You use the Receipt Reversal page to reverse a check you entered in error. You cannot reverse electronic funds transfers.
The Receipt Reversal page contains the following panels:
| Field | Description |
|---|---|
| These fields are view-only. | |
| LOB |
The unique code that identifies the line of business, a high-level payer, or funding source such as Medicaid. |
| Payee/Payer Type |
The type of financial entity that can make payments and/or receive payments. Examples: Provider, Member, Carrier |
| Payee/Payer ID Type Code |
The code associated with the type of payee/payer. Defaults: If the Payee/Payer Type is Provider, then the Payee/Payer ID Type Code is Medicaid. If the Payee/Payer Type is Member, then the Payee/Payer ID Type Code is Medicaid ID. If the Payee/Payer Type is Carrier, then the Payee/Payer ID Type is Carrier ID. |
| Payee/Payer ID |
Unique identifier of the payee/payer. |
| Payee/Payer Name |
The name of the payee/payer. Dependent upon the Payee/Payer Type Code and Payee/Payer ID on file in ND MMIS. |
| System Payee/Payer ID |
Unique identifier in ND MMIS that represents the payee/payer ID. |
| Member ID Type |
The type of Alternate ID being used as the Member ID. Examples: Medicaid, SPED, Voc Rehab |
| Member ID |
Unique identifier used for a member and is assigned when the member becomes eligible to receive Medicaid benefits. |
| Member Name |
The name of person associated with the member ID. |
| Field | Descriptions |
|---|---|
| These fields are view-only. | |
| FCN |
The transaction control number of the financial claim that is created for this receipt. |
| Financial Reason Code |
The code indicating why the transaction was added. |
| Established Date | The date that the receipt was created. |
| Original Amount |
The original amount of the receipt. Format: Displayed as currency with $ symbol left of the value and two digits to the right of the decimal. Input can be up to seven digits before the decimal and two digits after the decimal. Input Format: 9999999.99 Display Format: $9999999.99 |
| Balance Amount |
The current balance amount of the receipt transaction. |
| Related FT TCN |
The transaction control number (TCN) of the claim's financial transaction (FT) that is created during claims processing to reflect the receivable. |
| Field | Description |
|---|---|
| These fields are view-only. | |
| FCN |
The financial control number (FCN) assigned to the reversal transaction. The FCN consists of the date it was created, the media source (how it was received), and a document number. Format: YYYYMMDDMNNNNN |
| Financial Reason Code |
The code indicating why the transaction was added. |
| Established Date |
The date that the receipt was created. |
| Amount | The amount of the reversal. |
| Related FT FCN |
The transaction control number of the financial claim created for the reversal. |
Version as of 5/16/14.
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