From the dropdown menu options, select the relationship of the MHCP subscriber (recipient) to the policy holder. Pro cedure Code Modifier(s). Skilled Nurse Visit (LPN). The zip code for the address in address fields 1 and 2. Taxonomy for occupational therapist. Enter the 8-digit MHCP ID for the subscriber (recipient) indicated on the MHCP member identification card. Release of Information. The second address line reported on the provider file. 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.
Enter the date of payment or denial determination by the Medicare payer for this service line. When using a consolidated NPI, a table will display showing the locations and taxonomy code(s) information on file with MHCP. Attachment Control Number. An authorization number is not required if there is no authorization in the system and the service is a skilled nurse visit.
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. Prior Authorization Number. Situational Claim Information - Select the situational claim information accordion screen to report situational information when required. When reporting TPL adjustments at the claim (header level), enter the prior payer paid amount. Taxonomy code for occupational therapy. Enter the date the item or service was provided, dispensed or delivered to the recipient. Principal Diagnosis Code. 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.
Other Payers Claim Control Number. The patient control number will be reported on your remittance advice. Enter the NPI listed on the Explanation of Medicare Benefits (EOMB) used to submit the claim to Medicare. Use only when a modifier is listed on the service authorization (SA) or when a claim for private duty nursing shared services. Enter the code identifying the general category of the payment adjustment for this line. Enter the date associated with the Occurrence Code. For header (claim) level adjustment, select the code identifying the general category of the payment adjustment for this line from the dropdown menu options. 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. From the drop down menu, select whether the diagnosis code reported on this claim is in the ICD-9 or ICD-10 classification. Claim Action Button. Respiratory Therapy Visit Extended. This is available on the recipient's eligibility response). The middle initial of the subscriber. Enter the code identifying the reason the adjustment was made.
Telephone number reported on the provider file. Once the claim filing indicator is selected, additional fields will display for reporting TPL/private insurance. Speech Therapy Visit. 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. This must be the date the determination was made with the other payer.
From the dropdown menu options select the identifier of other payer entered on the COB screen. Adjustment Reason Code. Adjudication - Payment Date. Benefits Assignment. To delete, select Delete. Enter the number of units identified as being paid from the other payer's EOB/EOMB. Enter the Identifier of the insurance carrier.
From the dropdown menu options, select the code identifying type of insurance. Enter the HCPCS code identifying the product or service. Enter the appropriate revenue code used to specify the service line item detail for a health care institution. Skilled Nurse Visit Telehomecare. 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. This is the code indicating whether the provider accepts payment from MHCP. Enter the total dollar amount the other payer paid for this service line. Enter the policy holder's identification number as assigned by the payer. Home Health Aide Visit. Select one of the following: Subscriber. Outpatient Adjudication Information (MOA). Copy, Replace or Void the Claim.
Enter the service end date or last date of services that will be entered on this claim. Enter the claim number reported on the Medicare EOMB.
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