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Instructions for Completion of the Outpatient Services Medicare – Medicaid Crossover Invoice – HP-MC-003 HP Enterprise Services offers providers several options for electronic billing. Therefore, claims submitted on paper are paid once a month. The only claims exempt from this process are those which require attachments or manual pricing. To bill for Medicare – Medicaid crossover outpatient services, use the claim form HP-MC-003. The numbered items correspond to fields on the claim form. Each service should be billed separately, providing the appropriate information for each. Read and carefully adhere to the following instructions. Accuracy, completeness and clarity are important. Claims cannot be processed if applicable information is not supplied or is illegible. Paper claims should be typed whenever possible. Completed claim forms should be forwarded to the HP Enterprise Services Claims Department. View or print the HP Enterprise Services Claims Department contact information. NOTE: A provider rendering services without verifying eligibility for each date of service does so at the risk of not being reimbursed for the services. Field Name and Number Instructions for Completion Header 1 1. Medicaid Provider ID Enter your 9-digit Arkansas Medicaid billing provider ID number. 2. Beneficiary A. ID Enter the patient’s10-digit Medicaid ID number. B. First Name Enter the first initial of the patient’s first name. C. Last Name Enter the first two letters of the patient’s last name. 3. Medical Rec # Enter your office identifier. 4. Patient Status Enter the patient status. 5. Dates of Service A. Admission Enter the date the patient was admitted to the facility. B. From Enter the first date of service for the claim. C. Through Enter the last date of service for the claim. D. Days Covered Enter the number of covered days for the claim. 6. Diagnosis Enter the diagnosis code for the claim. 7. Type of Bill Enter the type of bill for the claim. Header 2 8. Medicare ICN Enter the Internal Control Number (ICN) from the Medicare Explanation of Benefits (EOB). 9. Medicare Paid Date Enter the date that is printed on the Medicare EOB. 10. Medicare Amounts A. Total Medicare Billed Enter the total billed amount for the entire claim from the Medicare EOB. B. Medicare Non-Covered Enter the Medicare Non-Covered amount for the entire claim from the Medicare EOB information. Field Name and Number Instructions for Completion C. Medicare Deductible Enter the deductible amount for the entire claim from the Medicare EOB. D. Medicare Blood Deductible Enter the blood deductible from the Medicare EOB, if applicable. E. Medicare Coinsurance Enter the coinsurance amount for the entire claim from the Medicare EOB. F. Other Insurance Amount Enter the amount paid by a third-party insurance company; if none, enter 0 (zero). This would be a company like Blue Cross, Health Advantage, etc. G. Net Billed Enter the total billed amount minus any other private insurance payment. This excludes any Medicare or replacement policy insurance. H. Medicare Paid Enter the Medicare Paid amount for the entire claim from the Medicare EOB.
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