Institutional Claim Detail (Main Tab) Page

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Institutional Claim Detail (Main Tab) Page

You use the Institutional Claim Detail page of Claims Inquiry to view a claim in ND MMIS.

The Main tab contains the following panels:

Claim Data
Member Data
Additional Member Data
Provide Data
Provider Addresses
Coverage & Admission Data, including:
- Other Payer
- Diagnosis & Procedures
Inpatient Pricing Data
Payment Data
Attachments
Override Exception
Additional Remarks
Manual EOBs
Override Adjustment Group Code

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.

Claim Data

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.

Member Data Fields

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.

Additional Member Data Fields

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.

Provider Data Fields

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.

Provider Addresses

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.

Coverage & Admission Data Fields

Field	Description
Other Insurance (Yes\No)	Indicates whether the patient is covered by other insurance.
Type of Bill	Type of Bill field from the institutional claim form. Identifies the facility type, class of care provided, and sequence (or frequency) of the bill.
DOS Begin	Date of Service Begin. The first date of service. Format: MM/DD/YYYY
DOS End	Date of Service End. The last date of service. Format: MM/DD/YYYY.
Covered Days	The number of inpatient days covered for the stay
Non-Covered Days	The number of inpatient days not covered for the stay.
Admit Date	The date the patient was admitted to the facility.
Admit Hour	The hour the patient was admitted to the facility.
Admit Type	Describes the admission of the patient to the facility.
Admit Source	Indicates the source of admission. Example: Transfer, Emergency
Discharge Date	The date the patient was released from the facility.
Discharge Hour	The hour the patient was released from the facility.
Patient Status	Indicates where or under what conditions the patient was discharged from the facility.
Length of Stay	The number of days the patient was admitted in the facility.
Hours Billed	The number of hours billed.
Benefit Plan	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.
Cat of Svc	Category of Service. The services for which enrolled providers are authorized to bill.
Fund Code	The budget and funding sources applicable to a claim.
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.
Svc Auth Req'd	Submitted Service Authorization Required. Indicates whether service authorization is required.
Service Auth Line Applied	Service Authorization Line Applied. Indicates to which line item the service authorization is applied.
Service 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.
Accident State	State in which the accident occurred.
Condition Codes Fields
Code	Indicates certain conditions apply to the claim.
Occurrence Codes Fields
Code	Indicates specific events related to the claim.
Date	Date associated with the occurrence code. Format: MM/DD/YYYY
Occurrence Spans Fields
Code	Indicates specific events related to the claim.
Begin Date	The first date associated with the occurrence span code. Format: MM/DD/YYYY
End Date	The last date associated with the occurrence span code. Format: MM/DD/YYYY
Value Codes Fields
Value Code	Identifies monetary information that is used in processing the claim.
Amount	The amount or unit associated with the value code. If the amount includes cents, you must enter the decimal point.
Payer Fields
Payer	Indicates the payer is the primary (A), secondary (B), or tertiary (C) payer.
Provider ID	The provider ID.
Prior Payment	The amount paid prior.
Est Amount Due	The estimated amount remaining to be paid.
Other Insured ID	A unique ID for the insured.
Treatment Auth	Service Authorization ID. A unique ID assigned to the service authorization.

Other Payer Fields

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.

Diagnosis and Procedures Fields

Field	Description
Diagnosis Fields
Admitting Diag Code	The diagnosis code used to admit the patient to the facility.
Emergency Diag Code	The emergency diagnosis code.
POA Code	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.
Type	Indicates whether the diagnosis code is the principal diagnosis. If not the field is left blank.
Code	Diagnosis Code. A standard code used to describe the nature of a patient's illness or injury.
POA Code	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.
DRG RC	The Diagnostic Related Grouping (DRG) return code.
Procedure Fields
Principal Procedure Code	Indicates the principal procedure. Links to the Rules Management Code Maintenance page for the procedure code, if you have access.
Type	Indicates whether the procedure code is the principal procedure. If not the field is left blank.
Date	The date of the procedure. Format: MM/DD/YYYY
DRG RC	The DRG return code.

Inpatient Pricing Data Fields

Field	Description
DRG Code	The Diagnosis Related Group (DRG) code.
Peer Group Code	The peer review authorization/approval code.
DRG Grouper Allowed	The DRG Grouper allowed.
Outlier Days	For inpatient DRG claims, outlier days are those days billed which fall outside of the number of days typically covered by the DRG code.
Outlier Amt	The total Prospective Payment System outlier and Capital Outlier amounts for this claim.
DRG Outlier Reduction Pct	The DRG outlier reduction percentage.
DRG Outlier Amt	The total Prospective Payment System outlier and Capital Outlier amounts for the claim as it relates to the Diagnosis Related Group.
DRG Allowed Amt	The DRG allowed amount.
Inpatient %	The inpatient percentage.
Calc Covered Days	The Diagnosis Related Group (DRG) length of stay days (calculated).
Base Rate Amt	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 Src	Indicates the source that is used to determine the base rate amount.
Cal Allow Amt	The calculated allowed amount is the base rate minus any cutbacks or base rate changes identified during pricing.
Allowed Charge	The total allowed amount.
Total Covered Charges	The total covered charges.
Total Non-covered Charges	The total non-covered charges.
Total Calc Covered Charges	The total calculated covered charges.
Reimb Amt	The reimbursement amount is the allowed charge minus any base rate changes such as TPL, patient liability, or co-pay.
Reimb Status	The reimbursement status. Examples: Billed, Allowed
Svc Auth	The service authorization ID.
Svc Auth Line	The service authorization ID line number.
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.
Amt	The amount of the base rate change.
Description	The identifier of the rate used for the base rate change.

Payment Data Fields

Field	Description
Patient Account #	The patient account number assigned by the provider. The patient account number (or patient control number) is 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 Claim Billed Amt	The total amount billed on the claim.
TPL Amt	The total amount paid for this claim by all third-party payers.
Reimb	The total reimbursement amount for this claim. Calculated by the system as the total allowed charges plus/minus all base rate changes.
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.
Partial Family Planning
Family Planning	Indicates whether the claim is for family planning services.
Fund Code	The budget and funding sources applicable to a claim.
Fed Amt	Amount assigned to Federal funds for those inpatient claims that are partial family planning. This is assigned in addition to the regular Federal amount assigned.
St Amt	Amount assigned to State funds for those inpatient claims that are partial family planning. This is assigned in addition to the regular State amount assigned.
Cnty Amt	Amount assigned to County funds for those inpatient claims that are partial family planning. This is assigned in addition to the regular County amount assigned.
Other Amt	Amount assigned to Other funds for those inpatient claims that are partial family planning. This is assigned in addition to the regular Other amount assigned.
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.
Medicare Fields These fields only display for a Medicare crossover claim.
Allow Amt	Medicare Allowed Amount. The amount Medicare will pay for the procedure or service.
Deductible Amt	Medicare Deductible Amount. The amount the insured must pay before Medicare will pay.
Coins Amt	Medicare Coinsurance Amount. Coinsurance is a percentage of the charge that the insured must pay.
Paid Amt	The amount Medicare paid.
MIC	Medicare Insurance Carrier. The ID for the private company that contracts to pay Medicare claims.
EOMB Date	The date of the Explanation of Medicare Benefits (EOMB). The EOMB explains what services the provider billed to Medicare, the Medicare allowed amount, how much Medicare paid, and what the patient and\or other insurance must pay.

Attachments Fields

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.

Override Exceptions Field

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

Additional Remarks Fields

Field	Description
Remark	Notes regarding a claim adjustment.
Adj Reason	Indicates the reason for the adjustment.

Manual EOBs Field

Field	Description
EOB Code	Explanation of benefits (EOB) code. A code that is associated with a message to be printed on the EOB.

Override Adjustment Group Code Fields

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.