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Enter the name of the Medicare or Medicare Advantage Plan. Prior Authorization Number. Use the Washington Publishing Company (WPC) health care codes lists to identify the claim status category and claim status codes displayed on the validate and submit claim response. Taxonomy code for occupational therapy. Select Submit to identify if the claim will be paid, denied, or suspended for review at the claim and service line level of the claim. Enter a unique identifier assigned by you, to help identify the claim for this recipient. For Medicare this would be the Medicare health insurance claim number (HICN) or the Medicare beneficiary identifier (MBI) number. Benefits Assignment.
This is the determination of the policy holder or person authorized to act on their behalf, to give MHCP permission to pay the provider directly. Enter the date associated with the Occurrence Code. Telephone number reported on the provider file. Enter the 8-digit MHCP ID for the subscriber (recipient) indicated on the MHCP member identification card. Diagnosis Type Code. Use only when a modifier is listed on the service authorization (SA) or when a claim for private duty nursing shared services. Adjudication - Payment Date. When reporting TPL adjustments at the claim (header level), enter the prior payer paid amount. Taxonomy code for occupational therapist. Other Payer Primary Identifier. Home Health Aide Visit Extended (waivers). This is the code indicating whether the provider accepts payment from MHCP.
Skilled Nurse Visit (LPN). Enter the Identifier of the insurance carrier. Claim Action Button. Private Duty Nursing RN. Submitting an 837I Outpatient Claim. C laim Adjustment Group Code. Select one of the follwoing: Other Payer Na me. The name of the Billing Provider: This could be an Organization, business or the Name of an individual provider identified by the NPI used to lo gin to MN– ITS. Date of Service (From). This must be the date the determination was made with the other payer. Enter the date the item or service was provided, dispensed or delivered to the recipient. Taxonomy for occupational medicine. Section Action Buttons. When reporting TPL at the claim (header level), enter the non-covered charge amount. Situational Claim Information - Select the situational claim information accordion screen to report situational information when required.
Enter the highest level of ICD or other industry accepted code(s) that best describe the condition/reason the recipient needed the service(s). The middle initial of the subscriber. From the dropdown menu options select the identifier of other payer entered on the COB screen. Skilled Nurse Visit Telehomecare. Dates must be within the statement dates enterd in the Claim Information Screen. For header (claim) level adjustment, select the code identifying the general category of the payment adjustment for this line from the dropdown menu options. Enter the unit(s) or manner in which a measurement has been taken. This is the determination of whether the provider has a signed statement by the recipient on file, authorizing the release of medical data to other organizations. The first 9 skilled nurse visits in a calendar year do not require an authorization unless the recipient has a current waiver service authorization SA)]. Pro cedure Code Modifier(s). Assignment/ Plan Participation. Use the Home Care Service Billing Codes in the chart below to determine the revenue code used for MHCP home care services.
Claim Filing Indicator. Enter the appropriate revenue code used to specify the service line item detail for a health care institution. Statement Date (To). Line Item Charge Amount. Enter the HCPCS code identifying the product or service. Enter the total dollar amount the other payer paid for this service line. Other Payers Claim Control Number. Service Line Paid Amount. From the dropdown menu options, select the appropriate code indicating the disposition or discharge status of the recipient on the date entered in the statement Date (To) field.
Select the radio button next to the location where the service(s) was provided. Payer Responsibility. From the dropdown menu options, select the code identifying type of insurance. Enter the number of units identified as being paid from the other payer's EOB/EOMB.
Select the appropriate response from the dropdown menu options, to identify the priority of the admission/visit. Select the appropriate source code from the dropdown menu options, indicating the point of location/origin for this admission or visit. Enter the policy holder's identification number as assigned by the payer. To (End) date not required as must be the same as the From (start) date of this line. Home Care Servies Billing Codes.
Adjustment Reason Code. Enter the code identifying the reason the adjustment was made.