Professional Claim Detail (Main Tab) Page

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Professional Claim Detail (Main Tab) Page

You use the Professional 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.

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.

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.

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.

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.

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 Charge	Total amount charged for services
TPL Amt	The total amount paid for this claim by all third-party payers.
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	Amount of the base rate change.
Description	Description of the base rate change.
Medicare Fields These fields are completed only for a Medicare crossover claim.
Allow Amt	Medicare Allowed Amount. The amount Medicare will pay for the procedure or service. If the amount includes cents, you must enter the decimal point.
Deduct Amt	Medicare Deductible Amount. The amount the insured must pay before Medicare will pay. If the amount includes cents, you must enter the decimal point.
Coins Amt	Medicare Coinsurance Amount. Coinsurance is a percentage of the charge that the insured must pay. If the amount includes cents, you must enter the decimal point.
Paid Amt	The amount Medicare paid. If the amount includes cents, you must enter the decimal point.
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.

Visit Data Fields

Field	Description
Other Insurance (Yes\No)	Indicates whether the patient is covered by other insurance.
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.
Unable to Begin Date	Date the patient is unable to work due to illness or injury The date the patient is unable to work due to illness or injury.
Unable to Work End Date	The date the patient is able to return to work
Hospital Begin	The beginning date of the hospital stay associated with the claim. Indicates the services are related to an inpatient hospital stay.
Hospital End	The ending date of the hospital stay associated with the claim. Indicates the services are related to an inpatient hospital stay.
Out Lab / Amt	Outside Laboratory Amount. Indicates outside lab services were provided and the amount associated with the services
Sub Svc Auth	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.
Anesthesia Principal Proc Code	The principal procedure code for anesthesia.
Anesthesia Other Proc Code	The other procedure code for anesthesia.
Diagnosis Fields
#	The line number for the diagnosis code.
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. Links to the Rules Management Code Maintenance page for the diagnosis code, if you have access.
Condition Code
Code	Indicates certain conditions apply to the claim.

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.