MHP Professional Claims Submission and Claims Status User Guide by 7zQ3v9s

VIEWS: 13 PAGES: 35

									Medicaid Management Information Systems
 Maine Integrated Health Management Solution
HealthPAS Online: Professional Claim Submission
         and Claim Status User Guide

                                  Date of Publication: 11/04/2010
                                  Document Number: UM00039
                                  Version: 1.0
Revision History
Version   Date       Author          Action/Summary of Changes         Status

0.1       03/29/2010 K. Weaver /     Created original / Quality        Draft
                     Maria Smith     Assurance

0.2       09/02/2010 R.J. Roy /      Updated based on system           Draft
                     Karleen         design and functionality;
                     Goldhammer      incorporated Molina name and
                                     logo.

0.3       09/07/2010 Karleen         Published draft interim version   Draft
                     Goldhammer      to make available to providers

0.4       09/08/2010 K. Goldhammer Make final changes from             Draft
                                   system validation as well as
          09/21/2010
                                   from State comments

0.5       09/23/2010 R.J. Roy        Prep for final State review.      Draft

1.0       11/04/2010 Maria Smith     Finalized after receiving         Final
                                     approval from the State on
                                     10/20/2010
Usage Information
Documents published herein are furnished “As Is.” There are no expressed or implied warranties. The
content of this document herein is subject to change without notice.
HIPAA Notice
This Maine HealthPAS Online portal is for the use of authorized users only. Users of the Maine
HealthPAS Online portal may have access to protected and personally identifiable health data. As such,
the Maine HealthPAS Online portal and its data are subject to the Privacy and security Regulations within
the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 (HIPAA).
By accessing the Maine HealthPAS Online portal, all users agree to protect the privacy and security of the
data contained within as required by law. Access to information on this site is only allowed for necessary
business reasons, and is restricted to those persons with a valid user name and password.
                                   Maine Integrated Health Management Solution
                    HealthPAS Online: Professional Claim Submission and Claim Status User Guide


Table of Contents
1. Introduction ............................................................................................................................................ 1
2. Information You Will Need.................................................................................................................... 1
3. System Requirements ............................................................................................................................. 1
4. Navigation Features ................................................................................................................................ 1
   4.1 Breadcrumbs ................................................................................................................................. 1
      4.2      Use of the Navigation Features..................................................................................................... 2
5. Form Entry: Claim Submission ............................................................................................................. 3
   5.1 Submit Claim – Find Member ...................................................................................................... 4
      5.2      Claim Submission – Professional Claim ...................................................................................... 5
               CPT Search Function .................................................................................................................. 11
      5.3      The Claim Wizard Confirmation Screen .................................................................................... 14
               5.3.1       Claim View .................................................................................................................... 14
               5.3.2       Adjudicate Claim ........................................................................................................... 16
               5.3.3       Edit Claim ...................................................................................................................... 17
               5.3.4       Upload Attachments ...................................................................................................... 18
6. Claim Status ......................................................................................................................................... 19
        6.1.1 View a Claim ................................................................................................................. 21
               6.1.2       Search Claim.................................................................................................................. 21
               6.1.3       Edit Claim ...................................................................................................................... 22
               6.1.4       Adjudicate Claim ........................................................................................................... 22
               6.1.5       Reverse Claim................................................................................................................ 22
Appendix A. Place of Service Code List ................................................................................................... 26
Appendix B. Claim Cover Sheet ............................................................................................................... 28
Appendix C. Resolutions for Claim Edits found in Adjudication ............................................................. 29


List of Figures
Figure 4-1: Breadcrumbs .............................................................................................................................. 1
Figure 4-2: Banner ........................................................................................................................................ 2
Figure 4-3: Standard Buttons ........................................................................................................................ 2
Figure 4-4: Left Navigation Menu ................................................................................................................ 3
Figure 5-1: Claim Submission ..................................................................................................................... 3
Figure 5-2: Find Member ............................................................................................................................. 4
Figure 5-3: Select Billing Provider .............................................................................................................. 4
Figure 5-4: Member Search ......................................................................................................................... 5

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                   HealthPAS Online: Professional Claim Submission and Claim Status User Guide

Figure 5-5: Member Search Results............................................................................................................. 5
Figure 5-6: Professional Claim Information ................................................................................................ 6
Figure 5-7: Professional Claim Service Line ............................................................................................... 6
Figure 5-8: Claim Information ..................................................................................................................... 7
Figure 5-9: Referring Provider..................................................................................................................... 7
Figure 5-10: Provider Search ....................................................................................................................... 8
Figure 5-11: Professional Diagnosis Section ............................................................................................... 8
Figure 5-12: Diagnosis Code Search Icon ................................................................................................... 8
Figure 5-13: Diagnosis Code Search ........................................................................................................... 9
Figure 5-14: Diagnosis Code Search Results ............................................................................................... 9
Figure 5-15: Professional Services Section ................................................................................................. 9
Figure 5-16: Claim Service Section ............................................................................................................ 10
Figure 5-17: CPT Search Function Icon .................................................................................................... 11
Figure 5-18: CPT Search Function ............................................................................................................ 11
Figure 5-19: CPT Search Function Results................................................................................................ 12
Figure 5-20: COB Information .................................................................................................................. 12
Figure 5-21: Oxygen Therapy .................................................................................................................... 13
Figure 5-22: Professional Additional Information Section ........................................................................ 13
Figure 5-23: Claim Confirmation Screen................................................................................................... 14
Figure 5-24: Claim View ........................................................................................................................... 15
Figure 5-25: Service Line Details .............................................................................................................. 16
Figure 5-26: Claim Standard Buttons ........................................................................................................ 16
Figure 5-27: Adjudicate Claim .................................................................................................................. 17
Figure 5-28: Claim Edit .............................................................................................................................. 17
Figure 5-29: Edit Claim ............................................................................................................................. 18
Figure 5-30: Claim Back, Save, Adjudicate .............................................................................................. 18
Figure 5-31: Upload Attachments .............................................................................................................. 18
Figure 6-1: Form entry ............................................................................................................................... 19
Figure 6-2: Select Provider ........................................................................................................................ 19
Figure 6-3: Claim Status Screen ................................................................................................................ 20
Figure 6-4: Claim Statuses .......................................................................................................................... 20
Figure 6-5: Claim Submission Standard Buttons ........................................................................................ 21
Figure 6-6: Claim Search ........................................................................................................................... 21
Figure 6-7: Edit Claim ............................................................................................................................... 22
Figure 6-8: Claim Edits Options ................................................................................................................ 22

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                   HealthPAS Online: Professional Claim Submission and Claim Status User Guide

Figure 6-9: Reverse a Claim ...................................................................................................................... 23
Figure 6-10: Claim Status-Reverse Claim ................................................................................................. 23
Figure 6-11: Verification question ............................................................................................................. 24
Figure 6-12: Successfully Reversed Claim Screen .................................................................................... 25




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1. Introduction
Through Health PAS OnLine - MyHealthPAS, providers have the ability to enter claims to MaineCare via
the internet. MaineCare providers can quickly and easily enter professional, institutional and dental
claims via MyHealthPAS.

2. Information You Will Need
Before you begin the claims submission process, you should gather all of the information you will need to
enter during each step. When completing and submitting a claim via the MyHealthPAS Provider Portal, it
will be useful to have the following information, forms, and other documents on hand:
       Before starting a claim verify that the recipient is eligible on the date of service for the services
        rendered.
       Medicaid is always the payer of last resort. If the member has Medicare or third party insurance,
        bill them first before billing Medicaid.
       Complete member, provider and service information associated with the claim.

3. System Requirements
To successfully use all features of Health PAS OnLine portal, ensure that your computer system meets the
following minimum requirements:
       Reliable online connection
       Web browser - The latest version of Microsoft Internet Explorer is recommended. As versions of
        Internet Explorer become available it is recommended that these versions are used.
       Adobe Acrobat Reader

4. Navigation Features
4.1     Breadcrumbs
When a link is clicked, the appropriate Web page is displayed to the right of the navigation bar.
Breadcrumbs shown in Figure 4-1 below indicate the current position within the site. Breadcrumbs are a
visual representation of the links followed to reach this page, displayed next to the You Are Here label.




                                                             Breadcrumbs




Figure 4-1: Breadcrumbs


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             HealthPAS Online: Professional Claim Submission and Claim Status User Guide

4.2     Use of the Navigation Features
Every screen of MyHealthPAS Online has a set of standard navigation features, including:
       The left navigation menu. Shown on the left side of each page, the left menu provides a list of
        all functions available to the user logged into the Provider portal.
       The HealthPAS Online/MaineCare Services banners. Found at the top of portal as seen in
        Figure 4-2 below, there are various links or information available to you including:
        o   Trading Partner ID: each trading partner has been assigned an identification number that
            must be included on any attachments submitted to MaineCare electronically through the
            portal. Go to this banner to reference this ID.
        o   Welcome User: indicates the user that is logged on to the portal.
        o   Online Help: provides help information for the standard website functions.
        o   Page Help: provides help information for the current webpage.
        o   Sign Out: this link will log the user out of the secure portal sessions. Public areas of the
            portal are still available.




Figure 4-2: Banner
       The standard buttons. There are standard buttons found below the fields of each provider
        functional screen that enable you to perform certain actions. The available actions depend on the
        purpose of the screen. Some of the most common buttons found associated with submission of a
        Prior Authorization include the Submit, Reset, Cancel and Continue, and Attach which allow you
        to submit information entered for a specific form, clear data on a page, Cancel a form and return
        to the Trading Partner page and Continue to navigate to the next screen. See Figure 4-3 below to
        view an example of the standard buttons.




Figure 4-3: Standard Buttons



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          Trading Partner Navigation. On the MyHealthPAS Online Trading Partner page, you have
           access to a series of links via different categories as shown in Figure 4-4 below.




Provider
Portal
Links




 Figure 4-4: Left Navigation Menu

 5. Form Entry: Claim Submission
 To begin a claim submission, click the Claim Submission link located below the Form Entry category on
 the portal links. After you click the link, the Submit Prior Authorization – Member Search screen is
 displayed.




 Figure 5-1: Claim Submission



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A Submit Claim button is also available directly from the Eligibility Verification screen, Patient Roster
screen and Primary Care Roster screen.
The Submit Claim function has a wizard that steps through the process. The wizard starts with Find
Member.

5.1     Submit Claim – Find Member




Figure 5-2: Find Member
Using the Find Member screen depicted above and the step-by-step instructions below to execute a
member search associated with a claim submission.

Step 1: Select the Billing Provider if more than one associated with Trading Partner ID, by clicking the
drop-down menu to select from a pre-determined list.
                                                                              Drop
                                                                              down


Figure 5-3: Select Billing Provider
Step 2: Select the claim type by clicking the circle to the left of the word Professional to designate the
appropriate claim submission form.

Step 3: Enter member search criteria. Two of the four search criteria values must be entered for a
successful member search: Member ID, Name (Last and First), Date of Birth, or Social Security
Number. The following guidelines provide additional instruction on entering the search criteria values for
the member search:
     The Last and First Name count as one search criteria value.
     In the name fields, the Last Name corresponds to the first field and the First Name corresponds to
        the second field as seen in Figure 5-4 below. Names must match exactly for the first five (5)
        letters of the last name and the first three (3) letters of the first name.
     The Date of Birth must be entered as mm/dd/ccyy and must match exactly. An example:
        February 14th 2008 would be 02/14/2008.


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        The Social Security Number must be entered with the dashes and must match exactly. For
         example: 111-22-3333.

                                                         Last
                                                         Name                                    First
  Enter
  any                                                                                            Name
  two
  rows



Figure 5-4: Member Search


Step 4: Select                  button to view the list of members that meet the search criteria values
entered. The                   button can also be selected to reset all of the member search criteria.

Step 5: Review the search results. The search results are returned under the Find Member Results tab as
depicted in Figure 5-5 below. The results include a list of all the members that meet the search criteria
including their Name, Gender, Date of Birth, Member ID, Plan and Plan Type.
Step 6: If there are multiple members returned, select the correct member by clicking the radio button in
front of the member’s name as indicated in Figure 5-5 below.

Step 7A: Once the correct member is selected, click the                       button.
OR

Step 7B: If the member isn’t returned in the search, click                      to reset and clear all the
values entered in the find member search.




                                  Click the
                                  radio button


Figure 5-5: Member Search Results

5.2      Claim Submission – Professional Claim
Upon the selection of the member for a profession claims submission, the Claim Wizard – Professional
Claim screen (CMS1500) will populate as seen in Figure 5-6 below. There are four sections associated
with this screen including Claim Information, Diagnosis, Services, and Additional Information.




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Figure 5-6: Professional Claim Information




Figure 5-7: Professional Claim Service Line


Use following steps to complete this screen:
Step 1: Complete the Claim Information Section
Use the bulleted tips below to complete this section
       The required values in this section include Rendering Provider, Patient Account # and Service
        Location when a Provider has enrolled with more than one.



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       Complete the Rendering Provider field by clicking on the drop-down arrow and making a
        selection from a pre-determined list. If there is more than one service location associated with the
        specified rendering provider, use the next drop down selection to identify the specific Service
        Location where the service took place.
       The Patient Account # field is assigned by the provider and may be alpha-numeric. It is
        information returned to the provider on any Remittance Advice.
       The Medical Record # is assigned by the provider and may be alpha-numeric.
       If the service requires prior authorization and an authorization was obtained for the service, enter
        the prior authorization number provided by MaineCare in the Prior Auth field.




                                                   Drop
                                                   down

Figure 5-8: Claim Information
       To select a Referring Provider click the magnifying icon to search for a provider or manually
        enter a provider's name. Clicking       icon opens a new window as seen in Figure 5-9 below.




Figure 5-9: Referring Provider

        Enter as much information in the boxes as possible and click the              button when finished.
        Clicking           at any time resets all the values.
           Dropdown boxes are used to select values for Specialty, Provider Type and State.
                o   Some lists may have a blank line to allow searching all data.
           All other fields must match exactly for this search function.



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        Once              is selected the results will be listed at the bottom of the Find a Provider page.
        The results show the provider’s name, address, specialty, accepting new patients, and gender.
        Click the Provider/Affiliation Name to select the provider and return to the Professional Claim
        Information page; Single-click to view the Provider/Affiliation.




Figure 5-10: Provider Search


Step 2: Complete the Diagnosis Section
Complete the Diagnosis section as depicted below.




Figure 5-11: Professional Diagnosis Section
The diagnosis section is used to enter the diagnoses associated with the services provided to the member.
Use the bulleted tips below to guide you through the completion of this section.
       To add a new line, tab at the end of the last line and a new line will appear. The Line # will
        increase as each line is added. Up to 12 diagnosis codes may be submitted. The Description and
        Type will appear once the code is entered by tabbing through to the next field. The first line
        entered will be the primary diagnosis and all additional lines will be considered secondary.
       There are four fields in the Diagnosis section: Line #, Code, Description, and Type. The only
        editable field is Code.


                         Click to search for Code




Figure 5-12: Diagnosis Code Search Icon

       To search for a Diagnosis Code, click       icon next to the Line # and a new search window will
        open as depicted below.

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                                                   Enter
                                                   description



Figure 5-13: Diagnosis Code Search



        Enter any part of the description of the code. Then click          to retrieve a list of results.
        The           button will clear the description field. The system will match your entry anywhere
        in the field.
        Figure 5-14 below shows how the results will be returned including the diagnosis Code IDs and
        Description. Click any Code ID link to populate the Code ID to the Diagnosis section.



Click
Code
ID



Figure 5-14: Diagnosis Code Search Results


Step 3: Complete the Services Section
Complete the Services Section as depicted below.




Figure 5-15: Professional Services Section
This section of the claims screen is used to enter the Services rendered to the member that will be
included in the claim submission. The fields and links associated with this section are summarized in the
table below:




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Figure 5-16: Claim Service Section

Field Name                  Field Description

                            Select the Enter NDC Codes check box to enter a service line for physician
                            administered drugs. This action will make the following fields on the service
                            line editable: NDC, Units of Measure, Quantity/Units and Price. When
                            applicable, NDC is the only required item. If other fields are entered they will
                            be edited when the claim is adjudicated.

                            Select this icon to delete a service line.


Line #                      This is a system generated field used to number each service line that is
                            added by a user. To add a service line, tab to the end of a line and a new line
                            will appear.

DOS From/DOS To             These are required fields used to enter the beginning/ending date for which
                            the service was provided. Dates must be entered as MM/DD/CCYY. An
                            example: February 14th 2008 would be 02/14/2008.

Place of Service                    This field is required
                                    Enter the appropriate two-digit place of service code(s).
                                    Identify the location, using a place of service code, for each item
                                     used or service performed.
                                    Full Service Transportation/Wheelchair Van Providers: Select code
                                     41, 42, or 99, as appropriate.
                                    Durable Medical Equipment and Supplies Providers: Use the Place of
                                     Service code where the member resides
                                    See Appendix A: Place of Service Code List for a full code list.


Code                        This field represents the CPT code for the service. Enter the code in this field
                            if known or use the      link to perform a code search.

Modifiers                   CPT code modifiers provide additional details regarding various services.

Related Diagnosis           The Related Diagnosis field corresponds with the Line # that supports the
                            service line in the Diagnosis section above.

Charge                      Total dollar amount charged for the services. The system will add the dollar
                            sign ($) and will assume two decimal places unless specifically entered by the
                            user.

Units                       Enter the number of times the service for which you are billing was
                            performed.

Early Periodic Screening    If the service you are billing for is associated with EPSDT enter Y in this field.
Diagnosis Treatment         This field defaults to N.
(EPSDT)

Authorization #             If applicable, enter the Authorization number that is applicable to that service
                            line.




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Field Name                 Field Description

Rendering Provider         This field captures the provider that rendered the service for which the claim
                           is being submitted. Select the appropriate provider by clicking on the drop-
                           down arrow and selecting the appropriate provider.

National Drug Code (NDC) The National Drug Code (NDC) is the number which identifies a drug. The
                         NDC number consists of 11 digits.
Units of Measure           Enter the NDC unit of measurement The unit of measurement codes are:
                                F2 -International Unit
                                GR-Gram
                                ML-Milliliter
                                UN- Unit
Quantity/Units             NDC units are based upon the numeric quantity administered to the patient
                           and the unit of measurement. Enter the actual metric decimal quantity
                           administered and the units of measurement.
Price                      Enter the price

CPT Code Description       Description of the service code entered for the specified service line.

Totals                     Total dollar amount charged for the claim. Total charges are the sum of all
                           charges and are derived from the detail line items which is system generated.



Note: When a service code is entered the description will appear below in the Current Procedural
Terminology CPT Code Description box. The Total price and total Units will be totaled in the grey area
next to the CPT Code Description field.

CPT Search Function

                             Click to search for Code




Figure 5-17: CPT Search Function Icon

To search for a Service Code, click    next to the Line # as indicated in Figure 5-17 above. A new
search window will open as depicted below.


                                                             Enter description




Figure 5-18: CPT Search Function




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Enter any part of the description of the code, and then click          to get a list of results.
will clear the description field. The system will match your entry anywhere in the field.
The results consist of a list of Service ID Codes and Descriptions. Click any Service ID Code link to
populate the Service Code area of the claim line with the selected Service Code.


                     Click
                     Service
                     Code


Figure 5-19: CPT Search Function Results


Step 4: Enter COB Information
More information for the COB may be added by selecting the link below.




The COB information is entered by Claim or by Service Line for any external totals to be applied as
COB.



                                           Select One




Figure 5-20: COB Information


Step 5: Complete Oxygen Therapy Information
To enter Oxygen Service Information, click the                                  link and then enter the
information in the fields provided. Click                  to add the information to the table. Edit the
value by selecting the Edit icon; modify the line as desired and click the Save button. Delete the value by
clicking the Delete button.



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                                                                        Select




Figure 5-21: Oxygen Therapy
Step 6: Complete the Additional Information Section
Enter Additional Information, if applicable to the claim submission. The Additional Information section
is used to enter information related to any third party liability associated with the claim.
If applicable, select the check box next to the correct type of accident associated with the claim:
Employment, Auto Accident or Other Accident. If a check box is selected enter the 2 letter
abbreviation of the state in which the accident took place.



                                                              Enter information, if applicable



Figure 5-22: Professional Additional Information Section
Step 7: Submit the Claim

When all the claim information has been entered, click                       to submit the professional
claim. Any errors will appear at the top of the page in a red font and must be corrected before the claim
can be submitted. Upon the successful submission of the claim, a Claim Wizard Confirmation screen will
populate.



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5.3     The Claim Wizard Confirmation Screen
Upon the successful submission of the claim, a Claim Wizard Confirmation screen will populate as seen
in Figure 5-23 below.




Figure 5-23: Claim Confirmation Screen


The Claim ID is populated on the confirmation screen. The Claim Wizard Confirmation screen also
presents the following options:
Claim View: Used to view information that was entered into the claim (claim summary)
Adjudicate Claim: separates the claim in to what the insurance will pay and what the member will pay.
Edit Claim: allows for editing the Claim.
Upload Attachment: this option is used to attach additional information required to support claim
submission.
New Claim: option used to create a new claim.

5.3.1     Claim View
Clicking the Claim # hyperlink reveals the original claim. Figure 5-24 below is an example of a claim
view:




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                                                                       Details link




Figure 5-24: Claim View




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Details of the service line may be viewed individually by clicking on Details at the end of the service line
as seen in Figure 5-24 above. An example of the service line detail is depicted below.




Figure 5-25: Service Line Details
After viewing the claim, the claim may be adjudicated or reversed by using the buttons at the bottom of
the screen as show in Figure 5-26 below.



Figure 5-26: Claim Standard Buttons

5.3.2     Adjudicate Claim
The Adjudicate Claim button on the confirmation page initiates the claim adjudication process and sends
the claim through predefined edits for real time claims processing. Based on adjudication, the user can
see if a claim has been successfully processed. If the claim fails to adjudicate, the user will be able to see
an error message, “There are outstanding edits,” and view what edits caused the claim to fail adjudication
under Outstanding Edits. (See Appendix C for a list of resolutions for the claim edits.) The Edit Claim
button is selected to modify the claim in order to fix any errors and attempt to adjudicate the claim again.
A claim on the portal can be adjudicated up to 10 times. "Number of online adjudication attempts: 3"
found at the top of the screen keeps a running count.




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                                     Warning




                                 Errors
                                                                          Click to edit




Figure 5-27: Adjudicate Claim

5.3.3        Edit Claim
After selecting the claim by clicking the circle to the left of claim number, scroll vertically to the bottom
of the page and select edit. Clicking the Edit Claim button opens the claim and offers the option to edit
the claim and add or delete parts of the claims as needed.
Claims may have edits posted that are visible at the top of the claim and indicate if the edit is a warning,
denial or pend. A pend edit is shown in the status field of Figure 5-28.




Figure 5-28: Claim Edit
Clicking the Edit Claim button opens the claim that was just submitted and offers the option to edit the
claim and add or delete parts of the claims as needed.
In the example below, from a Professional claim, a new line can be added in line 3 if need be. To add
more lines tab through the last line. In order to delete a line, select the option button in front of the line,
then click                .




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                                                              Add
                    Delete


Figure 5-29: Edit Claim


Upon completion, three buttons offer further options: Back, Save, Adjudicate. Click Back to return to
the Claim Edit screen. Click Save to save the progress. Click Adjudicate to adjudicate the edited claim.




Figure 5-30: Claim Back, Save, Adjudicate

5.3.4     Upload Attachments
Clicking the Upload Attachments button opens the following screen in a new window.




                                                   Drop
                                                   Down


                                                                   Browse local
                                                                   computer




Figure 5-31: Upload Attachments
Claim information is pre-populated on the top of the page. To add an attachment, follow the steps below:
Step 1: Click the drop down arrow to select the type of attachment that will be added (Valid formats for
attachments include: .pdf, .gif, .tiff, .jpeg, MS Word (.doc), MS Excel (.xls)).
Step 2: Select the Browse button to locate the file on the local computer.
Step 3: Click the                 button when the file to upload is listed in the Browse field.




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NOTE: If you are unable to upload electronic copies of attachments, use the Claim Supporting
Documents Cover Sheet from the Provider Page>Provider Documents>Forms (see also Appendix B)
along with the Claim number provided to you on the confirmation screen to be sent along with all
mailed documents. If the appropriate attachment is not present when the claim is reviewed, the claim will
deny. Mail to:
        Claims Unit- Attachments
        Office of MaineCare Services
        11 State House Station
        Augusta ME 04333

6. Claim Status
To check the status of a claim, follow the steps below:
Select the Claim Status link under Form Entry to access the screen. Click the Select Provider button to
bring up a list of the most current claims submitted for that user/provider.




Figure 6-1: Form entry



                                                Use Drop
                                                down



Figure 6-2: Select Provider


The results of a Billing Provider are shown in the order of the newest to the oldest claims. All the headers
sort the rows by that field using the selected header as the key value. To view claims in greater detail
click the Claim # link.




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                                                                          Click to search
                   Select




                 Click to view claims


Figure 6-3: Claim Status Screen


Figure 6-4: Claim Statuses

Claim Statuses
Initial Claim Statuses

Open          The claim has been has been entered with the required fields for submission.

Adjudicated The claim has been adjudicated, but is not ready for payment.

Deny          The claim has either failed adjudication or has been pended for manual review and
              is not ready to be submitted for payment.

Pay           The claim has passed the adjudication process and is ready to be submitted for
              payment.

Pend          The claim has been set aside for review to determine if it should be paid or denied.

Rev           The claim has been processed and paid with an over or under payment error. A
              mirror image of the claim has been created to correct any payment errors.

Rev synch Claim is waiting for all parts of adjustment to be complete.

Awaiting Payment Claim Statuses

Wait deny     Awaiting the finalization of the claim denial for inclusion on the check and
              remittance advice.

Wait pay      Awaiting the finalization of the claim payment submitted to AdvantageME for
              inclusion on the check and remittance advice.

Wait rev      Awaiting the finalization of the claim reversal for inclusion on the check and
              remittance advice.

Finalized Claim Statuses




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Claim Statuses
Paid         The claim has been finalized and submitted for payment. Checks have been
             printed and the payment process is complete.

Denied       The claim has failed the adjudication process and has been denied.

Reversed     The claim has been finalized. Checks have been printed. The payment process is
             complete but errors have been identified and a mirror image of the claim has been
             created to correct the errors.

Void         Claim not valid.



Selected claims may be Edited, Adjudicated, Reversed, Printed or Added Attachments (see below).


Figure 6-5: Claim Submission Standard Buttons



6.1.1     View a Claim
To view a claim, see Section 5.3.1 above.

6.1.2     Search Claim
To search for a specific claim, click the   icon. Searches may be done by any of the fields below. Enter
as many fields as possible and click the Search button. The Dates of Service From and To must be less
than 90 days. The Reset button clears all the values. The Close button closes the search area.




                                                      Enter as
                                                      much
                                                      information
                                                      as possible




Figure 6-6: Claim Search




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6.1.3     Edit Claim
Claims listed as "Pay", "Pend" or "Deny" have not been finalized; claims listed as "Paid" or "Denied"
have been finalized (processed through the payment cycle). Any claims that have not been processed
through the payment cycle may be edited. Claims that have been finalized cannot be edited, but must be
reversed. Click the option button in front of the claim to select it for editing. For additional information
about editing a claim see Section 5.3.3.




                           Select
                           claim



                    Click
                    to view


Figure 6-7: Edit Claim


Upon completion, three buttons offer further options: Back, Save, Adjudicate. Click Back to return to
the screen before. Click Save to save the progress. Click Adjudicate to adjudicate the edited claim. The
claim must be saved first, before it can be adjudicated again.




Figure 6-8: Claim Edits Options

6.1.4     Adjudicate Claim
To adjudicate a claim, see Section 5.3.2 above.

6.1.5     Reverse Claim
Any finalized claim (a claim that has been processed through a payment cycle and has the denied or paid
status) may be reversed and replaced by selecting                                  on the claim status
page. Claims listed as "Pay" or "Deny" have not been finalized; claims listed as "Paid" or "Denied" have
been finalized. Claims may be found by searching for a claim by clicking         . The Adjustment process
consists of a Reverse and Replace with the claim data able to be pre-populated, changed and resubmitted
during the Replace. A Reversal reverses everything on the claim; the charged amount is negated, the
units/visits are reverted back to only one unit/visit, etc. Both the Reversed Claim and the Replaced Claim
will remain in the system. This process is for accounting purposes and will show on the next Remittance
Advice.




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                                                           Reverse
                                                           Claim




Figure 6-9: Reverse a Claim


The Provider can preserve the existing date by checking ‘use the data from this claim as basis for the new
claim. The new claim will have applicable data copied over to new claim.




                                                               To preserve
                                                               existing date




Figure 6-10: Claim Status-Reverse Claim

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Click OK when the verification question pops up.




Figure 6-11: Verification question


After the revisions are completed, the new claim can be submitted using updated data. A Reversed Claim
will have an R1 (or sequential number) at the end of the Claim number; a Replaced Claim will have an
A1 (or sequential number) at the end of the Claim number.
The new Replaced Claim will require a new Patient Account # since it is a new claim.
The Provider may also choose to simply reverse a claim entirely by selecting the “Reverse claim only
option. A warning message, shown in Figure 6-11 is presented as one more chance for the provider to
confirm the action. A Reversal reverses everything on the claim; the charged amount and the units/visits
are negated, etc. A Reversed Claim will have an R1 (or sequential number) at the end of the Claim




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Figure 6-12: Successfully Reversed Claim Screen




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Appendix A. Place of Service Code List
Code                          Descriptor

01                            Pharmacy

03                            School

04                            Homeless Shelter

05                            Indian Health Service Free-standing Facility

06                            Indian Health Service Provider-based Facility

07                            Tribal 638 Free-standing Facility

08                            Tribal 638 Provider Based Facility

11                            Office

12                            Home

13                            Assisted Living Facility

14                            Group Home

15                            Mobile Unit

20                            Urgent Care Facility

21                            Inpatient Hospital

22                            Outpatient Hospital
Note: Should be used when a
provider qualifies as a
“Provider Based” entity under
42CFR413.65.

23                            Emergency Room – Hospital

24                            Ambulatory Surgical Center

25                            Birthing Center

31                            Skilled Nursing Facility

32                            Nursing Facility

33                            Custodial Care Facility

34                            Hospice

41                            Ambulance – Land

42                            Ambulance – Air or Water


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Code                          Descriptor

49                            Independent Clinic

50                            Federally Qualified Health Center

51                            Inpatient Psychiatric Facility

52                            Psychiatric Facility – Partial Hospitalization

53                            Community Mental Health Center

54                            ICF/MR

55                            Residential Substance Abuse Treatment Facility

56                            Psychiatric Residential Treatment Facility

57                            Non-Resident Substance Abuse Treatment Facility

61                            Comprehensive Inpatient Rehabilitation Center

62                            Comprehensive Outpatient Rehabilitation Center

65                            End Stage Renal Disease Treatment Facility

71                            State or Local Public Health Clinic

72                            Rural Health Center

81                            Independent Laboratory

99                            Other




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Appendix B. Claim Cover Sheet




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Appendix C. Resolutions for Claim Edits found in
            Adjudication
Edit        DESCRIPTION                              Instructions
Number

107         Negative charge on claim line            Negative charges not allowed; please correct

204         Invalid accommodation days               Must ensure accommodation days billed match
                                                     date span

219         Provider overlap of global days period   Global days in effect for prior services billed

311         Claim Submission Window Exceeded [All Verify date entries are correct
            Claims, header date]

329         Invalid Patient status for bill type     Must bill valid CMS patient status code + bill
                                                     type combinations

360         DRG is NOT in the selected DRG Group     That DRG is not to be submitted on claim

515         Invalid HCPCS for Revenue Code           Must bill valid CMS HCPC + Revenue code
                                                     combinations

530         Insufficient units for date span         Check number units billed with dates billed

541         Claim Line Submission Window             Correct date entries
            Exceeded

542         Claim Line Submission Window Overlap     Correct date entries

543         Inpatient Claim Submission Window        Correct date entries
            Exceeded [header to date]

662         Contract for service location on claim   Validate the service location is correct with your
            was not found                            initial provider registration record

990         Missing Claim Information                Required entry missing




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