You use the Dental Claim Detail page of Claims Inquiry to view a claim in ND MMIS.
The Line Item tab contains the following panels:
| 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 |
|---|---|
| To view details of a line item, in the Line Item table, click the appropriate row. | |
| LI |
The number of the line item. |
| Status |
Indicates the status of the line item. Examples: Pay, Suspend, Deny |
| Service Date | The date the service was rendered. |
| Q1 - Q5 |
Quadrant. The oral cavity designation code(s). Up to five. |
| System |
The ANSI ASC X12 code list qualifier that indicates the tooth numbering system used. Examples: JP - ADA's Universal/National Tooth Designation System, JO - ANSI/ADA/ISO Specification No. 3950 |
| Tooth # | The number of the tooth. |
| S1 - S5 | Surface of the tooth. |
| Proc Code |
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. |
| Total Charge | The total charge for the procedure. |
| Svc Units |
Service Units. Indicates quantity or frequency of units associated with the procedure. |
| Sub Svc Auth | The service authorization ID submitted on the claim. |
| Field | Description |
|---|---|
| Tooth # | The number of the tooth. |
| S1 - S5 | Surface of the tooth. |
| Field | Description |
|---|---|
| Status |
Indicates the status of the line item. Examples: Pay, Suspend, Deny |
| Service Date | Date the service was provided. |
| Quadrant (1-5) | Oral cavity designation code. |
| POS |
Place of Service. Indicates where the service was provided. |
| Proc Code |
Procedure Code. Indicates the procedure or service provided. Healthcare Common Procedure Coding System (HCPCS) or Current Dental Terminology (CDT) codes are typically used. |
| Total Charge | The total charge for the line item. |
| Svc Units |
Service Units. Indicates quantity or frequency of units associated with the procedure. |
| Base Rate Amt |
The base rate is the basic payment rate used to calculate the reimbursement amount for the claim. |
| Base Rate Src |
Indicates the source that is used to determine the base rate amount. |
| Calc Allowed Amt |
The calculated allowed amount is the base rate minus any cutbacks or base rate changes identified during pricing. |
| Allow Charge |
The allowed charge amount for the line item. |
| Allow Units |
The allowed units for the line item. |
| TPL Amount |
The amount paid by a third-party carrier. |
| Reimb Amount |
The reimbursement amount is the allowed charge minus any base rate changes such as TPL, patient liability, or co-pay. |
| Reimb Units |
The reimbursement units. |
| Reimb Status |
The reimbursement status. Examples: Billed, Allowed |
| 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. |
| Sub Svc Auth Req'd |
Submitted Service Authorization Required. Indicates whether service authorization is required. |
| Svc Auth Line Applied |
Service Authorization Line Applied. Indicates to which line item the service authorization is applied. |
| Svc Auth ID |
Service Authorization ID. A unique ID assigned to the service authorization. Links to the service authorization, if you have access. |
| Referral ID |
The referral identification. |
| Benefit Plan ID |
Unique identifier for the benefit plan. |
| Mapset ID |
The ID of the map definition that defines the services that are covered or not covered by the benefit plan. |
| Service Area |
The service area. Examples: Radiology, Transportation |
| 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. |
| Fund Code |
The budget and funding sources applicable to a claim. |
| Component |
Indicates whether the line item is adjudicated as a professional, technical or other type of service component. |
| Category of Svc |
The services for which enrolled providers are authorized to bill. |
| 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. |
| Procedure Description | A description of the procedure code. |
| Modifiers (1-4) |
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. |
| 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 |
|---|---|
| Base rate changes are changes to the allowed charge. These occur in pricing and final adjudication. Examples are service authorization cutbacks, spenddown, and TPL. | |
| Amt |
The amount of the base rate change. |
| Description |
The identifier of the rate used for the base rate change. |
| 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 |
|---|---|
| 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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