Document Number.

Identifies the claim as it is sequenced within a batch.

The type of claim.

Examples: Inpatient, Outpatient, Financial Transaction

Indicates the status of the claim.

Examples: Paid, To Be Paid, Denied, To Be Denied

The unique code that identifies the line of business, a high-level payer, or funding source such as Medicaid.

Document Type.

Indicates the type of document.

Examples: Adjustment Claims, FFS Provider Payment, Encounter Claims

Indicates the payment type of the claim.

Examples: For Payment, History Only

Transaction Type.

Indicates the transaction type of the claim.

Examples: Original Claim, Void

The location of a suspended claim.

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.

Indicates the reason for replacing or voiding the claim.

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.

Indicates whether the claim is currently in a pend status.

Line Item Summary Fields

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.

Indicates the status of the line item.

Examples: Pay, Suspend, Deny

Date of Service Begin. The first date of service.

Date of Service End. The last date of service.

Place of Service.

Physical location where the health care service was provided.

Examples: Office, Urgent Care Facility, Inpatient Hospital, Independent Clinic, School, Ambulance - Land

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 of the procedure code, if you have access.

Diagnosis Related. The diagnosis that is related to the procedure. 

Service Units.

Indicates quantity or frequency of units associated with the procedure.

The calculated allowed amount is the base rate minus any cutbacks or base rate changes identified during pricing.

The allowed units for the line item.

The number of the line item.

Indicates the status of the line item.

Examples: Pay, Suspend, Deny

Date of Service Begin. The first date of service.

Date of Service End. The last date of service.

Place of Service.

Physical location where the health care service was provided.

Examples: Office, Urgent Care Facility, Inpatient Hospital, Independent Clinic, School, Ambulance - Land

Procedure Code.

Indicates the procedure or service provided. Healthcare Common Procedure Coding System (HCPCS) or Current Dental Terminology (CDT) codes are typically used.

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.

The diagnosis that is related to the procedure.

Indicates quantity or frequency of units associated with the procedure.

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

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

The calculated allowed amount is the base rate minus any cutbacks or base rate changes identified during pricing.  

The calculated allowed amount is the base rate minus any cutbacks or base rate changes identified during pricing.

The allowed units for the line item.

The amount paid by a third-party carrier.

The reimbursement amount is the allowed charge minus any base rate changes such as TPL, patient liability, or co-pay.

The reimbursement units.

The reimbursement status.

Examples: Billed, Allowed

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.

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

Service Authorization ID. A unique ID assigned to the service authorization.

The submitted service authorization ID field is resolved by the system after adjudication and the field reflects the service authorization ID active in the system.

Links to the service authorization, if you have access.

The referral identification.

Unique identifier for the benefit plan.

The ID of the map definition that defines the services that are covered or not covered by the benefit plan.

The service area.

Examples: Radiology, Transportation

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.

The budget and funding sources applicable to a claim.

Indicates whether the line item is adjudicated as a professional, technical or other type of service component.

The Clinical Laboratory Improvement Amendments (CLIA) certification number of the lab that is associated with this line item. CLIA is a Centers for Medicare and Medicaid Services (CMS) program that regulates all non-research laboratory testing performed on humans.

The serial number of durable medical equipment (DME).

The line item number associated with the submitted provider.

The role of the provider.

Examples: Billing, Rendering

The type of provider ID.

Examples: Medicaid, National Provider ID (NPI)

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.

Unique code that indicates the type of provider ID entered.

Examples: DEA, NPI, SSN/EIN

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

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).

Medicare Fields

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

The amount Medicare paid.

Medicare Insurance Carrier. The ID for the private company that contracts to pay Medicare claims.

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.

The amount of the base rate change.

The description of the base rate change.

Adjustment Reason. Code for the reason for the adjustment.

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.

Override Adjustment Group Code

The drug unit price.

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