<p>HCBS Waiver, Alternative Care (AC), Moving Home Minnesota and Group Residential (GRH) Supplemental Services Claims Revised: 11-07-2016</p><p>Review MHCP Billing Policy for general billing requirements and guidance when submitting claims. Refer to additional billing requirements in the following sections of the MHCP Provider Manual before you submit the claim for services:  Home and Community Based Services (HCBS) Waiver Program S ervices  Elderly Waiver (EW) and Alternative Care (AC) Program Services  Waiver and AC Programs – Specialized Supplies & Equipment Authorization & Billing Responsibilities  Moving Home Minnesota Demonstration and Supplemental Services Billing Table </p><p>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)”</p><p>Submit the Claim To submit the claim follow the instructions in the tables below for each of the following claim screens:</p><p>Billing Provider Subscriber Claim Information Coordination of Benefits (COB) (complete only when the recipient has other/private insurance) Services</p><p>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. </p><p>Refer to the table below for instruction and information about each field on this screen. Field Name * Field Instruction (X12 Loop & element) Organization The field auto-populates with the name of the waiver/AC service provider. (Loop: 2010AA, NM103 (last or organization) NM104 (first) Taxonomy This field only displays information when a Health care provider specialty/location (Loop: 2000A, PRV03) code has been added to the provider file. Address 1 This field auto-populates with the first line of your address in your provider file. (Loop: 2010AA, N301) Address 2 This field auto-populates with the second line of your address in your provider file. (Loop: 2010AA, N302) City This field auto-populates with the city listed in the address of your provider file. (Loop: 2010AA, N401) State This field auto-populates with the state listed in the address of your provider file. (Loop: 2010AA, N402) Zip This field auto-populates with the zip code listed in the address of your provider file. (Loop: 2010AA, N403) Telephone This field auto-populates with the telephone number reported on the provider file. (Loop: 2010AA, PER04) Action Button Select Continue to proceed to the next screen.</p><p>Subscriber Use the Subscriber screen to report the recipient who received the service(s) reported on this claim. Refer to the table below for instruction and information about fields to complete on this screen when entienrg a claim for waiver or AC services. Field Name* Field Instruction (X12 loop & element) Subscriber ID Enter the 8-digit MHCP ID for the subscriber (recipient) indicated on the MHCP (Loop: 2010BA, NM109) member identification card. Birth Date Enter the birth date of the subscriber. (Loop: 2010BA, DMG02) Select the Search action button in this section to have MN-ITS find and display the subscriber associated with the subscriber ID and date of birth entered. The following fields auto-populate based on the information entered in the Subscriber ID and Birth Date fields Subscriber First Name The first name of the subscriber. (Loop: 2010BA, NM104) Middle Initial The middle initial of the subscriber. (Loop: 2010BA, NM105) Last Name The last name of the subscriber. (Loop: 2010BA,NM103) Gender The gender of the subscriber. (Loop: 2010BA, DMG03) Select Delete to remove the subscriber information if the incorrect recipient. Screen Action Button Select one of the following screen action buttons:  Continue to proceed to the next screen.  Back to go back to the previous screen</p><p>Claim Information Use the Claim Information screen(s) to report header (claim) level information that will identify the type of claim and details about the service(s). Information entered on the claim information screen will apply to all lines of the claim.</p><p>Refer to the table below for instruction and information about each field on this screen. Field Name* Field Instruction (X12 Loop & element) Claim Frequency Code The default is Original. Leave original if not submitting a Replacement or Void claim. (Loop: 2300, CLM05-3) Select replacement if you are replacing a claim that MHCP previously paid for this recipient.</p><p>Select void if you are voiding a claim that MHCP previously paid for this recipient. Payer Claim Control Number Enter the claim you want to replace or void. This field only displays if you selected (Loop: 2300, REF02) the replacement or void claim frequency code. Place of Service Select from the drop down menu to select the appropriate place of service. (Loop: 2300 CLM05-1) Select “12-Home” for most HCBS waiver and AC service claims. Patient Control Number Enter words, numbers, letters or a combination to report a unique code to identify this (Loop: 2300, CLM01) claim for this recipient in your records. This can be anything you want. MHCP will report this back to you on the remittance advice (RA). Assignment/ Plan Participation Select the code to report whether the provider accepts payment from MHCP if (Loop: 2300, CLM07) different than the default. The default is Assigned. The options are:  Assigned - provider has a participation agreement with MHCP  Assignment Accepted - provider accepts assignment only for clinical lab services  Not Assigned - neither assigned nor assignment accepted apply Benefits Assignment Select the benefit assignment to report the policy holder or person authorized to act (Loop: 2300, CLM08) on their behalf, gives MHCP permission to pay the provider directly if different than the default. The default is Yes.</p><p>The options are:  Yes - Benefits assigned to the provider  No - Benefits not assigned to the provider  Not Applicable - Patient refuses to assign benefits Release of Information Select the correct response if different than the default to report The determination of (Loop: 2300, CLM09) whether the provider has a signed statement by the recipient on file, authorizing the release of medical data to other organizations. The default is Yes. The options are:  Yes - Signature collected or required  Informed Consent - Signature not collected and not required Provider Indicator Select the correct response if different than the default to report whether the (Loop: 2300, CLM06) provider’s signature is on file, certifying services were performed by the provider. The default is Signature on File. Diagnosis Type Code From the drop down menu, select whether the diagnosis code reported is in the ICD- (Loop: 2300, HI01-1) 9 or ICD-10 classification. Diagnosis Code Enter the diagnosis code (ICD) that is listed on your service authorization (SA) or (Loop: 2300, HI01-2, HI02-2, Assesment and Service Plan document that coordinates with the dates of service for HI03-2, HI04-2) this claim </p><p>Select the Add action button in this section to include on the claim.</p><p>Once a diagnosis code is entered it will display in the table below. </p><p>Select the Delete button next to a diagnosis code to remove it from the claim. Situational Claim Information – Select this accordion panel to report service authorization/agreement number. Prior Authorization Number Enter the service agreement number from your service authorization (SA) letter. (Loop: 2300, REF02) Attachment Control Number Use only when submitting a claim with attachment. (Loop: 2400, PWK06) Enter the Code/number assigned by the provider, identifying an attachment for this claim. Review the Electronic Claim Attachments page for MHCP Attachment Criteria and additional information. Attachment Type Enter the code indicating the type ID and description of the attachment. (Loop: 2400, PWK01) Screen Action Button Select Continue to proceed to the next screen.</p><p>Coordination of Benefits (COB) Always complete this section if the recipient has a long term care insurance policy. Otherwise, use the COB screen only when reporting payments or denials from other payers, private insurance (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.</p><p>To report each type of other payer information at the claim/header level use the tables below:</p><p>TPL/Private Insurance (non-Medicare) Complete the following fields to report adjustment, payments and denials from the private insurance (Non-Medicare) carrier. Field Name* Field Instruction (X12 Loop & Element) Other Payer Name Enter the full name of the insurance carrier/other insurance. (Loop: 2330B, NM103) Other Payer Primary ID Enter the Identifier of the insurance carrier. (Loop: 2330B, NM109) This is reported as the carrier ID for the insurance coverage, in the Other Insurance section of the eligibility reponse for this recipient. Claim Filing Indicator Select from the drop down menu, the code identifying the type of insurance. (Loop: 2320, SBR09) The type of insurance is usually reported in the Other Insurance section of the eligibility response for this recipient. Once the claim filing indicator is selected, additional fields will display to report payments made by the TPL/other insurance. Payer Responsibility Select the code identifying the insurance carrier’s level of responsibility for payment (Loop: 2320, SBR01) of the claim, from the drop down menu. Scenarios:  If this insurance is the first payer and you sent the claim to and then MHCP second then this insurance is the primary payer  If this insurance is the second insurance you sent the claim to and now MHCP third, then this insurance is the secondary payer Insured ID Enter the policy holder’s policy number with this other insurance. (Loop: 2330A, NM109) Relationship Code Select from the drop down menu, the relationship of the MHCP subscriber (recipient) (Loop: 2320, SBR02) to the policy holder. Example: Recipient is the child to the person who holds this other insurance policy. Complete the following fields only if reporting adjustments at the claim level. Claim Adjustment Group Code Select the adjustment code from the drop down menu to report the type of adjustment (Loop: 2320, CAS01) reported by the other insurance. Use the Washington Publishing Company link, on right, to find the HIPAA compliant code that matches the adjustment response on the other payer’s EOB. Adj Reason Code This field is used only when reporting TPL/private insurance at the claim (header) (Loop: 2320, CAS02, CAS05, level rather than at the service line. CAS08, CAS11, CAS14, CAS17) Enter the code identifying the reason the other payer adjusted the payment. Use the Washington Publishing Company link, on right, to find the HIPAA compliant code that matches the adjustment response on the other payer’s EOB. Adj Amount This field is used only when reporting TPL/private insurance at the claim (header) (Loop: 2320, CAS03, CAS06, level rather than at the service line. CAS09, CAS12, CAS15 CAS18) Enter the dollar amount of the adjustment. Adj Quantity This field is used only when reporting TPL/private insurance at the claim (header) (Loop: 2320, CAS04, CAS07, level rather than at the service line. CAS10, CAS13, CAS16, CAS19) Enter the number of units not paid when the units paid are different than the number of units submitted on the claim. Action Button Select the Add action button in this section to include the adjustment entries on the claim. To remove an adjustment from the claim, select the Delete action button next to an adjustment. Repeat the Claim Adjustment entries to report all adjustments as noted on the EOB from the TPL/private insurance. Payer Paid Amount This field is used only when reporting TPL/private insurance at the claim (header) (Loop: 2320, AMT02) level rather than at the service line. Enter the total dollar amount paid by ther other payer. Non-Covered Charge Amount This field is used only when reporting TPL/private insurance at the claim (header) (Loop: 2320, AMT02) level rather than at the service line.Enter the total dollar amount the other payer did not pay. Benefits Assignment The determination of the policy holder, or person authorized to act on their behalf, to (Loop: 2320, O103) give the other payer permission to pay the provider directly Default is Yes Select the correct response if different than the default. Release of Information The determination of whether the provider has a signed statement by the recipient on (Loop 2320, O106) file, authorizing the release of medical data to other organizations Default is Yes Select the correct response if different than the default.</p><p>Section Action Button Select one of the following screen action buttons:  Save to save the entry  Delete to remove this entry  Add to save this entry and add another payer. Screen Action Button After you save the entry, select Continue to proceed to the next screen.</p><p>Services Use the Services screen to enter dates of service you provided waiver or AC services for the recipient. Information reported on a service line will override information reported at the header (claim) level for that line.</p><p>Refer to the table below to compelte each field in the services screen for instruction and information about each field on this screen. Field Name* Field Instruction (X12 Loop and element) Date of Service (From) Enter the date the service was provided. (Loop: 2400, DTP03) Procedure Code Enter the HCPCS code from your service authorization letter. (Loop: 2400, SV101-2) Procedure Code Modifier(s) Enter the modifier that clarifies or further identifies the service indicated in the (Loop: 2400, SV101-3, SV101-4, procedure code field. SV101-5, SV101-6) Diagnosis Pointer Review to ensure the diagnosis code is displaying in the first field. (Loop: 2400, SV107-1, SV107-2, Waiver/AC service claims only require the most current, most specific diagnosis SV107-3, SV107-4) code for the service provided on this claim line. If the code is not visible, use the drop down menu to select the correct diagnosis code for this line of the claim. Line Item Charge Enter your total charge for all units on this line. (Loop: 2400, SV102) To determine the total charge, multiply the number of units for this line to your usual and customary charge for this service. If you report other payers in the COB or line COB sections, your total charge must be the same as the amount you submitted or would have submitted to the other payer. Service Unit Count Enter the number of units for this service line. (Loop: 2400, SV104) Situational Services – Select this accordion panel to report additional information. *For Specialized Equipment and Supplies. Line Note When required, enter a description to provide additional information about this line (Loop: 2400, NTE02) item or service.</p><p>Other Payer – Use this section only if reporting other payer (TPL) COB payments or denials at the service (line). To complete this section, level accordion panel. If the recipient does not have other/private insurance to report, skip this accordion section. Other Payer Primary Identifier From the drop down menu, select the identifier of the TPL/private insurance carrier, (Loop: 2430, SVD01) HMO Medicare Risk or the NPI of the Medicare contractor. Service Line Paid Amount Enter the total dollar amount the other payer paid for this service line. (Loop: 2430, SVD02) Adjudication - Payment Date Enter the date of payment or denial determination by the Medicare payer for this (Loop: 2430, DTP03) service line.</p><p>This field is not required for TPL/private insurance reporting. Paid Unit Count Enter the number of units identified as being paid from the other payer’s EOB/EOMB (Loop: 2430,SVD05) for this service line. Claim Adjustment Group Code From the drop down menu, select the adjustment code identifying the general (Loop: 2430, CAS01) category of payment adjustment for this service line.</p><p>Use the Washington Publishing Company link, on right, to find the HIPAA compliant code that matches the adjustment response on the other payer’s EOB. Adjustment Reason Code Enter the code identifying the reason the other payer adjusted the payment for this (Loop: 2430, CAS02) service line.</p><p>Use the Washington Publishing Company link, on right, to find the HIPAA compliant code that matches the adjustment response on the other payer’s EOB. Adjustment Amount Enter the dollar amount of the specific adjustment for this service line. (Loop: 2430, CAS03) Adjustment Quantity Enter the number of units not paid when the units paid are different than the number (Loop: 2430, CAS04) of units submitted for this service line. Action Button Select the Add action button in this section to include the adjustment entries on the service line. Repeat the Other Payer COB Line Adjustment Entries to report all adjustments for this service line as noted on the EOB/EOMB. To remove an adjustment, select the Delete action button next to the adjustment. To remove the entire COB line entry, select the delete action button afer adding the information. Section Action Button Select the Save action button in this section, below the display of adjustments, to save the COB information for the payer to this service line Once saved, the COB Line Payments/Adjustments screen will appear with the following information:  Other Payer Primary identifier  Line Paid Amount  Total Adjustment for the service line Section Action Button as Select the Edit action button next to a payer to change the adjustment entries for the needed payer (the totals on this screen should equal the charge you sent to the primary payer). Section Action Button as Select the Add action button in this section, below the display of payers, to report needed another payer to this service line. Repeat the same steps to add additional payer information for this service line. Section Action Button Select one of the following:  Save/ View Line(s): to save the line item if only one line item is entered or if not using the Copy or Add action button for the next line.  Copy: to save and copy the service line information that was just entered so that you can make changes to the copied service line.  Delete: to remove the service line information that is displayed.  Add: to add a new service line to the claim. A new service line will display for you to enter new information for your next service line.</p><p>Select Save/View Line(s) once all entries are complete. Service Line Recap Table Each time you select save/view line, a summary table will display providing a summary for each line, showing  Line number  From and to Date  Procedure Code  Modifier  Charge  Units</p><p>Select the Edit button next to the line item if changes are needed to that service line.</p><p>Select Add below the service line summary table to add additional service line(s). Finish the claim Select one of the following screen action buttons to complete the claim:  Back to go back to the previous screen  Cancel to cancel the claim entry  Validate to determine if the claim has met the HIPAA-compliant and certain basic requirements at both the claim and line level information.  Submit to submit the claim for adjudication. The submit response will identify if the claim will be paid, denied or suspended for review at the claim level and the line level of the claim.</p><p>Use the Washington Publishing Company (WPC) health care codes lists to identify the claim status category and claim status codes displayed on the claim response <br> Review the Copy, Replace or Void User Guide for step-by-step instructions when completing these transactions.</p>