Institutional Claim Detail (Line Item Tab) Page

You are here: Claims > Inquiry > Claims Inquiry Field Descriptions > Institutional Claim Detail (Line Item Tab) Page

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

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 Fields

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

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.

Line Item Fields

Field	Description
To view line item details, in the Line Item table, click the appropriate row. The fields are described in the View Line Item Detail table below.
LI	The number of the line item.
Status	Indicates the status of the line item. Examples: Pay, Suspend, Deny
Rev	Service Line Revenue Code. Identifies specific accommodation or ancillary charges.
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.
Rate	The rate associated with the service provided.
DOS Begin	Date of Service Begin. The first date of service.
Total Chg	The total charge for the procedure.
Svc Units	Service Units. Indicates quantity or frequency of units associated with the procedure.
Allow Units	The allowed units.
Allow Chg	The allowed charge.
Base Rt	The base rate is the basic payment rate used to calculate the reimbursement amount for the claim.

Field

Description

To view line item details, in the Line Item table, click the appropriate row. The fields are described in the View Line Item Detail table below.

The number of the line item.

Status

Indicates the status of the line item.

Examples: Pay, Suspend, Deny

Rev

Service Line Revenue Code.

Identifies specific accommodation or ancillary charges.

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.

Rate

The rate associated with the service provided.

DOS Begin

Date of Service Begin. The first date of service.

Total Chg

The total charge for the procedure.

Svc Units

Service Units.

Indicates quantity or frequency of units associated with the procedure.

Allow Units

The allowed units.

Allow Chg

The allowed charge.

Base Rt

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

View Line Item Detail Fields

Field	Description
Line #	The number of the line item.
Status	Indicates the status of the line item. Examples: Pay, Suspend, Deny
Revenue Code	Identifies specific accommodation or ancillary charges. Links to the Rules Management Code Maintenance page for the revenue code, if you have access.
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.
Modifiers	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.
Room Rate	The rate associated with the service provided.
DOS Begin	Date of Service Begin. The first date of service.
Svc Units	Service Units. Indicates quantity or frequency of units associated with the procedure.
Total Charge	The total charge for the line item.
Non-covered Charge	The non-covered charge amount.
Family Planning	The family planning services indicator.
Base Rt Amt	The base rate is the basic payment rate used to calculate the reimbursement amount for the claim.
Base Rt Src	Base Rate Source. Indicates the source that is used to determine the base rate amount.
Calc Allow 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 Amt	The amount paid by a third-party carrier.
Reimb Amt	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
Svc Auth Req'd	Submitted Service Authorization Required. Indicates whether service authorization is required.
Svc Auth Line Appld	Service Authorization Line Applied. Indicates to which line item the service authorization is applied.
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	Category of Service. The services for which enrolled providers are authorized to bill.
Fed Amt	The Federal fund amount applied to the claim line.
St Amt	The State fund amount applied to the claim line.
Cnty Amt	The County fund amount applied to the claim line.
Other Amt	The Other fund amount applied to the claim line.
Procedure Description	A description of the procedure code.
APC Code	The code indicating the prospective payment group for hospital outpatient service. Example: APC 131
APC Status Code	The APC status code. Examples: Fiscal intermediaries/non OOPS, Codes not recognized by OPPS
Submitted Provider Fields
LI #	The line item number associated with the submitted provider.
Provider Role	The role of the provider. Examples: Billing, Rendering
Provider ID Type	The type of provider ID. Examples: Medicaid, National Provider ID (NPI)
Provider 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.
Medicare Fields These fields only display for a line on a Medicare crossover claim.
Allow Amt	Medicare Allowed Amount. The amount Medicare pays for the procedure or service.
Deductible Amt	Medicare Deductible Amount. The amount the insured must pay before Medicare pays.
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.
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 description of the base rate change.
Attachments Fields
LI #	The line item number to which the attachment is related.
Attachments	Indicates the type of attachment.
Additional Remarks Fields
Remark	Code for notes regarding a claim adjustment. Links to the Rules Management Text Management page for the remark code, if you have access.
Adj Reason	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 Fields
EOB Code	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.
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	???
Drug Identification Fields
National Drug Code	Identifies the manufacturer or distributor, product code, and package code of medications recognized by the Federal Drug Administration.
Drug Unit Price	The drug unit price. If the amount includes cents, you must enter the decimal point.
Unit Code	The unit code.
National Drug Unit Count.	The national drug unit count.
Prescription Qualifier	???
Prescription #	The prescription number.

Field

Description

Line #

The number of the line item.

Status

Indicates the status of the line item.

Examples: Pay, Suspend, Deny

Revenue Code

Identifies specific accommodation or ancillary charges.

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

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.

Modifiers

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.

Room Rate

The rate associated with the service provided.

DOS Begin

Date of Service Begin. The first date of service.

Svc Units

Service Units.

Indicates quantity or frequency of units associated with the procedure.

Total Charge

The total charge for the line item.

Non-covered Charge

The non-covered charge amount.

Family Planning

The family planning services indicator.

Base Rt Amt

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

Base Rt Src

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

Calc Allow 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 Amt

The amount paid by a third-party carrier.

Reimb Amt

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

Svc Auth Req'd

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

Svc Auth Line Appld

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

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

Category of Service. The services for which enrolled providers are authorized to bill.

Fed Amt

The Federal fund amount applied to the claim line.

St Amt

The State fund amount applied to the claim line.

Cnty Amt

The County fund amount applied to the claim line.

Other Amt

The Other fund amount applied to the claim line.

Procedure Description

A description of the procedure code.

APC Code

The code indicating the prospective payment group for hospital outpatient service.

Example: APC 131

APC Status Code

The APC status code.

Examples: Fiscal intermediaries/non OOPS,

Codes not recognized by OPPS

Submitted Provider Fields

LI #

The line item number associated with the submitted provider.

Provider Role

The role of the provider.

Examples: Billing, Rendering

Provider ID Type

The type of provider ID.

Examples: Medicaid, National Provider ID (NPI)

Provider 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.

Medicare Fields

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

Allow Amt

Medicare Allowed Amount. The amount Medicare pays for the procedure or service.

Deductible Amt

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

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.

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 description of the base rate change.

Attachments Fields

LI #

The line item number to which the attachment is related.

Attachments

Indicates the type of attachment.

Additional Remarks Fields

Remark

Code for notes regarding a claim adjustment.

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

Adj Reason

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 Fields

EOB Code

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.

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

???

Drug Identification Fields

National Drug Code

Identifies the manufacturer or distributor, product code, and package code of medications recognized by the Federal Drug Administration.

Drug Unit Price

The drug unit price.

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

Unit Code

The unit code.

National Drug Unit Count.

The national drug unit count.

Prescription Qualifier

???

Prescription #

The prescription number.