider reference list for each location code RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 58 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 ID Code Select one of the following values from the preloaded drop down list or Qualifier enter an appropriate value as specified 05 Medicaid Provider Number 99 Other Note This value is submitted in the Provider ID field NPI Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Last Org Enter the last name of the MA provider group or facility Name First Name Enter the MA provider s first name Step 3 Click __ Save when all data entry fields are completed Step 4 Click __ Add and repeat steps 2 3 and 4 to add another provider ID to the NCPDP Provider reference list Step 5 Click _ Close to exit the NCPDP Provider screen 8 3 837 Provider Reference List To complete the data entry fields needed to add or edit an 837 Provider reference list selection perform the following RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 59 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 1 Access the 837 Provider reference list 9 HP Provider Electronic Solutions E O s
296. lutions PES software you receive this error Application Complete the following steps to resolve this issue First step Select the Tools Database Recovery Unlock to unlock the claims Go to update create the claims If the step above does not resolve this issue Go to your local drive c papromise folder Look for the database with the extension panewecs Idb and delete it Do not delete the one with the extension mdb panewecs mdb 12 5 Get Upgrades You can go to the website to get the upgrades The website is http promise dpw state pa us ePROM _ProviderSoftware softwareDownloadMain asp Under Billing Information double click on the Provider Electronic Solutions Software and follow the instructions for the upgrade When using the Web Server download the upgrades follow the steps below to upgrade using the software You should only access this feature if you are notified that an upgrade to the Provider Electronic Solutions software is available To download an upgrade from the Web Server perform the following steps RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 356 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 1 From the main screen of the Provider Electronic Solutions software select the Get Upgrades option Step 2 The software uses the Web Server to download any applicable upgrades Step 3 After downloading the upgrade you need to access the
297. m Transmission the drop down list or enter an appropriate value as specified Code AA Available on Request at Provider Site BM By Mail EL Electronically Only EM E Mail FT File Transfer FX By Fax Attachment Enter the up to 10 digit number obtained from the PROMISe web site Control This number is used when a paper attachment is required by MA to cross RAPA MMIS CMcElheny PES _Manual_50104 00_ICD10 docx a st lt i lt i lt z W August 31 2015 178 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 3 Complete Header 2 HP Provider Electronic Solutions File Edit View Forms Tools Window Help fi 837 Institutional Nursing Facility zz Total Charge S DI Amount PI Billed Amount P Services Admission Add Date 00 00 0000 Time Type Admit Source c opy From DOS 00 00 0000 To BOS 00 00 0000 Discharge Time Delete Days Covered Non Covered Coinsurance o Undo All ndo Attending Provider ID Location Code HPI Save Last Org Name First Name hil SAn AN Rendering __ Edit an Provider ID Location Code HPI Last Org Name First Name hil z z Find Last Hame First Marne Billed Amount Last Submit Dt Print Close Date Enter the 2 digit month 2 digit day and 4 digit year the resident Admission was originally admitted to the facility For example enter
298. main screen of the Provider Electronic Solutions software choosing the Archive option then clicking on Create Archived files can also be restored if needed Only invoices in a finalized status are archived Invoices in an Incomplete status are deleted Invoices in Ready status remain untouched The default setting for this option is 100 days the maximum is 999 Max Batch Total number of batches retained in the Resubmission option of the Communications menu The default number of batches to retain is 100 the maximum is 999 The Resubmission option of the Communications menu lets you view the batches that were sent to HP Enterprise Services and identifies the forms sent within that batch RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 26 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Max Verify Max Log Max Submit Reports Max Bulletin Password Expiration Days Number of 835 Electronic Remittance Advices 271 Eligibility Responses and NCPDP Pharmacy Claim responses maintained in the View Batch Response 835 ERA electronic remittance advice option of the Communications menu Downloaded files are deleted on a first in first out basis The default number of files to maintain is 100 the maximum number is 999 Number of communication log files maintained in the View Communication Log option of the Communications menu The default number of files to maintai
299. mation regarding files After you have submitted batch files into the system you should wait 8 hours before downloading the associated Submit Reports To view the reports perform the following steps Step 1 Download the reports by following the instructions in section 10 1 Batch Submission RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 310 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 2 Select the View Submit Reports option from the Communication menu to access the Submit Report screen You are responsible for verifying that your claims are accepted for payment You will not be contacted by HP Enterprise Services if a claim or transaction is rejected 9 HP Provider Electronic Solutions File Forms Communication Lists Reports Tools Security Window Help Submission Resubmission View Batch Response 8s5 ERA View Bulletin View Submit Reports View Communication Log R PA MMIS CMcElheny PES_Manual_ 5010 4 00 _ICD10 docx August 31 2015 311 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 The Submit Reports screen is displayed UD HP Provider Electronic Solutions _ File Forms Lists Reports Tools Window Help O 2h aD OK xo I G Submit Reports Filename Fiesi _ Creation Date Creation Time C251397N 2250NGZI THN FIV 06 13 2015 14 37 28 C2390 2250N Gel TAM FIV l 06713 2015 13 20 02 C2533 2250N GKS T
300. mer Second Surgical Opinion Required Other or Additional Payer Prior Year s History Card s Reported Lost Stolen 7S 5 C zz P Contact Following Entity for Eligibility or Benefit Information Cannot Process Other Source of Data Health Care Facility Spend Down RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 368 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 16 2 Reject Reason Codes These codes are used when a rejection is sent back for a 270 Request rather than a 271 Response Error 271 X12 Error Status Code Code Description Why the Error Set 42 Unable to Respond at A PROMISe error has occurred Please try again Current Time PROMISe provider number is not 13 digits long Verify that you are using a valid 13 digit number and not an old 8 digit MA ID number Also returned for Health Care providers who are not using their National Provider Identifier after May 23rd 2008 43 Invalid Missing Provider Identification 50 Provider Ineligible for LIHEAP Providers are not eligible to enquire eligibility on Inquiries MA recipients 51 Provider Not on File Provider number submitted is not a valid number Verify the number submitted If an NPI is submitted and zip code or taxonomy is sent confirm that the zip code and or the taxonomy matches with the providers registered NPI information get eligibility for all the days requested
301. n POS Place of Service An alpha or numeric code denoting the actual place services are provided PROMISe Provider Reimbursement and Operations Management Information System in electronic format Provider An entity enrolled in the Pennsylvania Medical Assistance Program that provides services or supplies to recipients QSB Qualified Small Business RA Remittance Advice A notice sent to providers advising the status of claims received including paid denied in process and adjusted claims It includes year to date payment summaries and other financial information RARC Remittance Advice Remark Codes Recipient Person client or patient who 1s eligible to receive services under Pennsylvania s Medical Assistance Program Service Health Benefit Plan Coverage Type Code SSN Social Security Number Taxonomy Lists the code designating the provider type classification and specialty Code R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 379
302. n is 100 the maximum is 999 Maximum number of submission reports stored in the View Submit Reports option of the Communications menu The default number of stored files is 100 the maximum is 999 The View Submit Reports option lets you view the forms in a particular batch if they have passed the first level of HIPAA edits Maximum number of bulletins stored in the View Bulletin option of the Communications menu The default number of files to maintain 1s 10 the maximum is 999 Bulletins are messages that can be downloaded using the Submission option of the Communications menu Bulletins can be viewed by accessing the View Bulletin option of the Communications menu Number of days before your password expires After the allotted number of days you are prompted to change your password The default number of days for a password to expire is 30 the maximum is 99 You can change your password at any time by accessing the Change Password option of the Tools menu Step 2 Click __oK to save any changes you made to the Options box 7 HP Provider Electronic Solutions Application m r i You hawe changed information on this window Do you want to sawe changes Step 3 Click _ Close to exit the Options box RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 27 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 R PA MMIS CMcElheny PES_Manual_ 5010 4 00_I
303. n list or enter an appropriate value as specified E Code This code represents the external cause of injury Enter the external Diagnosis diagnosis code or select the external code from the field s pull down Codes list or enter an appropriate value as specified RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 183 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Auto Accident State Delay Reason Required on Institutional claims whenever a diagnosis is needed to describe an injury poisoning or adverse effect Enter the two letter abbreviation for the state where the accident occurred For example enter PA for Pennsylvania Enter the appropriate code to indicate why a claim is being submitted outside of the 180 day initial submission window This is an optional field 1 Proof of Eligibility Unknown or Unavailable 2 Litigation 3 Authorization Delays Billing Note If the provider is a qualified small business enter QSB in this field This field 1s optional Other Select the other insurance code from the drop down list or enter an Insurance appropriate value as specified Indicator Select Y 1f the recipient has other insurance Select N 1f the recipient does not have other insurance Crossover Populates the Crossover screen which is used to record a recipient s Indicator Medicare information Select the crossover code from the drop down list or en
304. ncounter record Consolidated Community Reporting Use Only RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 214 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 o Select CH if the claim is a Fee for Service claim The default value for this field 1s CH Value Enter the National Uniform Billing Committee NUBC code that relates Codes Amounts amounts or values to identify data elements necessary to process a form Fields 1 4 as qualified by the payer organization These values are preloaded and are HIPAA compliant If any changes or modifications need to be made to these values you will be notified by DHS or HP Enterprise Services Select the appropriate value from the drop down list or enter an appropriate value as specified 06 Medicare Blood Deductible 06 Medicare Blood Deductible 14 No Fault Auto Other 15 Workman s Compensation 16 PHS or Other Federal Agency 25 Drug Deduction 31 Patient Liability Amount 34 Offset to Patient Payment Amount Other Medical Expense 35 Offset to Patient payment Amount Health Insurance Premium 38 Medicare Blood Deductible Pints Furnished 39 Medicare Blood Deductible Pints Replaced 47 Any Liability Insurance 66 Patient Paid Amount In the right segment of this field enter the dollar amount for each code using a decimal point R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 do
305. ne click on the existing service line you want to copy then click _ Copy w A new service line is added to the screen that has the same data as the existing service line that you previously selected Edit the data in the new service line by clicking on the new line and changing the appropriate fields Step 9 4 To delete an existing service line click on the service line that you want to delete and then click Delete Sty The selected service line is deleted Step 10 Click ave to save the information in the institutional nursing form Step 11 Click Add to start another institutional nursing claim RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 197 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 9 7 Complete an 837 Institutional Outpatient Form The 837 Institutional Outpatient Form is used to create claims for outpatient services normally billed on a UB 04 form The 837 Institutional Outpatient Form is divided into ten screens Each screen contains the following claim data Hdr 1 Hdr 2 Hdr 3 Hdr 4 Pat O I Crossover Srv 1 Srv 2 Srv 3 Srv Adj Accesses the screen that contains the provider and recipient information Accesses the screen that contains the ICD Version diagnosis and condition code information Accesses the screen that contains information about the attending operating and rendering provider Access the screen that contains t
306. neral category of the adjustment made to the claim Select the adjustment group code from the drop down list or enter an appropriate value as specified CO Contractual Obligations CR Correction and Reversals OA Other Adjustments PI Payer Initiated Reductions PR Patient Responsibility Level of payer responsibility for the resident s other insurance Select the appropriate code from the drop down list or enter an appropriate value as specified P Payer 1 S Payer 2 T Payer 3 A Payer 4 B Payer 5 C Payer 6 D Payer 7 E Payer 8 F Payer 9 G Payer 10 H Payer 11 U Unknown Enter the number of days that are covered completely by Medicare Enter the Medicare ICN found on the Medicare EOMB for the service billed Enter the Medicare coinsurance amount using a decimal point This information can be found on the Medicare EOMB For example enter 5 00 if the paid amount was 5 00 An amount of 0 zero may be entered RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 223 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Paid Date Carrier Code Policy Holder Last Name Policy Holder First Name Policy Holder Insurance Type Code Policy Holder Enter the 2 digit month 2 digit day and 4 digit year the Medicare coinsurance was paid This information can be found on the Medicare EOMB Select th
307. nformation cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Medical Medical record number assigned to the recipient by your facility This field Record is automatically populated after you select or enter a recipient ID Number Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form Last Name Recipient s last name This field is automatically populated after you select or enter a recipient ID Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 176 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 First Name Middle Initial Patient Status Account Number Release of Medical Data Benefits Assignment Recipient s first name This field is automatically populated after you select or enter a recipient ID Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form Recipient s middle initial This field is automatically populated after you select or enter a recipient ID Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form Re
308. nformation in this field access the Policyholder form Step 11 1 To add another other insurance line click Add OL A new blank service line is added to the screen Click on the new service line and then enter the other insurance data in the appropriate data fields as described in this step Step 11 2 To copy the data from an existing other insurance line to a new service line click on the existing service line you want to copy and then click Copy Ol A new service line is added to the screen The new service line has the same data as the existing service line you previously selected You can edit the data in the new service line Simply click on the new service line and make changes to the appropriate fields Step 11 3 To delete an existing other insurance line click on the service line you want to delete and then click Delete OI The selected service line is deleted Step 12 Complete Crossover ig HP Provider Electronic Solutions 837 Institutional Inpatient Sax Ae File Edit View Forms Tools Window Help DExX VHe2 el Baler4ns E e Total Charge o DI Amount P Billed Amount PT Services Reason Codes Amts Add Release of Medical Data Benefits Assignment Y _ 1 o0 i C Claim Filing Ind Code MA Adjustment Group Cd 2 mi H Payer Responsibility Full Medicare Days al D Delete Medicare ICN Paid Date 00 00 0000 Paid Amount 00 Undo All Policy Holder Carrier Code Save Last Nam
309. ngredient to delete an existing ingredient line Step 10 Complete COB 1 Pharmacy Total Charge ME Amt Paid Ti Billed Amt iii Details 4 Coverage Type x Detail Humber Payer ID Qualifier Date 00000000 ICN Amount Paid Qualfier 1 OO x 2 mf af ns af sf a __ Delete s 7 nets e n 98 yg an Reiect Code 1 20 z 3 x 4f xl 5 i Add Payer Coverage Type PayerID Copy Payer Delete Payer Cave Send Last Name lled Amt Last Submit Dt Copy oee T Se s m ee e Step 10 1 Select 02 from the Other Coverage Code field on the Claim 1 screen to display the COB 1 screen Step 10 2 Click the COB 1 tab to access the COB 1 screen The COB 1 screen is displayed RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 293 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Coverage Type Payer ID Qualifier Select the coverage code from the drop down list or enter an appropriate value as specified Not Specified 01 Primary First 02 Secondary Second 03 Tertiary Third 04 Quaternary Fourth 05 Quinary Fifth 06 Senary Sixth 07 Septenary Seventh 08 Octonary Eighth
310. nnot be entered directly into this field If you need to add or edit information in this field access the Policy Holder Form Policyholder s first name This field 1s automatically populated after you select or enter a carrier code in the Group field Information cannot be entered directly into this field If you need to add or edit information in this field access the Policy Holder Form The window is only active if the payer is Medicare with Claim filing code of MB and the Payer Responsibility is not P Primary Select the appropriate value from the dropdown box that identifies the type of insurance listed 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End Stage Renal Disease in the Mandated Coordination Period with an Employer s Group Health Plan 14 Medicare Secondary No fault Insurance including Auto is Primary 15 Medicare Secondary Worker s Compensation 16 Medicare Secondary Public Health Service PHS or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran s Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan LGHP 47 Medicare Secondary Other Liability Insurance is Primary Step 13 Complete Service 1 RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 170 PA PROMISe Provider Electronic Solutions So
311. ntains the value 2 which Compound indicates that the claim is for a compound Select the Ingredients appropriate value from the drop down list or enter an appropriate value as specified 01 UPC 02 HRI 03 National Drug Code NDC 04 HIBCC 11 NAPPI 12 GTIN 15 GCN 28 FDB Med Name ID 29 FDB Routed Med ID 30 FDB Routed Dosage Form Med ID 31 FDB MEDID 32 GSN 33 HICL 99 Other RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 291 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Ingredient Quantity Enter the quantity of the ingredient used in the prescription Compound expressed in numeric metric decimal units This must be a Ingredients whole number This field is required if the compound indicator field contains the value 2 which indicates that the claim is for a compound Ingredient Cost Enter the ingredient cost for the quantity entered in the Compound Ingredient Quantity field including a decimal point This field Ingredients is required if the compound indicator field contains the value 2 which indicates that the claim is for a compound Basis of Cost Select the Basis of Cost Determination from the drop down list Determination gi Compound Ingredients Enter an appropriate value as specified Enter the appropriate code that indicates the method by which Ingredient Cost Submitted was calculated Each N
312. nter the changes in the appropriate fields To delete an existing other insurance line click on the service line that you want to delete and then click Delete O The selected service line is deleted R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 132 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 7 Complete Service Header 1 79 HP Provider Electronic Solutions File Edit View Forms Tools Window Help DRX Voalel eaalseras ml Kees ammm Total Charge T OI Amount ET Billed Amount PT Services Hdr 1 Hdr2 Hdr3 Hdr4 or Srv 1 sv 2 00 Place Of Service i Add Procedure fC Modifiers 1 le 2 O 3 a 3 ie Copy Tooth rt Surfaces 1 x 2 x 3 Mj 4 I M Quadrants 1 C 2 A 3 a sim l UE Placement Ind x Diag Ptr 1 2 3 7 4 Undo All Billed Amount f Units I Prior Placement Date 0070070000 Gave Add Srv ay OS Procedure Billed Amount I Oo Copy Srv Delete Srv Find Recipient ID Last Mame First Marne Billed Amount Last Submit Dt Find Print Close Date Of Enter the 2 digit month 2 digit day and 4 digit year that the services were Service rendered For example enter 10012015 if the date was October 1 2015 Place of Select the place of service code from the drop down list or enter an appropriate Service value as specified Place of service is the location where the service was performed The only Place of
313. ntion provided very early to prevent possible loss or impairment of life limb or body function 3 Elective Scheduled or planned admission Admission RAPA MMIS CMcElheny PES_Manual_50104 00_ICD10 docx a t lt O August 31 2015 67 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 4 Newborn Admission of a newborn baby Admission 5 Trauma Admission to a trauma center Center Description Enter the description of the admission type code Step 3 Click __ Save when all data entry fields are completed Add Step 4 Click and repeat steps 2 3 and 4 to add another admission type code to the Admission Type reference list Step 5 Click __ Close to exit the Admission Type screen 8 7 Admit Source Reference List Selection To complete the data entry fields needed to add or edit an Admit Source reference list selection perform the following steps Step 1 Click Lists Admit Source to access the Admit Source reference list Ag HP Provider Electronic Solutions File Edit View Forms Lists Tools Window Help 3x42 mlet BATS y E ap Admit Source Add Admit Source Code Description Delete Undo All cave Admit Source Code Description Find Physician Referral Clinic Referral HMO Referral Transfer from a Hospital Transfer from a Skilled Nursing Facility Transfer from Another Emergency Room Print Step 2 Enter the data r
314. number in this field You can locate the Batch Numbers under the Resubmission option of the View Communication Log menu Recipient Limits the summary report to Pharmacy Claims for the specified ID recipient Enter the appropriate recipient ID in this field Form Limits the summary report to Pharmacy Claims with the specified form Status status Select the appropriate form status from this drop down list Submit Limits the summary report to Pharmacy Claims transmitted on the Date specified date Enter the appropriate date in this field Step 4 After you enter the report criteria click 0K i The summary report is generated and displayed on your screen R PA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 342 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Use the scroll bars located on the right side and bottom of the screen to view the entire report IE HP Provider Electronic Solutions TZ File Forms Lists Reports Tools Window Help a Whe D G k o ie G NCPDP Pharmacy Summary Report Batch Number Recipient Caidhokder IDE Form Statue Submil Date O00 Recordz selected Fy Pharmacy Summary Report As ot 08 18 2015 ALL CLAMS Firct Name Billed Amt Lact Submit Ot Status E WIE Product ID 1 noo7io1se23 Step 6 Click Print to print the NCPDP Pharmacy Summary Report Step 7 Click _blase to exit the NCPDP P
315. ny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 313 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Tig HP Provider Electronic Solutions Submission Resubmission View Batch Response 835 ERA View Bulletin View Submit Reports View Communication Log The Communication Logs screen is displayed Step 2 Click on a batch record to select it and display its submission information The batch shown below was submitted successfully Note Submitted successfully does not necessarily mean that the files submitted were processed successfully into the PROMISe system You must download and review the following reports for any files that may have rejected for HIPAA errors Submission Transaction Report s Accepted Submit Report s and the Rejected Submit Report s and 999 Acknowledgement s HP Provider Electronic Solutions Forms Lists Reports Tools Window Help Filename Creation Date Creation Time 52251147 FIL 08 13 2015 11 45 44 52251146 FIL 0871372015 11 45 26 52251145 FIL 08 13 2015 11 45 14 52251144 FIL 0571372015 11 44 29 geo 1 145 FIV 0871372015 11 43 20 52251 109 Fly 493 08 13 2015 n22o71104 FIL 081372015 11 09 20 FILE 52251109 FIV 08 13 2015 11 Starting Submission Process Getting web submission options Formatting 270 Eligibility Request batch Sending Receiving batch transactions in progresa CONNECTION USING WEB SERVER ON 8 13 2015 AT 11 09 04
316. o Accident 24 Date Insurance Denied 02 No Fault Insurance Involved 25 Date Benefits Terminated Including Auto Accident Other By Primary Payer 03 Accident Tort Liability 71 Prior Stay Dates 04 Accident Employment Related 74 Noncovered Level of 05 Other Accident Care Leave of Absence 06 Crime Victim DR Disaster Related MR Disaster Related In the right segment of the field enter the 2 digit month 2 digit day and 4 digit year associated with occurrence code in the right segment of the field SS Each field is divided into three segments RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 148 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Oaren In the left segment of the field enter the appropriate occurrence span Span code as panen or select the appropriate occurrence span code from the Codes Dates segment s drop down list as described below Fields 1 3 01 Auto Accident 24 Date Insurance Denied 02 No Fault Insurance Involved 25 Date Benefits Terminated By Including Auto Accident Other Primary Payer 03 Accident Tort Liability 71 Prior Stay Dates 04 Accident Employment Related 74 Noncovered Level of 05 Other Accident Care Leave of Absence 06 Crime Victim DR Disaster Related MR Disaster Related In the middle segment enter the 2 digit month 2 digit day and 4 digit year the period of
317. o add another occurrence code to the Occurrence reference list Step 5 Click __ Close to exit the Occurrence screen 14 Other Insurance Reason Reference List To complete the data entry fields needed to add or edit Other Insurance Reason reference list selection perform the following steps Step 1 Click Lists Other Insurance Reason to access the Other Insurance Reason reference list Ag HP Provider Electronic Solutions File Edit View Forms Lists Tools Window Help Dx VH el Bala 2 e F Ag Other Insurance Reason Other Insurance Description Delete Undo All Cave leason Code Description Find Deductible Amount Coinsurance Amount Copayment Amount Payment adjusted because charges were paid by another pe Lifetime Benefits Maximum has been reached Charge exceeds fee schedulemaximum allowable Non covered services Print RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 78 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 2 Enter the data requested for each field as described below Other Enter the code that identifies the reason an adjustment was made by the Insurance other insurance carrier or enter an appropriate value as specified Reason Code 01 Deductible Amount 45 Charge exceeds fee 02 Coinsurance Amount schedule maximum allowable or 03 Copayment Amount contracted legislated fee arr
318. o exit the Recipient screen 8 5 Taxonomy Reference List To complete the data entry fields needed to add or edit a Taxonomy reference list selection perform the following steps R PA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 65 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 1 Click Lists Taxonomy to access the Taxonomy reference list ig HP Provider Electronic Solutions A _ File Edit View Forms Lists Tools Window Help 3 xv mle Bla e 14 E T ig Taxonomy Taxonomy Code Add Description Delete Undo All Save Taxonomy Code Find DOOUOOO000 Not Applicable Print Step 2 Enter the data requested for each field as described below Taxonomy Enter the appropriate Taxonomy code MA does not require this Code information to adjudicate a claim however it is required to make your transaction HIPAA compliant and to process the claim correctly A list of Taxonomy codes is found at Wwww wpc edi com codes codes asp Note The Taxonomy code is crucial to using the NPI National Provider Identifier If entering an NPI as the primary identifier you must use the correct Taxonomy code that you coordinated with Provider Enrollment for your legacy ID Nine Digit Provider ID plus Four Digit Service Location Code Description Enter the description of the taxonomy code Step 3 Click Save when all of the data entry fields are completed Step 4 Click o A
319. ode Lasti Hame First Hame Diagnosis Codes 1 52101 2 52102 3520 Step 6 Click Print to print the 837 Dental Detail Report Step 7 Click Clase to exit the 837 Dental Detail Report screen 11 6 837 Dental Summary Report You can generate a summary report for a Dental Claim using the Provider Electronic Solutions software The summary report contains only the key fields on the 837 Dental Form To generate an 837 Dental Summary Report perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select the 837 Dental option from the Summary Forms drop down menu The 837 Dental Summary Report screen is displayed Step 2 Click OK to include all the Dental Claims in the summary report RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 326 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 3 Click a when prompted by the box that advises you that all records will be selected A summary report is generated and displayed on your screen To limit the type of Dental Claims in the summary report enter the appropriate report criteria into one or more of the following fields Batch Number Recipient Client ID Form Status Submit Date Limits the summary report to Dental Claims in a specific batch Enter the appropriate Batch ID number in this field You can locate the Batch Numbers under t
320. oe MCPOP Pharmacy Eligibility 08713 2015 C2sl3930 Bar Professional 08713 2015 C2 Al SSE oa Institutional Nursing Fact 08 13 2015 C2 Also oa Institutional Inpatient 08713 2015 C25 SSE Bar Dental 08713 2015 Ue 1 a2 05713 2015 Step 8 Click _ Besubmit to complete the resubmission procedure Step 9 Click Close to exit the Resubmission screen 10 3 Batch Responses Use the Batch Submission function to download Batch Responses The responses are listed under the Files to Receive Note This is required in order to verify that all of the claims submitted were accepted The Submission option lets you receive multiple responses at the same time For example if you are receiving a Submission Transaction Report TXN and an 835 Electronic Remittance Advice you are receiving two files RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 306 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Method web DEE Diskette Drive gt Select All Deselect All Select All Deselect All Files To Send A Files To Receive 2 FU Eligibility Request E f 1 Eligibility Response s f6 Claim Status Request ff Claim Status Response s os Dental NLPOPR Pharmacy Response s os Institutional Inpatient 0395 E lectronice Remittance Advice Os Institutional Nursing Facility F 999 Acknowledgements odr Institutional Outpatient Accepted Submit Reports os Professorial Rejected Submit
321. of 9 numbers plus a check digit in the 10 position Qualifier code for the provider ID number This code must always be 05 for NCPDP providers Enter the 2 digit month 2 digit day and 4 digit year on which the service was provided For example enter 01012015 if the date was January 1 2015 Step 3 Click the Claim Reversal tab to access the Claim Reversal screen RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 300 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 The Claim Reversal screen is displayed Pharmacy Reversal Add Dtl Add Prescription Service H Ax 7 Service Qualifier f e i ifier Copy HDC Service ID HDC Service Qualifier U3 Hew Refill 0 Delete Undo All Dave E Send Copy Dl Delete Dt Prescription Service Rx Service Qualifier NDC Service ID NDC Service Qualifier New Refill Provider ID Date Of Service Last Submit Dt Enter the ID number of the prescription that was filled If the prescription number is less than 12 numeric characters add zeroes to the beginning of the prescription number to make it equal to 12 characters ex 000000001234 Select the qualifier code from the drop down list or enter an appropriate value as specified The qualifier code must always be 1 Select the eleven digit NDC for drug dispensed Qualifier code for the
322. of an individual provider or the business name of a group Last Org facility or billing service Name Submitter First name of an individual provider Complete this field only if the First Name Entity Type Qualifier is Person Contact Enter the name of the contact person This is a required field Name Cannot be the same as the Submitter Last Org Name Contact Phone Enter the phone number of the contact person Contact f Phone Contact Phone is always required and must be max length 11 5 4 How do I reset my Web password For security purposes your web password expires every 30 days When you submit a batch when your password expires the Web Password Reset screen will display prompting you to change your web password ve Web Password Reset ee Scat ae a ollowing information to update a Your web password has expired please complete the f your web password Old Password Hew Password Cone Rekep New Password RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 19 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 1 Step 2 Step 3 Step 4 Step 5 In the Old Password field enter your old password If you can t remember your password refer to the What if I can t remember my Web password Section of this document In the New Password field enter a new password To select a new password see the password rules table
323. of the other insurance carrier Other Insurance Enter the group name of the other insurance Group Name RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 83 Line 1l under Policy Holder Address Line 2 City State Zip PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Relationship to Select the appropriate code from the drop down list or enter an Insured appropriate value as specified This field contains the relationship for the recipient s other insurance and identifies the relationship between the recipient and the policyholder Last Name Enter the policyholder s last name First Name Enter the policyholder s first name ID Code Enter the ID number assigned to the policyholder by the other insurance company ID Qualifier Select the appropriate qualifier ID MI Member ID is the only option from the drop down list or enter an appropriate value as specified This code contains the qualifier code for the ID number assigned to the policyholder by the other insurance company This field identifies any qualifications that apply to the policyholder Enter the first line of the policyholder s street address Enter the second line of the policyholder s street address 1f applicable Enter the city where the policyholder s street address is located Enter the 2 letter abbreviation used to identify the state where the policyholder s street address is located
324. ollowing the guidelines below When using Type of Bill 111 to resubmit a previously rejected claim enter the 13 digit ICN as printed on the RA statement When using Type of Bill 117 or 118 to adjust or void a previously paid claim enter the 13 digit ICN as printed on the RA statement If submitting a claim adjustment for a claim processed prior to the implementation of PROMISe or when resubmitting a previously rejected claim processed prior to the implementation of PROMISe enter the 10 digit CRN followed by the 2 digit line number as printed on the RA Statement Select the 9 digit MPI number for the provider that the claim will be paid under billing provider from the drop down list or double click on the data entry portion of the field to add a reference list selection 4 digit location code associated with the MPI number selected in the Provider ID field This field is automatically populated after you select or enter an MPI number in the Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Provider s last name or the name of the group or facility This field is automatically populated after you select or enter an MPI number in the Provider ID field RAPA MMIS CMcElheny PES_Manual
325. on for conditions or diagnosis regulated by federal statutes Select Y Yes Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Benefits Select the appropriate assignment code from the drop down list or enter an Assignment appropriate value as specified Select Y if the recipient or authorized person has authorized benefits to be assigned to the provider RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 145 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Select N if the recipient or authorized person has not authorized benefits to be assigned to the provider Select W for Not Applicable Not applicable for this claim Report Type Enter the appropriate code for the type of attachment submitted from the Code drop down list or enter an appropriate value as specified AS Admission Summary NN Nursing Notes B2 Prescription OB Operative Notes B3 Physician Order OZ Support Data for Claim B4 Referral Form PN Physical Therapy Notes CT Certification PO Prosthetics or Orthotic DA Dental Models Certification DG Diagnostic Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports DS Discharge Summary EB Explanation of Benefits MT Models RT Report of Tests and Analysis Report Report Enter the appropriate code for the method of atta
326. on 4 00 Step 4 Complete Header 3 D HP Provider Electronic Solutions File Edit View Forms Tools Window Help JDEX VHalal ealevas m fi 837 Institutional Nursing Facility zz Total Charge P OI Amount ii Billed Amount Wii Services Add ICD Version ICD 0 Diagnosis Codes Copy Principal Other 1 2 3 Delete Admit i 5 6 Undo All E Code 7 8 Save Auto Accident State Delay Reason E dit AIl it Billing Note Other Insurance Ind N Crossover Ind N z z Find Recipient ID Last Hame First Marne Billed Amount Last Submit Dt f Print Close ICD Version Use the ICD 9 ICD10 Version for the code being submitted Principal primary diagnosis code is the most specific I ICD 9 CM ICD 10 CM PCS diagnosis code that relates to a recipient s stay Codes Select the principal diagnosis code from the drop down list or enter an appropriate value as specified Principal Diagnosis Other Fields Each Other field identifies an additional diagnosis code for the form 1 8 Diagnosis Select each additional diagnosis code from the drop down lists or Codes enter the appropriate value s or enter an appropriate value as specified Admit Admission code is the ICD 9 CM ICD 10 CM PCS diagnosis code Diagnosis that corresponds to the diagnosis of the recipient s condition that Codes prompted admission to the hospital Select the admission diagnosis code from the drop dow
327. on Lists Reports Tools Security Window Help 10 Eligibility Request 16 Claim Status Request a3 Dental 63 7 Institutional Inpatient 83 Institutional Nursing Facility 83 Institutional Outpatient 63 Professional NCPDP Pharmacy NCPDP Pharmacy Eligibility NCPDP Pharmacy Reversal Version 4 00 Note When you choose a selection from a drop down list many of the fields are populated For additional information on reference lists refer to the List options in section 6 3 4 of this manual Step 2 Complete Header 1 HP Provider Electronic Solutio eral File Edit View Forms Tools Window Help oe pag Intt eel i tatan teh 3 Institutional Outpatient Type OF Bill Original Claim Provider ID Location Code HPI Org Name Recipient ID Hedical Record Last Hame First Hame HI From DOS 00700 0000 To DOS 0070070000 Account tt Admit Source Admit Type Prior Authorization Patient Status Referral Code Release of Medical Data Benefits Assignment Y Report Type Code Report Transmission Code Attachment Ctl E R PA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 199 Total Charge DI Amount DI Billed Amount i Services Copy Delete Undo All Dare Find Print Close August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Type of Bill Original Claim Provider ID Location Code NP
328. ong Term Care Patient Admit 19 Split Billing 2 Other Override 20 340B 21 LTC Dispensing 7 Days or Less N A RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 2 8 3 Vacation Supply 30 LTC Dispensing Per Shift Dispensing 31 LTC Dispensing Per Med Pass Dispensing 32 LTC Dispensing PRN On Demand 33 LTC Dispensing 7 Day or Less 4 Lost Prescription 5 Therapy Change August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 22 LTC Dispensing 7 Days 6 Starter Dose 23 LTC Dispensing 4 Days 7 Medically 24 LTC Dispensing 3 Days Necessary 25 LTC Dispensing 2 Days 8 Process 26 LTC Dispensing 1 Day C omponnd iar Approved Level Of Service Basis of Cost Determination Dispensing Fee 27 LTC Dispensing 4 3 Days 28 LTC Dispensing 2 2 3 Days Or Fcounters 29 LTC Dispensing Daily and 3 Day 99 Other WKND Ingredients Select the level of service code from the drop down list or enter an appropriate value as specified This code identifies the type of service that was rendered 0 Not Specified 4 24 Hour Service 1 Patient Consultation 5 Patient 2 Home Delivery Consultation 3 Emergency aha generic In Home Service Select the Basis of Cost Determination from the drop down list or enter an appropriate value as specified Enter the appropriate
329. onic Solutions Software User Manual Version 4 00 N HP Provider Electronic Solutions SSS File Edit View Forms Tools Window Help DAX VHelel Balers alk fi 837 Institutional Nursing Facility a Total Charge ii OF Amount ii Billed Amount Iii Services Release of Medical Data Benefits Assianment Y Reason Codes Amts Claim Filing Ind Code Adjustment Group Cd Payer Responsibility Paid Date Amount 00 00 0000 gt Delete Policy Holder Carrier Codel Group a Group Name s s Undo All Last Nam si i i C First Name o Save Add Ol Carrier Code Group Group Hame Last Hame Edit All Copy Ol Delete Ol z Find Recipient ID Last Hame Billed Amount Last Submit Dt Print Cloze The Other Insurance screen is added to the claim if you selected Y in the Other Insurance Indicator field on the Header 3 screen Access the Other Insurance screen by clicking the OI tab Release of Select the release code from the drop down list or enter an Medical Data appropriate value as specified Select I Informed Consent to Release Medical Information Select Y Yes Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Use if the provider has a signed statement on file permitting the release of medical data to other organizations Benefits Select the assignment code from the drop down list or enter an Assignment appropriate value
330. ons software You can now log in using your current User ID and Password and begin using the software Note Use of software for purposes other than intended or any altering of software such as files being loaded into the software are not supported by the EDI Department 3 2 Installation from A CD ROM The Provider Electronic Solutions software was designed for installation on the hard drive of a personal computer PC or to a network To simplify installation an automatic installation program is already on the CD ROM Follow the installation instructions listed below Step 1 Place the CD ROM in the computer drive The system reads the CD ROM and automatically proceeds through the installation process If the Windows AutoPlay feature is turned off the software will not automatically proceed through the installation process Perform the following steps to begin the installation process Step 2 Select the Start Run option Step 3 Click Browse and select the appropriate CD ROM drive and highlight setup exe Step 4 Click Oren Step 5 Click __oK and proceed to Step 2 RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 6 When the Welcome screen is displayed click Next gt H P Provider Electronic Solutions Welcome to the InstallShield Wizard for HP Provider Electronic Solutions The InstallShield Wizard will
331. ools Security Window Help Gt amp DQ NCPDP Provider Recipient Taxonomy Admission Type Admit Source Carrier Condition Code Diagnosis Diagnosis ICD Modifier NDC Occurrence Other Insurance Reason Patient Status Place Of Service Policy Holder Procedure HCPCS Procedure HCPCS ICD10 Revenue Type Of Bill Value Code Step 3 Select Provider when the reference list is displayed R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 44 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 ig HP Provider Electronic Solutions File Edit View Forms Lists Tools Window Help ax 9a l ea 8 2 m h Fa Provider Provider ID License FaciltyID LocationCode Add ID Code Qualifier EE Entity Type Qualifier x Delete Last Org Name First Hame Mil SSN Tax ID Undo All Taxonomy Code i ttsti i S CO HPI ss Save Provider Address AAA Find Line1 Line City TT State Zip Le 4 Prowider ID Taxonomy Last Org Name Type Qualifier Step 3 1 Click __ Close to close the reference list box To access a reference list from a form screen perform the following steps Step 1 Access a form using the Forms menu or short cut icon Step 2 Double click the data entry field for the reference list you need Click the Provider ID data entry field as shown below to access the Provider reference list RAPA MMIS CMc
332. or Not Applicable Not applicable for this claim Select the appropriate claim code from the drop down list or enter an appropriate value as specified The claim code identifies the type of other insurance claim that is being submitted Note Consolidated Community Reporting for OMHSAS CCR submitters must use the Claim Filing Indicator Code HM Using HM activates the MCO ICN field MC Medicaid 11 Other Non Federal Program 12 Preferred Provider Organization PPO 13 Point of Sale POS 14 Exclusive Provider Organization EPO 15 Indemnity Insurance 16 Health Maintenance Organization HMO Medicare Risk 17 Dental Maintenance Organization AM Automotive Medical BL Blue Cross Blue Shield CH CHAMPUS CI Commercial Insurance Co DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B OF Other Federal Program TV Title V VA Veteran Administration Plan WC Worker s Compensation Health Claim ZZ Mutually Defined Adjustment group code identifies the general category of the adjustment being made to the claim Select the adjustment group code from the drop down list or enter an appropriate value as specified CO Contractual Obligations CR Correction and Reversals OA Other Adjustments PI Payer Ini
333. or OMHSAS CCR Enter the contract number held with DHS This field is used only by Consolidated Community Reporting for OMHSAS CCR submitter The contract version is the month of the contract that was in force at the time of the service Note Fee For Service Providers who are billing directly to Medical Assistance do not use this field For Consolidated Community Reporting for OMHSAS CCR Values 01 thru 12 Enter any appropriate billing notes in this field This field is optional Enter the appropriate Family Planning indicator in this field Step 11 1 Click Add Srv to add another service line Step 11 2 A new blank service line is added to the screen RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 262 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 11 3 Click on the new service line and then enter the service data in the appropriate data fields Step 11 4 Click on the existing service line that contains information you want to copy to a new service line Step 11 5 Click Copy Srv to add a new service line to the screen Step 11 6 The new service line has the same data as the existing service line you previously selected You can edit the data in the new service line Simply click on the new service line and make changes to the appropriate fields Step 11 7 Click on the service line that you want to delete and then click Delete Srv to delete an exist
334. or edit a Carrier reference list selection complete the following steps Step 1 Click Lists Carrier to access the Carrier reference list Ag HP Provider Electronic Solutions File Edit View EATE Lists Tools Window He DX lt J Hlp TeAm k 6 Carrier Carrer Code Carrier Code Qualifier Add Carner Hame Delete Carner Address 3 3 Undo All Carrier Hame MEDICARE PARAT B MEDICARE PARAT D INDEPENDENCE BLUE CROSS HIGHMARE BLUE CROSS BLUE SHIELD CAPITAL BLUE CROSS BLUE CROSS OF H E PA SECURITY 65 INDEPENDENCE PLAN SECURITY 65 HIGHMARE PLAN RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 70 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 2 Enter the data requested for each field as described below Carrier Enter the NEIC code that identifies the other insurance carrier or choose Code the appropriate code from the drop down list or enter an appropriate value as specified The carrier code is only requested on the Other Insurance OJ screen Carrier Choose the code that identifies any qualifications that apply to the Code carrier code from the drop down box or enter an appropriate value as Qualifier specified PI Payer Identification XV HCFA Payer ID Carrier Enter the name of the other insurance carrier Name These values are preloaded and are HIPAA compliant If any changes or modifications need to be made to these values
335. ormation regarding the Provider Electronic Solutions software or MA billing and policy questions please contact the phone numbers below Technical Questions with the Provider Electronic Solutions software HP Enterprise Services 1 800 248 2152 or 717 975 4100 Provider Assistance Center MA Billing or Policy Questions Provider Inquiry 1 800 537 8862 Practitioner Unit Provider Inquiry 1 800 537 8862 Pharmacy and Ancillary Unit Provider Inquiry 1 800 537 8862 Inpatient Unit Provider Inquiry Office 1 800 932 0939 of Long Term Living Unit Behavioral Health 1 800 433 4459 Provider Hotline Internet Resources Department of Human http www dhs state pa us Services Web site PROMISe Web site https promise dpw state pa us portal Default aspx alias promise d pw state pa us portal provider E mail Resources HP Enterprise Services papacl hp com Provider Assistance Center HIPAA Information pahipaa hp com PROMISe Information promise state pa us Contact Information Help ttp www dhs state pa for MA Providers us provider index htm RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 366 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 15 Appendix A Frequently Asked Questions 837 Institutional Long Term Care Forms How do I use the Provider Electronic Solutions software to bill Non Covered Medicare Services As a temporary sol
336. ort to Nursing Home Claims in a specific batch Enter the appropriate Batch ID number in this field You can locate the Batch Numbers under the Resubmission option of the View Communication Log menu RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 331 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Recipient Limits the summary report to Nursing Home Claims for the Cardholder ID specified recipient Enter the appropriate recipient ID in this field Form Status Limits the summary report to Nursing Home Claims with the specified form status Select the appropriate form status from this drop down list Submit Date Limits the summary report to Nursing Home Claims transmitted on the specified date Enter the appropriate date in this field The 837 Institutional Nursing Home Detail Report screen is displayed Step 2 Click OK to include all the Nursing Home Claims in the detail report Step 3 Click OK when prompted by the box that advises you that all records will be selected A detailed report is generated and displayed on your screen To limit the type of Nursing Home Claims in the detail report enter the appropriate report criteria into one or more of the following fields Step 4 After you enter the report criteria click OK The detailed report is generated and displayed on your screen R PA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 332 PA
337. ovider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Required when the rendering provider is supervised by a physician or dentist Supervising provider s first name This field 1s automatically populated after you select or enter an MPI number in the Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Required when the rendering provider is supervised by a physician or dentist Supervising provider s middle initial This field 1s automatically populated after you select or enter an MPI number in the Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Required when the rendering provider is supervised by a physician or dentist RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 128 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 6 Complete Other Insurance G HP Provider Electronic Solutions Sax File Edit View Forms Tools Window Help DRX CHe e aa a72 e eh Enl 837 Dental Total Charge PII Of Amount ii Billed Amount ea Services Hdr1 Hdr2 Hdr3 Hdr4 OF srv 1 swv2 Release of Medical Data UE Benefit Assignment Y Payer Responsibility i Add
338. patient 63 Professional NCPOP Pharmacy NCPOP Pharmacy Eligibility NCPOP Pharmacy Reversal Choosing a selection from a drop down list as indicated in the field completion instructions below completes many of the fields A drop down list is also known as a reference list For additional information on reference lists refer to the Lists options under Section 6 Step 2 Complete Header 1 R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 107 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 G HP Provider Electronic Solutions 4 4 File Edit View Forms Tools Window Help RX VH So BRES E E4 2 6 Claim Status Inquiry Request Hdr 1 Har2 HPI Delete Last Org Name First Name hil Undo All All Recipient ID Medical Record Gave E Last Name First Name hil Send Provider ID ee Y Location Code c Copy Find Billed Amount Last Submit Dt Fid Print Close Provider ID Select the 9 digit MPI number from the drop down box or enter an appropriate value as specified that was used to bill the submitted claim Location Enter the 4 digit location code that was used to bill the submitted claim Code This field is automatically populated after a Provider ID is submitted NPI Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Last Or
339. pecified form status Select the appropriate form status from this drop down list Submit Limits the detail report to Pharmacy Reversal Requests transmitted on Date the specified date Enter the appropriate date in this field Step 4 After you enter the report criteria click OF f The detailed report is generated and displayed on your screen R PA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 348 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Use the scroll bars located on the right side and bottom of the screen to view the entire report 7 HP Provider Electronic Solutions File Forms Lists Reports Tools Window Help Oba DOK S IF ig NCPOP Pharmacy Reversal Detail Report Batch Number D Recipient Cardholder Do Form Status o Submit Date 0000 0000 Records selected Pharmacy Reversal Detail Report SE S ALL CLAIMS Provider ID 000965884 Location Code 0001 HPI 18551492326 Provider ID Code Qualifier 05 Date DF Service 06 22 2015 Prescription 7 Service 0622201 Rx 7 Service Qualifier 1 NDC Service ID OO071015525 HDC Service Qualifier 03 New Refill 0 rT Step 6 Click Print to print the NCPDP Pharmacy Reversal Detail Report Step 7 Click Close to exit the NCPDP Pharmacy Reversal Detail Report screen 11 18 NCPDP Pharmacy Reversal Summary Report You can generate a summary report for NCPDP Pharmacy Reversal Requests using the Provider E
340. port File Forms Lists Reports Took Window Help Y Ghee DOR ol 1 5 837 Professional Summary Report Batch Number i Recipient Coardhokier IDE s lt i i S S Form Status Submit Date Drow Recordi selected 837 Professional Summary Report As of 00 10 2015 ALL CLAIMS Hecgwent ID Last Name First Hame Billed Amount Lar Submit Dit Datus 101772013 From 005 To DOS Procedure LI nits 1 Tea 3 12013 33211 STE 1S 62503 Step 6 Click Print to print the 837 Professional Summary Report Step 7 Click Close to exit the 837 Professional Summary Report screen 11 13 NCPDP Pharmacy Detail Report You can generate a detail report for Pharmacy Claims using the Provider Electronic Solutions software This detail report contains all the fields on the NCPDP Pharmacy Form To generate an NCPDP Pharmacy Detail Report perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select the NCPDP Pharmacy option from the Detail Forms drop down menu The NCPDP Pharmacy Detail Report screen is displayed Step 2 Click 0K to include all the Pharmacy Claims in the detail report Step 3 Click 0K when prompted by the box that advises you that all records will be selected RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 339 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 The detailed report is generated and
341. pplication If you have a form open the application requires you to close the form before you exit the application ip HP Provider ectronic Berean Forme m Communication tistsmReportsmToolseSecuritymWindowmi chy Open HIPAA Response File Exit 6 3 2 Forms The Forms option lets you select an on line form You can also click the appropriate short cut icon to access the forms Lists Reports Tools Security Window Help 10 0 Eligibility Request 16 Claim Status Request 37 Dental 637 Institutional Inpatient 63 Institutional Nursing Facility oa Institutional Qutpatient 37 Professional NCPOP Pharmacy NCPOP Pharmacy Eligibility NCPDP Pharmacy Reversal R PA MMIS CMcElheny PES_Manual_ 5010 4 00 _ICD10 docx August 31 2015 30 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 6 3 3 Communication The Communication option lets you submit batches of forms and process batch responses resubmit batches of forms and view Communication Log files File Forms Communication Lists Reports Tools Security Window Help Submission Resubmission View Batch Response 835 ERA View Bulletin View Submit Reports View Communication Log 6 3 4 Lists The Lists option lets you add and edit reference lists Reference lists are customized drop down lists that you create from which information is selected to complete data entry fields You can access reference lists by using the Lists option
342. ppropriate value as specified P Signature generated by provider because the patient was not physically present for service Enter the appropriate code for the type of attachment submitted as specified or select the appropriate code from this drop down list AS Admission Summary NN Nursing Notes B2 Prescription OB Operative Notes B3 Physician Order OZ Support Data for Claim B4 Referral Form PN Physical Therapy Notes CT Certification PO Prosthetics and Orthotic DA Dental Models Certification DG Diagnostic Report PZ Physical Therapy Certification DS Discharge Summary RB Radiology Films EB Explanation of Benefits RR Radiology Reports MT Models RT Report of Tests and Analysis Report RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 238 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Report Enter the appropriate code for the method of attachment transmission Transmission Code AA Available on request at provider site BM By mail EL Electronically Only EM E Mail FT File Transfer FX By Fax Attachment Enter the 9 digit attachment control number obtained from the Control PROMISe web site This number is used when a paper attachment is Number required by MA to cross reference the paper attachment with the electronic claim This number must also be written on the cov
343. priate code from the drop down list or enter an appropriate value as specified P Payer 1 S Payer 2 T Payer 3 A Payer 4 B Payer 5 C Payer 6 D Payer 7 E Payer 8 F Payer 9 G Payer 10 H Payer 11 U Unknown Select a carrier code from the drop down list or enter an appropriate value as specified The carrier code identifies the recipient s third party insurance carrier Policyholder s last name This field is automatically populated after you select a group number Information cannot be entered directly into this field If you need to add or edit information in this field access the Policy Holder Form Policyholder s first name This field 1s automatically populated after you select a group number Information cannot be entered directly into this field If you need to add or edit information in this field access the Policy Holder Form The window is only active if the payer is Medicare with Claim Code filing code of MB and the Payer Responsibility is not P Primary Select the appropriate value from the dropdown box that identifies the type of insurance listed or enter an appropriate value as RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 195 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 specified Insurance Type Code is a Do Not Use field in the 837 Institutional Implementation Guide 12 Medicare
344. priate value as specified Name of the person or entity who accepts the insurance policy indicated in the Carrier Code field This field is automatically populated when a Carrier code is selected Information cannot be entered directly into this field If you need to add or edit information in this field access the Policy Holder Form Step 12 2 The service adjustment lines are linked to the claim line that is highlighted when you access the Service Adjustment screen Make sure that you have the correct service line highlighted Step 13 Click Step 14 Click E Save to save the Institutional Outpatient form to start another Institutional Outpatient form Complete a 837 Professional Form The 837 Professional Form is used to create claims for outpatient services Note Dispensing Providers should use this option for submitting and voiding claims Note Consolidated Community Reporting for OMHSAS CCR submissions can now be performed using PES software Version 3 57 The 837 Professional Form is divided into eleven screens Each screen contains the following data RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 232 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Hdr 1 Accesses the screen that contains the provider and recipient information Hdr 2 Accesses the screen that contains the diagnosis information emergency indicator patient paid place of service prior autho
345. r 3 Copayment Amount 35 Lifetime Benefits Maximum has been reached 45 Charge exceeds fee schedule maximum allowable or contracted legislated fee arrangement 50 Non covered services In the right segment of this field enter the amount of the adjustment Use a decimal point Type of other insurance claim that is submitted Select the appropriate claim code from the drop down list or enter an appropriate value as specified MC Medicaid 11 Other Non Federal Program 12 Preferred Provider Organization PPO 13 Point of Sale POS 14 Exclusive Provider Organization EPO 15 Indemnity Insurance 16 Health Maintenance Organization HMO Medicare Risk 17 Dental Maintenance Organization AM Automotive Medical BL Blue Cross Blue Shield RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 222 CH CHAMPUS CI Commercial Insurance Co DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B OF Other Federal Program TV Title V VA Veteran Administration Plan August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Adjustment Group Code Payer Responsibility Full Medicare Days Medicare ICN Paid Amount WC Workers Compensation Health Claim ZZ Mutually Defined Ge
346. r 8 Pat O I Accesses the screen that contains admission discharge contract and DRG information Note This screen has been revised with PES 3 57 for Consolidated Community Reporting for OMHSAS CCR submissions Accesses the screen that contains Surgical code and date information Enter the date the 2 digit month 2 digit day and 4 digit year the procedure was performed in the right segment of the field For example enter 10012015 if the date was October Ist 2015 Accesses the screen that contains Diagnosis Codes Present on Admission E Code and Auto Accident State Accesses the screen that contains the Rendering Provider Attending Provider and Operating Provider information Accesses the screen that contains patient information which is used for newborns and is accessed by selecting Y in the Newborn Indicator located under the Hdr 5 tab The O I screen contains other insurance carrier information and 1s accessed by selecting Y in the Other Insurance Ind field located under the Hdr 5 tab Note Consolidated Community Reporting CCR for OMHSAS submissions must include the MCO ICN when the Claim Filing Indicator Code field is HM Crossover The Crossover screen contains Medicare information It is accessed by Srv 1 selecting Y in the Crossover Ind field located under the Header 5 This screen contains billing information For additional information on a particular field highlight the field with
347. ractive When a single form is submitted and a response is received back Transaction within a few minutes Batch When several forms are submitted at the same time and processed Transaction through the system This one batch transaction type is used to submit both 837 claim files and Batch 270 eligibility requests Step 3 Enter data for each transaction description regardless of the transaction type Step 4 Click a transaction description listed at the bottom of the Carrier screen and complete all applicable fields Step 5 Click the other transaction description and complete all applicable fields Step 5 1 Complete Carrier Step 6 Choose Intact Transmit from the bottom of the screen under Transaction Type to configure the Interactive Transaction Carrier DTR Leave this value at the automatically populated value 9600 Carrier ID Select INT_TOLL_FREE from the drop down list Phone Automatically populates when the Carrier ID is selected If you need Number to dial an access code prior to accessing an outside line enter that number followed by a comma prior to the phone number ex 9 18666270017 Net ID Enter PAMP Enter this field exactly as shown because the value is case sensitive RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 22 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Net Password Enter pamopds Enter this field exactly as shown
348. rade of the PES software Important note for users applying the upgrade Prior to running the upgrade complete the following e Make sure all claims have already been submitted and are in an F Finalized status DO NOT have any claims that are in Incomplete or Ready status e Please Archive claims that are in a Final status e Create a copy of the Database panewecs mdb and save it so that you have a backup of your database UPGRADES MUST BE INSTALLED IN SEQUENTAL ORDER 3 57 3 58 3 59 3 60 3 61 4 00 Note For the first submission after upgrading to the Provider Electronic Solutions PES Software Version 4 00 Do not copy claims that were created using PES version 3 61 or earlier Please key in all information for first submission after the upgrade to the PES version 4 00 For all submissions following you can copy claims and submit using this information RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 3 1 Installation from a Downloaded File You can download the Provider Electronic Solutions software from the DHS Web site at http promise dpw state pa us ePROM _ProviderSoftware softwareDownloadMain asp_ Please open the Instructions to download from the web and follow the instructions to download the Provider Electronic Solutions software Using the links on the Website Please install t
349. rating detail and summary reports the Reports menu lets you access a Reference list and view and print a Master list of the selections for that Reference list To generate a master list of selections for a Reference list perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select the reference list for which you would like to view selections from the Reports drop down menu The Master Listing screen is displayed It lists each selection of the reference list Step 2 Use the scroll bars located on the right side and bottom of the Master Listing screen to view all the selections for the reference list RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 351 PA PROMISe Provider Electronic Solutions Software User Manual 65 HP Provider Electronic Solutions File Forms Lists Reports Tools Window Help OS ha Db OK S Or rag Master Listing Listing Preview Provider Detail Listing o Asoft aiigogis Provider ID License B F aciity ID 100754414 Location Code 0073 ID Code Qualifier G2 Emily Type Qualifier 2 Last Org Name ALEERT EINSTEIN MEDICAL GROUP First Hame Hi SSH Tax ID Taxonomy Code O00000000 HFI Provider Addins Line 1 1 PHILA Line 2 City PHILA Slate FA Step 3 Click Print to print the master listing Step 4 Click Close to exit the Master Listing screen RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 352 Version 4 00
350. rdholder following format 10 digit ACCESS number and 2 digit card issue number 1 e 123456789000 First Name Enter the cardholder s first name Last Name Enter the cardholder s last name RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 57 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 3 Click __ Save when all data entry fields are completed If any required fields were missed you are prompted to complete them Step 4 Click _ Add and repeat steps 2 3 and 4 to add another NCPDP cardholder to the NCPDP Cardholder reference list Step 5 Click __ Close to exit the NCPDP Cardholder screen 8 2 NCPDP Provider Reference List To complete the data entry fields on the NCPDP Provider reference list perform the following Step 1 Click Lists NCPDP NCPDP Provider to access the NCPDP Provider reference list Ag HP Provider Electronic Solutions Ey Ly File Edit View Forms Lists Tools Window Help 3x e nlel ealas mlk G NCPDP Provider Provider ID 123456789 Location Code 0001 ID Qualifier 05 NPI 1111111122 Last Org Name NCPDP First Name TEST Undo All Trovider ID 111 0001 Step 2 Enter the data requested for each field as described below Provider Enter the 9 Digit MPI number assigned to you by DHS ID Location Enter the 4 digit location code assigned to you by DHS for your MPI Code Number If mu
351. re three Reason Code Amount fields Each field is divided into two segments In the left segment of the field select the appropriate reason code from the segment s drop down list or enter an appropriate value as specified The reason code identifies the reason the adjustment is being made to the claim line as described below 1 Deductible Amount 118 ESRD Network Support Adjustment119 Benefit Maximum for this time period has been reached 2 Coinsurance Amount 23 Payment adjusted because charges were paid by another payer 3 Copayment Amount 35 Lifetime Benefits Maximum has been reached 45 Charge exceeds fee schedule maximum allowable 50 Non covered services In the right segment of the field enter the amount of the adjustment using a decimal point For example enter 105 50 if the adjustment amount was 105 50 RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 167 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Claim Filing Indicator Code Adjustment Group Cd Select the appropriate claim code from the drop down list or enter an appropriate value as specified The claim code identifies the type of other insurance claim that is being submitted Note Consolidated Community Reporting for OMHSAS CCR submitters must use the Claim Filing Indicator Code HM Using HM activates the MCO ICN field MC Medicaid 11 Other Non
352. reached 2 Coinsurance Amount 23 Payment adjusted because charges were paid by another payer 3 Copayment Amount 35 Lifetime Benefits Maximum has been reached 45 Charge exceeds fee schedule maximum allowable or contracted legislated fee arrangement 50 Non covered services Enter the amount of the adjustment in the right segment of the field using a decimal point For example enter 105 50 if the adjustment amount was 105 50 RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 190 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Paid Date Amount Carrier Code Policy Holder Group Number Policy Holder Group Name Policy Holder Last Name Policy Holder First Name Policy Holder This field 1s divided into two segments In the left segment of the field enter the 2 digit month 2 digit day and 4 digit year on which the recipient s third party insurance carrier paid or denied the claim For example enter 10012015 if the date was October 1 2015 Enter the amount paid by the other insurance carrier in the right segment of the field using a decimal point For example enter 105 50 if the paid amount was 105 00 A zero 0 amount may be entered If the third party insurance carrier paid 0 00 you still should complete the Paid Date Amount field with the date of third party insurance EOB denial and the amount of 0 00 Select the ca
353. reas start with Eligibility or Benefit Information and end with Last Org Name A list of all possible responses is included in Appendix B Eligibility or benefit information can list Medicaid as the insurance type code because the recipient is enrolled in Pennsylvania MA This section also includes service program information related to the recipient s enrollment Eligibility or Benefit Information Insurance Type Code Eligibility Date Free Form Message Text Last Org Name Plan Coverage Description Eligibility benefit information on record for the recipient Active services indicate that the recipient is eligible for services on the date requested Recipient s coverage type Health Maintenance Organization indicates that the recipient is enrolled in one of the Managed Care plans Date a recipient is eligible for the benefit information listed Primary care provider listed on the recipient s record Organization indicated in the Eligibility or Benefit Information line Recipient s service program Consult the latest Health Care Benefits Package information to determine the recipient s level of coverage When a 270 request cannot be processed an error message is returned instead of a 271 response A list of the currently used error codes is included in Appendix B RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 101 PA PROMISe Provider Electronic Solutions Sof
354. reen that contains accident rendering provider and service facility location information Hdr 4 Access the screen that contains the From DOS To DOS referring provider and the Supervising Provider information Other Accesses the screen that contains other insurance carrier information and Insurance OI can be accessed by selecting Y in the Other Insurance Ind field located under the Header 3 tab Srv 1 Accesses the screen that contains service information RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 112 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Srv 2 Accesses the screen that contains miscellaneous treatment information Service Accesses the screen that contains third party insurance carrier adjustment Adjustment information It can be accessed by selecting Y in the Other Insurance Ind Srv Adj field located under the Header 3 tab then selecting Y in the Service Adjustment Ind field located under the Service 2 tab For additional information on a particular field highlight the field with your mouse and press F1 To create a dental claim perform the following steps Step 1 From the Provider Electronic Solutions software main screen access the 837 Dental Form in one of the following two ways Click L amp 837 Dental Shortcut Button on the Toolbar or Select the 837 Dental Option from the Forms drop down menu as shown below 4 HP Provider Ele
355. riate code from the drop down list or enter an Codes appropriate value as specified Ambulance 01 Patient was admitted to a hospital RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 261 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Patient Count Contract Type Contract Code Contract Version Billing Note Family Planning 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair Required when more than one patient is transported in the same vehicle for Ambulance or non emergency transportation services The indicator represents the contract between the provider and the managed care or sub capitation subcontractor Choose a value from the drop down list Note Fee For Service Providers who are billing directly to Medical Assistance do not use this field For Consolidated Community Reporting for OMHSAS CCR Enter the appropriate contract code information The contract number between the provider and the managed care or sub capitation subcontractor Note Fee For Service Providers who are billing directly to Medical Assistance do not use this field For Consolidated Community Reporting f
356. ric Drug Not Available in Marketplace 9 Substitution Allowed by Prescriber Date Enter the 2 digit month 2 digit day and 4 digit year on which the Prescribed prescription was written For example enter 01012015 if the date was January 1 2015 Other Select the other coverage code from the drop down list or enter an Coverage appropriate value as specified This code indicates if the recipient Code has other drug coverage The default value for this field is 00 If you select 02 the COB screen appears 00 Not Specified 01 No Other Coverage 02 Other Coverage Exists Payment Collected 03 Other Coverage Exists Claim Not Covered 04 Other Coverage Exists Payment Not Collected 08 Claim is Billing for Patient Responsibility Copay Usual and Enter the amount charged to cash customers for the prescription Customary exclusive of sales tax or other amounts claimed This value should Charge include a decimal point Step 3 1 Click Add DU to add another detail line A new blank detail line is added to the screen Step 3 2 Click on the new detail line and then enter the data in the appropriate data fields Step 3 3 Click Copy DU to copy the data from an existing detail line to a new detail line A new detail line is added to the screen The new detail line has the same data as the existing detail line you previously selected You can edit the data in the new detail line Step 3 4 Click on the new detail line to make
357. rization and contract information Note Consolidated Community Reporting for OMHSAS CCR encounter submissions are indicated using the Encounter Ind To submit an encounter select RP from the field s drop down list Hdr 3 Accesses the screen that contains accident ambulance and admission information Hdr 4 Accesses the screen that contains any referring rendering provider service facility and supervising provider information Hdr 5 Accesses the screen that contains condition codes and ambulance information Pat Accesses the screen that contains patient information for newborn recipients Other Accesses the screen that contains other insurance carrier information and Insurance can be accessed by selecting Y in the Other Insurance Ind field located under the Header 3 tab Note The MCO ICN is required for Consolidated Community Reporting for OMHSAS CCR encounters submissions Srv 1 Accesses the screen that contains service information Srv 2 Accesses the screen that contains ambulance information for individual service lines Srv 3 Accesses the screen that contains additional rendering provider information and the service adjustment indicator Srv Adj Accesses the screen that contains third party insurance carrier adjustment information It can be accessed by selecting Y in the Other Insurance Ind field located under the Header 3 tab and then selecting Y in the Service Adjustment Ind field located under the Service 3 Screen
358. rmation related to the claim Screen contains information regarding compound claims Screen contains information related to the reimbursement received from other payers Screen contains information related to the reimbursement received from other payers For additional information on a particular field highlight the field with your mouse and press F1 To create a pharmacy claim perform the following steps Step 1 RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx From the main screen of the Provider Electronic Solutions software access the NCPDP Pharmacy Form in one of two ways Click NCPDP Pharmacy Shortcut icon on the Toolbar or Select the NCPDP Pharmacy option from the Forms drop down menu August 31 2015 269 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 g HP Provider Electronic Solutions Forms Communication Lists Reports Tools Security Window 270 Eligibility Request 16 Claim Status Request 63 Dental 63 7 Institutional Inpatient amp 37 Institutional Nursing Facility 63 Institutional Outpatient 63 Professional NCPDP Pharmacy NCPDP Pharmacy Eligibility NCPDP Pharmacy Reversal The NCPDP Pharmacy Form appears with the Header screen displayed Step 2 Complete Header 1 Trans Code E1 Provider ID Location Code NPI Copy Date OF Service 0070070000 Delete Cardholder ID Undo All Last Name First Name Save Date OF
359. rmed Provider or double click in the data entry portion of the field to add a reference list selection Note The Referring Provider is required for all provider types Note Dispensing Providers Referring Provider is the Prescriber and must be submitted with an NPI Note For Access Plus Referred Services select the 13 digit MAID number for the referring provider from the field s pull down list Location Code Referring provider s 4 digit service facility location number for the Referring MPI number selected in the Referring Provider ID field This field Provider is automatically populated with the correct information after an MPI number is selected in the Referring Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 246 Provider Electronic Solutions Software User Manual NPI Referring Provider Last Org Name Referring Provider First Name Referring Provider Middle Initial Referring Provider Provider ID Rendering Provider Location Code Rendering Provider NPI Rendering Provider Last Org Name Rendering Provider RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx PA PROMISe Version 4 00 Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers pl
360. rom the drop Codes down list or enter an appropriate value as specified Admit ICD 9 CM ICD 10 CM PCS diagnosis code corresponding to the Diagnosis diagnosis that prompted the recipient s admission to the hospital Codes Select the admission diagnosis code from the drop down list or enter an appropriate value as specified RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 147 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 4 Complete Header 3 ig HP Provider Electronic Solutions File Edit View Forms Tools Window Help PH 837 Institutional Inpatient Total Charge OD 0I Amount 999i Billed Amount I Services Hdr1 Hdr2 Hdr3 Har 4 Har5 Hdr6 Har7 Hars sm1 Occurrence Codez Dates Add 1 oa e o a 3 loom Tn se coe __ Fi nnd 0171010701011 gsh o pooo Delete Occurence Span Codes Dates Condition Codes Undo All 1 0000 0000 00 00 0000 2 00 00 0000 00 00 0000 3 00 0070000 00 00 0000 Days Covered Non Covered Coinsurance Lifetime Reserve Recipient ID Last Hame First Marne Billed Amount Last Submit Dt Occurrence Each field is divided into two segments Codes Dates Fields 1 8 In the left segment of the field enter an appropriate occurrence code as specified or select the appropriate occurrence code from the segment s drop down list as described below 01 Aut
361. ronic Solutions Database in the following folder To install in this folder click Next or click Browse and select another folder fou can choose not to install H P Provider Electronic Solutions Database by clicking Cancel to exit Setup Destination Folder c papromise Browse InstallShield Step 10 When the Information screen is displayed click OF This screen shows the drive and directory where the files were installed H F Provider Electronic Solutions a 1 Please note the database destination folder For Future WORKSTATION setups Step 11 When the Setup Completed screen is displayed click Finish to complete the setup RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 H P Provider Electronic Solutions InstallShield Wizard Complete Setup has finished installing H P Provider Electronic Solutions on your computer Eancel 3 3 Install the Software to a Network Step 1 Install the Provider Electronic Solutions software as a Typical installation Step 2 When asked where you would like to install the database Select the location on the network Step 3 To install the software on the workstation Install the software as described above Step 4 When asked to choose between typical and workstation installation Select workstation installation Step 5 When asked where the database is located
362. rovider s middle initial This field 1s automatically populated with the correct information after an MPI number is selected in the Rendering Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form If the services are being rendered only in an inpatient hospital emergency room hospital special treatment room hospital short procedure unit ambulatory surgical center or a renal dialysis center Select the ID number for the service facility location from the drop down list or Double click on the data entry portion of the field to add a reference list selection The format of the Facility ID should be the 9 digit MPI number provided by the facility The 4 digit service facility location code associated with the MPI number selected in the Service Facility ID number field This field is automatically populated with the correct information after an MPI number is selected 1n the Facility ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Facility name if the services are being rendered in an inpatient hospital emergency room hospital special treatment room hospital short procedure unit ambulatory surg
363. rovider field Information cannot be entered directly into these fields to add or change information in these fields access the Provider List Form Select the 9 digit MPI number from the drop down list or double click on the data entry portion of the field to add a reference list selection This is required when the rendering provider is supervised by a physician or dentist Individual last name or organizational name 4 digit location code associated with the MPI number selected in the Provider ID field This field is automatically populated after you select or enter an MPI number in the Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form August 31 2015 127 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 NPI Supervising Provider Last Org Name Supervising Provider First Name Supervising Provider MI Supervising Provider Required when the rendering provider is supervised by a physician or dentist Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Required when the rendering provider is supervised by a physician or dentist Supervising Provider s last name or the name of the group or facility This field is automatically populated after you select or enter an MPI number in the Pr
364. rovider Electronic Solutions Software User Manual Version 4 00 successfully certify on Batch Transactions change this value to 4 for production Note PES users do not need to certify Production The default for this indicator is P since PES users do not need to Test Indicator certify on Batch Transactions if you choose to test change this value to T 5 7 Payer Processor The Payer Processor screen contains payer processor information To access the Payer Processor screen Step 1 Click the Payer Processor tab in the Tools Options box Modem web Batch Interactive Carrier Payer Processor Retention Hame DEPARTMENT OF HUMAN SERVICES ETIN 345529167 Identifier Code Qualifier Fi Identifier Code 2360031 13 Help NCPDP Certification ID P4 amp N01 500 HCPOP Submitter ID JB456571 F Eligibility Submitter ID E5654 H Print Eligibility Batch Eligibility Interactive Terminal ID FAB01001 Terminal ID PAxoono2 Transmission Type EOTH Close Note The ETIN number defaults to the production number 345529167 since PES users do not need to certify Note This screen automatically populates and should not be altered unless directed by HP Enterprise Services or DHS RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 24 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Modern web Batch Interactive Carrier Payer Processor
365. roxy Information fields including Address HTTP Port HTTPS Port and Proxy Bypass will be unprotected for entry Address HTTP Port and HTTPS Port will be required entry Dialup Network IS NO LONGER AVAILABLE Proxy Information Address is required entry when Use Proxy Server is selected This is the address Universal Resource Locator or URL of the proxy server used to connect to the internet HTTP Port is required entry when Use Proxy Server is selected This is the port number that the proxy server uses for standard Hyper text Transfer Protocol HTTP communication HTTPS Port is required entry when Use Proxy Server is selected This is the port number that the proxy server uses for secure Hyper text Transfer Protocol HTTPS communication Proxy Bypass is optional entry when Use Proxy Server is selected This is the address s URL s that do not use the proxy server to be rendered Select the Environment Indicator that you will be using If you are sending test files for Certification you would set this to T If you are sending production files for processing into the PROMISe system you will set this to P Environment Ind defaults to P Production environment This field is used in formatting the X12 transactions Interactive Ind Choose W Web for the Web based Interactive communication method B BBS for BBS modem method IS NO LONGER AVAILABLE Note After obtaining the Provider Electronic Solut
366. rrier System carrier information Payer Processor System payer processor information Retention System retention information a To make changes to the Options Form perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select Options from the Tools drop down menu The Options form appears with the Modem screen displayed Step 2 Select the screen that contains the fields you want to change Step 3 Make the appropriate changes and click K to save the changes For additional information about completing the Options screens see section 5 Complete Transmission Options of this manual Com Fort B Hodem Type Conexant Conexant SmartH SFi 92 56E OF PEI Modern Detect Step 4 Click A 00 exit the Options box RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 362 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 If you have made any changes and NOT clicked x the following screen is displayed HP Provider Electronic Solutions Application Click ow to save your changes or Click _ Mo to delete your changes or Click __ Cancel to return to the Options box RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 363 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 13 Security Functions The Provider Electronic Solutions software provides a secur
367. rrier number for the third party insurance from the drop down list or enter an appropriate value as specified or double click on the data entry portion of the field to add a reference list selection Resource code that identifies the third party insurance carrier This field is automatically populated after you select or enter a carrier code Information cannot be entered directly into this field If you need to add or edit information in this field access the Policy Holder Form Name of the group or business that makes the insurance available to the insured person this is not the third party insurance carrier This field 1s automatically populated after you select or enter a Carrier Code Information cannot be entered directly into this field If you need to add or edit information in this field access the Policy Holder Form Policyholder s last name This field is automatically populated after you select or enter a carrier code Information cannot be entered directly into this field If you need to add or edit information in this field access the Policy Holder Form Policyholder s first name This field 1s automatically populated after you select or enter a carrier code RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 191 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Information cannot be entered directly into this field If you need to add or edit information
368. rsal RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 94 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 9 1 Complete a 270 Eligibility Request Use the 270 Eligibility form to verify recipient eligibility This form is divided into three screens Each screen contains Header 1 Provider and recipient information Service Service Type code Header 2 Information about a specific request Use one of the following combinations of recipient information to recipient eligibility e Recipient ID number and card issue number e Recipient Social Security Number SSN and birth date e Recipient first and last name and birth date Please use the most specific information available to obtain the most accurate eligibility information possible For additional information on a particular field highlight the field with your mouse and press F1 To create a 270 Eligibility Report perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software access the 270 Eligibility Request Form using one of the two ways listed below Click 270 Eligibility Request Shortcut Button on the Toolbar or Select the 270 Eligibility Request Option from the Forms drop down menu The 270 Eligibility Request form is displayed with the Header 1 screen displayed as shown on the next screen RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 95 PA
369. s or future greater than last day of the current month R a ePrescribing Date Of Service cannot be in the past ___ Security Number SSN submitted contains alpha characters or is not 9 digits Verify the SSN you submitted Inconsistent with Error only applies to inquiries that include a procedure code Patient s Age or NDC The recipient is too young or too old for the procedure code or NDC submitted Inconsistent with Error only applies to inquiries that include a procedure code Patient s Gender or NDC The gender of recipient is not valid for the procedure code or NDC submitted Patient Birth Date Does Error returned if DOB submitted does not match recipient Not Match That for the DOB on file Patient on the Database ane Recipient number submitted on the inquiry 1s invalid is not Subscriber Insured ID e numeric or 10 digits in length or the card issue number is invalid Verify that you submitted a valid 10 digit recipient number and the current card issue number lt OR gt Under 5010 the Error 72 can be returned in situations where more than one recipient 1s found for the search criteria specified on the 270 Typically Name DOB or SSN Dob search lt OR gt With CAQH CORE an error 72 1s now returned when the valid RID sent does not match any RID on CIS lt OR gt the RID sent is all ZERO s Invalid Missing Missing First or Last Name Subscriber Insured Name 75 Subscriber Insured Not Recipient was no
370. s Assignment vx Patient Signature gt Report Type Code x Report Transmission Code x Attachment Ctl _ i E Recipient ID Last Name First Hame Billed Amount Last Submit Dt 1112345671 TESTER a Undo All Sony Delte Undo An E l Save FRE RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 54 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 7 HP Provider Electronic Solutions 837 Professional J File Edit View Forms Tools Window Help DRX 9He S Be0 804 8 k Total Charge EET 01 Amount ET Billed Amount i Services Bl Hdr 1 Har 2 Hdr3 Hdr4 Hdr5 svi sw2 sr3 Claim Frequency i Original Claim s Add Provider Role Copy Provider ID 111111111 Location Code 0001 NPI 3333333333 Dalen Last Org Name TESTER 1 First Name TEST MI Recipient ID SaaS Medical Rec DOB 00 00 0000 Last Name First Name Hl Release of Medical Data gt Account H o Benefits Assignment vx Patient Signature xl Report Type Code gt Report Transmission Code gt Attachment Ctl A l Recipient ID Last Mame First Marne Billed Armour Last Submit Dit 1112345671 TESTER 7 Undo All Save _ cw Delete _ Undaan e l dd Step 3 Click the selection listed at the bottom of the screen that you would lik
371. s Codes Reason For isit 1 2 3 Principal Other 1 gt ss ST a mo E Code 2a 3 4 S E y JA a 1 12 Find Print Close Last Name First Name Billed Amount Last Submit Dt Use the ICD 9 ICD10 Version for the code being submitted Most specific ICD 9 CM ICD 10 CM PCS diagnosis code that indicates what caused the recipient to contact the facility Select the Reason for Visit diagnosis code from the drop down list or enter an appropriate value as specified Primary diagnosis code is the most specific ICD 9 CM ICD 10 CM PCS diagnosis code that relates to a recipient s stay Select the principal diagnosis code from the drop down list or enter an appropriate value as specified Indicate additional diagnoses that relate to the recipient s condition Diagnosis code that describes the external cause of the recipient s injury Select the external diagnosis code from the drop down list or enter an appropriate value as specified August 31 2015 205 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Condition Each Condition Code field identifies a condition relating to the invoice that may Codes affect payer processing Enter the appropriate 2 character condition code or select the appropriate code from the drop down list or enter an appropriate value as specified 02 Condition is Employment Related 03 Patient Covered by Insurance Not Reflected Here 05 Lien
372. s are populated A drop down list is also known as a reference list For additional information on reference lists refer to the List options in Section 6 R PA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 297 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Provider ID Location Code NPI Date Of Service Provider ID Qualifier Cardholder ID Last Name First Name Select the 9 digit MPI for the payee from the drop down list or double click on the data entry portion of the field to add a reference list selection 4 digit location code associated with the 9 digit MPI selected This field is automatically populated after you select a Provider ID Pharmacists who qualify as a QSB should add a Q as the fifth character in the Location Code Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Enter the 2 digit month 2 digit day and 4 digit year on which the service was provided For example enter 01012015 if the date was January 1 2015 Qualifier code for the Provider ID Number The qualifier code must always be 05 for NCPDP providers Select the cardholder ID number from the drop down list or double click on the data entry portion of the field to add a reference list selection Cardholder ID numbers are issued to recipients who are authorized to receive Pennsylvania Medicai
373. s of a dispensed drug Note Required if being used by Dispensing Provider August 31 2015 226 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Drug Unit of Select the value from the drop down box or enter an appropriate value Measure as specified Step 9 1 Step 9 2 Step 9 3 Step 9 4 GR Gram ML Milliliter UN Unit Note Required if being used by Dispensing Provider To add additional service lines and revenue codes clic A new blank service line is added to the screen Click on the new service line and then enter the service data in the appropriate fields as described above To copy the data from an existing service line to a new service line click on the existing service line you want to copy then click Copy Sv A new service line is added to the screen that has the same data as the previously selected service line Edit the data in the new service line by clicking on the new service line then making changes to the appropriate fields To delete an existing service line click on the service line that you want to delete Delete Srv and then click The selected service line 1s deleted RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 22 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 10 Complete Service 2 p 837 Institutional Outpatient o eal Total Charge i Ol Amount i Billed Amount
374. s with the specified form status Select the appropriate form status from this drop down list Limits the summary report to Pharmacy Reversal Requests transmitted on the specified date Enter the appropriate date in this field Step 4 After you enter the report criteria click 0K f The software generates the summary report and displays it on your screen Step 5 Use the scroll bars located on the right side and bottom of the screen to view the entire report R PA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 350 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Ag HP Provider Electronic Solutions File Forms Lists Reports Tools Window Help ey OhGabOR S Ik ig NCPDP Pharmacy Reversal Summary Report Batch Number O Recipient Cardholder C Form Status o Submit Date 0070070000 Records selected Pharmacy Reversal Summary Report AS Of 08 18 2015 ALL CLAIMS Provider ID NDC Service ID Prescription Date Of Service Last Submit Dt Status ON0S6886 40001 06 22 2015 06 22 2015 HPI 1851492326 Provider ID NDC Service ID Prescription Date OF Service Last Submit Dt Status OO0S6888 40007 062272015 067 2272015 HPI 1651492326 Step 6 Click Erint to print the NCPDP Pharmacy Reversal Summary Report Step 7 Click Close to exit the NCPDP Pharmacy Reversal Summary Report screen 11 19 Master List of Selections for a Reference List In addition to gene
375. se whenever you have trouble accessing your data The repair procedure tries to validate all system tables and all indexes Note You should compact your database after you use the repair procedure To repair your database perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select the Repair option from the Database Recovery drop down menu The message Repairing Database is displayed while the database is being repaired Step 2 After the database has been successfully repaired this Application box is displayed with a message that indicates if the action was successful Step 3 Click OF to clear the message from your screen 12 4 Unlock Your Database You should unlock your database whenever system errors cause your database to lock To unlock your database perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select the Unlock option from the Database Recovery drop down menu RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 355 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 2 After the database has successfully unlocked this Application box is displayed with a message that indicates if the action was successful Application Step 3 Click 0K to clear the message from your screen Note If when submitting claims using the Provider Electronic So
376. st To complete the data entry fields needed to add or edit a National Drug Code NDC reference list selection perform the following steps Step 1 Click Lists NDC to access the NDC reference list RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 75 PA PROMISe Provider Electronic Solutions Software User Manual 9 HF Provider Electronic Solutions File Edit View Forms Lists Tools Window Help 5 xe mlel alas a m r Version 4 00 GO NDC HDC Description Description Step 2 Enter the data requested for each field as described below Delete Undo All Save Find Print NDC Enter the NDC for the drug dispensed This field accepts a maximum of 11 numeric characters Enter a description of the NDC being added Step 3 Click aave when all data entry fields are completed Step 4 Click o d and repeat steps 2 3 and 4 to add another NDC to the NDC reference list Step 5 Click Cose to exit the NDC screen 8 13 Occurrence Reference List To complete the data entry fields needed to add or edit an Occurrence reference list selection perform the following steps RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 76 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 1 Click Lists Occurrence to access the Occurrence reference list Ag HP Provider Electronic Solutions File Edit View Forms Lists Tools EA
377. st Ong Mame SAVEGH PEDIATRIC THERAPY SERVICE Fint Hame Recipient ID Medical Record 8 Lat Mame Fast Hame SOPHIA From DOS 057 1272013 To BOS 0571272013 Type OF BH Billed Amoun Claim Accoum _ Step 6 Click o Print to print the 276 Claim Status Request Detail Report Step 7 Click Cose to close the Detail Report screen 11 4 276 Claim Status Summary Report You can generate a summary report for a Claim Status Request using the Provider Electronic Solutions software This summary report contains only the key fields on the 276 Claim Status Request Form To generate a 276 Claim Status Request Summary Report perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software select the 276 Claim Status option from the Detail Forms menu The 276 Claim Status Request Summary Report screen is displayed Step 2 Click OR to include all the requests in the summary report Step 3 Click o K when prompted by the box that advises you that all records will be selected A detailed report is generated and displayed on your screen RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 322 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 To limit the type of request in the summary report enter the appropriate report criteria into one or more of the following fields Batch Number Recipient Cardholder ID Form Status Submit Date
378. t ef 6 Claim Status Request 2r Claim Status Response s of Dental NLCPOP Pharmacy Response s oa Institutional Inpatient 035 Electronic Remittance Advice dr Institutional Nursing Facility 999 Acknowledgenent s oa Institutional Outpatient Accepted Submit Report s oo Professional Rejected Submit Repart s NCPDP Pharmacy Bulletiri MLCPOP Pharmacy Eligibility Submission Transaction Reports R PA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 104 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 7 Step 8 Note Keep in mind that submitting by batch lets you receive several form types at the same time Although you can receive several form types simultaneously only the 270 Eligibility Request forms are processed for the next day of service Click Submit Note Ifthe transmission was unsuccessful read the message or communication log make the necessary changes and resubmit the files Select the 999 Acknowledgment s Accepted Submit Report s Rejected Submit Report s and Submission Transaction Report s Note These reports help determine what errors were encountered in processing the submitted file View Batch Response 835 ERA The View Batch Response 835 ERA option allow you to view and print a 271 Eligibility Responses or an 835 Electronic Remittance Advices ERA Note CARC Claim Adjustment Reason Codes RARC Remittance Advice Remark Codes
379. t 31 2015 111 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 View Batch Response 835 ERA The View Batch Response 835 ERA option allow you to view and print a 271 Eligibility Responses or an 835 Electronic Remittance Advices ERA Note CARC Claim Adjustment Reason Codes RARC Remittance Advice Remark Codes Additional information is located at the following links KEES For complete CARC RARC Descriptions please visit the following web site Washington Publishing Company _ http www wpc edi com CAQH CORE website http www cagh org Step 5 Select the Communication View Batch Response 835 ERA option from the main screen Step 6 Click the corresponding filename listed under the Filename column to view a particular batch Step 7 Use the scroll bar to view the batch response or Press _ Erint to print the 277 Claim Status Inquiry Responses Each form is assigned a transaction reference number which indicates the beginning of a new 277 Claim Status Inquiry Response 9 4 Complete the 837 Dental Form The 837 Dental Form is used to create claims for dental services The 837 Dental Form is divided into seven screens Each screen contains the following claim data Hdr 1 Accesses the screen that contains the provider and recipient information Hdr 2 Accesses the screen that contains ICD Version Diagnosis Codes and orthodontic treatment information Hdr 3 Accesses the sc
380. t Name Enter the Last name of the Prescriber Prescriber First Name Enter the First name of the Prescriber Prescriber Address Enter the Address of the Prescriber Prescriber Phone Number Enter the phone number starting with the area code do not put in Prescriber the dashes City Prescriber Enter the City for the Prescriber State Enter the State using the drop down list Prescriber Zip Prescriber Enter the 9 digit zip code corresponding to the city and state listed in the City and State fields This field holds a maximum of 9 numeric characters RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 284 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 6 Complete Coupon Pharmacy Total Charge J Amt Par D Billed Amt Ss Details Coupon Type Coupon Number Coupon Amount OO Delete Undo All Save Prescription Decimal Qty p00 Send Last Name First Name led Amt Last Submit Dit ree eRe Coupon Type Select the Coupon Type from the drop down list or enter an appropriate value as specified 01 Price Discount 02 Free Product99 Other Coupon Enter the Coupon Number Number Coupon Enter the amount for the Coupon amount Amount RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 285 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 7 Complet
381. t found based on the information submitted Found Verify the recipient information 76 Duplicate Based on the information submitted more than one recipient Subscriber Insured ID was found Use another search criteria such as Recipient Number number and card issue number RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 370 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Error 271 X12 Error Status Code Code Description Why the Error Set ia aes Te aut The Out of Network Provider ID submitted is not found toe reer es Verify you are using a valid 13 digit PROMISe out of network provider number OR ePrescribing At LP2100A level of the transaction the DHS Tax ID is present but it is not correct Verify that you are submitting the valid tax ID for DHS Invalid Card Internal The recipient s 2 digit card number supplied on the EVS Only Users see AAA request did not match the recipient s current active card 72 number Only appears in the PROMISE Online application EVS users see a 72 returned for an invalid card Recipient Not Found The Recipient ID and Card DOB were not found on file Internal Only Users see EVS users see a 72 returned AAA 72 Payer Name or Identifier The submitter did not identify DHS as the entity they are Missing sending the 270 request to e HIPAA Compliant Codes Currently PROMISe does not use all of the codes that
382. t or enter an MPI number in the Provider ID Attending field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Attending provider s middle initial This field 1s automatically populated after you select or enter an MPI number in the Provider ID Attending field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Select the 8 or 9 character Medical License number for the operating or surgical physician from the drop down list or double click on the data entry portion of the field to add a reference list selection 4 digit location code associated with the MPI number selected in the Provider ID field This field is automatically populated after you select or enter an MPI number in the Provider ID field August 31 2015 159 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form NPI Enter the NPI National Provider Identifier Numeric 10 digit identifier e th e o Operating consisting of 9 numbers plus a check digit in the 10 position Last Org Operating physician s last name This field is automatically populated after you Name select or enter an MPI number in the Provider ID Operating fi
383. t version from the pull down list The contract version is the month of the contract that was in force at the time of the service Note Fee For Service Providers who are billing directly to Medical Assistance do not use this field For Consolidated Community Reporting for OMHSAS CCR DRG is the diagnosis related group under which inpatient claims are adjudicated Information in this field is required for any inpatient encounter Consolidated Community Reporting for OMHSAS CCR submission Enter the appropriate CCR DRG Note The DRG field is activated when RP is indicated on Hdr 5 AND has a payer on the OI tab with the Claim Filing Indicator Code HM Without both conditions being met the DRG field will remain disabled RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 155 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 7 Complete Header 6 ig HP Provider Electronic Solutions eo j File Edit View Forms Tools Window Help 3 Rxv majet aalas mlk 837 Institutional Inpatient Sas Total Charge PTI Ol Amount TT Billed Amount INT Services Hdr 1 Hdr2 Hdr3 Hdr4 Hdr5 Hdr 6 Har 7 Harg svt Surgical Codes D ates if J J00400 0000 2 covOovoooo A aA i IW 5 oaoa e i pooni _ Com a OOOO 8 ooo a i o Delete wp i i oar oa OOOO Undo All Bp 117070771110 9 as NR COTE N 7070000 16 i i oann asl o poo save gp i i o
384. ter an appropriate value as specified Select Y 1f the recipient has Medicare Select N 1f the recipient does not have Medicare R PA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 184 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 5 Complete Header 4 ig HP Provider Electronic Solutions File Edit View Forms Tools DRX GHa olt Ba 874 E K Window Help fi 837 Institutional Nursing Facility Total Charge PT O Amount i Billed Amount ih Services Hdr 1 Hdr2 Hdr3 Hdr4 Hars svi Occurence Codes Dates 1 l 0000 0000 2 00 00 0000 3 jooon oggi Condition Codes il 2 I i Patient Estimated Amount Due OO Recipient ID Last Name Occurrence Code Dates Occurrence Span Codes Dates Fields 1 4 Occurrence Span Codes D ates 1 oa foa Copy a p ioaroon a D loooooO a ono ioooooO Undo All Yalue Codes Amounts Save if f om 2 00 Edit All 3 ot 4 p Delete First Marne Billed Amount Last Submit Dt eee erktet This field is not currently used in completing the 837 Institutional Nursing Facility Form Each field is divided into three segments In the left segment of the field enter the appropriate occurrence span code as specified or select the appropriate occurrence span code from the segment s drop down list as described below 74 Non covered Level of Care Leave of Absence In the middle s
385. tered Pharmacy Select the code from the drop down list or enter an appropriate value Type as specified 1 Community Retail Pharmacy Services 2 Compounding Pharmacy Services 3 Home Infusion Therapy Services 4 Institutional Pharmacy Services 5 Long Term Care Pharmacy Services 6 Mail Order Pharmacy Services 7 Managed Care Organization Services 8 Specialty Care Pharmacy Services 99 Other RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 2 5 Provider Electronic Solutions Software User Manual RX Service Rx Service Qualifier Authorized Refills NDC Service ID NDC Service Qualifier Quantity Dispensed New Refill Days Supply Compound Ind Dispense As Written RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx PA PROMISe Version 4 00 Enter the prescription ID number of the prescription that was filled If the prescription number is less than 12 numeric characters add zeroes to the beginning of the prescription number to make it equal to 12 characters ex 000000001234 Select the qualifier code from the drop down list or enter an appropriate value as specified The qualifier code must always be 1 for NCPDP claims Enter a number to indicate how many times this prescription can be filled Zero indicates Not Specified Select the 11 digit NDC for the product that was dispensed If the compound indicator field contains the value 2 then
386. ternational Classification of Diseases 10 Revision Clinical Modification CM PCS ICN Internal Control Number unique claim number that distinguishes claims within PROMISe and appears on a Remittance Advice statement PROMISe Pennsylvania Medical Assistance Legacy Numbers Master Provider Index Legacy MPI number a 13 digit number that consist of the 9 digit provider ID and a Numbers 4 digit location number MA Medical Assistance MA ID Medical Assistance Identification number MCO Managed Care Organization MAMIS Medical Assistance Management Information System MMIS Medicaid Management Information System NCPDP National Council of Prescription Drugs Program An ANSI accredited group that maintains a number of standard formats for use by the retail industry R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 378 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Acronym Description Word NDC National Drug Code A unique 1 1 digit number assigned to drugs that identifies the manufacturer drug strength and package size of each drug NEIC National Electronic Insurance Clearinghouse NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position OMHSAS Office of Mental Health and Substance Abuse Services PCP Primary Care Physician PHI Protected Health Information POA Present on Admissio
387. tes to continue with the archive procedure This Archive Forms screen is displayed Select All Deselect All 270 Eligibility Request Form type efb Claim status Request 03r Dental ee selected oa Institutional Inpatient 4 DA Institutional Nursing Facil O37 Institutional Outpatient archived EF Archive forme at least 100 days old Archive file CApapromisearchive081 11502 ach Browse conea_ Step 6 Select a form to use for the archive procedure or Click _ 3e lect All to select all the forms for the archive procedure or Click Deselect All lto deselect all the selected forms Step 7 Select the maximum age in the number of days for forms to be archived The default value is 100 days indicates that all claims older than 100 days will be archived Step 8 Enter the location of the archive file in the Archive file field You can place the compressed archive file on a diskette or leave it on your hard drive Step 9 Click Browse to select a different directory for the archive file if desired Step 10 Click _ Eancel lto cancel the archive procedure RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 358 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 11 or Click OF to continue with the archive procedure After the database has been successfully archived the following message is displayed Step 12 Click
388. that you want to delete and then click Delete stv to delete an existing service line The selected service line is deleted RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 260 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 11 Complete Service 2 EJ 837 Professional Total Charge PT DI Amount _ Billed Amount oo Services HE Ambulance Add Transport Reason a Transport Distance Patient Weight 0 Condition Codes 1 2 3 z Copy Patient Count F 5 il Delete Contract Type Contract Code Contract ersion E Undo All Billing Note Family Bet nel Last Submit Dt Transport Select the transport reason code from the drop down list or enter Reason Code an appropriate value as specified Ambulance A Patient was transported to the nearest facility for care of symptoms complaints or both B Patient was transported for benefit of a preferred physician C Patient was transported for the nearness of family members D Patient was transported for the care of a specialist or specialized equipment E Patient was transported to Rehabilitation Facility Transport Enter the number of miles the recipient was transported by Distance ambulance Ambulance Patient Weight Enter the weight of the patient in pounds at the time of transport Ambulance by ambulance Condition Select the approp
389. the current claim or reference list selection and displays it When the report is displayed you can either view or print it Close Close Closes the form If you made changes to the current claim or reference list you are prompted to save those changes before leaving the form or reference list RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 40 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 7 Reference Lists A reference list is a drop down list that you build As with any drop down list a reference list contains selections that can be used to complete data entry fields However a reference list is unique because you add the selections to the list After you have added your selections to a reference list you can access the selections in that list to quickly complete data entry fields of the form you are completing For example if your office has three providers you are required to enter provider information such as MPI location code provider name Taxonomy Code NPI National Provider Identifier and provider address Including the Nine Digit Zip Code for each form completed Entering the same information for multiple providers each time you complete a form is very time consuming The Provider reference list solves this dilemma by letting you enter and save information for each provider as a selection in a drop down box Once you have added the selection to the Provider
390. the state where the accident occurred For example enter PA for Pennsylvania Country If the auto accident occurred outside the United States enter the three letter abbreviation for the country where the auto accident occurred For example enter CAN for Canada RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 123 Provider Electronic Solutions Software User Manual Provider ID Rendering Provider Location Code Rendering Provider NPI Rendering Provider Last Org Name Rendering Provider First Name Rendering Provider MI Rendering Provider Facility ID Service Facility Location RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx PA PROMISe Version 4 00 Provider who rendered the service s Select the 9 digit MPI number for the provider of service s from the drop down list or double click on the data entry portion of the field to add a reference list selection Rendering Provider s service location This field is automatically populated after you select or enter an MPI number in the Provider ID Rendering Provider field Information cannot be entered directly into these fields to add or change information in these fields access the Provider List Form Enter the NPI National Provider Identifier Numeric 10 digit identifier consisting of 9 numbers plus a check digit in the 10 position Rendering Provider s last name or group organization name This fiel
391. tiated Reductions PR Patient Responsibility RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx 163 August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Reason There are three Reason Code Amount fields Each field is divided Codes Amts into two segments Fields 1 3 In the left segment of the field select the appropriate reason code from the segment s drop down list or enter an appropriate value as specified The reason code identifies the reason the adjustment is being made to the claim line as described below 1 Deductible Amount 118 ESRD Network Support Adjustment 119 Benefit Maximum for this time period has been reached 2 Coinsurance Amount 23 Payment adjusted because charges were paid by another payer 3 Copayment Amount 35 Lifetime Benefits Maximum has been reached 45 Charge exceeds fee schedule maximum allowable 50 Non covered services In the right segment of the field enter a numeric value for the amount of the adjustment using a decimal point For example enter 100 00 if the adjustment amount was 100 Payer Level of payer responsibility for the recipient s other insurance Responsibility Select the appropriate code from the drop down list or enter an appropriate value as specified P Payer 1 S Payer 2 T Payer 3 A Payer 4 B Payer 5 C Payer 6 D Payer 7 E Payer 8 F Payer 9 G Payer 10
392. tient Signature Insurance Type Code Paid Date Amount MCO ICN Select the signature code from the drop down list or enter an appropriate value as specified The signature code identifies how a recipient s or authorized person s signature was obtained and how it is retained by the provider P Signature generated by provider because the patient was not physically present for service The window is only active if the payer is Medicare with Claim filing code of MB and the Payer Responsibility is not P Primary Select the appropriate value from the dropdown box or enter an appropriate value as specified that identifies the type of insurance listed 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End Stage Renal Disease in the Mandated Coordination Period with an Employer s Group Health Plan 14 Medicare Secondary No fault Insurance including Auto is Primary 15 Medicare Secondary Worker s Compensation 16 Medicare Secondary Public Health Service PHS or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran s Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan LGHP 47 Medicare Secondary Other Liability Insurance is Primary This field 1s divided into two segments In the left segment of the field enter the 2 digit month 2 digit day
393. tly into this field If you need to add or edit information in this field access the Recipient Form MI Recipient s middle initial This field is automatically populated after you select or enter a recipient number Information cannot be entered directly into this field If you need to add or edit information in this field access the Recipient Form Patient Status Recipient s status on the last date of service billed on this claim Enter the appropriate 2 digit status code or select the status code from the drop down list or enter an appropriate value as specified 1 Dischrgd to home or self care 05 Dischrgd transfrrd to routine discharge another type of institution for 02 Dischrgd trnsfrrd to another inpatient care hospital for inpatient care 07 Left against medical advice 03 Dischrgd transfrrd to skilled or discontinued care nursing facility 20 Expired 04 Dischrgd transfrrd to an 30 Still a patient intermediate care facility RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 144 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Account Enter the medical record number assigned to the recipient by the provider Number for the service that was performed A unique account number is required for each claim submitted to be able to obtain claim status information If the same account number is used for each claim submitted the claim status 1s reported on
394. tware User Manual Version 4 00 NDC If dispensing medication enter the NDC number in this field using the 5 4 2 format Zero fill to complete the 5 4 2 format Enter the zeroes in the beginning of the segment Ex 00123 0123 01 Dashes are not required in the field but are shown for clarity If you are dispensing medication you will need to create a separate claim for the administration procedure Note Required if being used by Dispensing Provider Drug Units The actual count of Milliliters Grams or Units of a dispensed drug Note Required if being used by Dispensing Provider Drug Unit of Select the value from the drop down box or enter an appropriate value Measure as specified GR Gram ML Milliliter UN Unit Note Required if being used by Dispensing Provider Step 10 1 Click Add S1 to add another service line A new blank service line 1s added to the screen Step 10 2 Click on the new service line and then enter the service data in the appropriate data fields Step 10 3 Click on the existing service line that contains information you want to copy to a new service line Step 10 4 Click Copy stv to add a new service line to the screen The new service line has the same data as the existing service line you previously selected You can edit the data in the new service line Simply click on the new service line and make changes to the appropriate fields Step 10 5 Click on the service line
395. tware User Manual Version 4 00 Note Always select the 999 Acknowledgement s Accepted Submit Report s Rejected Submit Report s and Submission Transaction Report s for the files to receive 9 2 2 Batch Submission Batch Submission means that an inquiry is submitted as a group with other form types A batch transmission lets you enter multiple requests and submit them to HP Enterprise Services to be processed overnight for the next day of service In order to access the Web System BBS for Batch Eligibility submissions a valid live BBS Logon ID and password are required To obtain these IDs please register at http www dhs state pa us provider promise certification index htm To submit a batch 270 Eligibility Request perform the following steps Note You must choose the Web Server option BBS Batch option is no longer available to send the files Complete the 270 Eligibility Request as directed in Section 9 1 Complete a 270 Eligibility Request of the Provider Electronic Solutions Software User s Manual J HP Provider Electronic Solutions File Forms Communication Lists Reports Tools Security Window Help Submission Resubmission View Batch Response 35 ERA View Bulletin View Submit Reports View Communication Log Note You can enter as many 270 Eligibility Requests as needed at one time All requests in an R status are sent at one time R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31
396. ty Type Qualifier is a 1 or the business name of a group or facility R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 264 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Service when the Entity Type Qualifier is a 2 Not all 35 characters will Facility display on the Provider Last Name fields on the Header screens Location Service Select the adjustment code from the field s drop down list or enter Adjustment an appropriate value as specified Indicator Select Y 1if a third party insurance carrier has made a payment toward the claim Selecting Y will add the Service Adjustment screen to the form for this claim line Select N 1if a third party insurance carrier has not made a payment toward the claim Service adjustment is defined as an adjustment that is being made to the billed amount by an insurance carrier other than MA For example a service adjustment would be completed if a third party insurance carrier either paid a monetary amount toward the claim or denied the claim prior to the claim s submission to MA If multiple professional service lines were entered on the Service 1 screen these service lines also appear on the Service 2 screen Each service line contains the data fields described in this step Click on a service line to access its data fields Each service line is linked to a separate Service Adjustment screen Therefore it is necessary to complet
397. ty ID 1111111 Location Code 000 ID Code Qualifier ie Entity Type Qualifier 1 Delete Last Org Name TESTER 1 First Name TEST Undo All Mil SSN 7 Tax ID 123456789 Taxonomy Code 2222222220 HPI 2333333333 jave Provider Address _ soos SSS L _ _ _ o Find Line 1 TEST STREET Line Fim City ANYTOWN State Fa Zip fi 7111 1111 Print Provider ID T axonorny Last Org Name Type Qualifier 111111111 0001 O TESTER 1 n5555SRSS O0OS 2011111111 BILLING RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 52 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 3 Tab to or click the data entry field to be edited and make the appropriate changes by typing over the already populated information Ag HP Provider Electronic Solutions File Edit View Forms Lists Tools Window Help ce Oe Ag Provider r Provider ID License Facility ID 11111111 Location Code jion Add ID Code Qualifier EEE Entity Type Qualifier 1 x Delete Last Org Name TESTER 1 First Name TEST Undo All Mil SSN 7 Tax ID 123456789 Taxonomy Code 2222222220 HPI 2333333333 jave Provider Address _ soos SSS L _ _ _ o Find Line 1 TEST STREET Line Fim City ANYTOWN Stat
398. ty and State fields This field holds a maximum of 9 numeric characters Note If the zip code is not 9 digits the file will fail Note If entering an NPI as the primary identifier you must use the correct Nine Digit Zip Code that you coordinated with Provider Enrollment for your legacy ID Nine Digit Provider ID plus Four Digit Service Location Code R PA RAPA MMIS CMcElheny PES Manual_50104 00 ICD10 docx i 2 August 31 2015 Manual_5010 4 00_ICD10 docx August 31 2015 62 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 3 Once all of the data entry fields is completed click _ Save If any required fields were missed you are prompted to complete them 6 HP Provider Electronic Solutions File Edit View Forms Lists Tools Window Help ox a i SILILI i Provider m a xX Provider ID License Facility ID qt Location Code joon Add ID Code Qualifier fae Entity Type Qualifier fi Delete Last Org Name TESTER 1 First Name TEST Undo All MI SSN Z Tax ID 123456789 Taxonomy Code 2222222220 HPI 2333333333 Dave Provider Address HA Find Line 1 TEST STREET Line City BENYT Ow N State Fa Zip fi 111 1111 Print rovider ID Tasonomy E Name 111111111 0001 O TESTER 1 555555555 0005 2011111111 BILLING Add Step 4 To add another provider ID to the Provider reference list click and repeat steps 2 3 and 4 as shown above Step 5 Clic
399. ues to identify data elements necessary to process a form as qualified by the payer organization These values are preloaded and are HIPAA compliant If any changes or modifications need to be made to these values you will be notified by DHS or HP Enterprise Services Select the appropriate value from the drop down list or enter an appropriate value as specified 06 Medicare Blood Deductible 35 Offset to Patient Payment 14 No Fault Auto Other Amount Health Insurance Premiums 38 Medicare Blood Deductible Pints Furnished 39 Medicare Blood Deductible Pints Replaced 15 Workman s Compensation 16 PHS or Other Federal Agency 25 Drug Deduction 31 Patient Liability Amount 34 Offset to Patient Payment l 47 Any Liability Insurance Amount Other Medical Expenses 66 Patient Paid Amount Description Enter a description of the value code RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 92 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 3 Click o Save when the data entry fields are completed Step 4 Click o Ad and repeat steps 2 3 and 4 to add another type of value code to the Value Code reference list Step 5 Click Cose to exit the Value Code screen R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 93 PA PROMISe Provider Electronic Solutions Software User
400. uests using the Provider Electronic Solutions software This detail report contains all the fields on the NCPDP Pharmacy Reversal Form To generate an NCPDP Pharmacy Reversal Detail Report perform the following steps Step 1 From the main screen of the Provider Electronic Solutions software selecting the NCPDP Pharmacy Reversal option from the Detail Forms drop down menu The NCPDP Pharmacy Reversal Detail Report screen is displayed Step 2 Click OK to include all the Pharmacy Reversal Requests in the detail report Step 3 Click OK when prompted by the box that advises you that all records will be selected RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 347 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 A detail report is generated and displayed on your screen To limit the type of Pharmacy Reversal Requests in the detail report enter the appropriate report criteria into one or more of the following fields Batch Limits the detail report to Pharmacy Reversal Requests in a specific Number batch Enter the appropriate batch ID number in this field You can locate the Batch Numbers under the Resubmission option of the View Communication Log menu Recipient Limits the detail report to Pharmacy Reversal Requests for the specified ID recipient Enter the appropriate recipient ID in this field Form Limits the detail report to Pharmacy Reversal Requests with the Status s
401. ummary report Step 3 Click _ 0K when prompted by the box that advises you that all records will be selected A detailed report will then generate and display on your screen RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 319 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 4 Enter the appropriate report criteria into one or more of the following fields to limit the type of request in the summary report Batch Limits the summary report to requests in a specific batch Number Enter the appropriate batch ID number in this field You can locate the Batch Numbers under the Resubmission Option of the Communications Menu Recipient Limits the summary report being requested to return information only for Client ID the specified recipient Enter the appropriate recipient ID in this field Form Limits the summary report being requested to include only the claims Status with the specified form status Select the appropriate form status from this drop down list Limits the summary report to requests transmitted on the specified date Enter the appropriate date in this field Step 5 After you enter the report criteria click OR The summary report is generated and displayed Step 6 Use the scroll bars located on the right side and bottom of the screen to view the entire report Ap HP Provider Electronic Solutions File Forms Lists Reports Tools Window H
402. unt Last Submit Dt Print Close Service Adjustment Choose the appropriate option to indicate if there has been an Indicator adjustment against the claim by another payer Y Yes N No Step 12 Complete Service Adjustment R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 230 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Ey 837 Institutional Outpatient oc e Total Charge PO Ol Amount 999999 Billed Amount i Services Adjustment Group Cd Add Reason Codes Amts 1 OU 2 00 Copy Paid Date Amount 00 00 0000 oo 3 00 Delete Carrier Code Undo All Hame PoE Add Srv Adi Srv Carmier Code Carmier Marne J Adjusment Group Cd Copy Srv Adi Delete Srv Adi Find Recipient Last Name First Name J Billed Amount Last Submit Dt Print Close Step 12 1 To access the Service Adjustment screen set the Other Insurance Indicator on Header 3 to Yes and the Service Adjustment Indicator on Srv 3 to Y The Service Adjustment screen is displayed Adjustment General category of the adjustment made to the claim Select the Group Code adjustment group code from the drop down list or enter an appropriate value as specified CO Contractual Obligation CR Correction and Reversals OA Other Adjustment PI Payer Initiated Reductions PR Patient Responsibility Reason There are three Re
403. up to 15 consecutive Hospital Days Revenue Code Specific accommodation or ancillary service Select the revenue Basis of code from the drop down list or enter an appropriate value as specified 0100 Indicates the number of facility days 0183 Indicates the number of leave days 0185 Indicates the number of hospital days When billing for co insurance days and no other billable days exist refer to the Frequently Asked Questions in Appendix A Select the DA days institutional basis code from the drop down Measurement list or enter an appropriate value as specified The basis code Units identifies the units in which a value is being expressed or the manner in which a measurement was taken DA Days Institutional MJ Minutes Professional UN Unit Institutional and Professional Enter the number of units provided to the resident for the revenue code being billed For example enter 1 if one unit was provided to the recipient Zero 0 units are an acceptable entry Note Other Provider fields are not used in the 837 Institutional Long Term Care claim Leave these fields blank Step 9 1 To add another service line click Add Srv A new blank service line is added to the screen Step 9 2 Click on the new service line and then enter the service data in the appropriate fields as described in this step Step 9 3 To copy the data from an existing service line to a new service li
404. us a check digit in the 10 position Referring provider s last name or organization name This field is automatically populated with the correct information after an MPI number is selected in the Referring Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Referring provider s first name This field is automatically populated with the correct information after an MPI number is selected in the Referring Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Referring provider s middle initial This field is automatically populated with the correct information after an MPI number is selected in the Referring Provider ID field Information cannot be entered directly into this field If you need to add or edit information in this field access the Provider Form Provider who rendered the service Select the 9 digit MPI number for the provider of service s from the drop down list or double click on the data entry portion of the field to add a reference list selection Complete this field if a group s MA ID was entered on Header 1 indicates that a group receives the payment instead of an individual provider Rendering provider s 4 digit service facility location number for the MPI number selected in the Referring Provider ID
405. ution to address the issue surrounding non covered Medicare Charges MAMIS Attachment Type Codes 40 45 you would complete the PES 837 LTC transaction as follows Go to Header 3 and set the Crossover Indicator to Yes Go to the Crossover screen and fill out all of the appropriate Medicare Information Indicate a Medicare Denial by using the Reason code 50 use the resident s date of admission as the Paid Date and use 11111111111111 as the Medicare ICN number R PA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 367 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 16 Appendix B Eligibility Response Code Tables 16 1 Eligibility or Benefit Information Codes The codes in the table below may be included in the Eligibility Benefit Response Information sections of the 271 Response 1 2 Active Coverage Active Full Risk Capitation Active Services Capitated Active Services Capitated to Primary Care Physician Active Pending Investigation Inactive Inactive Pending Eligibility Update Inactive Pending Investigation Co Insurance Co Payment Deductible Coverage Basis Benefit Description Exclusions Limitations Out of Pocket Stop Loss Unlimited Non Covered Cost Containment Reserve Primary Care Provider Pre existing Condition Managed Care Coordinator Services Restricted to the Following Provider Not Deemed a Medical Necessity Benefit Disclai
406. utomatically populated when you select a recipient number from the Recipient ID field Recipient s date of birth This field 1s automatically populated when you select a Recipient Number from the Recipient ID field Field is required if using recipient s SSN or name for eligibility Your own identification number for the recipient This field is automatically populated when you select a recipient number from the recipient ID field Recipient s last name This field 1s automatically populated when you select a recipient number from the recipient ID field Recipient s first name This field is automatically populated when you select a recipient number from the Recipient ID field Field is required if using recipient last name for eligibility Recipient s middle initial This field 1s automatically populated when you select a recipient number from the Recipient ID field Recommended if using recipient last name for eligibility Enter the procedure code or NDC code for which you are requesting eligibility August 31 2015 97 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Modifiers Procedure Code Qualifier From DOS From Date Of Service To DOS To Date Of Service 1 4 Enter the 2 digit modifier for the procedure code entered in the Procedure field if the MA Program Fee Schedule indicates that the procedure code requires a modifier Enter the qualifier for the code set th
407. which the Accident accident that related to charges or to the recipient s current condition diagnosis or referenced treatment occurred For example enter 10012015 if the date of the accident was October 1 2015 State Enter the two letter abbreviation for the state where the accident Accident occurred For example enter PA for Pennsylvania Country If the auto accident occurred outside of the United States enter three Accident letter country abbreviation where the auto accident occurred For example enter CAN for Canada Transport Reason ambulance transport was used Please follow current Reason Code ambulance policy when choosing a transport reason code Select the Ambulance RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 243 Provider Electronic Solutions Software User Manual Transport Distance Ambulance Patient Weight Ambulance Condition Codes Ambulance Admission Date Discharge Date Special Program Code RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx PA PROMISe Version 4 00 reason code from the drop down list or enter an appropriate value as specified A Patient was transported to nearest facility for care of symptoms complaints or both B Patient was transported for the benefit of a preferred physician C Patient was transported for the nearness of family members D Patient was transported for the care of a specialist or for
408. x File Edit View Forms Lists Tools Window Help 3x2 Alel Blasm Ag Provider Provider ID License Facility ID Location Code Add ID Code Qualifier Ezz Entity Type Qualifier v Delete Last Org Name First Name MI SSN Tax ID _Undo All_ at Taxonomy Code Save Provider Address Line 1 Line 2 Provider ID 111111111 0001 Jatate TESTER 1 55555555 0005 211111111 BILLING Step 2 Enter the data requested for each field as described below Provider ID Provider or group that receives payment for the services rendered the individual provider that rendered services or the facility where services were rendered Enter the 9 digit Master Provider Index MPI number that was assigned to you by DHS This reference list is also linked to the Referring and Rendering Provider ID fields which means that when you access the dropdown selections for the Provider ID Referring Provider ID or Rendering Provider ID you access the same list of providers This reference list is also linked to the Attending Provider Referring Provider ID and Operating Physician fields used on the 837 Institutional Inpatient Institutional Outpatient and Institutional Nursing Facility which means that when you access the dropdown selections for the Provider ID Attending Provider Referring Provider ID or Operating Physician you access the same list of providers If one of your rendering providers 1s sometimes a r
409. y Forms drop down menu The 837 Institutional Nursing Home Summary Report Screen is displayed RAPA MMIS CMcElheny PES_Manual_5010 4 00_ICD10 docx August 31 2015 333 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Step 2 Click OK to include all the Nursing Home Claims in the summary report Step 3 Click OK when prompted by the box that advises you that all records will be selected A summary report is generated and displayed on your screen To limit the type of Nursing Home Claims in the summary report enter the appropriate report criteria into one or more of the following fields Batch Number Recipient Cardholder ID Form Status Submit Date Limits the summary report to Nursing Home Claims in a specific batch Enter the appropriate Batch ID number in this field You can locate the Batch Numbers under the Resubmission option of the View Communication Log menu Limits the summary report to Nursing Home Claims for the specified recipient Enter the appropriate recipient ID in this field Limits the summary report to Nursing Home Claims with the specified form status Select the appropriate form status from this drop down list Limits the summary report to Nursing Home Claims transmitted on the specified date Enter the appropriate date in this field Step 4 After you enter the report criteria click OF The summary report is generated and displayed on your screen R
410. y Medical MA Medicare Part A MB Medicare Part B OF Other Federal Program TV Title V VA _ Veteran Administration Plan WC Worker s Compensation Health Claim ZZ Mutually Defined August 31 2015 PA PROMISe Provider Electronic Solutions Software User Manual Version 4 00 Paid Date Amount Carrier Code Policy Holder Group Policy Holder Group Name Date other insurance payment was received and amount of other insurance payment This field is divided into two segments In the left segment of the field enter the 2 digit month 2 digit day and 4 digit year that the recipient s third party insurance carrier adjudicated the claim For example enter 10012015 if the date was October 1 2015 Enter the amount paid by the other insurance carrier in the right segment of the field using a decimal point For example enter 100 75 if the paid amount was 100 75 Third party insurance carrier This field is automatically populated after you select a group number from the Group field Information cannot be entered directly into these fields to add or change information in these fields access the Policy Holder List Form Select the Group Number for the third party insurance from the drop down list or double click on the data entry portion of the field to add a reference list selection Name of the group or business that makes the insurance available to Policy Holder the insur
411. your mouse and press F1 To complete an 837 Institutional Inpatient Claim use the following steps Step 1 From the main screen of the Provider Electronic Solutions software access the 837 Institutional Inpatient form one of two ways Click 837 Institutional Inpatient Shortcut icon on the Toolbar or Select the 837 Institutional Inpatient form from the Forms drop down menu RAPA MMIS CMcElheny PES_Manual_ 5010 4 00_ICD10 docx August 31 2015 141 PA PROMISe Provider Electronic Solutions Software User Manual fe HP Provider Electronic Solutions Communication Lists Reports Tools Security Window Help 2 0 Eligibility Request 16 Claim Status Request a3 Dental 63 7 Institutional Inpatient 83 Institutional Nursing Facility 83 Institutional Outpatient 63 Professional NCPDP Pharmacy NCPDP Pharmacy Eligibility NCPDP Pharmacy Reversal Version 4 00 Note When you choose a selection from a drop down list as indicated in the field completion instructions below many of the fields are then completed A drop down list is also known as a reference list For additional information on reference lists refer to the List options under Section 6 Step 2 Complete Header 1 The 837 Institutional Inpatient form is displayed with the Header 1 screen displayed HP Provider Electronic Solution File Edit Wiew Forms Tools Window Help DEX 9B2 el Ba a7e m zf 837 Institution

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