1. Type

If claim is related to an accident, place a check mark in box next to appropriate type of accident. Electronic claims allow for up to two types, CMS 1500 paper claims allow for only one type. If two boxes are checked for paper claims, the first type checked will print on claim.

2. Special Program Codes

Special Program: Code indicating the Special Program under which the services rendered to the patient were performed

Delay Reason: Code indicating the reason a request was delayed

3. Primary  

Release of Information Signature: Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations

Signature Executed for Patient: Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider

4. Secondary

Release of Information Signature: Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations

Signature Executed for Patient: Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider

1. Pick Up Address: Enter full address

2. Drop Off Address: Enter full address

3. Ambulance Certification: Check Y or N if applicable

4. Reason for Ambulance

Contract Type: Select Contract Type from drop down list and complete remaining fields, as required by payer

1. Illness, Injury or Pregnancy

2. Patient Treatment Dates

3. Hospital, Disability Dates

File Information:

Fixed Format Information

Data in fixed format agreed upon by sender and receiver

At the time of publication of this implementation, K3 segments have

no specific use. The K3 segment is expected to be used only when

necessary to meet the unexpected data requirement of a legislative

authority.

Enter Medicaid Resubmission number

To transmit information in a free-form format, if necessary, for comment or

special instruction

Text: Type free text

Type: Select type of note from drop down list

Reference information as defined for a particular Transaction Set or as specified

by the Reference Identification Qualifier

Number: Enter original ID

Policy ID: Select payer from list of patient insurance from Insurance Tab

Lab: Select Facility where lab services are performed from the drop down list. The CLIA number will be included in the claim file and pulled from the Facility Manager.

Code: If services are EPSDT related, use drop down list and select appropriate code for visit.

Nature of Condition: Select condition from drop down list

Description: Type description

Additional Description: Type additional description

Certification Number: Type Mammography certification number

Code: Enter Exemption code, if applicable.

Allowable values for this element are:

1 Immediate/Urgent Care

2 Services Rendered in a Retroactive Period

3 Emergency Care

4 Client has Temporary Medicaid

5 Request from County for Second Opinion to Determine if Recipient Can Work

6 Request for Override Pending

7 Special Handling

Exemption Number: Enter exemption number.

Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims.

Number: Enter Medical Record number, if applicable.

Required when the provider needs to identify for future inquiries, the

actual medical record of the patient identified for this episode of care.

Procedure 1: Click to open Select Charge dialog, and search for procedure code 1.

Procedure Code 2: Click to open Select Charge dialog, and search for procedure code 2.

To supply information related to the delivery of health care

Required when condition information applies to the claim.

Code qualifying the Reference Identification

Identifier: Enter Reference Identification Qualifier

Required when it is necessary to identify claims which are atypical in

ways such as content, purpose, and/or payment, as could be the case for

a demonstration or other special project, or a clinical trial.

Number: Enter number

Required when the physician is billing Medicare for Care Plan Oversight

(CPO).

Required when patient is known to be deceased and the date of death is available to the provider billing system.

Date of Death: Enter date of death.

Required when claims involve Medicare Durable Medical Equipment Regional Carriers Certificate of Medical Necessity (DMERC CMN)

Weight: Enter Patients weight.

Required when mandated by law. The determination of pregnancy shall be completed in compliance with applicable law. The “Y” code indicates that the patient is pregnant.

Pregnant: Place a check mark in box if Yes.

Claim Number: This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer.

Contact Name: Required when the Subscriber contact is a person other than the person identified in the Subscriber Name.

Contact Phone: Required when this information is deemed necessary by the submitter.

Patient ID Type: Select Patient ID Type or Do not Send

Patient ID: Enter Patient ID

First Contact Date: This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any means. It is not necessarily the Initial Treatment Date.

Service Facility

Contact: Service Facility Contact Information

Phone: Service Facility Contact Phone

Use drop down options to overwrite existing Providers/Facilities at the Claim level.

Add Referral and Prior Authorization numbers at the claim level for select payers

Referral Numbers: Enter referral number and select payer from drop down list from patient insurance demographics.

Prior Authorization: Enter prior authorization number and select payer from drop down list from patient insurance demographics.

Control Number: Enter the control number

Report Type Code: Select from the drop down list.

Transmission Type: Select from the drop down list.

Required when there is a paper attachment following this claim.

OR

Required when attachments are sent electronically but are transmitted in another functional group rather than by paper.

OR

Required when the provider deems it necessary to identify additional information that is being held at the provider’s office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim.

Spectacle Lenses: Select Yes or No for applicable options.

Spectacle Frames: Select Yes or No for applicable options.

Contact Lenses: Select Yes or No for applicable options.