Document Number. Identifies the claim as it is sequenced within a batch.

The transaction control number (TCN) is a unique number assigned by the ND MMIS to each claim.

Format: YYDDD M BBBB NNNNNN T, where:

YYDDD is the Julian date when the batch was created.

M is the media source, such as web, fax, paper, X12, agency interfaces.

BBBB is the batch number.

NNNNNN is the document number.

T is the transaction type.

The type of claim.

Examples: Inpatient, Outpatient, Financial Transaction

Indicates the status of the claim.

Examples: Paid, To Be Paid, Denied, To Be Denied

The unique code that identifies the line of business, a high-level payer, or funding source such as Medicaid.

Document Type.

Indicates the type of document.

Examples: Adjustment Claims, FFS Provider Payment, Encounter Claims

Indicates the payment type of the claim.

Examples: For Payment, History Only

Transaction Type.

Indicates the transaction type of the claim.

Examples: Original Claim, Void

The location of a suspended claim.

The TCN of the claim that is replaced.

Links to the Claims Inquiry page for the claim associated with the control number, if you have access.

Indicates the reason for replacing or voiding the claim.

The TCN of the replacement claim, used when adjusting a previously adjudicated claim.

Links to the Claims Inquiry page for the claim associated with the control number, if you have access.

Code for the location and the user name to which the claim is to suspend. Overrides the location\user name to which the claim would normally suspended.

A unique identifier assigned to a member.

Links to the Member Summary page for the member, if you have access.

The member ID submitted on the claim.

Suffix of the member's name.

Examples: Jr. ,Sr., III

The member's date of birth.

Format: MM/DD/YYYY

The gender of a person, usually male or female. In some cases, the gender may also be unknown.

Category of Eligibility Code-Description.

Indicates the basis for the member's eligibility for Medicaid. To be eligible for Medicaid benefits, a member must meet the eligibility requirements for one or more specifically defined coverage groups.

Available Eligibility Spans Fields

Category of Eligibility Code-Description.

Indicates the basis for the member's eligibility for Medicaid. To be eligible for Medicaid benefits, a member must meet the eligibility requirements for one or more specifically defined coverage groups.

Type of Bill field from the institutional claim form. Identifies the facility type, class of care provided, and sequence (or frequency) of the bill.

Date of Service Begin. The first date of service.

Format: MM/DD/YYYY

Date of Service End. The last date of service.

Format: MM/DD/YYYY.

The date the patient was admitted to the facility.

Indicates the source of admission.

Example: Transfer, Emergency

The date the patient was released from the facility.

Unique identifier for the benefit plan.

The ID of the map definition that defines the services that are covered or not covered by the benefit plan.

The budget and funding sources applicable to a claim.

Submitted Service Authorization. The service authorization ID submitted on the claim. Certain services, as defined by North Dakota, require authorization before the services are performed.

Submitted Service Authorization Required. Indicates whether service authorization is required.

Service Authorization Line Applied. Indicates to which line item the service authorization is applied.

Service Authorization ID. A unique ID assigned to the service authorization.

Links to the service authorization, if you have access.

Condition Codes Field

To add a condition codes, complete the fields, and then click (the plus icon). You can add a maximum of 24 condition codes. To edit, on the appropriate row, click (the pencil icon). To delete, click (the garbage can icon).

Occurrence Codes Fields

To add a occurrence codes, complete the fields, and then click (the plus icon). You can add a maximum of 24 occurrence codes. To edit, on the appropriate row, click (the pencil icon). To delete, click (the garbage can icon).

Date associated with the occurrence code.

Format: MM/DD/YYYY

Occurrence Spans Fields

To add a occurrence spans, complete the fields, and then click (the plus icon). You can add a maximum of 24 occurrence spans. To edit, on the appropriate row, click (the pencil icon). To delete, click (the garbage can icon).

The first date associated with the occurrence span code.

Format: MM/DD/YYYY

The last date associated with the occurrence span code.

Format: MM/DD/YYYY

Value Codes Fields

To add value codes, complete the fields, and then click (the plus icon). You can add a maximum of 24 value codes. To edit, on the appropriate row, click (the pencil icon). To delete, click (the garbage can icon).

The amount or unit associated with the value code.

If the amount includes cents, you must enter the decimal point.

Indicates the payer is the primary (A), secondary (B), or tertiary (C) payer.

The provider ID.

Links to the Provider Inquiry page for the provider, if you have access.

The amount paid prior.

The estimated amount remaining to be paid.

A unique ID for the insured.

To add TPL information, click Add TPL Information. You can add a maximum of 10 TPL payers. To edit, on the appropriate row, click (the pencil icon). To delete, in the table, click (the garbage can icon). These fields cannot be edited. If the information is incorrect, the claim must be reversed and a new claim submitted.

The other insured's date of birth.

Format: MM/DD/YYYY

TPL Amounts Fields

To add TPL Amounts, complete the fields, and the click (the plus icon). To edit, on the appropriate row, click (the pencil icon). To delete, click (the garbage can icon).

Line item number to which the TPL amounts information is related.

A zero (0) indicates the amount is claim level.

The amount billed to the TPL payer.

If the amount includes cents, you must enter the decimal point.

The TPL payer allowed amount. The amount the TPL payer will pay for the procedure or service.

If the amount includes cents, you must enter the decimal point.

TPL payer deductible amount. The deductible is the amount the insured must pay before the TPL payer will pay.

If the amount includes cents, you must enter the decimal point.

TPL payer coinsurance amount. Coinsurance is a percentage of the charge that the insured must pay.

If the amount includes cents, you must enter the decimal point.

The amount the TPL payer paid.

If the amount includes cents, you must enter the decimal point.

Present On Admission Code. Code that indicates if the diagnosis was present at the time the order for inpatient admittance occurred.

Examples: Y - Diagnosis was present, N - Diagnosis was not present, U - Documentation insufficient to determine if it was present, W - Clinically undetermined, 1 - Exempt from POA reporting or not used.

To add diagnosis codes, complete the fields, and then click (the plus icon). You can add a maximum of 38 codes. To edit, on the appropriate row, click (the pencil icon). To delete, click (the garbage can icon).

The diagnosis code.

A standard code used to describe the nature of a patient's illness or injury.

Links to the Rules Management Code Maintenance page for the diagnosis code, if you have access.

Present On Admission Code. Code that indicates if the diagnosis was present at the time the order for inpatient admittance occurred.

Examples: Y - Diagnosis was present, N - Diagnosis was not present, U - Documentation insufficient to determine if it was present, W - Clinically undetermined, 1 - Exempt from POA reporting or not used.

The Diagnostic Related Grouping (DRG) return code.

The principal procedure code.

Links to the Rules Management Code Maintenance page for the procedure code, if you have access.

To add surgical procedure codes, complete the fields, and then click (the plus icon). To edit, on the appropriate row, click (the pencil icon). To delete, click (the garbage can icon).

The surgical procedure code.

Links to the Rules Management Code Maintenance page for the procedure code, if you have access.

The date of the procedure.

Format: MM/DD/YYYY

To add a line item, in the Line Items table, complete the fields. If more lines are needed, click Add more lines. You can add a maximum of 999 line items. If you need more detail, edit the line after you add it.

Existing line items are displayed in the table. To edit, on the appropriate row, click (the pencil icon). The Edit Line (n) panel is expanded. The fields are described in the Edit Line (n) Fields table below.

To delete, on the appropriate row, click (the garbage can icon).

The number of the line item.

Indicates the status of the line item.

Examples: Pay, Suspend, Deny

Service Line Revenue Code.

Identifies specific accommodation or ancillary charges.

Procedure Code.

Indicates the procedure or service provided. Healthcare Common Procedure Coding System (HCPCS) or Current Dental Terminology (CDT) codes are typically used.

Links to the Rules Management Code Maintenance page for the procedure code, if you have access.

Date of Service Begin. The first date of service.

Format: MM/DD/YYYY

Service Units.

Indicates quantity or frequency of units associated with the procedure.

These fields are displayed when editing a line item. To edit, complete the fields, and then on the Edit Line (n) action bar, click Save.

When the line panel is expanded, to go to the next line item, click Next Line. To go back to the previous line item, click Previous Line.

These fields display only the exceptions for this line item.

The exception code related to this line item.

Exceptions are posted to a claim when edits, which are business rules defined by North Dakota to manage claim processing, evaluate the claim data, and find discrepancies. These may include the absence of required data or the presence of invalid data.

The description of the exception related to this line item.

The number of the line item.

Indicates the status of the line item.

Examples: Pay, Suspend, Deny

Identifies specific accommodation or ancillary charges.

Procedure Code.

Indicates the procedure or service provided. Healthcare Common Procedure Coding System (HCPCS) or Current Dental Terminology (CDT) codes are typically used.

A two-digit code attached to the procedure code to modify or clarify the description of the procedure. Up to four modifiers may be submitted on a claim for each procedure code, if applicable.

The rate associated with the service provided.

If the amount includes cents, you must enter the decimal point.

Date of Service Begin. The first date of service.

Format: MM/DD/YYYY

Service Units.

Indicates quantity or frequency of units associated with the procedure.

The total charge for the line item.

If the amount includes cents, you must enter the decimal point.

The non-covered charge amount.

If the amount includes cents, you must enter the decimal point.

The base rate is the basic payment rate used to calculate the reimbursement amount for the claim.

The base rate amount can only be entered if the base rate source is MM (Manually Priced)

If the amount includes cents, you must enter the decimal point.

Base Rate Source. Indicates the source that is used to determine the base rate amount.

The calculated allowed amount is the base rate minus any cutbacks or base rate changes identified during pricing.

The allowed charge amount for the line item.

The allowed units for the line item.

The amount paid by a third-party carrier.

The reimbursement amount is the allowed charge minus any base rate changes such as TPL, patient liability, or co-pay.

The reimbursement units.

The reimbursement status.

Examples: Billed, Allowed

Submitted Service Authorization Required. Indicates whether service authorization is required.

Service Authorization Line Applied. Indicates to which line item the service authorization is applied.

Indicates the basis for the member's eligibility for Medicaid. To be eligible for Medicaid benefits, a member must meet the eligibility requirements for one or more specifically defined coverage groups.

Unique identifier for the benefit plan.

The ID of the map definition that defines the services that are covered or not covered by the benefit plan.

The service area.

Examples: Radiology, Transportation

Category of Service.

The services for which enrolled providers are authorized to bill.

The budget and funding sources applicable to a claim.

Indicates whether the line item is adjudicated as a professional, technical or other type of service component.

The Clinical Laboratory Improvement Amendments (CLIA) certification number of the lab that is associated with this line item. CLIA is a Centers for Medicare and Medicaid Services (CMS) program that regulates all non-research laboratory testing performed on humans.

Submitted Provider Fields

To add submitted provider information for the line, in the Submitted Provider table, complete the fields, and then click (the plus icon).

To edit, on the appropriate row, click (the pencil icon). To delete, click (the garbage can icon).

The line item number associated with the submitted provider.

The role of the provider.

Examples: Billing, Rendering

The type of provider ID.

Examples: Medicaid, National Provider ID (NPI)

Unique identifier used for a provider of healthcare services.

Format: Up to 15 alphanumeric characters

Links to the Provider Inquiry page for the provider, if you have access.

Unique code that indicates the type of provider ID entered.

Examples: DEA, NPI, SSN/EIN

The provider's certified medical specialty. The provider specialty is based on the Level Ill Area of Specialization of the Taxonomy Code Set.

Examples: Allergy, Blood Banking, Dentistry, Dermatology, Podiatry

CMS defines the Taxonomy Codes as an administrative code set for identifying the provider type and the area of specialization for all health care providers. The code set is used in X12-278 Referral Certification and Authorization and the X12 837 Claim transactions. It is maintained by the National Uniform Claim Committee (NUCC).

Base Rate Changes Fields

Base rate changes are changes to the allowed charge. These occur in pricing and final adjudication. Examples are service authorization cutbacks, spenddown, and TPL.

The description of the base rate change.

These fields only display for a line on a Medicare crossover claim.

Medicare Allowed Amount. The amount Medicare will pay for the procedure or service.

If the amount includes cents, you must enter the decimal point.

Medicare Deductible Amount. The amount the insured must pay before Medicare will pay.

If the amount includes cents, you must enter the decimal point.

Medicare Coinsurance Amount. Coinsurance is a percentage of the charge that the insured must pay.

If the amount includes cents, you must enter the decimal point.

The amount Medicare paid.

If the amount includes cents, you must enter the decimal point.

Attachments Fields

To add attachment information for the line, in the Attachments table, complete the fields, and then click (the plus icon).

To edit, on the appropriate row, click (the pencil icon). To delete, click (the garbage can icon).

Note: If you add or edit this information, both fields are required.

Indicates the type of attachment.

Additional Remarks Fields

To add additional remarks information for the line, in the Additional Remarks table, complete the fields, and then click (the plus icon).

To edit, on the appropriate row, click (the pencil icon). To delete, click (the garbage can icon).

Note: If you add or edit this information, both fields are required.

Code for notes regarding a claim adjustment.

Links to the Rules Management Text Management page for the remark code, if you have access.

Adjustment Reason. Code for the reason for the adjustment.

Links to the Rules Management Text Management page for the adjustment reason code, if you have access.

Manual EOBs Field

To add manual EOB information for the line, in the Manual EOBs table, complete the field, and then click (the plus icon).

To edit, on the appropriate row, click (the pencil icon). To delete, click (the garbage can icon).

Explanation of Benefits (EOB) Code. A code that is associated with a message to be printed on the EOB. Enter a code to prompt ND MMIS to print the message associated with the code on the EOB for the claim.

Links to the Rules Management Text Management page for the EOB code, if you have access.

Drug Identification Fields

To add drug identification information for the line, click Add Drug Identification. To edit, in the table, click the appropriate row.

The drug unit price.

If the amount includes cents, you must enter the decimal point.

Indicates the physician signed the form and the date signed.

Format: MM/DD/YYYY

The total amount billed for services.

If the amount includes cents, you must enter the decimal point.

The total reimbursement amount for this claim. Calculated by the system as the total allowed charges plus/minus all base rate changes.

The financial control number (FCN) assigned to the financial document. The FCN consists of the date it was created, the media source (how it was received), and a document number.

Format: YYYYMMDDMNNNNN

A unique identifier assigned to the referral request by ND MMIS.

Indicates to whom payment is made.

Examples: Provider, Member

Identifier for the payee.

Medicare Fields

These fields are completed only for a Medicare crossover claim.

Medicare Allowed Amount. The amount Medicare will pay for the procedure or service.

If the amount includes cents, you must enter the decimal point.

Medicare Deductible Amount. The amount the insured must pay before Medicare will pay.

If the amount includes cents, you must enter the decimal point.

Medicare Coinsurance Amount. Coinsurance is a percentage of the charge that the insured must pay.

If the amount includes cents, you must enter the decimal point.

The amount Medicare paid.

If the amount includes cents, you must enter the decimal point.

Medicare Insurance Carrier. The ID for the private company that contracts to pay Medicare claims.

Base Rate Changes Fields

Base rate changes are changes to the allowed charge. These occur in pricing and final adjudication. Examples are service authorization cutbacks, spenddown, and TPL.

The amount of the base rate change.

The identifier of the rate used for the base rate change.

Submitted Providers Fields

To add submitted provider information, in the Submitted Providers table, complete the fields. If more lines are needed, click Add more lines. You can add a maximum of 8 providers. To delete, click (the garbage can icon). These fields cannot be edited. If the information is incorrect, the claim must be reversed and a new claim submitted.

The role of the provider.

Examples: Billing, Rendering

The type of provider ID.

Examples: Medicaid, National Provider ID (NPI)

Unique identifier used for a provider of healthcare services.

Format: Up to 15 alphanumeric characters

Links to the Provider Inquiry page for the provider, if you have access.

Unique code that indicates the type of provider ID entered.

Examples: DEA, NPI, SSN/EIN

The provider's certified medical specialty. The provider specialty is based on the Level Ill Area of Specialization of the Taxonomy Code Set.

Examples: Allergy, Blood Banking, Dentistry, Dermatology, Podiatry

CMS defines the Taxonomy Codes as an administrative code set for identifying the provider type and the area of specialization for all health care providers. The code set is used in X12-278 Referral Certification and Authorization and the X12 837 Claim transactions. It is maintained by the National Uniform Claim Committee (NUCC).

The Diagnosis Related Group (DRG) code.

The inpatient percentage.

The base rate is the basic payment rate used to calculate the reimbursement amount for the claim.

The base rate amount can only be entered if the base rate source is MM (Manually Priced).

If the amount includes cents, you must enter the decimal point.

Indicates the source that is used to determine the base rate amount.

The calculated allowed amount is the base rate minus any cutbacks or base rate changes identified during pricing.

The reimbursement amount is the allowed charge minus any base rate changes such as TPL, patient liability, or co-pay.

The reimbursement status.

Examples: Billed, Allowed

Base Rate Changes Fields

Base rate changes are changes to the allowed charge. These occur in pricing and final adjudication. Examples are service authorization cutbacks, spenddown, and TPL.

The amount of the base rate change.

The transaction control number (TCN) of the claim that replaces or voids a previously submitted claim.

Links to the Claims Inquiry page for the claim associated with the control number, if you have access.

The transaction control number (TCN) in history.

Links to the Claims Inquiry page for the claim associated with the control number, if you have access.

The type of claim.

Examples: Inpatient, Outpatient, Financial Transaction

To add an attachment indicator, complete the fields, and then click (the plus icon). You can add a maximum of 12 attachment indicators. To edit, on the appropriate row, click (the pencil icon). To delete, click (the garbage can icon).

Note: If you add this information, both fields are required.

To add override exceptions, complete the fields, and then click (the plus icon). You can add a maximum of 20 override exceptions per claim. To edit, on the appropriate row, click (the pencil icon). To delete, click (the garbage can icon).

Note: If you add this information, both fields are required.

Override exception code. Indicates an exception code that is overridden during claims processing.

To add additional remarks information for the line, complete the fields, and then click (the plus icon). You can add a maximum of 10 additional remarks codes. To edit, on the appropriate row, click (the pencil icon). To delete, click (the garbage can icon).

Note: If you add this information, both fields are required.

Code for notes regarding a claim adjustment.

Links to the Rules Management Text Management page for the remark code, if you have access.

To add manual EOB codes for the line, complete the fields, and then click (the plus icon). You can add a maximum of 10 manual EOB codes. To edit, on the appropriate row, click (the pencil icon). To delete, click (the garbage can icon).