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PC ACE Pro32 User Manual - Cahaba Government Benefit

1. Usage Element Value Comment Required NM101 PR Payer Code to identify an organizational entity or other payer Required NM102 2 Non Person Entity Code to identify type of entity Required NM103 Name Last or Organization Name Required NM108 PI Payer Identification Code to identify Payer or organization XV Health Care Financing Administration National Plan ID Required NM109 Payer Identification Code Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 194 Loop 2400 Service Line Contract Information Required CN101 01 Diagnosis Related Group DRG Code to identify the contract type 02 Per Diem 03 Variable Per Diem 04 Flat 05 Capitated 06 Percent 09 Other Situational CN102 The amount of the contract agreement Obligated to Accept as Payment in Full Amount Loop 2430 Line Adjudication Information Usage Seg El Value Comment Required SVD01 Payer Identification Code Required SVD02 The amount paid by the primary payer for each service line Zero 0 is an acceptable value for this element Required SVD03 HC Health Care Financing Administration Code to identify the type of medical 1 Common Procedural Coding System procedure HCPCS Codes IV Home Infusion EDI Coalition HIEC Product Service Code ZZ Mutually Defined Required SVD03 Procedure Code 2 Situational SVD03 Procedure Code Modifier 3 Pr
2. Save Cancel Enter any information required on Line Item Details for the processing of the claim as usual Enter information into Extended Details and Ext Details 2 if required Repeat this process for each line charge on the claim Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 98 When all of the line level information has been entered click the Extended Payer tab Institutional Claim Form Primary Payer Secondary Payer Tertiary Payer COB Info Primary COB Info Secondary M Claim Adjustments Z COB Amounts MIA MOA Information ANSI 837 Only A Claim Level Adjustments CAS yj COB MIA MOA Amounts Num Group Reason Amount Units m Code Amount EI C C ee a a ee 7 EET E Medicare Inpatient Adjudication MIA Remarks Codes a es ee ees ee Medicare Outpatient Adjudication MOA Remarks Codes a ee ees F Claim Adjudication Date za aes Save Cancel Click the COB Info Primary tab to enter the primary paid and adjustments In the COB MIA MOA Amounts section enter the amount the primary payer paid with C4 in the Code field and the total submitted charges with a T3 in the Code field Enter any other amounts such as the primary paid amount with the appropriate code You may right click the Code field and select the appropriate code from a list In the Claim Level Adjustment
3. It is important that you retrieve and view your reports and if you are set up for them your electronic remittances promptly after they become available These reports will indicate if your files are being accepted for processing or if they rejected because of an edit When you check your reports in a timely manner you will become aware of any issues so you can correct them and resubmit your claims before your cash flow is interrupted Reports and remittances are available for you to retrieve for 45 days after which time they will roll off of our FTP server and can no longer be retrieved You can retrieve same report or remittance as many times as you want as long as it is not over 45 days old Manually Transmitting Claim Files and Claim Status Requests In order to transmit your claim files and your claim status requests you will need to know how to view the files on your system using Windows Explorer Different versions of Windows have different ways of doing this If you need help using Windows Explorer see the documentation you received with Windows or contact your support for your system Claim and claim status request file naming conventions The instructions below will guide you through renaming the claim file and claim status requests before submitting them This is necessary because if a file is not named correctly it will not be processed by our system Please use the formats described below when naming your files The same f
4. 22 Medicaid Resubmission Codes amp Ref No Medicaid Resubmission Codes amp Reference Number Enter one of the following values indicating the reason for the claim submission 00 Original claim 01 Void Cancel prior claim 02 Resubmission Enter into the second field the Reference Number assigned by the payer to the original claim 25 Fed Tax ID Federal Tax Identification The federally assigned Tax Identification Number TIN of the billing provider will be entered automatically based on the Billing Provider entered at the top of the form If the number shown in the field is incorrect it must be changed in the reference file No change should be made to this field SSN EIN SSN EIN Indicator One of the following values indicating the type of Provider Tax ID identified in Field 25 provider will be entered automatically based on the Billing Provider entered at the top of the form E Employer Identification Number S Social Security Number X Corporate Name but Social Security Number If the value shown in the field is incorrect it must be changed in the reference file No change should be made to this field Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 137 27 Provider Accepts Assignment Provider Accepts Assignment One of the following values indicating whether or not the provider accepts assignment will be entered automatically based on the Billing
5. Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 91 gt Print View Reports Medicare Provider Provider Provider Remittance Advice Detail Summary Report Remittance Detail Remittance Summary Cancel Double click a report to have it displayed on your screen You may experiment to discover which report will work best for you The first report Medicare Remittance Advice Detail will display the remittance in a format that is similar to the Standard Paper Remittance SPR that you would receive in the mail Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 92 If you get the Report Selection Criteria screen you can use this to select claims for a particular beneficiary or provider or display a certain page range If you leave all of these fields blank and click OK the entire remittance will be displayed Report Selection Criteria Start Page End Page Provider PCH HIC ICH Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 93 PC ACE Pro32 and Medicare Secondary Payer Some beneficiaries may have an insurance policy that is primary to Medicare For these beneficiaries the claim must first be submitted to the primary payer and then submitted to Medicare after the primary company has adjudicated the claim Before Medicare can pay these claims the primary payment information must be received otherwise Medi
6. 2 Patient Last Name First Name MI Gen 3 Bitthdate Sex MS ES SS Ind SOF Rep ee es es CU CU CU Sd 5 Patient Address 1 Patient Address 2 Patient City State Patient Zip Patient Phone a a 10 Patient Condition RelatedTo ROI ROlDate Other Ins 14 Date Ind of Curent 15 First Date 16 UTW Disability Dates amp Type Employment Accident E PETE E 2 E e e to pf 17 Referring Physician s Name Last First MI 17a Referring Phys ID Type 18 Hospitalization Dates 20 Outside Lab amp Charges E EO wf m oo 19 Reserved For Local Use 22 Medicaid Resubmission Code amp Ref No Es ee 25 Fed Tax ID SSN EIN 2 Provider Accepts Assignment 33a PIN No 31 Provider SOF Date _ _ ___Faciity Denta coB Y Frequency 33b GRP no Save Cancel 1 The LOB Line of Business field should contain MCB Medicare Part B Complete all necessary information 2 The COB Coordination of Benefits field should contain the letter Y Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 101 i Professional Claim Form Patient Info amp General Insured Information Biling Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured I 6 Sub Payer Payer Name Insured s ID PRel _Insured s Last Name FirstName MI Gen Doss pueros J Of Meocarerspta rr oorr SS E 1 13 Birthdate Sex Sig AOB Insured s Address 1 Insured s Address 2
7. 24d Modiiess3 amp 4 Hospice Employed Purch Charges 0 00 SalesTax 0 00 Anesthesia Other Minutes _o Co Pay Status Initial Treatment _4 Postage Claim 0 00 Units Type Code Purchased Services E Shipped Date i Line Level Supporting Provider Information Last Org Name First Name MI Suffix Provider IDs Types Payer IDs NT Purch Service DO O y O O y O o DO o oO O o Supervising pooo poo poo poo a oding fo f ff E _ i zT tf a TOF Referring 2nd SY tis tis i ste Asst Surgeon Poo Do is tis oo Save Cancel 24d Modifiers 3 amp 4 Modifiers 3 amp 4 Enter the HCPCS modifiers that identify the special circumstances related to the performance of the service Right click in the desired field to select the correct modifier from the modifier list Anesthesia Minutes Anesthesia Minutes Enter the actual number of minutes the patient was anesthetized or number of minutes of PP S Ae Units Type Code Units Type Code Describes the type of units entered F2 International Unit MJ Minutes UN Units Hospice Employed Hospice Involvement Indicator Y Yes physician is employed by the hospice N No physician is not employed by the hospice Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 148 Co Pay Status The status of the beneficiary s co pay 0 co pay exempt 1 recipient di
8. The zip code for the facility must be the full nine digit zip code Attachment information for the entire claim can also be submitted in the Claim Supplemental Information PWK section Right click the Type and Trans fields and select the appropriate values and enter your Attachment Control Number For more information on submitting this information and for the cover sheets you will need to use when you fax it to us visit our website at http www cahabagba com news part a claims submission with pwk You may enter notes about the claim in the Claim Notes NTE area Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 36 Clicking Extended General 2 opens the screen below Institutional Claim Form L x Patient Info amp Codes Billing Line Items Payer Info Diagnosis Procedure Diag Proc 2 Extended General Ext General 2 Extended Payer Additional Condition Occurrence Span Value Codes Condition Codes 11 16 Occurrence Codes 9 16 ode Date Code Date Code Date Code Date TITTI m C E N eN E i e a tee Occurrence Span Codes 5 10 Value Codes 13 16 Code From Thru Code From Thru Code From hru Code Amount Code Amount ETEA TAA M TEA TEA E AA A G E a fo h I F H F E L T ___ Reserved CMS 1450 Claim Form Locators UB92 and UB 04 FL11 Bes gag FL6B UB Fest weg o arw aawa Fuse ues O amS aawa FLS By zw Save Canc
9. 2420H Ambulance Drop Off Location Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 186 Appendix C Entering Medicare Secondary Payer MSP Claims Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 187 MSP General Information e Medicare Secondary Payer MSP pc ronically Electronic Data Interchange EDI Instructions for Part B Providers Want to avoid denial of your MSP claim Are you confused about what is required when submitting information to Medicare for secondary payment This article is designed to assist you with the proper submission of your electronic claims especially when there is primary payment made by another payer What is an MSP claim Medicare Secondary Payer MSP claims are those claims that are submitted to another insurance company payer before they are submitted to Medicare When a Medicare beneficiary has other insurance primary to Medicare the other insurer s payment information must be included on the claim that is submitted to Medicare Without this information your claim will be denied Likewise information not properly submitted on the claim can potentially result in the claim being paid incorrectly or denied CMS now requires all claims including MSP claims to be filed electronically with few exceptions Please reference CMS Change Request 3440 available at http www cms hhs gov Transmittals downloads R450CP pdf and the Administration Simplif
10. Date of Last Menstrual Period LMP First Date Enter the first date of same or similar illness 16 UTW Disability Dates amp Type 17 Referring Physician s Name Last First Ml UTW Disability Dates Enter the beginning and ending dates that the patient in the provider s opinion was or will be unable to perform the duties normally associated with his her work Type Enter one of the following values indicating the type of disability 1 Short Term Disability 2 Long Term Disability 3 Permanent Total Disability 4 No Disabilit Referring Physician s Name Enter the referring physician s last name first name and middle initial 17a Referring Phys ID Referring Physician s ID Enter the referring physician s UPIN 18 Hospitalization Dates Hospitalization Dates Enter the beginning and ending hospital dates related to current service Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 136 20 Outside Lab amp Charges Outside Lab amp Charges Enter the following value indicating if outside charges are included in this claim Y Yes outside lab charges included in this claim N No outside lab charges not included in this claim If Y enter the dollar amount of the outside charges included in the claim 19 Reserved For Local Use Reserved for Local Use Refers to Block 19 of the CMS 1500 Claim form usage varies by state
11. Information window will display where you can enter necessary information After adding information click Save e Updating or Viewing an existing Provider Click the View Update button or double click the record you wish to view update and the Professional Provider Information window see Figure 4 10 will display After making the necessary corrections click Save e Deleting an existing Provider record Select the desired record from the Provider list click the Delete button and confirm the deletion Note Claims are linked to provider records by an internal control number Deleting a provider record will irrevocably break any such links that may exist in claims in the system The Provider Deletion Confirmation will display and outline alternatives to deleting Entering Provider Information The Professional Provider information form provides access to a provider s type name and address information identification fields Provider or Group ID No LOB Payer ID and Group Label miscellaneous information and optional local fields The professional provider structure defines three distinct provider types Group Practice lIdentifies the provider record as representing a group practice for billing purposes When creating group provider records the user must enter a unique Group Label to identify the group The members of the group must be assigned as Individuals Individual in Group ldentifies the provider record as
12. Mutually Defined AD American Dental Association Codes Dental Only Description Free form description of procedure used when submitter feels the code used does not adequately describe the service Obstetric Anesthesia Additional Units Obstetric Anesthesia Additional Units Used to report additional anesthesia to reflect unusual complexity of procedure National Drug Code or UPN Type National Drug Code The National Drug Code or the Universal Product Number and NDC or UPN qualifier Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 151 National Drug Unit Price National Drug Unit Price The unit price of the specified drug Nat Drug Units Type National Drug Units The dispensing quantity of the specified drug Type F2 International Unit GR Gram ME Milligram ML Milliliter UN Unit DME Length of Need Days Length of Need The length of time in days the Durable Medical Equipment DME will be needed DME Purchase Price Purchase Price The purchase price for the Durable Medical Equipment DME DME Rental Price DME Length of Need Days Rental Price The rental price for the Durable Medical Equipment DME DME Length of Need The length of time the Durable Medical Equipment DME will be needed DME Purchase Price DME Purchase Price The Durable Medical Equipment DME purchase price DME Rental Price DME Rental Price The
13. Payer Name pc es Group Number First Name E es eS E ey State Zip ay LOB M Insured Information Options C Common Inst amp Prof Claim Office Separate Inst amp Prof Clear All Fields For Insured Gen Insured ID Sex DOB za Employ Status Assign of Benefits Release of Info ROI Date fi Retire Date i Save Cancel Payer ID Payer National Identification Number Right click in the Payer ID field and select the appropriate Payer ID number from the Payer Selection screen Payer Name Payer Description The Payer description will automatically be entered when the Payer ID number is selected LOB Line of Business The line of business LOB will automatically be entered when the Payer ID number is selected Group Name Group Name The name of the group or plan through which insurance is being provided Group Number Group Number The identification number assigned by the payer to the group or plan through which insurance is provided Claim Office Claim Office Identifies specific payer location responsible for processing claims for this patient Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 117 Insured Information F7 Rel Relationship A code indicating the relationship of the patient to the insured Enter one of the following values 01 Spouse 04 Grandfather or grandmothe
14. State Enter the insured s state Zip Zip Code Insured s 5 or 9 digit zip code Telephone Telephone Number Insured s telephone number including area code Sex Sex A code indicating the insured s sex Enter one of the following values M Male F Female U Unknown DOB Date of Birth Enter the insured s date of birth in MMDDYYCC format Employ Status Employment Status Enter one of the following values indicating the insured s employment status 1 Full time 2 Part time 3 Not employed 4 Self employed 5 Retired 6 On active military duty 9 Unknown Assign of Benefits Release of Info Assignment of Benefits A code indicating whether the provider has been authorized to receive benefit payments on behalf of the insured Enter one of the following values Y Yes payment to provider is authorized W Not Applicable use if patient refuses to assign benefits N No payment to provider is not authorized Release of Information A code indicating whether the provider has on file for this patient a signed statement permitting the release of medical data to other organizations in order to adjudicate the claim Enter one of the following values Informed consent to release data regulated by statute Y Yes provider has a signed statement permitting data release ROI Date Release of Information Date Specifies the date that the patie
15. services were performed will be entered automatically based on the Patient Control Number entered at the top of the form If the name shown in the field is incorrect it must be changed in the reference file No change should be made to this field Middle Initial The middle initial for individual for whom the services were performed will be entered automatically based on the Patient Control Number entered at the top of the form If the initial shown in the field is incorrect it must be changed in the reference file No change should be made to this field Gen Generation Identifier The generation identifier if any will be entered automatically based on the Patient Control Number entered at the top of the form If the identifier shown in the field is incorrect it must be changed in the reference file No change should be made to this field 3 Birth date Birth date The date the patient was born will be entered automatically based on the Patient Control Number entered at the top of the form If the date shown in the field is incorrect it must be changed in the reference file No change should be made to this field Sex Sex One of the following values indicating the sex of the patient will be entered automatically based on the Patient Control Number entered at the top of the form M Male F Female U Unknown If the value shown in the field is incorrect it must be changed in the reference fi
16. should be made to this field Insured s ID Insured s Identification Number The Insured s identification number assigned by the payer will be entered automatically based on the PCN entered into the Patient Info amp General tab If the number shown in the field is incorrect it must be changed in the reference file No change should be made to this field Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 140 6 P Rel Patient Relationship One of the following values indicating the relationship of the patient to the insured will be entered automatically based on the PCN entered into the Patient Info amp General tab 01 Spouse 04 Grandfather or grandmother 05 Grandson or granddaughter 07 Nephew or niece 09 Adopted child 10 Foster child 15 Ward 17 Stepson or stepdaughter 18 Self 19 Child 20 Employee 21 Unknown 22 Handicapped dependent 23 Sponsored dependent 24 Dependent of a minor dependent 29 Significant other 32 Mother 33 Father 34 Other adult 36 Emancipated minor 39 Organ donor 40 Cadaver donor 41 Injured plaintiff 43 Child where insured has no financial responsibility 53 Life partner 76 Dependent G8 Other relationship If the value shown in the field is incorrect it must be changed in the reference file No change should be made to this field Insured s Last Name First Name
17. 1 pi 42 44 44 Modifiers ae 45 Service Date 46 47 48 LN Rev Cd HCPCS 1 2 3 4 From Date ThruDate Units Days Total Charges Non Cov Charges 1 a ee e e E E __ E o To jf iee IIM af i f_ ff eE e MIM E i i i i i E i I jf i E E ii E i o j jf i_ _f _j _f__ ____ ___hf 8 Se Recalculate Totals l 0 00 0 00 Save Cancel Complete the fields on this screen as required on the Institutional claims form For Institutional Service lines the value in the Units Days field must be greater than zero If necessary click the Extended Details 1 or Extended Details 2 tab for the line item you are billing for This will open the Extended Details screen Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 30 Institutional Claim Form xi Patient Info amp Codes Billing Line Items Payer Info Diagnosis Procedure Diag Proc 2 Extended General Ext General 2 Extended Payer Line Item Details Extended Details Line 1 Ext Details 2 Line 1 a M Miscellaneous Line level Extended Details Form Loc 49 i Proc Desc Service Tax 000 Procedure Type E nal Drug Code OoOo o O Facility Tax 000 Units Type onal Drug Unit Price 0000 Line Ref No Nat Drug Units Type 000 Assessment Date EE AE Drug Ref No Type M Line level Supporting Provider Information Last Name First Name MI Suffix Provider IDs Types Payer IDs Operating
18. 61 Start your FTP software and log onto your FTP account using the instructions you were given by your Network Service Vendor and according to the instructions provided with your FTP client software On the left side of your screen navigate to your WINPCACE directory and locate the file you need to send When you locate the file click it one time to select it In the example below the file is named pali0001 8375010 clm which is an Alabama Part A claims file Size Type Modled T gappoace 20130027 277ca8010 2p 700 Wn VANDIT E ganpoace 20130327 BKB 2013 3 27 2013 1204 GAPPCACE TGAP0000 8375010 20130327 112051 999 303 999 3 27 0013 1204 A poace32ini GAPPCACE TGABQ000 2785010 20130027 1206 98 299 999 9 27 20131204 9 a SS p 1 object s selected 1 KB Connected to bluecmsftp bebsal org 16 object s 2 75 MB Information Window Source Status Progress Transtened Rate kBps Time Left Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 62 Click the right arrow to upload the file to your FTP account Size Tye Modfed 4 700 Win 3 27 00137141 SKB 2013 3 27 2013 1204 GAPPCACE TGAPO000 8376010 20130027 112061998 303 999 3 27 2013 1204 GAPPCACE TGABOOOO 2785010 20130027 1206 98 VANNI 1 object s selected 1 KB Connected to bluecmsftp bebsal org 16 object s 2 75 MB Information Window Source Status Progress Transfened Rate kBps Time Left When the tran
19. An optional code indicating the provider ID number type used OB State License Number 1A Blue Cross Provider Number Solo Group Dental Only 1B Blue Shield Provider Number 1C Medicare Provider Number 1D Medicaid Provider Number 1E Dentist License Number Dental Only 1G Provider UPIN Number Prof Only 1H TRICARE CHAMPUS Identification Number 1J Facility ID Number Solo Group Only B3 Preferred Provider Organization Number Solo Group Only BQ Health Maintenance Organization Code Number Solo Group Only El Employer s Identification Number FH Clinic Number Solo Group Only G2 Provider Commercial Number G5 Provider Site Number Solo Group Dental Only LU Location Number N5 Provider Plan Network Identification Number Individual Only SY Social Security Number TJ Federal Taxpayers Identification Number Individual Only U3 Unique Supplier Identification Number USIN Solo Group Only X5 State Industrial Accident Provider Number XX National Provider ID NPI Provider Name Suffix Provider Name Suffix The solo or individual in group provider name suffix Provider Country Provider Country Code Country code for provider if other than US Provider Name Match Provider Name Match An optional string used during the claim import process to facilitate the provider matching process Use only under the supervision of your system mai
20. Bil el Patient Last Name First Name MI Suffix Fed Tax ID Statement Covers Period Patient Address 1 Patient Address 2 Patient City State PatientZip Country Patient Phone e a FL 38 Birthdate Sex MS Admission HR Type SAC DHA Stat Medical Record No Condition Codes i fj to_i gee e ye Fee epPyEy Ty Occurrence Occurrence Occurrence Occurrence Occurrence Span Occurrence soan Code Date Code Date Code Date Code Date Code From Thru Code From es ee ee ATETEA EA ETZ p EEE J TRE H EET JEET EREN J EEE EEE Value Value Value Value Value Value Code Amount Code Amount Code Amount Code Amount Code Amount Code Amount E E e M ___fj ___fi ____ Save Cancel Enter any Occurrence Codes and Value Codes required in the relevant sections on this screen Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 95 If you need to enter more Condition Occurrence Span or Value Codes click the Ext General 2 tab im Institutional Claim Form S Enter any additional information required for processing this claim Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 96 Next click the Diagnosis Procedure tab Institutional Claim Form p Patient Info amp Codes Biling Line Items Payer Info Diagnosis Procedure Diag Proc 2 Extended General Ext G
21. Codes 1 8 l 24a Service Dates 24b 24c 24d ae eae 24e 24f 24g 24h 24j LN From Thru PS EMG Proc Diagnosis Charges Units EPFP AT Pardes Phys a es p a se ee a _j vi_j fj jf jf fj jii__f___jjjj a _jsvi_j fj jf jf fj ji_ _f__jjjj a _j _j ff f_ jf if ij g __ TJ ic a _j vi_fj jf ij jf j e A 28 Total Charge 0 00 Recalculate 29 Amount Paid 0 00 30 Balance Due 0 00 Save Cancel Enter the Claim Diagnosis Codes You must have at least one valid diagnosis code on the claim To bring up a list of valid diagnosis codes hit your F2 key or right click your mouse while this field is selected Enter the From date of service This date will automatically be plugged into the Through date of service if you are entering a date range you can change this by keying over the To date with the correct date PS is the place of service code To bring up a list of valid place of service codes hit your F2 key or right click this field EMG is used to indicate if the service being billed is for an emergency situation Right click to select Yes Emergency related or No not emergency related Proc is the procedure code being billed Hitting F2 or right clicking while this field is selected will bring up a list of valid codes for this field Modifiers 1 and 2 are where you would enter the first two modifiers for the code being billed If you have more than two modifiers cl
22. Durable medical Equipment DMC DME Rental Price DME Rental Unit Price Ind Rental Price Indicator The unit of time covered by the rental price indicated 1 Weekly 4 Monthly 6 Daily Facility Name Facility Name The name of the facility where the services were rendered Facility Address Facility Address The street address of the facility where the services were rendered Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 152 Facility City St Zip Facility City State Zip The city state and zip code of the facility where the services were rendered Facility IDs Types Facility IDs Types The identifier for the facility where the services were rendered Types OB State License Number 4010 only 1A Blue Cross Provider Number 4010 only 1B Blue Shield Provider Number 4010 only 1C Medicare Provider Number 4010 only 1D Medicaid Provider Number 4010 only 1G Provider UPIN Number 4010 only 1H TRICARE CHAMPUS _ Identification number 4010 only 24 Employer s Identification Number 4010 only 34 Social Security Number 4010 only El Employers Identification Number 4010 only G2 Provider s Commercial Number LU Location Number NS Provider Plan Network Identification Number Prof 4010 only SY Social Security Number 4010 only TJ Federal Taxpayer s Identification Number 4010 only X4 Clinical Lab
23. ID see Submitter Code User Name can be used interchangeably with user ID Assigned by Cahaba EDI Services and given to users in a letter when they are approved to use PC ACE Pro32 User ID see User Name Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 184 Appendix B Loops and Segments Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 185 1000A Submitter 1000B Receiver 2000A Billing Pay To Provider 2000B Subscriber 2010AA Billing Provider 2010AB Pay to Provider 2010BA Subscriber 2010BB Payer 2310A Referring Provider Part B Attending Provider Part A 2310B Rendering Provider Part B Operating Physician Part A 2310C Service Facility Location Part B Other Operating Physician Part A 2310D Supervising Provider Part B Rendering Provider Part A 2310E Ambulance Pick Up Location Part B Service Facility Location Part A 2310F Ambulance Drop Off Location Part B Referring Provider Part A 2320 Subscriber Primary Payer 2330A Other Subscriber 2330B Other Payer 2400 Service Line 2420A Rendering Provider Part B Operating Physician Part A 2420B Purchased Service Provider Part B Other Operating Physician Part A 2420C Service Facility Location Part B Rendering Provider Part A 2420D Supervising Provider 2420E Ordering Provider 2420F Referring Provider 2420G Ambulance Pick Up Location
24. ID Type 1 l ID Type 2 j Pay To Provider Information specify only if different Name tid Address Fee Tax ID Type LO O O i y ft ww oide S ttsti i C C ciystZip o O Sec ID Type HH Country Sec ID Type Save Cancel Right click Provider Accepts Assign and select the appropriate value It is not required but recommended that you enter a contact e mail address for the practice in the E Mail Address box Enter the providers mailing address NPI and Tax ID Type in the Pay To Provider section if the address is a PO Box or Lockbox The full nine digit zip code must be used Leave Country Sec ID Type 1 and Sec ID Type 2 blank If the facility s information in the General Info tab is the actual mailing address this section does not need to be completed This will not affect the facility s address information in the Medicare system and will not change the address for remittances or correspondence Click Save when complete Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 14 Entering Provider Information for Professional Providers Part B You will see the Professional Provider Information screen shown below Professional Provider Information eee 0E Group Practice Individual in Group Solo Practice Te Provider Type Group Practice Group Name L4 Group Label Poo Last First
25. Insured Patient Legal Representative Information Name L F E Address City St Zip Phone __ _ Country Facility Information Name Address City St Zip Cnty 7 IDs X Phone Ext _ Fac Type Miscellaneous Patient amp General Information Date of Death OE E a AE A Accident Date Accident State Hour Accident Country Responsibility Ind FL 10d Homebound Ind Date Care Assumed Date Care Relinquished _ _ Date Last Seen Date Last Worked Return To Work Date First Contact Date i Special Program Indicator Medical Rec No IDE Number Form Loc 31 EPSDTReferal Submission Reason Code Delay Reason Code Pregnancy Indicator Claim Tag Patient Weight Ibs Contact Prescription Date Patient Legal Representative Information Name L F Legal Representative Name Enter the name last name first name of the responsible person who is to receive the explanation of benefits and or the payment on behalf of the patient Address Legal Representative Address Enter the mailing address of the responsible party City State Zip Legal Representative City State Zip Enter the city state and zip code of the responsible party Country Legal Representative Country Enter the county of the responsible party if outside of the US Phone Legal Representative Phone Number Enter the phone number of the responsible party Cahaba Government B
26. Insured s Last Name The last name of the insured will be entered automatically based on the PCN entered into the Patient Info amp General tab If the name shown in the field is incorrect it must be changed in the reference file No change should be made to this field First Name The first name of the insured will be entered automatically based on the PCN entered into the Patient Info amp General tab If the name shown in the field is incorrect it must be changed in the reference file No change should be made to this field Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 141 Middle Initial The middle initial of the insured will be entered automatically based on the PCN entered into the Patient Info amp General tab If the initial shown in the field is incorrect it must be changed in the reference file No change should be made to this field Gen Generation Identifier The generation identifier if any will be entered automatically based on the PCN entered into the Patient Info amp General tab If the identifier shown in the field is incorrect it must be changed in the reference file No change should be made to this field Birth date Birth date The date of birth of the insured will be entered automatically based on the PCN entered into the Patient Info amp General tab If the date shown in the field is incorrect it must be changed in the reference file No chan
27. KB 106 KB 1KB 20 KB 1KB 1KB 1KB 2 KB 25 KB 1KB 3 KB 388 KB 436 KB 183 KB 25 KB 17 KB Type Application Application Application Application Application ctl File Text Document ctl File ctl File DAT File DAT File Text Document DAT File DAT File Application Extension Application Application DAT File DAT File Date Modified 3 17 2005 9 53 PM 2 27 2013 2 39 PM 11 1 2010 9 02 AM 3 13 2013 4 10 PM 1 18 2011 11 35 AM 4 25 2013 8 41 4M 4 25 2013 8 41 4M 4 30 1999 3 05 PM of7 2006 7 37 AM 4 25 2013 8 41 4M 4 25 2013 8 41 4M 4 25 2013 8 40 4M 3 27 2013 12 33 PM 4 22 2013 3 22 PM 8 22 2002 12 54 PM 3 25 2013 11 51 4M 3 25 2013 11 52 AM 9 9 2011 12 27 PM 9 8 2011 4 13 PM Click the file name once to select it then right click and select Rename from the menu File Edit View Favorites Back amp wi P Search Folders fa E x i fi Address CAWINPCACE Name I Ansid24r exe P ansi837h exe P Ansi837i exe A Ansi837u exe g Ansi997r exe K ANSI CTL E BCCLMACT LOG RI BCPRNTMP CTL RY BCPRNTV2 CTL E BCREQ276 DAT T BSCLMA Scan for Viruses fe BSREQ2 Open With Sjestran 2 Winzip 3 4d dll Copy To Folder BB Clients2 Move To Folder 98 Clientup Send To Emcsp30 Emespc ai g enabaut copy hi4v2Fle Create Shortcut Th hiSv26le Delete h4e5fid ees hsefid h4s7fild h1450fld pdf Properties Size
28. Line 1 Ext Details 3 Line1 Chiropractic Initial Treatment Date EE Date of Last X Ray a x Rays on File at Site Nature of Condition Acute Manifestation Date _ _ Symptom Description Save Cancel Initial Treatment Date Date of Last X Ray Initial Treatment Date Enter the initial treatment date in MM DD CCYY format Date of Last X Ray Enter the last x ray date in MM DD CCYY format X Rays on File at Site X Rays on File at Site Enter one of the following values indicating the location of the x rays Y X rays are on file maintained and ready for review at site N X rays are not maintained and are not ready for review on site Nature of Condition Nature of Condition A Acute Condition C Chronic Condition D Non acute E Non life threatening F Routine G Symptomatic M Acute Manifestation of a chronic condition Acute Manifestation Date Acute Manifestation Date Enter the acute manifestation date in MM DD CCYY format Symptom Description Symptom Description Enter the symptom description Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 164 Mammography Attachment HCFA 1500 Claim Form Mammography Certification Number Mammography Certification Number Enter the mammography certification number Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 165 EPO Attachment Pr
29. List Claims button igi Professional Claims Menu x File View Roster Maintain Import Claims List Claims Process Claims Prepare Claims This will bring up the List Claims screen Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 47 isi Professional Claim list File Filter Actions Reports M Status LOB PCN Patient Last Bill Provider Type Entered a MCB 112227101060 CRUSOE Group 11 15 2006 MCB 123 CRUSOE Group 02 26 2007 MCB 789 PUBLIC Group 11 17 2006 MCB 456 ZIEGLER Group 07 03 2006 kai Sort By Patient Name PCN C Entry Date C Serice Date Claim La Locatipn to be transmitted 7 Status lt lt All gt gt OB k lt All gt gt ace Clear Filters Advanced Filter Options New View Update Copy Delete Close You can select which claims you want to see by selecting the claim Location or the claim Status Claim location indicates if the claim is clean no errors and has not been transmitted yet if the claim has been transmitted but not yet paid transmitted and paid or has been paid only Claim status indicates if the claim contains no errors if the claim contains errors or is unprocessed Claims with errors status ERF or ERN should have those errors corrected before they can be prepared and transmitted Claims with a status of UNP must be processed before they can be prepared and transmitted
30. Pro32 Claims Processing System PME E3 Click the Reference File Maintenance the screen below icon This action will open Click Codes Misc igi Reference File Maintenance iol x File view Reports Patient Payer Provider Inst Provider Prdf Codes Misc Shared Institutional Professional TOB POS DATA COMM CON OCC SP AL CHARGES MASTER HCPCS REVENUE CODE SPECIALTY MODIFIERS ICDS PHYSICIAN FACILITY MISC ANSI Close Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 8 Next click Submitter to open the Submitter Information Screen igi Reference File Maintenance Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 9 On the Submitter Setup Screen select Institutional for Part A or Professional for Part B 010211796 TEST SUBMITTER Click Copy to enter the submitter information for your practice Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 10 Professional Submitter Information x General Prepare ANSI Info ANSI Info 2 ANSI Info ta LOB I Payer ID B ID TESTOOO1 EIN Name TEST SUBMITTER Address h23 MAIN STREET City JANYWHERETOWN State ST Zip 5995959 Phone 999 999 9999 Fas Co County o Contact JOHN DOE EMal Save Cancel You will need to update this to correspond with the submitter information provided in
31. Reactivating and Modifying Prepared Claims You must reactivate a claim that has been prepared before it can be modified To look at claims that have been transmitted click Location and select TR Transmitted Only This will bring up the list of claims that you have already prepared You can sort the list of claims by Patient Name PCN Entry Date Service Date or Transmit Date If you need to reactivate a claim to be resubmitted you must first select the claim by clicking the box in the first column next to the claim This will place a check mark in the box You can select as many claims as you need Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 48 Next click Actions Select Reactivate All Checked Claims After changing the Location back to CL to be transmitted you will be able to edit the claims to correct any errors and resubmit them The Action menu also gives you the option to purge print hold delete or archive claims You may also reactivate one claim at a time If you are reactivating claims that were prepared with an older version of PC ACE Pro32 you may have some additional edits you will need to correct before you can prepare and retransmit the claim Processing Claims If you are using PrintLink to convert your claim files from an upstream office management system or if you have reactivated and modified claims you will need to select Process Claims after importing or react
32. __ Save Cancel Common Payer MSP Information OTAF Obligated to Accept In Full Amount the primary payer and the provider have agreed would be considered payment in full for the services Zero Payment Ind Zero Payment Indicator Z primary payment was equal to zero N primary payment was greater than zero Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 178 system Utilities Backup System Utilities File Maintenance Backup Validate Restore This utility performs a backup of the PC ACE Pro32 databases and configuration settings Specify a destination drive e g amp or hard disk folder path and click the Start Backup button Destination Drive or Folder Include infrequently changed database files backup will be larger Options Start Backup Close You can perform a backup of the PC ACE Pro32 database files and configuration settings from the Backup sub tab All files to be included are compressed into a single archive and written to the specified destination drive or directory The following controls and options apply to the backup operation Destination Drive or Folder Specifies the drive or Windows folder directory to which the backup archive file will be written This path may point to a removable media device or to a standard Windows directory on a hard disk drive local or remote Disk spanning is sup
33. cannot be changed from this tab You must exit the Claim Form and make the necessary change s directly to the appropriate Reference File Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 139 Insured Information Professional Claim Form Patient Info amp General Insured Information Biling Line Items Ext Patient General Ext Pat Gen 2 Ext Payet Insured 6 Sub Payer ID Payer Name Insured s ID P Rel Insured s Last OrgName First Name MI Gen TO es J Jj A IOo F J J AO Fo F J Jf 13 Birthdate Sex Sig AOB Insured s Address 1 Insured s Address 2 Insured s City State Zip EE I J I I eS O eee 2 County Insured s Phone Ext ESC Employer Name Group Name Group Number E E P po fo 00 Clear Payer E E pO fo 0 Clear Payer _ i I po fo P Clear Payer Payer ID Payer ID The National identification number for the payer will be entered automatically based on the Billing Provider entered into the Patient Info amp General tab If the number shown in the field is incorrect it must be changed in the reference file No change should be made to this field Payer Name Payer Name The descriptive name associated with the payer identification number will be entered automatically based on the Billing Provider entered into the Patient Info amp General tab If the name shown in the field is incorrect it must be changed in the reference file No change
34. indicated You may enter the e mail address of the contact person for this provider in the E Mail Address box if you want While this is not required it is recommended If you are entering the Group Provider information or if the provider is a Solo Practice and the mailing address for the practice is different from the physical address enter the mailing address the NPI and the Tax ID Type in the Pay To Provider Information area Leave the Country Prov ID No Type Sec ID Type 1 and Sec ID Type 2 fields empty The address information entered here will not alter the address information for the practice in the Medicare system When you are finished click Save If you have omitted any required information you will get a list of errors and the fields in error will be flashing If there are no errors the record will be saved and you will be taken back to the Provider Information screen At this point you may enter another provider number close the reference file maintenance screen or move to another tab in the reference file maintenance screen Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 18 Entering Payers The payer information for Medicare has already been entered into your system You will only need to enter payers if you are planning to bill Medigap or Medicare Secondary Payer MSP On the Reference File Maintenance screen click the Payer tab This will open the Payer Screen ii Ref
35. is interrupted See the Manually Retrieving Files for PC ACE Pro32 section elsewhere in this manual for instructions on retrieving these reports Viewing a Daily Log To view retrieved daily logs click the Institutional or the Professional Claims menu on the PC ACE Pro32 toolbar ro32 Claims Processing Siig Since these screens are identical for both only the Professional screens will be used in the screen shots below Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 69 Click Maintain gt Launch Report Manager i Professional Claims Menu File View Roster Process Claims Reverse Claim Inport Transmission Log Acknowledgment File Log Launch Report Manager Prepare Claim Status Request File Claim Status Response amp Acknowledgment Log Purge Claim Activity Log List Claims Prepare Claims Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 70 Double click the report you want to view to display it i2 PC ACE Pro32 Report Manager File Filter Action Help Date Time Desorption chive Fie 03 27 2013 12 34 Daily Log Report 03 27 2013 DL130327 001 afm B Select Report Type Daily Log Report View Report Print Report Close Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 71 Use the navigation buttons at the top to page through print or close the daily log i Report
36. may point to a removable media device diskettes writeable CDROM or to a standard Windows directory on a hard disk drive local or remote Disk spanning is supported for backup archives on diskette The user will be prompted to insert specific diskettes from the backup archive as needed Note When restoring backup archives that span multiple diskettes insert the last diskette in the set first The system will prompt for the first and subsequent diskettes as the restoration proceeds Restore system and user configuration settings Specifies whether or not to restore the system and user configuration settings that were included in the backup archive These settings define system user preference settings for example Unless otherwise instructed by a technical support specialist this Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 180 option should always be checked Once the desired source drive folder path and option settings have been specified click the Start Restore button to proceed The restore operation will overwrite your current database files with older data from the specified backup You should perform this operation only under the supervision of authorized technical support personnel You will be notified when the restore operation completes PC ACE Pro32 will terminate automatically following a restore operation The restored database files and configuration settings will be available the next time th
37. needed to show payer adjustment Situational CAS11 Claim Adjustment Reason Code Use as needed to show payer adjustment Situational CAS12 Monetary Amount Use as needed to show payer adjustment Situational CAS13 Quantity Use as needed to show payer adjustment Situational CAS14 Claim Adjustment Reason Code Use as needed to show payer adjustment Situational CAS15 Monetary Amount Use as needed to show payer adjustment Situational CAS16 Quantity Use as needed to show payer adjustment Situational CAS17 Claim Adjustment Reason Code Use as needed to show payer adjustment Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 196 Situational CAS18 Monetary Amount Use as needed to show payer adjustment Situational CAS19 Quantity Use as needed to show payer adjustment Line Adjudication Date Usage Seg El Value Comment Required DTPO0O1 573 Date Time Qualifier Required DTP02 D8 Date Expressed in Format CCYYMMDD Required DTP03 Date Time Period Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 197 Appendix D Contacting Cahaba EDI Services Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 198 Cahaba EDI Services J10 A B MAC AL GA and TN Part A and Part B users Phone 866 582 3253 Part A E mail PartAEDIServices cahabagba com Part B E mail PartBEDIServices cahabagba com Cahaba
38. tab If the name shown in the field is incorrect it must be changed in the reference file No change should be made to this field Group Name The name of the group or plan through which insurance is being provided will be entered automatically based on the PCN entered into the Patient Info amp General tab If the name shown in the field is incorrect it must be changed in the reference file No change should be made to this field Group Number Clear Payer Group Number The identification number assigned by the payer to the group or plan through which insurance is provided will be entered automatically based on the PCN entered into the Patient Info amp General tab If the number shown in the field is incorrect it must be changed in the reference file No change should be made to this field Clear Payer Click the Clear Payer button to clear the payer information for the corresponding line Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 144 Line Item Details E Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Line Item Details Extended Details Line 1 Ext Details 2 Line 1 Ext Details 3 Line 1 Diagnosis Codes 1 8 kz zz m E 24a Service Dates 24b 24c 24d 24d Moser 24e 24f 24g 24h 24 LN From Thru PS EMG Proc 1 Diagnosis Charges Units EPFP AT Rendena Phys TTT T
39. when a claim status request 276 is submitted and accepted The file naming convention for the 277CA is User ID date 277ca5010 zip For example a 277CA for Tennessee submitter could be named tnbpcace 20130327 277ca501 0 Zip The file naming convention for the 277 is User ID date 2775010 zip Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 66 For example a file for a Georgia submitter could be named gapcace 20130401 2775010 Zip These files should be saved to the C WINPCACE mailbox directory Start your FTP client software and log onto your FTP account On your local drive usually on the left navigate to your WINPCACE mailbox folder Size Type Modified CF abpeace 20111115 277ca8010 zp ie 825 Win 5 14 2013 2 20PM ET abpeace 20130325 ppbal 8355010 zip BKB Win 4 22 2013750AM lt Mm gt O object s 0 Bytes o Connected to bluecmsftp bebsal org 2 object s 9 KB Information Window glx Source Status Progress Transferred Rate kBps Time Left Click the 277CA or 277 that you want to retrieve once to select it In the example above the file name is albpcace 20111115 277ca5010 zip Click the left arrow to retrieve the file to your mailbox folder Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 67 To process and view a 277CA and 277 see the instructions elsewhere in this manual 835s The file naming convention for
40. your EDI enrollment acceptance letter The LOB will be MCA for Part A or MCB for Part B Right click on the Payer ID field and click the appropriate payer ID on the list to select it ID is the submitter code that was assigned to you by EDI Services and can be found on your approval letter If your submitter code is not entered correctly our system will not accept your claims For E Mail enter the e mail address of the person in your practice who should be contacted if there are any issues with your electronic claims This is not required but it is recommended The EIN Fax and Country boxes may be left blank Enter your company name address phone number and contact name Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 11 Entering Providers In Reference File Maintenance click the Provider Inst tab for Institutional Part A provider information or Provider Prof for Professional Part B provider information ioj xi igi Reference File Maintena File View Reports Patient Payer Provider Inst Provider Prof Codes Misc LOB Provider Name Provider ID PayerID Provider NPI Pe fees IE SotBy LOB ProviderName Provider ID C Tag M List Filter Options Show all providers no filter applied C Show only providers associated with selected provider 43 include Provider IDs starting with c Fil include Provider Names starting with
41. 121 KB 306 KB 127 KB 182 KB 106 KB 1KB 20 KB 1 KB 1 KB 1 KB 2 KB 25 KB 1 KB 3 KB 388 KB 436 KB 183 KB 25 KB 17 KB 19 KB 46 KB 123 KB Type Application Application Application Application Application ctl File Text Document ctl File ctl File DAT File DAT File Text Document DAT File DAT File Application Extension Application Application DAT File DAT File Application Adobe Acrobat Doc Adobe Acrobat Doc be Acrobat Doc be Acrobat Doc Adobe Acrobat Doc Adobe Acrobat Doc Date Modified 3 17 2005 9 53 PM 2 27 2013 2 39 PM 11 1 2010 9 02 AM 3 13 2013 4 10 PM 1 18 2011 11 35 4M 4 25 2013 8 41 4M 4 25 2013 8 41 4M 4 30 1999 3 05 PM 9 7 2006 7 37 4M 4 25 2013 8 41 4M 4 25 2013 8 41 4M 4 25 2013 8 40 4M 3 27 2013 12 33 PM 4 22 2013 3 22 PM 8 22 2002 12 54 PM 3 25 2013 11 51 4M 3 25 2013 11 52 4M 9 9 2011 12 27 PM 9 8 2011 4 13 PM 12 11 2000 1 39 PM 10 27 2006 9 37 AM 9 7 2010 10 47 AM 5 20 2003 1 45 PM 5 20 2003 1 49 PM 5 20 2003 1 50 PM 9 4 2006 7 34 PM Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 59 After clicking Rename you will see the file is selected and you can now change the file name File Edit View Favorites Tools Help Back gt S P Search Key Folders oy x e i O C AWINPCACE Address Name Size Type Date Modified Pl ansi824r exe 121 KB Application 3 17 2005 9 53 PM Pl ans
42. 2 A PC ACE Pro32 cahaba User s Guide Combined Institutional and Professional version Rev 07 28 2015 v3 4 Introduction PC ACE Pro32 is the HIPAA compliant software package Cahaba Government Benefit Administrators LLC distributes to providers looking for an inexpensive way to file claims electronically The software is free and designed for small practices that want to transmit claims directly to the Medicare carrier PC ACE Pro32 can be used to submit both Institutional Part A and Professional Part B claims When there is a function that is specific to Part A or Part B there is a separate section for it in this manual but most functions are identical for Institutional and Professional claims Part of this manual details how to install and set up the software It also details what information must be entered into the software and how to perform the functions necessary to enter and transmit claims Part Il provides more detailed descriptions of the screens you will see when you use the software This documentation was prepared for users who are familiar with basic medical claim coding and filing and for users who have a basic understanding of the version of Windows installed on their PC It is recommended that you read the documentation and use the Help utility in PC ACE Pro32 to become familiar with the software This document was developed for PC ACE Pro32 version 2 50 and later Cahaba Government
43. 8 2015 76 e On the Confirm screen click Yes to only include rejected claims on the report or No to include all claims This will open the report viewer x Do you want the Claim Acknowledgment report to include only rejected claims i F Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 77 e Use the navigation buttons at the top to move from one page of the report to another to print the report or to change the appearance of the report on your screen The first page of the report will give details that pertain to the entire file PC ACE Pro32 ANSI 277 CLAIM ACKNOWLEDGMENT REPORT File Date Time 11 15 2011 15 21 00 Acknowledgement Created 6504 05 33 15 2011 15 23 Sender Code G30 10302 Receiver Code G503 ALEPCACE tt Transmission Ackzovledgezent 1 Information Source ID 10102 Name CABABA GBA Transmission Receipt Control 1010220111128000001 Receipt Dete 11 35 2011 Process Date 11 15 2011 Information Receiver Acknowledgement 1 information Source I9 10102 Nase CAEASA GBA Receiver Mame CAHABA GSA J10 A B EAC ID ALBPCACE Receiver Info Receiver Trece 000017 Total Rejected Quantity 3 Total Rejected Amount 150 00 Receiver Status States Dete 11 15 2011 Total Submitted Charges 150 00 Acknowledgement 1 Category Al Ackzowledgement Receipt Tke claim encounter has been received This does not mean that the claim has been accepted
44. 9 Ctrl ISA GS ST 00000000311 Archive Filename AHO80915 001 Click the Response tabs if there is more than one response for this claim When you have finished click Close to close this screen For questions about claims denials or claims in a pending status contact the Provider Call Center for your state For a list of Provider Contact Center phone numbers visit our website at http www cahabagba com contact htm Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 86 Processing and Viewing an Electronic Remittance Advice 835 After retrieving your electronic remits in PC ACE Pro32 click the ANSI 835 Functions button See the instructions for retrieving electronic remittances elsewhere in this manual mt PC ACE Pro32 Claims Processing oR File wiew Security Help At the System Selection screen click the Institutional for Part A or the Professional for Part B button AN5I 835 System Selection Eg ANSI 535 Selection Options Prrrrereeerrrr errr rer rrr rrr irr rrr rere Institutional Professional Close Since the screens for the Institutional and the Professional processors are identical the example below will use the Professional processor DETER Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 87 On the ETRA Processor screen click Select ANSI File iat PC ACE Pro32 Professional ETRA Proc
45. Benefit Administrators LLC v3 4 Revised 07 28 2015 2 Part I Installing and using PC ACE Pro32 ccssseeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeneees 5 GETING SIAN G ronseis da ennn ae aae aeaa aea aaa aa re aaia aeaa De aa Eaa 6 Connecting 10 Canaan snyst eenn o i e RA aeameed pases 6 MN SUA AUN Oh e eaea a A E age erage aan A 6 Signing onto PC ACE Pro32 resi tins tana van ane Baie ane sadn A vaciwhieay cans oaepecae vad 7 Entering Submitter Information sistas cycsecn0s Seecestaseictuadet ati deacds adhd bedaagueonebeheaye 8 Entenng ProvidelS reisene iin coer taet hail silent i oeeat tock A maid 12 Entering Payers serinenn a ce sata Maa ot ose a Rel ott rere et et bericht last 19 Entering BeneficlalleS iesnas a aei iai 21 Entering Referring Ordering Attending Physician Information 25 Claims Entry and Processing ssssssnnnsennnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn nnmnnn 28 E teiing FANNIN S ce ee ea E E a A aE a aE 28 Listing GlaiM Sisan an a a a a a A 47 Reactivating and Modifying Prepared Claims ccccccccsseeeeseeseeteeteeteeeeeens 48 Processing CLAMS 5 pc25 cits 25s nnen as Nicola Gosia a ae Gs Needs 49 Preparing SARIS e Set sa cht cocscet at mint ansatuaiensaun E E E A 49 Creating a Request for Claim Status 20 0 eccceeescsceeeseeseteeeeeeeeceeeeeeecneeaeees 50 Filing claims and claim status requests and retrieving reports 55 Manually Transmitting Claim Files and Claim Status Reque
46. Claims Claim List Reactivate All Checked Claims Location Hold All Checked Claims Print All Checked Claims Checked Archive All Checked Clair t All Checked Claims Media Request All Checked Claims Status Request All Checked Claims Status Checked Claims Status Il gt gt LOB k lt All gt gt Clear Filters Advanced Filter Options New When you get the message Ready to add all checked claims to the claim status queue click OK If you are not ready click Cancel If you click OK you will get a message indicating that the claims have been successfully added to the claim status request queue Click OK to clear this message You may add more claims to the claim status request queue at this time If you are finished close the claims list by clicking Close This will take you back to the Professional Claims Menu Click Maintain then click Prepare Claim Status Request File Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 53 ist Professional Caime Many Reverse Claim Import Transmission Log Acknowledgment File Log Prepare Claim Status Request File Claim Status Response Log Purge Claim Activity Log Process Claims Prepare Claims Click the Prepare Status Request button to prepare the file for transmission Proressional Gaim status faqusge pile Prepare m Include Requested Claims Matching LOB z Payer All Payers fo
47. Government Benefit Administrators LLC v3 4 Revised 07 28 2015 199
48. I TOTTI TTE ee ey ees a A B E I fj jj jf ff ii__ E a Ii jf fj I II Sees SE ee ee ee ev _fv7_f fof f fo ff JJ TT 28 Total Charge C no 0 00 Recalculate 29 Amount Paid 0 00 30 Balance Due 0 00 Save Cancel Claim Diagnosis Codes 1 8 Claim Diagnosis Codes Enter the Diagnosis Code s identifying a diagnosed medical condition resulting in a line item service 24a Service Dates From Thru Service Dates From Enter the date the service was initiated Service Dates Through The date entered into the From field will automatically be entered into the Thru field This date can be changed if needed by typing over the automatic entry 24b PS Place of Service Enter the code that identifies where the service was performed Right click the PS field to select from the Place of Service POS Codes 24c EMG Emergency Indicator Indicates whether or not the charges are emergency related Y Yes emergency related N No not emergency related 24d Proc Procedure Code Enter the HCPCS CPT 4 code that describes this service Right click in the Proc code field to select from the HCPCS codes A procedure code must be entered before you can select an attachment see field AT Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 145 24d Modifiers 1 2 Modifiers 1 and 2 Enter the HCPCS modifier code s that identifies the special circumstances re
49. Insured s City State Zip p o T NEA N E E E E E EEEN E EE E E E a ki Phone r m ee _ Clear Payer T P sd Clear Pay ss sd Clear Paye iii Save Cancel 3 On the Insured Information tab enter the primary payer into the Payer ID field You may need to add this payer in Reference File Maintenance before you are able to select it in the claim You will need to also fill in the other fields relating to the insured s primary insurance 4 Enter Medicare as the Secondary Payer ID Right click on this field and select the appropriate identifier from the list Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 102 Professional Claim Form Es Patient Info amp General Insured Information Biling Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Line Item Details Extended Details Line 1 Ext Details 2 Line 1 MSP COB Line 1 Claim Diagnosis Codes 1 36610 2 3 4 5 6 7 8 24a Service Dates 24b 24c 24d 24d Modifiers 24e 24f LN From Thru PS TS Proc 1 2 Diagnosis Charges link EPFPEMCB AT Rendering Physician 1 ae m2005 fir o fi soo fof TTT z Seisis T ET ETT IT J _ _ jj jj fj e A E o__ jii_ jf jf jf C C s_ _ E e e re A E E O A aLa E 28 Total Charge 50 00 0 00 30 Balance Due 50 00 29 mount Paid Save Cancel On the Billing Line Items tab complete the line infor
50. LLC v3 4 Revised 07 28 2015 43 If you must enter line level facility information the facility where this service was rendered is different from the facility where the rest of the charges were rendered or if you need to enter National Drug Code NDC or Universal Product Number UPN information click Ext Details 2 Professional Claim Form Patient Info amp General Inswed Information Biling Line it Patient General Ext Pat Gen a Ext Payer Insured Line ltem Detail Extended Details Line 1 Ext Details 2 Line 1 Ext Details 3 Line 1 iscellaneous Information Proc Type Dese Facility Name Obstetric Anesthesia Additional Units __ 000 Facility Address National Drug Code or UPN Type o Co OWS _ National Drug Unit Price Nat Drug or UPN Units Type 000 Fac IDs Types Po Drug Ref No Type fo Hi Fac Type E Drug Prescription Date Line level Reference IDs Types Payer IDs DME Length of Need Days a A DME Purchase Price m DME Rental Price EE 4 E v DME Rental Unit Price Ind Save Cancel Enter the information in the indicated fields on this screen If the procedure code billed is a miscellaneous code or has NOC Not Otherwise Classified as part of the description right click the Proc Type Desc and select HC and enter a more detailed description of the service in the description box Enter National Drug Code or Universal Product Number information on this screen if it
51. M 10 Le NPI Address 5 Tax ID Type PO UPIN City St Zip cd E Specialty Type Org o Phone CL Fax JL Taxonomy Contact J7 E Assign E Participating Group ID No LOB SignatueInd Date _ _ Payer ID No Tag Provider Roles Billing a Rendering Ni Remarks Provider Associations Select Nore Provider ID Provider Group Name Save Cancel If you are entering the information for a group practice first click Group Practice to enter the group number information You will click Individual in Group after you have entered and saved the group number You will need to enter the information for the group and for each provider in the group For a solo practice click Solo Practice Group Name Organization is the name of the practice When entering solo practice information this field will be called Organization and is optional This field will not be available when entering individual provider numbers in the group Last First MP is the last name first name and middle initial of the provider If you are entering group number information you may leave these fields blank City St Zip Enter the address city state and zip information The Zip must be the full nine digit zip code For the Group Practice information or if the provider is a solo practice the address on this screen must be the physical Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 15 address of th
52. New View Update Delete Close Click New to begin entering your provider information This will bring up the provider information screen Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 12 Entering Provider Information for Institutional Providers Part A For Institutional Part A users the below screen will appear Institutional Provider mo 6 General Info Extended Info Name Address NPI Tax ID Type Cys O J lt Phone ountry Site Contact Provider ID No Payer ID Tag Include In Lookups fr Remarks Provider Associations _Select_ Save Cancel Complete the information on this screen as appropriate for the facility Provider ID No is the PTAN or OSCAR of the facility LOB will be MCA for Medicare Part A The Zip must be the full nine digit zip code The actual physical address of the facility must be used PO Boxes and Lockboxes will not be accepted Enter the NPI and the Tax ID and Type Taxonomy is optional Click the Extended Info tab Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 13 Institutional Provider Information x General Info Extended Info Provider ID No Type Ji E Mail Address Provider Accepts Assign E Provider SOF E Provider Name Match l M Secondary Provider IDs ANSI use only 7 Force Legacy ID Requires POA Reporting
53. Other Operating DO O i poo pooo tis Rendering S siz Hl pooo pooo a Save Cancel If you are billing for a miscellaneous procedure code or a code that has NOC Not Otherwise Classified as part of its description you can right click the Procedure Type box and select HC and enter the description of the procedure in the Proc Desc field National Drug Code NDC information and pricing may also be entered on this screen Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 31 If the charge you are billing for requires an attachment click Ext Details 2 ional Claim Form Info amp Codes Biling Line Items Payer Info Diagnosis Procedure roc 2 Extended General Ext General 2 Extended Payer Line Item Details Extended Details Line 1 Ext Details 2 Line 1 M Miscellaneous Line level Extended Details continued Line Supplemental Information PWK Num Type Trans Attachment Control Number Hl CE ee EEs Save Cancel Complete these fields as required for the Institutional claims form Right click Type and Trans to select the appropriate values and enter your Attachment Control Number Once you receive an acknowledgement that your claim has been accepted you will need to complete the fax cover sheet from our website print it out and fax it a
54. Preview Zoom f 4 4f Pasioni gt pif Close KKKKKKKKEKKEKKEKKEKKEKKEKEKKEKKEKKEEKEKKEKRKEKERKEKRKEKKEEKEKKERKEKERKEKRKEKKEKERKEREE TTNBOOO0 2765010 zip Date 03 26 2013 Time 14 50 31 KEKKKKKKKKKKKKKKKKKKKKKAKKKKKKKKAKKKKKKKKKKEKKKKKKKEKKKKKKKKKKKKAKKKKKKKEKKKKKKEREE UNZIP RESULTS FILE UNZIPPED SUCCESSFULLY RCCEPTED KEKKKKKKEKKKKEKKKKEKKEKKEKKKEKKKKKEKKKEKKAKKEKKKKEKKKEKEKKEEKKEKKAEEKKEKKKAKEKKKEKKEKKEKEKEEK TTNPO0000 8375010 zip Date 03 26 2013 Time 14 50 31 KKKKKKKKKKKKKKKKKKKKAKAKKAAAAKKKKKKKKKKEKKKKKKKKKKAKAAAAKAKAKKKKKKKKKKKEKKKKKKKEEE UNZIP RESULTS FILE UNZIPPED SUCCESSFULLY ACCEPTED KKKKKKKKKKKKKKKKKKKKAKAAKKAKAKKKKKKKKKKKKKKKKKKKKKKAKKKAAKAKAKKAKKKKKKKKKKKKKRKKEEE TTNBOOOO 2765010 276 Date 03 26 2013 Time 14 50 57 Processing and Viewing a File Acknowledgement 999 The 999 is a report that is produced on an hourly basis that indicates if a file was accepted accepted with errors or rejected You will receive one 999 for each claim or claim status request file submitted See the directions in the Data Communications section for instructions on retrieving the 999 The screens for Institutional and Professional are identical so only the screens for Professional are shown Once you have retrieved all of your 999 files click the appropriate claim processing option Institutional or Professional on the PC ACE Pro32 toolbar Cahaba Government Benefit Administrators LLC v3 4
55. Provider ID applies A Provider record must be established for each LOB for which claims will be submitted Right click in the field and select MCB SC Med Part B from the list of available values Payer ID Payer Identification The Payer ID field if specified designates this provider as being for use with this specific payer only This feature allows the creation of a payer specific Provider ID if required by the payer Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 123 Tag Tag An optional user assigned tag or pneumonic that can be established to assist in easy identification of the provider record Group Label Group Label Specifies the group label assigned to a Group Practice provider and to the Individual in Group providers that belong to this group Each Group Practice provider must be assigned a unique alphanumeric group label and each provider assigned to the group practice must have the same value in his or her Group Label Note If the Provider Type is Solo Practice this field will not be available NPI National Provider Identifier Enter the National Provider Identifier Tax ID Type Tax Identification Number Enter the federally assigned Tax Identification Number TIN of the billing provider either the Employer ID number EIN or the Social Security Number SSN The data is automatically posted to claim form b
56. Provider entered at the top of the form A Assigned B Assignment accepted on Clinical Lab Services only Prof only C Not assigned If the value shown in the field is incorrect it must be changed in the reference file No change should be made to this field 31 Provider SOF Provider Signature on File One of the following values indicating if the signature of the provider of service s reported on this claim which acknowledges the performance of the service s and authorizes payment is on file in the provider s office will be entered automatically based on the Billing Provider entered at the top of the form Y Signature of provider is on file N Signature of provider is not on file If the value shown in the field is incorrect it must be changed in the reference file No change should be made to this field Date Date The date of the providers signature if applicable will be entered automatically based on the Billing Provider entered at the top of the form If the date shown in the field is incorrect it must be changed in the reference file No change should be made to this field 32 Facility Info Facility Information Enter one of the following values indicating whether the facility information is included with the claim Y Yes facility information included N No facility information not included Dental Dental One of the following values indicating whether this claim is being submitted
57. Revised 07 28 2015 72 At the Claims Menu click Maintain then Acknowledgement File Log i Professional Claims Menu File View Roster PEII lt Reverse Claim Import Transmission Log Acknowledgment File Log a Launch Report Manager Prepare Claim Status Request File Claim Status Response amp Acknowledgment Log Purge Claim Activity Log List Claims Process Claims Prepare Claims Double click the 999 you want to view to open it on your screen Wi Professional Acknowledgment File Log 03 26 2013 T 000029 TNBPCACE lt gt View Report i Refresh Close Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 73 isi Report Preview Zoom im 4 4 Pagetaft gt gt Close PC ACE Pro32 ANSI 997 999 ACKNOWLEDGMENT REPORT File Date Time 03 26 2013 15 22 00 Serial No 000029 Acknowledgment Created GS04 05 03 26 2013 15 22 Sender Code G502 10302 Receiver Code GS03 TNBPCACE Ack Transaction Set Control No STO2 0001 Prepare Serial Number 000029 Group Control Number AK102 29001 Version Release Industry Code AK103 005010x 222a1 Transaction Set Control Number AK202 000029001 Implementation Convention Ref AK203 005010x 222a1 Transaction Set Status IKS501 Accepted Functional Group Status AK901 A Accepted Transaction Sets Included AK902 1 Transaction Sets Received AK903 1 Transacti
58. Status Ind Placement Status Indicator Indicate the status of the placement Prior Placement Date Prior Placement Date Actual The date of any previous placement Estimated If the actual prior placement is not known the estimated date of placement Treatment Period Treatment Period Enter the start and stop dates of the treatment Orthodontic Treatment Orthodontic Treatment Indicate if services were performed for orthodontic treatment Y yes services were performed as part of orthodontic treatment N no services were not performed as part of orthodontic treatment Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 168 Total treatment Months Total Treatment Months If orthodontic treatment the number of months the patient will be undergoing the treatment Months Remaining Months Remaining If patient is undergoing orthodontic treatment the number of months remaining Ortho Appliance Placement Orthodontic Appliance Placement Date The date the orthodontic appliance was placed Replacement Orthodontic Appliance Replacement Date The date the orthodontic appliance was replaced Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 169 Extended Patient General Patient Legal Representative Information Professional Claim Form Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer
59. TV Title V VA Veteran Administration Plan WC Workers Compensation Health Claim ZZ Mutually Defined Loop 2320 Other Subscriber Information Required if other payers are known to potentially be involved in paying on this claim Usage Element Value Comment Required SBRO1 P Primary Code identifying the insurance carrier s level S Secondary of responsibility for payment of a claim If T Tertiary claim is being sent to Medicare Part B the Use to indicate payer of last resort code would be P to identify primary information Required SBR02 01 Spouse Specifies the relationship to the insured 04 Grandfather or Grandmother 05 Grandson or Granddaughter 07 Nephew or Niece 10 Foster Child 15 Ward 17 Stepson or Stepdaughter 18 Self 19 Child 20 Employee 21 Unknown 22 Handicapped Dependent 23 Sponsored Dependent 24 Dependent of a Minor Dependent 29 Significant Other 32 Mother 33 Father 36 Emancipated Minor 39 Organ Donor 40 Cadaver Donor 41 Injured Plaintiff 43 Child Where Insured has No Financial Responsibility 53 Life Partner G8 Other Relationship Situational SBRO3 Policy or group number Situational SBR04 Name of plan Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 191 Required Required SBRO5 SBRO9 AP Auto Insurance Policy C1 Commercial CP Medicare Conditional
60. Text Document 4 25 2013 8 41 4M ge BCPRNTMP CTL 1KB ctl File 4 30 1999 3 05 PM K BCPRNT 2 CTL 1KB ctl File 9 7 2006 7 37 AM es BCREQ276 DAT 1KB DAT File 4 25 2013 8 41 4M paliooo1 8375010 clm 2KB CLM File 4 25 2013 8 41 AM E BSCLMACT LOG 25KB Text Document 4 25 2013 8 40 4M es BSREQ276 DAT 1KB DAT File 3 27 2013 12 33 PM es BSTRANS DAT 3KB DAT File 4 22 2013 3 22 PM c4dll il 388 KB Application Extension 8 22 2002 12 54 PM of Client32 exe 436 KB Application 3 25 2013 11 51 4M Logging on To send and receive data you need to log onto your account on Cahaba s FTP server The approval letter you received when your submitter code was established will contain your user ID and password See the documentation for your FTP software for instructions on entering your user ID and password and using the software The instructions below assume you have a basic familiarity with your FTP software Manually Sending Files from PC ACE Pro32 Below are instructions for manually sending files from PC ACE Pro32 to our Secure FTP Server so they can be processed These instructions assume you have some sort of FTP software such as WS FTP also known as lpswitch or Cute FTP Pro More than likely the screen shots below will not match exactly with what you see when you follow these instructions You should be able to adapt the information below to your particular system Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015
61. U Unknown Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 111 Employment Status Employment Status Enter one of the following values 1 Full time 2 Part time 3 Not employed 4 Self employed 5 Retired 6 On active military duty 9 Unknown Student Status Student Status Enter one of the following values F Full time P Part time N Not a student CBSA Code Core Based Statistical Area Code Enter the 5 digit code specifying the area in which the patient lives Discharge Status Discharge Status Enter one of the following values 01 Discharged to home or self care routine discharge 02 Discharged transferred to a short term general hospital for inpatient care 03 Discharged Transferred to SNF with Medicare cert in anticipation of skilled care 04 Discharged transferred to a facility that provides custodial or supportive care 05 Discharged transferred to a Designated Cancer Center or Children s Hospital 06 Discharged transferred to home under care of organized HH serv org pending covered skilled care 07 Left against medical advice or discontinued care 08 Discharged transferred to home under care of home IV drug therapy provider not Medicare cert 09 Admitted as an inpatient to this hospital 20 Expired or did not recover Christian Science Patient 21 Discharged transferred to Court Law Enforcement 30 St
62. ab will display under the Billing Line Items Line Item Details tab with the fields required for the associated attachment Rendering Physician Rendering Physician Enter the National Provider Identifier assigned to the rendering provider Right click in the field to select from the Rendering Provider list Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 146 28 Total Charges Total Charges The Total Charges field will update when the Recalculate button is clicked Do not enter information into this field 29 Amount Paid 30 Balance Due Amount Paid Enter the amount paid by the patient at the time the claim services were rendered Balance Due The Balance Due field will update when the Recalculate button is clicked Do not enter information into this field Recalculate Recalculate Click this button to recalculate and update the Total Charges and Balance Due fields from the current claim line items charges values and the Amount Paid field value Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 147 Billing Line Items Extended Details Professional Claim Form a x Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen a Ext Payer Insured Line Item Details Extended Details Line 1 Ext Details 2 Line 1 Ext Details 3 Line 1 M Miscellaneous Extended Details
63. al Beneficiary Information Patient Information pa o x Extended Info Primary Insured Inst Primary Insured a Secondary Insured Tertiary Insured 4 gt Name First Name Gen Patient Control No PCN hie Patient Address Patient Status Address Active Patient fr Discharge Status Sex E Death Ind City State Zip DOB j_ _ ____ DOD aa __ Marital Status Signature On File Country Phone Employment Status E Release of Info o Student Status ROI Date a 3 oes CBSA Code Save Cancel Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 23 nation stion Extended Info Primary Insured Inst Primary Insured Prof Secondary Insured pall g Payer ID Payer Name LOB M Insured Information Optio C Common Inst amp Prof Group Name Group Number Claim Office Separate Inst amp Prof Clear All Fields For Insured Insur ation F7 Employer Information F8 Rel Z Last Name First Name MI Gen Insured ID 23 p Address Sex Assign of Benefits DOB j_ Release of Info ae sig City Zip Employ Status ROI Date ez a County Phone pare ats L Save Cancel The Payer Name and LOB fields will automatically populate with the payer s information when you enter the Payer ID You may right click and select the payer off the list The Group Name Group Number and Claim Office fields should be lef
64. an Situational SBRO5 12 Medicare Secondary Working Aged Code to identify the type of insurance Beneficiary or Spouse with Employer policy within a specific insurance Group Health Plan program 13 Medicare Secondary End Stage Disease Beneficiary in the 12 month 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 Services 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 Situational SBRO9 09 Self pay Code to identify the type of claim 10 Central Certification 11 Other Non Federal Programs 12 Preferred Provider Organization PPO 13 Point of Service POS 14 Exclusive Provider Organization EPO 15 Indemnity Insurance 16 Health Maintenance Organization HMO Medicare Risk AM Automobile Medical BL Blue Cross Blue Shield Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 190 CH Champus Cl Commercial Insurance Co DS Disability HM Health Maintenance Organization LI Liability LM Liability Medical MB Medicare Part B MC Medicaid OF Other Federal Program
65. ass e aac newts sienna estan tales sa scale teehee GameNet 115 Primary Secondary and Tertiary Insured 0 0 0 0 eccceseeescsseeeceseeseeseeseeseens 117 Provider TYPOS sinesine aa ae Aaaa a aaa AEAEE a aaa EENE 121 Entering Provider Information 2cn0 ttdn red alee inne 121 Provider INTOFMALION vcicseesiecseececesscicseewseiwecieceiweciseeeweeeseeusewcsceusweasieeveeccceunse 122 General Momeder denote a Ea a aes e e vette Aa 122 EXESTAC OC A Nge E AE E E 127 Entering Claim Information ProfeSsional ccsssssssseeeeeeeeeeeeeeeeeeeeeeees 131 Patient Info amp General cn ctwaicionaive Gass adidas Sekine eA een Rey eas 131 insured Informations 1cs50 varaash thee seaeaasenicncaeakgatagnniat dave dearer R nA NA 140 Line item Details as 2 ccs ae nite atest edie adipsia ea iets 145 Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 3 Billing Line Items Extended Details 0 0 0 0 ccccseseesesseeeceeeseeeceeeeeeecseeaeenees 148 Billing Line Items Ext Details 2 sicssed csc coviaed conumonucien datagdeuseua qatactaaimes 151 Billing Line Items Ext Details 3 suit cossssvaceecsinnins cous desacseeban aheerutean nevesteutnecaavasianaes 155 Billing Line Items MSP GO Biss ses scaseccsseccscesyaasavensbaatcvsrcedsvenseaclavsarcreunteckscavizees 157 Ambulance Attachment sssssssesesesesesesesesesesesesesesssssssseseseseseseseseseseseseseseseseseses 159 CLA Attachments sess sancenscsanactdatar cesses ne n te 162 Podiat
66. ayers already entered into your system You will then be able to select the payer needed When you have completed entering the patient information click the Save button If required information is missing you will get an error list and the fields in error will begin flashing You will then be able to correct the errors and save the record Entering Referring Ordering Attending Physician Information You may enter referring ordering attending physician information into a database in PC ACE Pro32 This will save you from having to enter the same referring ordering attending physician s information each time you need it on a claim From the Reference File Maintenance screen click the Codes Misc tab ii Reference File Maintenance q O x File view Reports Patient Payer Provider Inst Provider Pro Codes Misc Shared InstitUbbons Professional TOB POS DATA COMM CON OCC SP VAL TOS HCPCS REVENUE CODE CHARGES MASTER MODIFIERS SPECIALTY PHYSICIAN FACILITY MISC ANSI Now click the PHYSICIAN button This will bring up the Physician Setup screen Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 25 ia pa SEeLUL Physician ID Physician NPI Sot By Name Last First MI Physician ID List Filter Options Show all physicians no filter applied Filter list to include Physician IDs starting with Filter list to
67. bility insurance AP Auto Insurance Policy C1 Commercial CP Medicare Conditionally Primary GP Group Policy HM Health Maintenance Organization IP Individual Policy LD Long Term Policy LT Litigation MB Medicare Part B MC Medicaid MI Medigap MP Medicare Primary OT Other PP Personal Payment SP Supplemental Policy Insured s Contact Contact Contact person other than the insured Patient ID Membership ID ID number of the patient for this plan if plan issues ID numbers to each dependent Payer Insured Reference IDs Types Reference Identifiers Additional identifiers required by this payer for the services billed such as Prior Authorization Numbers Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 177 Extended Payer Insured MSP Info Primary Secondary COB Info Primary Professional Claim Form x Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Common Payer MSP Information OTAF _ i Zero Payment Ind I m Additional Adjustment COB Amounts MOA Information ANSI 837 Only COB Info Secondary Claim Level Adjustments CAS COB MOA Amounts Num Group Reason Amount Units Num Code Amount EITO C ETT E ETE TER mmm Medicare Outpatient Adjudication MOA Remarks Codes S f f i Claim Adudication Date _ _
68. by a dentist office will be entered automatically based on the Billing Provider entered at the top of the form Y Dental claim submitted by a dentist office N Not a dental claim If the value shown in the field is incorrect it must be changed in the reference file No change should be made to this field COB Coordination of Benefits Enter a Y if the claim is for a beneficiary who has an insurance primary to Medicare otherwise leave blank Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 138 Frequency Frequency Indicator One of the following values indicates if the claim is an original a replacement or a void claim 1 Original 7 Replacement 8 Void cancel of a prior claim 33a PIN No PIN Enter the unique Provider ID of the rendering provider solo or group member For claims billed to a group this provider serves as the rendering provider for all service lines 33b GRP No Group Number The group number will be entered automatically based on the Billing Provider entered at the top of the form If the number shown in the field is incorrect it must be changed in the reference file No change should be made to this field The Professional Claim Form Patient Info amp General tab includes fields that will automatically fill with information pulled from the Reference Files If any of the automatically entered information is incorrect it
69. care will deny payment for those services PC ACE Pro32 allows you to submit this information electronically This document describes the required fields needed to submit a Medicare Secondary Payer claim Before entering MSP claims the primary payer may need to be entered See instructions on entering payers in this manual The _ beneficiary s information with the primary and secondary payers will also need to be entered See instructions for entering beneficiaries in this manual There are two levels of information when sending MSP line level and claim level The process is different for Part A and for Part B so there are different sections for Institutional and for Professional claims Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 94 Entering MSP Claims Part A Institutional Before entering MSP claims the primary payer and the beneficiary s information with the primary and secondary payers will need to be entered See instructions for entering payers and beneficiaries elsewhere in this manual There are additional instructions on entering MSP claims at the end of this manual In the Patient Info amp Codes tab enter any information needed to process the claims Institutional Claim Form _ x Patient Info amp Codes Billing Line Items Payer Info Diagnosis Procedure Diag Proc 2 Extended General Ext General 2 Extended Payer Loe Mca FLI _FL2 Patient Control No f Type of
70. ce entered the patient s name and address information will populate automatically Right clicking this field will bring up a list of the patients you have entered into the database so you can select the one you are entering a claim for If the claim requires an ordering or referring physician s NPI you will need to enter it in block 17 of this screen If you have entered the ordering or referring physician s information in Reference File Maintenance then you can right click the Referring Phys IDs Types field to bring up the list of providers you have entered then left click to select the one you need to use You may also enter this information directly onto the form placing an XX in the small box after the box where you enter the NPI The Reserved for Local Use block is the free form line where any additional information you feel is relevant to the processing of the claim can be entered You would enter a Y in the COB field if you are entering a claim where Medicare is secondary For more information on entering these types of claims see PC ACE Pro32 and Medicare Secondary Payer elsewhere in this manual Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 40 Next click the Billing Line Items tab Professional Claim Form xi Patient Info amp General _ Billing Line Items ht Gen 2 Ext Payer Insured Line Item Details Extended Details Line 1 Ext Details 2 Line Ext Details 3 Line 1 Diagnosis
71. cription is where you will enter the company name The Address amp Contact Information section is where you will enter the address of the payer Right click Source to select the appropriate value When you have completed entering this information click Save For an explanation of Medigap and a link to the list of Medigap identifiers visit our website at www cahabagba com part_b education_and_outreach general_billing_info coba htm Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 20 Entering Beneficiaries From the Reference File Maintenance screen click the Patient tab Click New to bring up the patient information screen isi Reference File Maintenance loj x LastName FirstName Mi DOB LOB vi 88 BENEFICIARY TESTINGANOTH 10 10 1940 MCB MSP BENE 1 BENEFICIARY MSP TESTING 01 10 1945 COM TESTINGBENE NAME BOGUS B 01 01 1930 MCB af SortBy Patient PEN Patient Name List Filter Options Show all patients no filter applied C Filter list to include Patient PCNs starting with Filter list to include Patient Names starting with New elete Plan of Care Close Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 21 x Insured Inst l Primary Insured Prof l Secondary Insured l tM MLA Patient Information General Information Last Name Gen Patient Control No PCN TT M Patient Ad
72. d C Not assigned B Assignment accepted on Clinical Lab services only Prof only Participating Participating Provider Enter one of the following values indicating if the provider participates in the Medicare program Y Participates in Medicare program N Does not participate in Medicare Program Signature Ind Signature Indicator Enter one of the following values indicating if the provider s signature is on file Y Signature of provider is on file N Signature of provider is not on file Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 125 Date Signature Date If the Signature Ind is Y then enter the date that the provider s signature was placed on file with the payer receiver Provider Roles Billing Enter one of the following values to determine whether this provider will be included in the lookup list during claim entry Y Include in Billing Provider lookups N Do not include in Billing Provider lookups Rendering Enter one of the following values to determine whether this Individual in Group or Solo Practice provider record will be included in the service line Rendering Provider block 24k lookup list during claim entry Y Include in Rendering Provider lookups N Do not include in Rendering Provider lookups Note If the Provider Type is Group Practice this field will not be available Rema
73. d X Claim Service Thru Date Is Required X Patient Address Line 1 Is Required X Patient City ls Required X Patient State ls Required Double click error to jump to the corresponding field gt Indicates that error must be corrected before saving If there are no errors or when all errors have been resolved you will get a blank Payer Info amp Codes screen after clicking Save where you may begin entering another claim When you have entered all of your claims click Cancel to exit the claim entry system Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 38 For Professional Part B Users To enter process or prepare claims to transmit click the Professional Claims Menu This will bring up the Professional Claims Menu below igi Professional Claims Menu File View Roster Maintain List Claims Process Claims Prepare Claims If you are using PrintLink you will first need to Import Claims This will begin the file conversion process If any claims have errors you will be notified as the claims are converted If you are importing your claims using PrintLink and need help setting up your mapping you will need to contact one of the private vendors who support this function For a list of vendors who support PrintLink visit our website at www cahabagba com part_b edi ga_pc_ace_pro32_using_printlink htm To enter claims directly into the software click Enter Claims This will open the Profe
74. d not pay when asked 2 recipient did pay when asked 3 recipient was not asked Purchased Services Purchased Services Indicator Y service was purchased from another entity N service was not purchased from another a ae O a O Purch Charges Purchased Charges The amount of the charges that were purchased from another entity Initial Treatment Initial Treatment Date The date the patient was first treated for the condition Shipped Date Shipped Date The date the billed item was shipped Sales Tax Sales Tax The sales tax applicable for the billed item Postage Claim Postage Amount The Amount of postage claimed for the billed item Line Level Supporting Provider Information Last Org Name Last name of Provider or Organization Name The last name of the provider or the name of the organization used for the line item First Name First Name of Provider The first name of the provider of the services being billed MI Middle Initial The middle initial of the provider of the services being billed Suffix Suffix The suffix for the provider s name Jr Sr etc for the provider of the services being billed Provider IDs Types Payer IDs Provider Identifiers Types Payer IDs Identifier used for the provider Types G2 provider commercial number LU location number Payer IDs the payer ID of the non destination payer who assigned the identifier used Cahaba Government Benef
75. dress Patient Status Address Active Patient a Discharge Status OO Sex Death Ind f City State Zip whale Dop Marital Status E Signature On File J E Count Phone Employment Status Release of Info pats Dee Student Status ROI Date 7 Motes CBSA Code Save Cancel Enter the patient s name address date of birth etc on this screen Patient Control Number PCN is your account or medical record number for this patient If you encounter a field that you are not familiar with left click it and a tip screen giving a more complete description of the field will appear Right clicking many fields will give you a list of values that should be entered in the field allowing you to select which one is appropriate The first of the two blocks in the Signature on File area is for Part A The second is for Part B For Release of Info the only acceptable values are I and Y ROI Date is the date that the beneficiary signed the Release of Info form Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 22 Part A users will click the Primary Insured Inst tab to enter the patients primary payer information Part B users will click the Primary Insured Prof tab to enter the patient s primary payer information Combined Part A and Part B users will need to enter this information in both tabs These screens are the same for Institutional and Profession
76. e should be made to this field Zip Code The zip code for the insured will be entered automatically based on the PCN entered into the Patient Info amp General tab If the zip code shown in the field is incorrect it must be changed in the reference file No change should be made to this field Country Country Code The insured individual s country code if other than the US Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 143 Insured s Phone Ext Insured s Telephone Number The telephone number and extension for the insured will be entered automatically based on the PCN entered into the Patient Info amp General tab If the number shown in the field is incorrect it must be changed in the reference file No change should be made to this field ESC Employment Status Code One of the following values indicating the employment status of the insured will be entered automatically based on the PCN entered into the Patient Info amp General tab 1 Full time 2 Part time 3 Not employed 4 Self employed 5 Retired 6 On active military duty 9 Unknown If the value shown in the field is incorrect it must be changed in the reference file No change should be made to this field Employer Name Group Name Employer Name The name of the insured s employer will be entered automatically based on the PCN entered into the Patient Info amp General
77. e program is executed Exclusive system access is required to perform a restore operation in PC ACE Pro32 If this program is in use on another client workstation you will be notified when the Start Restore button is clicked You can either instruct the other users to exit PC ACE Pro32 and then continue the restore operation or simply cancel the restore request Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 181 Part IIl Troubleshooting and Appendixes Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 182 Appendix A Definitions of Terms Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 183 FTP stands for File Transfer Protocol The method PC ACE Pro32 uses to send and receive data once a connection has been established LOB stands for Line of business Refers to a specific type of business such as Medicaid private insurance Medicare Part B Medicare Part A etc Medicare Secondary Payer MSP a situation where another insurance company is primary over Medicare MSP see Medicare Secondary Payer above Network Service Vendor a company that provides connectivity NSV see Network Service Vendor above Submitter Code a code that identifies the sender of a file to our system This will be assigned by EDI Services and is given to PC ACE Pro32 users in a letter faxed to them when they are approved to use the software Submitter
78. e provider PO Boxes and Lockboxes will not be accepted If the physical address and the mailing address for the provider are different you may enter the mailing address in the Extended Info tab Phone and Contact will be the phone number and name of the person you want us to contact if there are problems with your file Provider ID No is where you will enter the provider s Medicare Part B number If you selected Group Practice as the provider type then this field will be labeled Group ID No The legacy number or PTAN will go here You may also enter the NPI in this field If the NPI is entered here you will need to click the Extended Info tab and place an XX in the Provider ID No Type field Even if you enter your PTAN PC ACE Pro32 will only send the NPI on your claims LOB stands for Line of Business and this will always be MCB for Professional Claims Right click the Payer ID field and select the appropriate payer Tag is an optional field where you can enter information to help you identify a particular provider This is helpful if you need to keep track of multiple providers Group Label is required if you are entering a group number or individual provider numbers associated with a group This enables PC ACE Pro32 to keep track of which provider numbers go with which group and also helps you to keep track if you have multiple groups you are billing for You may create any group label you wish but each pr
79. e the Loops and Segments Table beginning on Page 201 Claim Level Primary Payer Paid Amount For claim level information physicians and suppliers must indicate the other payer paid amount for the claim in loop 2320 AMTO1 D qualifier and AMT02 the monetary amount NOTE All line level payments when added together must equal the total amount paid on the claim Line Level Primary Payer Paid For line level information physicians and suppliers must indicate the other payer paid amount for that particular service in loop 2430 SVD0O2 Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 189 Loops and Segments Table The following are instructions for the segments and elements that are required when submitting MSP information electronically Please note that some segments and elements are situational but may become required when used Loop 2000B Subscriber Information Usage Element Value Comment Required SBRO1 P Primary Code identifying the insurance carrier s S Secondary level of responsibility for payment of a T Tertiary claim To identify whether Medicare is Use to indicate payer of last resort primary secondary or tertiary For Medicare Secondary Payer MSP claims being sent to Medicare Part B the code would be S Situational SBR02 18 Specifies the relationship to the person insured Situational SBRO3 Policy or group number Situational SBR04 The name of group pl
80. ease of Information A code indicating whether the provider has on file for this patient a signed statement permitting the release of medical data to other organizations in order to adjudicate the claims Enter one of the following values Informed consent to release data regulated by statute Y Yes provider has a signed statement permitting data release ROI Date Release of Information Date Specifies the date that the patient signed the Release of Information statement Notes Notes Enter any notes pertinent to the patient Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 114 Extended Info Patient Information j x General Information Extended Info Primary Insured Inst Primary Insured Prof Secondary Insured 4 gt M Patient Legal Representative Information Professional use only Name L F Address City ST Zip ff Country Phone Lo DA M Primary Provider ID Institutional use only Provider ID press F2 to select M Biling Rendering Provider IDs Professional use only Billing Provider ID press F2 to select Rendering Provider ID Save Cancel Last Name Last Name of Patien s Legal Representative Enter the patient s legal representative s last name First Name First Name of Patient s Legal Representative Enter the patient s legal representative s first name MI M
81. el Enter any information required for the Institutional claim form Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 34 Clicking the Diag Proc 2 tab will open the screen below Institutional Claim Form yi eee ee ee M B B B S B B B B B Enter any information required for processing of the claim Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 35 Clicking the Extended General screen open the following screen Institutional Claim Form e x Patient Info amp Codes Billing Line Itep Bgnosis Procedure Diag Proc 2 Extended General Ext General 2 3 er M Claim Supplemental Information PWK M Facility Information Dat Num Type Trans Attachment Control Number Description ype im mmr ater Name Address HE City State mClaim Notes NTE File Information K3 a Num Type Narrative Zip Country __ l Facility Type 1 r Tax ID Type NPI P y Si M Miscellaneous General Information Delay Reason Code Accident State Claim Tag n EPSDT Referral E E Enter the facility information as well as any other information required for the processing of the claim If you have entered the facility information in Reference File Maintenance you may right click the ID Type field and select it from a list
82. el Enter any information required for the processing of an Institutional claim form Clicking Extended Payer opens the following screen Patient Info amp Codes Billing Line Items Payer Info Diagnosis Procedure Diag Proc 2 Extended General Ext General 2 Extended Payer Primary Payer Secondary Payer Tertiary Payer Payer Address amp Miscellaneous M Insured Address amp Miscellaneous Address Address DO e Ciy svzp j____ Ciy St Zip T E Payer Source Code Provider Accepts Assign nile E Birthdate i Sex o Provider SOF E PatientiD ICN DCN Add l Ref No Type M Investigational Device Exemption IDE Numbers Add l Ref No Type IDE No 1 IDE No 2 IDE No 3 ave Cancel S Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 37 Enter the Primary Secondary or Tertiary Payer information if required for the processing of the claim When you have entered all of the required information click the Save button If required information is missing or invalid you will get an Edit Validation Errors List If you double click on an error message you will be taken to the field in error which will also be flashing Edit alidation Errors List X Patient Control Number Ils Required X Type Of Bill ls Required X Patient Last Name Is Required Patient First Name Is Required X Claim Service From Date Is Require
83. enefit Administrators LLC v3 4 Revised 07 28 2015 170 Facility Information Facility Name Facility Name Enter the name of the Hospital Nursing Facility Laboratory or other facility where services being submitted on this claim were rendered Address Line Facility Address Line Enter the address of the facility where services were rendered City Facility City Enter the city of the facility where services were rendered State Facility State Enter the state code of the facility where services were rendered Zip Facility Zip Code Enter the 9 digit zip code of the facility where services were rendered Cnitry IDs Facility Country and IDs Country code of country where facility is located if outside of the United States Identification number and ID number type for facility Fac Type Facility Type Code Code to identify the type of facility Leave blank to use default 77 Service Location Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 171 Miscellaneous Patient amp General Information Date of Death Date of Death Enter the date the patient was deceased Required if death indicator D Accident Date Accident State Hour Accident Date Enter the date the accident occurred Accident State Enter the State Postal Code identifying the state in which the automobile accident occurred Accident Hour Enter
84. eneral 2 Extended Payer Principal Diag Other Diagnosis Codes 1 17 ee B Ej E E E E E E E E E DX PC Admitting Diagnosis Patient s Reason For Visit Codes 1 3 External Cause of Injury Codes 1 3 PPS DAG Principal Proc Code Date Other Procedure Codes Dates 1 5 NPI Exempt POA Type LiF CRE L i L I L ES Bl E E E p Remarks Supporting Provider Information Type Last Org Name FirstName Ml Suffix Provider IDs Types a a E E C O E E E C D E B O S E Save Cancel To indicate that this is a Medicare Secondary Payer claim enter a Y in the COB field Enter any other information required on this screen Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 97 Next click the Billing Line Items tab Institutiona Form Patient Info acd Billing Line Items Payer Info Diagnosis Procedure Diag Proc 2 Extended General Ext General 2 Extended Peye Line Item Details Extended Details Line 1 Ext Details 2 Line 1 MSP COB Line 1 42 44 Modifiers 44 45 Service Date 46 47 48 Rev Cd HCPCS 1 2 3 4 Rate From Date ThuDate Units Days Total Charges Non Cov Charges I a aa a a ZA mmm ms yy _ yf fe E n i i f_i_ _ _j _ f j_ _ ___ aq o o T ee T__ ___ ___ oo o SS tdi _ __s_f __ ___ _ ___ ef ff ff f___ e__ ___ __ ____ ___ 7 _ __ _ _f_ _ ___ __s_ __ _ __ ____ ___ I 8 ___ ____ Recalculate Totals 0 00 0 00
85. ent Benefit Administrators LLC v3 4 Revised 07 28 2015 172 Special Program Indicator Medical Rec No Special Program Indicator A code indicating a special program or project under which services were rendered to the patient 01 EPSDT or CHAP 02 Physically Handicapped Children s Program 03 Special Federal Funding 05 Disability 06 PPB Medicare 100 Payment 07 Induced Abortion Danger to Life 08 Induced Abortion Rape or Incest 09 Second Opinion or Surgery 30 Medicare Demo Project Lung Volume Reduction Surgery 31 Veteran s Administration VA claim 45 Chiropractic Services Demonstration P Partnership Internal External TRICARE use only R Resource Sharing TRICARE use only Medical Record Number Enter the number assigned by the provider to identify the patient s medical records IDE Number Investigational Device Exemption Enter the investigational device exemption IDE number for FDA Approved clinical trials EPSDT Referral EPSDT Referral An indicator that reflects whether or not an EPSDT referral was given to a patient EPSDT Referral Codes AV Available not used NU Not Used S2 Under Treatment ST New Services Requested Submission Reason Code Submission Reason An optional code specifying the reason the claim was submitted Submission Reason Code PB Predetermination of Dental Benefits Cahaba Government Benefit Ad
86. ent Benefit Administrators LLC v3 4 Revised 07 28 2015 188 Line Adjustments Line Adjudication CAS Segment Adjustment Reason Line adjustments are required if the primary payer made line level adjustments that caused the amount paid to be different from the amount originally charged Line adjustment information is reported in the CAS segment including the claim adjustment group code claim adjustment reason code and the monetary adjustment amounts Line Adjudication segment is used to report the date the claim was adjudicated by the primary payer and is required on all MSP claims CAS Segment is used to report the adjustment reason codes and amounts as needed Adjustment Reason is used to report the adjustment on each service line such as co insurance deductible contractual adjustment etc Example The provider submits an MSP claim with the following 60 Billed Amount 20 Network Discount 40 Primary Allowed Amount 10 Co payment Amount 30 Primary Paid Amount The 20 difference between the allowed and the billed amount will be a Contract Obligation CO adjustment The 10 difference between the primary paid and the primary allowed will be a Patient Responsibility PR adjustment The primary payment will be 30 The Claim Adjustment Reason codes are located on the Washington Publishing Company web site http www wpc edi com Instructions for Electronic Billing of MSP Claims For more detailed information se
87. ent Benefit Administrators LLC v3 4 Revised 07 28 2015 45 When you have completed entering the claim click Save If required information is missing or invalid you will get an Edit Validation Errors List and be given the opportunity to correct them Edit alidation Errors List gt Patient Control Number ls Required Patient Last Mame Is Required Patient First Name ls Required gt Patient Birth Date Is Required gt Patient sex Code Is Required gt Patient Address Line 1 ls Required Patient City ls Required gt Patient state ls Required Patent ZIP Code Is Required Double click error to jump to the comespanding field gt Indicates that error must be corrected before saving The fields with errors will also start flashing You can click the tabs in the Claim Form screen to see all of the fields involved or use the Tab key to move to the next error Clicking the error message will take you to the field where the correction needs to be made Once you have corrected the errors click Save again to save the claim If the errors have all been corrected or if there were no errors you will get a blank Patient Info amp General screen where you may begin entering the next claim or click the Cancel button if you are done entering claims Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 46 Listing Claims To look at claims that have already been entered or imported click the
88. er s UPIN Unique Provider Identification Number Provider Last Name Enter the referring provider s last name First Name Enter the referring provider s first name Middle Initial Enter the referring provider s middle initial State Enter the referring provider s practicing state Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 150 Billing Line Items Ext Details 2 Professional Claim Form Patient Info amp General Insured Information Biling Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Line Item Details Extended Details Line 1 Ext Details 2 Line 1 Ext Details 3 Line 1 gt Line level Miscellaneous Information Proc Type Dese Facility Name Obstetric Anesthesia Additional Units 6 000 Facility Address National Drug Code or UPN Type E National Drug Unit Price 0000 yey a Nat Drug or UPN Units Type 0 000 E Fac IDs Types j Drug Ref No Type ree Drug Prescription Date i ar a Line level Reference IDs Types Payer IDs DME Length of Need Days DME Purchase Price DME Rental Price DME Rental Unit Price Ind Line level Miscellaneous Info Proc Type Desc Procedure Type ER Jurisdiction Specific Procedure and Supply Codes HC CMS Procedure Coding System HCPCS Codes Prof Only IV Home Infusion EDI Coalition HIEC Product Service Code Prof Only WK Advanced Billing Concepts ABC Codes ZZ
89. erence File Maintenance File View Reports Patient Payer 10101 J10 A B MAC CAHABA GBA Inst Only 10102 MCB J104 B MAC CAHABA GBA Prof Only 10201 MCA J10A 8 MAC CAHABA GBA Inst Only 10202 MCE J104 B MAC CAHABA GBA Prof Only 10301 MCA J10A B MAC CAHABA GBA Inst Only 10302 MCB J10 4 B MAC CAHABA GBA Prof Only SotBy PayerID PayerDescription PayerLOB Payer State List Filter Options Show all payers no filter applied Filter list to include Payer IDs starting with Filter list to include Payer Names starting with View Update To enter a Medigap identifier or a payer primary to Medicare click New This will open the payer information screen Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 19 Payer ID LOB Receiver ID a Override x fal Full Description Address amp Contact Information Flags Address A Source eaa Media City State Zip Usage L o __ Contact Name Phone Ext Fax ae aos a PrintLink Matching Descriptions Save Cancel If you are entering a Medigap payer enter the Medigap identifier in the Payer ID field and GAP in the LOB field o If you are entering a payer that is primary to Medicare you may use 99999 as the Payer ID and COM or other appropriate line of business in the LOB field If you need to enter more payers for MSP then you can use 99998 99997 etc as payer IDs Full Des
90. es Inc On the Claims Menu click Maintain then Claim Status Response amp Acknowledgement Log it Professional Claims Menu E3 File view Roster Eien 4 as Reverse Chim Import Transmission Log Acknowledgment File Log Launch Report Manager Prepare Claim Status Request File Claim Status Response Acknowledgment Log Purge Claim Activity Log ieee laine Process Claims Prepare Claims This will bring up the list of available Claim Status Response Logs Select the log you want to view by clicking it Click View Response Report to see the Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 81 response from the Medicare processing system to each request in the file Click View Ack Report to view the report Click Post Response File which will become available when a 277 has been selected to have PC ACE Pro32 post the results to the claims history ii Professional Claim Status Response amp Acknowledgment Log po fieke le et ee pa Posted A 03 26 2013 15 35 10302 ET ISIS View Ack Report Delete Refresh Close Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 82 To view the claim status response for a particular claim click List Claims on the Professional Claims menu Click Location in the lower left corner and select TR transmitted only This will bring up the list of claims in this status AE bigs bist File Filter Ac
91. essor Z led ri FI Select ANSI File Translate Import ETRA 4 Export Data Print iew Reports Reference Files Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 88 This will display the list of available remits Double click the remit to be viewed or click it once and click the Select button ii Select an ANSI File File Date File Size File Name 03 26 2013 41027 albpcace 20130325 ppball1 8355010 10 31 2006 1744 SAMPLE DAT Delete Cancel This will return you to the ETRA processor screen Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 89 Click the Translate Import ETRA button ist PC ACE Pro3 Professional ETRA Processor A x E e Select ANSI File Translate Import ETRA a Export Data Print View Reports Reference Files File successfully translated mz albpcace 20130325 ppb When translation is complete File successfully translated will appear at the bottom of the screen This typically only takes a few seconds Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 90 To view the remit click Print View Reports it PC ACE Pro32 Professional ETRA Processor E m File Help EA ch Select ANSI File Translate Import ETRA Export Data 2 ham Print View Reports Reference Files lalbpcace 20130325 ppbi This will bring up a list of available reports File successfully translated
92. for adjudication States 19 Entity acknowledges receipe of claim encounter Mote This code requires use of an Entity Code Encity PR Payer Provider of Service Acknowledgement 1 Information Source 13 10102 Name CABABA GBA Receiver Name CAHABA GBA J10 A B HAC ID ALBPCACE Provider Name PROVIDER TESTING A wrt 1234567890 Provider Info e The next page will indicate if the claims for particular providers in the file were accepted If a rejection is indicated at this level the individual claims Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 78 for that provider will not be listed If the claims were accepted at the provider level then the individual claims will follow the provider level acceptance If there are multiple providers in the file the results for the next provider will appear after the results for the previous provider PC ACE Pro32 ANSI 277 CLAIM ACKNOWLEDGMENT REPORT File Date Time 11 15 2011 13 12 00 Provider Trace 2111611 15666466612 Teral docepeed Quanity 1 Total dccepted keout 150 00 Provider Status Total Submitted Charges 150 00 Acknowledgenest 1 Caregory Al Acknowledgemest Receipt The claim encounter bas been received This does not mean thet the claim has been accepted for adjudication Status 19 Entity eckmosledges receipt of cleim enccunter Mote This code reqsizes ase of an Estity Code Estity PR Payer tet Claim Actmowledgenent 11
93. form If the state shown in the field is incorrect it must be changed in the reference file No change should be made to this field Patient Zip Patient Zip Code The patient s zip code will be entered automatically based on the Patient Control Number entered at the top of the form If the zip code shown in the field is incorrect it must be changed in the reference file No change should be made to this field Patient Phone Patient Telephone Number The patient s telephone number will be entered automatically based on the Patient Control Number entered at the top of the form If the number shown in the field is incorrect it must be changed in the reference file No change should be made to this field 10 Patient Condition Related To Employment Accident Patient Condition Related to Employment Enter one of the following values Y Yes employment related N No not employment related U Unknown Patient Condition Related to Accident Enter one of the following values A Auto Accident O Other non auto accident N No accident ROI Release of Information One of the following values indicating whether the provider has on file a signed statement permitting the release of medical data to other organizations in order to adjudicate the claim will be entered automatically based on the Patient Control Number entered at the top of the form Y Yes signed release on file M Modified o
94. ftware and when you perform periodic upgrades For most users the default file locations indicated will be appropriate Change these if necessary and click Next When the installation is complete the setup screen will close automatically after a few seconds You will see a red and white icon labeled PC ACE Pro32 on your Windows desktop You will also see an icon labeled PC ACE Pro32 Readme File Double clicking this icon will open a text file which gives instructions for installing PC ACE Pro32 onto a network Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 6 Signing onto PC ACE Pro32 You will be asked for your user ID and password when you click any of the buttons on the PC ACE Pro32 toolbar after you start the software SYSADMIN is the default user ID and password for signing on to the software Once you have signed on you can change this in the Security options of the software Please be very careful if you do choose to change the user ID and password If you lose or forget this information we have no way of retrieving it for you You may need to uninstall and reinstall the software losing any data you may have entered User ID SYSADMIN Password pem Cancel Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 7 Entering Submitter Information Double click the PC ACE Pro32 icon This will open the software and cause the PC ACE Pro32 toolbar to be displayed igi PC ACE
95. ge should be made to this field Sex Sex One of the following values indicating the sex of the insured will be entered automatically based on the PCN entered into the Patient Info amp General tab M Male F Female If the value shown in the field is incorrect it must be changed in the reference file No change should be made to this field Sig Signature One of the following values indicating how the patient subscriber authorization signatures were obtained and how they are being retained by the provider will be entered automatically based on the PCN entered into the Patient Info amp General tab C 1500 Signed CMS 1500 claim form on file S 1500 Signed signature authorization Form Block 12 on file M 1500 Signed signature authorization Form Block 13 on file B 1500 Signed signature authorization Form Block 12 amp 13 on file P 1500 Signature generated by provider patient not physically present If the value shown in the field is incorrect it must be changed in the reference file No change should be made to this field Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 142 13 AOB Assignment of Benefits One of the following values indicating whether or not the provider has obtained a signed form authorizing the payer to pay the provider will be entered automatically based on the PCN entered into the Patient Info amp General tab Y Yes payment
96. he archive details date of backup etc are presented to the user No data will be restored during the validation process so it is always safe and advisable to validate an archive before attempting a subsequent restore operation Source Drive or Folder Specifies the drive or Windows folder directory from which the backup archive file will be read This path may point to a removable media device diskettes writeable CDROM or to a standard Windows directory on a hard disk drive local or remote Disk spanning is supported for backup archives on diskette The user will be prompted to insert specific diskettes from the backup archive as needed Note When validating backup archives that span multiple diskettes insert the last diskette in the set first The system will prompt for the first and subsequent diskettes as the validation proceeds Once the desired source drive folder path has been specified click the Start Validate button to proceed You will be presented with details of the validated backup archive upon completion Restore From the Restore sub tab you can restore database files and configuration settings optional from a backup file The Restore option will only be visible to users with the appropriate permissions The following controls and options apply to the restore operation Source Drive or Folder Specifies the drive or Windows folder directory from which the backup archive file will be read This path
97. he provider Fed Tax ID Type Federal Tax Identifier Type The SSN or EIN of the provider Prov ID No Type Provider Identifier Type The unique pay to provider number used for this Line Of Business LOB Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 129 Sec ID Type 1 First Secondary Identifier Type The first of two optional secondary identifiers that may be used if additional identifiers are required to specify the provider Sec ID Type 2 Second Secondary Identifier Type The second of two optional secondary identifiers that may be used if additional identifiers are required to specify the Po provider S Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 130 Entering Claim Information Professional Patient Info amp General Proiessional Fin For Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured LOB MCB Billing Provider 26 Patient Control No 8 Pat Status Death 12 Legal NPI 2 Patient Last Name First Name MI Gen 3 Birthdate Sex MS ES SS Ind SOF Rep Exempt i g E ie oe i oe 5 Patient Address 1 Patient Address 2 Patient City State PatientZip Country Patient Phone Ey T O 10 Patient Condition Related To ROI ROIDate Other lns 14 Date Ind of Curent 15 First Date 16 UTW Disability Dates amp Type Employment E Accident E Ta E e E e
98. i837h exe 306 KB Application 2 27 2013 2 39 PM Pl ansi837i exe 127 KB Application 11 1 2010 9 02 AM Pl ansi837u exe 182KB Application 3 13 2013 4 10 PM Gg Ansi997r exe 106KB Application 1 18 2011 11 35 AM Pi ANSI CTL 1KB ctlFile 4 25 2013 8 41 AM E BCCLMACT LOG 20KB Text Document 4 25 2013 8 41 AM RA BCPRNTMP CTL 1 KB ctl File 4 30 1999 3 05 PM mi BCPRNTY2 CTL 1KB ctl File 9 7 2006 7 37 4M BCREQ276 DAT 1KB DAT File 4 25 2013 8 41 4M fo BCTRANS DATE 2KB DAT File 4 25 2013 8 41 AM BSCLMACT LOG 25KB Text Document 4 25 2013 8 40 4M BSREQ276 DA4T 1KB DAT File 3 27 2013 12 33 PM BSTRANS DAT 3KB DAT File 4 22 2013 3 22 PM Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 60 Type in the new file name using the file naming conventions given previously In the example below the file name was changed to pali0001 8375010 clm After renaming the file hit your Enter key or click somewhere else on the screen to de select it File Edit view Favorites Tools Help Q pack amp S pi Search Folders IFS EJ XxX e iil c WINPCACE Address Name Size Type Date Modified P Ansi824r exe 121 KB Application 3 17 2005 9 53 PM P ansi837h exe 306 KB Application 2 27 2013 2 39 PM P Ansi837i exe 127 KB Application 11 1 2010 9 02 AM P Ansi837u exe 182 KB Application 3 13 2013 4 10 PM g Ansi997r exe 106KB Application 1 18 2011 11 35 4M ge ANSI CTL 1 K6 ctl File 4 25 2013 8 41 4M E BCCLMACT LOG 20 K6
99. ication Compliance Act ASCA of 2001 An exception to this rule is when there is more than one payer responsible for payment before Medicare considers the charges These claims may still be submitted hardcopy Complete information about submitting electronic MSP claims is included in the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 Health Care Claim 837 The Technical Report Type 3 TR3 documentation is available at http www wpc edi com If another insurance company pays primary benefits secondary Medicare benefits may be payable to supplement the amount paid by the primary insurer Medicare secondary benefits may be payable if all of the following situations apply s The primary insurers payment is less than the provider s charges for Medicare covered services The primary insurers payment is less than the maximum amount payable by Medicare and The provider does not accept and is not obligated to accept the primary insurer s primary payment as payment in full The following commonly used terms and field explanations will serve as a guide for submitting proper electronic MSP claims Commonly Used Terms Contractual Contractual Obligation is the difference between billed amount Obligation and primary allowed amount that cannot be billed to the patient Patient Patient responsibility is the difference between primary allowed amount Responsibility and the primary PE paid amount Cahaba Governm
100. ick Extended details Line 1 to enter the third and or fourth modifiers If the charge you are billing for requires a CLIA number or if you are an ambulance provider chiropractic practice physical therapist or entering charges which require a special attachment such as the date last seen by primary care physician you can right click the AT field This will allow you to select from a variety of attachments Selecting one will add an additional tab to the claim entry screen with the name of the attachment For example if you select Ambulance you will see a tab next to Ext Details 2 Line 1 that will be labeled Ambulance Clicking the new tab will allow you to enter the details relevant to the attachment you selected You will need to do this for each line charge that requires an Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 41 attachment If you have multiple line charges that require an attachment and the information required is the same as the first attachment hitting the F5 key will copy the previous information to the new attachment Most CPT codes which require an attachment will cause the appropriate attachment tab to appear automatically when you enter them If a code does not cause an attachment tab to appear you may need to verify whether or not the information you were entering is still required for that code Diagnosis is where you will link the charge with the primary diagnosis associated w
101. iddle Initial of Patien s Legal Representative Enter the patient s legal representative s middle initial Address Line 1 Address Line 1 of Patient s Legal Representative Enter the address of the patient s legal representative Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 115 Address Line 2 Address Line 2 of Patient s Legal Representative Enter additional address information on the second address line If there is no additional address information bypass this field by pressing lt TAB gt City City Enter the city of the patient s legal representative State State Enter the two character abbreviation of the state in which the patient s legal representative resides Zip Zip Code Enter the 5 or 9 digit zip code Phone Telephone Number Enter the telephone number of the patient s legal representative including area code Provider ID Provider Identifier Enter the provider number for the Primary Provider or press F2 to select from the list Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 116 Primary Secondary and Tertiary Insured Patient Information x General Information Extended Info Primary Insured Inst Primary Insured Prof Secondary Insured 4 gt Payer ID Group Name Insured Information F7 Employer Information F8 Rel LastName Address e ooo E g County Phone
102. ile name should not be used twice in the same day If you need to send multiple files in the same day you can use a different four digit sequence in the file name The state code al ga tn should correspond with the state code that appears in your submitter code Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 55 Part A For claims the file naming convention is p al ga tn i0000 9999 8375010 clm For example a claim file from a Tennessee submitter could appear as ptni0012 8375010 clm For claim status requests the file naming convention is p al ga tn a0000 9999 2765010 276 For example a claim status request file from an Alabama submitter could appear as pala0001 2765010 276 Part B For claims the file naming convention is p al ga tn p0000 9999 8375010 clm For example a claim file from a Georgia submitter could appear as pgap0010 8375010 clm For claim status requests the file naming convention is p al ga tn b0000 9999 2765010 276 For example a claim status request file from a Tennessee submitter could appear as ptnb0003 2765010 276 PC ACE Pro32 file names PC ACE Pro32 uses the following file names Please note that you may not see a particular file name if you have not prepared any claims or created any claim status requests Also if your Windows Explorer is configured to not show file name extensions you may not see the DAT at the end of the file names PC ACE Pro32 crea
103. ill patient or expected to return for outpatient services 40 Expired at home 41 Expired in a hospital SNF ICF FREE 42 Expired place unknown 43 Discharged transferred to a federal health care facility 50 Discharge to hospice home 51 Discharge to hospice medical facility 61 Discharged transferred to a hospital based Medicare approved swing bed 62 Discharged to rehabilitation facility unit Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 112 63 Discharged to long term care LTC hospital 64 Discharged transferred to nursing home certified under Medicaid but not under Medicare 65 Discharged transferred to a psych hospital or psych distinct part unit of hospital 66 Discharges transfers to to Critical Access Hospitals 69 Discharged transferred to a Designated Disaster Alternative Care Site 70 Discharged transferred to another Institution Type not Defined Elsewhere in this List 81 Discharged to Home or Self Care with a Planned Acute Care Hospital Inpatient Readmission 82 Discharged Transferred to a Short Term General Hospital for Inpatient Care w PACHIR 83 Discharged Transferred to a SNF with a Medicare Certification w PACHIR 84 Discharged Transferred to a Facility that Provides Custodial or Supportive Care w PACHIR 85 Discharged Transferred to a Designated Cancer Center or Children s Hospital w PACHIR 86 Discharged Transfer
104. include Physician Names starting with To enter a referring or ordering physician s information click New This will bring up the Physician Information screen Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 26 Physician Information Physician ID Type EA Physician s Last Name First Name MI Suffix Address moo City Stale ip Phone BE yy aa Federal Tax ID Type NPI Taxonomy po a Cancel Enter the physician s NPI in Physician ID Type should be XX Phone Address City State Zip and Federal Tax ID Type are optional fields If the Zip is entered it must be the full nine digit zip code Since you are entering the NPI in the Physician ID Type field the NPI field at the bottom should be left blank Taxonomy is not required but if a taxonomy code is entered it must be valid Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 27 Claims Entry and Processing Entering Claims For Institutional Part A Users To enter import or process claims or prepare claims to transmit click the i te Fa SiH Institutional Claims Menu button on the PC ACE Pro32 toolbar This will bring up the Institutional Claims Menu below iii Institutional Claims Menu x File view Attachments Maintain List Claims Process Claims Prepare Claims To enter claims click Enter Claims to open the Institutional Claim Form Cahaba Government Benefit Admin
105. ip Patient Weight Patient Weight Enter the patient s weight Miles Miles Enter the number of miles Ambulance Pick Up Location Pick Up Address The address city state and zip where the patient was picked up for transport Ambulance Drop Off Location Drop Off Address Address city state and zip where the patient was dropped off Purpose of Round Trip Purpose of Round Trip Enter the purpose of the round trip Purpose of Stretcher Purpose of Stretcher Enter the purpose of the stretcher if applicable Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 161 CLIA Attachment HUFA 15UU Claim Form CLIA Certification Number CLIA Certification Number Enter the CLIA Certification Number if applicable Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 162 Podiatry Attachment Professional Claim Form Date Last Seen Date Last Seen Enter the date last seen Supervising Provider ID Supervising Provider Identifier Enter the identifier assigned to the supervising provider by the destination payer Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 163 Chiropractic Attachment Professional Claim Form Ix Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Line Item Details Extended Details Line 1 Ext Details 2
106. is required Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 44 If you need to enter narrative information for this line or need to submit attachment information click Ext Details 3 to open the screen below Professional Claim Form Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pd Ext Payer Insured Line Item Details Extended Details Line 1 Ext Details 2 Line 1 Ext Details 3 Line 1 M Line level Miscellaneous Information continued Ordering Provider Address Address l m City St ZipCntry __ _ yt M Line Supplemental Information PWK Num Type Trans Attachment Control Number l n 2 mop Up El M Line Notes NTE File Information K3 Num Type Narrative 1 i A Fa Ea Save Cancel Attachment information for the charge should be entered in the Line Supplemental Information PWK section Right click the Type and Trans fields to select the appropriate value and enter your Attachment Control Number For more information on submitting claim attachments and the cover sheets to be used for faxes visit our website at http www cahabagba com news part b claims submission with pwk In the Line Notes NTE File Information K3 section right click in the Type field and select ADD Then enter the relevant information in the Narrative box Cahaba Governm
107. istrators LLC v3 4 Revised 07 28 2015 28 Institutional Claim Form yi xX Patient Info amp Codes Biling Line Items Payer Info Diagnosis Procedure Diag Proc 2 Extended General Ext General 2 Extended Payer LOB MCA Flt _FL2_ __ Patient Control No Type of Bill be Patient Last Name First Name MI Suffix Fed Tax ID Statement Covers Period t a Patient Address 1 Patient Address 2 Patient City State PatientZip County Patient Phone Rea Birthdate Sex MS Admission A HourTyp Sre D Hour Stat Medical Record No Condition Codes ee tps Tet et COU Occurrence Occurrence Occurrence Occurrence Occurrence Span Occurrence Span Code Date Code Date Code Date Code Date Code tom hru Code rom E TE TETE TEC C TEC E i A a a ee M Value Value Value Value Value Value Code Amount Code Amount Code Amount Code Amount Code Amount Code Amount T Em g g g U g m p m p m p ___ji ___j g ___ Save Cancel On the Patient Info amp Codes tab MCA should already appear as the LOB Complete the fields on this screen as required for the Institutional claim form Then click the Billing Line Items tab Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 29 Institutional Claim Form xi Patient Info amp Codes Billing Line Items P3 ha Proc 2 Extended General Ext General 2 Extended Payer Line Item Details Extended Details Line 1 Ext Details 2 Line
108. it Administrators LLC v3 4 Revised 07 28 2015 149 Supplemental Provider Information Supervising Provider ID Provider UPIN Supervising Provider Identification Provider Last Name First Name MI State Enter the National Provider Identifier assigned to the supervising provider who supervised the service Provider UPIN Enter the supervising provider s UPIN Unique Provider Identification Number Provider Last Name Enter the supervising provider s last name First Name Enter the supervising provider s last name Middle Initial Enter the supervising providers middle initial State Enter the supervising provider s practicing state Ordering Provider ID Provider UPIN Ordering Provider Identification Provider Last Name First Name MI State Enter the National Provider Identifier assigned to the physician who ordered the service Provider UPIN Enter the ordering providers UPIN Unique Provider Identification Number Provider Last Name Enter the ordering provider s last name First Name Enter the ordering provider s first name Middle Initial Enter the ordering provider s middle initial State Enter the ordering provider s practicing state Referring Provider ID Provider UPIN Referring Provider Identification Provider Last Name First Name MI State Enter the National Provider Identifier assigned to the referring provider who referred the services Provider UPIN Enter the referring provid
109. ith the charge Enter a number here that corresponds with number of the relevant diagnosis code in the Claim Diagnosis Codes fields For example if you have ICD 9 code 4281 as the first Claim Diagnosis Code field and this is the primary diagnosis for the code you are billing on the first line item you would put a 1 in this field Charges is where the billed amount for the line item will be entered Units is the number of service field This field contains one decimal position so the number 1 will appear as 1 0 The default for this field is 1 0 If this is not correct you can change it to the correct value by keying over it Rendering Physician is where the performing physician s Medicare Part B provider number PTAN or NPI will be entered if you are billing for a group practice If you are entering claims for a group practice you right click in this field and the Provider Selection screen will come up so you can select the rendering provider Total Charge is the total billed amount for the claim You can click Recalculate to have this amount calculated and plugged in by the software Amount Paid is the amount paid by the beneficiary The Balance Due field will be calculated by the software Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 42 If the claim has more than two modifiers contains purchased service information or if you are billing for anesthesia you will need to click the Extended Details tab Pr
110. itial R Return T Transfer X Round Trip Transport To For Transport To For Enter one of the following values indicating the reason for transport A To the nearest facility for care of symptoms and or complaints B For the benefit of a preferred physician C For the nearness of family members D For the care of a specialist or for availability of specialized equipment E Patient was transferred to a rehabilitation facility Stretcher Stretcher Enter one of the following values indicating the use of a stretcher Y Patient was moved by stretcher N Patient was not moved by stretcher Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 159 Bed Confined Before Bed Confined Before Enter one of the following values indicating the status of the patient Y Patient was bed confined before ambulance service N Patient was not bed confined before ambulance service Bed Confined After Bed Confined After Enter one of the following values indicating the status of the patient Y Patient was bed confined after ambulance service N Patient was not bed confined after ambulance service Bed Chair Confined During Bed or Chair Confined During Y Patient was bed or chair confined during ambulance service N Patient was not bed or chair confined during ambulance service Unconscious Shock Unconscious Shock Enter one of the following values indicating the sta
111. ivating them You will be allowed to select which claims to be processed You can select a particular LOB and or a particular provider number If you leave these fields blank then all claims in the claim file will be processed You can also designate if you want claims with errors presented during processing for immediate correction or you have the option of getting a list of claims with errors after processing has been completed Preparing Claims Before transmitting you must first click Prepare Claims This creates the actual ANSI 837 file that you will transmit to us Here you are given the option to select a particular LOB payer and or provider number Note only perform this action when you have finished entering or reactivating and editing your claims and are about to transmit them Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 49 Creating a Request for Claim Status It is possible to use PC ACE Pro32 to get the status of a claim previously submitted with PC ACE Pro32 This is a batch process which means you will send a file with the status requests and the Medicare processing system will create a response file during the overnight processing cycle if you submit your request before 3 30 p m Central Time Requests after 3 30 p m Central Time will take an extra business day To create claim status requests click the Institutional Claims Processing button for Part A or Professional Claims Processi
112. l amount paid by the primary payer U Unknown Required DMG01 D8 Code indicating the format of the date Required DMG02 Date of birth CCYYMMDD Required DMG03 F Female Code indicating the sex of the individual M Male Other Insurance Coverage Information on File at Health Care Service Provider or at Utilization Review Organization Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statues M The Provider has Limited or Restricted Ability to Release Data Related to a Claim N No Provider is Not Allowed to Release Data O On file at Payer or at Plan Sponsor Y Yes Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required Ol03 N No A Y value indicates insured or authorized Y Yes person authorizes benefits to be assigned to the provider an N value indicates benefits have not been assigned to the provider Situational Ol04 B Signed signature authorization form Indicates how the patient or subscriber or forms for both HCFA 1500 Claim authorization signature was obtained and how Form block 12 and block 13 are on file itis being retained by the provider C Signed CMS Claim Form on file M Signed signature authorization form for CMS Claim Form block 13 on file P Signature generated by provider because the patient was not physically present for services S Signed
113. lated to the performance of the service Right click in the Modifiers field to select from the HCPCS Modifiers List Third and fourth modifiers if needed can be entered on the Extended Details screen 24e Diagnosis Diagnosis Enter the pointer to the claim diagnosis code Claim Diagnosis Codes in the order of importance to this service 24f Charges Charges Enter the charges related to this service 24g Units Units Enter the number of services rendered in days or units EP Early and Periodic Screen for Diagnosis and Treatment of Children Enter one of the following values indicating whether or not Early and Periodic Screen for Diagnosis and Treatment of Children EPSDT services were involved with this detail line Y Yes EPSDT involvement N No EPSDT not involved FP Family Planning Indicator Enter one of the following values indicating whether or not Family Planning Services were involved with this detail line Y Yes family planning involved N No family planning not involved AT Attachment Enter one of the following values for the associated attachment 0 Cancel automatic attachment 1 Ambulance attachment 2 CLIA 3 Podiatry attachment 4 Chiropractic attachment 5 Mammography attachment 6 EPO attachment 7 Physical therapy attachment A Dental attachment You must first enter a procedure code before any of these values will be available A new sub t
114. le No change should be made to this field Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 132 8 Pat Status MS ES SS Patient Marital Status One of the following values indicating the marital status of the patient will be entered automatically based on the Patient Control Number entered at the top of the form S Single M Married X Separated D Divorced W Widowed P Life Partner U Unknown If the value shown in the field is incorrect it must be changed in the reference file No change should be made to this field Patient Employment Status One of the following values indicating the employment status of the patient will be entered automatically based on the Patient Control Number entered at the top of the form 1 Full Time 2 Part time 3 Not employed 4 Self employed 5 Retired 6 On active military duty 9 Unknown If the value shown in the field is incorrect it must be changed in the reference file No change should be made to this field Patient Student Status One of the following values indicating the patients student status will be entered automatically based on the Patient Control Number entered at the top of the form F Full time P Part time N Not a student If the value shown in the field is incorrect it must be changed in the reference file No change should be made to this field Death Ind Death Indicator One of
115. lected Claim Status Show Selected Claim Status History Gm Copy All Checked Claims Sort By Delete All Checked Claims oe Purge All Checked Claims Claim List Reactivate All Checked Claims Location Hold All Checked Claims Print All Checked Claims Checked Archive All Checked Claims Set All Checked Claims Media Request All Checked Claims Status This will bring up the Claim Status Request Response History for this claim You may have multiple requests and responses for the same claim Double click the response you wish to view it Claim Status Request hesponse History 09 16 2008 13 26 Request 09 16 2008 13 48 Response FSF 6 9 15 2008 592 08 07 28 2008 aT View Delete Print History Close Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 85 Gam Status Response Details Response Posted 09 16 2008 13 48 General Claim Information Claim Trace 20444 456739055556 ICN DCN 1199999111444466 General Status Information Status Date 09 15 2008 Submitted Charges 2 800 00 Payment Amount Date Method 592 08 07 28 2008 Check Check Issue EFT Eff Date 07 28 2008 Check EFT Trace Response 2 Response 3 Finalized Forwarded The claim encounter Al processing has been completed Any applicable x payment has been made and the claim encounter has i Status Claim encounter has been forwarded to entity Entity Create Date Time 09 15 2008 23 5
116. lock 25 during claim entry Type A code that identifies the type of Provider Tax ID entered in the previous field Enter one of the following values E Employer Identification Number S Social Security Number X Corporate Name but Social Security Number UPIN Unique Provider Identification Number Enter the providers Unique Provider Identification Number UPIN The UPIN is required for Medicare provider records Specialty Specialty Enter the appropriate code indicating that primary specialty of the provider for this Line of Business as defined by the payer receiver Right click in the Specialty field and choose from the Provider Specialties list Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 124 Type Org Type of Organizational Structure The organizational structure of the provider Enter one of the following values 001 Solo Practice 002 Partnership 003 PA Professional Association 004 Clinic 005 Single entity facility hospital 006 Distinct part facility hospital 007 Individual 008 Corporation Taxonomy Taxonomy Code A code indicating the type classification and specialization of the provider for this Line of Business These codes are defined in the Health Care Provider Taxonomy Code list Accept Assign Accept Assignment Enter one of the following values indicating whether the provider accepts assignment for this Line of Business A Assigne
117. long with the attachment to the number provided See the instructions for this process on our website at http www cahabagba com news part a claims submission with pwk Click Line Item Details to return to the previous screen and enter another line item Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 32 Clicking Payer Info brings up this screen ae ees Enter any information that is needed for the processing of this claim Some of the fields on this screen will automatically be populated from the information entered for the beneficiary Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 33 Clicking the Diagnosis Procedure tab will open the screen below Institutional Claim Form yi X Patient Info amp Codes Billing Line Items Payer Info Diagnosis Procedure Diag Proc 2 Extended General Ext General 2 Extended Payer Principal Diag Other Diagnosis Codes 1 17 m B B E E B B E m B B E E B B B B DX PC Admitting Diagnosis Patient s Reason For Visit Codes 1 3 External Cause of Injury Codes 1 3 PPS DRG Principal Proc Code Date Other Procedure Codes Dates 1 5 NPI Exempt POA Type COB H H CRE E js C E Ea m E a a a Remarks Supporting Provider Information Type Last Org Name First Name MI Suffix Provider IDs Types i O ees E E ees m S O O o Save Canc
118. lue shown in the field is incorrect it must be changed in the reference file No change should be made to this field NPI Exempt NPI Exempt Enter a Y to indicate if claim is exempt from NPI reporting status Set this field to Y to bypass NPI editing requirements only when applicable 5 Patient Address 1 Patient Address 1 The patient s mailing address will be entered automatically based on the Patient Control Number entered at the top of the form If the address shown in the field is incorrect it must be changed in the reference file No change should be made to this field Patient Address 2 Patient Address 2 Line two if any of the patients mailing address will be entered automatically based on the Patient Control Number entered at the top of the form If the address shown in the field is incorrect it must be changed in the reference file No change should be made to this field Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 134 Patient City Patient City The city in which the patient resides will be entered automatically based on the Patient Control Number entered at the top of the form If the city shown in the field is incorrect it must be changed in the reference file No change should be made to this field State State The state in which the patient resides will be entered automatically based on the Patient Control Number entered at the top of the
119. lues indicating the payment source for this claim for the indicated payer 09 Self Pay 10 Central certification 11 Other non Federal programs 12 Preferred provider organization PPO 13 Point of service 14 Exclusive provider organization EPO 15 Indemnity insurance 16 HMO Medicare risk 17 Dental maintenance organization AM Automobile medical BL Blue Cross Blue Shield CH Tricare Champus Cl Commercial insurance Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 176 DS Disability Fl Federal Employees Program HM Health maintenance organization LI Liability LM Liability medical M Family or friends MB Medicare Part B MC Medicaid MH Managed care non HMO OF Other Federal program P Blue Cross SA Self administered group TV Title V VA Veteran Administration WC Worker s Compensation health claim ZZ Mutually defined Insurance Type Insurance Type Indicator A code that indicates the type of insurance 12 MSP Working aged beneficiary spouse with employer group plan 13 MSP ESRD Beneficiary 12 month coordination period employer group plan 14 MSP No fault insurance including auto other 15 MSP Worker s compensation 16 MSP PHS or other federal agency 41 MSP Black Lung 42 MSP Veteran s Administration 43 MSP Disabled beneficiary under age 65 with LGHP 47 MSP Other lia
120. ly Primary GP Group Policy HM Health Maintenance Organization HMO IP Individual Policy LD Long Term Policy LT Litigation MB Medicare Part B MC Medicaid MI Medigap Part B MP Medicare Primary OT Other PP Personal Payment Cash No Insurance SP Supplemental Policy 09 Self pay 10 Central Certification 11 Other Non Federal Programs 12 Preferred Provider Organization PPO 13 Point of Service POS 14 Exclusive Provider Organization EPO 15 Indemnity Insurance 16 Health Maintenance Organization HMO Medicare Risk AM Automobile Medical BL Blue Cross Blue Shield CH Champus Cl Commercial Insurance Co DS Disability HM Health Maintenance Organization LI Liability LM Liability Medical MB Medicare part B MC Medicaid OF Other Federal Program TV Title V VA Veteran Administration Plan Refers To Veterans Affairs Plan WC Worker s Compensation Health Claim ZZ Mutually Defined Unknown Code to identify the type of insurance policy within a specific insurance program Code to identify the type of claim Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 192 Loop 2320 Other Subscriber Information Coordination of Benefits COB Payer Paid Amount and Allowed Amount Subscriber Demographic Information Required AMTO1 D Code to identify the primary paid amount Required AMT02 Tota
121. m the backup To backup to a CD you will first need to perform the backup to your CA drive and then burn the resulting file which will be named PCACEPBK ZIP to a blank CD You may also perform the backup to a network drive if your system is part of a network by changing the destination drive to your network drive Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 108 Part Il Field by Field Explanations Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 109 Patient Information General Information Patient Information i x General Information Extended Info Primary Insured m Primary Insured Prof Secondary Insured 4 Last Name First Name e oe a Po M Patient Address Address ee ooo m City E Country Phone o Gen Patient Control No PCN l Patient Status Active Patient ly Sex E DOB A Discharge Status Death Ind po 4 Signature On File Release of Info Marital Status Employment Status ROlDate J _ _ Student Status i ote CBSA Code E Save Cancel Last Name Patient s Last Name Enter the patients last name as it appears on his or her Medicare card including spaces dashes apostrophes etc First Name Patient s First Name Enter the patient s first name MI Patient s Middle Initial Enter the patient s middle initial Gen Patient s Genera
122. mation the same as if Medicare Part B was the primary insurance After the first line on the claim is completed click the MSP COB Line 1 tab and begin to enter information from your primary EOB Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 Professional Claim Form X Patient Info amp General Insured Information Biling Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Line Item Details Extended Details l Ext Details 2 Line 1 Ext Details 3 Line 1 MSP COB Line 1 M Common Line MSP Amounts E Line level Adjudication COB Information ANSI 837 Use Only Approved E Service Line Adjudication SYD Information SVD P S Proc Qual Code Modifiers 1 thru 4 Paid mount Paid Units B U Line w o 2 i i E w o o eee ee w o o eee ee M Line Adjustment CAS amp Miscellaneous Adjudication Info gt Procedure Code Description Line Level Adjustments CAS a OTAF 0 00 Num Group Reason Amount Units EIT lL _ o 1 i EET Adj Payment Date Remaining Owed Save Cancel 7 Enter information from primary EOB if applicable denied deductible and co insurance 8 Service Line Adjudication SVD Information e Right click in P S Proc fields and select the appropriate information e Right click in Proc Field and select the appropriate information e Inthe Qual Code field enter the same procedure code fr
123. ment adjustment CO Contractual Obligations CR Correction and Reversals OA Other Adjustments PI Payer Initiated Reductions PR Patient Responsibility Reason Reason Code A code identifying the detailed reason an adjustment was made Amount Adjustment Amount The amount of the adjustment associated with this group and reason code Units Adjustment Units The number of units associated with this group and reason code Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 158 Ambulance Attachment Professional Claim Form Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen a Ext Payer Insured Ix Line Item Details Extended Details Line 1 Ext Details 2 Line 1 Ext Details 3 Line 1 Ambulance Type of Transport E Physical Restraints subarea Loewen Transport To For E Visible Hemorrhaging E Aei Stretcher E Services Available E Bed Confined Before E Medically Necessary E en _ e Bed Confined After Patient Admitted E Ambulance Drop Off Location Bed Chair Confined During Patient Count Aake o Unconscious Shock E Patient Weight FO Emergency Situation E Miles p City St Zip Cntry ss je Purpose of Round Trip Purpose of Stretcher Save Cancel Type of Transport Type of Transport Enter one of the following values indicating the type of transport In
124. ministrators LLC v3 4 Revised 07 28 2015 173 Delay Reason Code Delay Reason A code that specifies why a claim was delayed Required when claim is submitted past the date of filing limitations and any of the allowable codes apply Delay Reason Codes 1 Proof of Eligibility Unknown or Unavailable 2 Litigation 3 Authorization Delays 4 Delay in Certifying Provider 5 Delay in Supplying Billing Forms 6 Delay in Delivery of Custom made Appliances 7 Third Part Processing Delay 8 Delay in Eligibility Determination 9 Original Claim Rejected or Denied Unrelated to the billing Limitation Rules 10 Administration Delay in the Prior Approval Process 11 Other 15 Natural Disaster Pregnancy Indicator Pregnancy Indicator A code indicating whether or not the patient was pregnant Pregnancy Indicator Codes Y the patient was pregnant N the patient was not pregnant Claim Tag Patient Weight Ibs Claim Tag An optional user assigned tag or pneumonic that can be established for easy identification of the claim record The data is not reported in the claims transmission file Patient Weight The weight of the patient in pounds on the date services were rendered Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 174 Ext Pat Gen 2 Professional Claim Form Patient Info amp General Insured I
125. nd log onto your FTP account In the area for your local drive in your FTP software navigate to the mailbox subdirectory Name Name Size Type Modtied 4 TD abpoace 20130326 277oa601 0129 671 Win 3 26 2013 8061 abpoace 20130025 3KB 203 3y26 2013 2011 ls ALBPCACE TALPOOO0 8376010 20190326 122063 998 303 999 3 26 2013 201 ly g il gt ii a O object s 0 Bytes Connected to bluecmsftp bebsal org 13 object s 230 KB Information Window Bix Progress Transferred Rate kBps Time Left Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 65 Click the file name to be retrieved once to select it then click the left arrow to retrieve the file and store it in the mailbox subdirectory Sie Type Modlied A OW abpcace 20190326 277ca800 ap BT Win 3 26 2013 8051 i abpoace 2 30326 3KB 2013 32803201 El 26 1330 303 999 3 26 2013 201 lv a D object s 0 Bytes V Connected to bluecmsftp bebsal ora 1 object s selected 303 Bytes Information Window Staus Progress Transtened Rate kBps Time Left See the instructions elsewhere in this manual for viewing the 999 277CAs and 277s The 277CA is the claims acknowledgement report and gives the details for accepted claim files The 277 is a response to a submitted and accepted claim status request file 276 One 277CA is created per day when at least one file is submitted and accepted A 277 is created
126. nformation Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Diagnosis Codes 9 12 ICD Ind Anesthesia Proc Codes Claim Supplemental Information PK Condition Codes Num Type Trans Attachment Control Number Al 1 v Dental Tooth Status DN2 Claim Notes NTE File Information K3 Num Tooth No Status Num Type Narrative 1 i l a nm fe Additional Supporting Provider Information Last Org Name First Name MI Suffix Provider IDs Types Referring 2nd gt Supervising Asst Surgeon Save Cancel Diagnosis Codes 9 12 Additional Diagnosis Codes Ninth through twelfth diagnosis codes for claim if necessary Claim Supplemental Information PWK Supplemental Information Indicator Indicates type of supplemental information available to support billing for services on the claim Claim Notes NTE File Information K3 Claim Notes Free form message for additional information needed to support the services billed on the claim ICD Ind Diagnosis Code Qualifier Indicates if diagnosis codes used are ICD 9 or ICD 10 9 ICD 9 CM 0 ICD 10 CM Anesthesia Procedure Codes Anesthesia Procedure Codes Surgical codes for procedure where anesthesia is being billed Condition Codes Condition Codes Used when condition codes apply to claim Dental Tooth Status DN2 Tooth Status Used to indicate status of tee
127. ng button for Part B on the PC ACE Pro32 tool bar Since this function is the same for Institutional and Professional claims only the Professional screens will be shown Click the List Claims button igi Professional Claims Menu x Fie view Roster Maintain Import Claims Enter Claims XEF SEF List Claims Process Claims Prepare Claims Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 50 isi Professional Claim last File Filter Actions Reports Go Sort By PatientName PCN C Entry Date Service Date Claim List Filter Options Location to be transmitted Status lt lt All gt gt 7 LOB lt lt All gt gt v to be transmitted PD Ta team Clear Filters Advanced Filter Options Checked Le tle Ta team View ow ow Delete Click Location in the lower left corner then click TR from the drop down box This will bring up the list of claims you have prepared Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 51 ii Professional Claim list Fie Filter Actions Reports EEA ren Pai iot sav a MCB 12556 JOHNSON ma oe CO CLN MCB 99999 BENE NAME AF ZZZZ222 Solo 08 01 2008 0 am SotBy Patient Name PCN C Entry Date C ServiceDate Tra Claim List Filter Options Location TR transmitted only Status lt lt All gt gt L0B lt All gt gt v E A Clear Filter Advanced Filter Options Ne
128. now A i J 4 Z n A Pa i CACE maibor Y K a ee heal Name Size pl abpeace 20130325 ppball 8355010 2p BKB 3 albpcace 20130327 27 7ce bin 514 E abpcace 20130327 ez 2K8 ALBPCACE TALIOONO 837 Area 303 i El athnrane 2130998 977 maBNN zin F71 4 4 2 i O object s 0 Bytes Connected to bluecmsftp bcbsal org 13 object s 230 KB Information Window Source Status Progress Transfered Rate kBps Time Left Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 64 On the left side of your FTP client screen navigate to the C WINPCACE mailbox subdirectory On the right side click the file once to select it then click the left arrow button to retrieve it Your FTP client will then retrieve the file and place it in the WINPCACE mailbox folder See the directions elsewhere in this manual for instructions on viewing the daily log 999s Each file submitted creates a 999 which will indicate if the file was accepted accepted with errors or rejected To retrieve and process a 999 with PC ACE Pro32 sign onto your FTP account using your FTP software The file naming convention for a 999 is User ID filename 837 or 276 5010 date time 999 In the example below the file name is ALBPCACE TALP0000 8375010 20130326 133053 999 To view a 999 with PC ACE Pro32 it must be retrieved to a particular subdirectory This subdirectory is C WINPCACE mailbox Start your FTP client a
129. nt signed the Release of Information statement Retire Date Retire Date The insured s retire date Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 119 Employer Information F8 Employer Name Employer Name Enter the name of the insured s employer Employee ID Employee Identification Enter the unique identification number assigned by the employer to the insured Address Address Enter the current mailing address of the insured s employer City City Enter the city of the insured s employer State State Enter the state of the insured s employer Zip Zip Code Enter the 5 or 9 digit zip code of the insured s employer Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 120 Provider Types The Provider tab of the Reference File Maintenance form provides access to maintain the providers to be referenced on Professional claims This is the Plan Information as issued by your State Agency Setup of the Professional Part B provider reference file is required to process Professional claims All providers referenced on professional claims must be represented in this reference file The Professional Provider tab can be sorted by LOB Type Provider Group Name Provider ID Group Label and Tag The following options can be performed from the Provider tab e Adding a Provider Click the New button and the Professional Provider
130. ntainer Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 128 Force Legacy ID Force Legacy Identifier A code specifying if this provider s legacy identifier should always be reported in ANSI transactions regardless of the NPI Y Yes use legacy identifier N No do not use legacy identifier E Mail Address Contact E Mail Address The E mail address for the contact person for the practice Secondary Provider IDs ANSI use only ID Type 1 First Secondary Identifier Type The first of two optional secondary identifiers that may be used if additional identifiers are required to specify the provider ID Type 2 Second Secondary Identifier Type The second of two optional secondary identifiers that may be used if additional identifiers are required to specify the provider Pay To Provider Information specify only if different Organization Organization Name The name of the organization Last First Ml Provider s Last Name First Name Middle Initial The name of the provider Address Provider Address The mailing address for the provider City St Zip City State Zip Code The mailing city state and full nine digit zip code for the provider Country Country Code The Country Code for the provider if outside of the US Name Suffix Provider Name Suffix The name suffix for the solo or individual in group provider NPI National Provider Identifier The NPI for t
131. ocedure Modifier 1 Situational SVD03 Procedure Code Modifier 4 Procedure Modifier 2 Situational SVD03 Procedure Code Modifier 5 Procedure Modifier 3 Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 195 Situational SVD03 Procedure Code Modifier 6 Procedure Modifier 4 Required SVD05 Paid units of service Situational SVD06 Assigned Number used only for bundling of service lines Line Adjustment Usage Seg El Value Comment Required CAS01 CO contractual Obligations Code to identify the general category of CR Correction and Reversals payment adjustment OA Other Adjustments PI Payer Initiated Reductions PR Patient Responsibility Required CAS02 Claim Adjustment Reason codes are located on the Washington Publishing Company web site at http Awww wpc edi com Required CAS03 Monetary Amount Use this amount for the adjustment amount Situational CAS04 Quantity Use as needed to show payer adjustment Situational CAS05 Claim Adjustment Reason Code Use as needed to show payer adjustment Situational CAS06 Monetary Amount Use as needed to show payer adjustment Situational CAS07 Quantity Use as needed to show payer adjustment Situational CAS08 Claim Adjustment Reason Code Use as needed to show payer adjustment Situational CAS09 Monetary Amount Use as needed to show payer adjustment Situational CAS10 Quantity Use as
132. ofessional Claim Form xj Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Line Item Details Extended Details Line 1 Ext Line 1 Ext Details 3 Line 1 m Miscellaneous Extended Details 24d Modifiers 3 amp 4 E e Employed Purch Charges 0 00 Sales Tax 0 00 Anesthesia Other Minutes o Co Pay Status E Initial Treatment a Postage Claim 0 00 Units Type Code chased Services E Shipped Date _ Line Level Supporting Provider Information Last Org Name First Name MI Suffix Provider IDs Types Payer IDs Rendering Ee iy sis pooo X Purch Service poo DOO y O sid i Supervising Po poo i OoOo O O ti vr vie cr Referring ti i sCsr siz ti i X Referring 2nd Poo DOO i ti i X Asst Surgeon i siz sd i i a Save Cancel You can enter the third and fourth modifiers on the Extended Details screen You may also enter the number of minutes for anesthesia services If you are billing for anesthesia services right click Units Type Code and select MJ to specify that the value in the Units field for this charge is the number of minutes If you are billing for purchased services this information can be entered in this screen Hospice Information if needed can also be entered on this screen Cahaba Government Benefit Administrators
133. ojessional l Giaim For Patient Info amp General Insured Information Biling Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Line Item Details Extended Details Line 1 Ext Details 2 Line 1 MSP COB Line 1 EPO HGB HCT Date HGB Result 00 HCT Result 0 0 Patient Weight lbs _0 Dosage o Serum Creatine Date Creatine Result 0 0 HBG HCT Date HBG HCT Date Enter the HBG HCT date in MM DD CCYY format HGB Result HGB Result Enter the HGB result HCT Result HCT Result Enter the HCT result Patient Weight Patient Weight Enter the patient weight in pounds Dosage Dosage Enter the dosage amount Serum Creatine Date Serum Creatine Date Enter the serum creatine date in MM DD CCYY format Creatine Result Creatine Result Enter the creatine result Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 166 Physical Therapy Attachment ax Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Line Item Details Extended Details Line 1 Ext Details 2 Line 1 Ext Details 3 Line 1 Physical Therapy Attending Supervising Phys ID Date Last Seen EE er ee Treatment Plan on File Save Cancel Attending Physician UPIN Attending Physician UPIN Enter the attending physician UPIN Select from the Physician UPIN listing by righ
134. om billing line item e Paid Amount field enter the amount primary insurance paid even if the amount is zero e Tab to Paid Units field and enter the same number of units from billing line item 9 Line Level Adjustments CAS section determines the line level adjustments that caused the amount paid to be different from the original charged amount e Right click the Group and Reason field to select the appropriate information e Inthe amount field enter the amount for the reason code e Next enter the units from the original service line 10 Enter the Adj Payment Date This is the date the primary payer adjudicated the service line Once information is complete on the first line you can go back to the Line Item Details and complete information on second service line etc Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 104 Claim Level Information Professional Claim Form gt Common Payer MSP Information OTAF Zero Payment Ind Additional Adjustment Z COB Amounts MOA Te ANSI 837 Only D Claim Level Adjustments CAS COB MOA Amoufits Num Group Reason Amount Units Num Code Amount w o __ zz E w 6 lli E ___ OO _ se Medicare Outpatient Adjudication MOA Remarks Codes T F tT Claim Adjudication Date _ _ Save Cancel 11 Click the Ext Payer Insured tab and click the COB Info Primary tab 12 Right click the Zero Payment Ind and
135. on Sets Accepted AK904 1 l Use the navigation buttons at the top of the screen to page through the report print it or close it Processing a Claim Acknowledgement File 277CA See the directions in the Data Communications section of this manual for instructions on retrieving 277CA files e On the PC ACE Pro32 tool bar click the Institutional Claims Processing button or the Professional Claims Processing button whichever is appropriate O x iat PC ACE Pro3z Claims Processing Syster File View Security Help e Click Maintain then Claim Status Response amp Acknowledgement Log ist Professional Claims Menu File view Roster MEnelin 4 Transmission Log Acknowledgment File Log Launch Report Manager Prepare Claim Status Request File Claim Status Response amp Acknowledgment Log Purge Claim Activity Log List Claims Process Claims Prepare Claims Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 75 e Click to select the report to be viewed and then click the View Ack Report button ill Institutional Claim Status Response amp Acknowledgment Log z jox 115201 15 21 1002 ALBPCACE i OOO000O0 N A F 1115 2011 154 1002 ALBPCACE 0 doooo0o01 1 OOO00ON1 M A F 11 16201 wa pon T View Ack Report Fost Response File i i Retresh Close Cahaba Government Benefit Administrators LLC v3 4 Revised 07 2
136. oratory Improvement Act CLIA number 4010 only X5 State Industrial Accident Provider Number 4010 only XX National Provider Identifier NPI Identifier The Payer Identifier of the non destination payer that assigned this identifier Leave blank if the destination payer assigned the identifier Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 153 Fac Type Facility Type The type of facility indicated by the facility information above 77 Service Location FA Facility 4010 only LI Independent Lab 4010 only TL Testing Laboratory 4010 only Line level Reference IDs Types Payer IDs Reference IDs An optional code identifier or reference number providing additional service line information required by the payer Types 9F Referral Number G1 Prior Authorization Number 6R Line Item Control Number X4 Clinical Laboratory Improvement Act CLIA number 4010 only F4 Referring CLIA facility Certification Number 4010 only BT Immunization Batch Number Prof only 1S Ambulatory Patient Group APG number Prof 4010 only G3 Predetermination of Benefits Identification Number Dental only OZ Universal Product Number Prof 4010 only VP Vendor Product Number Prof 4010 only Payer IDs The Payer ID of the non destination payer that assigned the identifier Leave blank when ID was assigned by the destination payer Cahaba Governmen
137. ovider in the group must have the same group label as the group number NPI is the National Provider Identifier You may enter the group s NPI here or in the Group ID No field Tax ID Type is the tax ID number of the practice Type indicates if you are using an Employee Identification Number or EIN indicated by E or a Social Security Number indicated by S UPIN is the Unique Physician Identification Number associated with this provider This field should be left blank Specialty is the specialty code for the practice you are entering To see a list you can right click this field scroll down and select the appropriate specialty code for your practice Type Org indicates if the practice is a corporation private practice etc You can right click this field and select the appropriate value Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 16 Taxonomy is the taxonomy code for the practice you are entering You can right click this field to bring up a list and use the filtering options to help you to select the appropriate taxonomy code This field is not required Accept Assign will either be A for accepts assignment or N for does not accept assignment Participating will either be Y if the provider has signed an agreement with Medicare to accept assignment on all Medicare patients or N if the provider has not signed a participation agreement Signature Ind should be Y since the pro
138. ported for backups to diskette The user will be prompted to insert blank diskettes as needed To backup to a CD the backup must first be performed to the C drive or a network drive Then the resulting backup file can be burned to a CD Include infrequently changed database files Specifies whether or not to include certain infrequently changed database files in the backup The optional files include only reference file databases that are generally static for long periods Examples include the HCPCS Codes and Edit Validation database files The backup archive will be somewhat smaller if these optional files are omitted Note To ensure minimal problems in the event that a database restoration is required we recommend leaving this option checked for all backups Once the desired destination and options have been specified click the Start Backup button to proceed You will be notified upon successful backup completion Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 179 Note Exclusive system access is required to perform backups in PC ACE Pro32 If this program is in use on another client workstation you will be notified when the Start Backup button is clicked You can either instruct the other users to exit PC ACE Pro32 and then continue the backup or simply cancel the backup request Validate You can validate an existing backup file from the Validate sub tab The backup archive s integrity is confirmed and t
139. r 05 Grandson or granddaughter 07 Nephew or niece 09 Adopted child 10 Foster child 15 Ward 17 Stepson or stepdaughter 18 Self 19 Child 20 Employee 21 Unknown 22 Handicapped dependent 23 Sponsored dependent 24 Dependent of a minor dependent 29 Significant other 32 Mother 33 Father 34 Other adult 36 Emancipated minor 39 Organ donor 40 Cadaver donor 41 Injured plaintiff 43 Child where insured has no financial responsibility 53 Life partner 76 Dependent G8 Other relationship If the value entered is 18 Self the following fields will automatically be entered Last Name First Name MI Gen Insured ID Address City State Zip Telephone Sex DOB Last Name Last Name Enter the insured s last name First Name First Name Enter the insurea s first name MI Middle Initial Enter the insured s middle initial Gen Generation Identifier Enter the insured s generation identifier If you enter a generation designation such as Il IH Jr etc in the GEN field do not use periods or commas Insured ID Insured Identification Enter the insured s_ identification number assigned by this payer Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 118 Address Address Line 1 and Line 2 Enter the insured s address information City City Enter the insured s city State
140. r LOB s m Submission Status Production C Test Claim Status Request File Prepare Progress eeeEeeeeeee ooo After the request has been prepared you will need to submit it in order for it to be processed If you prepare another status request file before submitting this one the second one will overwrite the first so it would never be submitted to the Medicare system for processing Once the status request has been prepared the file can be submitted See the instructions for sending a claim status request 276 file elsewhere in this manual Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 54 Filing claims and claim status requests and retrieving reports After preparing your claims and creating your claim status requests you will need to send them to Cahaba to be processed Once a file has been received our system produces reports for you to retrieve Some Network Service Vendors provide scripts for submitters who use the free version of PC ACE Pro32 that will submit and retrieve their files Your Network Service Vendor will support any scripts they provide for you to use in conjunction with PC ACE Pro32 The following instructions are for submitters who do not have these scripts and need to send and receive their files manually These instructions assume you have PC ACE Pro32 installed on your C drive If you have the software installed on another drive substitute that drive letter for C
141. r restricted release on file N No signed release not on file If the value shown in the field is incorrect it must be changed in the reference file No change should be made to this field Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 135 ROI Date ROI Date The date that the patient signed the Release of Information statement if applicable will be entered automatically based on the Patient Control Number entered at the top of the form If the date shown in the field is incorrect it must be changed in the reference file No change should be made to this field Other Ins Other Insurance Indicator Enter one of the following values indicating if the patient has other insurance which may or may not be reflected on this claim 1 Yes patient has other insurance 2 Yes patient has other insurance not on claim 3 No patient does not have other insurance 14 Date Ind of Current Date Indicator 15 First Date Date of Current Enter the previous date that the patient experienced symptoms similar or identical to those for which services submitted on this claim were rendered Indicator of Current Enter one of the following values indicating as to whether the patient reported that they have previously experienced symptoms similar or identical to those for which services submitted on this claim were rendered 0 No symptom date 1 Date of first symptoms of illness 2
142. r s Name For Individual in Group and Solo Practice Providers enter the provider s last name first name and middle initial Note If the Provider Type is Group Practice this field will not be available Address Address Line 1 and Line 2 Enter the provider s physical address City St Zip City State Zip Code Enter the provider s physical city state and 9 digit zip code Phone Telephone Number Enter the provider s service telephone number including area code Fax Group ID No or Provider ID No Fax Enter the providers service fax number including area code Group Identification Number If the Provider Type is Group Practice enter the unique provider or group identifier used on claims for this Line of Business LOB If the Payer ID field is also specified then this provider group identifier is used only on that Payer s claims Provider Identification Number If the Provider Type is Individual in Group or Solo Practice enter the unique provider or group identifier used on claims for this Line of Business LOB If the Payer ID field is also specified then this provider group identifier is used only on that Payer s claims If an NPI is entered here the value XX must appear in the Provider ID No Type field on the Extended Info screen LOB Line of Business The internal Line of Business LOB or payer category to which this
143. red to a Home Under Care of Organized Home Health Service Org w PACHIR 87 Discharged Transferred to Court Law Enforcement w PACHIR 88 Discharged Transferred to a Federal Health Care Facility w PACHIR 89 Discharged Transferred to a Hospital based Medicare Approved Swing Bed w PACHIR 90 Discharged Transferred to an IRF including Rehab Distinct Part Units of a Hospital w PACHIR Death Ind Death Indicator Code indicating whether or not the patient is deceased Enter one of the following values Y Patient is deceased N Patient not deceased DOD Date of Death Enter patient s date of death if deceased Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 113 Signature On File Signature on File The first field is for Institutional Claims the second is for Professional For Institutional Claims first block Y Signed signature authorization is on file N Signed signature authorization is not on file For Professional Claims second block Enter one of the following CMS 1500 values specific to the claim type C 1500 Signed CMS 1500 on file S 1500 Signed signature authorization form Block 12 on file M 1500 Signed signature authorization form Block 13 on file B 1500 Signed signature authorization form Blocks 12 amp 13 on file P 1500 Signature generated by provider patient not physically present Release of Info Rel
144. remittances 835s is User ID date ppbal1 8355010 zip To retrieve an electronic remittance 835 start your FTP software and log onto your FTP account The file name for the remittance in the example below is albpcace 20130325 ppbal1 83550 10 Zip On your local drive navigate to your C WINPCACE mailbox directory Locate and click the remittance you want to retrieve from your FTP account and click the left arrow to retrieve the remittance to the mailbox directory addr ss ftp bluecmsftp bcbsal org albpcace UserID b9929 Password eeeeece Q Size Type Modified CD albpoace 20111115 277ca6010 zip 825 Win 5 14 2013220 PM 9 ET abpcace 20130225 ppball 8355010 zip BKB Win 4 22 2013 750 AM g T u gt K m i E O object s 0 Bytes o Connected to bluecmsftp bcbsal org 2 object s 9 KB Information Window glx Source so Status Progress Transferred Rate kBps Time Left To view the remittances see the instructions elsewhere in this manual Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 68 Viewing and Processing Reports Once a file is received Cahaba produces reports that show whether or not the file was accepted or rejected and also provides details for accepted files It is important that you retrieve and process these reports so that you will become aware of and correct any issues that may prevent us from accepting your claims for processing before your cash flow
145. representing an individual provider that is a member of one of the existing Group providers When creating Individual in a Group provider records select the desired Group Label from a lookup list of applicable group providers Claims may not be billed directly to the Individual in a Group provider rather these providers are specified as rendering providers on the CMS 1500 claim form Group information should be entered first Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 121 Solo Practice ldentifies the provider record as representing a solo practice provider Solo practice providers are not associated with any provider group Provider Information General Info Professional Provider Information Hengennc IN OnE LOB Provider D_ Provider Group Name Swe cancel Provider Type Provider Type Select the appropriate Provider type Group Practice Individual in Group or Solo Practice Group Name or Organization Group Name If the Provider Type is a Group Practice enter the group name for Group Providers in the Group Name field Organization If the Provider Type is Solo Practice enter an optional organization name in the Organization field Note If the Provider Type is Individual in Group this field will not be available Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 122 Last First Ml Provide
146. rks Remarks Optional information can be entered in this field Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 126 Extended Info x General Info Extended Info CLIA No Provider Name Match Mammography No Force Legacy ID E HMO Contract No E Mail Address Dental Provider Provider ID No Type _ mM Secondary Provider IDs ANSI use only Provider Name Suffix ID Type 1 sis i Provider Country ID Type 2 is E M Pay To Provider Information specify only if different Organization fc f NPI LastFistM O FedTaxiD Tye Address fC O Prov ID No Type sis O o See en Cisvzip O Seye Country Name Suffix ae Save Cancel CLIA No CLIA Number The Clinical Laboratory Improvement Act number for the provider Mammography No Mammography Number The mammography certification number assigned to this provider HMO Contract No HMO Contract Number The HMO Contract identifier required for Medicare Providers in states where a Medicare HMO Contract is in effect Dental Provider Dental Provider Indicates if the provider is a dental provider who will be submitting claims for dental services Y Dentist office submitting dental claims N Not a dentist office Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 127 Provider ID No Type Provider ID number type
147. rom billing line item Level Adjustments CAS section determines the line level adjustments that caused the amount paid to be different from the original charged amount a b C Right click the Group and Reason field to select the appropriate information In the amount field enter the amount for the reason code Next enter the units from the original service line Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 107 System Functions Performing Backups When closing PC ACE Pro32 you are given the option to perform a backup of your files If you want to perform a backup click Start Backup If not click Close System Utilities x File Maintenance Backup Validate Restore This utility performs a backup of the PC 4CE Pro32 databases and configuration settings Specify a destination drive e g A or hard disk folder path and click the Start Backup button Destination Drive or Folder JV Include infrequently changed database files backup will be larger Options Start Backup Close Click the drop down box at the end of the Destination Drive or Folder field to navigate to the destination where you want the backup to be created Click the Start Backup button to perform the backup It is recommended that you perform backups on a regular basis Clicking Options will allow you to select specific database files to be included in or excluded fro
148. rvice IMG toure eisai sores 5 itt cod ales E RE 195 Loop 2430 Line Adjudication Information cccceseeceseeeeeeseeeeeeneeseeeees 195 Appendix D Contacting Cahaba EDI Services ccccsssseeneseseeeeenes 198 Cahaba EDI Services s 2 cacitss acess cassoesttcuncdave avqeis ds iacsseanoaaetes aaqueiee raeiiaeaae 199 Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 4 Part Installing and using PC ACE Pro32 Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 Getting Started Connecting to Cahaba PC ACE Pro32 users must use a Network Service Vendor to establish a connection to Cahaba For a list of Network Service vendors visit our website at http www cahabagba com part b claims 2 electronic data interchange edi network service vendors The Network Service Vendor you chose will guide you through the process of using your connection to log onto your FTP account at Cahaba to send and receive your files Installation To install PC ACE Pro32 navigate to the website provided by EDI Services and click the link to download When prompted choose Run to run setup You may receive a warning that says the publisher could not be identified If you do click Run anyway You will be prompted for a password during the installation process Use the installation password provided with your approval letter You will only use this password during the installation of the so
149. ry Attachment ir ene A emer aat 163 G hiropractic Attachment inean a S ota da ER 164 Mammography AttaG limi enitiee soc idesseetovarscnetnesidrasnruchstoctadl abseeetaccatagteoate dant 165 EPO Attachment ssec des deers r Mavstiavad A weiemiild oan eae bies 166 Physical Therapy Attachment ni caissi lt iessassscalignedsseatsattonetrenncasyceRreseatiecieane 167 De ntal Attachment sanie E E 168 Extended Patient General ssesesesesesesesesessssssssssssssseseseseseseseseseseseseseseseseses 170 Ext Pau Gen 2 aaea oe cient i lea E a E a a G 175 Extended Payer Insured Primary Secondary Tertiary Payer Insured 176 Extended Payer Insured MSP Info Primary Secondary cceeee 178 System UTUS a a aaraa a araara aae aaa aa ma aaa ea aaa aa a aaa anaa iiaiai aiaia aa 179 BACKUP EE E E E E MEAN RO E E ar CEO 179 Validat sasoie eedt E E ie E eM A eee 180 FHSS TONG farsa e n a a T a n a see NS 180 Part Ill Troubleshooting and Appendixes ccccccceseeeeeeeeeeeeeeeeeeeeees 182 Appendix A Definitions Of Terms ccceeesssseeeeesseeeeeeeeneeeeeeesneeneeeennes 183 Appendix B Loops and Segments cccccsssseeeeesseeeeeeesseeeeneesseeneenennes 185 Appendix C Entering Medicare Secondary Payer MSP Claims 187 MSP General Information at sescacciaustsed susescevieisaeaadavae vodavd taste cadets aes tea iad 188 Loops and Segments Table sic trs cicte Qeshotes cous ea a coated nel 190 KOOP 2400 Se
150. ry EOB Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 106 Professional Claim Form Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Line Item Details Extended Details Line 1 Ext Details 2 Line 1 Ext Details 3 Line1 MSP COB Line 1 be M Common Line MSP Amounts Additional Line level Adjudication COB Information ANSI 837 Use Only Approved 40 00 Service Line Adjudication SVD Information DTAF oo SVD P S Proc Qual Code Modifiers 1 thru 4 Paid Amount Paid Units B U Line wo o o oS M Line Adjustment CAS amp Miscellaneous Adjudication Info for SYD 1 above Procedure Code Description Line Level Adjustments C4 a Num Group Reason Amount Units 1 feo fs _ 2000 ___o000 Adj Payment Date 06 30 2005 PR f 1000 f __ 0 000 Remaining Owed nn a ipce mo im a E TCC Save Cancel 3 Service Line Adjudication SVD Information a b C d e 4 Line Right click in P S Proc fields and select the appropriate information Right click in Proc Field and select the appropriate information In the Qual Code field enter the same procedure code from billing line item Paid Amount field enter the amount primary insurance paid even if the amount is zero Tab to Paid Units field and enter the same number of units f
151. s CAS section enter any adjustment information Enter the date of the primary remittance in the Claim Adjudication Date field Click Save when you are done If there are no errors you will be presented with a blank Patient Info amp Codes screen where you may begin entering a new claim or click the Cancel button if you have finished entering claims If there are errors you will be presented with a list and you may click on the error message to be taken to the field where the error occurred Fields in error will also begin flashing Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 99 Claims that do not balance will not be accepted into the processing system The Total Primary Payer Paid Amount C4 plus the adjustment amounts must equal the Total Submitted Charge T3 Example Total Submitted Charge 125 00 C4 Payer Paid Amount 75 00 Adjustments 50 00 T3 Total Submitted Charge 125 00 Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 100 Entering MSP Claims Part B Professional There is a section giving additional information about entering MSP claims at the end of this manual Line Level MSP Information Professional Claim Form X I Patient Info amp General Insured Information Biling Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured LOB Mce Billing Provider 26 Patient Control No fal 8 Pat Status Death 12 Legal
152. select the appropriate information 13 COB MOA Amounts right click and select D for the total amount paid for the claim 14 Fill in the Claim Adjudication Date Note Total of all line level amounts must equal claim level amounts MSP claims that do not balance at the line and the claim level will not be accepted To balance an MSP claim the total submitted charge minus all adjustment amounts must equal the payer paid amount Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 105 Professional Claim Form Xx Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Line tem Detall Extended Details Line 1 Ext Detals2 Line 1 MSP COB Line HJ 2 Claim Diagnosis Codes 1 36610 2 3 4 5 6 7 e 24a Service Dates 24b 24c 24d 24d Modifiers 24e 24f ILN From Thu PS TS Proc 1 2 Diagnosis Charge EPFPEMCB AT Rendering Physician fires cess rT Rare TY fF mm fo PP PT a E n N A a A a A T e m a a a n a a a a aaa eet Ji 7 gt sJ _ __ JJ _ J e E eo _fi _j j jj no sie 28 Total Charge 60 00 Recalculate 29 Amount Paid 0 00 30 Balance Due 60 00 1 Complete the billing line item In this case the charge is 60 00 2 After the first line on the claim is completed click the MSP COB Line 1 tab begin to enter information from your prima
153. sfer is complete you should see the file listed in your FTP account E INSTALL LOG j 1KB CLM 4 25 2013 851 e pal 837501 0 cn i 700 Win 3 27 2013 7141 E poace32eve i SKB 2013 3 27 2013 12 04 A poace22ii GAPPCAE TGAPOOD TSO 1302771206188 W W 3 27 2013 1204 y aia ai a R k a 1 object s selected 1 KB Connected to bluecmsftp bebsal org 17 object s 2 75 MB Information Window Source Status Progress Transfened Rate kBps Time Left Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 63 You can select another file and send it at this time if needed Manually Retrieving Files for PC ACE Pro32 Below are instructions for manually retrieving files from the Cahaba Secure FTP Server and having them processed in PC ACE Pro32 These instructions assume you have some sort of FTP software such as WS FTP or Cute FTP Pro More than likely the screen shots below will not match exactly with what you see when you follow these instructions You should be able to adapt the information below to your particular system Daily Logs You will have one daily log per day for each day you send a file The file naming convention for the daily log is User ID date The user ID in the example below is albpcace and the date is 20130327 Log onto your FTP account following the directions provided by your Network Service Vendor and if this does not open your FTP software start it
154. signature authorization form for CMS Claim Form block 12 on file Required Ol06 A Appropriate Release of Information Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 193 Loop 2330A Other Subscriber Name and Address Loop 2330B Other Payer Name Usage Element Value Comment Required NM101 IL Code identifying the insured or subscriber Required NM102 1 Person Code qualifying the type of entity 2 Non Person Entity Required NM103 Last Name or Organization Name Situational NM104 Subscriber first name Situational NM105 Subscriber middle Situational NM107 Subscriber generation suffix Required NM108 MI Member Identification Number to Code to indicate Member ID convey the following terms Insured s ID Subscriber s ID Health Insurance Claim Number HIC etc Required NM109 Identification Number Required N301 Address Information address 1 Situational N302 Address Information address 2 required if second address exists Situational N401 City Name Required when information is available Situational N402 State or Province Code Required when information is available Situational N403 Postal Code Required when information is available Situational N404 Country Code Required if the address is out of the U S
155. ssional Claim Form window Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 39 Proressional Gaim Ronm Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured LOB MCB Biling Provider i 26 Patient Control No i 2 Legal NPI o Pat statu Des 2 Patient Last Name First Name MI Gen 3 Birthdate Sex MS ES SS Ind SOF Rep Exempt ee en CU a a o SC dKd 5 Patient Address 1 Patient Address 2 Patient City State PatientZip County Patient Phone maa PE E 10 Patient Condition Related To ROI ROIDate Otherlns 14 Date Ind of Current 15 First Date 16 UTW Disability Dates amp Type Employment Accident z ve ff Gmi E E gt Hetering Phys Name Last Ura gt Surfs Fi gF 18 Hospitalization Dates 20 Outside Lab Chgs Ps tof YyN __o 00 Medicaid Resubmission Code amp Ref No E 25 Fed Tax ID SSN EIN E 27 Provider Accepts Assignment PIN No 31 ProviderSOF Date _ _ __Faciity Denta coB Frequency 33 GRP No Save Cancel On the Patient Info amp General screen the line of business should already appear as MCB Billing Provider is the group or solo practice provider number for Medicare Part B This will automatically populate when you enter the LOB if you only have one group or solo practice provider number in your provider database Patient Control No is the account number of the patient On
156. sts 0 55 Manually Sending Files from PC ACE Pro32 ooo eccseeseeecneeteeseeeeteeeeeees 61 Manually Retrieving Files for PC ACE Pro32 ooo eccseeseescneeteeseeeeteeeeeees 64 Viewing and Processing RePOrts cccccceesesesseeeeeeeeeeeseeeeeeeeeeeeeeeeeeeeneees 69 Viewing a Daily Log orale Ge NN NO See de Bat DAE ad ae 69 Processing and Viewing a File Acknowledgement 999 cccseseseteenees 72 Processing a Claim Acknowledgement File 277CA ccccccceseecseteeseeteenees 74 Processing a Response to a Claim Status Request 277 cccceseseteenees 81 Processing and Viewing an Electronic Remittance Advice 835 4 87 PC ACE Pro32 and Medicare Secondary Payet sccccessssssseeeeeeeeeees 94 Entering MSP Claims Part A Institutional ccc ccccceseeseeteeeeeteeeeteenees 95 Entering MSP Claims Part B Professional ccccccccesseeeeteeseeteeeeeens 101 System FUNCIONS 9 ctidecesenencscdeuedasetesanentiedsnccateventuaidassadedcesstuenesantseddaseanstenatun 108 Performing Back pS renien harat hs siesta atte te ater aint A TEA ante 108 Part Il Field by Field Explanations ccccccssssssseeeeeeeeeeeeeseeeeeeeeeeeeeeeeeeeeees 109 Patient INfOrMatioMscecccscocsdeswcceecctwsceuccsedecescsedccuccsesecescsedcsuccscdccuucacdesucceesecuces 110 General Information wii esatrecetsatt can cencaithae ace sated caesntiincessancnees ace ee tiiaen eae 110 EIST SC NNO nai soca tease cr
157. t Information Source ID 10102 Name CAEABA GEA Pecetwer Nene GENERAL INTERWAL MED D ALBPCACE Provider Nene GENERAL INTERWAL MED meh 1234567890 Patient tee BENEFICIARY TESTING Subscriber 1234567894 Clais Trace 11151100010012315 Iwa 291234567891011 Service dete 05 03 2010 Status General States Date 11 15 2011 Total Submitted Charges 150 00 Ackzosledgenent 1 Accepted Category A Acknosledgenest icceptance isto edjudiceticn system The claim encounter bes bees accepted isto the adjudication sre Status 20 Accepted for processing Ezzity PR Payer Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 79 e Rejected claims will appear with an explanation for the rejection Rejected claims will need to be reactivated corrected and resubmitted For help reactivating transmitted claims see the instructions elsewhere in this manual Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 80 Processing a Response to a Claim Status Request 277 Since these screens are the same for Professional and Institutional users only the Professional screens are shown Once a response has been retrieved PC ACE Pro32 will process it automatically and create reports indicating the result of the claim status request To view these reports click the Institutional or Professional Claims Menu button on the PC ACE Pro32 toolbar Copyright 1998 2011 MedLink Technologi
158. t Benefit Administrators LLC v3 4 Revised 07 28 2015 154 Billing Line Items Ext Details 3 me x Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Line Item Details Extended Details Line 1 Ext Details 2 Line 1 Ext Details 3 Line 1 M Line level Miscellaneous Information continued Ordering Provider Address I m CyS S e Eee Line Supplemental Information PWK Num Type Trans Attachment Control Number al O EE Address M Line Notes NTE 7 File Information K3 Num Type Narrative Save Cancel Ordering Provider Address Address Address The address of the ordering physician for this item City St Zip Cntry City State Zip Country The city state and zip code for the ordering physician for this item Line Supplemental Information PWK Type Type The type of additional documentation kept on file Trans Format of additional documentation Attachment Control Number Control number assigned to the documentation Required when the value in the previous field AA available on request at provider site Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 155 Line Notes NTE File Information K3 Type Type The type of line notes submitted ADD Additional Information Prof only CDP Goals Rehabilitation Po
159. t blank when entering the beneficiary s Medicare information If the patient has insurance primary to Medicare you would utilize these fields for the information for that insurance policy See the instructions for entering Medicare Secondary Payer claims in this manual for more information Insured Information Options should always have Separate Inst amp Prof selected Enter the patient s HIC Medicare number in the Insured ID field Do not use spaces or hyphens Rel is the patient s relationship to the insured This should always be 18 for Medicare which means the patient is the insured Enter a Y W or N whichever is appropriate in the Assign of Benefits box Enter a Y or an I whichever is appropriate in the Release of Info box Enter the date the beneficiary signed the release of information form in the ROI Date box If the patient has a Medigap policy click the Secondary Insured tab The Medigap identifier will need to be entered in the Payer ID field Before the Medigap information can be entered the Medigap company may need to be Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 24 added to the list of Payers See the Entering Payers section for instructions on how to enter Medigap companies To select from a list of available payers click the Payer ID field and press your F2 key or right click your mouse This will bring up the list of p
160. t clicking in the form Date Last Seen Date Last Seen Enter the Date Last Seen in MM DD CCYY format Treatment Plan On File Treatment Plan On File Enter one of the following values indicating the status of the treatment plan Y Plan of treatment is on file N Plan of treatment is not on file Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 167 Dental Attachment LIT Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Line Item Details Extended Details Line 1 Ext Details 2 Line 1 Ext Details 3 Line 1 Dental Ix Tooth 1 Tooth 2 Tooth 3 Tooth 4 Tooth Number or Arch E E Tooth Surfacefs include up to five surfaces per tooth Quadrant s H E H Placement Status Ind E Prior Placement Date Actual _ Estimated _ Treatment Period Start Date fee End Date rE Orthodontic Treatment Total Treatment Months Months Remaining Ortho Appliance Placement _ Replacement Les __ Save Cancel Tooth Number Or Arch Tooth 1 Tooth 2 Tooth 3 Tooth 4 Identify each tooth where this procedure was performed Tooth Surfaces s Surfaces Identify up to five surfaces per tooth where this procedure was performed Quadrant s Quadrant s Area of the oral cavity where services were performed Up to five per line can be specified Placement
161. tential or Discharge Plans Prof only PMT Payment Prof 4010 only TPO Third Party Organization notes Prof 4010 only K3 File Information Narrative Free Form Narrative The free form narrative that provides the additional information for the item billed Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 156 Billing Line Items MSP COB Professional Claim Form ee x Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured Line Item Details Extended Details Line 1 Ext Details 2 Line 1 Ext Details 3 Line 1 MSP COB Line 1 M Common Line MSP Amounts Additional Line level Adjudication COB Information ANSI 837 Use Only Service Line Adjudication SYD Information SVD P S Proc Qual Code Modifiers 1 thru 4 Paid Amount Paid Units B U Line S I LL T B EMT 2 2 2 oe ee 2 2 ee ee M Line Adjustment CAS amp Miscellaneous Adjudication Info Procedure Code Description Line Level Adjustments CAS Approved 0 00 Num Group Reason Amount Units F w e o Adj Payment Date EZE 2 I ooo a O e _s_ Remaining Owed Save Cancel Common Line MSP Amounts Approved Approved Amount the primary payer approved for this line charge OTAF Obligated to Accept in Full Amount the provider agreed to accept as payment in full under the pro
162. tes these files in the C WINPCACE folder Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 56 Part A Claims BCTRANS DAT Claim status requests BCREQ276 DAT Part B Claims BSTRANS DAT Claim status requests BSREQ276 DAT Renaming the claim and claims status transmit files After you have prepared your claims or created your claim status request see instructions elsewhere in this manual for preparing claims and claim status requests open Windows Explorer and navigate to your C WINPCACE folder Locate the file that you need to transmit using the PC ACE Pro32 file names list above The example below uses Alabama Part A claims as an example Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 57 Open Windows Explorer and navigate to the WINPCACE folder Locate the file that needs to be renamed For Part A claims the file is BCTRANS DAT File Edit view Bak QJ amp P Search Key Folders s X 19 f Address Name Ansi824r exe Ansi837h exe Ansi837i exe Ansi837u exe gy 4nsi997r exe K ANSI CTL BCCLMACT LOG K BCPRNTMP CTL RA BCPRNTY 2 CTL E BCREQ276 DAT E BCTRANS DAT BSCLMACT LOG BSREQ276 DAT E BSTRANS DAT 2 C4dll dll 9 Client32 exe pa Clientup exe Emcsp301 dat Emcspc60 dat Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 gt CAWINPCACE Size 121 KB 306 KB 127 KB 182
163. th involved in a dental claim Additional Supporting Provider Information Referring 2 Referring Provider Identifier Used if more than one referring or ordering provider is required for this claim Supervising Supervising Provider Identifier for the supervising provider Asst Surgeon Assistant Surgeon Identifier for the assistant surgeon Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 175 Extended Payer Insured Primary Secondary Tertiary Payer Insured Payer Address amp Miscellaneous Professional Claim Form Patient Info amp General Insured Information Billing Line Items Ext Patient General Ext Pat Gen 2 Ext Payer Insured ed Secondary Payer Insured Tertiary Payer Insured m Miscellaneous Primary Payer Insured Information Payer Address City St Zip Payer Source Insurance Type Insured s Contact Patient ID Payer Insured Reference IDs Types Save Cancel Miscellaneous Primary Secondary Tertiary Payer Insured Payer Address Address Line 1 and Line 2 Enter the payer s claim mailing address for this particular Payer ID and claim office City St Zip City State Zip Code Enter the payer s claim mailing city state and 5 or 9 digit zip code for this particular Payer ID and claim office Payer Source Payer Source Code Enter one of the following va
164. the following values indicating if the provider is billing services for a patient that is deceased will be entered automatically based on the Patient Control Number entered at the top of the form D Patient is deceased N Patient is not deceased If the value shown in the field is incorrect it must be changed in the reference file No change should be made to this field Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 133 12 SOF Signature on File One of the following values will be entered automatically based on the Patient Control Number entered at the top of the form C 1500 Signed CMS 1500 claim Form on file S 1500 Signed signature authorization Form Block 12 on file M 1500 Signed signature authorization Form Block 13 on file B 1500 Signed signature authorization Form Block 12 amp 13 on file P 1500 Signature generated by provider patient not physically present If the value shown in the field is incorrect it must be changed in the reference file No change should be made to this field Legal Rep Legal Representative One of the following values indicating that someone other than the patient is to receive the explanation of benefits and or the payment will be entered automatically based on the Patient Control Number entered at the top of the form Y Yes there is a responsible party N No there is not a responsible party If the va
165. the hour 0 23 when the accident occurred that necessitated the rendering of a service submitted on this claim Accident Country Responsibility Ind Accident Country Enter the country code where the accident occurred if outside of the United States Responsibility Indicator Enter one of following values indicating whether or not the accident or illness was caused by another party Y Yes accident illness caused by another party N No accident illness not caused by another party FL 10d Reserved Currently not in use Homebound Ind Homebound Ind Enter one of the following values indicating whether an independent lab rendered services to a homebound patient Y Yes patient is homebound N No patient is not homebound Date Care Assumed Date Care Assumed Enter the date the care of the patient was assumed by another physician Date Care Relinquished Date Care Relinquished Enter the date the care of the patient was relinquished by another physician Return to Work Date Return to Work Date The date that in the provider s opinion the patient will be able to return to work Prescription Date First Contact Date Date of Prescription The date the prescription was written for hearing devices or vision frames being billed on this claim First Contact Date The first date the beneficiary first consulted the provider by any means for this condition Cahaba Governm
166. tion Identifier Enter the patient s generation identifier If you enter a generation designation such as Il Ill Jr etc in the GEN field do not use periods or commas Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 110 Patient Control No PCN Patient Control Number A unique identification assigned to the patient by the provider The account number or medical records number assigned to the patient by the provider s office Patient Address Patient Address Line 1 and Line 2 Enter the patient s address Enter additional address information on the second address line If there is no additional address information bypass this field by pressing lt TAB gt City City Enter the city in which the patient lives State State Enter the two character abbreviation of the state in which the patient lives Zip Zip Code Enter a valid 5 or 9 digit zip code Phone Telephone Number Enter patient s telephone number including area code Patient Status Active Patient Active Patient Enter one of the following values Y Patient is active N Patient is inactive Sex Sex Enter one of the following values M Male F Female U Unknown DOB Date of Birth Enter the patient s date of birth in MMDDYYCC format Marital Status Marital Status Enter one of the following values S Single M Married X Separated D Divorced W Widowed P Life Partner
167. tions Reports aia SotBy Patient Name PCN C Entry Date C Service Date Claim List Filter Options Location to be transmitted 7 Status lt lt All gt gt 7 LOB lt lt All gt gt v to be transmitted TRIP Ta tated Clear Filters Advanced Filter Options Checked ee fll Ta tated Delete Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 83 wi Professional Claim list Fie Filter Actions Reports stais toe PCN Patents il Provider E CLN MCB 12556 JOHNSON UILLA E E Solo ea O CLN MCB 99999 BENE NAME 47 ZZ2Z2222 08 01 2008 0 sH Solo am Sot By Patient Name PCN C Entry Date Serice Date Transmit Date Claim List Filter Options Location TR transmitted only Status lt lt All gt gt LOB lt lt All gt gt v A Clear Filters Advanced Filter Options New View Copy Close Delete Click the claim you want to view the status response request log for and then click Actions Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 war LY Yoa ety List File Fifer Actions Ref orts __Refresh Claim List Create New Claim View Selected Claim Copy Selected Claim Delete Selected Claim Purge Selected Claim Reactivate Selected Claim Hold Selected Claim Print Selected Claim Archive Selected Claim Show Selected Claim Payments Set Selected Claim Media Request Se
168. to Ex ay 17 Referring Phys Name Last Org First MI Suffix Referring Phys IDs Types 18 Hospitalization Dates 20 Outside Lab Chgs A Lee ofj ynf o0 19 Reserved For Local Use 22 Medicaid Resubmission Code amp Ref No 25 Fed Tax ID SSN EIN 2 Provider Accepts Assignment PIN No 31 Provider SOF Date _ _ Facility Denta coe Frequency 33 GRP No Save Cancel LOB Line of Business Enter the line of business LOB or payer category for this claim Billing Provider Billing Provider Enter the unique Provider ID assigned for ID purposes by the payer receiver and for which payment is requested The ID must reside on the Provider database in Reference Files for the claim s LOB and will correspond to the claim field 33a PIN No or 33b GRP No 26 Patient Control No Patient Control Number Enter the unique identification number assigned to the patient by the provider to identify the patient 2 Patient Last Name Patient Last Name The last name of individual for whom the services were performed will be entered automatically based on the Patient Control Number entered at the top of the form If the name shown in the field is incorrect it must be changed in the reference file No change should be made to this field Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 131 First Name First Name The first name of individual for whom the
169. to provider is authorized W Not Applicable use if patient refuses to assigned benefits N No payment to provider not authorized If the value shown in the field is incorrect it must be changed in the reference file No change should be made to this field Insured s Address 1 Insured s Address 1 The current mailing address of the insured will be entered automatically based on the PCN entered into the Patient Info amp General tab If the address shown in the field is incorrect it must be changed in the reference file No change should be made to this field Insured s Address 2 Insured s Address 2 The current mailing address line 2 if needed of the insured will be entered automatically based on the PCN entered into the Patient Info amp General tab If the address shown in the field is incorrect it must be changed in the reference file No change should be made to this field Insured s City Insured s City The city if the insured will be entered automatically based on the PCN entered into the Patient Info amp General tab If the city shown in the field is incorrect it must be changed in the reference file No change should be made to this field State Zip State The state of the insured will be entered automatically based on the PCN entered into the Patient Info amp General tab If the state shown in the field is incorrect it must be changed in the reference file No chang
170. tus of the patient Y Patient was unconscious or in shock N Patient was not unconscious or in shock Emergency Situation Emergency Situation Enter one of the following values indicating the status of the situation Y Emergency situation N Not an emergency situation Physical Restraints Physical Restraints Enter one of the following values indicating the status of physical restraints Y Physical restraints needed N No physical restraints used Visible Hemorrhaging Visible Hemorrhaging Enter one of the following values indicating the patient s status Y Visible hemorrhaging noted N No visible hemorrhaging noted Services Available Services Available Enter one of the following values indicating the status of the services Y Services were available at the first facility N Services were not available at the first facility Medically Necessary Medically Necessary Enter one of the following values indicating the status of medical necessity Y Ambulance service was medically necessary N Ambulance service was not medically necessary Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 160 Patient Admitted Patient Admitted Enter one of the following values indicating the status of the patient s admission Y Patient was admitted to a hospital N Patient was not admitted to a hospital Patient Count Patient Count Number of patients transported during this tr
171. vider s signature will be on file with Medicare Part B if a Medicare Part B provider number has been issued Date is the date of the signature we have on file If you do not know the exact date an approximate date will work Provider roles Billing Rendering indicates whether or not this provider is the actual performing provider the billing provider or both The default values for these fields are usually correct for the type of provider you are entering If all of the information has been entered click the Save button Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 17 If your practice needs to include mammogram certification numbers or CLIA numbers on claims next click Extended Info If you entered an NPI number in the ID number field on the General Info screen you must place an XX in the ID No type field on this screen Ix General Info Extended Info CLIA No Provider Name Match Mammography No Force Legacy ID E HMO Contract No E Mail Address Dental Provider Provider ID No Type Provider Name Suffix Provider Country M Pay To Provider Information specify only if different Organization fo LastFM FedTaxiDType Address DOO y O Prov ID No Type tis SecID Type t H ciysvzip O Seye Country i Name Suffix oOo ID Type 1 ID Type 2 Close Enter the CLIA and or mammography number in the fields
172. visions of the contract for this line item Additional Line level Adjudication COB Information P S Primary Secondary Indicates if the information applies to the primary or secondary payer P Primary Payer S Secondary Payer Proc Qual Code Procedure Qualifier Code Qualifier Qualifier to indicate what type of code is used for the procedure HC CMS Common Procedure Coding System HCPCS IV Home Infusion EDI Coalition HIEC Code AD American Dental Association Code ZZ Mutually Defined Code The code used on this line item Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 157 Modifiers 1 thru 4 Modifiers 1 through 4 Modifiers used for this line item Paid Amount Paid Amount Primary amount paid for this line item Paid Units Paid Units Number of units paid by the primary for this line item B U Line Bundling Unbundling Line A reference identifier used only for bundling of service lines The line number of the service line into which this line was bundled Line Adjustment CAS amp Miscellaneous Adjudication Info for SVD above Procedure Code Description Procedure Code Description A description of the procedure code specified on this SVD line Adj Payment Date Primary Paid Date The date of the remittance from the primary payer for this line item Group Group Code A code identifying a general group category of pay
173. w View Copy Delete Close You may have several claims listed You can use the Sort By options across the middle to sort the claims by Patient Name PCN Entry Date Service Date or Transmit Date You may also use the Advanced Filter Options to find the claims to be reactivated This may make it easier for you to find the particular claims you want to request a status for When you locate a claim you want to request a status for click the empty box in the first column This will place a check mark in it If you select a claim and then change your mind you can click this box again to remove the check mark Cahaba Government Benefit Administrators LLC v3 4 Revised 07 28 2015 52 Once you have selected all of the claims you want a claim status for click Actions then Request All Checked Claims Status ini professora cin last Reports Claim List FS BillProvider_ Type _ Serv From SUS Solo i 6 2008 E O77170 Create New Claim view Selected Claim Copy Selected Claim Delete Selected Claim Purge Selected Claim Reactivate Selected Claim Hold Selected Claim Print Selected Claim Archive Selected Claim Show Selected Claim Payments Set Selected Claim Media b Request Selected Claim Status Show Selected Claim Status History Km Copy All Checked Claims Sort By Delete All Checked Claims C Service Date Transmit Date eae Purge All Checked

PC ACE Pro32 User Manual - Cahaba Government Benefit

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