Enter the date of payment or denial determination by the Medicare payer for this service line. C laim Adjustment Group Code. Enter the appropriate revenue code used to specify the service line item detail for a health care institution. Prior Authorization Number. Skilled Nurse Visit Telehomecare. Enter the Identifier of the insurance carrier. The last name of the subscriber. Taxonomy code for occupational therapy association. Other Payer – Use this accordion screen when reporting COB at the line level for either (Medicare Part B and/or TPL). Situational (Continued) Claim Information. Telephone number reported on the provider file. Other Payer Primary Identifier. When using a consolidated NPI, a table will display showing the locations and taxonomy code(s) information on file with MHCP.
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. Claim Action Button. Enter the total dollar amount the other payer paid for this service line. Skilled Nurse Visit (LPN). Enter the date associated with the Occurrence Code.
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. Other Providers- Select the Other Providers accordion panel when required to report other provider information on the service line, if different than what was reported at the claim level. Benefits Assignment. Speech Therapy Visit. Enter the code identifying the general category of the payment adjustment for this line. Home Care (Non-PCA) Services. Select the appropriate source code from the dropdown menu options, indicating the point of location/origin for this admission or visit. Enter the total dollar amount of the specific adjustment for the reason code entered on this service line. Taxonomy for occupational therapist. G0154 (through 12/31/15). Section Action Buttons.
Claim Filing Indicator. Payer Responsibility. If different than the provider reported on the claim information screen: Select one of the following screen action buttons: Note: You must always select Save/View Lines(s) after entering all lines to see the validate and submit action buttons. Enter the number of units identified as being paid from the other payer's EOB/EOMB. Home Care Servies Billing Codes. Taxonomy code for occupational therapy. Statement Date (To). Use only when submitting a claim with an attachment.
For header (claim) level adjustment, select the code identifying the general category of the payment adjustment for this line from the dropdown menu options. Service Line Paid Amount. Respiratory Therapy Visit Extended. Date of Service (From). Select one of the follwoing: Other Payer Na me. Regular Private Duty RN. Coordination of Benefits (COB). Select the radio button next to the location where the service(s) was provided. Enter a unique identifier assigned by you, to help identify the claim for this recipient. Select one of the following: Subscriber. Private Duty Nursing RN.
The following fields auto-populate based on the information entered in the Subscriber ID and Birth Date fields: Subscriber First Name. When reporting TPL adjustments at the claim (header level), enter the prior payer paid amount. Dates must be within the statement dates enterd in the Claim Information Screen. Enter the total adjusted dollar amount for this line. This is available on the recipient's eligibility response). Release of Information. The patient control number will be reported on your remittance advice. 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)]. Line Item Charge Amount. Adjudication - Payment Date. For Medicare this would be the Medicare health insurance claim number (HICN) or the Medicare beneficiary identifier (MBI) number. Enter the 8-digit MHCP ID for the subscriber (recipient) indicated on the MHCP member identification card. Enter the name of the TPL insurance payer.
Enter the policy holder's identification number as assigned by the payer. When appropriate, enter the service authorization (SA) number. Enter the service end date or last date of services that will be entered on this claim. The middle initial of the subscriber. Copy, Replace or Void the Claim. 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. Enter the date the item or service was provided, dispensed or delivered to the recipient. Physical Therapy Assistant Extended. Outpatient Adjudication Information (MOA). An authorization number is not required if there is no authorization in the system and the service is a skilled nurse visit.