assignment or plan participation code

Skip To: Main Content | Subnavigation |

Basic Instructions

Revised: March 4, 2024

Review MHCP Billing Policy for general billing requirements and guidance when submitting claims. Refer to additional billing requirements in the service specific section of the MHCP Provider Manual before you submit the claim for services.

Log in to MN–ITS

1. Log in to MN–ITS
2. From the left menu:
a. Select MN–ITS
b. Select Submit DDE Claims (837)
c. Select Professional (837P)

Submit the Claim

To submit the claim, follow the instructions in the tables below for each of the following claim screens:

Billing Provider Subscriber Claim Information Coordination of Benefits (COB) Services

Validate claim before you submit using X12 (formerly known as Washington Publishing Company) to make sure you:

· Completed all fields
· Can make corrections
· Can avoid denied claims

Billing Provider

The billing provider screen auto-populates with the information in the enrollment profile for the NPI/UMPI used to login to MN–ITS. If changes are needed, use the Change of Enrollment Information to notify MHCP Provider Enrollment.

Refer to the following table for instruction and information about each field on this screen.

Subscriber (member)

Use the Subscriber screen to report the member who received the services reported on this claim.

Refer to the following table for instructions and information about each field on this screen.

Claim Information

Use t he C laim I nformation screens to report claim level information that will identify the type of claim and details about the services.

Coordination of Benefits (COB)

Use the COB screen to report other payers, third party liability (TPL) or Medicare’s financial responsibility for all or a portion of the claim. If no other payers are involved with this claim, select the Continue button at the bottom of this screen to proceed to the next screen.

To report each type of other payer information at the claim (header) level use the tables below:

Third Party Liability (TPL)/Other insurance (non-Medicare)

Medicare and HMO Medicare Risk

Third Party liability (TPL)/Other Insurance (non-Medicare) Complete the following fields to report adjustment, payments and denials from the private insurance (Non-Medicare) carrier.

If reporting MB-Medicare Part B or 16-Health Maintenance Organization, HMO Medicare Risk insurance, use the instructions in the Medicare and HMO Medicare Risk table.

Medicare and HMO Medicare Risk Complete the following fields to report adjustment, payments and denials from Medicare or an HMO Medicare Risk plan.

Use the Services screen to describe details for each service being billed. Information reported on a service line will override information reported at the claim (header) level for that line.

Copy, Replace or Void (take back) the Claim

After submitting the claim and receiving a claim response, an option to Copy, Replace, or Void the claim is available. Use each of these features to do the following:

Copy - To correct an error of a denied claim or to copy information from other similar claims previously submitted

Replace - If the claim paid, but paid incorrectly or a line item was denied. The user may access the claim, correct the information and resubmit. The original paid amount will be taken back and replaced with the correct information on the replacement claim

Void (take back) - If the claim was submitted in error. This reverses the claim and takes the payment back

Review the Copy, Replace, Void (take back), or Reverse a Claim User Guide for step-by-step instructions when completing these transactions.

SOS Electronic Claims Module : Loop2300SegCLM07

RecentChanges
RecentlyCommented
Login/Register
Your hostname is customer.clientshostname.com

Description

Data entry and remarks, g5 professional, g5 institutional, g4 professional, g4 institutional.

There are no comments on this page. [ Add comment ]

Owner: JoeSur

837 Institutional Claim Scenario

837 institutional claim scenario and mapping guidelines.

837 Institutional Claim example presented in today’s post shows a standard 837 Institutional claim. As we spoke in our previous post, the 837 Healthcare Claim transaction has three different implementation guides specifically developed for Professional , Institutional and Dental claims. The specifications are geared to meet the individual requirements of the three different types of claim forms. 837 Institutional Claim manual allows for Value Codes, Occurrence Codes and Occurrence Spans. These fields are specific to the UB04 claim form only.

In today’s 837 Institutional Claim example there are two claims in this scenario (Two CLM 2300 Loop Levels). Here are the attributes of the 837 Institutional Claim example:

The submitter of these claims is UCLA MEDICAL CENTER The receiver of the claim is BCBS DISNEY The billing provider is UCLA MEDICAL CENTER The first patient “Mickey Mouse” is the subscriber The payer is BCBS DISNEY.

Mickey Mouse visited the emergency room because he had an open wound (ICD-9 8842) when he was driving around with Donald Duck (E8199 Person injured in unspecified motor-vehicle accident) and went to visit the hospital. Mickey’s visit was on January 24th, 2012 where Mickey was admitted to the Hospital ER Procedure Code 99201 (HCPCS) $150 and treated by Dr. Watson with a Laceration Repair Procedure Code 26591 (HCPCS) – cost $75.

The second patient “Donald Duck” is the subscriber and was treated by Dr. Watson with the same procedure and diagnosis codes. Donald and Mickey had the same insurance except Donald had a different member ID with BCBS Disney.

837 Institutional Claim Raw Data

ST*837*3706*005010X223A2 BHT*0019*00*004545*20120124*135420*CH NM1*41*2*UCLA MEDICAL CENTER*****46*1982 PER*IC*ANN GILLIS*TE*8185601000 NM1*40*2*BCBS DISNEY*****46*47198 HL*1**20*1 PRV*BI*PXC*282N00000X NM1*85*2*UCLA MEDICAL CENTER*****XX*1215193883 N3*757 WESTWOOD PLAZA N4*LOS ANGELES*CA*900257437 REF*EI*123456789 HL*2*1*22*0 SBR*P*18*******CI NM1*IL*1*MOUSE*MICKEY****MI*60345914A N3*1565 DISNEYLAND DRIVE*SUITE 101 N4*ANAHEIM*CA*92802 DMG*D8*19281118*M REF*SY*055090001 NM1*PR*2*BCBS DISNEY*****PI*8584537845 CLM*ABC9001*225***22:A:1*Y*C*Y*Y DTP*434*RD8*20120124-20120124 CL1*3*7*1 HI*BK:8842 HI*PR:8842 HI*BN:E8199 NM1*71*1*WATSON*JOHN*H***XX*1134125736 LX*1 SV2*0450*HC:98765*150*UN*1 DTP*472*D8*20120124 LX*2 SV2*0360*HC:26591*75*UN*1 DTP*472*D8*20120124 HL*3*1*22*0 NM1*IL*1*DUCK*DONALD****MI*60345914B N3*1565 DISNEYLAND DRIVE*SUITE 102 N4*ANAHEIM*CA*92802 DMG*D8*19340619*M REF*SY*066080002 NM1*PR*2*BCBS DISNEY*****PI*8584537845 CLM*ABC9002*225***22:A:1*Y*C*Y*Y DTP*434*RD8*20120124-20120124 CL1*3*7*1 HI*BK:8842 HI*PR:8842 HI*BN:E8199 NM1*71*1*WATSON*JOHN*H***XX*1134125736 LX*1 SV2*0450*HC:98765*150*UN*1 DTP*472*D8*20120124 LX*2 SV2*0360*HC:26591*75*UN*1 DTP*472*D8*20120124 SE*53*3706

837 Institutional Claim Deciphering Raw Data BHT – 2000A

Beginning of Hierarchical Transaction: BHT*0019*00*004545*20120124*135420*CH BHT01 Hierarchical Structure Code : Information Source, Subscriber, Dependent BHT02 Transaction Set Purpose Code : Original BHT03 Reference Identification : 004545 BHT04 Date : 1/24/2012 BHT05 Time : 1:54:20 PM BHT06 Transaction Type Code : Chargeable

LOOP 1000A Submitter Name Submitter Information: NM1*41*2*UCLA MEDICAL CENTER*****46*1982 NM101 Entity Identifier Code : Submitter NM102 Entity Type Qualifier : Non-Person Entity NM103 Name Last or Organization Name : UCLA MEDICAL CENTER NM108 Identification Code Qualifier : Electronic Transmitter Identification Number (ETIN) NM109 Identification Code : 1982

Submitter Contact Information: PER*IC*ANN GILLIS*TE*8185601000 PER01 Contact Type: Information Contact “IC” PER02 Contact Name: ANN GILLIS PER03 Communication Qualifier: Telephone “TE” PER04 Telephone Number: 8185601000

LOOP 1000B Receiver Name Receiver Information: NM1*40*2*BCBS DISNEY*****46*47198 NM101 Entity Identifier Code : Receiver “40” NM102 Entity Type Qualifier : Non-Person Entity “2” NM103 Name Last or Organization Name : BCBS DISNEY NM108 Identification Code Qualifier : Electronic Transmitter Identification Number (ETIN) “46” NM109 Identification Code : 47198

LOOP 2000A BILLING PROVIDER Billing Provider Hierarchical Level: HL*1**20*1 HL01 Hierarchical ID: 1 HL02 Parent Hierarchical ID: No Parent HL03 Hierarchy Level Name: “20” = Information Source HL04 Number of Hierarchical Children: 1 more additional subordinate HL

Provider Specialty Information: PRV*BI*PXC* 203BA0200N PRV01 Type of Provider: Billing “BI” PRV02 Code Qualifier: Health Care Provider Taxonomy Code “PXC” PRV03 Provider Taxonomy Code: 203BA0200N

837 Institutional Claim Deciphering Raw Data 201AA – 2000B

LOOP 2010AA BILLING PROVIDER NAME Billing Provider Information: NM1*85*2*UCLA MEDICAL CENTER*****XX*1215193883 NM101 Entity Identifier Code : Billing Provider “85” NM102 Entity Type Qualifier : Person “2” Organization NM103 Name Last or Organization Name : UCLA MEDICAL CENTER NM108 Identification Code Qualifier : National Provider Identifier “XX” NM109 NPI: 1215193883

Billing Provider Address:757 WESTWOOD PLAZA N301 Street Address: 757 WESTWOOD PLAZA Billing Provider City, State, ZIP Code: N4*LOS ANGELES*CA*900257437 N401 City: LOS ANGELES N402 State: CA N403 Zip: 900257437 Billing Provider Tax Identification: REF*EI*123456789 REF01 Reference Qualifier: Employer’s Identification Number “EI” REF02 EIN: 123456789

LOOP 2000B SUBSCRIBER HIERARCHICAL (Claim 1) Subscriber Hierarchical Level: HL*2*1*22*0 HL01 Hierarchical ID: 2 HL02 Parent Hierarchical ID: 1 (Information Source/Billing Provider) HL03 Hierarchy Level Name: “22” = Subscriber HL04 Number of Hierarchical Children: 0 (Subscriber is the patient)

Subscriber Information: SBR*P*18*******CI SBR01 Payer Responsibility Sequence Number Code: Primary “P” SBR02 Individual Relationship Code: Self “18” SBR09 Code identifying type of claim: Commercial Insurance Co. “CI” LOOP 2010BA SUBSCRIBER NAME Subscriber Information: NM1*IL*1*MOUSE*MICKEY****MI*60345914A NM101 Entity Identifier Code : Subscriber “IL” NM102 Entity Type Qualifier : Person “1” NM103 Subscriber Last Name: Mouse NM104 Subscriber First Name: Mickey NM108 Identification Code Qualifier : Member Identification Number “MI” NM109 Member Identification Number: 60345914A Subscriber Address: N3*1565 DISNEYLAND DRIVE*SUITE 101 N301 Street Address: 1565 DISNEYLAND DRIVE N302 Street Address Line 2:SUITE 101 Subscriber City, State, ZIP Code: N4*ANAHEIM*CA*92802 N401 City: ANAHEIM N402 State: CA N403 Zip: 92802 Subscriber Demographic Information: DMG*D8*19281118*M DMG01 Date Time Period Format Qualifier: Date Expressed in Format CCYYMMDD “D8” DMG02 Subscriber Birth Date: 19281118 DMG03 Subscriber Gender Code: ‘M’ for Male Subscriber Secondary Identification: REF*SY*055090001 REF01 Reference Qualifier: Social Security Number “SY” REF02 SSN: 055090001

837 Institutional Claim Deciphering Raw Data 2010BB – 2400 (Claim 1)

LOOP 2300 CLAIM INFORMATION Claim Information: CLM*ABC9001*225***22:A:1*Y*C*Y*Y CLM01 Claim ID: ABC9001 CLM02 Claim Amount: 225 CLM05-1 Place of Service Code: ’22’ Outpatient Hospital CLM05-2 Facility Code Qualifier: ‘A’ Uniform Billing Claim Form Bill Type CLM05-3 Claim Frequency Code: ‘1’ The only bill to be received for a course of treatment CLM06 Provider or Supplier Signature On File Indicator: ‘Y’ Yes CLM07 Assignment or Plan Participation Code: ‘C’ Not Assigned CLM08 Benefit Indicator: ‘Y’ Yes – Subscriber authorized the payer to remit payment directly to the provider CLM09 Release of Information Indicator: ‘Y’ Yes – Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

ICD9Diagnosis Codes: HI*BK:8842 HI01-1 ‘BK’ for Primary Diagnosis HI01-2: 8842 (Open Wound) HI*PR:8842 HI01-1 ‘BK’ for Patient’s Reason For Visit HI01-2: 8842 (Open Wound) HI*BN:E8199 HI01-1 ‘BN’ for External Cause Of Injury HI01-2: (E8199 Person injured in unspecified motor-vehicle accident)

LOOP 2400 SERVICE LINE Service Line Number 1: LX*1

LOOP 2310A ATTENDING PROVIDER NAME Attending Provider Name: NM1*71*1*WATSON*JOHN*H***XX*1134125736 NM101 Entity Identifier Code : Attending Provider “71” NM102 Entity Type Qualifier : Person “1” NM103 Name Last or Organization Name : WATSON NM104 First Name: WATSON NM103 Middle Name or Initial: WATSON NM108 Identification Code Qualifier : National Provider Identifier “XX” NM109 NPI: 1134125736

Institutional Service Line Item Details: SV2*0450*HC:99201*150*UN*1 SV201 Service Line Revenue Code: 0450 SV202-01 Procedure Code Qualifier: ‘HC’ HCPCS SV202-02 Procedure Code: 99201 (Hospital Visit) SV203 Procedure Amount: $150 SV204 Unit of Measure Code: ‘UN’ Units SV205 Service Unit Count: 1

Date or Time or Period: DTP*472*D8*20120124 Date/Time Qualifier : ‘472’ Service Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD Date Time Period : 20120124

Service Line Number 2: LX*2

Institutional Service Line Item Details: SV2*0360*HC:26591*75*UN*1 SV201 Service Line Revenue Code: 0360 SV202-01 Procedure Code Qualifier: ‘HC’ HCPCS SV202-02 Procedure Code: 26591 (Laceration Repair) SV203 Procedure Amount: $75 SV204 Unit of Measure Code: ‘UN’ Units SV205 Service Unit Count: 1

837 Institutional Claim Deciphering Raw Data 2000B – 2300 (Claim 2)

Grayed out and smaller font items indicate that the elements are the same as in Claim 1 LOOP 2000B SUBSCRIBER HIERARCHICAL (Claim 2) Subscriber Hierarchical Level: HL*3*1*22*0 HL01 Hierarchical ID: 3 HL02 Parent Hierarchical ID: 1 (Information Source/Billing Provider) HL03 Hierarchy Level Name: “22” = Subscriber HL04 Number of Hierarchical Children: 0 (Subscriber is the patient)

LOOP 2010BA SUBSCRIBER NAME Subscriber Information: NM1*IL*1*DUCK*DONALD****MI*60345914B NM101 Entity Identifier Code : Subscriber “IL” NM102 Entity Type Qualifier : Person “1” NM103 Subscriber Last Name: Duck NM104 Subscriber First Name: Donald NM108 Identification Code Qualifier : Member Identification Number “MI” NM109 Member Identification Number: 60345914B

Subscriber Address: N3*1565 DISNEYLAND DRIVE*SUITE 102 N301 Street Address: 1565 DISNEYLAND DRIVE N302 Street Address Line 2:SUITE 102 Subscriber City, State, ZIP Code: N4*ANAHEIM*CA*92802 N401 City: ANAHEIM N402 State: CA N403 Zip: 92802 Subscriber Demographic Information: DMG*D8*19340619*M DMG01 Date Time Period Format Qualifier: Date Expressed in Format CCYYMMDD “D8” DMG02 Subscriber Birth Date: 19340619 DMG03 Subscriber Gender Code: ‘M’ for Male Subscriber Secondary Identification: REF*SY*066080002 REF01 Reference Qualifier: Social Security Number “SY” REF02 SSN: 066080002

837 Institutional Claim Deciphering Raw Data 2010BB -2300 – 2400 (Claim 2)

LOOP ID – 2010BB PAYER NAME Payer Name: NM1*PR*2*BCBS DISNEY*****PI*8584537845 NM101 Entity Identifier Code : Payer “PR” NM102 Entity Type Qualifier : Non-Person Entity “2” NM103 Name Last or Organization Name : BCBS DISNEY NM108 Identification Code Qualifier : National Plan ID “PI” NM109 Identification Code : 8584537845 LOOP 2300 CLAIM INFORMATION Claim Information: CLM*ABC9002*225***22:A:1*Y*C*Y*Y CLM01 Claim ID: ABC9002 CLM02 Claim Amount: 225 CLM05-1 Place of Service Code: ’22’ Outpatient Hospital CLM05-2 Facility Code Qualifier: ‘A’ Uniform Billing Claim Form Bill Type CLM05-3 Claim Frequency Code: ‘1’ The only bill to be received for a course of treatment CLM06 Provider or Supplier Signature On File Indicator: ‘Y’ Yes CLM07 Assignment or Plan Participation Code: ‘C’ Not Assigned CLM08 Benefit Indicator: ‘Y’ Yes – Subscriber authorized the payer to remit payment directly to the provider CLM09 Release of Information Indicator: ‘Y’ Yes – Provider has a Signed Statement Permitting Release ICD9Diagnosis Codes: HI*BK:8842 HI01-1 ‘BK’ for Primary Diagnosis HI01-2: 8842 (Open Wound) HI*PR:8842 HI01-1 ‘BK’ for Patient’s Reason For Visit HI01-2: 8842 (Open Wound) HI*BN:E8199HI01-1 ‘BN’ for External Cause Of Injury HI01-2: (E8199 Person injured in unspecified motor-vehicle accident) LOOP 2400 SERVICE LINE Service Line Number 1: LX*1 LOOP 2310A ATTENDING PROVIDER NAME Attending Provider Name: NM1*71*1*WATSON*JOHN*H***XX*1134125736 NM101 Entity Identifier Code : Attending Provider “71” NM102 Entity Type Qualifier : Person “1” NM103 Name Last or Organization Name : WATSON NM104 First Name: WATSON NM103 Middle Name or Initial: WATSON NM108 Identification Code Qualifier : National Provider Identifier “XX” NM109 NPI: 1134125736 Institutional Service Line Item Details: SV2*0450*HC:99201*150*UN*1 SV201 Service Line Revenue Code: 0450 SV202-01 Procedure Code Qualifier: ‘HC’ HCPCS SV202-02 Procedure Code: 99201 (Hospital Visit) SV203 Procedure Amount: $150 SV204 Unit of Measure Code: ‘UN’ Units SV205 Service Unit Count: 1 Date or Time or Period: DTP*472*D8*20120124 Date/Time Qualifier : ‘472’ Service Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD Date Time Period : 20120124 Service Line Number 2: LX*2 Institutional Service Line Item Details: SV2*0360*HC:26591*75*UN*1 SV201 Service Line Revenue Code: 0360 SV202-01 Procedure Code Qualifier: ‘HC’ HCPCS SV202-02 Procedure Code: 26591 (Laceration Repair) SV203 Procedure Amount: $75 SV204 Unit of Measure Code: ‘UN’ Units SV205 Service Unit Count: 1 Date or Time or Period: DTP*472*D8*20120124 Date/Time Qualifier : ‘472’ Service Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD Date Time Period : 20120124.

The above mentioned example, including mapping guides, can serve for deeper understanding of healthcare claims EDI processing. If you are somehow connected to HIPAA EDI and electronic data interchange in the healthcare industry, EDI Academy trainings may serve you to get useful knowledge. Visit our site to learn the schedule of the courses interesting for you.