(the plus sign) beside a panel to open the panel. Click 
(the minus sign) to close the panel. You use the Dental Claim Detail page of Claims Inquiry to view a claim in ND MMIS.
The Main tab contains the following panels:
You can open or close certain panels. Click (the plus sign) beside a panel to open the panel. Click (the minus sign) to close the panel.
| Field | Description |
|---|---|
| Doc # |
Document Number. Identifies the claim as it is sequenced within a batch. |
| TCN | The transaction control number (TCN) is a unique number assigned by the ND MMIS to each claim. |
| Claim Type |
The type of claim. Examples: Inpatient, Outpatient, Financial Transaction |
| Status |
Indicates the status of the claim. Examples: Paid, To Be Paid, Denied, To Be Denied |
| LOB |
The unique code that identifies the line of business, a high-level payer, or funding source such as Medicaid. |
| Doc Type |
Document Type. Indicates the type of document. Examples: Adjustment Claims, FFS Provider Payment, Encounter Claims |
|
Pay Type |
Indicates the payment type of the claim. Examples: For Payment, History Only |
| Trans Type |
Transaction Type. Indicates the transaction type of the claim. Examples: Original Claim, Void |
| Location |
The location of a suspended claim. |
| Adjud Date / Time | Adjudication Date / Time. The date and time the claim was last adjudicated. |
| Replaced TCN |
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. |
| Replacement Reason |
Indicates the reason for replacing or voiding the claim. |
| Replacement TCN |
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. |
| Submitted Void/Replace TCN | ??? |
|
External TCN |
A TCN assigned to the claim by a system other than the ND MMIS. |
| X12 Version Number | ??? |
| Fiscal Pend ID | Indicates the condition for which the claim was pended. |
| Fiscal Pend Indicator |
Indicates whether the claim is currently in a pend status. |
| Org Fiscal Pend Date |
The date that the claim was first placed into fiscal pend status. |
| Field | Description |
|---|---|
| Member ID |
A unique identifier assigned to a member. Links to the Member Summary page for the member, if you have access. |
| Name | The member's full name. |
| Date of Birth | The member's date of birth. |
| Submitted Member ID | The member ID submitted on the claim. |
| Age | The member's age at time of service. Calculated by the system based on date of birth compared to date of service. |
| Gender | The member's gender. |
| COE Code-Desc |
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. |
| Field | Description |
|---|---|
| Available Eligibility Spans Fields | |
| Begin Date | The date the member is eligible for benefits. |
| End Date | The date the member is no longer eligible for benefits. |
| COE Code-Desc |
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 Benefit Plans Fields | |
| Begin Date | The date the member is eligible for the specified plan. |
| End Date | The date the member is no longer eligible for the specified plan. |
| Plan ID |
Unique identifier for the benefit plan. |
| Field | Description |
|---|---|
|
TPL Summary Fields To view TPL information, in the TPL Summary table, click the appropriate row. |
|
| Seq Number | The sequence number of the TPL payer, incremented and assigned by ND MMIS. |
| Other Payer Carrier Code | The carrier code for the TPL payer. A carrier is private company that contracts to pay Medicare claims. |
| Other Insured - Provider ID | The provider ID for the TPL payer. |
| Other Insured - ID | The TPL payer's ID for the other insured. |
| Other Insured - Last Name | The last name of the other insured. |
| View TPL Information Fields | |
| Sequence Number | The sequence number of the TPL payer, incremented and assigned by ND MMIS. |
| Other Payer Carrier Code |
The carrier code for the TPL payer. A carrier is private company that contracts to pay Medicare claims. |
| Other Insured Provider ID | The provider ID for the TPL payer. |
| Other Insured ID | The TPL payer's ID for the other insured. |
| Other Insured Last Name | The last name of the other insured. |
| Other Insured First Name | The first name of the other insured. |
| Other Insured MI | The middle initial of the other insured. |
| Date of Birth | The other insured's date of birth. |
| Gender | The gender of the other insured. |
| Relationship to Patient | The patient's relationship to the other insured. |
| Other Insured's Address (Address Line 1 and 2, City\ State\ Zip Code\Country\Subdivision Code) | The other insured's address. |
| Insurance Plan Name | The name of insurance benefit plan. |
| Employer's Name | The name of the other insured's employer. |
| Accept Medicare Assign? | Displayed for Institutional and Professional claims. Indicates whether the TPL payer accepts Medicare assignment. |
| TPL Amounts Fields | |
| LI # |
The line item number to which the TPL amounts information is related. A zero (0) indicates the information is claim level. |
| Billed Amount | The amount billed to the TPL payer. |
| Allowed Amount |
The TPL payer allowed amount. The amount the TPL payer will pay for the procedure or service. |
| Deductible Amount |
TPL payer deductible amount. The deductible is the amount the insured must pay before the TPL payer will pay. |
| Coinsurance Amount | TPL payer coinsurance amount. Coinsurance is a percentage of the charge that the insured must pay. |
| Paid Amount |
The amount the TPL payer paid. |
| Est Amount Due | Displayed only for Institutional claims. The estimated amount the patient is responsible for paying. |
| Field | Description |
|---|---|
| Line # |
Line item number to which the submitted provider applies. A zero (0) indicates this provider is applied to the claim level. |
| Prov Role |
The role of the provider. Examples: Billing, Rendering |
| Prov ID Type |
The type of provider ID. Examples: Medicaid, National Provider ID (NPI) |
| Prov ID |
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. |
| Prov Type |
Unique code that indicates the type of provider ID entered. Examples: DEA, NPI, SSN/EIN |
| Prov Specialty |
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 |
| Taxonomy |
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). |
| Used | Indicates which provider ID the ND MMIS used in processing the claim (Medicaid or NPI). |
| Submitted | A check indicates the provider information was submitted on the claim. |
| Tax ID/SSN | The provider's Tax ID or Social Security number. |
| Sign Date | Indicates the physician signed the claim form and the date signed. |
| Service Facility Taxonomy | Displayed if Institutional claim. The service facility's taxonomy. |
| In Kind Ind | If the provider is in-kind, ND MMIS reduces the claim payment to the amount that is covered only by federal match money, so additional state-budgeted money is not paid by DHS. |
| Field | Description |
|---|---|
| Billing Provider Address | |
| Address Line 1 and 2 | The billing provider's address. |
| City | The billing provider's city. |
| State | The billing provider's state. |
| Zip and Extension | The billing providers zip. |
| Rendering Provider Address | |
| Address Line 1 and 2 | The rendering provider's address. |
| City | The rendering provider's city. |
| State | The rendering provider's state. |
| Zip and Extension | The rendering provider's zip. |
| Field | Description |
|---|---|
| Patient Acct # | The patient account number assigned by the provider. Used by providers for financial tracking and posting payments. |
| Medical Record # | A unique number assigned by the provider to the patient's medical history and care records. |
| Total Charge | The total amount charged for services. |
| TPL Amt |
The amount associated to a TPL payer. |
| Net Amt |
The net amount. |
| Reimb |
The reimbursement amount. |
| 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 |
| R/A# | The sequential number of the remittance advice statement for the claim. |
| EFT/Check # | The unique check or electronic funds transfer number assigned to the payment transaction. |
| Internal Warrant # | Uniquely identifies a payment to a provider for a given payment cycle. |
| Paid Date | Indicates the date the claim was paid. |
| Payee Type |
Indicates to whom payment is made. Examples: Provider, Member |
| Payee ID |
Identifier for the payee. |
| Fund Code |
The budget and funding sources applicable to a claim. |
| Fed Amt | The Federal fund amount applied to the claim. |
| St Amt | The State fund amount applied to the claim. |
| Cnty Amt | The County fund amount applied to the claim. |
| Other Amt | The Other fund amount applied to the claim. |
|
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. |
|
| Amount |
The amount of the base rate change |
| Description |
The description of the base rate change |
| Field | Description |
|---|---|
| Other Insurance | Indicates whether the patient is covered by other insurance. |
| Place of Service |
Physical location where the health care service was provided. Examples: Office, Urgent Care Facility, Inpatient Hospital, Independent Clinic, School, Ambulance - Land |
| Accident | Indicates the patient's illness or injury is related to the patient's occupation or workplace (Employment), an automobile accident (Auto), or another type of accident (Other). |
| Accident/Illness Date | The accident or onset of illness date. |
| Accident State | State in which the accident occurred. |
| Sub Svc Auth ID |
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. |
| Referral ID |
The referral identification. |
| Field | Description |
|---|---|
| Line # | Line item number to which the attachment is related. A zero (0) indicates this attachment is related to the claim level. |
| Attachmt |
Indicates the type of attachment. |
| Field | Description |
|---|---|
| Override Exceptions |
Override exception code. Indicates an exception code that is overridden during claims processing. |
| Field | Description |
|---|---|
| Remark |
Notes regarding a claim adjustment. |
| Adj Reason | Indicates the reason for the adjustment. |
| Field | Description |
|---|---|
| EOB Code | Explanation of benefits (EOB) code. A code that is associated with a message to be printed on the EOB. |
| Fields | Description |
|---|---|
|
Override Adjustment Group Code |
|
| Line # | The line item number to which the override adjustment group code is related. |
| Adj Reason | The adjustment reason. |
| Override Adj Grp Cd | ??? |
Version as of 5/16/14.
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