You use the Void or Replace Claims page to enter void or replacement claims into ND MMIS.
The Void or Replace Claims page contains the following panels:
| Field | Description |
|---|---|
| Doc # | The document number for the void or replacement transaction. |
| TCN |
The transaction control number (TCN) is a unique number assigned by the ND MMIS to each claim. |
| LOB |
The unique code that identifies the line of business, a high-level payer, or funding source such as Medicaid. |
| Location |
The location of a suspended claim. |
| Doc Type |
Indicates the type of document. Automatically completed. Example: Adjustment Claims |
| Status |
Indicates the status of the claim. Examples: Paid, To Be Paid, Denied, To Be Denied |
| Adjudication Date | The date the claim was last adjudicated. |
| Payment Type |
Indicates the payment type of the claim. Examples: For Payment, History Only |
| Pay Type |
Indicates the payment type of the claim. Examples: For Payment, History Only |
| Claim Type |
The type of claim. Examples: Inpatient, Outpatient, Financial Transaction |
|
Trans |
Indicates the transaction type of the claim. Examples: Original Claim, Void |
| Field | Description |
|---|---|
| Provider ID Type |
The type of provider ID. Examples: Medicaid, National Provider ID (NPI) |
| Billing Provider ID |
Unique identifier used for a provider of healthcare services. Format: Up to 15 alphanumeric characters |
| Member ID | A unique ID assigned to a member. |
| TCN to be Voided/Replaced | The TCN of the claim that is replaced or voided. |
| Reason |
Indicates the reason the claim is replaced or voided. |
| FCN |
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 |
Version as of 5/16/14.
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