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PA PROMISe Provider Internet User Manual

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1. PROMISe Internet Portal PA PROMISe System Documentation To Complete Claim Billing Information Note Claims should be completed in accordance with DPW s guidelines policies and procedures Refer to the DPW web site for more specific information on completing a claim submission Step Action Response 1 In the Billing Information section type a value in the Original Claim Recipient ID Patient Account Last Name First Name Middle Initial Attachment Control Prior Authorization fields 2 In the Report Type Code and Report Transmission Code drop down lists select a value 3 Type a value in the Patient Pay Amount field To Complete the Claim Diagnosis Information Step Action Response 1 In the Diagnosis section in the Code Type drop down list select a value 2 Type up to 8 values in the Diagnosis Code field s To Complete Claim Service Information Step Action Response 1 In the Service Information section type a value in the Rendering Provider ID Location Referring Provider ID Location and Referral Number fields 2 In the Place of Service drop down list select a value 3 Type a value in the Facility ID Facility Name Admission Date Discharge Date Similar Illness Date and Onset of Current Illness Date fields 4 In the Special Program Code drop down list select a value 5 Type a value in the Billing Note field 6 In the Release of Medical Data Benefit Assignment Patient Sig
2. Field Descriptions ae Data Field Description ype Length Exit Exit ePEAP Button 0 ePEAP Menu Opens the ePEAP menu window Button 0 Help Describes the fields on the ePEAP window Button 0 PROMISe Provider Internet User Manual docx July 3 2014 267 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description noe Length NPI National Provider Identifier Number 10 Physical Site Street address associated with a service location Character 78 Address Service Number assigned to an individual service location Character 4 Location View Opens the Specialties window for the selected service Hyperlink 0 Specialties location View Opens the Taxonomy window for the selected service Hyperlink 0 Taxonomy location I wish to be Select to be included in the SelectPlan for Women directory Checkbox 0 included I wish to be Select to be removed from the SelectPlan for Women Checkbox 0 removed directory Continue Moves to the next page Button 0 Cancel Cancels the transaction Button 0 6 38 ePEAP Verify Provider Membership Group providers can use the ePEAP Verify Provider Membership in My Group window to verify that individual providers have made fee assignments to the group at the current group service location This window is accessed by clicking the Verify Provider Membership link in the ePEAP Menu PROMISe Provider Internet User Manual docx July 3 2014 268 Pr
3. ePEAP Menu PROMISe Provider Internet User Manual docx 280 July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation 6 42 ePEAP Field Edits All of the field edits for the ePEAP Internet system are listed in this section Error Field Code Address 1 2 City 3 Comment do not use this 1 box to request changes Continue 1 5657 5658 5662 5663 5664 PROMISe Provider Internet User Manual docx Error Message Enter Address to continue You must update at least one item to continue City can only contain letters spaces and hyphens Enter comments to continue NPI must be numeric NPI must be 10 digits in length Your NPI and Taxonomy selections already match what is on file for this Service Location You must select at least one Taxonomy Code The number entered is not a valid NPI number Please verify and re enter This NPI has been discontinued and cannot be used Please verify and re enter This NPI is associated with another individual Please verify and re enter This individual is associated with a different NPI Only one NPI is allowed per legal entity for individuals This NPI is associated with another legal entity Please verify and re enter 281 To Correct Enter the first street address Enter the first street address Enter a valid city name Enter in comments Enter a numeric value Enter a 10 dig
4. 1 application using instructions provided in desktop Section 2 9 of this manual Click on the ePEAP Provider Enrollment 2 Automation Project link in the Other The ePEAP Menu window opens Links section of the window 3 Select the Enrollment Information option a PEA EBay nen I Mormatigi window opens 4 Cisne Address Information unk The ePEAP Provider Address Information window opens To Update Provider Address Information Step Action Result Select any of the following options ear 1 Click the Pay to Change Address link The Manage Active Addresses window opens 2 Click the Mail to Change Address link The Manage Active Addresses window opens 3 Click the Home Office Change Address The Manage Active Addresses window link opens 4 Click the Email Change Email link The Manage Email Address window opens 5 Click the Pay to Change Phone Fax link The Edit Address Related Information window opens 6 Click the Mail to Change Phone Fax The Edit Address Related Information link window opens 7 Click the Home Office Change The Edit Address Related Information Phone Fax link window opens Other Options Step Action Result 1 Click the Enrollment Information button Return to the Enrollment Information window 2 Click the ePEAP Menu button Return to the ePEAP Menu window Click the Help button Describes the fields on the ePEAP window 4 Cli
5. ingredient Cost must be of the format 999999 99 00 DEFAULT w EA EACH v Patient Paid Amount PROMISe Provider Internet User Manual docx 148 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation DUR PPS Reason For Service DD DRUG DRUG INTERACTION m Service Code 00 NO INTERVENTION Result Of Service 00 NOT SPECIFIED Clinical Add Diagnosis Code Qualifier Diagnosis Code 1 01 IcD9 v i E Measurements Add Measurement Date Time Dimension Unit 1 NOT SPECIFED m NoT sPeciFIeD COB Add Coverage Type Payer ID Qualifier Payer ID Payer Date 1 NoT SPECIFIED _ y o1 NationaL paver o w Internal Control Number Hide COB Amounts Add Amount Paid Qualifier Amount Paid 1 07 DRUG BENEFIT m dd Reject Code F dd Patient Responsibility Qualifier 1 NOT SPECIFIED Coupon Add Coupon Type Coupon Number Coupon Amount 01 PRICE DISCOUNT Claim Status Information Claim Status Not Yet Submitted Field Descriptions Field Description Data Type Length Add Amount Paid Add Amount Paid Qualifier Button 0 Qualifier Add COB Add COB information Button 0 Add Coupon Add Coupon information Button 0 Add Diagnosis Add Diagnosis information Button 0 Code Qualifier Add Add Measurement information Button 0 Measurements Add Patient Add Patie
6. 59 4 Provider Ti ir tes vis ssvessrececcesatcccecscacnsesaneccs esac scnca axeden inseaeeee ea iesaiste soa eaS oos scence Seeiso esae 69 4 1 About Internal Control Numbers ICNS 0 ccccccsessccececceeceesensecececececseserseaeeeeeeeens 69 4 2 Using the Provider Claim Inquiry Window cccsscceesseceesececeeceeceeeeeceeeeeceteeeesaes 69 To Search for A Claim by Recipient ID oo ee ceecesecsseceseeeseeeseeeeneeeseeeseecsaecsaecsaecnaeeaeeees 70 To Search for A Claim by Patient Account Number eeeeeceeeeeeeneeeseeeeeeeeeaecesecnseesseenes 70 To Search for A Claim by ICN ceceni snes ro E E E E E R E E 71 To View Recipient EISTO Y t nie teea aa o ee ena o ESTER EE a 71 To Submit a Claim Adjustment erccnreciiieni iieiaei e 71 4 3 Recipient Eligibility CriicaliOms ccictesivcudsonlesteeiaiel aide sedinas aude oaad ona enes T2 S Provider RCM ON US ca csccssices cess cacsaaixehecossececavasoonacoee suds asonaesoca teens usencano reon aissos eRe 75 5 1 About the Provider Report Index Window sessseeessssesseessessseresseeesseesseesseesseresseee 75 6 PA PROMISe Internet WindOws sssccsssssssssssssssssssosssssssnsssessscsssnsssossscsssnsseosssesssnssooess 76 6 1 My Profle My Profle e r aa E A a E bats 76 6 121 Accessibility atid Use siani tniii ia e a eaa a i A Ee a E E a 78 Fo Access My Profile window ssciscecsici sstsseieciti ce iie e tas den ste e n e 78 6 2 Alternate No Access Alternate No
7. Description ID assigned to the prescriber Number assigned to a drug dispensed to a recipient Origin of prescription Prior authorization number found Prior authorization number submitted on the claim Clarifies the prior authorization number Number of units of a drug dispensed to a recipient Type of utilization conflict detected or the reason for the pharmacist s professional service The number of refills that are authorized Reject Code Action taken by a pharmacist in response to a conflict or the result of a pharmacist s professional service Type of billing submitted Pharmacist intervention when a conflict code Data Type Number Number Drop Down List Box Number Number Drop Down List Box Number Drop Down List Box Character Character Drop Down List Box Drop Down List Box Drop Down List has been identified or service has been rendered Box Click to display additional COB Amounts State where the patient lives Clarification for the claim submission Values are selected from the drop down list box Valid values are e MO Months e QI Quarterly e WK Weekly Submits claim to DPW Taxonomy for Billing Provider ID Taxonomy for Prescribing Provider ID Time indicator for Measurements PROMISe Provider Internet User Manual docx 154 Button Character Drop Down List Box Button Character Character Character Length 9 12 10 10 10 10 10
8. Step Action Result Click to place a checkmark next to I wish 1 to be included in the SelectPlan for Women Directory 2 Click Continue to process the request The Review Tour Mingea koman window opens PROMISe Provider Internet User Manual docx 262 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Step Action Result Review Your Changes This is a summary of your requests Please review this information for accuracy When you are satisfied click Continue To modify a request item return to that page Continue to Make Changes Cancel All Changes Submit Changes Changes Requested For Provider ID 300276278 DOGOOD MEDICAL ASSOCIATES Service Location 0001 Change SelectPlan for Women Directory Current Requested SelectPlan No Yes Directory Continue to Make Changes Cancel All Changes Submit Changes Click the Submit Changes button to 3 include the Service Location in the directory The Review Your Changes Contact Information window opens PROMISe Provider Internet User Manual docx July 3 2014 263 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Step Action Result Review Your Changes Contact Information This information may be used to contact you about this request This information will not be used for any other
9. System Documentation Step Action Response 5 Type up to 3 values in the Adjustment Group Code Reason Code and Amount fields 6 Type a value in the Paid Date Paid Amount and Allowed Amount fields To Remove Other Insurance Information Step Action Response 1 In the Other Insurance section click the Remove button To Add Medicare Information Step Action Response it Type a value in the Full Medicare Days field To Complete Claim Service Lines Information Response Type a value in the From Date To Date Revenue Code Procedure and Modifiers 2 fields In the Basis of Measurement drop down list select a value The claim is submitted Type a value in the Units Unit Rate and Billed Amount fields To Submit Claim Step Action Response 1 Click the Submit button The claim is submitted To Create New Claim Form Step Action Response 1 Click the New button The screen refreshes to create new claim form To Copy a Paid Claim Note The Copy button is only available on paid claims Step Action Response 1 Using Claim Inquiry inquiry asp If a match is found the search results list is complete a claim search displayed 2 Select a paid claim The paid claim displays 3 Click the Copy button All data from the selected paid claim is copied to a new claim 6 10 Switch Provider Number The Switch Provider window is
10. link which opens the ePEAP Menu Click the Enrollment Information link to open the Enrollment Information window and then click the Address Information link to open the Provider Address Information window Then click the Change Address link to open the Manage Active Addresses window PROMISe Provider Internet User Manual docx 218 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout Department of Public Welfare DEAP Office of Medical Assistance Programs OMAP Your Provider ID 300180963 DOGOOD JAMES L Status Active NPI 1234567893 View Taxonomy ePEAP Access Full Access Service Location 0001 123 HOPE RD HARRISBURG PA 17011 Provider Type 31 PHYSICIAN View Specialties Manage Pay to Mail to and or Home Office Address Instructions All addresses assigned to your Provider ID are listed below in alphabetical order by city Please click select next to the address you wish to assign as the new Pay to Mailto and or Home Office address for your Service Location If the desired address is not listed you may Add to List Address Phone Fax Handicap Assigned to Your Access Service Location 234 NEW HAVEN RD 717 975 1234 Yes Pay To CAMP HILL PA 17011 0000 000 000 0000 select 123 HOPE RD 717 444 4444 HARRISBURG 17011 0000 000 000 0000 select 1423 HOPE RD 717 444 4444 HARRISBURG PA 17011 0000 000 000 0000 select
11. 97 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length OCD 2 Second designation of the quadrant s of the Drop Down List 0 mouth on which services were performed or will Box be performed OCD 3 Third designation of the quadrant s of the mouth Drop Down List 0 on which services were performed or will be Box performed OCD 4 Fourth designation of the quadrant s of the mouth Drop Down List 0 on which services were performed or will be Box performed OCD 5 Fifth designation of the quadrant s of the mouth Drop Down List 0 on which services were performed or will be Box performed Original Claim Claim number for the original claim Character 13 Other Accident Indicates whether an accident resulted from Drop Down List 0 Accident another reason than Auto Accident or Employment Box related accident Paid Amount Service Adjustment amount paid Number 9 Paid Date Date service line adjustment paid amount was paid Date 8 MM DD CCYY Patient Account Patient account number is assigned by the provider Character 38 and relates to the recipient s number in the providers system Patient Pay Amount of claim to be paid by the recipient Number 9 Amount Place Of Service Location where a health care service was rendered Drop Down List 0 Service Lines for a service line Box list box Place of Service Type of location where the health care service was Drop Down List 0 re
12. Ext and Fax fields 2 If the location is handicapped accessible click Yes otherwise click No 3 Assign Current Location nnnn as Check all boxes that apply Preselected Pay to Address items cannot be removed you can only add Mail to Address a function to this service location Home Office Address 4 Click the Continue button The Review Your Changes window opens Other Options Step Action Result 1 Click the Cancel button The update is cancelled and returns to the Provider Address Information window 2 Click the Reset button The contents on this page are cleared 3 Click the Address Menu button Returns to the Provider Address Information window 4 Click ePEAP Menu Returns to the ePEAP Menu window 5 Click the Help button Describes the fields on the ePEAP window 6 Click the Review Submit button The Review Your Changes window opens 7 Click the Exit button Returns to the ePEAP Menu window Field Descriptions Field Description Data Type Length Address Selected address Complete address street Character 87 city state and ZIP code Address Menu Returns to the Provider Address Information Button 0 window Cancel Cancels the update process Button 0 Continue Continues the update process Button 0 Exit Exits ePEAP Button 0 Ext Phone extension number Number 4 PROMISe Provider Internet UserManual docx ss ss i i i OOSOSO duly 8 2014 227 Provider Internet User Manual PROMISe Internet Portal PA PROMI
13. Internet windows Other Diagnosis code can only contain alphanumeric characters that is 8 or 9 characters in length Enter an ICN that is not an encounter Enter an Other Diagnosis code that contains only alphanumeric characters Other Diagnosis code cannot be Enter an Other Diagnosis code less than 3 characters in length PROMISe Provider Internet User Manual docx 135 that is at least 3 characters in length July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Other 2 Diagnosis Other 3 Diagnosis Other 4 Diagnosis Other 5 Diagnosis Other 6 Diagnosis Other 7 Diagnosis Other 8 Diagnosis Error Code 0 Error Message Other Diagnosis code can only contain alphanumeric characters Other Diagnosis code cannot be less than 3 characters in length Other Diagnosis code can only contain alphanumeric characters Other Diagnosis code cannot be less than 3 characters in length Other Diagnosis code can only contain alphanumeric characters Other Diagnosis code cannot be less than 3 characters in length Other Diagnosis code can only contain alphanumeric characters Other Diagnosis code cannot be less than 3 characters in length Other Diagnosis code can only contain alphanumeric characters Other Diagnosis code cannot be less than 3 characters in length Other Diagnosis code can only contain alphanume
14. Last day of span Event that is related to payment of the claim This event occurs over a span of days First day of span PROMISe Provider Internet User Manual docx 120 Data Type Drop Down List Box Drop Down List Box Drop Down List Box Date MM DD CCYY Date MM DD CCYY Date MM DD CCYY Date MM DD CCYY Date MM DD CCYY Date MM DD CCYY Date MM DD CCYY Date MM DD CCYY Drop Down List Box Date MM DD CCYY Date MM DD CCYY Drop Down List Box Date MM DD CCYY Date MM DD CCYY Drop Down List Box Date MM DD CCYY Length 0 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Occurrence Span Last day of span Date 8 Code 3 To Date MM DD CCYY Occurrence Span Event that is related to payment of the clam Drop Down List 0 Code 4 This event occurs over a span of days Box Occurrence Span First day of span Date 8 Code 4 From Date MM DD CCYY Occurrence Span Last day of span Date 8 Code 4 To Date MM DD CCYY Operating Provider Number of the licensed physician other than Character 9 ID the attending physician as defined by the payer organization Original Claim Original claim number for the claim This is Character 13 required when the Claim Frequency code is other than one Other 1 Diagnosis Other diagnosis code for this claim Character 8 Other 2 Diagnosis Other diagnosis code for
15. Medical Degree DC Chiropractor License Start End Historic Medicare Information Read Only Need to update Click here Issued By Medicar Number Medicare Effective Date End Date Type yyyymmdd yyyymmdd MA Enrollment Medicar 10070926 22991231 Dates 070919 2007 1212 Start 01 01 2004 VITET 599912 End 12 31 2299 Medicare Indicator Information Medicare Indicator is assigned to Service Location 0001 C Remove Association from Service Location 0001 View Active Service Locations f Cominue Cancer f Reset Enrollment Information ePEAP Menu Help Review Submit PROMISe Provider Internet User Manual docx July 3 2014 210 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Formats for Medicare Indicator Information display Medicare Indicator not assigned Service Location does not have a validated NPI number Medicare indicator information An NPI number is required to designate Service Location with a Medicare Indicator View Active Service Locations Medicare Indicator not assigned Service Location has a validated NPI number Medicare Indicator information No Medicare Indicator is currently designated for NPI 1234567893 C Assign Association to Service Location 0001 View Active Service Locations Medicare Indicator assigned to current Service Location Medicare indicator informat
16. Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation o If you have been enrolled as an MA provider for one full calendar month or more in 2014 but less than the full calendar year in 2013 you are attesting that at least 60 of Medicaid billed codes billed from your enrollment date in 2013 to the day in which you attest are the qualifying E amp M and vaccine administration or product codes Layout Medical Assistance Program Fee Increase for Select Primary Care Services Physician Attestation Form for Calendar Years 2013 2014 Please complete the information in the sections and Ill or IV sign and return per the instructions NOTE EACH physician must complete an Attestation Form to be considered to meet elig equirements PRINT CLEARLY FIRST NAME LAST NAME PRACTICE NAME Optional INDIVIDUAL NP TS DIGIT PROVIDER ID s DESIGNATED CONTACT NAME DESIGNATED CONTACT PHONE NUMBER DESIGNATED CONTACT E MAIL ADDRESS Check specialty s that apply C Family Medicine C internal Medicine Pediatric Medicine AND Cl Subspecialty if applicable Section 1202 of the ACA and the implementing regulatons require states to increase fees for specified primary care services to at least the Medicare Physician Fee Schedule rate in effect for calendar years CYs 2013 and 2014 or if higher the CY 2009 Medicare conversion from January 1 2013 through December 31 2014 The regulation at 42 CFR 447 400 provides
17. Service Adjustment Indicates if service adjustment details are present Drop Down List 0 Indicator Special Program Code for this service line Box Special program code that contains code values Drop Down List 0 for EPSDT Physical Handicapped Children s Box Program Special Federal Funding and Disability These are the values allowed by HIPAA for this field Valid values are e 02 Physically Handicapped Children s Program e 03 Special Federal Funding e 05 Disability e 09 Second Opinion or Surgery PROMISe Provider Internet User Manual docx July 3 2014 169 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Srv Srv Adj State Accident Submit Tax ID Taxonomy Billing Provider Taxonomy Referring Provider Taxonomy Rendering Provider To DOS To DOS Service Lines list box Transport Distance Ambulance Transport Reason Code Ambulance Units Units Service Lines list box X Anesthesia Code X Condition Code X Diagnosis Code X Service Line Adjustment list box Zip Billing Provider Zip Referring Provider Zip Rendering Provider Description Sequential number of a service detail Sequential number of a service line adjustment State where the automobile accident occurred Submits claim to DPW Tax ID number for ISOs Taxonomy for Billing Provider ID Taxonomy for Referring Provider ID
18. Taxonomy Zip License MM DDIYYYY NDC Qualifier 03 NATIONAL DRUG CODE NDC NDC NDC is required Quantity Dispensed Quantity Dispensed is required New Refill is required New Refill Refills Authorized Days Supply is required Days Supply Prescription Origin Code 0 NOT KNOWN 1 NOT A COMPOUND Compound Indicator Dispense As Written 0 NO PRODUCT SELECTION INDICATED w Biling Note Add Submission Clarification Code xE w 1 NO OVERRIDE NeW eed help submitting a claim View sample claim submissions here Cardholder DOB Pregnancy Indicator Eligibility Clarification Code Attachment Control Patient Relationship Code Additional Patient Info Ind Other Coverage Code Usual and Customary Charge Pharmacy Service Type Level of Service Prior Authorization Type Prior Authorization Number Submitted Prior Authorization Number Found Dispensing Fee Submitted Gross Amount Due Ingredient Cost Basis of Cost Determination Unit of Measure MM DDIYYYY NOTSPECIFED v 0 NOT SPECIFIED v m 1 CARDHOLDER v 1 No m 0 NOT SPECIFIED BY PATIENT m Usual and Customary Charge is required 1 COMMUNITY RETAIL PHARMACY SERVICES m 0 NOT SPECIFIED v 1 PRIOR AUTHORIZATION v Gross Amount Due is required
19. 2 In the Release of Medical Data Benefit Assignment and Emergency drop down lists select a value To Complete Admission Discharge Information Step Action Response 1 In the Admission Discharge section type a value in the From DOS To DOS Admission Date Admission Hour Admission Type Admission Source and Discharge Hour fields To Complete Claim Diagnosis Information Step Action Response 1 In the Diagnosis section in the Code Type drop down list select a value 2 Type a value in the Primary Admission Diagnosis E Code fields 3 Click the Add button and type up to 8 values in Other field To Add Claim Surgical Code Date Information Step Action Response 1 In the Surgical Code Date section type up to 6 values in the Surgical Code and Date fields PROMISe Provider Internet User Manual docx July 3 2014 143 PROMI Provider Internet User Manual Se Internet Portal PA PROMISe System Documentation To Add Occurrence Code Date Information Step Action Response 1 In the Occurrence Code Date section type up to 8 values in the Surgical Code and Date fields To Add Occurrence Span Code Information Step Action Response 1 In the Occurrence Span Code section type more than 30 values in the Occurrence Span Code and
20. At least 60 percent of your billings for services rendered to Medicaid beneficiaries were for Healthcare Common Procedure Coding System HCPCS Evaluation and Management E amp M procedure codes 99201 through 99499 Current Procedural Terminology CPT vaccine administration codes 90460 90461 90471 90472 and or the toxoid vaccine product codes listed below currently used by the MA Program for purposes of vaccine administration payment PROMISe Provider Internet User Manual docx July 3 2014 275 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation PA MA VACCINE PRODUCT CODES 90585 90656 90693 90714 90735 90632 90657 90696 90715 90736 90633 90658 90698 90716 90743 90634 90660 90700 90717 90744 90636 90669 90702 90718 90746 90645 90670 90703 90719 90747 90646 90675 90704 90721 90748 90647 90676 90705 90723 90749 90648 90680 90706 90725 G0008 90649 90681 90707 90727 G0009 90650 90690 90708 90732 90654 90691 90710 90733 90655 90692 90713 90734 If you attest that you qualify for the increased fees based on your board certification you must also provide documentation of current board certification in family medicine internal medicine or pediatric medicine as granted by the ABPS the ABMS or the AOA to OMAP on or before December 31 2013 If your board certification documentation is valid through December 31 2014 you will continue to be eligible for the enhanced primary care pa
21. Condition Code 7 Date of Birth Date of Death Discharge Hour Error Code 1 Error Message Condition Code can only contain alphanumeric characters Condition Code must be 2 characters in length Condition Code can only contain alphanumeric characters Condition Code must be 2 characters in length Condition Code can only contain alphanumeric characters Condition Code must be 2 characters in length Condition Code can only contain alphanumeric characters Condition Code must be 2 characters in length Condition Code can only contain alphanumeric characters Condition Code must be 2 characters in length Condition Code can only contain alphanumeric characters Condition Code must be 2 characters in length Condition Code can only contain alphanumeric characters Patient date of birth for Patient must be a valid date less than or equal to today s date Patient date of death for Patient must be a valid date less than or equal to today s date Discharge Hour must be a valid 24 hour time PROMISe Provider Internet User Manual docx 130 To Correct Enter a Condition Code that contains only alphanumeric characters Enter 2 characters for the Condition Code Enter a Condition Code that contains only alphanumeric characters Enter 2 characters for the Condition Code Enter a Condition Code that contains only alphanumeric characters Enter 2 characters for the Condition Code Enter a Condit
22. Enter the answer to the question in the Your Answer field and click the Submit button 5 A validation message appears stating that the password will be sent to your email account PROMISe Provider Internet User Manual docx July 3 2014 30 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation v Forgot Password You have successfully validated your Password We have sent an email with your account information to the email address on record Email notifications can take 15 to 30 minutes to be delivered The email message you receive should read in part as follows This email was sent to confirm that we have reset your password in the PROMISe Internet Portal Your temporary password is listed below You need to login to the portal as soon as possible and enter a new password The next time you login you will be prompted to change your password 2 6 Forgot User ID In the event that you ve forgotten your User ID follow the steps below 1 Access the PROMISe Welcome Page 2 Click the Forgot User ID link Provider Login Broadcast Message This is a test of the Broadcast Providers with Service Plai Waiver providers who bill PROI the internet during a nightly m more information click more Where do I enter my password Notice Due to required Commonweal 9 00PM and 1 00AM on the isi PROMISe Provider Internet User Manu
23. Field All fields Card Number input Date of Birth Input Description Data Type Length Benefit quantity Character 0 Recipient number ID plus validation digit Character 10 Recipient ID returned in the search results Character 10 This field does not include the ACCESS card number Clears all entries from Selected Service Type Button 0 Code Recipient s Social Security Number Number 9 Searches database for the desired record Button 0 Type of Coverage Character 0 Code for Service Type List Box 0 Type of Provider Character 0 HIPAA mandated status for the eligibility or Character 70 benefit detail being displayed Time period of the benefit being described Character 999 To date that service provider wishes to verify Date 10 eligibility MM DD CCYY Type of eligibility being displayed in the given Character 150 summary line Date the verification request was run Date 10 MM DD CCYY Date of the recipient request Date 10 MM DD CCYY Number assigned to each eligibility response Number 13 used by the provider when contacting the EVS help desk to identify a specific EVS request Piron Error Message To Correct Code 0 Required recipient information is Verify and re enter not complete Please verify and re verification information enter verification information 0 Card Number must be a number Enter a numeric card number 0 Date of Birth is an invalid date Enter a valid date x PROMISe Provider Internet User Manual docx 1
24. Field Description Data Type Length Cancel End manage NPI Taxonomy request Button 0 Continue Moves to the next logical page or form Button 0 NPI Text entry field for the service location NPI Read Character 10 only if already on file in PROMISe Reset Restores the page to initial values Character 2000 Taxonomy Code Unlabeled field New instance for each active Character 10 taxonomy code on file Taxonomy Code Unlabeled field New instance for each active N A 0 Selector taxonomy on file Taxonomy Unlabeled field New instance for each active Character 50 Description taxonomy on file 6 32 ePEAP Review Changes The ePEAP Review Changes window is used to review and submit data update requests that were entered during the current ePEAP session This window can be accessed from the PA PROMISe Internet Provider Main Page by selecting ePEAP Provider Enrollment Automation Project From here select Enrollment Information and then click the Review Submit button In addition this window is automatically displayed each time the user makes a valid change and clicks the Continue button on any other ePEAP window PROMISe Provider Internet User Manual docx July 3 2014 245 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Layout PENNS YWANAD 2 PEAP Office of Medical Assistance Programs OMAP __ s Review Your Changes Changes Requested For Provider
25. Information window Exit Exit ePEAP Button 0 Gender Provider s gender if an individual Drop Down List Box 0 otherwise leave blank PROMISe Provider Internet User Manual docx 213 July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Help Issued By License License End Date License Start Date MA Enroll End Date Description Description of the fields on the ePEAP window Authority state agency that issued the provider s medical license Practitioners in Pennsylvania must be licensed and currently registered by the appropriate state agency Date license expires Date this license was first issued or a renewal date Date provider officially terminates enrollment concludes a period in which the provider is authorized to receive Medicaid payments for services rendered MA Enroll Start Date Date the provider officially began as a Medical Degree Medicare Indicator Information Medicare Number Medicare Type NPI New Medicare Provider Name Provider Type Provider Type Description Medical Assistance provider and became authorized to receive Medicaid payments Provider s medical degree Assign move or remove Medicare Indicator when current service location has a validated NPI number Medicare billing number assigned to the provider service location Read only as of 2 1 2008 Type of Medicare billing num
26. Internet Portal PA PROMISe System Documentation Other Options Step Action Result 1 Click the Close button Opens the ePEAP Menu window Field Descriptions Field Description Data Type Length Close Closes the current window Button 0 Displaying Results List of results in increments of Drop down List Box 15 1000 Only displayed when more than 1000 results are returned Effective Date Individual membership effective Date MM DD CCYY 8 date End Date End date of individual s group Date MM DD CCYY 8 membership Group Name Group name Character 50 Group Provider ID Group provider number Character Location Group provider location Character 4 Member Name Group member s name Character 50 Member Number Group member s provider number Character 9 Provider Type Group member s provider type Character 2 Service Location Group member s service location Character 4 View Results Displays a group of results Button 0 PROMISe Provider Internet User Manual docx July 3 2014 272 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 40 ePEAP Upload PDF The Upload PDF allows ePEAP users to upload documents into ePEAP Workflow and Doc Search Documents must be in the Adobe Portable Document Format PDF and may not exceed 4 MB in size Layout veo pennsylvania PSD DEPARTMENT OF PUBLIC WELFARE Your
27. Internet Portal PA PROMISe System Documentation Field Error Error Message To Correct Code Tooth Number 0 Service Line Tooth Enter a tooth Number can only contain number 01 33 and alphanumeric characters A T 1 Service Line Valid Enter a tooth values for Tooth Number number 01 33 and are 01 33 and A T A T Total Months Orthodontic Treatment 0 Total months must be Enter total months greater than or equal to greater then months remaining months remaining Units 0 Service Line Units is a Enter a value for required field units 1 Service Line Units Enter a positive may not be a negative number of units number 6 7 1 Accessibility and Use To access and use the Provider Dental Claim window complete the steps in the step action table s Note The following step action tables are organized to coincide with information as it is grouped in the online claim submission form window Billing Information is presented first then Claim Service information and on through the subsequent groups ending with Service Lines information To Access Provider Dental Claim Window Step Action Response 1 Logon to PA PROMIS e using the steps presented in The Provider Main Page the General User Manual window opens 2 Click the Claims tab The Claims window opens 3 Click the Submit Dental link The Provider Dental Claim window opens To Complete Claim Billing Information Note Claims should be complete
28. This information is auto filled from the Name field the legal name of the data available in PROMISe The user institution corporate entity practice may not update this information via the or individual provider associated EFT Enrollment Application window if with the service location s pay to appropriate address 2 In the Provider Information Section This information is auto filled from the Street field the number and street data available in PROMISe The user name where the provider service may update this information via the EFT location is located Enrollment Application window if appropriate 3 In the Provider Information Section This information is auto filled from the City field the city associated with the data available in PROMISe The user provider service location s street may update this information via the EFT address Enrollment Application window if appropriate 4 In the Provider Information Section This information is auto filled from the State Province field the two data available in PROMISe The user character code associated with the may update this information via the EFT state name Enrollment Application window if appropriate 5 In the Provider Information Section This information is auto filled from the Zip Code Postal Code field the full data available in PROMISe The user nine digit zip code assigned by the may update this information via the EFT Postal Service Enrollment Applica
29. X Service Line Removes the service line adjustment Adjustment Zip Billing Zip for Billing Provider ID Provider Zip Referring Zip for Referring Provider ID Provider Zip Rendering Zip for Rendering Provider ID Provider PROMISe Provider Internet User Manual docx 101 Box Button Button Button Button Character Character Character o Oo o o July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Edits Field Adjustment Group Code Admission Date Amount repeats up to 3 times Anesthesia Units Appliance Placement Date Benefits Assignment Other Insurance Billed Amount Code Type PROMISe Provider Internet User Manual docx Error Code 0 102 Error Message To Correct Adjustment Group Code Enter a valid is a required field Adjustment Group Code x is not a valid day in Enter a valid date month Use a value in the range l days in month Reason Amount must Enter a numeric be numeric Service Adjustment Amount Reason Amount Do not enter a reasonCounter 1 negative Service may not contain a negative Adjustment value Amount Service Line Do not enter a Anesthesia Units must be negative greater than zero Anesthesia Unit Count Service Line Enter Appliance Appliance Placement Date Placement Date must be less than or equal that is less than or to today s date equal
30. and FAR 52 227 19 June 1987 as applicable and any applicable agency FAR Supplements for non Department of Defense Federal procurements CMS Disclaimer The scope of this license is determined by the AMA the copyright holder Any questions pertaining to the license or use of the CPT should be addressed to the AMA End Users do not act for or on behalf of the CMS CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS OMISSIONS OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE In no event shall CMS be liable for direct indirect special incidental or consequential damages arising out of the use of such information or material Should the foregoing terms and conditions be acceptable to you please indicate your agreement and acceptance by clicking below on the button labeled accept The window layout above displays the default viewable area of the scrollable data the layout below displays the remaining data PROMISe Provider Internet User Manual docx July 3 2014 180 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation POINT AND CLICK LICENSE FOR USE OF CURRENT DENTAL TERMINOLOGY CDT End User License Agreement These materials contain Current Dental Terminology CDTTM Copyright 2010 American Dental Association ADA All rights
31. posca a E e E teen ieee E E 278 To Access the ePEAP Upload PDF Window sessssssesseeeesessessessisseesrsstesresressesresserrreseesrsresr 278 Field Descriptions A eenei a Ea E ie ea E E AERE O EA A A haute etl 278 6 42 ePEAP Field EditS ssossasiirnnrissiieiseo tais nn ia E AI a aes 281 PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 1 Introduction The PROMISe Provider Portal allows providers alternates billing agents and out of network OON providers with the proper security access to submit claims verify recipient eligibility check on claim status and update enrollment information Specifically users can use the Internet to e Electronically file claims for all claim types and adjustments in either a real time or an interactive mode from any location connected to the Internet e View the status of any claim or adjustment regardless of its method of submission e Access computer based training programs that will let users complete training courses from your desktop at your convenience e Update specific provider enrollment information electronically e Verify recipient eligibility within seconds of querying 1 1 Key Features and Benefits The interactive features on the PROMISe Provider Portal provide easy access and exchange of up to date information previously unavailable between providers DPW and drug manuf
32. relating to any unswor falsifications to authorities cca NEWLY ENROLLED PA MA PHYSICIAN PROVIDERS more than 31 days billing history in the current year and not enrolled at any time in the previous calendar year attest that am an eligible primary care physician or subspecialist but do not have a certification recognized by the ABMS ABPS or AOA attest that at least 60 of the procedure codes billed to Medicaid in the prior full calendar month as of the signature date of this attestation form were for the ESM vaccine administration and or vaccine product codes as set forth above attest that the information submitted in this attestation is true and accurate understand that any false statements made herein are subject to the penalties contained in 18 PA C S 4904 relating to any unswom falsifications to authorities a aca a i PROMISe Provider Internet User Manual docx July 3 2014 277 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 41 1 Accessibility and Use To access and view the ePEAP Upload PDF window complete the steps in the following step action tables To Access the ePEAP Upload PDF Window Step Action Result 1 Select the Upload PDF link in the ePEAP Menu The Upload PDF window opens Field Descriptions Field Description Data Type Length Browse Opens a Windows E
33. 1 4 adjustments are added To Remove Claim Service Adjustments Information Step Action Response 1 In the Service Adjustment section click the Remove The service adjustment is button removed To Submit Claim Step Action Response 1 Click the Submit button The claim is submitted PROMISe Provider Internet User Manual docx 177 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Copy a Paid Claim Note The Copy button is only available on paid claims Step Action Response 1 Using Claim Inquiry inquiry asp If a match is found the search results list is complete a claim search displayed 2 Select a paid claim The paid claim displays 3 Click the Copy button All data from the selected paid claim is copied to a new claim PROMISe Provider Internet User Manual docx 178 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 14 Provider Rate Disclaimer rate_disclaimer This page displays the legal disclaimer that providers have to accept to be able to download the MA Program Outpatient Fee Schedule Layout Rate Information Disclaimer Outpatient Fee Schedule OMAP Outpatient Fee User Agreements Before searching and or viewing the outpatient fee schedule information on this site you must read and register your
34. 2014 259 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To View Taxonomy Codes Associated With a Service Location Step Action Result Click on the View Taxonomy link for the requested Service Location 1 The following pop up window opens Z NPI Taxonomy Microsoft Internet Explorer provided by EDS COE DER Taxonomy for DOGOOD JAMES L NPI ID 1234567893 Provider ID 300180963 Service Location 0002 ALLOPATHIC amp OSTEO PHYSCNS 208D00000 GENERAL PRACTICE DEFAULT SPCLTY CD Close Field Descriptions Data Field Description Type Length Exit Exit ePEAP Button 0 ePEAP Menu Opens the ePEAP menu window Button 0 Help Describes the fields on the ePEAP window Button 0 NPI National Provider Identifier Number 10 Physical Site Street address associated with a service location The address Address consists of the following items Name Address Line 1 Address Line 2 City State Zip 10 digit Service Number assigned to an individual service location Character 4 Location View Opens the Specialties window for the selected service Hyperlink 0 Specialties location View Opens the Taxonomy window for the selected service Hyperlink 0 Taxonomy location PROMISe Provider Internet User Manual docx July 3 2014 260 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 37 eP
35. 250 Description Report Hyperlink containing the date the report was Hyperlink 0 Instance generated in Day Month Date Year format Selecting this link displays a graphical representation of the actual report in Adobe format Report Name of the report for which the query is performed Character 150 Name The user can return to the Provider Report Index to select a different report to query List Reports Earliest date to search for instances of this report Date 8 From MM DD CCYY Request Performs the report query Results are returned in the Button 0 Reports bottom portion of the window Return to Returns the user to the Provider Report Index Button 0 Report Menu window To Latest date to search for instances of this report Date 8 MM DD CCYY PROMISe Provider Internet User Manual docx July 3 2014 199 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Edits Field pes Error Message To Correct Code Request Reports 0 Invalid date combination entered TO date must occur after the FROM date must be further in the past FROM date than TO date 1 Invalid date combination entered User cannot query for reports in Dates cannot be in the future the future 2 Invalid date combination entered User cannot query on more than FROM and TO dates cannot be more 90 days of reports at one time than 90 days apart 3 Please enter both dates User must enter both a FROM and a TO d
36. 4 In the Pattern Time Code drop down list select a value To Add Claim Service Lines Information Step Action Response 1 In the Service 1 section click the Add button 2 Type a value in the From DOS and To DOS fields 3 In the Place of Service drop down list select a value 4 Type a value in the Procedure Modifiers 1 2 3 and 4 if applicable Diagnosis Pointer CLIA Number and Comment fields 5 In the Basis of Measurement drop down list select a value 6 Type a value in the Units and Billed Amount fields 7 In the Units Billed Amount Emergency Family Planning EPSDT and Contract Type drop down lists select a value 8 To add additional lines of service information click the An additional line is added to Add button and repeat steps 1 9 the claim repeat step 10 as necessary To Remove Service Lines Information Step Action Response 1 In the Service Lines section click the Remove button The service line is removed To Add Claim Service Adjustments Information Step Action Response 1 In the Service Adjustments for Service Line 1 section in the Adjustment Code Group drop down lists select a value 2 Type up to 3 values in the Reason Codes Amount fields 3 Type a value in the Paid Date Paid Amount and Carrier Code fields 4 Type a value in the Carrier Name field 5 To add additional service adjustments click the Add button The additional service and repeat steps
37. 4123 HOPE RD 717 444 4444 000 000 0000 HARRISBURG 17011 0000 select 423 HOPE RD 717 444 4gqd HARRISBURG 17011 0000 000 000 0000 select 423 HOPE RD 717 444 4444 Service Location HARRISBURG PA 17011 0000 000 000 0000 select 123 HOPE RD 717 444 7777 Home Office HARRISBURG PA 17041 0000 717 444 5555 Mail To Address Menu ePEAP Menu Help Review Submit 6 24 1 Accessibility and Use To access the Provider Address Information complete the steps in the step action table s PROMISe Provider Internet User Manual docx July 3 2014 219 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Access the Manage Active Addresses Information Step Action Result 1 Sign on to the PA PROMISe Internet The Provider Main Page appears on the application using instructions provided in desktop Section 2 9 of this manual 2 Click on the ePEAP Provider Enrollment The ePEAP Menu window opens Automation Project link in the Other Links section of the window 3 Select the Enrollment Information option The ePEAP Enrollment Information window opens 4 Click the Address Information link The ePEAP Provider Address Information window opens 5 Click the Manage Active Addresses link The Manage Active Addresses window opens To Update Address Related Information Step Action Result 1 Click the Select link next to the a
38. 81 Non Covered Days e 82 Coinsurance Days e 83 Lifetime Reserves Third code and description of monetary data as Drop Down List required by the payer organization Press the Box underlined Add link to add another Value Code 5010 values are e 80 Covered Days e 81 Non Covered Days e 82 Coinsurance Days e 83 Lifetime Reserves Fourth code and description of monetary data Drop Down List as required by the payer organization Press the Box underlined Add link to add another Value Code 5010 values are e 80 Covered Days e 81 Non Covered Days e 82 Coinsurance Days e 83 Lifetime Reserves Fifth code and description of monetary data as Drop Down List required by the payer organization Press the Box underlined Add link to add another Value Code 5010 values are e 80 Covered Days e 81 Non Covered Days e 82 Coinsurance Days e 83 Lifetime Reserves PROMISe Provider Internet User Manual docx 125 Length 0 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Value Code 6 Sixth code and description of monetary data as Drop Down List 0 required by the payer organization Press the Box underlined Add link to add another Value Code 5010 values are e 80 Covered Days e 81 Non Covered Days e 82 Coinsurance Days e 83 Lifetime Reserves Value Code 7 Seventh code and description of monetary data Drop Down Li
39. A N A N A Select a county for the drop down list Enter numeric date Enter 8 numbers Enter a date within the valid date range Enter in a valid end date Enter a future end date Enter numeric values Enter 8 numbers Enter a date within the valid date range Enter in a 10 digit fax number Enter in a 10 digit fax number Enter a 10 digit fax number July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Error Field Code Medicare Number 3 Pay to 1 Phone 3 Phone 8 Phone Fax 3 Provider ID 1 Provider ID of Group 1 Service Location of Group 4 PROMISe Provider Internet User Manual docx Error Message Fax number must be 10 digits Medicare number must be 0 9 or A Z Medicare number must be at least 6 characters in length You must change at least one pay to value to continue Pay to code must be numeric Phone number must be numeric Phone number must be 10 digits Phone number must be numeric Phone number must be 10 digits The fax number must be numeric The fax number must be 10 digits Enter Provider Number to continue Provider Number must be numeric To Correct Enter a 10 digit fax number Enter an alphanumeric Medicare number Enter a Medicare number with 6 10 characters Select new pay to value from the drop down list Select new pay to value from the drop down list Enter a 10 digit ph
40. Adjustment Group Code Amount 3 Reason Code Adjustment Group Code Amount Paid Date Paid Amount Medicare Approved Amount Inpatient and LTC Only Medicare Full Medicare Days Service Lines SVC Date of Service Revenue Code Units Billed Amount i SS Se ee ee Delete From Date MWODIYYYY Outpatient Only To Date AM DDPVYYY Outpatient Only Revenue Code j Procedure zz Modifiers 1 Outpatient Only 2 Outpatient Only 3 Outpatient only a Outpatient Only Basis of Measurement iv Units Units is required Billed Amount Billed Amount is required Claim Status Information Claim Status Not Yet Submitted PROMISe Provider Internet User Manual docx 114 July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Descriptions Field Add Condition Code Add Occurrence Code Date Add Occurrence Span Code Date Add Other POA Add Other Insurance Add Service Lines Add Surgical Code Date Add Value Code Amount Adjustment Group Code 1 Other Insurance Adjustment Group Code 2 Other Insurance Adjustment Group Code 3 Other Insurance Admission Date Admission Diagnosis Admission Hour Admission Source Admission Type Amount Other Insurance Amount 2 Other Insurance Amount 3 Other Insurance Description Add
41. Agent ID and social security number SSN or employer identification number EIN into the applicable fields 3 Click the Continue button PROMISe Provider Internet User Manual docx 14 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 4 The Registration Security Information window appears rN pennsylvania Home gt Registration Selector gt Registration Monday 06 21 2010 12 07 PM EST Registration Step 2 of 2 Security Informa Indicates a required field The User ID and Password cannot be the same and the password must be 8 20 characters in length contain a minimum of 1 numeric digit 1 uppercase letter and 1 lowercase letter User 10 Password Confirm Password Please provide your contact information below Display Name Sample Name Phone Number Email Confirm Email Please choose a personalized Site Key and enter a passphrase that will be used to verify your identity upon logging into the PROMISe Internet portal Site Key oT r p KALAS Apple OBalloon O Balloons Baseball Billiards Passphrase Please select a unique challenge question and provide an answer for each of the question groups below Challenge Question 1 What is your mother s maiden name Answer to 1 Challenge Question 2 Who was your
42. Code is entered Occurrence Date must be less than or equal to today s date Occurrence Date is a required field when Occurrence Code is entered Occurrence Date must be less than or equal to today s date Occurrence Date is a required field when Occurrence Code is entered Occurrence Date must be less than or equal to today s date Occurrence Date is a required field when Occurrence Code is entered Occurrence Date must be less than or equal to today s date Occurrence Date is a required field when Occurrence Code is entered Occurrence Date must be less than or equal to today s date Occurrence Span Code must be 2 characters in length To Correct Enter the Occurrence Date Enter an Occurrence Date that is less than or equal to today s date Enter the Occurrence Date Enter a Occurrence Date that is less than or equal to today s date Enter the Occurrence Date Enter a Occurrence Date that is less than or equal to today s date Enter the Occurrence Date Enter an Occurrence Date that is less than or equal to today s date Enter the Occurrence Date Enter a Occurrence Date that is less than or equal to today s date Enter the Occurrence Date Enter a Occurrence Date that is less than or equal to today s date Enter the Occurrence Date Enter a Occurrence Date that is less than or equal to today s date Enter 2 characters for the Occurrence Span Code Occurrence Span Code can only Enter a Occurrence Span Code
43. Date fields To Add Condition Code Information Step Action Response 1 In the Condition Code section type more than 20 values in the Condition Code field To Add Value Code Amount Information Step Action Response 1 In the Value Code Amount section type up to 12 values in the Value Code and Amount fields To Add Days Information Step Action Response 1 In the Days section type a value in the Covered Non Covered Medicare Coinsurance Days and Lifetime Reserve Days fields To Add Patient Information Newborn Only Step Action Response 1 In the Patient Information Newborn Only section type a value in the Patient ID Last Name First Name and Middle Initial 2 In the Gender drop down list box select a value 3 Type a value in the Date of Birth and Date of Death fields 4 Click the Add button to add additional Patient Information To Remove Patient Information Step Action Response 1 Click the Remove button To Add Other Insurance Information Step Action Response 1 In the Other Insurance section click the Add button 2 Type a value in the Group Number Group Name Carrier Code Policy Holder ID Code Policy Holder Last Name and Policy Holder First Name fields 3 In the Release of Medical Data and Benefit Assignment drop down lists select a value 4 Type a value in the Claim Filing Code field PROMISe Provider Internet User Manual docx July 3 2014 144 Provider Internet User Manual PROMISe Internet Portal PA PROMISe
44. Dimension for measurements Indicates if the prescriber s instructions regarding generic substitution were followed Dispensing fee submitted Pharmacy is clarifying eligibility based on receiving a denial Email address of the patient First name of the Medicaid recipient The NCPDP transaction limits first name to 12 characters First name of the patient Gross amount due Click to hide additional COB amounts Cost of ingredients Internal Control Number Last name of the Medicaid recipient The NCPDP transaction limits first name to 15 characters Last name of the patient Type of service the provider rendered License number for prescribing provider Measurement date PROMISe Provider Internet User Manual docx 151 Data Type Length Date 8 MM DD CCYY Date 8 MM DD CCYY Number 3 Character 15 Drop Down List 0 Box Drop Down List 0 Box Drop Down List 0 Box Character 9 Drop Down List 0 Box Character 80 Character 12 Character 12 Character 9 Button 0 Character 9 Character 30 Character 15 Character 15 Drop Down List 0 Box Character Date 8 MM DD CCYY July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length NDC National Drug Code used to identify a specific Character 11 drug or service ID NDC Qualifier Qualifying value for the NDC field Drop Down List 0 Box NPI Billing NPI for Billing Provider ID C
45. Documentation The window Layout above displays the default viewable area of the scrollable data the Layout below displays the remaining data Ambulance Transport Reason Code Iv Transport Distance Patient Weight Patient Newborn Only Patient Last Name First Name Middle Initial Patient ID Last Name First Name Middle Initial Gender v Date of Birth MM DD YYYY Date of Death MM DD YY YY Other Insurance Ol Carrier Code Group Number Group Name Policy Holder Last Name ETI Group Number Group Name Carrier Code Carrier Name Policy Holder ID Code Policy Holder Last Name Policy Holder First Name Individual Relationship Release of Medical Data PROMISe Provider Internet User Manual docx July 3 2014 161 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Benefits Assignment Claim Filing Code Patient Signature Service Lines SVC From DOS ToDOS Place of Service Procedure Units Billed Amount From DOS MM DDIYYYY From DOS is required To DOS MM DDIYYYY To DOS is required Place of Service Procedure Procedure is required Modifier1 Modifier2 1 Modifier3 Modifier4 Diagnosis Pointer 1 2 4 CLIA Number Comment Basis of Measurement w Units Billed Amount Emergency No m Family Planning No m E
46. ERA issues Required when Clearinghouse is the selected Method of Retrieval Clearinghouse Contact Telephone number of contact Numeric 10 aes Telenor Required when ei Clearinghouse is the selected Method of Retrieval Clearinghouse Contact Email address of contact Alpha numeric 50 Name Email Address Submission Information Reason for Submission Indicates provider s reason for Radio Buttons N A submitting the ERA form Possible values are e New Enrollment e Change Enrollment e Cancel Enrollment Authorized Signature PROMISe Portal User ID of Alpha numeric 50 Electronic Signature of person submitting enrollment Person Submitting Enrollment Printed Name of Person Name of the submitter Alpha numeric 50 Submitting Enrollment Printed Title of Person Title of the submitter Alpha numeric 50 Submitting Enrollment PROMISe Provider Internet User Manual docx July 3 2014 67 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Description Data Type Length Submission Date The date on which the enrollment is submitted Auto filled with current date Format CCY YMMDD Numeric 8 Requested ERA Effective Date Date the provider wishes to begin ERA Auto filled with current date User may not specify a past date Format CCY YMMDD Numeric Continue Opens ERA Agreement Window Button N A Cancel Discards any
47. Explorer window Button 0 on which the user can select a filie to upload Comments About Optional Comments Alphanumeric 1800 the PDF Contact Name Name of person uploading the file Alphanumeric 50 Email Address Email address of the person Alphanumeric 35 uploading the file Exit Ends the user s ePEAP session Button NPI User s NPI Number Phone Number Phone number of person uploading Number 10 the file Please select a Description corresponding to a Drop Down List Box 0 description PEAP Document Type Description Other corresponds to PEAP Document Type ePEAP Upload Provider Type User s Provider Type code and Alphanumeric 0 description Send Uploads the file Button Service Location User s service location code and Alphanumeric address Status Status of user s service location in Character 0 PROMISe Possible values are Active or Closed PROMISe Provider Internet User Manual docx July 3 2014 274 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Upload Form Path name of file selected for Alphanumeric 0 upload View Specialties Opens a new window that displays Hyperlink 0 specialty codes assigned to the user s service location View Taxonomy Opens a new window that displays Hyperlink 0 taxonomy codes assigned to user s service location Your Provider ID User s MPI and Legal Entity Name Alphanumeric ePEAP Access Indica
48. July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Medicaid Message Text Eligibility Detail Middle Initial Input Modifier 1 Input Modifier 2 Input Modifier 3 Input Modifier 4 Input Name Eligibility Summary Name Recipient Period Count Eligibility Detail Period End Eligibility Detail Period Start Eligibility Detail Policy Number Eligibility Detail Procedure Drug Code Input Procedure Drug Type Input Procedure Service Eligibility Detail Description Data Type Contains category program status and service Character program Free form message field returned by the EVS Character Various messages can appear in this repeating field Recipient s middle initial used to search by Character name Modifier for which eligibility is being Character requested This field is optional Modifier for which eligibility is being Character requested This field is optional Modifier for which eligibility is being Character requested This field is optional Modifier for which eligibility is being Character requested This field is optional Name of the primary entity associated with the Character given summary line Recipient s name returned by the EVS A Character maximum of 35 characters for last name 25 characters for first name and 1 character for middle initial can be displayed Information about the numb
49. July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Transaction Code Unit Unit of Measure Usual and Customary Charge Value X Amount Paid Qualifer X Clincal X COB X Coupon X Measurements X Patient Responsibility Qualifier X Reject Code X Submission Clarification Code Zip Billing Provider Zip Prescribing Provider Zip Code Field Edits Field Cardholder DOB Cardholder ID Date Prescribed Date of Service Description Data Type Length Transaction code for transactions Drop Down List 0 Box Unit of measurement Drop Down List 0 Box NCPDP standard product billing codes Drop Down List 0 Box Amount usually charged for the prescription Number 8 exclusive of sales tax or other amounts claimed Value for measurements Character 15 Remove the Amount Paid Qualifier Button 0 Remove the Clinical information Button 0 Remove the COB information Button 0 Remove the Coupon information Button 0 Remove the Measurement information Button 0 Remove the Patient Responsibility Qualifier Button 0 Remove the Reject Code Button 0 Remove the Submission Clarification Code Button 0 Zip for Billing Provider ID Character 9 Zip for Prescribing Provider ID Character 9 Patient s zip code Character 9 Error Error Message To Correct Code 0 Date of Birth must be valid and Enter a date that is less than or less than or equal to today s
50. MM DD CCYY Surgical Code Date Requested anticipated or actual date of Date 8 6 surgery MM DD CCYY Taxonomy Taxonomy for Attending Provider ID Character 10 Attending Provider Taxonomy Billing Taxonomy for Billing Provider ID Character 10 Provider Taxonomy Taxonomy for Operating Provider ID Character 10 Operating Provider Taxonomy Other Taxonomy for Other Provider ID Character 10 Provider To Date Latest ending date for service lines Date 8 MM DD CCYY To DOS Latest ending date of service found on the Date 8 claim MM DD CCYY Units Number of units provided to patient Number 10 Units Service Lines Number of units provided to patient Number 10 List Box Value Code 1 Code and description of monetary data thatis Drop Down List 0 necessary for processing the claim as required Box by the payer organization Press the underlined Add link to add another Value Code 5010 values are e 80 Covered Days e 81 Non Covered Days e 82 Coinsurance Days e 83 Lifetime Reserves PROMISe Provider Internet User Manual docx July 3 2014 124 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Value Code 2 Value Code 3 Value Code 4 Value Code 5 Description Data Type Second code and description of monetary data Drop Down List as required by the payer organization Press the Box underlined Add link to add another Value Code 5010 values are e 80 Covered Days e
51. Other Insurance 1 section click the Add button 3 Type a value in the Group Number Group Name Carrier Code Carrier Name Policy Holder ID Code Policy Holder Last Name and Policy Holder First Name fields 4 In the Release of Medical Data and Benefit Assignment drop down lists select a value 5 Type a value in the Claim Filing Code field 6 In the Patient Signature drop down list select a value 7 To add an additional insurance policy click the Add button and complete steps 1 6 To Remove Other Insurance Information Step Action Response 1 In the Other Insurance section click the The other insurance information is Remove button removed To Complete Claim Home Health Treatment Plan Information Step Action Response 1 In the Home Health Treatment Plan section in the Discipline Type Code drop down list select a value 2 Type values in the Total Visit s Rendered and Total Visit s Projected fields To Complete Claim Home Health Service Delivery Information Step Action Response 1 In the Home Health Service Delivery section type a value in the Number of Visits field 2 In the Frequency Duration of Visits and Pattern Code drop down lists select a value 3 Type a value in the Frequency Count and Duration of Visits Count fields PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Step Action Response
52. PROMISe Provider Internet User Manual docx July 3 2014 270 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout Provider Group Members Microsoft Internet Explorer provided by EDS COE Provider Group Members Group Provider ID 300276278 Location 0001 Group Name DOGOOD MEDICAL ASSOCIATES Member Service Location Provider Type Effective Date End Date Member Name Number 300180963 0001 31 04 01 2006 0411 2006 DOGOOD JAMES L 300180963 0001 31 04 49 2006 0149 2007 DOGOOD JAMES L 300180963 0001 31 01 24 2007 12 31 2299 DOGOOD JAMES L 6 39 1 Accessibility and Use To access and view the ePEAP Provider Group Members window complete the steps in the following step action tables To Access the ePEAP Provider Group Members Window Step Action Result 1 Select the View Provider Group Members The Provider Group Members window link in the ePEAP Menu opens To View More Than 1000 Records Step Action Result 1 If more than 1000 records are on file for a provider group only the first 1000 are initially displayed To view additional results select the desired block of records from the Displaying results drop down list 2 Click View Results The selected block of records is displayed in the Provider Group Members window PROMISe Provider Internet User Manual docx July 3 2014 271 Provider Internet User Manual PROMISe
53. Page The Registration Selector window will appear Yoo pennsylvania r Ce CROCE PROMISe Internet Home gt Registration Selector Thursday 07 22 2010 07 58 AM EST Registration Select one of the following options that best describes your role Alternate An individual or entity tha nrolled in the Pennsylvania An account created by a Provider for use by an individual Medicaid program as a provider of services within the provider s organization Alternate accounts can be authorized by a provider to bill for more than one 13 digit MPI and Service Location SU ih Billing Agent Out of Network A third party individual or entity who is authorized to submit An individual or entity that is authorized to access specific Medicaid transactions on behalf of a Provider functionality within the PROMISe Internet Portal Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 2 Select the Provider option The Registration Personal Information window will appear rey pennsylvania DEPARTMENT OF PUBLIC WELFARE Home gt Registration Selector gt Registration Monday 04 19 2010 03 00 PM EST Registration Step 1 of 2 Personal Information Indicates a required field Please provide the following information to get started First Name Last Name Provider ID SSN EIN 3 Enter your first name last name 13
54. Paid Amount Amount paid within a service line adjustment Number 9 Paid Date Date service line adjustment paid amount was Date 8 paid MM DD CCYY Patient Account Number assigned to the patient by their provider Character 38 used by the provider for their own internal claim submission tracking Patient ID Patient identifier given by the provider Character 10 Patient Pay Amount the recipient pays Number 9 Amount Patient Signature Indicates if the patient or subscriber Drop Down List 0 authorization signatures were obtained Box Patient Signature Indicates if the patient or subscriber Drop Down List 0 Other Insurance authorization signatures were obtained Box Patient Weight Weight of the patient transported by ambulance Number 4 Ambulance Place Of Service Location where a health care service was Drop Down List 0 Service Lines rendered for a service line Box Place of Service Location where a health care service was Drop Down List 0 rendered Box Policy Holder First First name of policyholder Character 25 Name Other Insurance PROMISe Provider Internet User Manual docx S y A 167 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Policy Holder ID Code Policy Holder Last Name Other Insurance list box Policy Holder Last Name Other Insurance Pregnancy Indicator Prior Authorization Procedure Procedure Service Lines list box
55. Prescription 0 Prescription is required Enter a valid prescription number Quantity Dispensed 0 Quantity Dispensed is required Enter a valid quantity dispensed Usual and Customary 0 Usual and Customary Charge is Enter a valid usual and Charge required customary charge 1 Usual and Customary Charge Enter a dollar amount in the must be of the format format 999999 99 99999 9 09 6 11 1 Accessibility and Use To access and use the Provider Pharmacy Claim window complete the steps in the step action table s Note The following step action tables are organized to coincide with information as it is grouped in the online claim submission form window Billing Information is presented first then Claim Service information and on through the subsequent groups ending with Service Lines information To Access Provider Pharmacy Claim Window Step Action Response 1 Logon to PA PROMIS e using the steps presented in The Provider Main Page the General User Manual window opens 2 Click the Claims tab The Claims window opens 3 Click the Submit Pharmacy link The Provider Pharmacy Claim window opens PROMISe Provider Internet User Manual docx July 3 2014 156 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation To Complete Claim Billing Information 157 Note Claims should be completed i
56. Reason Code 1 Reason Code 2 Reason Code 3 Recipient ID Referral Code Referring Provider ID Related Causes 1 Related Causes 2 Description ID Code for Policy Holder Last name of policyholder Last name of policyholder Is recipient pregnant PA number submitted on the claim Product service procedure code and related data elements Product service procedure code and related data elements Detailed reason the adjustment was made Detailed reason the adjustment was made Detailed reason the adjustment was made ID number issued to recipients who are authorized to receive Medicaid services The field accepts the 9 digit recipient ID and the single verification digit Referral code provided for referring provider ID number of the provider that referred the recipient to another provider for services Other causes related to the accident Valid values are e AA Auto Accident e EM Employment e OA Other Accident Other causes related to the accident Valid values are e AA Auto Accident e EM Employment e OA Other Accident PROMISe Provider Internet User Manual docx 168 Data Type Character Character Character Drop Down List Box Number Character Character Drop Down List Box Drop Down List Box Drop Down List Box Character Character Character Drop Down List Box Drop Down List Box Length 12 35 35 10 10 13 July 3 2014 Provider Interne
57. Service drop down list select a value 4 Type a value in the Procedure Modifier 1 2 3 and 4 and Tooth Number fields 5 In the Tooth Surface 1 2 3 4 5 OCD 1 2 3 4 5 and Placement Indicator drop down lists select a value 6 Type a value in the Prior Placement Date Appliance Placement Date Anesthesia Quantity Qualifier Anesthesia Units Units and Billed Amount fields To Remove Service Lines Information Step Action Response 1 In the Service Lines section click the Remove button To Add Claim Service Adjustments Information Step Action Response 1 In the Service Adjustments section click the Add button 2 In the Service Adjustment 1 section in the Adjustment Code Group drop down lists select a value 4 Type a value in the Reason Codes Amount Paid Date Paid Amount and Carrier Code fields To Remove Claim Service Adjustments Information Step Action Response 1 In the Service Adjustment section click the Remove button To Submit Claim Step Action Response 1 Click the Submit button The claim is submitted To Create New Claim Form Step Action Response 1 Click the New button The screen refreshes to create new claim form To Copy a Paid Claim Note The Copy button is only available on paid claims Step Action Response 1 Using Claim Inquiry inquiry asp If a match is found the search results list is complete a claim search displayed 2 Select a paid claim The paid claim displays 3 Click the Copy button All data fr
58. Submit Opens the Review Your Changes window Button 0 Sve Loc Service location of the group Character 4 ePEAP Menu Opens the ePEAP menu window Button 0 6 31 ePEAP Manage NPI Taxonomy The ePEAP Manage NPI Taxonomy window is used to capture a provider s NPI number and associated taxonomy codes If the NPI is not currently on file the NPI field will appear blank and be available for data entry If the NPI is on file the NPI field will display the value and will be read only All potentially valid taxonomy codes and descriptions for the provider will appear below the NPI field with a corresponding checkbox Taxonomy codes that are already associated with the NPI and are active will be checked To check the valid combinations of provider type specialty to taxonomy codes see the Provider Type and Specialty to Taxonomy Crosswalk on the DPW website This window can be accessed from the PA PROMISe Internet Provider Main Page and select ePEAP Provider Enrollment Automation Project From here select Enrollment Information and then Manage NPI Taxonomy Codes This window is accessible by the provider community PROMISe Provider Internet User Manual docx July 3 2014 239 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout PENNS YLUANID ii PEAP Office of Medical Assistance Progra ms OMAP Your Provider ID 300180963 DOGOOD JAMES L Status Active NPI 1234567893 Vie
59. Surgical Date has been entered Surgical Code can only contain alphanumeric characters Surgical Code is a required when Surgical Date has been entered Surgical Code can only contain alphanumeric characters PROMISe Provider Internet User Manual docx 139 To Correct Enter the Release of Medical Data Enter the Release of Medical Data for OI Enter a Report Transmission Code Enter a Report Type Code Enter a Revenue Code that is 3 or 4 characters in length Enter a positive numeric value for the Revenue Code Enter a state abbreviation consisting of 2 alpha characters Enter a Surgical Code that contains only alphanumeric characters Enter the Surgical Code Enter the Surgical Code Enter a Surgical Code that contains only alphanumeric characters Enter the Surgical Code Enter a Surgical Code that contains only alphanumeric characters Enter the Surgical Code Enter a Surgical Code that contains only alphanumeric characters July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Surgical Code 5 Surgical Code 6 Surgical Code Date 1 Surgical Code Date 2 Surgical Code Date 3 Surgical Code Date 4 Surgical Code Date 5 Surgical Code Date 6 To Date Error Code 1 Error Message Surgical Code is a required when Surgical Date has been entered Surgical Code can only contain a
60. The Provider Claim Inquiry window is used by providers to search all fee for service claims associated with their provider number Fee for service claims on which the billing provider or submitting provider matches the inquiring provider s ID can be searched The search can be narrowed by specifying the ICN date range or claim status criteria Only the top section of the window above the Search button appears when the window is first accessed The search results section in the lower portion of the window as shown in the Layout below appears after a search has been initiated This section displays the search results This window is accessed by selecting Claim Inquiry from the Claims option in the Menu Bar on the Provider Main Page or by clicking the Claim Inquiry link on the Provider Main Page PROMISe Provider Internet User Manual docx July 3 2014 86 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Layout rN pennsylvania DEPARTMENT OF PUBLIC WELFARE PROMISe Internet eeu Claims Malet Cm ae eel MC a Claim Inquiry Submit institutional Submit Professional Submit Dental Submit Pharmacy Search Request ACN Claims gt Claim Inquiry Recipient ID ICN Date of Service Inquiry Information Claim Inquiry 1234567890123 3210987654321 Any Status Wednesday 11 09 2011 03 30 PM EST Field Descriptions Field Billed Amount Cla
61. The ePEAP Add A Group For Fee Assignment link Assignment window opens To Add a Group for Fee Assignment Information Step Action Result 1 Enter the provider ID number of the group being added in the Provider ID of Group field 2 Enter the service location number of the group being added in the Service Location of Group field 3 Click the Continue button The Review Your Changes window opens Click Continue to return to the Enrollment Information window Other Options Step Action Result 1 Click the Fee Assignment Menu button Opens the Fee Assignment Menu window 2 Click the ePEAP Menu button Opens the ePEAP Menu window 3 Click the Help button Describes the fields on the ePEAP window 4 Click the Review Submit button The request summary is reviewed and submitted 5 Click the Exit button Opens the PA PROMISe Provider Main Page PROMISe Provider Internet User Manual docx 235 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Descriptions Field Description Data Type Length Continue Moves to the next logical page or form Button 0 Exit Exit ePEAP Button 0 Fee Assign Menu Returns the ePEAP user to the Fee Assignment Button 0 window Help Describes the fields on the ePEAP window Button 0 Provider ID of Provider identification number of the group Number 9 Group Review Submit Opens th
62. Transfer EFT This window is accessed from the PA PROMISe Internet Provider My Home Page and clicking on the EFT and ERA Enrollment menu option in the menu bar The window displays the current EFT and ERA activity status in PROMISe of the provider service location that the user is currently logged into on the portal Valid values are e Enrolled PROMISe EFT status is active e Pre notification PROMISe sending test transactions for 3 weeks before full enrollment e Not Enrolled PROMISe EFT status is cancelled or EFT was never set up Layout VEN pennsylvania PROMISe Internet My Home Roero MC el erea OEE ea Enrolled Provider Search EFT and ERA Enrollment My Home gt EFT and ERA Enrollment Wednesday 12 11 2013 11 56 AM EST Electronic Funds Transfer EFT and Electronic Remittance Advice ERA Enrollment Provider 1D 123123123 0032 Name OURTOWN HOSPITAL Electronic Funds Transfer EFT EFT Status Financial Institution Routing Number Provider s Account Number Type of Account Enrolled 012345870 i 2345 Checking Most Recent Online EFT Enroliment Request Submission Date Request Status EFT Enroliment Request q4 Electronic Remittance Advice ERA ANSI X12 835 transactions ERA Status Submitter ID for ANSI X12 Not Enrolled Most Recent Online ERA Enroliment Request Submission Date Request Status ERA Enrollment Request 3 2 1 Accessibility and Use To complete the Electr
63. Unique PIN Alternate Code Status 1 Alt Standin 00 00 0000 9876 00000 Active In Progress 8 To change an alternate s status click his or her name lt TMENT OF PUBLIC WELFARE rey ennsylvania My Home gt Manage Alternates Thursday 06 24 2010 09 44 AM EST Alternate Assignment Edit Alternate Click Inactivate to release the alternate listed below Back to My Home First Name Sample Last Name User Birth Date 01 01 19 Unique PIN 1234 Alternate Code 00000 Alternates Click the Alternate s name to change the status of the alternate Name a Birth Date Unique PIN Alternate Code PROMISe Provider Internet User Manual docx July 3 2014 24 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 9 Click the Inactivate button to deactivate a given alternate 10 A confirmation pop up box displays confirming the action v Alternate Assignment x The alternate status for Sample User Account has been set to Inactive 11 The Inactivate button is replaced by the Reactivate button to reactivate the alternate click the Reactivate button 2 4 2 Adding a Registered Alternate Providers billing agents and OON providers have the option of either creating a new alternate login or of granting permission to an existing one The Add Registered
64. Your Provider ID User s MPI and Legal Entity Name Alphanumeric ePEAP Access Indicates whether or not user s service location is authorized to update enrollment information through ePEAP Possible values Full Access or Read Only Character ePEAP Menu Returns to the ePEAP Menu Button PROMISe Provider Internet User Manual docx 279 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout Q pennsylvania DEPARTMENT OF PUBLIC WELFARE Your Provider ID 000850955 COWANSVILLE AREA HLTH CTR NPI View Specialties Service Location 0001 RR 1 BOX 168 COWANSVILLE PA 16218 9410 Provider Type 08 CLINIC Session time 21 10 Status Active ePEAP Access Full Access Revalidation Date 03 24 2016 Friday 16 August 2013 1 48 pm Upload PDF PDF and file size must not exceed 4 megabytes Instructions To send a file from your computer to the Department of Public Welfare please follow the four steps below The file must be in the Portable Document Format Upload From C Users basti_PAXIX Doc Step 1 Please click Browse and then select a PDF from your computer Step 2 Please select a description for the PDF Attest 60 Percent Primary Care x required Step 3 Please tell us how to contact you Optionally add comments about the PDF Step 4 Please send the PDF
65. button To cancel the operation and return to the Add Registered Alternate tab click the Cancel button If no changes are necessary click the Confirm button An Alternate Confirmation pop up box appears confirming that the registered alternate has been added to the user s alternate list A row of information about the added registered alternate appears at the bottom of the Manage Alternates window To change an alternate s status click his or her hyperlinked name Click the Inactivate button to deactivate a given alternate A confirmation pop up box displays confirming the action The Inactivate button is replaced by the Reactivate button to reactivate the alternate click the Reactivate button First Time Access for Alternates Initial Password Once an alternate has been created for a provider billing agent or OON provider in PROMISe the alternate must go through the registration process 1 On the PROMISe Welcome Page click the Register Now link The Registration Selector window displays PROMISe Provider Internet User Manual docx July 3 2014 26 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Ve ennsylvania WON eae oes PROMISe Internet Home gt Registration Selector Thursday 07 22 2010 07 58 AM EST Registration Select one of the following options that best describes your role 98 Provider Alternate An individual or entity that i
66. compliance with both the License for Use of Physicians CURRENT PROCEDURAL TERMINOLOGY CPT 2005 Fourth Edition and the Point and Click license for use of ADA CURRENT DENTAL TERMINOLOGY Version 2009 10 Please read over each of the documents displayed below and signify your acceptance of them by clicking on the I Accept button at the bottom of this page Upon accepting the terms of these documents you will be automatically forwarded to the Outpatient Fee Schedules License For Use Of Physicians Current Procedural Terminology Fourth Edition CPT CPT codes descriptions and other data only are copyright 2011 American Medical Association All rights reserved CPT is a registered trademark of the American Medical Association AMA You your employees and agents are authorized to use CPT only as contained in the following authorized materials of Centers for Medicare and Medicaid Services CMS internally within your organization within the United States for the sole use by yourself employees and agents Use is limited to use in Medicare Medicaid or other programs administered by CMS You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement Any use not authorized herein is prohibited including by way of illustration and not by way of limitation making copies of CPT for resale and or license transferring copies of CPT to any party not bound by this agreement creat
67. contain alphanumeric characters PROMISe Provider Internet User Manual docx 133 that contains only alphanumeric characters July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Occurrence Span Code 1 From Date Occurrence Span Code 1 To Date Occurrence Span Code 2 Occurrence Span Code 2 From Date Occurrence Span Code 2 To Date Occurrence Span Code 3 Occurrence Span Code 3 From Date Error Code 0 Error Message Span From Date is a required field when Occurrence Code is entered Span From Date must be less than or equal to today s date Span From Date must be less than or equal to Span To Date Span Thru Date is a required field when Occurrence Code is entered Span Thru Date must be less than or equal to today s date Occurrence Span Code must be 2 characters in length To Correct Enter the Span From Date Enter a Span From Date that is less than or equal to today s date Enter a Span From Date that is less than or equal to Span To Date Enter the Span Thru Date Enter a Span Thru Date that is less than or equal to today s date Enter 2 characters for the Occurrence Span Code Occurrence Span Code can only Enter a Occurrence Span Code contain alphanumeric characters Span From Date is a required field when Occurrence Code is entered Span From Date must be less than or equal to today s date Span From Date
68. coupon Valid values are e 01 Price Discount e 02 Free Product e 99 Other Type of coverage PROMISe Provider Internet User Manual docx 150 Data Type Button Button Drop Down List Box Drop Down List Box Character Character Character Drop Down List Box Character Drop Down List Box Character Character Date MM DD CCYY Character Drop Down List Box Button Character Character Drop Down List Box Drop Down List Box Length 0 0 30 11 20 64 20 12 15 July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Date Of Service Date Prescribed Days Supply Diagnosis Code Clinical Diagnosis Code Qualifier Clinical Dimension Dispense as Written Dispensing Fee Submitted Eligibility Clarification Code Email First Name First Name Additional Patient Information Gross Amount Due Hide COB Amounts Ingredient Cost Internal Control Number Last Name Last Name Additional Patient Information Level of Service License Measurement Date Description Date that services were performed Date that a physician prescribed a drug for a recipient Number of days a prescribed drug should last a recipient Diagnosis code for the claim or encounter record Diagnosis code for the claim or encounter record You can add up to three diagnosis codes
69. data entered and returns user to the EFT and ERA Enrollment Window PROMISe Provider Internet User Manual docx 68 Button N A July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 4 Provider Inquiries Through the PA PROMISe Internet application providers can check a claim s status along with other claim inquiry capabilities The search can be narrowed by specifying the ICN date range claim status or claim type criteria 4 1 About Internal Control Numbers ICNs Each claim is assigned a 13 digit Internal Control Number ICN This ICN identifies each claim as it is processed tracked and reported The ICN 13 digit number is assigned to the invoice by DPW and includes e Digits 1 and 2 represent the Region Code e Digits 3 through 7 represent the Year and Julian Date that the claim was submitted and facilitate time limit editing e Digits 8 and 9 represent the Batch Number e Digits 10 through 13 represent the Claim Sequence within the batch Reai Yearand Batch Claim egion Julian Number Sequence Code ry ha amn 1204047891011 4 2 Using the Provider Claim Inquiry Window The Provider Claim Inquiry window is used to search claims view original claims by ICN verify recipient eligibility check the status of one or more claims or make an adjustment to a claim Regardless of submission media you can retrieve all claims associated with your prov
70. equal to today s date date 0 Cardholder ID is required Enter a valid cardholder ID 0 Date Prescribed must be valid Enter a date that is less than or and less than or equal to today s equal to today s date date 0 Date of Service is required Enter a valid Date of Service 1 Date of Service must be valid Enter a date that is less than or and less than or equal to today s equal to today s date date PROMISe Provider Internet User Manual docx 155 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field ar Error Message To Correct ode Days Supply 0 Days Supply is required Enter a valid days supply 1 Days Supply Must be a whole Enter a value between 1 and 999 number between 1 and 999 Gross Amount Due 0 Gross Amount Due is required Enter a valid gross amount due 1 Gross Amount Due must be of Enter a dollar amount in the the format 999999 99 format 999999 99 Ingredient Cost 0 Ingredient Cost must be of the Enter a dollar amount in the format 99999999 format 999999 99 NDC 0 NDC must be 11 digits Enter a value that is 11 digits New Refill 0 New Refill is required Enter a value Patient Paid Amount 0 Patient Paid Amount must be of Enter a dollar amount in the the format 999999 99 format 999999 99 Prescriber ID 0 Prescriber ID is required Enter a valid prescriber ID 1 Prescriber must be 8 valid Enter a prescriber ID that is at characters or more least 8 digits
71. first employer x Answer to 2 Challenge Question 3 what is the name of your favorite school teacher x Answer to 3 User Agreement By checking the box provided below and transmitting this form electronically I state I am the person whom I represent myself to be herein and I affirm the information within this web application is complete and accurate and made subject to the penalties of 18 Pa C S 4904 relating to unsworn falsification to authorities In addition I acknowledge that misstating my identity or assuming the identity of another person may subject me to misdemeanor or felony criminal penalties for identity theft pursuant to 18 Pa C S 4120 or other sections of the Pennsylvania Crimes Code By entering my full name in the space provided below and transmitting this form electronically I state that I am the person whom I represent myself to be herein and I acknowledge that I have read and understand the User Agreement and agree to the terms and conditions as described about the role that I will perform Please sign by typing your full name here PROMISe Provider Internet User Manual docx July 3 2014 15 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 5 The Display Name field is already populated with the first and last name you entered on the first Registration window 6 Create and enter a User I
72. for more detailed information about Field Edits Features Additional functions available through menu options where applicable Accessibility and Use Narrative Description of how the window is accessed followed by Step Action Tables systematic instructions to navigate within and between PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation windows and perform basic functions and operations within the window 1 4 About Field Edits All relevant Field Edits for the windows in the Provider Internet User Manual are listed after the Field Descriptions for each window in Section_5 if Field Edits are applicable to the window being described Not all windows are subject to Field Edits If Field Edits do not apply to a window the Field Edits table states No Field Edits found for this window Windows that do not require field edit information are usually windows that do not contain fields in which you enter or save information Field Edits are a combination of error messages which the system detects and communicates and the corrective actions that should be taken to remedy them The columns of information in the Field Edits tables should be used to understand the error messages you may receive while using the PA PROMISe Internet application and what to do about them The Field column reflects the name
73. headings for eight window functions Additional features commands and window options appear in horizontal sub menus and take you to a specific function or window Available Menu Bar options will vary depending on your user role i e Provider Billing Agent or Out of Network Provider Select a command or window option in the following manner 1 Drag the cursor over the desired command on the Menu Bar 2 A horizontal menu appears with secondary options for the Claims Eligibility and Trade Files menus Select the desired option The table below describes the menu and window options that are accessible from the Menu Bar Menu Selection My Home Displays or returns to the Provider My Home Page Claims Claim Inquiry Displays the Claim Inquiry function Submit Institutional Displays the online Institutional Claim form in a new window Submit Professional Displays the online Professional Claim form Submit Dental Displays the online Dental Claim form in a new window Submit Pharmacy Displays the online Pharmacy Claim form in a new window Search Request Displays the Provider Claim Attachment Number Request Attachment Control Number function A search for an existing attachment control number may also be performed Eligibility Inquiry Displays the Recipient Eligibility Verification function Trade Files Download Displays the Web based file download function Files t
74. herein and I affirm the information within this web application is complete and accurate and made subject to the penalties of 18 Pa C S 4904 relating to unsworn falsification to authorities In addition I acknowledge that misstating my identity or assuming the identity of another person may subject me to misdemeanor or felony criminal penalties for identity theft pursuant to 18 Pa C S 4120 or other sections of the Pennsylvania Crimes Code By entering my full name in the space provided below and transmitting this form electronically I state that I am the person whom I represent myself to be herein and I acknowledge that I have read and understand the User Agreement and agree to the terms and conditions as described about the role that I will perform Please sign by typing your full name here PROMISe Provider Internet User Manual docx July 3 2014 28 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 Create and enter a User ID into the User ID field e The User ID must be 6 to 20 characters in length and contain only letters and numbers e The User ID and Password cannot be the same e Once you ve entered text in the User ID field click the Check Availability button to see whether the User ID you selected is already in use If it is not in use the first confirmation message will appear if it is in use the second confirmation message will appear v User ID
75. is cancelled and the content is cleared Button 0 New city Character 18 Opens the Review Your Changes window Button 0 Pennsylvania county where address is located Drop down 0 List Box Exits ePEAP Button 0 Telephone extension for new address Number 4 Fax number for the specific address code Character 10 Indicates by Yes or No whether address is Radio Button 0 handicap accessible Describes the fields on the ePEAP window Button 0 Assigns this new address as the home office Check Box 0 address for current service location Assign this new address as mail to address for Check Box 0 current service location Assigns this new address as the pay to address Check Box 0 for current service location Phone number for the specific address code Character 10 July 3 2014 224 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Reset Clears all fields Button 0 Review Submit Opens the Review Your Changes window Button 0 State New state Drop down 0 List Box ZIP Code New 5 digit ZIP code plus 4 digit suffix Character 9 ePEAP Menu Returns to the ePEAP menu window Button 0 6 26 ePEAP Edit Address Related Information The ePEAP Edit Address Related Information window is used to modify address related phone and fax numbers and handicap access status information for the current provider In addition the user can assign or unassign this address as t
76. log you out and you ll receive a Timeout Notification Session Ended message Any work that has not yet been submitted will be lost v Timeout Notification Session Ended x Your session has ended for security reasons due to inactivity Click OK to return to the Welcome page You will have to log on again to start a new session 1 Click the OK button 2 Click the Home tab 3 You will be returned to the Welcome to PROMISe Page PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 2 Registering for and Logging On to the PROMISe Provider Portal Providers must follow the security process to be granted access to the PROMISe Provider Portal application Please follow the steps listed below to attain this access e You must be registered with the Commonwealth or Pennsylvania as an enrolled and valid provider e You must have a provider ID and service location s This information becomes very important when you request authorization for a logon ID and password e You must have a computer with access to the Internet and an active Internet account Use this link http promise dpw state pa us to access the PROMISe Welcome Page Yoo ennsylvania ie sii fap ee PROMISe Internet Home Wednesday 11 02 2011 11 35 AM EST Provider Login User ID Forgot U
77. menu for the current ePEAP window Button 0 Manage Opens the Manage NPI and Taxonomy Codes Hyperlink 0 NPI Taxonomy window Review Submit Opens the Review Your Changes window Button 0 6 22 ePEAP Basic Enrollment Information The ePEAP Basic Enrollment Information window is used by the provider community to display and update basic provider information Existing provider information is automatically displayed This window is accessed from the PA PROMISe Internet Provider Main Page by clicking on the ePEAP Provider Enrollment Automation Project link in the Other Links section of the window to open the ePEAP Menu Under Provider Options click the Provider Enrollment link to open the ePEAP Enrollment Information window Click on the Base Information link to open the ePEAP Basic Enrollment Information window PROMISe Provider Internet User Manual docx July 3 2014 209 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout Department of Public Welfare 7 es e Office of Medical Assistance Programs OMAP Your Provider ID 300180963 DOGOOD JAMES L Status Active NPI 1234567893 view Taxonomy ePEAP Access Full Access Service Location 0001 123 HOPE RD HARRISBURG PA 17011 Provider Type 31 PHYSICIAN View Specialties Basic Enrollment Information Legal Entity Information ACH Existing DEA Birth Date 02 03 1966 is Gender M UPIN
78. must be less than or equal to Span To Date Span Thru Date is a required field when Occurrence Code is entered Span Thru Date must be less than or equal to today s date Occurrence Span Code must be 2 characters in length that contains only alphanumeric characters Enter the Span From Date Enter a Span From Date that is less than or equal to today s date Enter a Span From Date that is less than or equal to Span To Date Enter the Span Thru Date Enter a Span Thru Date that is less than or equal to today s date Enter 2 characters for the Occurrence Span Code Occurrence Span Code can only Enter an Occurrence Span Code contain alphanumeric characters Span From Date is a required field when Occurrence Code is entered Span From Date must be less than or equal to today s date PROMISe Provider Internet User Manual docx 134 that contains only alphanumeric characters Enter the Span From Date Enter a Span From Date that is less than or equal to today s date July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Occurrence Span Code 3 To Date Occurrence Span Code 4 Occurrence Span Code 4 From Date Occurrence Span Code 4 To Date Operating Provider ID Original Claim Other 1 Diagnosis Error Code 2 Error Message Span From Date must be less than or equal to Span To Date Span Thru Date is a required field whe
79. of a field found in one or more of the windows of this application The Error Code is a numeric value the system uses to identify the correct error message to display The Error Message column shows the message displayed by PA PROMISe to tell you the error has occurred The content of each error message is specific to the field in which the error occurred The To Correct column describes how to correct the detected error PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 1 4 1 Sample Error Message Scenario The following scenario depicts a sample of when an error message occurs and how to correct it You are working in a window that contains the field Adjustment Group Code When you finish entering information in the window and attempt to go to another window or complete the action on which you are working the following error message appears Adjustment Group Code is a required field This error message indicates to you that you have forgotten to enter information in this field or that the information you entered is not correct and the system requires this information to correctly process the task you are performing To correct the error locate the Adjustment Group Code field in the Field Edits table for that window and follow the instruction in the To Correct column For this field and error the instructions are Ent
80. on with the current date on which the EFT which the EFT application form is application form is submitted in format submitted in CCYYMMDD format CCYYMMDD The User may not update this field 26 Click the Submit EFT Enrollment The Electronic Funds Transfer EFT Form option to submit the EFT Enrollment Application Agreement window opens PROMISe Provider Internet User Manual docx 51 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout I hereby authorize the Commonwealth of Pennsylvania to post payments into the financial account referenced above I certify the foregoing information is true accurate and complete under penalty of perjury If the signatory is a preparer and not the provider identified by the Medicaid Number noted above the signatory acknowledges that as the preparer he or she is providing the information on behalf of the provider and that the provider authorized the preparer to complete this action I acknowledge that I read and understand this agreement If there is an EFT failure I agree to have the payment made by check and mailed to the address listed on the PROMISe provider file Electronic signature By selecting the Accept button you are signing this agreement electronically You agree your electronic signature is the legal equivalent of your written signature on the agreement and the provider and any preparer is bo
81. only contain alphanumeric characters Service Line Modifier A must be 2 characters Service Line Modifier 4 can only contain alphanumeric characters NPI must be 10 digits NPI must be 10 digits Original Claim must be 13 characters Original Claim must be numeric Original Claim Number is a Required Field 104 To Correct Enter a character Facility ID Enter a valid 2 character modifier code Enter a valid 2 character modifier code Enter a valid 2 character modifier code Enter a valid 2 character modifier code Enter a valid 2 character modifier code Enter a valid 2 character modifier code Enter a valid 2 character modifier code Enter a valid 2 character modifier code Enter a 10 digit NPI Enter a 10 digit NPI Enter a valid 13 character Original Claim Enter a valid 13 character Original Claim Enter a valid 13 character Original Claim July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Paid Amount Paid Date Patient Pay Amount Prior Authorization Prior Placement Date Procedure Reason Code PROMISe Provider Internet User Manual docx Error Code 3 105 Error Message The ICN entered for the Original Claim number is an encounter Encounters may not be adjusted or voided Service Adjustment Paid Amount is a required field Service Adjustme
82. password Your personalized site key token helps you identify that you are at the valid PROMISe Portal site Note If you have not created your personalized site key token you will be asked to do so before you sign into the PROMISe Portal Close Logout Link The Logout link is located in the upper right corner of most PROMISe Internet windows Clicking this link will cause the following confirmation message to appear Logout Confirmation Are you sure you want to logout Click the OK button to logout You will be returned to the PROMISe Welcome Page in a logged out status 1 6 Timeout Notifications If you step away from your PC or stop working in the Provider Portal for more than 25 minutes you ll receive a Timeout Notification instructing you to click the Extend button to continue working in the portal PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Timeout Notification x As of 11 43 AM your session will expire in 3 minutes To remain logged in and avoid losing any data that you may have entered please click Extend Otherwise you will be logged off and your current session will end Any unsaved data will be lost If you step away from your PC or stop working in the Provider Portal for more than 30 minutes the system will
83. provider for the PROMISe Internet Portal A confirmation email containing your login information has been sent to the email address provided Email notifications can take 15 to 30 minutes to be delivered 12 The user will be returned to the initial Welcome to PROMISe page and will need to logon 2 5 Forgotten Passwords In the event that you forget your password follow the steps below These steps apply to providers OON providers billing agents and alternates 1 On the PROMISe Welcome Page enter your user ID in the User ID field and click the Log In button 2 On the Challenge Question page enter the answer to the challenge question posed in the Your Answer field click the Continue button 3 On the Site Token Password page click the Forgot Password link The Forgot Password page appears DEPARTMENT OF PUBLIC WELFARE ry pennsylvania Home Home gt Forgot User ID gt Challenge Question gt Site Token Password gt Forgot Password Thursday 04 22 2010 09 19 AM EST Forgot Password Indicates a required field Answer the following challenge question We will use the answer to help authenticate your identity If we find a match an email will be sent to your email address on record Challenge Question What is the name of your favorite school teacher Your Answer 4 On the Forgot Password page another challenge question will be posed
84. service for further assistance through service plans in HCSIS w between 11 40PM and 12 10AM nay be unavailable for short periods Quick Links month Need Help Thank you for your patience Use the Internet Help Manuals here Notice Demo of PA PROMISe Welcome to the new PROMISe Internet Portal where you will find a new look along with enhanced security features We appreciate your patience as you may be required to take a few moments to e Learning courses make updates to your user profile m Provider Awareness PROMISe Internet A ee m CMS 1500 08 05 PWR Rao EEE oO m CMS 1500 08 05 Waivers y lt O IVI D P kdd UB 04 Outpatient Field Descriptions Field Description Data Type Length Try Again Returns to the log in page Button Field Edits Field Error Code Error Message To Correct o Error Code Messages found for this window 6 4 File Download File Download The File Download window is used to download specific files from the DPW secure web site Downloads are limited to 4 MB or less until web site performance warrants increasing the file size limits PROMISe Provider Internet User Manual docx July 3 2014 80 Provider Internet User Manual PA PROMISe System Documentation PROMISe Internet Portal This window is accessed from the Menu Bar by selecting the Download option from the Trade File menu Layout Download Trade Files gt Dow
85. system ensures the IP address is valid For domain names the system verifies that the domain name is validly composed and contains a proper ending a three letter domain or a two letter country code PROMISe Provider Internet User Manual docx July 3 2014 228 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout p EN N S A Welfare a Your Provider ID 300180963 DOGOOD JAMES L NPI 1234567893 View Taxonomy Service Location 0001 PHYSICIAN PEAP Status ePEAP Access Active Full Access 123 HOPE RD HARRISBURG PA 17011 Provider Type 31 View Specialties Manage E mail Address Instructions Add or update your e mail address as needed Then click Continue Your e mail address for messages from the Medical Assistance Program jdogood doc cam so Address Menu ePEAP Menu Help Review Submit Eg 6 27 1 Accessibility and Use To access the Manage E mail Address window and add or update your e mail address complete the steps in the following step action tables To Access the Manage E mail Address Step Action Result 1 Sign on to the PA PROMISe Internet application using instructions provided in Section 2 9 of this manual The Provider Main Page appears on the desktop 2 Click on the ePEAP Provider Enrollment Automation Project link in the Other Links section of the window 3 Select the Enrollment Information o
86. that contains only alphanumeric characters July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Occurrence Code 2 Occurrence Code 3 Occurrence Code 4 Occurrence Code 5 Occurrence Code 6 Occurrence Code 7 Occurrence Code 8 Occurrence Code Date 1 Error Code 0 Error Message Occurrence Code must be 2 characters in length Occurrence Code can only contain alphanumeric characters Occurrence Code must be 2 characters in length Occurrence Code can only contain alphanumeric characters Occurrence Code must be 2 characters in length Occurrence Code can only contain alphanumeric characters Occurrence Code must be 2 characters in length Occurrence Code can only contain alphanumeric characters Occurrence Code must be 2 characters in length Occurrence Code can only contain alphanumeric characters Occurrence Code must be 2 characters in length Occurrence Code can only contain alphanumeric characters Occurrence Code must be 2 characters in length Occurrence Code can only contain alphanumeric characters Occurrence Date is a required field when Occurrence Code is entered Occurrence Date must be less than or equal to today s date PROMISe Provider Internet User Manual docx 132 To Correct Enter 2 characters for the Occurrence Code Enter a Occurrence Code that contains only alphanumeric characters Enter 2
87. that in order to be eligible for the increased payment the services must be provided by a as defined in 42 CFR 440 50 or under the personal supervision of a physician with specialty designation in family practice general intemal medicine and pediatrics or a subspecialty recognized by the American Board of Medical Specialties ABMS the American Board of Physician Specialties ABPS or the American Osteopathic Association AOA and the physician self attests that the physician Is board certified with such a specialty or subspecialty as set forth above or e has furnished evaluation and management E amp M and vaccines services that equal at least 60 of the Medicaid codes billed a during the most sr ee Calendar Year or b for newly enrolled physicians the prior month plus a partial year or c the prior month s in the current year CERT BEGIN DATE CERT END DATE ee ee pea an aa e issued by the ABMS ABPS or AOA attest that the information ened Bs seers See ee soe understand that any false statements made herein are subject to the penalties contained in 18 PA C S unswom fais ications to authorities onai o bu Complete this section only if you are NOT board certified as described above but at least 60 of the Medicaid codes that you billed are Evaluation and Management E amp M Codes 99201 through 99499 and Current Procedural Terminology CPT Vaccine Administration Codes 90460 90461 90471 90472 90473 and 90474 or their s
88. the 837 transaction for the claim requiring the attachment In box 2 fill in the Provider Number that was used for filing the 837 transaction for the claim requiring the attachment In box 3 fill in the Service Location that was used for filing the 37 transaction for the claim requiring the attachment In box 4 fill in the Recipient Number that was used for filing the 837 transaction for the claim requiring the attachment In box 5 fill im the Attachment Control Number ACN that was used for filing the Electronic Claim 837 requiring the attachment The ACN on this form must be EXACTLY THE SAME as the number placed in the PWE segment on the 837 mamsaction If the ACN is not EXACTLY the same as the PWE segment there may be delays im processing the claim Place this completed form on top of the attachment s for each claim submitted on the 837 that requires an attachment This form is NOT REQUIRED for claims not requiring attachments Submit to Department of Public Welfare Office of Medical Assistance Programs P O Box 8194 Harrisburg PA 17105 This form is NOT REQUIRED for claims not requiring attachments This form is for use with ELECTRONICALLY FILED CLAIMS ONLY PROMISe Provider Internet User Manual docx July 3 2014 84 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Descriptions Field Description Data Type Length ACN Attachment control number shown in t
89. this claim Character 8 Other 3 Diagnosis Other diagnosis code for this claim Character 8 Other 4 Diagnosis Other diagnosis code for this claim Character 8 Other 5 Diagnosis Other diagnosis code for this claim Character 8 Other 6 Diagnosis Other diagnosis code for this claim Character 8 Other 7 Diagnosis Other diagnosis code for this claim Character 8 Other 8 Diagnosis Other diagnosis code for this claim Character 8 Other Provider ID Provider ID of the referring provider Character 13 Paid Amount Other Amount paid for this adjustment Number 9 Insurance Paid Date Other Date amount was paid Date 8 Insurance MM DD CCYY Patient Account Patient ID number Character 30 Patient ID Patient Patient identifier given by the provider Character 10 Patient Pay Amount Amount the recipient pays Number 9 Patient Reason for Patient Reason for Visit diagnosis code Character 6 Visit outpatient only Patient Status Patient s medical status as of the ending date of Drop Down List 0 service of the period covered by the claim Box POA Diagnosis POA Character 1 Policy Holder First First name of policyholder Character 25 Name Other Insurance PROMISe Provider Internet User Manual docxssstsi s lt ititws y 2094 121 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Policy Holder ID Code Other Insurance Policy Holder Last Name Other Insurance List Box Polic
90. to PA PROMISe using the steps presented in the The Provider Main Page General User Manual window opens 2 Click the My Profile link The My Profile window opens 6 2 Alternate No Access Alternate No Access The Alternate No Access window is displayed upon logging in when an alternate has web site access but is not authorized for access in association with any providers The user has no other access when this page displays PROMISe Provider Internet User Manual docx 78 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout oN pennsylvania DEPARTMENT OF PUBLIC WELFARE PROMISe Internet Home Monday 08 02 2010 11 10 AM EST User ID This is a test message for training This is addional information v Security Warning x Forgot User ID You do not have any providers associated with your account at J ough service plans in HCSIS this time You have been logged off and redirected back to the f between 11 40PM and 12 10AM Register Now provider welcome page Where do I enter my password Please contact customer service for further assistance nay be unavailable for short periods Quick Links month Need Help Thank you for your patience Use the Internet Help Manuals here Notice Demo of PA PROMISe Welcome to the new PROMISe Internet Portal where you will find a new look along with enhanced security feature
91. to today s date Other Insurance Benefits Select a Benefits Assignment for Ol is Assignment value a required field Service Line Billed Enter amount Amount is a required field billed Service Line Billed Enter a positive Amount may not be a billed amount negative number Code Type field is Select an ICD code required type Both ICD 9 and ICD 10 Select the correct codes have been found ICD code type within this inquired claim Please choose the correct ICD code type July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Country Accident Date Accident Date of Service Date of Service Service Line list Diagnosis Pointer Discharge Date PROMISe Provider Internet User Manual docx Error Code 0 Error Message To Correct Accident country can only Enter a valid contain alphanumeric country characters Accident country cannot Enter a valid be less than 2 characters in country length x is not a valid day in Enter a valid date month Use a value in the range l days in month Accident Date needs to be Enter a valid date a valid date Accident Date must be less Enter a valid date than or equal to today s date When Accident Date is Select a related entered a related cause cause Employment Other or Auto must be Yes Accident Date must be Enter an accident entered when date Employment Other
92. used by providers or billing agents with multiple locations to switch between different authorized provider account profiles and locations Users with only one provider location do not have access to this option PROMISe Provider Internet User Manual docx July 3 2014 145 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Provider numbers can be switched by selecting the radio button next to the available options Confirmation of the current provider number appears as the page title and changes as new selections are made This window is accessed through the Switch Provider Number link on the Provider Main Page Layout oN pennsylvania DEPARTMENT OF PUBLIC WELFARE PROMISe Internet lt 2 Switch Provider Switch Provider Monday 08 02 2010 11 39 AM EST Switch Provider Currently you are logged in as an alternate for 0019284080001 Selected Provider Switch Provider Enter at least one selection criteria below and click Search to retrieve information Display Name First Name Last Name Email Available Providers Select a Provider that you wish to switch to then click Submit button Total Records 5 Email Address Display Name a First Name Last Name biller Account 0005084360001 biller provider com 2 O Paddy O Shea Account 0006074990001 InvalidEmailAddress state pa us 3 OTest Contact Account 00
93. 0 07 58 AM EST Registration Select one of the following options that best describes your role Provider An individual or entity that is enrolled in the Pennsylvania Medicaid program as a provider of services 7 Su pumy Agent A third party individual oMemtity Who is authorized to submit Medicaid transactions on behalf of a Provider QR Alternate An account created by a Provider for use by an individual within the provider s organization Alternate accounts can be authorized by a provider to bill for more than one 13 digit MPI and Service Location til Out of Network An individual or entity that is authorized to access specific functionality within the PROMISe Internet Portal PROMISe Provider Internet User Manual docx July 3 2014 13 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation 1 Select the Billing Agent option The Registration Personal Information window appears ry pennsylvania DEPARTMENT OF PUBLIC WELFARE Home gt Registration Selector gt Registration Registration Step 1 of 2 Personal Information Indicates a required field Please provide the following information to get started First Name Last Name Billing Agent ID SSN EIN Wednesday 04 28 2010 03 09 PM EST Ee 2 Enter your first name last name Billing
94. 0 in the Adjustment 2 row Up to eleven additional adjustments can be added 12 Click the Submit button The adjustment s for this claim is are submitted 6 7 Provider Dental Claim Dental asp The Provider Dental Claim window is used to display or input dental claims From here a provider can enter or review all of the required information to submit a dental claim including multiple detail lines Note Maximum field lengths for this window are limited by HIPAA X12 guidelines Differences may appear between fields on this window and fields on other windows that are based on different underlying HIPAA transaction formats The provider can access this window by selecting Submit Dental link from Claims option list or select Dental from the Claims Submission page The first window Layout below shows the initial viewable display the following Layouts show the remaining data viewable by scrolling Layout PROMISe Provider Internet User Manual docx July 3 2014 91 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Dental Claim NeW Need help submitting a claim View sample claim submissions here Billing Information 0008509550001 np Taxonomy Zip v Medical Record Prior Authorization Report Type Code Report Transmission Code Patient Pay Amount Service Information Referring Provider ID Release of Medical Data Referral Benefits Assignment Yes
95. 00 we are providing for your convenience a listing of the provider facilities which can be used to look up the 13 digit PROM Se provider ID This list is searchable by facility name and is accessed through the following link Facility Provider Numbers Billing Information Billing Provider 0008509550001 Attachment Control NPI Taxonomy Zip Claim Frequency igir v Prior Authorization Original Claim Report Type Code Recipient ID Report Transmission Code Patient Account Patient Pay Amount Last Name First Name Middle Initial Diagnosis Code Type Add Diagnosis Code Anesthesia Add Anesthesia Related Procedures Condition Code Add Condition Code Service Information Rendering Provider ID Release of Medical npr Data Taxonomy Zip Tax ID Benefits Assignment Either Rendering Provider ID or Tax ID is Required Referring Provider ID na NPE ee Patient Signature Taxonomy Zip Referral Code Pregnancy Indicator Place of Service Facility ID SS Facility Name Contract Type Admission Date MMDDIYYYY Contract Code Discharge Date MM IDDIYYYY Contract Version Special Program Code Billing Note v Date MM DDIYYYY State J Country J PROMISe Provider Internet User Manual docx July 3 2014 160 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System
96. 01 2009 01 31 2009 Eligibility 01 01 2009 01 31 2009 Benefit Related Entity Payer e Information Contact Telephone Eligibility Detail Status Medicaid Service Type Health Benefit Plan Coverage Insurance Type Medicaid i Coverage Description Category J Program Status 00 Service Program B Service 01 01 2009 01 31 2009 Eligibility 01 01 2009 01 31 2009 Benefit Related Entity payer o Ee Information Contact Telephone a PROMISe Provider Internet User Manual docx 74 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 5 Provider Reports You can generate online reports from the PA PROMISe Internet Web site This section describes reports that are available to providers 5 1 About the Provider Report Index Window The Provider Report Index window is used to display the online reports that are available to providers These reports are displayed in one or more groupings The window sample below shows the Provider and MCO groupings Reports can be viewed in groupings associated to your specific user ID and you are able to query the COLD system for versions of those reports You can generate a Remittance Advice RA report through the Provider Report Index window This report supports a search range of up to 90 days based on the weekly PROMISe processing cycles The search button returns a list of RAs sen
97. 12390650005 test test com 4 OTest Contact Account 0005895050003 test123 test com 5 OTester Account 0008802930003 test eds com Field Descriptions Field Description Home Returns to the provider home page Provider Radio button used to switch to a different provider account Button Number profile Field Edits ield rror Code rror Message To Correct PROMISe Provider Internet User Manual docx July 3 2014 146 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Error Code Error Message To Correct No Error Code Messages found for this window 6 10 1 Accessibility and Use To access and use the Switch Provider Number window complete the steps in the step action table s To Access Provider Number Management Window Step Action Response 1 Logon to PA PROMISe using the The Provider Main Page window opens steps presented in the General User Manual 2 Click the Switch Provider link The Available Provider Numbers window opens Providers with only one provider location do not have this link option To Switch Provider Number Step Action Response 1 In the Provider Number section click the Radio The selected Provider Button next to the Provider ID option information window opens 6 11 Provider Pharmacy Claim Pharmacy asp The Provider Pharmacy Claim window is used to submit pharmacy claims A
98. 2 All questions related to electronic EFT enrollment should be directed to the PAC at 1 800 248 2152 or papacl hp com Layout Yoo pennsylvania Oo sectlechint VAA rana PROMISe Internet Enrolled Provider Search EFT and ERA Enrollment q My Home Wednesday 12 11 2013 12 14 PM EST Name OURTOWN HOSPITAL Please be aware if you are running Microsoft Internet Explorer IE 10 and are experiencing issues with navigating be x past the Portal site s logon screen then follow these instructions This browser configuration will allow you to the Provider ID 1234123410 NPI view Portal application in Compatibility V ad d allow the site to function as normal For more information click here e Location ID 0032 gt My Profile gt Manage Alternates Manage Billing Agents d OPW Resources DPW Home OPW Provider Information PROMISe Provider Internet User Manual docx July 3 2014 42 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation 3 1 1 Accessibility and Use To access the EFT and ERA Enrollment window and submit an Electronic Funds Transfer EFT and or an Electronic Remittance Advice ERA application complete the steps in the following step action tables To Access the Electronic Funds Transfer EFT and Electronic Remittance Advice ERA Enrollment Application Window STEP ACTION RE
99. 3 Comprehensive Inpatient Facility e 14 Homeless Shelter e 15 Correctional Institution Patient Patient Responsibility Qualifier Drop Down List 0 Responsibility Box Qualifier Payer Date Payer date for COB Date 8 MM DD CCYY Payer ID Payer ID for COB Character 10 Payer ID Qualifier Payer ID Qualifier for COB Drop Down List 0 Box Pharmacy Service Pharmacy service type Drop Down List 0 Type Valid values are Box e 1 Community Retail Pharmacy Services e 2 Compounding Pharmacy Services e 3 Home Infusion Therapy Services e 4 Institutional Pharmacy Services e 5 Long Term Care Pharmacy Services e 6 Mail Order Pharmacy Services e 7 Managed Care Organization Services e 8 Specialty Care Pharmacy Services e 99 Other Phone Patient s phone number Character 11 Pregnancy Indicator Is recipient pregnant Drop Down List 0 Box PROMISe Provider Internet User Manual docx a y 2094 153 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Prescriber ID Prescription Prescription Origin Code Prior Authorization Number Found Prior Authorization Number Submitted Prior Authorization Type Quantity Dispensed Reason for Service Refills Authorized Reject Code Result of Service Rx Qualifier Service Code Show COB Amounts State Submission Clarification Code Submit Taxonomy Billing Provider Taxonomy Prescribing Provider Time
100. 308 1419 2007 9 25 31 AM Received 1089 64323 1423 2007 11 21 45 AM Complete 1090 64324 142412007 8 27 18 AM Complete 1091 64325 1 24 2007 8 40 50 AM Complete About this Request Date Closed 01 24 2007 at 8 40 AM Tracking Number 1091 64325 Contact Information Name Mortimer Snerd Phone 717 222 0001 E mail mort dogood com Fax Changes Requested For Provider ID 300180963 DOGOOD JAMES L Service Location 0001 234 NEW HAVEN RD Change Address CAMP HILL PA 17011 Current Requested Phone 717 975 9876 717 975 1234 Phone Ext 567 6 33 1 Accessibility and Use To access the ePEAP Recent Requests window and view cancel or submit a message to DPW complete the steps in the following step action tables To Access the ePEAP Recent Request window Step Action Result 1 Select Recent Requests from the ePEAP The Recent Requests window opens Menu View Recent Requests Step Action Result 1 Click the View link next to the request to The request you selected will be displayed view below the request list PROMISe Provider Internet User Manual docx July 3 2014 251 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Contact DPW Step Action Result 1 To contact DPW regarding the status of an The Contact DPW message form opens In Process request click the Contact link 3 To clear any entered text c
101. 44 11212006 248 45 PM Comphte View 1027 64288 12006 11 0834 AM Compbte View 1072 64207 W1W2007 9 20 00 AM Comphte View Cancel Contact 1074 64208 WIDM2007F 9 25 31 AM Received View 1089 64322 WIWNQOOF 11 21 45 AM Complete View 1090 64224 W24 2007 8 27 18 AM Compbte View 1091 64325 12412007 3 40 50 AM Complate Pres Po PROMISe Provider Internet User Manual docx July 3 2014 250 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation The following window is displayed after selecting a request and clicking View Your Provider ID 300180963 DOGOOD JAMES L Status Active NPI 1234567893 View Taxonomy ePEAP Access Full Access Service Location 0001 123 HOPE RD HARRISBURG PA 17011 Provider Type 31 PHYSICIAN View Specialties Recent Requests Options Tracking Submit Date Status Contact 636 64096 9 28 2005 3 08 30 PM In Process Contact 637 64097 10 3 2005 3 39 47 PM In Process Contact 639 64098 10 7 2005 8 36 02 AM In Process Contact 7771 64145 4 24 2006 4 06 50 PM In Process 921 64230 11 20 2006 3 35 46 PM Complete 922 64231 11 20 2006 3 42 17 PM Complete 923 64232 11 20 2006 3 43 37 PM Complete 947 64240 11 21 2006 1 16 51 PM Complete 949 64241 11 21 2006 1 19 36 PM Complete 9654 64243 11 21 2006 2 30 20 PM Complete 9956 64244 11 21 2006 2 48 45 PM Complete 1027 64288 12 8 2006 11 08 34 AM Complete 1073 64307 1419 2007 9 20 09 AM Complete Cancel Contact 1074 64
102. 93 July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field en Error Message To Correct ode 1 Date of Birth cannot be past today Enter a date that is not in the future 2 value is an invalid month of the Enter a valid month year Use a value in the range of 1 12 3 value is a not a valid day in Enter a valid day of the month Use a value in the range month of 1 31 Date of Birth Second Input 0 Date of Birth is an invalid date Enter a valid date x 1 Date of Birth cannot be past today Enter a date that is not in the future 2 value is an invalid month of the Enter a valid month year Use a value in the range of 1 12 3 value is a not a valid day in Enter a valid day of the month Use a value in the range month of 1 31 Date of Service From 0 From Date of Service is an invalid Enter a valid date date x 1 Please enter Date of Service Enter a valid Date of Service date 2 value is an invalid month of the Enter a valid month year Use a value in the range of 1 12 3 value is a not a valid day in Enter a valid day of the month Use a value in the range month of 1 31 Procedure Drug Code Input 0 Please select a Procedure Drug Select a Procedure Drug Type Type Procedure Drug Type Input 0 Please enter a Procedure Drug Enter a valid Code Procedure Drug code Recipient ID Input 0 x is not a valid Recipient ID Enter a valid recipient ID SSN Inp
103. ACCESS ccccssssecccecceecsessnsececesececsesesssaeeeseseens 78 6 3 Billing Agent No Access Billing Agent No ACCESS cceesceceeneeceeeeeceeeeeseteeeesees 79 6 4 File Download File Download vecaccvarnasere us taiee ive evento ilaetaudivee eltaedihes 80 6 4 Accessibility and Uses ecsccsscestsbtos iasecichshes oeae o EEL EEEE EE AARE E EEEE R EAEE EOE EOE edged 82 To Access File Download WindoW esssssssssesssesssesssesssesssressressresstesstesstesseesseesseesseesseesseessees 82 To View Downloaded File Information eeeceseceseceseceseeeseeeeeeeeaeeeseeeaeecaaecsaecsaecnaeenseeees 82 6 5 Provider Claim Attachment Number Request Provider Claim Attachment Number Request 82 PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 65 1 Accessibility and Use seniiti ates ieee he E a ett 85 To Access Provider Claim Attachment Number Request Window cccccesecceesteceeneeeteeees 85 To S arch tor AGN Details a teas de ecssastsensvneseSeat eed ecanas aveoatastd bdavns aaea SE EREE ais 86 To Search for All Provider Attachment Numbers c cccccsssessssssssssssssssssssssssssssssssesseseees 86 To Search for New Claim Attachment Number seseesseseseserererrrerererererererererererererererererereree 86 6 6 Provider Claim Inquiry Gnquiry aSp ssscsaseseseqeisansnacodsdeyqedeniweecaus soeceaptadoacosatesedos
104. Alternate function is used to grant permission to an existing alternate 1 Log on to PROMISe via the Welcome to PROMISe Welcome Page 2 Click the Manage Alternates link to access the Manage Accounts window 3 The Add New Alternate tab is selected by default Select the Add Registered Alternate tab room pennsylvania DEPARTMENT OF PUBLIC WELFARE My Home gt Manage Alternates Thursday 06 24 2010 09 29 AM EST Alternate Assignment Back to My Home Add New Alternate Add Registered Alternate Indicates a required field Enter the Last Name and the Alternate Code to add that alternate to your alternate list then click Submit to proceed Last Name Alternate Code L Suomi Alternates Click the Alternate s name to change the status of the alternate Name a Birth Date Unique PIN Alternate Code Status 1 User Sample 01 01 1918 1234 00000 Active 4 Enter the alternate s last name and Alternate Code into the relevant fields and click the Submit button PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 5 10 11 12 13 14 15 2 4 3 A modified version of the Add Registered Alternate tab appears that allows the user to confirm the values entered Review the values displayed To edit further click the Edit
105. Assistar Your Provider ID 300180963 DOGOOD JAMES L Status Active NPI 1234567893 view Taxonomy ePEAP Access Full Access Service Location 0001 123 HOPE RD HARRISBURG PA 17011 Provider Type 31 PHYSICIAN view Specialties Fee Assignment Information You may add a Group to assign fees to an account Add a Group for Fee Assignment other than your own You may also review your current fee assignments and terminate any of them Manage Fee Assignments Enrollment Information ePEAP Menu Help Review Submit PROMISe Provider Internet User Manual docx July 3 2014 231 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 28 1 Accessibility and Use To access the ePEAP Fee Assignment Information window and update fee assignment information complete the steps in the following step action tables To Access the ePEAP Fee Assignment Information window Step Action Result 1 Sign on to the PA PROMISe Internet application using instructions provided in Section 2 9 of this manual The Provider Main Page appears on the desktop 2 Click on the ePEAP Provider Enrollment The ePEAP Menu window opens Automation Project link in the Other Links section of the window 3 Select the Enrollment Information option The ePEAP Enrollment Information window opens 4 Click the Fee Assignment Information The ePEAP Fee Assignment Information link windo
106. Availability The User ID is available v User ID Availability The User ID has already been taken Please enter another one and try again 7 Create a password and enter it into the Password and Confirm Password fields The password e Cannot be the same as the user s User ID e Must be between 8 and 20 characters in length e Can only contain letters and numbers e Must contain one capital letter one lowercase letter and one numeric digit Enter your phone number and email address into the fields indicated 9 Select three challenge questions from lists provided in the window and type in answers This information is used by the system to verify the identity of the OON provider at a future time when resetting a password Note You must select three distinct questions or you will be unable to proceed 10 After completing the Registration form read the User Agreement enter your name into the Please sign by typing your full name here field and click the Submit button to submit the form electronically If all required information is present you will be able to gain access to the PA PROMISe Web application 11 A registration confirmation message appears PROMISe Provider Internet User Manual docx July 3 2014 29 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation v User Successfully Registered You have successfully registered as a
107. Button Sequential number of each service detail line Number PROMISe Provider Internet User Manual docx 100 Length 0 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Data Type Length Taxonomy Taxonomy for Billing Provider ID Character 10 Billing Provider Taxonomy Taxonomy for Referring Provider ID Character 10 Referring Provider Taxonomy Taxonomy for Rendering Provider ID Character 10 Rendering Provider Tooth Number Indicator for the tooth on which services were performed or will be performed Tooth Surface 1 First designation of the surface s of the tooth on which services were performed or will be performed Tooth Surface 2 Second designation of the surface s of the tooth on which services were performed or will be performed Drop Down List Box Drop Down List Box Drop Down List Box Tooth Surface 3 Third designation of the surface s of the tooth on Drop Down List which services were performed or will be performed Box Tooth Surface 4 Fourth designation of the surface s of the tooth on Drop Down List which services were performed or will be performed Box Tooth Surface 5 Fifth designation of the surface s of the tooth on Drop Down List which services were performed or will be performed X Adjustment Removes the service line adjustment X Diagnosis Removes the diagnosis X Reason Code Removes the reason code
108. Button 0 PROMISe Provider Internet User Manual docx July 3 2014 257 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type via US mail Retype Email Confirm email address is correct Character address View Specialties Opens a window displaying the specialty Hyperlink code s associated with the provider service location View Taxonomy Opens a window displaying the taxonomy Hyperlink code s associated with the NPI 6 36 ePEAP Active Service Location The Active Service Locations window is used by providers to display all active Service Locations for the provider This window is accessed by clicking the Active Service Locations link in the ePEAP Menu Layout PENNSVIUANIL WK DEAP Office of Medical Assistance Programs OMAP Your Provider ID 300180963 DOGOOD JAMES L Status Active NPI 1234567893 View Taxonomy ePEAP Access Full Access Service Location 0001 123 HOPE RD HARRISBURG PA 17011 Provider Type dil PHYSICIAN View Specialties Active Service Locations for MAID 300180963 Medicare Service Location NPI Physical Site Address Options Indicator 0001 1234567893 DOGOOD JAMES L view Specialties X Currently Logged In 123 HOPE RD View Taxonomy HARRISBURG PA 17011 1234567893 DOGOOD JAMES L view Specialties Pending 234 NEW HAVEN RD iew Taxonom CAMP HILL PA 17011 M DOGOOD PHYSICIAN SERVICES View Specialtie
109. By clicking the Change Password button a user s password can be changed See Section 2 7 3 Changing a Password PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 2 10 Submitting Claims Electronically Using PA PROMISe The PA PROMISe Internet application has been designed to make claim submission as efficient as possible using the currently available electronic technology Each claim submission window constitutes an online claim form that is easy to fill out and submit The provider number and service location NPI Number Taxonomy Code and ZIP Code automatically appears at the top of each claim based on the Logon ID used to log into PA PROMISe You can also adjust a claim or one of its service lines through this online feature Each claim a submission window in Section 5 PA PROMISe Internet Windows includes detailed information regarding how to perform these functions 2 10 1 About Dental Claims Providers can access the online Dental claim form by clicking on the Submit Dental link in the Claims option in the menu bar of the Provider My Home Page window Section 5 8 Provider Dental Claim provides step by step information for submitting or adjusting a Dental claim 2 10 2 About Institutional Claims Providers can access the online Institutional claim form by clicking on the Submit I
110. CDT You shall not remove alter or obscure any ADA copyright notices or other proprietary rights notices included in the materials The window layout above displays the default viewable area of the scrollable data the layout below displays the remaining data PROMISe Provider Internet User Manual docx July 3 2014 181 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 2 Any use not authorized herein is prohibited including by way of illustration and not by way of limitation making copies of CDT for resale and or license transferring copies of CDT to any party not bound by this agreement creating any modified or derivative work of CDT or making any commercial use of CDT License to use CDT for any use not authorized herein must be obtained through the American Dental Association 211 East Chicago Avenue Chicago IL 60611 Applications are available at the American Dental Association web site http hwww ADA org 3 Applicable Federal Acquisition Regulation Clauses FARS Department of restrictions apply to Government Use Please click here to see all U S Government Rights Provisions 4 ADA DISCLAIMER OF WARRANTIES AND LIABILITIES CDT IS PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND EITHER EXPRESSED OR IMPLIED INCLUDING BUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE NO FEE SCHEDULES BASIC UNIT RELATIVE VALUES OR RELATED LISTI
111. Chapter 105 and 45 CFR Parts 160 162 and 164 Any person knowingly violating these restrictions may be sentenced to pay a fine or imprisonment or both Electronic signature By selecting the Accept button you are signing this agreement electronically You agree your electronic signature is the legal equivalent of your written signature on the agreement and the provider and any preparer is bound by this signature Accept The ERA Agreement displays the terms and conditions for ERA enrollment and allows the user to accept or decline the terms 1 Click the ACCEPT option to submit The Electronic Remittance Advice ERA the ERA Enrollment data data is added to the PROMISe database for review and processing 2 Click the Decline option The user will be returned to the ERA Enrollment Application window PROMISe Provider Internet User Manual docx July 3 2014 63 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Descriptions Field Description Data Type Length Provider Information Provider Name Name of the service location Alpha numeric 50 Provider Address Street Street address lines 1 and 2 of Alpha numeric 50 the service location address Provider Address City City portion of service location Alpha numeric 18 address Provider Address State portion of service location Alpha 2 St
112. City AwTown State Province ra I ZIP Code Postal Code e Financial Institution Routing Number 012315870 Type of Account at Financial Institution Checking Savings Provider s Account Number with Financial Institution 000001234 Account Number Linkage to Provider Identifier Information oniy wilt not change grouping of payments by PROMISE Provider Tax Identification Number TIN 01 1112486 national Provider Identiner wet LL S SOS Submission Information Reason for Submission choose one New Enroliment Change Enrotiment Cance Enrotiment Authorized Signature Electronic Signature of Person Submitting Enrollment pi002457861286 Printed Name of Person Submitting Enroliment MARY SMITH Printed Title of Person Submitting Enroliment Submission Date format CCYYMMOD Submit EFT Enrolment Form PROMISe Provider Internet User Manual docx July 3 2014 47 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Open the Electronic Funds Transfer EFT Enrollment Application Window STEP ACTION RESPONSE 1 Click the EFT Enrollment Request Option The Electronic Funds Transfer EFT Enrollment Application window opens To Complete the Electronic Funds Transfer EFT Enrollment Application STEP ACTION RESPONSE 1 In the Provider Information Section
113. Code Error Message To Correct No Error Code Messages found for this window 6 15 1 Accessibility and Use To access and use the Outpatient Fee Schedule Download window complete the steps in the step action table s To Access Outpatient Fee Schedule Download Window Step Action Response 1 Log on to PA PROMISe using the steps The Provider Main Page window presented in the General User Manual opens 2 Click the Outpatient Fee Schedule link The Rate Information Disclaimer window opens 3 Review the Terms and Conditions displayed in the Rate Information Disclaimer Window 4 To accept the Terms and Conditions click the I The Outpatient Fee Schedule Accept button Download Files window opens 5 To reject the Terms and Conditions click the I The Provider Main window opens Decline button To Download Outpatient Fee Schedule in Excel Format Step Action Response 1 Click the Download The file download begins The downloaded file is in a Excel Version hyperlink compressed format ZIP and must be decompressed before it can be opened PROMISe Provider Internet User Manual docx July 3 2014 186 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Download Outpatient Fee Schedule in PDF Format Step Action Response 1 Click the Download PDF Version hyperlink The file download begins To Download Outpatient Fee Schedule
114. Code Service line adjustment carrier ID Drop Down List 0 Service Line Box Adjustment Carrier Name Name of other insurance carrier Character 14 Other Insurance Claim Filing Type of claim to be filed Drop Down List 0 Code Other Box Insurance Claim Frequency Submission type indicator for this claim Drop Down List 0 Box PROMISe Provider Internet User Manual docxsssi lt is sSSS y 2094 95 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Code Type ICD type indicator for this claim Drop Down List 0 Box Comments Free form field for comments or special Character 80 instructions pertaining to service information Copy Copies a paid claim s data to anew unprocessed Button 0 claim Country Country where the automobile accident occurred Character 3 Accident if this claim relates to an auto accident Date Accident Date of the accident related to the patient s current Date 8 condition diagnosis treatment and charges MM DD CCYY referenced in this claim transaction Date of Service Date services were rendered for the service line Date 8 detail MM DD CCYY Date of Service Date services were rendered for the service line Date 8 Service Line detail This field is auto populated by the value MM DD CCYY list entered in the Date of Service field in the area below Delete Other Deletes existing other insurance line from claim Button 0 Ins
115. Continue button 5 The Registration Security Information window displays with the Display Name field already completed Yow pennsylvania Home gt Registration Selector gt Registration Monday 06 21 2010 12 07 PM EST Registration Step 2 of 2 Security Information Indicates a required field The User ID and Password cannot be the same and the password must be 8 20 characters in length contain a minimum of 1 numeric digit 1 uppercase letter and 1 lowercase letter User ioo Password Confirm Password Please provide your contact information below Display Name Sample Name Phone Number Email Confirm Email Please choose a personalized Site Key and enter a passphrase that will be used to verify your identity upon logging into the PROMISe Internet portal Site Key Apple O Balloon O Balloons Baseball O Billiards Passphrase Please select a unique challenge question and provide an answer for each of the question groups below Challenge Question 1 l What is your mother s maiden name v Answer to 1 Challenge Question 2 who was your first employer v Answer to 2 Challenge Question 3 What is the name Answer to 3 l User Agreement By checking the box provided below and transmitting this form electronically I state I am the person whom I represent myself to be
116. D into the User ID field e The User ID must be 6 to 20 characters in length and contain only letters and numbers e The User ID and Password cannot be the same e Once you ve entered text in the User ID field click the Check Availability button to see whether the User ID you selected is already in use If it is not in use the first confirmation message will appear if it is in use the second confirmation message will appear v User ID Availability The User ID is available v User ID Availability x The User ID has already been taken Please enter another one and try again Create a password and enter it into the Password and Confirm Password fields The password e Cannot be the same as the user s User ID e Must be between 8 and 20 characters in length e Can only contain letters and numbers e Must contain one capital letter one lowercase letter and one numeric digit Type your phone number and email address into the fields indicated Select three challenge questions from lists provided in the window and enter answers This information is used by the system to verify the identity of the billing agent at a future time when resetting a password Note You must select three distinct questions or you will be unable to proceed After completing the Registration form read the User Agreement enter your name in the Please sign by typing your full name here field and click the Submit bu
117. Date Add Surgical Code Date MM DDIYYYY 1 Date is required Occurrence Code Date Add Occurrence Code Date MM DDIYYYY 1 Date is required Occurrence Span Code Date Add Occurrence Span Code Date MM DD YYYY i m Start date is required End date is required Condition Code Add Condition Code EJ m Value Code Amount Add Value Code Amount E a Days Covered inpatient and LTC Only Non Covered inpatient and LTC Only Medicare Coinsurance Days inpatient and LTC Only Lifetime Reserve Days inpatient Only Patient Newborn Only Patient ID Last Name OoOo o First Name Middle Initial Gender wl Date of Birth O umov Date of Death i umov Other Insurance Ol Carrier Code Group Number Group Name Policy Holder Last Name blank record may not submitted Please delete if not used Group Number Lo Group Name ae Carrier Code w Policy Holder ID Code E Policy Holder Last Name DOOS 4 Policy Holder First Name LOO o y Individual Relationship v Release of Medical Data Benefit Assignment v Claim Filing Code iv PROMISe Provider Internet User Manual docx July 3 2014 113 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 1 Reason Code Adjustment Group Code Amount 2 Reason Code
118. EAP SelectPlan for Women Directory The SelectPlan for Women Directory window is used by providers of certain provider types to manage their inclusion in the SelectPlan for Women directory This window is accessed by clicking the SelectPlan for Women Directory link in the ePEAP Menu The Active Service Locations window is used by providers to display all active Service Locations for the provider This window is accessed by clicking the Active Service Locations link in the ePEAP Menu Layout PENNS CAMA uhe man PEAP Your Provider ID 300276278 DOGOOD MEDICAL ASSOCIATES Status Active NPI 1384654368 View Taxonomy ePEAP Access Full Access Service Location 0001 123 E MAIN ST CAMP HILL PA 17011 6312 Provider Type 31 PHYSICIAN View Specialties SelectPlan for Women Directory SelectPlan for Women Directory SelectPlan for Women is an MA benefit that covers family planning and related services to help women stay healthy SelectPlan for Women services are provided under the Fee for Service FFS delivery system even if you are ina managed care zone For more details about this program you may access Provider Quicktip 73 available here kTips PROMIS kTip73_pdf SelectPlan for Women website www_selectplanforwomen_state pa_us An online directory is available on the SelectPlan for Women website to help SelectPlan for Women recipients select a medical provider for family planningservices Whether or not you are currently liste
119. HARRISBURG PA 17011 Provider Type 31 PHYSICIAN View Specialties Manage Remittance Advice RA Remittance Advice 1 Select an RA option 2 Ifthe On Line option is selected you will not receive RAs by mail 3 If US Mail is selected the RAs will be sent by mail after your request has been processed NOTE With either RA option you can still view your RAs on this website After making changes please click the Continue button to complete your request REMITTANCE ADVICE Remittance advices are available on line through the PROMISe website Do you wish to OAccess RAs on line through PROMISe and eliminate receipt of paper RAs Receive paper RAs via US mail Confirmation Window Remittance Advice Windows Internet Explorer REMITTANCE ADVICE Press OK to discontinue the mailing of paper RAs Press Cancel to return Lox _cencel_ PROMISe Provider Internet User Manual docx July 3 2014 256 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 35 1 Accessibility and Use To access the ePEAP Manage Remittance Advice window and manage the delivery of Medical Assistance Remittance Advices complete the steps in the following step action tables To Access the ePEAP Manage Remittance Advice Window Step Action P Result Sign on w the PA PROMISe Internet The Provider Main Page appears on the 1 application using instru
120. ID 300180963 DOGOOD JAMES L Service Location 0001 Change Medicare Number 0122245678 Current Requested Medicare Type Railroad DME PROMISe Provider Internet User Manual docx 246 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation After reviewing and clicking the Submit Changes button the following window will display Review Your Changes Contact Information This information may be used to contact you about this request This information will not be used for any other purpose ion After completing the Contact Information and clicking the Submit button the following window will display PENNS VIMANAD DEAD Raat ban PEAP Changes Are Complete Your provider information has been updated as you requested If you wish to view your request again please select Recent Requests from the ePEAP Menu The Tracking Number for this Request was 1321 64401 Thank you for using ePEAP PROMISe Provider Internet User Manual docx July 3 2014 247 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation The following message is displayed if your request cannot be updated immediately DPW will review and process the request manually Your request has been submitted to DPW for review View request status at Recent Requests on the ePEAP Menu Tracking Number 771 64145 6 32 1 Accessibilit
121. Indicator Prior Placement Date Appliance Placement Date Anesthesia Quantity Qualifier Anesthesia Units Units ocbD Billed Amount ON e 4 5 C m i umom MM DD YYYY x m Service Line 1 Billed Amount is required Service Adjustments for Service Line 1 Add Reason Code lt Reason Code is required Amount Adjustment Group Code _ w Amount is Adjustment Group Code is required required Paid date Paid date is required Paid Amount Carrier Code a w Carrier Code is required a Claim Status Information Claim Status Not Yet Submitted Field Descriptions Field Description Data Type Length Add Adjustment Adds a new adjustment reason code Hyperlink 0 Reason Add Diagnosis Add new diagnosis code Hyperlink 0 Add Other Add new other insurance line for Other Insurance Button 0 Insurance to claim Add Service Adds a new service adjustment line For each new Hyperlink 0 Line adjustment service line the Reason Adjustments Codes Amount Adjustment Group Code must be entered Add Service Add new service line to the claim Button 0 Line Add Adjustment Add new adjustment line to the claim Button 0 Adjustment General category of the associated payment Drop Down List 0 Group Code adjustment reason code Box Admission Date Date recipient was admitted for service Date 8 MM DD CCYY Amount Service Dollar amount of the adjustment for th
122. Internet Portal PA PROMISe System Documentation Layout Outpatient Fee Schedule Download Files Please note that the downloadable fee schedule is updated quarterly with the most recent update having occurred on June 25 2013 Other changes may have been made to the fee schedule since that time and have not been captured on this downloadable update Refer to the name of the file to determine the quarter For example Excel Fee Schedule By Provider Type 2Q2008 zip reflects the fee schedule run at the beginning of the 2nd quarter of 2008 Also please note that due to size some tabs within an Excel workbook may be broken into two parts When this occurs the tab name will reflect the provider type Part A and the next one will reflect the same provider type Part B An online version of the fee schedule is available at http Awww dpw state pa us publications forproviders schedules mafeeschedules index htm For the most recent information related to the service you are providing you may refer to the on line fee schedule which is updated daily DEPARTMENT OF PUBLIC WELFARE DISCLAIMER If you are a provider who only provides Home and Community Based Waiver Services please refer to the Home and Community Services Information System HCSIS for your reimbursement rates Use links below to download the Outpatient Fee Schedule Download Excel Version Download PDF Version Download Comma Delimited File Download Comma Delimited Layout R
123. Internet User Manual docx 56 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation DEPARTMENT OF P ELFARE E pennsylvania Enrolled Provider Search EFT and ERA Enrollment My Home gt EFT and ERA Enrollment Electronic Funds Transfer EFT and Electronic PROMISe Internet Wednesday 12 11 2013 11 56 AM EST Remittance Advice ERA Enrollment Provider ID 123123123 0032 Electronic Funds Transfer EFT EFT Stolus Financial Institution Rouling Number Most Recent Online EFT Enroliment Request Submission Date Provider s Account Number Enrolled 0123488700 Name OURTOWN HOSPITAL Type of Account Checking Request Status EFT Enrollment Request Electronic Remittance Advice ERA ERA Status Submitter ID for ANSI X12 Not Enrolled Most Recent Online ERA Enroliment Request Submission Date 3 3 1 Accessibility and Use ANSI X12 835 transactions Request Status ERA Enrollment Request To complete the Electronic Remittance Advice Enrollment Application window complete the steps in the following step action tables To Open the Electronic Remittance Advice ERA Enrollment Application Window STEP ACTION RESPONSE 1 Click the ERA Enrollment Request The Electronic Remittance Advice ERA Option Enrollment Application window opens PROMISe Provider Internet User Manual docx 57 July 3 2014 Prov
124. LIC WELFARE Your Provider ID 300276278 DOGOOD MEDICAL ASSOCIATES NPI 1384654368 View Taxonomy ePEAP Access Service Location 0001 111 DOGOOD LN ANYTOWN PA 17011 Provider Type 31 PHYSICIAN Status Active Full Access View Specialties vider Options Enroliment Information Recent Requests Terminate MA Enroliment Manage Bulletins Manage Remittance Advice Active Service Locations SelectPlan for Women Directory Upload PDF View Helpful Hints ePEAP Menu PROMISe Provider Internet User Manual docx 203 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout Groups Only pennsylvania Your Provider ID 300276278 oe ee ASSOCIATES NPI fad Service Location 0001 111 DOGOOD LN ANYTOW PA 17011 Provider Type 31 PHYSICIAN Status Active ePEAP Access Full Access View Specialties ePEAP Menu Provider Options Enrollment Information For Groups Only Verify Provider Membership Recent Requests View Provider Group Members Terminate MA Enrollment Manage Bulletins Manage Remittance Advice Active Service Locations SelectPian for Women Directory Upload PDF View Helpful Hints ePEAP Menu 6 20 1 Accessibility and Use To access the ePEAP Menu complete the steps in the step action table s To Access the ePEAP Menu Step Action 1 Acc
125. NGS ARE INCLUDED IN CDT THE ADA DOES NOT DIRECTLY OR INDIRECTLY PRACTICE MEDICINE OR DISPENSE DENTAL SERVICES THE SOLE RESPONSIBILITY FOR THE SOFTWARE INCLUDING ANY CDT AND OTHER CONTENT CONTAINED THEREIN IS WITH INSERT NAME OF APPLICABLE ENTITY OR THE CMS AND NO ENDORSEMENT BY THE ADA IS INTENDED OR IMPLIED THE ADA EXPRESSLY DISCLAIMS RESPONSIBILITY FOR ANY CONSEQUENCES OR LIABILITY ATTRIBUTABLE TO OR RELATED TO ANY USE NON USE OR INTERPRETATION OF INFORMATION CONTAINED OR NOT CONTAINED IN THIS FILE PRODUCT This Agreement will terminate upon notice to you if you violate the terms of this Agreement The ADA is a third party beneficiary to this Agreement 5 CMS DISCLAIMER The scope of this license is determined by the ADA the copyright holder Any questions pertaining to the license or use of the CDT should be addressed to the ADA End Users do not act for or on behalf of the CMS CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS OMISSIONS OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE IN NO EVENT SHALL CMS BE LIABLE FOR DIRECT INDIRECT SPECIAL INCIDENTAL OR CONSEQUENTIAL DAMAGES ARISING OUT OF THE USE OF SUCH INFORMATION OR MATERIAL The window layout above displays the default viewable area of the scrollable data the layout below displays the remaining data PROMISe Provider Internet User M
126. OMISe System Documentation Establishing a New Provider User Account If you have not established an account previously you will need to go through the Registration process Note PA PROMISe supports user IDs issued from both PA PROMISe and DPW Unified Security Because a provider user ID is comprised of the nine digit PROMISe provider number plus a four digit service location providers with more than one service location may create more than one account Click the Register Now link located under the Log In button on the PROMISe Welcome Page The Registration Selector window will display 2 1 Process for Registering and Obtaining a Password Providers The User Registration process allows providers OON providers and billing agents to request access to the PA PROMISe Web site by submitting the necessary entity information requested in these online forms You are asked to fill in the Web form with identifying information email address and to confirm that you have read and understand the disclaimers presented Note This section addresses the registration process for providers the processes for OON providers billing agents and alternates will be discussed in subsequent sections A provider is defined as an individual state or local agency corporate or business entity that is enrolled in the healthcare program as a provider of services 1 Click the Register Now link located under the Log In button on the PROMISe Welcome
127. OMISe Provider Internet User Manual docx 49 The Provider Contact Telephone Number field is a required field and is not auto filled The User must enter the telephone number of the provider contact for July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation handling EFT issues 12 In The Provider Contact Information The Provider Contact Email Address field Section Email Address field the is a required field and is not auto filled electronic mail address to send The User must enter the email address of provider contact correspondence the provider contact for handling EFT issues 13 In the Financial Institution The Financial Institution Name field is a Information Section Financial required field and is not auto filled The Institution Name field the official User must enter the name of the name of the provider s financial provider s financial institution institution 14 In the Financial Institution The Financial Institution Address Street Information Section Financial field is a required field and is not auto Institution Address Street field the filled The User must enter the street street number and street name where number and the street name of the the financial institution is located provider s financial institution 15 In the Financial Institution The Financial Institution Address City Information Section Financial f
128. Other Provider ID that is less than 10 or 13 characters in length Enter a numeric 13 digit Other Provider ID Enter a positive numeric value for the Paid Amount for OI Enter a positive numeric value for Paid Amount Enter a Paid Date for OI that is less than or equal to today s date Enter a date for Paid Date that is less than or equal to today s date Enter a Patient Account Enter a Patient Account that does not contain or Enter the Patient ID Enter a Patient ID that is 10 characters in length Enter a positive numeric value for the Patient Pay Amount Enter the Patient Status Enter more than two characters for the Patient Status Enter a positive numeric value for the Patient Status Enter 10 characters for the Prior Authorization Enter 5 characters for the Procedure Enter a Procedure that contains only alphanumeric characters Enter a positive value for Amount for OI July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Error Code Field 1 2 Reason Amount 2 0 Other Insurance Reason Amount 3 0 Other Insurance Reason Code 1 Other0 Insurance 1 Reason Code 2 Other0 Insurance 1 Reason Code 3 Other0 Insurance 1 Recipient ID 0 1 Referral Code 1 2 Error Message Reason Amount must be numeric Reason Amount may not contain a negative value Amount 2 for OI may not contain a negative value
129. PA PROMISe User Manual PA PROMISe Provider Internet User Manual SYSTEM DOCUMENTATION LIBRARY REFERENCE NUMBER 00000164 SECTION 4 5B LIBRARY REFERENCE NUMBER 0000082 PROVIDER INTERNET USER MANUAL REVISION DATE 07 03 2014 VERSION 5 19 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Library Reference Number 00000082 This document contains confidential and proprietary information of the Pennsylvania PROMISe account of HP Enterprise Services and may not be disclosed to others than those to whom it was originally distributed It must not be duplicated published or used for any other purpose than originally intended without the prior written permission of Pennsylvania PROMISe Information described in this document is believed to be accurate and reliable and much care has been taken in its preparation However no responsibility financial or otherwise is accepted for any consequences arising out of the use or misuse of this material Address any comments concerning the contents of this manual to HP Enterprise Services Attention Documentation Unit PA MMIS 225 Grandview Ave MS A20 Camp Hill PA 17011 HP is an equal opportunity employer and values the diversity of its people 2014 Hewlett Packard Development Company LP PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMIS
130. PDF format Layout AS h S I i lt br e Sas SIF DHA 2 A Pa amp E S B 2 BS wh so Bookmarks 3 2 v 3 a S a j j j l l Phi 4 tore Pa Wsin Ole WE Field Descriptions Field Description Data Type Length PDF image PDF for Remittance advice Report N A 0 PROMISe Provider Internet User Manual docx July 3 2014 201 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Edits Field Error Code Error Message To Correct No Error Code Messages found for this window 6 19 1 Accessibility and Use To access and use the Report View window complete the steps in the step action table s To Access Provider Report Request Window Step Action Response 1 Logon to PA PROMISe using the steps The Provider Main Page window opens presented in the General User Manual 2 Click the Report tab The Provider Report Index window opens 3 Select the desired report The Provider Report Request window opens 4 In the List Reports From and To drop down lists select a value 5 Click the Request Reports button A list of dates for which the report is available appears in the window 6 Click the hyperlink for the specified date Displays a graphical representation of the requested actual report in Adobe format 6 20 ePEAP Menu When you ha
131. PROMISe Internet Portal PA PROMISe System Documentation 3 Enrolling for Electronic Funds Transfer EFT and Electronic Remittance Advice ERA on the PROMISe Portall c ccsssssssssssssssssssssecssccccsesscssssecccccescscsssssececesecsssscssececess 42 3 1 About the Electronic Funds Transfer Enrollment Application Window 42 Sided Accessibility sands Uses cess Sel ese e ea a eean sede Gee vedee Pan eyes Ou Seabee nace biGh ep e hee Ges tates 43 To Access the Electronic Funds Transfer EFT and Electronic Remittance Advice ERA Enrollment Application Window csccsscesssecssecseceseceseceseeeseessceeeeeesaeeeseeeaeecsaecsaecaecaeesseeess 43 3 2 Enrolling for Electronic Funds Transfer EFT and Electronic Remittance Advice ERA On the PROMISE Portal ict swrs tr dedreaiet ciate Pan dv adele tails a iaia 46 IZE Accessibility and U sei e ar e ae ea aeia e AO e aA E EE ER E EE 46 To Open the Electronic Funds Transfer EFT Enrollment Application Window 48 To Complete the Electronic Funds Transfer EFT Enrollment Application 0 0 0 eee 48 3 3 Electronic Remittance Advice ERA Enrollment Application Window 56 323 1 gt Accessibility and Use onrera ost beg as EERE E EEE AE E E E eet 57 To Open the Electronic Remittance Advice ERA Enrollment Application Window 57 To Complete the Electronic Remittance Advice ERA Enrollment Application
132. PSDT No m Contract Type v Contract Code Contract Version Service Adjustments for Service Line 1 Add Adjustment Claim Status Information Claim Status Not Yet Submitted Field Descriptions Field Description Add Anesthesia Add new anesthesia code to claim Code Add Condition Add new condition code to claim Code Add Diagnosis Add new diagnosis code to claim Code PROMISe Provider Internet User Manual docx July 3 2014 162 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Add Other Insurance Add Patient Add Service Line Adjustment Add Service Lines Add Adjustment Adjustment Group Code Admission Date Amount 1 Amount 2 Amount 3 Anesthesia Related Procedures Attachment Control Basis for Measurement Benefits Assignment other insurance Benefits Assignment Billed Amount Billed Amount Service Lines list box Billing Note CLIA Number Description Add new other insurance line to claim Add new other insurance line to claim Add new service line adjustment to claim Add new service line to claim Add a new adjustment to claim General category of payment adjustment Date that the recipient was admitted or start of care Dollar amount of the adjustment Dollar amount of the adjustment Dollar amount of the adjustment Anesthesia Relate
133. Provider ID 300276278 DOGOOD MEDICAL ASSOCIATES Active NPI 1384654368 View Taxonomy ePEAP Access Full Access Service Location 0001 111 DOGOOD LN ANYTOWN PA 17011 Provider Type 31 PHYSICIAN View Specialties Session time 29 00 Monday 24 December 2012 2 57 pm Upload PDF Instructions To send a file from your computer to the Department of Public Welfare please follow the four steps below The file must be in the Portable Document Format PDF and file size must not exceed 4 megabytes Step 1 Please click Browse and then select a PDF from your computer Upload From Step 2 Please select a description for the PDF E Step 3 Please tell us how to contact you Optionally add comments about the PDF required Contact Name Email Address Phone Number Step 4 Please send the PDF ePEAP Menu PROMISe Provider Internet User Manual docx July 3 2014 273 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 40 1 Accessibility and Use To access and view the ePEAP Upload PDF window complete the steps in the following step action tables To Access the ePEAP Upload PDF Window Step Action Result 1 Select the Upload PDF link in the ePEAP Menu Field Descriptions The Upload PDF window opens Field Description Data Type Length Browse Opens a Windows
134. Provider Internet User Manual docx July 3 2014 37 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation pennsylvania DEPARTMENT OF PUBLIC WELFARE PROMIS e Internet My Home Claims Eligibility Trade Files Reports Outpatient Fee Schedule ePEAP Hospital Assessment Help My Home Wednesday 11 02 2011 12 01 PM EST Name Account Please review and update your service location s contact information Click the link for ePEAP above 1234567890123 Then select Enrollment Information and Address Information from the ePEAP menus Provider ID 1234567890123 Location ID 0001 gt My Profile gt Manage Alternates The Pennsylvania Medical Assistance EHR Incentive Program is now available Manage Billing Agents If you applied at CMS s EHR Incentive Program Registration and Attestation R amp A website you will see a link to the Medical Assistance Provider Incentive Repository MAPIR after you log on with your PROMISe Internet Portal User ID If you do not have a PROMISe Internet Portal User ID please register by following the Quick Links on the left of C t s P20 If you have applied at CMS s EHR Incentive Program Registration and Attestation R amp A website for an HIT incentive DPW Home payment and do not see the MAPIR link at left please contact the MA HIT Initiative Support Center at 1 855 259 2114 or email RA mahealthit state pa us DPW Provider Information ePre
135. Reason Amount must be numeric Reason Amount may not contain a negative value Amount 3 for OI may not contain a negative value Reason Amount must be numeric Reason Amount may not contain a negative value Reason Code 1 for OI can only contain alphanumeric characters Reason Code can only contain alphanumeric character s Reason Code 2 for OI can only contain alphanumeric characters Reason Code can only contain alphanumeric character s Reason Code 3 for OI can only contain alphanumeric characters Reason Code can only contain alphanumeric character s Recipient ID is a required field Recipient ID must be 10 characters in length Referral Code must be 2 characters in length Referral Code can only contain alphanumeric characters PROMISe Provider Internet User Manual docx 138 To Correct Enter a numeric value for Reason Amount Enter a positive numeric value for Reason Amount Enter a positive value for Amount 2 for OI Enter a numeric value for Reason Amount Enter a positive numeric value for Reason Amount Enter a positive value for Amount 3 for OI Enter a numeric value for Reason Amount Enter a positive numeric value for Reason Amount Enter the Reason Code 1 for OI that contains only alphanumeric characters Enter a Reason Code that contains only alphanumeric character s Enter the Reason Code 2 for OI that contains only alphanumeric characters Enter a Reason Code that contai
136. Referring 0 NPI must be 10 digits Enter a 10 digit NPI Provider NPI Rendering 0 NPI must be 10 digits Enter a 10 digit NPI Provider Original Claim 0 Original Claim is a required field Enter valid Original Claim when Claim Frequency Code is 7 or 8 1 Original Claim must be 13 characters Enter a 13 character Original in length Claim 2 The ICN entered for the Original Enter a Fee For Service claim Claim number is an encounter number Encounters may not be adjusted or voided Other Accident 0 When Accident Date is entered a Select a related cause accident related cause Employment Other Employment Other Accident or Accident or Auto Accident must be Auto Accident when Accident chosen Date is entered Patient Account 0 Patient Account is a required field Enter an Account 1 Patient Account may not contain Remove and characters or from Account Patient ID 0 Patient ID for Patient is a required Enter valid Patient ID field PROMISe Provider Internet User Manual docxsssstsi s sSSS y 2094 172 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Error Error Message To Correct Code 1 Patient ID for Patient must be 10 Enter a 10 character Patient ID character s in length Patient Pay 0 Patient Pay Amount may not contain a Do not enter negative Patient Pay Amount negative value Amount Patient 0 Patient Signature is required when Enter Patient Sig
137. Rendering Provider D Emergency Orthodontic Treatment Total Months Months Remaining Add Diagnosis Code Accident pens Causes Date MMOD YYYY State County The window Layout above displays the default viewable area of the scrollable data the Layout below displays the remaining data PROMISe Provider Internet User Manual docx July 3 2014 92 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Other Insurance Ol Carrier Code Group Number Group Name Policy Holder Last Name Add Line cannot be submitted blank Group Number Group Name j_ gt Carrier Code m Carrier Name eee Policy Holder ID Code Ae Policy Holder Last Name Policy Holder First Name e eee Individual Relationship O WH Release of Medical Data m Benefits Assignment sd Claim Filing Code m Service Lines SVC Date of Service Place of Service Procedure Units Billed Amount Add Date of Service MM DDIYYYY Service Line 1 Date of Service is required Place of Service w Procedure Service Line 1 Procedure is required Modifier 1 PROMISe Provider Internet User Manual docx July 3 2014 93 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Diagnosis Pointer iv Tooth Number Tooth Surface Placement
138. S has been received and processed by DPW claims may not process correctly You must include a copy of this page with your documentation Provider ID 200180963 Service Location 0001 NPI 1224567893 6 As noted in the window above forward a copy of your NPI assignment documentation to the listed address and include a printout of the page showing your Provider ID Service Location and NPI number This information is required to validate your NPI assignment If documentation is not received claims may be rejected 7 Click the Continue button The ePEAP Main Menu window opens Note Until the NPI number is validated by DPW a red Pending label will display next to the NPI field on all window headers PROMISe Provider Internet User Manual docx July 3 2014 243 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Add or Change Taxonomy Codes Step Action 1 Click the Manage NPI Taxonomy link 2 Select new taxonomy code s to be added by clicking the check box es next to the code Remove existing taxonomy codes by clicking the check box es next to the code to remove the check mark This window will only display the taxonomies valid for the registered Provider Type and Specialty combination Click the Continue button Result The ePEAP Manage NPI and Taxonomy Codes window opens The Review Your Changes wind
139. SPONSE 1 Sign on to the PA PROMISe The Provider Main Page appears on the Internet application desktop 2 Click on the EFT and ERA The EFT and ERA Enrollment window Enrollment menu option in the menu opens bar of the window 3 Click the EFT Enrollment Request The Electronic Funds Transfer EFT option Enrollment Application window opens 4 Click the ERA Enrollment Request The Electronic Remittance Advice ERA option Enrollment Application window opens Field Descriptions Field Description Data Type Length Provider ID 13 digit PROMISe Provider ID currently Alpha numeric 14 selected for the Portal user Formatted with a dash between the 9 digit MPI and the 4 digit service location code Name Name of the provider service location Alpha numeric 50 Electronic Funds Transfer EFT Status Service location s EFT activity status in Alpha 15 PROMISe Possible values and meanings are e Enrolled PROMISe EFT status is active e Pre notification PROMISe sending test transactions for 3 weeks before full enrollment e Not Enrolled PROMISe EFT status is cancelled or EFT was never set up Financial Institution Identifies service location s financial Numeric 9 PROMISe Provider Internet User Manual docx July 3 2014 43 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Description Data Type Length Routing Number institution Field wi
140. Se System Documentation Field Description Data Type Length Fax Fax number for the specific address code Character 10 Handicap Access Indicates by Yes or No whether address is Radio 0 handicapped accessible Button Help Describes the fields on the ePEAP window Button 0 Home Office Address Assigns new address as the Home Office Check Box 0 address for current service location Mail to Address Mail to Address for current service location Check Box 0 Pay to Address Pay to Address for current service location Check Box 0 Phone Phone number for the specific address code Character 10 Reset Resets the form Button 0 Review Submit Opens the Review Your Changes window Button 0 ePEAP Menu Returns to the ePEAP menu window Button 0 6 27 ePEAP Manage Email Address The ePEAP Manage Email Address window is used by providers to update the email address to which messages from the Medical Assistance program are sent This window is accessed from the PA PROMISe Internet Provider Main Page through the ePEAP Provider Enrollment Automation Project link which opens the ePEAP Menu Click the Enrollment Information link to open the Enrollment Information window then the Address Information link to open the Provider Address Information window Click the Change E mail link to open the Manage E mail Address window Several edits ensure the validity of an email address If an IP address is given instead of a symbolic name the
141. Taxonomy for Rendering Provider ID Ending date of service Ending date of service Distance traveled during transport Indicates the reason for the ambulance transport Number of units provided to patient Number of units provided to patient Removes the Anesthesia Code Removes the Condition Code Removes the Diagnosis Code Removes the Service Line Adjustment Zip for Billing Provider ID Zip for Referring Provider ID Zip for Rendering Provider ID PROMISe Provider Internet User Manual docx 170 Data Type Number Number Character Button Number Character Character Character Date MM DD CCYY Date MM DD CCYY Number Drop Down List Box Number Number Button Button Button Button Character Character Character Length OO NN NY 10 10 July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Error Code Field Edits Field Add other 0 insurance Admission Date 0 Anesthesia 0 Code Auto Accident 0 accident Billed Services 0 Billing Note 0 Code Type 0 1 Country 0 accident 1 Date accident 0 Date of Birth 0 Date of Death 0 Diagnosis Code 0 can repeat 8 times 1 Discharge Date 0 PROMISe Provider Internet User Manual docx Error Message To Correct A blank record may not be submitted Enter information for Other Please delete if not used Insurance Admission Date must be less tha
142. Type Character Character Character Drop Down List Box Character Character Character Drop Down List Box Drop Down List Box Drop Down List Box Character Character Drop Down List Box Length 12 35 35 10 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Release of Medical Indicates whether the provider has informed Drop Down List 0 Data Other Insurance consent to release medical info For conditions Box or diagnosis regulated by federal status or a signed statement on file to permit the release of medical data to other organizations Valid Values are e I Informed Consent to Release Medical Info For conditions or diagnoses regulated by Federal Statutes e Y Yes the provider has a signed statement permitting the release of medical billing data related to a claim Report Transmission Timing transmission method or format by Drop Down List 0 Code Report Type Code Revenue Code Service Lines which reports are to be sent Timing Box transmission method or format by which reports are to be sent Title or contents of a document report or Drop Down List 0 supporting item Box Specific accommodation or ancillary service Character 4 revenue code pertaining to this claim Srv Sequential number of a service detail Number 2 State State accident occurred in Character 2 Submit Submit clai
143. UBLIC WELFARE Home gt Challenge Question Thursday 05 06 2010 02 47 PM EST Answer the challenge question to verify your identity uestion Site Key Challenge Question What is the name of your favorite pet The PROMISe Portal uses a personalized site key to protect your Privacy online To use a site key you are asked to respond to your Challenge Forgot answer to challenge question question the first time you use a pora e pasi pis Select This is a personal computer Register it now the correct answer to the Challenge question your site key token displays which ensures that you have been correctly identified Similarly by displaying your personalized site key token you can be sure that this is the Continue actual PROMISe Portal and not an unauthorized site Your Answer This is a public computer Do not register it If this is your personal computer you can register it now by selecting This is a personal computer Register it now If this is not your personal computer such as a public computer select This is a public computer Do not register it 4 Inthe Your Answer field enter the answer you created for the challenge question posed Select the personal computer or public computer option If you select the personal computer option the Portal will skip the Challenge Question window for future logons If you select the public computer optio
144. User Manual docx July 3 2014 82 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout rN pennsylvania DEPARTMENT OF PUBLIC WELFARE PROMIS e Internet aso Claims Mais mic E E E E Ms a a Claim Inquiry Submit Institutional Submit Professional Submit Dental Submit Pharmacy Search Request ACN Claims gt Search Request ACN Wednesday 11 09 2011 02 02 PM EST Provider Claim Attachment Number Request Step 1 Request an ACN or search for an existing ACN Criteria wei Provider ID 1234567890123 Attachment Control Number Recipient ID PROMISe Provider Internet User Manual docx July 3 2014 83 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation The window Layout above displays the default viewable area of the scrollable data the Layout below displays the remaining data PROMISe Paper Attachment to Electronic Claim Cover Sheet National Provider Number NPI Provider Number Service Location Recipient Number Attachment Control No Purpose This form is to be used when a claim requiring a paper attachment is being submitted electronically on the 837 transaction Submission of this completed form along with the required attachment and electronically submitted claim will allow the appropriate review process to be conducted Instructions l In box 1 fill in the NPI that was used for fling
145. Value Amount value Value Code Amount 0 Value Amount is required when Enter the Value Amount 6 Value Code is entered 1 Value Amount must be numeric Enter a positive numeric value and may not contain a negative for the Value Amount value Value Code Amount 0 Value Amount is required when Enter the Value Amount 7 Value Code is entered 1 Value Amount must be numeric Enter a positive numeric value and may not contain a negative for the Value Amount value Value Code Amount 0 Value Amount is required when Enter the Value Amount 8 Value Code is entered 1 Value Amount must be numeric Enter a positive numeric value and may not contain a negative for the Value Amount value Value Code Amount 0 Value Amount is required when Enter the Value Amount 9 Value Code is entered 1 Value Amount must be numeric Enter a positive numeric value and may not contain a negative value for the Value Amount 6 9 1 Accessibility and Use To access and use the Provider Institutional Claim window complete the steps in the step action table s Note The following step action tables are organized to coincide with information as it is grouped in the online claim submission form window Billing Information is presented first then Claim Service information and on through the subsequent groups ending with Service Lines information To Access Provider Institutional Claim Window Response 1 Logon to PA PROMISe using the steps presented in The Provider Mai
146. Window 2 To accept the Terms and Conditions click the I The Outpatient Fee Schedule Accept button Download Files window opens PROMISe Provider Internet UserManual docx ss a duly 8 2014 183 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Step Action Response 3 To reject the Terms and Conditions click the I The Provider Main window opens Decline button 6 15 Provider Rate File Provider_Rate_File This window can only be accessed after reviewing and accepting the applicable terms and conditions on a separate Rate Information Disclaimer window This window allows a provider to download the current MA Program Outpatient Fee Schedule files The files are available in three different formats Microsoft Excel Adobe Acrobat Reader PDF or Comma Delimited CSV files This window also provides access to a Microsoft Word document that explains the Comma Delimited file Layout To reduce file size and facilitate download speed the Excel and CSV files are in a compressed format ZIP The downloaded Fee Schedule files are organized by provider type and are updated quarterly The Excel file will be initially protected If users desire to resort the columns the users may unprotect the downloaded file through the Tools menu selecting Protection and choosing Unprotect PROMISe Provider Internet User Manual docx July 3 2014 184 Provider Internet User Manual PROMISe
147. Y PROMISe Provider Internet User Manual docx a y A 165 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field From DOS Service Lines list box Gender Patient Group Name Other Insurance list box Group Name Other Insurance Group Number Other Insurance list box Group Number Other Insurance Individual Relationship Last Name Last Name Patient list box Last Name Patient Medicare Approved Amount Middle Initial Middle Initial patient Middle Initial Patient list box Modifier 1 Modifier 2 Modifier 3 Modifier 4 New NPI Billing Provider Description Beginning date of service Gender of the patient Group name of other insurance carrier Group name of other insurance carrier Group number of other insurance carrier Group number of other insurance carrier Patient s relationship to the Policy Holder Last name of the Medicaid recipient Last name of the patient Last name of the patient Amount of service line adjustment approved by Medicare Middle initial of the Medicaid recipient Middle initial of the patient Middle initial of the patient First modifier code that supplies additional information on the procedure code Second modifier code that supplies additional information on the procedure code Third modifier code that supplies additional information on the procedure code Fourth modifier code tha
148. Y Yes the provider has a signed statement permitting the release of medical billing data related to a claim Indicates whether the provider has informed Drop Down List consent to release medical info For conditions or Box Other Insurance diagnosis regulated by federal status or a signed Rendering Provider ID Report Transmission Code Report Type Code Service Adjustment Indicator Special Program Code State Accident Submit Svc statement on file to permit the release of medical data to other organizations Valid Values are e I Informed Consent to Release Medical Info For conditions or diagnoses regulated by Federal Statutes e Y Yes the provider has a signed statement permitting the release of medical billing data related to a claim ID of the performing provider that performed the Character service Defines timing transmission method or format by Drop Down List which reports are to be sent Box Title or contents of a document report or Drop Down List supporting item Box Indicate whether service adjustment details are Drop Down List present for this service line Box Contains values for EPSDT Physical Drop Down List Handicapped Children s Program Special Federal Box Funding and Disability special programs These are the values allowed by HIPAA for this field State where the automobile accident occurred if Character this claim is associated with an auto accident Submits the claim to DPW
149. acturers One of the immediate advantages you will realize is that you do not need to purchase install or develop special software or applications to use the PA PROMISe Internet application The PA PROMISe Internet solution allows you to log on using a standard Internet browser to enter or request information Any information you pull from this application is specific to your provider number and will not be shared with others If you have an account that was already established for the PROMISe Provider Internet there is no need to re register as your information will be migrated over to the new portal 1 2 Secured External Web site PA PROMISe provides security to the Internet Web based application through an external Web site Through the use of your unique user logon ID password and site certificate features this secure external facing Web site is accessible through the public Internet The options and activities listed below are available to PROMISe providers managed care organizations and drug labeler and manufacturer communities who have received authorization to access this site Providers and Managed Care Organizations e Receive messages and informational notices from the Department of Public Welfare DPW These messages are displayed when a provider arrives at the PROMISe Welcome window e Maintain passwords and if authorized as a provider out of network OON provider or billing agent create and manage
150. aid Amount 21 60 Medicare Approved Amount 127 00 Carrier Code 5 Carrier Code is required Verify that Carrier Code is entered for all details m R Claim Status Information Claim Status Paid PROMISe Provider Internet User Manual docx 41 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 3 Enrolling for Electronic Funds Transfer EFT and Electronic Remittance Advice ERA on the PROMISe Portal The PA PROMISe Internet application has been designed to make enrolling for Electronic Funds Transfer EFT as efficient as possible using the currently available electronic technology 3 1 About the Electronic Funds Transfer Enrollment Application Window The Electronic Funds Transfer Enrollment Application window constitutes an online application form that is easy to fill out and submit Providers and Provider Alternates who are registered on the PROMISe Provider Portal can access the online EFT Enrollment Application form by clicking on the EFT and ERA Enrollment menu option in the menu bar of the Provider My Home Page window and then clicking on the EFT Enrollment Request button on the EFT and ERA Enrollment Window Please allow four weeks for the enrollment process which includes pre notification verification If after four weeks you do not start receiving EFT payments please contact the Provider Assistance Center PAC at 1 800 248 215
151. al docx July 3 2014 31 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 3 The Forgot User ID window displays oN pennsylvania DEPARTMENT OF PUBLIC WELFARE Home gt Forgot User ID Tuesday 06 29 2010 10 02 AM EST Forgot User ID Indicates a required field Enter the following account information We will use these values to help identify your account If we find a match an email will be sent to your email address on record User Type Provider In Network x Provider ID Select your user type from the User Type drop down field Enter your 13 digit provider ID in the Provider ID field Click the Submit button A PSN A conformation message will appear and an email message containing your User ID will be sent to you 2 7 Changing a Password To change a password access the My Profile window by clicking the My Profile link on the Provider My Home Page This process is identical for providers OON providers billing agents and alternates PROMISe Provider Internet User Manual docx July 3 2014 32 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Fe x pennsylvania DA DEPARTMENT OF PUBLIC WELFARE MyHome Claims Eligibility Trade Files Reports Outpatient Fee Schedule ePEAP Help My Home gt My Profile Thursday 04 22 2010 07 58 AM EST My Profile Back to My Home Na
152. and Obtaining a Password OON Providers 00 17 2 4 About Alternates tan pae a a E N E EN NE 21 24 1 Creating an Alternate onrera iiri ceases n i a iT EE a T a iT 21 Adding a New Alt rnat ss nra unnin uncogasehagceus iaer kn teen iaee ia ii enait eise 22 2 4 2 Adding a Registered Alternaten crionn n a i e i i i 25 2 4 3 First Time Access for Alternates Initial Password ccccscsceceessececeeneeeeeseaeeecneaeeeenenaes 26 LD Forgotten PASSWOrdS rae a an fatnasiadtanlanscasda dacs a S 30 2 6 Forgot User Mielnie e a T e R TE aE 31 2 7 Chanem e amp Password a a OS she BE OE E aE 32 2 8 Denial of ACCESS pinnin na n EER EASTSEE dal eee a iiaii 34 2 9 How to Log On To PA PROMIS escscsessssssssssssssesessscssesssssssssstsssssesssssessesneaseasees 35 2 10 Submitting Claims Electronically Using PA PROMIS o ecsscsscsscssessseseesseseeseeeees 40 2A0 About Dental Claims 233 siiessieien teeta Uae BU ted Ree ea es 40 2 10 2 About Institutional Claims 2 0 0 cece eesceeneceeceeeeeeeeaeceeaceceeceecaeeeeaaeceeaeecseeseaecseaeeeeeeeees 40 2 10 3 About Pharmacy Claims re ecese rna eene ae ee hen nett 40 2 10 4 About Professional Claims ccc ceecceessceeseceeceecseeeeaeceeaceceeeeecsaeceeaaeceeaeecsaeeeeaaeceeaeeceeeeees 40 2 10 5 About the Copy Function sietetsn ieee te raged tealencenin an toriay ea alin Sieve ene 41 PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual
153. anges window Button 0 ePEAP Menu Opens the ePEAP Menu window Button 0 6 29 ePEAP Add a Group for Fee Assignment The ePEAP Add a Group for Fee Assignment window is used by providers to add fee assignments for the current provider service location PROMISe Provider Internet User Manual docx July 3 2014 233 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation This window is accessed from the PA PROMISe Internet Provider Main Page through the ePEAP Provider Enrollment Automation Project link which opens the ePEAP Menu Click the Enrollment Information link to open the Enrollment Information window then the Fee Assignment Information link to open the Fee Assignment Information window Click the Add a Group for Fee Assignment link to display the Add a Group for Fee Assignment window Layout PENNSYIVANID Z PEAP of Medical Assistance Progra Your Provider ID 300180963 DOGOOD JAMES L Status Active NPI 1234567893 view Taxonomy ePEAP Access Full Access Service Location 0001 123 HOPE RD HARRISBURG PA 17011 Provider Type 31 PHYSICIAN View Specialties Add a Group for Fee Assignment Enter the Provider ID and Service Location of the Group to add _ Click Continue Select the date to begin fee assignment Click Continue Review Request and Submit awn Add this Group Provider ID of Group Service Location of Group Fee Assign Menu ePEAP Menu He
154. anual docx July 3 2014 182 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation DEPARTMENT OF PUBLIC WELFARE DISCLAIMER If you are a provider who only provides Home and Community Based Waiver Services please refer to the Home and Community Services Information System HCSIS for your reimbursement rates Last modified on December 9 2011 Accept Field Descriptions angi Data Field Description Type Length I Accept Button to accept the disclaimer and open the Downloadable Fee Button 0 Schedule page where download options are available I Button to decline the disclaimer and return to the Provider s Internet Button 0 Decline Portal Home page Field Edits Field Error Code Error Message To Correct No Error Code Messages found for this window 6 14 1 Accessibility and Use To access and use the Rate Information Disclaimer window complete the steps in the step action table s To Access Rate Information Disclaimer Window Step Action Response 1 Log on to PA PROMISe using the steps presented The Provider Main Page window in the General User Manual opens 2 Click the Outpatient Fee Schedule link The Rate Information Disclaimer window opens To Accept Reject Terms and Conditions and Access the Outpatient Fee Schedule Download Window Step Action Response 1 Review the Terms and Conditions displayed in the Rate Information Disclaimer
155. aracters Admission Type is a required field The first two characters of Attending Provider ID must be alpha the Admission Hour Enter the Admission Source Enter a Admission Source that contains only alphanumeric characters Enter the Admission Type Enter alphabetic characters for the first two characters of the Attending Provider ID Attending Provider ID must be 8 Enter an Attending Provider ID or 9 characters in length Other Insurance Benefits that is 8 or 9 characters in length Enter the Other Insurance Assignment for OI is a required Benefits Assignment for OI field Billed Amount is a required field Enter the Billed Amount Billed Amount must be numeric Enter a positive numeric value and may not contain a negative value Policy Holder Carrier Code for OI is a required code Code Type field is required Both ICD 9 and ICD 10 codes have been found within this inquired claim Please choose the correct ICD code type Condition Code must be 2 characters in length PROMISe Provider Internet User Manual docx 129 for Billed Amount Enter the Policy Holder Carrier Code for OI Select an ICD code type Select the correct ICD code type Enter 2 characters for the Condition Code July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Condition Code 2 Condition Code 3 Condition Code 4 Condition Code 5 Condition Code 6
156. ary Submit Requests Fee Assignment Information wns Manage NPI Taxonomy Review Submit _ePenP menu Herp ern 6 21 1 Accessibility and Use To access the ePEAP Enrollment functions complete the steps in the following step action tables To Access the ePEAP Enrollment Information Window Step Action Result 1 Select the ePEAP Menu link The ePEAP Menu window opens 2 Select the Enrollment Information option The Enrollment Information window from the ePEAP Menu opens To Request Changes to Basic Enrollment Information Step Action Result PROMISe Provider Internet User Manual docx July 3 2014 207 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Step Action 1 Select Base Information Result The Basic Enrollment Information window opens To Request Changes to Provider Address Information Step Action Result 1 Select Address Information The Provider Address Information window opens To Request Changes to Fee Assignment Informat Step Action ion Result 1 Select Fee Assignment Information The Fee Assignment Information window opens To Manage NPI Codes and Associated Taxonomy Codes Step Action Result 1 Select the Manage NPI Taxonomy button The Manage NPI and Taxonomy Codes window opens To Review and Submit Completed Chang
157. ate Province address 2 character postal abbreviation code Provider Address Zip Zip code portion of service Alpha numeric 10 Code Postal Code location address Full 9 digit zip code with a dash inserted between first 5 and last 4 numbers Provider Identifier Information Provider Identifiers Tax ID of provider legal entity Numeric 9 Provid gt Federal Tax Only last 4 digits of the Tax ID Identification Number or Bis une will be displayed other digits Employer Identification f will be masked Number Provider Identifiers National Provider Identifier Numeric 10 National Provider assigned to the service location Identifier NPD Other Identifiers PA PROMISe Alpha 10 Assigning Authority PA PROMISe Other Identifiers Trading 13 digit PROMISe Provider ID Numeric 9 4 Partner ID PA selected for the Portal user PROMISe Formatted as 9 digit MPI and 4 digit Service Location Code Other Identifiers Trading Adds a new row for Trading Link N A Partner ID PA Partner ID PA PROMISe PROMISe Provider Internet User Manual docx July 3 2014 64 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Description Data Type Length PROMISe 9 digit MPI is auto filled the Ada NewSe rice same as the first row and may Locat not be updated ocation 4 digit Service Location is initially blank and must be
158. ate accounts can be authorized by a provider to bill for more than one 13 digit MPI and Service Location D Billing Agent A third party individual or entity who is authorized to submit An individual or entity thatts authorized to access specific Medicaid transactions on behalf of a Provider functionality within the PROMISe Internet Portal 2 Select the OON Provider option 3 The Registration Personal Information window displays PROMISe Provider Internet User Manual docx July 3 2014 17 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation W pennsylvania DEPARTMENT OF PUBLIC WELFARE Home gt Registration Selector gt Registration Wednesday 04 28 2010 03 12 PM EST Registration Step 1 of 2 Personal Information Indicates a required field Please provide the following information to get started First Name 7 Last Name OON Provider ID SSN EIN Continue Cancel 4 Enter your first name last name OON Provider ID and social security number SSN or employer identification number EIN into the applicable fields 5 Click the Continue button PROMISe Provider Internet User Manual docx July 3 2014 18 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 The Registration Security Information window displays pen
159. ate though they can be the same date 6 18 1 Accessibility and Use To access and use the Provider Report Request window complete the steps in the step action table s To Access Provider Report Request Window Step Action Response 1 Logon to PA PROMISe using the steps presented in The Provider Main Page the General User Manual window opens 2 Click the Report tab The Provider Report Index window opens 3 Select the desired report The Provider Report Request window opens PROMISe Provider Internet User Manual docx July 3 2014 200 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To View Provider Reports Step Action Response 1 In the List Reports From and To drop down lists select a value 2 Click the Request Reports button A list of dates for which the report is available appears in the window 3 Click the hyperlink for the specified Displays a graphical representation of the date requested actual report in Adobe format 6 19 Report View Report View The Report View Window displays the remittance advice reports in PDF format based on processing date supplied by the external web user A list of Remittance Advice reports for a 90 day period will be retrieved based on the user supplied report date criteria The user can then select a specific report date and view the Remittance Advice report for the selected report date in
160. ax Identification Number TIN 01 1112486 National Provider identifier wen Yd Method of Retrieval Clearinghouse PA PROMISe Priovider Electronic System PES Other please describe J Electronic Remittance Advice Clearinghouse Information r r appicsbie Clearinghouse Name O Clearinghouse Contact Name Telephone Number EJ Emaii Address TE Submission Information Reason for Submission choose one New Enrollment Change Enrotiment Cancel Enrotiment Authorized Signature Electronic Signature of Person Submitting Enroliment 002457861286 Printed Name of Person Submitting Enrollment u MARY Smita Printed Title of Person Submitting Enrollment OFFICE MANAGER Submission Date format CCYYMMOD Submit ERA Enrolment Form PROMISe Provider Internet User Manual docx July 3 2014 58 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Complete the Electronic Remittance Advice ERA Enrollment Application STEP ACTION RESPONSE 1 The Provider Information Section Name field represents the legal name of the institution corporate entity practice or individual provider associated with the service location This information is auto filled from the data available in PROMISe The user may not update this information via the ERA Enrollment Application window 2 The Provider Informati
161. ber Possible Drop Down List Box values are DME Medicare A Medicare B and Railroad Read only as of 2 1 2008 NPI of the group Adds a set of Medicare fields in which the user can enter information about a new Medicare number Fields added are Medicare number Medicare Type Effective Date and End Date Unlabeled field following Your Provider ID Name of current provider as used on official Commonwealth records Provider Type for current Service Location Unlabeled field following Provider Type Describes provider type PROMISe Provider Internet User Manual docx 214 Data Type Button Character Character Date MM DD CCYY Date MM DD CCYY Date MM DD CCYY Date MM DD CCYY Drop Down List Box Check Box Alphanumeric Character Button Character Character Character Length 0 40 10 10 10 50 50 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Reset Clears the contents of the form fields on a Button 0 page Review Submit Reviews the Request Summary and Button 0 Submit Request document Service Location Current provider service location for this Character 4 ePEAP session Service Location Unlabelled field following Service Character 78 Address Location Abbreviated address of current service location Status Status of provider service location Will Character 8
162. bility atid Usinor ee eeter Aaa EAEE eee eee hee 195 To Access Provider Recipient Eligibility Verification Window ceeeeeeeeseeeseeeneeeneeenees 195 To Search by Recipient ID and Card Numbet uu eecesceeeeeeeeeeeeeeeseecseecaaecaaecaesnaeenseen 195 To Search by Recipient ID and Date of Birth ee eeeeeeeeereeeeeeeseeeseeesaecaecnaecnaeenaeen 195 To Search by SSN ienie ghee eae aac ee ye lel ee ee ee eel eee ee 196 To Search by Recipient Name e st siete ei Lede Sie ee ee 196 To Clear Window for New Search 00 eeessecssecsseceseceseceseeeseesseeeeaeesseeeseeeseecaaecnaecaecaeeaeen 197 6 17 Provider Report Index Provider Report Index eee eeeeeeseeeneeeneeceteeeeeeeeaees 197 617 1 Accessibility and Use sss c eresartie a RE eth cd cen whieh sae 198 To Access Provider Report Index Window uu ee esseessecsseceseceseceseeeseeeseeeeneeeaeeeseeeaeesnaeenaees 198 ToView Provider Reports sederet oeiee i yolgeiis shan Geter E A E A E Ei 198 6 18 Provider Report Request Provider Report Request seeseeeeseeeseseresreerrsressrsereses 198 6 18 1 Accessibility and Useiic cscs inin r a a a n a e a 200 To Access Provider Report Request Window essessesseseseeseesreseesesresresresesressesrreseesreseese 200 To View Provider Reports 2 ccssi et iat eae ete ead ie ea 201 6 19 Report View R port VIEW efri Sete cscysty sehen o e i e r e 201 I91 Accessibility and Use nesae eae aroi peal bie Se a a ala a ee nee 202 To A
163. ble s To Access Provider Claim Attachment Number Request Window Step Action Response 1 Logon to PA PROMISe using the steps presented in the General User Manual The Provider Main Page window open PROMISe Provider Internet User Manual docx 85 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Step Action Response 2 Click the Claims tab and select Search The Provider Claim Attachment Request Attachment Control Number Number Request window opens To Search for ACN Details Step Action Response 1 In the Criteria section type a value for the Provider ID and Recipient ID fields 2 Type a value in the Attachment Control Number field 3 Click the Search button If a match is found the details of that attachment control number will be displayed for the provider To Search for All Provider Attachment Numbers Step Action Response 1 In the Criteria section type a value for the Provider ID field 2 Click the Search button If a match is found all attachment numbers for that provider are displayed To Search for New Claim Attachment Number Step Action Response 1 In the Criteria section type a value for the Provider ID and Recipient ID fields 2 Click the Request button A new claim attachment number is displayed 6 6 Provider Claim Inquiry inquiry asp
164. bmit 0 Please specify ICN Recipient ID Patient Enter at least one of Account or enter a Date Range the specified fields Thru Date Input 0 Thru date must be later than From Date PROMISe Provider Internet User Manual docx 88 Enter a Thru date later then the From date July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation f Error Field or Error Message To Correct Code 1 x is not a valid day in month Use a value in Enter a valid date the range 1 days in month 6 6 1 Accessibility and Use To access and use the Provider Claim Inquiry window complete the steps in the step action table s To Access Provider Claim Inquiry Window Step Action Response 1 Complete the Logon steps found in Section 2 The DPW PA PROMISe Web Logging On To The PROMISe Provider Internet site logon window opens Site 2 Click the Claims tab The Claims tab opens 3 Click on Claim Inquiry The Claim Inquiry window opens To Search for A Fee for Service Claim by Recipient ID Step Action Response 1 Type a value in the Recipient ID field 2 In the Claim Status drop down list select a value 3 In the Date of Service section enter a value in the From Date field 4 In the Date of Service section enter a value in the Thru Date field 5 Click the Submit button If a match is found the search resul
165. ccess Provider Report Request Window 00 ec eecessecssecssecsseceseceeceseeeseeseeeeeneeeneeenaeeaaes 202 6 20 PEAP MENU 3st scstuvcid ienaa Mangas oi eteelos a a a a a e 202 0 20 T Accessibility and USec eiee e E odes AOA E EAA E e E E E E 204 To Access th ePEAP Menu csrccrnennn neharmonia n i a a i a i 204 ePEAP Menu Field Descriptions s maniariee ra a i a ria E a e EE SE Ea E 206 6 21 Using the ePEAP Enrollment Information Options eseeseseseseeesesreeseseresresseerreere 206 6 21 1 Accessibility and Use wicca aie ine oo ate eal ane ate 207 To Access the ePEAP Enrollment Information Window 0 0 00 cee ceeceecceeeeeeeeeeeeeeseeeaeeeneeenaees 207 6 22 ePEAP Basic Enrollment Information scesscvssicssibassphnevoade seveeusayansyantyseealagucusaiedsedns 209 6 22 1 Accessibility and Us n aian i cui Sale beste dite Mica AA T E ult dew eee 212 To Access the ePEAP Basic Enrollment Information Window eceseeeseeseeereeereeeeees 212 PROMISe Provider Internet User Manual docx July 3 2014 vii Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Enter Enrollment Change sheise e ea ea nel ae ee oi eae 212 Field Descriptions 5 c sshices eae teehee ithe ede thal eet ib eet ioe rete ees 213 6 23 ePEAP Provider Address Information scssorsvesssevecesnsensoonsorssessosacostsossenne 215 6 23 Accessibility and Use sessc eiat aR EEA eee ahah Cuda 216 Other OPO esd
166. ceesaeceeaeeceeeeeeaeeeeaeceeneeenaees 108 To Add Claim Other Insurance Information ccccccssssssssssssssesssssssssssesssssssssssssessssseseees 108 To Remove Other Insurance Information ccccccsesssssssssssssssssssssssssssssssesssssssesssessseeeeeees 108 To Add Claim Service Lines Information sesesesesererererererererererererererererererererererererererereree 108 To Remove Service Lines Information 0 00 cccccccccccccsesssccccsceeceeeeececeeeeeeeeeeaeaeaeeeaeaeeeaeaeaeaes 109 To Add Claim Service Adjustments Information ccccecsceceseceeseeceececeeececeeeeenaeceeaeeeeeees 109 To Remove Claim Service Adjustments Information ccceecceesseceeececeeeeeeseceeaeceeaeeesaees 109 lI sta 041 i Oo eT a a ee Re Rie RR A eB Ree RE ee 109 To Greate New Claim FOMI i iiscsissscecsthencstalscacctesedgenscanacenstneasatnnalacctabcedearebabacerebavasebababacstatsens 109 To Copy a Paid Clams secs csecticisceni nates a eta hate A sa Ge At a 109 6 8 Provider Help Provider Help jicscccsssivecesciassivcssetaianecndunceerasedvedeaavcsadee tn seston beasactesenys 110 6 8 1 Accessibility and U Sec x aise en ei eck lie eee nage GL aad BE 110 To Access Help Window esi es sce beet a E aes er eee ENRE ieee weil 110 6 9 Provider Institutional Claim Institutional asp cccceesseceeeneeeeeeeeceeeeeceeeeeeeteeeees 110 6 9 1 Accessibility and Use inina eorne EEEO EE TE cds E a E E 142 To Acce
167. characters for the Occurrence Code Enter a Occurrence Code that contains only alphanumeric characters Enter 2 characters for the Occurrence Code Enter a Occurrence Code that contains only alphanumeric characters Enter 2 characters for the Occurrence Code Enter a Occurrence Code that contains only alphanumeric characters Enter 2 characters for the Occurrence Code Enter an Occurrence Code that contains only alphanumeric characters Enter 2 characters for the Occurrence Code Enter a Occurrence Code that contains only alphanumeric characters Enter 2 characters for the Occurrence Code Enter an Occurrence Code that contains only alphanumeric characters Enter the Occurrence Date Enter a Occurrence Date that is less than or equal to today s date July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Occurrence Code Date 2 Occurrence Code Date 3 Occurrence Code Date 4 Occurrence Code Date 5 Occurrence Code Date 6 Occurrence Code Date 7 Occurrence Code Date 8 Occurrence Span Code 1 Error Code 0 Error Message Occurrence Date is a required field when Occurrence Code is entered Occurrence Date must be less than or equal to today s date Occurrence Date is a required field when Occurrence Code is entered Occurrence Date must be less than or equal to today s date Occurrence Date is a required field when Occurrence
168. ck the Exit button The ePEAP Menu window opens PROMISe Provider Internet User Manual docx 217 July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Step Action 5 Click the Review Submit button Result The Review Your Changes window opens 6 Click the New Service Location Request Form link Field Descriptions Field Change Address Change Email Change Phone Fax Enrollment Information Exit Help Review Submit ePEAP Menu A copy of the Pennsylvania Promise New Service Location Application is downloaded to the user s computer for printing Description Data Type Length Displays the Manage Active Addresses window Button 0 Displays the Manage Email window Button 0 Displays the Edit Address window Button 0 Opens the Enrollment Information window Button 0 Exit ePEAP Button 0 Describes the fields on the ePEAP window Button 0 Opens the Review Your Changes window Button 0 Returns the ePEAP user to the ePEAP menu Button 0 window 6 24 ePEAP Manage Active Addresses The ePEAP Manage Active Addresses window displays all addresses assigned to the ePEAP user s Provider ID It is used to select alternate Pay to Mail to and Home Office addresses for the user s service location This window is accessed from the PA PROMISe Internet Provider Main Page by clicking the ePEAP Provider Enrollment Automation Project
169. claim To View Recipient Eligibility Step Action Response 1 Complete a claim If a match is found the search results list is displayed search 2 Click the Recipient The Recipient Eligibility Verification window opens and displays ID link information for the requested Recipient ID To Submit A Fee for Service Claim Adjustment Step 1 Action Type a value in the Recipient ID field or ICN Select a value from the Claim Status drop If the date of service is known enter values in Press the Submit button Click on the ICN link for which an adjustment is to be made Scroll down the claim window to the Service Adjustments for Service Line 1 group PROMISe Provider Internet User Manual docx Response Fee for service claim records that match the search criteria are displayed in the lower portion of the window Note that all ICNs and Recipient IDs are hyperlinked The original claim is displayed July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Response the Adjustment Group Code drop down box the Reason Code drop down box Enter the amount of the adjustment for this claim in the Amount box at the end of the Adjustment row Select a value from the Carrier Code drop down box If another adjustment is to be added to this claim click the Add Adjustment button to activate the Adjustment 2 row Repeat Steps 7 through 1
170. ction are listed in alphabetical order and include explanations of the fields fields edit error messages and functions of each window Note All relevant Field Edits for the windows in the Provider Internet User Manual are listed after the Field Descriptions for each window However not all windows are subject to Field Edits If Field Edits do not apply to a window the Field Edits table states No Field Edits found for this window 6 1 My Profile My Profile The My Profile window is used by providers to display or edit security profile information for users associated with the provider s account Information that can be edited or maintained includes the contact name email address phone number site key and pass phrase challenge questions and password All users must select and answer three security questions The answers provided are stored in the system and used for self authentication Users who access this window are prompted to select security questions if none have yet been established for the account or if their security questions are the previously used custom ones which are no longer valid The new pre selected security questions must be used This window is accessed by selecting the My Profile option The system automatically displays the user s profile information Some of the form fields are conditionally displayed depending on the permissions established for the user PROMISe Provider Internet User Manual docx Jul
171. ctions provided in desktop Section 2 9 of this manual Click on the ePEAP Provider Enrollment 2 Automation Project link in the Other The ePEAP Menu window opens Links section of the window 3 Select the Manage Remittance Advice The ePEAP Manage Remittance Advice option window opens To Discontinue Delivery of Paper Remittance Advices Step Action Result Click on the Access RAs on line through PROMISe and eliminate receipt of paper The Remittance Advice Confirmation pop up window appears RAs radio button to discontinue delivery of paper RAs 2 Click Continue to process the request 3 Press OK to terminate the mailing of paper RAs or Cancel to return The Review Your Changes window is displayed To Restart Delivery of Paper Remittance Advices Step Action Result Click on the Receive paper RAs via US 1 mail radio button to restart delivery of paper RAs 2 Click Continue to process the request The Review Your Changes window is displayed Field Descriptions Field Description Data Type Length Access RAs on Select to receive RAs on line Radio Button 0 line Cancel Sends user back to previous window Button 0 Continue Forwards user to Review Request window Button 0 My Email address is Display update mail to email address Character 100 NPI NPI of the group Character 10 Receive paper RAs Select to receive RAs by US mail Radio
172. d Amount Other Insurance Paid Date Other Insurance Patient Account Patient ID Patient Pay Amount Patient Status Prior Authorization Procedure Reason Amount 1 Other Insurance Error Code 0 Error Message To Correct The first two characters of Other Enter alphabetic characters for Provider ID must be alpha Other Provider ID must be less than 10 or 13 characters in Length 13 digit Other Provider ID must be numeric Paid Amount for OI must be numeric and may not contain a negative value Paid Amount may not contain a negative value Paid Date for OI must be less than or equal to today s date Paid Date must be a date less than or equal to today s date Patient Account is a required field Patient Account may not contain or Patient ID for Patient is a required field Patient ID for Patient must be 10 characters in length Patient Pay Amount must be numeric and may not contain a negative value Patient Status is a required field Patient Status cannot be less than 2 characters in length Patient Status must be numeric and cannot contain a negative value Prior Authorization must be 10 characters in length Procedure must be 5 characters in length Procedure can only contain alphanumeric characters Amount for OI may not contain a negative value PROMISe Provider Internet User Manual docx 137 the first two characters of the Other Provider ID Enter an
173. d Procedures code Attachment control number ACN is used to relate attachments to this claim Units in which a value is being expressed Indicates benefits assignment Valid values are e Yes e No e Not Applicable Indicates benefits assignment Valid values are e Yes e No e Not Applicable Amount requested for payment by a provider for services rendered Amount requested for payment by a provider for services rendered Free form field for comments or special instructions Clinical Laboratory Improvement Amendment CLIA ID number PROMISe Provider Internet User Manual docx 163 Data Type Button Button Button Button Button Drop Down List Box Date MM DD CCYY Number Number Number Number Number Drop Down List Box Drop Down List Box Drop Down List Box Number Number Character Character Length 0 MM O O 80 10 July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Carrier Code Other Insurance list box Carrier Code Other Insurance Carrier Code Service Line Adjustment list box Carrier Code Service Line Adjustment Carrier Name Other Insurance Claim Filing Code Other Insurance Claim Frequency Code Type Comment Condition Code Contract Code Contract Code Service Lines Contract Type Contract Type Service Lines Contract Version Contrac
174. d data elements This list field is auto populated by the value entered in the Procedure field below Reason Code Reason the adjustment was made Drop Down List 0 Box Recipient ID ID for recipients who are authorized to receive Character 10 Medicaid services The field accepts the 9 digit recipient ID and the single verification digit Referral Referral number provided for referring provider Number 4 Referring ID of the provider that referred the recipient to Character 9 Provider ID another provider for services Related Causes 1 Other causes related to the accident Drop Down List 0 Valid values are Box e AA Auto Accident e EM Employment e OA Other Accident Related Causes 2 Other causes related to the accident Drop Down List 0 Valid values are Box e AA Auto Accident e EM Employment e OA Other Accident PROMISe Provider Internet User Manual docx July 3 2014 99 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Release of Medical Data Release of Medical Data Description Data Type Indicates whether the provider has informed Drop Down List consent to release medical info For conditions or Box diagnosis regulated by federal status or a signed statement on file to permit the release of medical data to other organizations Valid Values are e I Informed Consent to Release Medical Info For conditions or diagnoses regulated by Federal Statutes e
175. d in accordance with DPW s guidelines policies and procedures Refer to the DPW web site for more specific information on completing a claim submission Step Action Response 1 In the Billing Information section type a value for the Attachment Control Original Claim Recipient ID Patient Account Last Name First Name Middle Initial Medical Record and Prior Authorization 2 In the Report Type Code and Report Transmission Code drop down lists select a value PROMISe Provider Internet User Manual docx July 3 2014 107 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Step Action Response 3 Type a dollar value in the Patient Pay Amount field To Complete Claim Service Information Step Action Response 1 In the Service Information section type a value in the Referring Provider ID Release of Medical Data Referral and Rendering Provider ID fields 2 In the Benefits Assignment Emergency and Place of Service drop down lists select a value 3 Type a value in the Facility ID Facility Name Admission Date Discharge Date Total Months and Months Remaining fields 4 In the Special Program Code drop down list select a value 5 Type comments in the Comments field To Complete Diagnosis Step Action Response In
176. d in the SelectPlan for Women directory will be indicated below If you wish to change your status from what is currently indicated please check the appropriate box Please note all requested changes will be reflected in the directory the day following the request You are not currently enrolled in the SelectPlan for Women Directory To be added to the directory select the check box below O wish to be included in the SelectPlan for Women Directory Continue Cancel ePEAP Menu PROMISe Provider Internet User Manual docx July 3 2014 261 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 37 1 Accessibility and Use To access the ePEAP SelectPlan for Women Directory window add your service location to the directory or remove your service location from the directory complete the steps in the following step action tables To Access the ePEAP SelectPlan for Women Directory Window Step Action A Result Sign on te the PA PROMIS Internet The Provider Main Page appears on the 1 application using instructions provided in desktop Section 1 5 of this manual Click on the ePEAP Provider Enrollment 2 Automation Project link in the Other The ePEAP Menu window opens Links section of the window 3 Select the SelectPlan for Women The ePEAP SelectPlan for Women Directory link Directory window opens To Add Service Location to the Directory
177. d may not contain a negative value Middle name for Patient can only contain Alphanumeric character s Modifier 1 can only contain alphanumeric characters Modifier 1 must be 2 characters in length Modifier 2 can only contain alphanumeric characters Modifier 1 must be 2 characters in length NPI must be 10 digits NPI must be 10 digits NPI must be 10 digits NPI must be 10 digits Occurrence Code must be 2 characters in length Occurrence Code can only contain alphanumeric characters PROMISe Provider Internet User Manual docx 131 To Correct Enter the First Name of the Patient Enter a First name for the Patient that contains only Alphanumeric character s Enter a From Date that is in the MM DD YYYY format Enter a From DOS that is less than or equal to today s date Enter the Last name of the Patient Enter a Last name for the Patient that contains only Alphanumeric characters Enter a Medical Record that does not contain or Enter a positive numeric value for the Approved Amount for OI Enter a Middle name for the Patient that contains only Alphanumeric character s Enter only alphanumeric characters for Modifier 1 Enter 2 characters for Modifier 1 Enter only alphanumeric characters for Modifier 2 Enter 2 characters for Modifier 1 Enter a 10 digit NPI Enter a 10 digit NPI Enter a 10 digit NPI Enter a 10 digit NPI Enter 2 characters for the Occurrence Code Enter an Occurrence Code
178. d under the Fee for Service FFS delivery system even if you are in a managed care zone For more details about this program you may access Provider Quicktip 73 available here http www_dpw_state_pa us Resources Documents Pdf Publications QuickTips PROMISeQuickTip73_pdf_ or visit the SelectPlan for Women website www_selectplanfonvomen state paus An online directory is available on the SelectPlan for Women website to help SelectPlan for Women recipients select a medical provider for family planningservices Whether or not you are currently listed in the SelectPlan for Women directory will be indicated below If you wish to change your status from what is currently indicated please check the appropriate box Please note all requested changes will be reflected in the directory the day following the request You are currently enrolled in the SelectPlan for Women Directory To be removed from the directory select the check box below wish to be removed from the SelectPlan for Women Directory Continue Cancel ePEAP Menu The Review Your Changes Summary window opens 2 Click Continue to process the request PROMISe Provider Internet User Manual docx July 3 2014 265 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Step Action Result Review Your Changes This is a summary of your requests Please review this information for accuracy Wh
179. ddress to be updated The Edit Address Related Information window opens You can change the phone number fax number and or handicap access status for this address You may also assign this address to replace the current Pay to Mail to and or Home Office Address for your service location 2 Click the Add to List hyperlink The Add New Pay To Mail To and or Home Office Address window opens This window is used to specify an address and assign it to replace the current Pay to Mail to and or Home Office address for your service location Other Options Step Action Result 1 Click the Address Menu button Return to the Provider Address Information window 2 Click the ePEAP Menu button Opens the ePEAP Menu window 3 Click the Help button Describes the fields on the ePEAP window 4 Click the Review Submit button The Review Your Changes window opens 5 Click the Exit button Exits ePEAP and returns to the Provider Main Page of PA PROMISe PROMISe Provider Internet User Manual docx 220 July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Descriptions Field Description Data Type Length Add to List Links to the Add Address window Hyperlink 0 Address Complete address street city state and ZIP code Character 87 Address Menu Opens the Address Menu window Button 0 Assigned to Your Indicates relationship i
180. ded Field Descriptions Field Edits Field Error Code Error Message No Error Code Messages found for this window PROMISe Provider Internet User Manual docx Field Description Date Date the file is available for downloading Available Date Date the file is downloaded Downloaded Filename Hyperlink to the file available for download Type Specifies the format of the file Various values include Postscript Word and Excel Unknown displays if the file type is unknown 81 Data Type Length Date 8 MM DD CCYY Date 8 MM DD CCYY Hyperlink 0 Character 50 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 4 1 Accessibility and Use To access and use the File Download window complete the steps in the step action table s To Access File Download Window Step Action Response 1 Logon to PA PROMISe using the steps presented in The Provider Main Page the General User Manual window opens 2 Click the Trade Files link 3 Click the Download link The File Download window opens To View Downloaded File Information Step Action Response 1 Click the Filename link The information is displayed 6 5 Provider Claim Attachment Number Request Provider Claim Attachment Number Request The Provider Claim Attachment Number Request window is used by providers to request new or view prior attachment contro
181. digit Provider ID number and social security number SSN or employer identification number EIN into the applicable fields 4 Click the Continue button The Registration Security Information window opens The Display Name field is already populated with the first and last name entered in the Registration Personal Information window PROMISe Provider Internet User Manual docx July 3 2014 10 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Fe pennsylvania D ARTMENT O UBLIC Home gt Registration Selector gt Registration Monday 06 21 2010 12 07 PM EST Registration Step 2 of 2 Security ormation Indicates a required field The User ID and Password cannot be the same and the password must be 8 20 characters in length contain a minimum of 1 numeric digit 1 uppercase letter and 1 lowercase letter User ID IB Check Availability Password Confirm Password Please provide your contact information below Display Name Sample Name Phone Number Email Confirm Email Please choose a personalized Site Key and enter a passphrase that will be used to verify your identity upon logging into the PROMISe Internet portal Site Key gt LAG Apple Balloon O Balloons Baseball Billiards Passphrase Please select a unique challenge question and provide an an
182. display Active or Inactive Tape Bill Provider submits claims via tape Character UPIN Unique Provider Identification Number Character 6 assigned to each Medicare provider View Active Service Displays active service locations for the HyperLink 0 Locations current Provider ID View Taxonomy Opens the w_epeap_view_taxonomy N A 0 window in a new window Your Provider ID Identifies current provider for this ePEAP Number 9 session Uses number assigned to provider at time of enrollment in MA program ePEAP Access EPEAP access levels include Read Only Character 16 access or Full access Your access level is always displayed in the upper right corner of an ePEAP page ePEAP Menu Returns to the ePEAP Menu window Button 0 6 23 ePEAP Provider Address Information The ePEAP Provider Address Information window is available to the provider community and displays the current Pay to Mail to Home Office and Email addresses associated with the user s service location The window includes Change buttons that allow the user to change any of the displayed address information This window is accessed from the PA PROMISe Internet Provider Main Page by clicking on the ePEAP Provider Enrollment Automation Project link which opens the ePEAP Menu Click the Enrollment Information link to open the Enrollment Information window and then click the Address Information link Note This window cannot be used to add a ne
183. docx July 3 2014 53 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Description Data Type Length The maximum number of service locations that may be added is 100 The first time the user clicks this link on a new application a pop up message will appear to caution the user about adding service locations DPW will provide the wording for this pop up message Provider Contact Information Provider Contact Name of contact in provider Alpha numeric 50 Name Contact office for handling EFT issues Provider Contact Phone number of contact person Numeric 10 Name Telephone Number Provider Contact Phone number extension of Numeric 4 Name Telephone contact person Number Extension Provider Contact Email Address of contact person Alpha numeric 50 Name Email Address Provider Institution Information Financial Institution Name of the provider s financial Alpha numeric 50 Name institution Financial Institution Street address portion of Alpha numeric 50 Address Street provider s financial institution address Financial Institution City portion of provider s Alpha numeric 18 Address City financial institution address Financial Institution State portion of provider s Alpha 2 Address State Province financial institution address 2 character postal abbreviation code Financial Institut
184. e System Documentation Revision History Document Revision Version Revision Page Reason for Revisions Number Date Number s Revisions Completed By Deere Wee tee dee Team peer ee eee es Team Codes Team Version 5 9 4 19 2012 141 Took out HP Documentation Newborn Team 1 Changed sentence structure Version 5 10 8 8 2012 Added Copy HP Documentation function Team information Version 5 11 10 4 2012 Updated EVS HP Documentation information Team Version 5 12 1 4 2013 Added HP Documentation information Team relating to NPI processing and new EVS search criterion Version 5 13 2 4 2013 Updated NPI HP Documentation fields to indicate Team they re required Version 5 14 3 6 2013 Updated Portal HP Documentation Login Team information Version 5 15 9 20 2013 Integrated ePEAP HP Documentation Manual Added information on Attestation Form ee eee a nam 13689 Team ven eee E rea een 14597 Team Version 5 18 04 08 2014 Updated for HP Documentation enhancements to Team the fee schedule PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Document Revision Version Revision Page Reason for Revisions Number Date Number s Revisions Completed By Version 5 19 07 03 2014 Updated PO Box HP Documentation on ACN form Team PROMISe Provider Internet User Manual docx July 3 2014 Prov
185. e Amount must be numeric and may not contain a negative value Value Amount is required when Value Code is entered Value Amount must be numeric and may not contain a negative value Value Amount is required when Value Code is entered PROMISe Provider Internet User Manual docx 141 To Correct Enter a To DOS that is less than or equal to today s date Enter a positive numeric value for Unit Rate Enter the Units Enter a positive numeric value for Units Enter the Value Amount Enter a positive numeric value for the Value Amount Enter the Value Amount Enter a positive numeric value for the Value Amount Enter the Value Amount Enter a positive numeric value for the Value Amount Enter the Value Amount Enter a positive numeric value for the Value Amount Enter the Value Amount Enter a positive numeric value for the Value Amount Enter the Value Amount Enter a positive numeric value for the Value Amount Enter the Value Amount July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Error Error Message To Correct Code 1 Value Amount must be numeric Enter a positive numeric value and may not contain a negative for the Value Amount value Value Code Amount 0 Value Amount is required when Enter the Value Amount 5 Value Code is entered 1 Value Amount must be numeric Enter a positive numeric value and may not contain a negative for the
186. e Password must contain 1 capital Confirm New Password letter 1 lowercase letter and 1 numeric digit 3 Enter current password in the Current Password field Enter a new password in the New Password and Confirm New Password fields The new password e Cannot be the same as the user s User ID e Must be between 8 and 20 characters in length e Can only contain letters and numbers e Must contain one capital letter one lowercase letter and one numeric digit 4 Click the Submit button A message stating that your password has been successfully changed appears Password Changed You have successfully changed your Password We have sent an email with your new password to the email address on record Email notifications can take 15 to 30 minutes to be delivered 2 8 Denial of Access Under certain circumstances you may be denied access to the system Your account can become disabled or inaccessible for the following reasons e You have made five unsuccessful logon attempts e You have answered any of the challenge questions incorrectly five times e You have forgotten your password and have a Unified Security logon ID which can be reset in the Forgot Password window See Section 2 5 Forgotten Passwords PROMISe Provider Internet User Manual docx July 3 2014 34 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation e You must contact th
187. e Provider Assistance Center to reset your account s status 2 9 How to Log On To PA PROMISe Note If you are an existing provider upon logging in you will be directed to the My Profile page the following pop up message will appear Please review your account information for accuracy and update any missing or outdated information OK There you will need to verify your current settings select a passphrase challenge questions and answers and a site key token Follow the instructions below to log on to PA PROMISe 1 Access the PROMISe Welcome Page from the OMAP Web site or use this link http promise dpw state pa us Yoo ennsylvania Oe ee PROMISe Internet Home Wednesday 11 02 2011 11 35 AM EST Provider Login User ID Forgot User ID Register Now The Pennsylvania Medical Assistance EHR Incentive Program is now available If you applied at CMS s EHR Incentive Program Registration and Attestation R amp A website you will see a link to the Medical Assistance Provider Incentive Repository MAPIR after you log on with your PROMISe Internet Portal User ID If you do not have a PROMISe Internet Portal User ID please register by following the Quick Links on the left of this Where do I enter my password page Quick Links Need Help Dovmload the Internet Help Manuals here Requires Adobe Acrobat gt Dovmload the ePrescribing User Manual pe here gt De
188. e Review Your Changes window Button 0 Service Location Service location of the group Character 4 of Group ePEAP Menu Returns the ePEAP user to the ePEAP menu window Button 0 6 30 ePEAP Manage Fee Assignments The ePEAP Manage Fee Assignments window lists the fee assignments for the current provider service location and selects fee assignments to be terminated This window is accessed from the PA PROMISe Internet Provider Main Page through the ePEAP Provider Enrollment Automation Project link which opens the ePEAP Menu Click the Enrollment Information link to open the Enrollment Information window then the Fee Assignment Information link to open the Fee Assignment Information window Click the Manage Fee Assignments link to display the window PROMISe Provider Internet User Manual docx July 3 2014 236 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout Initial PENNS IUANIO DEAD ic Welfare H Office of Medical Assistance Programs OMAP DE he ad Manage Fee Assignments Instructions 1 Select the fee assignment you wish to terminate 2 Select the date to terminate the fee assignment 3 Review your Pay to Address and change if needed Active Fee Assignments Layout After Selection PENNS YIMAMI ZZ PEAP Stien tial Aaeistanca Programe OMAP _ idii Manage Fee Assignments Instructions 1 Select the fee assignment you wish to terminate 2 Selec
189. e arroen e e A eE a E e E eE Ena Eoee 217 Field Descriptions ssc ee e EEE O eee tes Bac nie AE 218 6 24 ePEAP Manage Active Addresses occ csssssaveacesstscsvaisassaecivasedeeasaavsnacdessecadenspeveate tenes 218 6 24 1 Accessibility and Users a ete dete N ea n 219 Other Options sie a eee ese he oes tetas a a es ei aaa a en te Ta 220 Field Descriptions cu Soccer a as es a eee 221 6 25 CPEAP Adda New Address os oroni una a e a a a a S 221 6 235 Accessibility and US seica nieee eee a e aa seen een eee 222 To Update Address Informationer eiieeii eiie e REE ee ER Aa a ia 223 Other OPUONS eiiie e neee re onee EEE EE EE E Ea ae aaa 223 Field D scfiptionS naeniniein inaen ia a ea r a a p E i i 224 6 26 ePEAP Edit Address Related Information eseesssseseseseesersesersersersssesresrsseserse 225 6 26 1 Accessibility and Useras nana Gace SRL AL a a hs 226 To Change Address Related Information cccccecscessssceesseceeneeceaeceesaeceeaceceeeeeesaeeneaaecenees 227 Other Cpt OMS croas neeite Teenaa a eea EE a iea e aa pentane 227 Field Descriptions ccs acetic ee e e ee O NOR R O A E AE a 227 6 27 PEAP Manage Email Address onein a E EE ete 228 6 27 1 Accessibilitysand Usei tetee eiA OA hoe E E E A E E E oe 229 To Access the Manage E mail Address ee essecsseceseceseceseceseeeseeeseeeseeseneseneeeaeeeneecaaeenaees 229 To Add or Modify E mail Address eee eeeesceesecssecsseceseceseceseceseeeseesseessaeeeaeeeaeecaaee
190. e associated Number 10 Line Adjustment reason code PROMISe Provider Internet User Manual docx July 3 2014 94 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Anesthesia Required field on anesthesia service lines if one or Drop Down List 0 Quantity more extenuating circumstances were present at Box Qualifier the time of service Anesthesia Units Number of anesthesia units used for this service Number 4 line Appliance Date the orthodontic appliances were placed Date 8 Placement Date MM DD CCYY Attachment Attachment control number ACN is used to Number 9 Control relate attachments to this claim Benefits Indicates if benefits are to be assigned Drop Down List 0 Assignment Valid values are Box e Yes e No e Not Applicable Benefits Indicates if benefits are to be assigned Drop Down List 0 Assignment Valid values are Box Other Insurance e Yes e No e Not Applicable Billed Amount Amount of money requested for payment by a Number 9 provider for services rendered Billed Amount Amount of money requested for payment by a Number 9 Service Lines provider for services rendered This field is auto list populated when an amount is entered in the Billed Amount field below Carrier Code Other insurance carrier code Drop Down List 0 Other Insurance Box Carrier Code Other insurance carrier name or type Drop Down List 0 Other Insurance Box list Carrier
191. e ePEAP Menu Field Descriptions Field Description Data Type Length Address Menu Opens the Address Menu window Button 0 Cancel Cancels the update process Button 0 Continue Opens the Review Your Changes window Button 0 Exit Exits ePEAP Button 0 Help Describes the fields on the ePEAP window Button 0 Reset Resets the form Button 0 Review Submit Opens the Review Your Changes window Button 0 PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Your e mail address Provider s legal entity e mail address Character 70 for messages from the Medical Assistance Program ePEAP Menu Returns the ePEAP user to the ePEAP menu Button 0 window 6 28 ePEAP Fee Assignment Information The ePEAP Fee Assignment Information window contains a menu of maintenance options for providers to use to manage fee assignment From this window the following options can be selected e Adda Group for Fee Assignment e Manage Fee Assignments This window is accessed from the PA PROMISe Internet Provider Main Page through the ePEAP Provider Enrollment Automation Project link which opens the ePEAP Menu Click the Enrollment Information link to open the Enrollment Information window and then click the Fee Assignment Information link to open the Fee Assignment Information window Layout PENNS MN PEAP ix
192. e eeeesecsseceseceseceseceseeeeeeeeeeecaeeeseeeseeenaeenaees 175 To Complete Claim Ambulance Information cee eeeceseceseceseceseeeseeeseeseneeeaeeeaeeeneeenaeenaees 175 To Add Patient Information Newborn Only 0 ceeeeeesccesseceeeeeceseeeeaeceeaeeceeeeesaeensaaeeenees 176 To Remove Patient Information 0 c ce ccccceescecesececeeceesaeceeneeceeeeeaeceeaaeceeaeeceaeeeeaeceeaaeenenees 176 To Add Claim Other Insurance Information cee ceeeeeceseeeseeeeeceeeeeeseeeseecaaecaecaecnaeenaeees 176 To Remove Other Insurance Information ceccceceecceesseceeececeeeeeeaeceeaceceeaeeceeesenaeceeaaeceeees 176 To Complete Claim Home Health Treatment Plan Information cece eseeceseceneeeeee 176 To Complete Claim Home Health Service Delivery Information eee eeeeeseceseceteeeeeee 176 To Add Claim Service Lines Information 0 0 ceeceeceseceseeeseeeseeeeseeeseeeseecsaecaecaecnaeenseen 177 To Remove Service Lines Information cec ce ceecceeseccesseeceecceceeeeeeaeceeaaeceeaeecsaeeeeaeceeaeeeeenees 177 To Add Claim Service Adjustments Information cee eeeceeceeeneeereeeeeeseecaaeceaecaecnaeeaeen 177 To Remove Claim Service Adjustments Information ce eeeeeseeeseeeseeeseeeeecnsecnsecnseenaeens 177 TO SUbMIt Clan eee eaire e eA EERE E EEE Uae datd n iSe 177 To C py a P rd Claims eeit aeee a aa a a E LadseeteahaMeetlovs 178 6 14 Provider Rate Disclaimer rate_disclaimer ese
193. e of the provider contact for handling ERA issues required field and is not auto filled The user must enter the name of the provider contact for handling ERA issues PROMISe Provider Internet User Manual docx 60 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 13 The Provider Contact Information The Provider Contact Telephone Number Section Telephone Number field field is not auto filled The user may represents the provider contact phone enter the telephone number of the provider number for ERA issues contact for handling ERA issues 14 The Provider Contact Information The Provider Contact Email Address field Section Email Address field is arequired field and is not auto filled represents the electronic mail address The user must enter the email address of to send provider contact the provider contact for handling ERA correspondence issues 15 The Electronic Remittance Advice The Preference for Aggregation field is Information Section the Preference not auto filled The user may select one for Aggregation of Remittance Data of the appropriate valid values by clicking field indicates the provider s preference the Radio Button next to the value for aggregation Valid values are Note this field is optional If one of the e Provider Tax Identification valid values is selected the user must Number TIN complete field 16 Provide
194. e values and their meanings are e Enrolled Service location is assigned a Submitter ID and has Auto RA Date less than or equal to current date e Not Enrolled Service location is not assigned a Submitter ID and or has Auto RA Date greater than current date Submitter ID for Submitter ID assigned to the service Numeric 9 ANSI X12 location Field may be blank if service location s ERA status is Not Enrolled Most Recent Online Submission Date of most recent ERA Numeric 8 ERA Enrollment Enrollment request submitted on the Request Submission Portal for the service location Due Format is CCYYMMDD Field will be blank if an online ERA Enrollment request has never been submitted for the service location Most Recent Online Current status of the ERA Enrollment Alpha 9 ERA Enrollment Request Possible values are Request Request Siati e Accepted e Pending e Rejected Field will be blank if an online ERA Enrollment request has never been submitted for the service location ERA Enrollment Opens ERA Enrollment Application Button N A Request Window PROMISe Provider Internet User Manual docx July 3 2014 45 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 3 2 Enrolling for Electronic Funds Transfer EFT and Electronic Remittance Advice ERA On the PROMISe Portal This window allows registered PROMISe provider service locations to enroll for payment by Electronic Funds
195. ePEAP displays Character 10 as a link to a request document View Displays selected request at bottom of window Hyperlink 0 ePEAP Menu Opens the ePEAP menu window Button 0 6 34 ePEAP Terminate Medical Assistance Participation You can use the ePEAP Terminate Medical Assistance Participation window to end your Medical Assistance participation at a service location This window is accessed by clicking the Terminate MA Enrollment link in the ePEAP Menu Layout Penns MU is PEAP Your Provider ID 300 80963 DOSOOD JAMES L Status Actie NPI 1232567893 view Taronomy ePEAP Access Full Scceans Service Location cool 123 HOPE RD HARRISBURG PA 17011 Provides Type 31 PHYSICIAN view Soeciakiesi Terminate Medical Assistance Participation To terminate your participation as an MA Provider at this Service Location 1 Enter an End Date 2 Optionally enter Comment Provider ID 300180963 Service Location 0001 Effective End Date api Eilr plav g Continue Cancel ES Tern 6 34 1 Accessibility and Use To access the ePEAP Terminate Medical Assistance Participation window and terminate your participation as a MA provider at this service location complete the steps in the following step action tables PROMISe Provider Internet User Manual docx July 3 2014 253 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Access the ePEAP Terminate Medical As
196. ear if it is in use the second confirmation message will appear v User ID Availability The User ID is available v User ID Availability x The User ID has already been taken Please enter another one and try again 9 Create a password and enter it into the Password and Confirm Password fields The password e Cannot be the same as the user s User ID e Must be between 8 and 20 characters in length e Can only contain letters and numbers e Must contain one capital letter one lowercase letter and one numeric digit 10 Enter your phone number and email address into the fields indicated 11 Select three challenge questions from lists provided in the window and type in answers This information is used by the system to verify the identity of the OON provider at a future time when resetting a password Note You must select three distinct questions or you will be unable to proceed 12 After completing the Registration form read the User Agreement enter your name into the Please sign by typing your full name here field and click the Submit button to submit the form electronically If all required information is present you will be able to gain access to the PA PROMISe Web application PROMISe Provider Internet User Manual docx July 3 2014 20 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 13 The following confirmation me
197. ection Reason for Submission required field and is not auto filled The field s must select one of the reasons User must select the reason for submitting the EFT form Valid values are New Enrollment Change Enrollment Cancel Enrollment 22 In the Submission Information The Authorized Signature field is auto Section Authorized Signature field filled with the electronic signature of the the PA PROMISe User ID of an PROMISe Portal User ID of the person individual authorized by the provider submitting the enrollment form The User or it s agent to initiate modify or may not update this field via the EFT terminate the EFT enrollment Enrollment Application window 23 In the Submission Information The Printed Name of Person Submitting Section Printed Name of Person Enrollment field is a required field and is Submitting Enrollment field the not auto filled The User must enter the name of the individual who submitted name of the individual who submitted the the EFT application form EFT application form 24 In the Submission Information The Printed Title of Person Submitting Section Printed Title of Person Enrollment field is not auto filled The Submitting Enrollment field the title User may enter the title of the individual of the individual who signed the EFT who submitted the EFT application form application form 25 In the Submission Information The Submission Date field is auto filled Section Submission Date field the
198. ection 2 9 of this manual 2 Click on the ePEAP Provider Enrollment The ePEAP Menu window opens Automation Project link in the Other Links section of the window PROMISe Provider Internet User Manual docx 222 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Step 3 Action Select the Enrollment Information option Result The ePEAP Enrollment Information window opens 4 Click the Address Information link The ePEAP Provider Address Information window opens 5 Click the Change Address link The Manage Active Addresses window opens 6 Click the Add to List link The Add New Pay To Mail To and or Home Office Address window opens This window is used to specify a new address and assign it to replace the current Pay to Mail to and or Home Office address for your service location To Update Address Information Step Action Result 1 Enter the new information in the Address Two lines are provided for the address one field line must be completed at a minimum 2 Enter the City 3 Select a State from the drop down list 4 Enter the ZIP Code The first five digits are required the next four ZIP 4 are optional 5 Click the County drop down list and select the Pennsylvania county for this address 6 Enter the Phone Number Include area code and extension if applicable 7 E
199. eeaeecsaecaecaeeeaeeaeen 157 To Add Claim Details Information eee cesecesecsseceseceseeeseeeseeeeneeeseeeseeeaeecaaecnaecsaecnaeeaeen 157 To Complete Claim DUR PPS Information 0 00 0 ceeeesceeeeeeeeeseeeeseeeseeeaeecaaecaecaecnaeeaeen 157 To Complete Clinical Information cece cescesecsseceseceseceseeeseeeeeeeeaeeeseeeaeecaaecsaecsaecaeenaeen 157 To Complete COB Information eee cescceseceseceseceeceseeeseeeseeeeeeecaeeeseecsaecaaecaecsaeenaeeaeens 158 TO SUbMIt Claim eron vecogvaacashscdeecteyessvtasaneedeccstassaadanes act ERE r ean enak eta eaS ARo aatas 158 To Bill for Compo nd Drugs escencia eena i a tends cokes 158 Po Copy a P rd Claim ieser ee e e E E E E EREE 158 6 12 Provider ProDUR Warning Provider ProDUR Warning eeeeseeceeeeererrereree 158 6 13 Provider Professional Claim Professional asp ccesscecseseeceeeeceeeeeeeeeeeeeteeeees 159 G13 Accessibility and US minerne ieaie iae a E EAEE EEE A ENERE ESS 174 To Access Provider Professional Claim WindoW seeeeseeeeeseereesrerresersreseesrrsresresreesesrrsseee 174 To Complete Claim Billing Information seeseseeeseseereeseseessesrissessresresresressestrsserriesesstsseeses 175 To Complete the Claim Diagnosis Information eeseseeeesseereesesressesrrsserrssresrsresresressesrrssene 175 To Complete Claim Service Information ee eeeessecsseceseceseceseceseeeseeeseeeeeeesaeeeaeeeaaesaaeenaees 175 To Complete Claim Accident Information e
200. eeeeeseseeeeeseeeseeresresrrserrsressererssee 179 PROMISe Provider Internet User Manual docx July 3 2014 vi Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 614 1 Accessibility and Use wiccic cesta eta neil eesti ois E e a eee ete ede 183 To Access Rate Information Disclaimer Window cescesceseceseceseeeeeeeeeeeeseeeseeeaeeeaaeesaees 183 To Accept Reject Terms and Conditions and Access the Outpatient Fee Schedule Download WAND OW eetl a elk leh ie dln Sete ee tea ds Ae delet to Mitac eae saad 183 6 15 Provider Rate File Provider_Rate File ccccccccccccccsssessensececececeeeesenseaeeeeeeeens 184 6 15s1 AccessibilitysandW Seiten cscectevetee ceil e AEE ictus EEE I E chet iets ets E Rnleeees toes 186 To Access Outpatient Fee Schedule Download Window eeceeeeeseeeeeeeeeeeeeeeseeeaeeeaeeenaees 186 To Download Outpatient Fee Schedule in Excel Format 0 cece ceeeeeeeeeeeeeeeeeeeeeneeeeeeaees 186 To Download Outpatient Fee Schedule in PDF Format 0 eee eeeeeeeseeeneeeneecesecnaecnaeenseen 187 To Download Outpatient Fee Schedule in Comma Delimited Format eee eeeeeeeeees 187 To Download Comma Delimited Layout 0 000 eecesceseceseeeseeeseeeeseeeseesseecaaecaesaeceaeenaeen 187 6 16 Provider Recipient Eligibility Verification Provider Recipient Eligibility VeritiGatl On RE EEEE a OR SK ek OS teeth Pelee Mah teh EE fat A tah ta SS Nae 187 6 16 1 Accessi
201. elect a value 4 Optional In the Procedure Drug Type drop down list select a value 5 Optional Type a value in the Procedure Drug Code field 5 Optional Type a value in the Modifier 1 field 6 Optional Type a value in the Modifier 2 field 7 Optional Type a value in the Modifier 3 field 8 Optional Type a value in the Modifier 4 field 9 Click the Search button If a match is found the search result is displayed To Search by Recipient Name Step Action Response 1 Type a value in the First Name Middle Initial and Last Name fields 2 In the Date of Birth drop down list select a value 3 In the Date of Service From and To drop down lists select a value 4 Optional In the Procedure Drug Type drop down list select a value 5 Optional Type a value in the Procedure Drug Code field 5 Optional Type a value in the Modifier 1 field 6 Optional Type a value in the Modifier 2 field 7 Optional Type a value in the Modifier 3 field 8 Optional Type a value in the Modifier 4 field 6 Click the Search button If a match is found the search PROMISe Provider Internet User Manual docx 196 result is displayed July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Clear Window for New Search Step Action Response 1 Click the Clear button The window is cleared and ready for new search criteria 6 17 Pr
202. em Documentation 5 Create a user ID and enter it into the User ID field e The User ID must be 6 to 20 characters in length and contain only letters and numbers e The User ID and Password cannot be the same e Once you ve entered text in the User ID field click the Check Availability button to see whether the User ID you selected is already in use If it is not in use the first confirmation message below will appear if it is in use the second confirmation message will appear v User ID Availability The User ID is available v User ID Availability The User ID has already been taken Please enter another one and try again 6 Create a password and enter it into the Password and Confirm Password fields The password e Cannot be the same as the user s User ID e Must be between 8 and 20 characters in length e Can only contain letters and numbers e Must contain one capital letter one lowercase letter and one numeric digit 7 Type your phone number and email address into the fields indicated Select three secret questions from lists provided in the window and enter answers This information is used by the system to verify the identity of the provider at a future time when resetting a password Note You must select three distinct questions or you will be unable to proceed 9 After completing the Registration form read the User Agreement enter your name into the Please sign by typi
203. en you are satisfied click Continue To modify a request item return to that page Continue to Make Changes Cancel All Changes Submit Changes Changes Requested For Provider ID 300276278 DOGOOD MEDICAL ASSOCIATES Service Location 0001 Change SelectPlan for Women Directory Current Requested SelectPlan N Directory Yes g Continue to Make Changes Cancel All Changes Submit Changes n ar eae Changes uon ii The Review Your Changes Contact 3 include the Service Location in the Information window opens directory PROMISe Provider Internet User Manual docx July 3 2014 266 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Step Action Result Review Your Changes Contact Information This information may be used to contact you about this request This information will not be used for any other purpose Name Dr James DoGood Phone 717 y 555 1212 Fax Ls W A E mail jdogood medical com Required 4 Enter a contact name phone number and email address 5 Click the Submit button Your request is submitted Changes Are Complete Your provider information has been updated as you requested If you wish to view your request again please select Recent Requests from the ePEAP Menu The Tracking Number for this Request was 3555 64942 Thank you for using ePEAP Continue
204. er a valid Adjustment Group Code Go back to that field in the window and enter the correct information You may then proceed to the next task you want to perform in the system 1 4 2 Sample Field Edits Table Field Error Error Message To Correct Code Add ingredients 1 This claim type can This claim type can have a maximum of have a maximum of 25 Service Lines 25 Service Lines Admission Date 0 Admission Date Enter an Admission must be less than or Date less than or equal to today s date equal to today s date 0 x is not a valid Enter a valid date day in month Use a value in the range 1 days in month Adjustment Group Code repeats up to 3 times 0 Adjustment Group Enter a valid Code is a Adjustment Group required field Code Amount 1 1 Amount must be Need to enter an greater than 0 amount greater than 0 PROMISe Provider Internet User Manual docx ss ss s sSS y 2094 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 1 5 The Menu Bar and other Functions Common to almost all PA PROMISe Provider Internet windows are the tab options found on the Menu Bar which is shown below This Menu Bar is located below the Pennsylvania Department of Public Welfare window banner Additionally the Logout links appears on most pages 1 5 1 The Menu Bar MyHome Claims Eligibility Trade Files Reports Outpatient Fee Schedule ePEAP Help The Menu Bar contains the
205. er and frequency Number of benefit Locks in eligibility segments to specify the Date end of the lock in period The lock in starting MM DD CCYY period is not returned by EVS if it falls outside the range of dates specified on the EVS request Locks in eligibility segments to specify the Date beginning of the lock in period The lock in MM DD CCYY starting period is not returned by EVS if it falls outside the range of dates specified on the EVS request Policy number associated with this other or Character additional payer eligibility detail Procedure or drug for which eligibility is Character being requested This field is optional Code list type from where the following Drop Down List procedure drug code field value is pulled This Box field is optional Composite of the medical procedure Character PROMISe Provider Internet User Manual docx 192 Length 0 264 35 61 10 10 30 11 999 July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Quantity Eligibility Detail Recipient ID Input Recipient ID Recipient Reset SSN Input Search Service Type Service Type Code Services Restricted to Following Provider Status Eligibility Detail Time Period Qualifier Eligibility Detail To Input Type Eligibility Summary Verification Date Verification Date Result Verification Number Field Edits
206. er for their own internal claim submission tracking Medicare approved amount Number of Medicare Coinsurance days Middle initial of the Medicaid recipient Middle initial of the patient First modifier code that supplies additional information on the procedure code Second modifier code that supplies additional information on the procedure code Third modifier code that supplies additional information on the procedure code Fourth modifier code that supplies additional information on the procedure code Click to add a new claim PROMISe Provider Internet User Manual docx 118 Data Type Character Drop Down List Box Number Character Character Character Character Drop Down List Box Character Character Number Character Number Number Number Character Character Character Character Character Button Length 3 0 14 14 17 17 35 35 24 July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Non Covered Days NPI Attending Provider NPI Billing Provider NPI Facility NPI Operating Provider NPI Other Provider OI Other Insurance List Box Occurrence Code 1 Occurrence Code 2 Occurrence Code 3 Occurrence Code 4 Occurrence Code 5 Description Data Type Number of days not covered Number NPI for Attending Provider ID Character Note Not enabled until a 7 or 8 digit ID is ente
207. ernet User Manual PA PROMISe System Documentation Layout Recipient Eligibility Verification Information Recipient Eligibility Verification Card Number Procedure Drug Code Required Recipient ID or Recipient ID Date of Birth E or SSN Date of Birth 3 or Name First MULast Date of Birth 3 Required Date of Service From 91 04 2013 FFB To 01 04 2013 jai Optional Procedure Drug Type Select One Ee Modifier 2 3 4 or Service Type Code Supported Selected 1 Medical Care a 2 Surgical E 4 Diagnostic X Ray Z 5 Diagnostic Lab 6 Radiation Therapy 7 Anesthesia 8 Surgical Assistance 12 Durable Medical Equipment Purchase 13 Ambulatory Service Center Facility 18 Durable Medical Equipment Rental X mm PROMISe Provider Internet User Manual docx 73 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Verification No i 06 23 2010 Recipient ene Recipient ID MEM Date of Birth Gender E Eligibility Summary Type Name Begin End Managed Care BHDA DAUPHIN COUNTY CBHNP 01 01 2009 01 31 2009 Category Medicaid Program Status 00 01 01 2009 01 31 2009 Service Program HCB02 Eligibility Detail Status Managed Care Service Type Health Benefit Plan Coverage Insurance Type Health Maintenance Organization HMO Service 01
208. es Step Action Result 1 Select the Review Submit button The Review Your Changes window opens Other Options Step Action Result 1 Click the ePEAP Menu button Opens the ePEAP Menu window 2 Click the Help button Displays the ePEAP Help window 3 Click the Exit button PROMISe Provider Internet User Manual docx Opens the PA PROMISe Provider Main Page July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Descriptions Field Description Data Type Length Address Accesses the Provider Address Information window Hyperlink 0 Information used to change the Address Phone FAX data for the Pay To Mail To and Home Office addresses and to change the provider s email address Note This window cannot be used to add a new service location Base Information Each enrolled MA provider has basic information that Hyperlink 0 should be kept current This link accesses the ePEAP Basic Enrollment Information window used to display and update this information including medical degrees licensing ID numbers billing and Medicare participation ePEAP Menu Opens the ePEAP Menu window Button 0 Exit Exits ePEAP and returns to the PA PROMISe Button 0 Provider Main Page Fee Assignment Accesses these options Add a Group for Fee Hyperlink 0 Information Assignment Manage Fee Assignments Help Opens the Help
209. es 268 6 38 1 Accessibility and Use vcs nerro narios eee less tiger ETa EE TE a 269 To Access the ePEAP Verify Provider Membership in My Group Window ceeeeees 269 Other Options ire e ae Taa aE E E E ives stcagess EEEE E aa EA EE OE EASE 270 Field Descriptions oinnia e a a els aa A dei ea en ee 270 6 39 ePEAP Provider Group Members iiiss cssscisssicesstecieaicasveccevasacvecsaaescaceesaececeathevastebenss 270 6 39 1 Accessibility and Usna inenen sene i ees ete AD eee te 271 To Access the ePEAP Provider Group Members Window ceeceeceesceeeeeeeeeeeeeaeeeaeeenaees 271 Other Opti Om essed 5s esdeed snceaces ees Pues eap a E sede a erie R et ae Taa ea yhe asad ees 272 Field Description Sarre seeder cen AE E EE Ee es ETE ah ee E etl EENE 272 PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 40 EPBAP Upload PDP a sissiedss sed ecasdiaciad seca tle sadedacnpaaaiaaicatasdsiadeaeeaeaadsudaawitedaaeeoans 273 6 4021 Accessiblity and USE geinent erene e aeto EE AEE A REEERE E KE rE N Dee i 274 To Access the ePEAP Upload PDF Window sesseessessesseseesessessrssersresreeresresresesserrresessresrese 274 Hield Descriptions 5 2 3e ois she cette let T dee E E TA E E EE a N aA s 274 6 41 ePEAP Upload Attestation Form sssssssesssesesesesssessseessessseesseressseesseesseesseeeseeesseee 275 6 411 Accessibility and Uses
210. ess the PA PROMISe Provider Internet using the instructions provided in Section 2 9 This application is accessed from the DPW Web site by clicking the PROMISe Online link Result The Provider Internet application opens Step by step instructions are found in the Provider Internet User Manual 2 Log into the application by entering your Logon ID and Password and click the Log On button The Provider Main Page opens PROMISe Provider Internet User Manual docx 204 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Step Action Result 3 Click the ePEAP Provider Enrollment The ePEAP Menu opens Automation Project link To Access Options Step Action Result 1 Click the Enrollment Information link The Enrollment Information window opens 2 Click the Recent Requests link The Recent Requests window opens 3 Click the Terminate MA Enrollment link The Terminate Medical Assistance Participation window opens 4 Click the Manage Remittance Advice link The Manage Remittance Advice window opens 5 Click the Active Service Locations link The Active Service Location window opens 6 Click SelectPlan for Women Directory Displays the SelectPlan for Women Directory where a Provider can choose to include or remove their Service Location from the Directory 7 Click Upload PDF Passes control to t
211. et Portal Provider Internet User Manual PA PROMISe System Documentation Field Occurrence Code 6 Occurrence Code 7 Occurrence Code 8 Occurrence Code Date 1 Occurrence Code Date 2 Occurrence Code Date 3 Occurrence Code Date 4 Occurrence Code Date 5 Occurrence Code Date 6 Occurrence Code Date 7 Occurrence Code Date 8 Occurrence Span Code 1 Occurrence Span Code 1 From Date Occurrence Span Code 1 To Date Occurrence Span Code 2 Occurrence Span Code 2 From Date Occurrence Span Code 2 To Date Occurrence Span Code 3 Occurrence Span Code 3 From Date Description Sixth code that defines a significant event related to this bill that may affect payer processing Seventh code that defines a significant event related to this bill that may affect payer processing Eighth code that defines a significant event related to this bill that may affect payer processing Date associated with Occurrence Code 1 Date associated with Occurrence Code 2 Date associated with Occurrence Code 3 Date associated with Occurrence Code 4 Date associated with Occurrence Code 5 Date associated with Occurrence Code 6 Date associated with Occurrence Code 7 Date associated with Occurrence Code 8 Event that is related to payment of the claim This event occurs over a span of days First day of span Last day of span Event that is related to payment of the claim This event occurs over a span of days First day of span
212. eturn All services performed in the ASC SPU require an approved Place of Service Review PSR as per regulation 11150 59 or in the case of emergency services a retrospective approval for the services Services that exceed the limits of the Fee Schedule require an approved Program Exception PE prior to the services being rendered To view and print the PDF form you will need to install the Acrobat Reader software N To enlarge the PDF format select the Zoom Menu option from the viewer and select the size to view You may either increase or decrease the size PROMISe Provider Internet User Manual docx July 3 2014 185 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Descriptions Data Field Description Type Length MA Fee Schedule Opens the MA Fee Schedule webpage with access to Hyperlink 0 link the Online Fee Schedule Download Comma Download Outpatient Fee Schedule in Comma Hyperlink 0 Delimited File Delimited CSV format ZIP file Download Comma Download a Microsoft Word document explaining the Hyperlink 0 Delimited Layout Comma Delimited Comma Separated Value file format Download Excel Download Outpatient Fee Schedule in Microsoft Excel Hyperlink 0 Version format ZIP file Download PDF Download Outpatient Fee Schedule in Adobe Acrobat Hyperlink 0 Version Reader PDF format Return Return to Provider Main Menu Hyperlink 0 Field Edits Field Error
213. f any of this address to the Character 50 Service Location current service location Possible values are No or any combination of Service Location Address Mail to Address Pay to Address and or Home Office Address ePEAP Menu Opens the ePEAP menu window Button 0 Exit Exits ePEAP Button 0 Handicap Access Values Yes or No indicate handicap access Character 3 Status Help Describes fields on the ePEAP window Button 0 Phone Fax Phone and fax numbers for the address Character 20 Review Submit Reviews the request summary and submit request Button 0 document Select Links to the Edit Address window Hyperlink 0 6 25 ePEAP Add a New Address The ePEAP Add a New Address window is used to specify a new Pay to Mail to and or Home Office address for a provider s service location This window is accessed from the PA PROMISe Internet Provider Main Page by clicking the ePEAP Provider Enrollment Automation Project link which opens the ePEAP Menu Click the Enrollment Information link to open the Enrollment Information window and then click the Address Information link to open the Provider Address Information windows Click the Change Address button to open the Manage Active Addresses window Then click the Add to List link Note This window cannot be used to add a new service location or modify a service location s physical address To add a new service location or cha
214. fessional asp The Provider Professional Claim window displays professional claims From here a provider can enter all of the required information to submit a professional claim including multiple detail lines This window also contains a link to searchable PDF files that list rendering provider ID numbers to identify the facility where services were rendered This window is accessed by selecting Submit Professional from the Claims menu or by clicking the Claim submission link to open the Claim Menu then clicking the Professional link Dispensing Physicians and Certified Registered Nurse Practitioners CRNPs should use the Pharmacy claim window when submitting drug claims Note Maximum field lengths for this window are limited by HIPAA X12 guidelines Differences may appear between fields on this window and fields on other windows that are based on different underlying HIPAA transaction formats The first window Layout below shows the initial viewable display the following Layouts show the remaining data viewable by scrolling PROMISe Provider Internet User Manual docx July 3 2014 159 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout Professional Claim NewlNeed help submitting a claim View sample claim submissions here If your Professional claim requires the 13 digit provider ID identifying the facility where services were rendered usually submitted in box 32 of the CMS 15
215. from the DPW Web site which is accessed from the Provider My Home Page 1 3 Windows The provider Internet windows give you the ability to electronically file claims and manage your online account This manual will lead you through the process of filing a claim and maintaining passwords and permissions for your account Section 5 of this manual provides detailed information for each window in the PA PROMISe Provider Internet Portal Documentation for each window includes Window Narrative Brief description of the window its purpose and use Layout Sample screen shot of the window that illustrates all data fields and controls buttons drop down boxes etc Field Description Table Detailed description of each data field and object within the window including field lengths and data types The Field Descriptions help you understand the information requested in the windows and explain the information you are asked to provide in the window fields All field description tables are located in Section 5 Provider Internet Windows Field Edits The Field Edits tables explain what to do if you encounter error messages while using a window Error Messages Error Codes and Corrective Actions to fix incorrect invalid entries or actions are listed in these tables which are included following the Field Descriptions in the window documentation in Section 5 Provider Internet Windows of this document See Section 1 4 below
216. haracter 10 Provider NPI Prescribing NPI for Prescribing Provider ID If Prescribing Character 10 Provider ID is entered this field is required New Add a new claim Button 0 New Refill Indicates if the prescription is new or a refill of Number 2 a prior prescription Other Coverage Indicates if the patient has other insurance Drop Down List 0 Code coverage Box Patient Gender Code Patient s gender Drop Down List 0 Valid values are Box e 0 Not Specified e Male e 2 Female Patient ID Patient s ID number Character 20 Patient ID Indicator Type of patient s ID Drop Down List 0 Box Patient Paid Amount Amount paid by the recipient toward this claim Character 9 Patient Relationship Patient s relationship to the policyholder Drop Down List 0 Code Valid value is Box e 1 Cardholder PROMISe Provider Internet User Manual docx July 3 2014 152 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Patient Residence __Patient s place of residence Drop Down List 0 Valid values are Box e 0 Not Specified e Home e 2 Skilled Nursing Facility e 3 Nursing Facility e 4 Assisted Living Facility e 5 Custodial Care Facility e 6 Group Home e 7 Inpatient Psychaitric Facility e 8 Psychiatric Facility e 9 Intermediate Care Facility ICFMR e 10 Residential Substance Abuse e 11 Hospice e 12 Psychiatric Residential Facility e 1
217. haracter 9 Output digit To view more information about a specific recipient ID click the linked recipient ID in this field Status Input Type of claim status for which the search is performed Values are Approved Denied Paid Box Drop Down List 0 Rejected and Suspended Status Current status of the claim as reported by the system Character 0 Output Values are Approved Denied Suspended or Paid Submit Searches database for the desired record Button 0 Thru Date Ending date of search Date 8 Input MM DD CCYY Thru Date Ending date of performed services Date 8 Output CCYYMMDD Voucher Amount of the claim payment check Number 9 Amount Field Edits Field Pi Or Error Message To Correct Code From Date Input 0 x is not a valid day in month Use a value in Enter a valid date the range 1 days in month 1 When ICN is not specified the date range may Enter a shorter range not exceed one year Please enter a shorter of days or populate period of time or specify the ICN the ICN field 2 When searching by Provider ID and date range Enter a shorter range the date range may not exceed 31 days Please of days or populate enter a shorter period of time or specify the ICN field additional search criteria ICN Input 0 ICN must be 13 characters Enter a numeric 13 character ICN 1 ICN must be a number Enter a numeric 13 character ICN Recipient ID 0 X is not a valid Recipient ID Enter a valid Recipient ID Su
218. hat are available to the provider who is identified in the logon information are displayed Select the desired file to download Reports Displays the Report function Only reports that are available to the provider who is identified in the logon information are displayed Select the desired report Outpatient Fee Schedule Displays the Outpatient Fee Schedule ePEAP Displays the ePEAP Menu window Help Opens the PA PROMISe Internet Help function PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 1 5 2 Where Do I Enter My Password Link The Where do I enter my password link is located at the bottom of the Provider Login box on the left hand side of the PROMISe Welcome Page Clicking it displays a dialogue box that includes a brief explanation of the login process Where do I enter my password x The way you sign into the the PROMISe Portal provides a better safeguard to the privacy and security of your healthcare information You may have signed into other web sites by using a User ID and Password The PROMISe Portal also uses your site key token Here is how the service works 1 Type your User ID and click Log In 2 Your site key token displays If you recognize your site key token you know you can safely type your password If you do not recognize your site key token do not type your
219. he Pay to Mail to or Home Office address for the current provider service location This window is accessed from the PA PROMISe Internet Provider Main Page by clicking the ePEAP Provider Enrollment Automation Project link which opens the ePEAP Menu Click the Enrollment Information link to open the Enrollment Information window and then click the Address Information link to open the Provider Address Information windows Click the Change Phone Fax button to open the Edit Address Related Information window PROMISe Provider Internet User Manual docx July 3 2014 225 PROM Provider Internet User Manual ISe Internet Portal PA PROMISe System Documentation Layout Your Provider ID NPI Service Location Provider Type 300180963 DOGOOD JAMES L 1234567893 View Taxonomy 0001 123 HOPE RD HARRISBURG PA 17011 31 PHYSICIAN Edit Address Related Information Instructions You may use the form below to change the phone number fax number and or handicap access status for this address You may also assign this address to replace the current Pay to Mail to and or Home Office Address for your Service Location After making desired changes please click Continue Status ePEAP Access Active Full Access View Specialties Ext 567 Address 234 NEW HAVEN RD CAMP HILL PA 17011 Phone 717 975 1234 Fax 3 Handicap Access Yes ONo Assign to Serv
220. he ePEAP Upload PDF window For Groups Only Step Action Result 1 Select the Verify Provider Membership link The Verify Provider Membership In My Group window opens 2 Select the View Provider Group Members The Provider Group Members pop up link window opens PROMISe Provider Internet User Manual docx 205 July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation To Access Help Step Action Result 1 Select the View Helpful Hints link The Helpful Hints for the ePEAP User window opens and displays a list of tips for using the page To Exit ePEAP Step Action Result 1 Click the Exit button Opens the Provider Main Page ePEAP Menu Field Descriptions Field Enrollment Information Exit Help Manage Remittance Advice Active Service Locations Recent Request SelectPlan for Women Directory Terminate MA Enrollment Upload PDF Verify Provider Membership View Helpful Hints View Provider Group Members Description Opens the ePEAP enrollment window Exits ePEAP Describes the fields on the ePEAP window Opens the Manage Remittance Advice window Opens the Active Service Locations window Opens the Recent Request window Opens the SelectPlan for Women Directory Opens the Terminate MA Enrollment window Opens the Upload PDF window Opens the Provider Membership w
221. he search Number 9 results list Attachment Displays a newly issued attachment control Number 9 Control Number number or filters the search results by attachment control number ACN Date Issued Date the provider requested the attachment Date 8 control number through the Internet MM DD CCYY Date Received Date the paper attachment for an electronic claim Date 8 was received MM DD CCYY NPI NPI of the provider requesting an attachment Character 10 control number Provider ID ID of the provider requesting an attachment Character 9 control number Recipient ID Recipient number associated with the claim for Character 10 which the ACN was requested Recipient ID Recipient number associated with the claim for Character 10 Detail which the ACN was requested Request Returns a new attachment control number Button 0 Search Searches database for the desired record Button 0 Service Location Provider s service location Character 4 Status Status of the attachment number request Valid Character 8 values are Issued and Received Field Edits Field Eor Error Message To Correct Code Recipient IDO x is not a valid Recipient ID Enter a valid recipient ID number 1 Recipient ID must be 10 Enter a numeric 10 character characters Recipient ID 2 Recipient ID must be numeric Enter a numeric 10 character Recipient ID 6 5 1 Accessibility and Use To access and use the Provider Claim Attachment Number Request window complete the steps in the step action ta
222. ical Date Enter a Surgical Date that is between From DOS date and To DOS date Enter the Surgical Date Enter a Surgical Date that is between From DOS date and To DOS date Enter the Surgical Date Enter a Surgical Date that is between From DOS date and To DOS date Enter a To Date that is in the MM DD YYYY format July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field To DOS Unit Rate Units Value Code Amount 1 Value Code Amount 10 Value Code Amount 11 Value Code Amount 12 Value Code Amount 2 Value Code Amount 3 Value Code Amount 4 Error Code 0 0 Error Message To DOS must be less than or equal to today s date Unit Rate must be numeric and may not contain a negative value Units is a required field Units must be numeric and may not contain a negative value Value Amount is required when Value Code is entered Value Amount must be numeric and may not contain a negative value Value Amount is required when Value Code is entered Value Amount must be numeric and may not contain a negative value Value Amount is required when Value Code is entered Value Amount must be numeric and may not contain a negative value Value Amount is required when Value Code is entered Value Amount must be numeric and may not contain a negative value Value Amount is required when Value Code is entered Valu
223. ice Location 0001 as Check all that apply Pay to Address Mail to Address O Default assignment for this service location To replace a default assign another address f Cominue Concer Reser Home Office Address Address Menu ePEAP Menu Help Review Submit Eg 6 26 1 Accessibility and Use To access the Edit Address Related Information window and perform address maintenance tasks complete the steps in the following step action tables To Access the Edit Address Related Information Window Step 1 Sign on to the PA PROMISe Internet application using instructions provided in Section 2 9 of this manual CS The Provider Main Page appears on the desktop 2 Click on the ePEAP Provider Enrollment The ePEAP Menu window opens Automation Project link in the Other Links section of the window 3 Select the Enrollment Information option The ePEAP Enrollment Information window opens 4 Click the Address Information link The ePEAP Provider Address Information window opens 5 Click the Change Phone Fax button The Edit Address Related Information window opens PROMISe Provider Internet User Manual docx 226 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Change Address Related Information Sep acion e 1 Enter the new information in the Phone
224. id Number noted above the signatory acknowledges that as the preparer he or she is providing the information on behalf of the provider and that the provider authorized the preparer to complete this action I acknowledge that I read and understand this agreement Terms and Conditions The Provider gives the Agent permission to work on its behalf with the Department of Public Welfare Department to verify Medical Assistance eligibility process claims and or receive the 835 file if applicable The Provider agrees that all information disclosed by the Department is confidential and agrees that they shall safeguard and maintain the confidentiality of all information received in accordance with federal and state law The Provider agrees that the use or disclosure of information for research or purposes other than as intended is strictly prohibited by federal and state law Further the Provider agrees not to disclose any information obtained from the Department unless they have obtained express prior written approval from the Department The Provider and their employees will use the information received only to verify an individual s eligibility for the Medical Assistance Program process claims and or receive the 835 file NOTICE State and Federal law place stringent restrictions on the disclosure of information concerning applicants and recipients of assistance 42 U S C 1396a a 7 42 C F R 431 300 62 P S 404 and 55 Pa Code
225. ider number A search can be narrowed by specifying the ICN recipient ID number patient account number date range or claim status criteria You can perform a search only for claims submitted by your provider number and service location s Note When performing a claim inquiry for claims submitted via a media other than the Internet please allow for processing time before the claim appears in the system For example if you submit your claims via paper please allow 7 to 10 business days before performing a claim inquiry Refer to Section 5 7 for a full description of the Provider Claim Inquiry window PROMISe Provider Internet User Manual docx July 3 2014 69 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout rey pennsylvania DEPARTMENT OF PUBLIC WELFARE PROMISe Internet MUUGA Claims Mae iis Claim Inquiry Submit institutional Submit Professional Submit Dental Submit Pharmacy Search Request ACN Claims gt Claim Inquiry Wednesday 11 09 2011 03 30 PM EST Claim Inquiry 1234567890123 Inquiry Information Recipient ID Patient Account ICN 3210987654321 Claim Status Any Status Date of Service From Date Thru Date Recipient ID Recipient DOB Patient Acct From Date 9876543210 OLTLS 02 02 2008 987654321 The actions described in the tables below are the primary tasks that can be performed in the Claim Inquiry window More detailed
226. ider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Table of Contents TL gt MIVGP OG UCU OM Sais sscceis sccccsecisesdescadesacadasssdesisdsendgessincabisioccansssstenseausoaedeastecevadhosdesdoued es iais estosse 1 1 1 Key Peaturessand Benetts co c25 ccts51 cctasncsencts sian atanecscchiatencteteesradicai a iai E 1 1 2 Secured External Web Site s iieczieic ose taeeeiieeeei er eeienia ania ealitadaede 1 1 3 WTA 05 05 Sie thse tS ah Penang ahh Geet an Gute he Gu Beda aah ca eio Gee gta N tat s a E S 2 1 4 AboutField Edilsin e e a a a eaa 3 1 4 1 Sample Error Message Scenario essesesssesesssssseestesseseesseretesescteseesttseesessdeesesotssesorestsseescsreee 4 1 4 2 Sampl Field Edits Table ss eaicis Aen sia ei ae ea ee ee 4 1 5 The Menu Bar and other Functions seessesesesessessessssressessrssresseseresressersresresseeseeseessee 5 tal The Meni Bile a A ie al gen E A A a aa 5 1 5 2 Where Do I Enter My Password Link eeseseeseeeesesseseesesresresresresreserrisseertesrenresresresresseee 6 Logout PiNK ninii ir n E E iene ETE O E ee E E EE E EETA A 6 1 6 Timeout Notifications i c 4 02 nannan nnns a esa 6 2 Registering for and Logging On to the PROMISe Provider Portal sccessesees 8 2 1 Process for Registering and Obtaining a Password Providers 9 2 2 Process for Registering and Obtaining a Password Billing Agents eee 13 2 3 Process for Registering
227. ider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation pennsylivan PROMISe Internet Engibity Trade Files Repons Outpationt Fee Schedule ePEAP HonpitalAnsesument Holp Enrolied Provider Search EPT and ERA Enrolment 7 o n My Home gt EFT and ERA Enrollment Wednesday 12 11 2013 01 30 PM EST Electronic Remittance Advice ERA Ea Enrollment Application Provider Information Provider Name CURTOWN HOSPITAL Provider Address Street 323 MAPLE STREET city ANYTOWN State Province ZIP Code Postal Code Provider Identifiers Provider Identifiers Provider Federal Tax Identification Number TIN or Employer Identification 07 1112486 Number EIN National Provider Identifier NPT Other Identifiers Assigning Authority PA PROMISE Trading Partner 10 F 001 V 9 digt Provider ID and 4 digt Service Location i New Serice Location Assigning Authority FA PROMISO EDI Unit Trading Partner ID CJ k9 tigit Submitter ID for ANSI X12 v5010 Transactions Provider Contact Information Provider Contact Name Contact MARY SMTH Telephone Number E55 Base Telephone Number Extension er Email Address ma mith ourtownhos pital org Electronic Remittance Advice Information Preference for Aggregation of Remittance Data e g Account Number Linkage to Provider Identifier information only Will not change aggregation by PROMISe Provider T
228. ider Internet User Manual docx July 3 2014 viii Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Error Messages te isctstiascss seter see atin Si ei tent eet oi eins 240 6 311 Accessibility and Usero nere te E E ested eet auth aortic eee E E laws 241 To Access the Manage NPI and Taxonomy Codes Window scesccsseceseeeeeeeeeeeeeseeensees 241 Other Options sc sci ia cleo eera N a e e a e ted eG T i 244 6 32 ePEAP Review Changes cies ssccccdssccccatevevsncvarnuvalaesaduatevavaseciasesvadsaaveadeuteicetenteavaaneseegs 245 6 32 1 Accessibility and Use iis ninrin eneee pe hee a EE E eee ene 248 To Access the Review Your Changes WindoW esssseseseereesesreesesrrsserrisseesresresrrsressesressene 248 To Review Approve and Submit Your Changes cc cescescescsseceseeeeeeeeeeeeseeeneeeaeesaaeenaees 248 Field Descriptions sessin ea edesaesce0k fate a tence ddan a E a 249 6 33 PEAP Recent Request WindoWonecsceec nnen a E 250 6 3371 Accessibility and Usero iaat RN RAE E EE E denned 251 To Access the ePEAP Recent Request Window cs escssecssecsseceseceseceeeeeseeseneeeaeeeaeeeaaeenaes 251 Cancel Requests niinn a a ted Mh ae aa Gets e ahaa eect 252 Other Optionss oc 5 ci0 b 38 ses seers vig alone aces eee ts ea a E E E i e a 252 Field Descriptions kn oianetan A eetas aaeei Ea T EED E N states 252 6 34 ePEAP Terminate Medical Assistance Participation sess
229. ield is a required field and is not auto Institution Address City field the city filled The User must enter the City associated with the financial institution associated with the provider s financial address street field institution address 16 In the Financial Institution The Financial Institution Address Information Section Financial State Province field is a required field and Institution Address State Province is not auto filled The User must enter field the two character code associated the two character code associated with the with the state province name state associated with the state province of the provider s financial institution 17 In the Financial Institution The Financial Institution Routing Number Information Section Financial field is a required field The information Institution Routing Number field the is auto filled if available If the 9 digit identifier of the financial information is not auto filled the User institution where the provider must enter the provider s financial maintains an account which EFT institution routing number payments are to be deposited 18 In the Financial Institution The Type of Account at Financial Information Section Type of Institution field is a required field and is Account at Financial Institution not auto filled The User must select the field the account type e g Checking type of account the provider will use to Saving payment are to be deposited receive EFT pa
230. iens 86 6 6 1 Accessibility and User e or ep ee cac des VEN OSEKE ea SEN eTEN EEEE E EENET EET EA ENES KEETE 89 To Access Provider Claim Inquiry Window c cescescssceseeeseeeseeeeaeeeseeeseecsaecsaecaecnseesseeees 89 To Search for A Fee for Service Claim by Recipient ID ooo eee eeeeseeeneeeneeensecnsecnseenseeees 89 To Search for A Fee for Service Claim by Patient Account Number 89 To Search for A Fee for Service Claim by ICN 00 cece ceeceseceeeeeseeeeeeeeseeeaeecsaecsaecaecnaeesseeees 90 To View Next Fee for Service Claim cccccccccesssssssssssssssssssssssssessssssssessessssssesssesssssesseeeeeees 90 To View Recipient Plipibility ereot au aide eee A 90 To Submit A Fee for Service Claim Adjustment cee eeceeccesceeeneeeeeeseeeseecaecssecssecsaeenseeees 90 6 7 Provider Dental Claim Dental asp ecccesssecessecesceceseeeceenceceeceececeecseeeeeeteeeesaes 91 6 7 1 Accessibility and Us s nitent EE EE cee ah eee eh Sse 107 To Access Provider Dental Claim Window cccccccssssssssssssssssesssssssssssssssssesessessssseseseseees 107 To Complete Claim Billing Information 0 0 0 ccc ceecceessccesseeceeceeceeeesaeceeaeeceeeeeesaeeneaaeeneeees 107 To Complete Claim Service Information cceccccsscesseceseceeeeeeesaeceeaeeceeeeeeaeceeaaeceeaeeesaees 108 To Complet Diagnosis niser na E e EE mse Aaa is el neg oa ECETES 108 To Complete Claim Accident Information cee ccccecscecesececeee
231. ility and Use To access and use the Help manual complete the steps in the step action table s To Access Help Window Step Action Response 1 Click the Help link The PROMISe Internet User manual opens 6 9 Provider Institutional Claim Institutional asp The Provider Institutional Claim window is used to submit 837 Institutional claims From this window a provider can enter all of the required information to submit an institutional claim including multiple detail lines This window is accessed through the Submit Institutional option under Claims in the Menu Bar or by clicking the Institutional link on the Claims Menu page The first window Layout below shows the initial viewable display the following Layouts show the remaining data viewable by scrolling Note Maximum field lengths for this window are limited by HIPAA X12 guidelines Differences may appear between fields on this window and fields on other windows that are based on different underlying HIPAA transaction formats PROMISe Provider Internet User Manual docx July 3 2014 110 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout PROMISe Provider Internet User Manual docx July 3 2014 111 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Institutional Claim Need help submitting a claim View sample claim submissions here Billing Informat
232. im Status Clear Date of Service From Date Input From Date Output ICN Input ICN Output Next Patient Account Input Patient Account Output Description Billed amount for the specified service Filters the search by claim status Valid values are Approved Denied Paid Rejected and Suspended Clears previous search results Selects search by date of service Beginning date of search Beginning date of performed services Internal control number entered by the user to identify a claim Internal control number that identifies a claim To view more information about a specific ICN click the linked ICN number in this field Link to the next page if one exists Recipient s ID number assigned by providers and used internally in their system Recipient s ID number assigned by providers and used internally in their system PROMISe Provider Internet User Manual docx 87 Data Type Number Drop Down List Box Button Radio Button Date MM DD CCYY Date CCYYMMDD Character Character Hyperlink Character Character Length 9 13 13 38 38 July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Description Data Type Length Previous Link to the previous page if one exists Hyperlink 0 Recipient ID Recipient ID number ID plus check digit Number 10 Recipient ID Recipient identification number ID plus check C
233. in Comma Delimited Format Step Action Response 1 Click the Download The file download begins The downloaded file is in a Comma Delimited File compressed format ZIP and must be decompressed hyperlink before it can be opened To Download Comma Delimited Layout Step Action Response 1 Click the Comma Delimited The file download begins The downloaded file is a Layout hyperlink Microsoft Word doc document 6 16 Provider Recipient Eligibility Verification Provider Recipient Eligibility Verification The Provider Recipient Eligibility Verification window is used to perform inquires against PA PROMISe recipient data Inquiries can be made by recipient ID card number SSN date of birth or recipient name date of birth Single date or range of up to 31 days must be entered to limit the search results A procedure code drug code or modifier can optionally be provided The EVS engine returns eligibility information for the provider s ability to provide the drug or service and the recipient s eligibility to receive the drug or service This feature is supported only for fee for service recipients The user can access this window by selecting Eligibility Verification from the Provider Main menu page or select Inquiry from the Eligibility option list Note Information returned by this window may be modified or limited at a future date by the decisions made by the Confidentiality work group The First w
234. indow Displays helpful hints for the ePEAP user Displays pop up window with list of Provider s group members 6 21 Using the ePEAP Enrollment Information Options Data Type Hyperlink Button Button Hyperlink Hyperlink Hyperlink Hyperlink Hyperlink Hyperlink Hyperlink Hyperlink Hyperlink Length 0 The ePEAP Enrollment Information link will access the enrollment options of the PEAP system The links in the Request Changes box of the ePEAP Enrollment Information window are used to access the windows listed below PROMISe Provider Internet User Manual docx 206 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Base Information Opens the Basic Enrollment Information window Address Information Opens the Provider Address Information window Fee Assignment Information Opens the Fee Assignment Information window Manage NPI Taxonomy Opens the Manage NPI and Taxonomy Codes window These windows are described in this section Layout PEW SM in PEAP Your Provider ID 300180963 DOGOOD JAMES L Status Active NPI 1234567893 view Taxonomy ePEAP Access Full Access Service Location 0001 123 HOPE RD HARRISBURG PA 17011 Provider Type 31 PHYSICIAN View Specialties Enrollment Information Instructions Request Changes Base Information Address Information Select an item to update Make changes Review Request Summ
235. indow Layout below shows the initial viewable display PROMISe Provider Internet User Manual docx July 3 2014 187 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout Recipient Eligibility Verification Recipient Eligibility Verification Information Required Recipient ID j Card Number or Recipient ID Date of Birth E or SSN Date of Birth E3 or Name First MULast Date of Birth 3 Required Date of Service From 91 04 2013 EE To 91 04 2013 E5 Optional Procedure Drug Type Select One e Procedure Drug Code Modifier 4 2 E or Service Type Code Supported Selected 1 Medical Care a 2 Surgical a 4 Diagnostic X Ray D 5 Diagnostic Lab gt 6 Radiation Therapy fiss 7 Anesthesia 8 Surgical Assistance 12 Durable Medical Equipment Purchase 13 Ambulatory Service Center Facility 18 Durable Medical Equipment Rental X crear The following message will display Click OK to acknowledge _ EVS does not guarantee payment of claim Providers need to validate a the procedure is covered through provider handbooks MA bulletins and RA alerts PROMISe Provider Internet User Manual docx July 3 2014 188 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation The following Layouts show the remaining data viewable by scrolling erificati
236. information on this window and its functions can be viewed in Section 5 7 Provider Claim Inquiry window To Search for A Claim by Recipient ID Step Action Response 1 Type a value in the Recipient ID field 2 In the Claim Status drop down list select a value 3 In the Date of Service section enter a value in the From Date field 4 In the Date of Service section enter a value in the Thru Date field 5 Click the Submit button If a match is found the search results list is displayed 6 Click the claim link The detailed claim is displayed To Search for A Claim by Patient Account Number Step Action Response 1 Type a value in the Patient Account field 2 In the Claim Status drop down list select a value 3 In the Date of Service section enter a value in the From Date field 4 In the Date of Service section enter a value in the Thru Date field PROMISe Provider Internet User Manual docx July 3 2014 70 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Step Action Response 5 Click the Submit button If a match is found the search results list is displayed 6 Click the claim link The detailed claim is displayed To Search for A Claim by ICN Step Action Response l Type a value in the ICN field 2 In the Claim Status drop down list select a value 3 In the Date of Service section enter a
237. ing any modified or derivative work of CPT or making any commercial use of CPT License to use CPT for any use not authorized herein must be obtained through the AMA CPT Intellectual Property Services 515 N State Street Chicago IL 60610 Applications are available at the AMA Web site http www ama assn org go cpt PROMISe Provider Internet User Manual docx July 3 2014 179 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Applicable FARS DFARS Restrictions Apply to Government Use This product includes CPT which is commercial technical data and or computer data bases and or commercial computer software and or commercial computer software documentation as applicable which were developed exclusively at private expense by the American Medical Association 515 North State Street Chicago Illinois 60654 U S Government rights to use modify reproduce release perform display or disclose these technical data and or computer data bases and or computer software and or computer software documentation are subject to the limited rights restrictions of DFARS 252 227 7015 b 2 November 1995 and or subject to the restrictions of DFARS 227 7202 1 a June 1995 and DFARS 227 7202 3 a June 1995 as applicable for U S Department of Defense procurements and the limited rights restrictions of FAR 52 227 14 June 1987 and or subject to the restricted rights provisions of FAR 52 227 14 June 1987
238. ion Billing Provider 0008509550001 nP Taxonomy Zip Claim Type j Attachment Control Bill Type Medical Record Original Claim Prior Authorization Recipient ID Report Type Code Patient Account Report Transmission Code Last Name Gross Patient Pay First Name Patient Pay Amount Middle Initial Service Information Patient Status Release of Medical Data Attending Provider ID n Benefit Assignment Taxonomy Zip Operating Provider ID D NPE ESS Pregnancy Indicator Taxonomy Zip Other Provider ID SS Ne SS Emergency Taxonomy Zip Referral Code Facility ID Facility Name Billing Note Accident State l Admission Discharge From DOS To DOS Admission Date Admission Hour Admission Type Admission Source Discharge Hour Diagnosis Code Type Primary D POA inpatient ony Admission Diagnosis inpatient and LTC Only Patient Reason for Visit l Outpatient Only Add Other POA Inpatient Only seq Emergency Code POA l Inpatient Only Add Emergency code POA PROMISe Provider Internet User Manual docx July 3 2014 112 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation The window Layout above displays the default viewable area of the scrollable data the Layout below displays the remaining data Surgical Code
239. ion Medicare Indicator is assigned to Service Location 0001 C Remove Association from Service Location 0001 iew Active Seri Medicare Indicator assigned to another Service Location Medicare Indicator Information Medicare Indicator is assigned to Service Location 0002 O Change Association to Service Location 0001 View Active Service Locations PROMISe Provider Internet User Manual docx July 3 2014 211 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 22 1 Accessibility and Use To process ePEAP Base Information change requests complete the steps in the following step action tables To Access the ePEAP Basic Enrollment Information Window Step Action Result 1 Sign on to the PA PROMISe Internet application using instructions provided in Section 2 9 of this manual The Provider Main Page appears on the desktop 2 Click on the ePEAP Provider Enrollment The ePEAP Menu window opens Automation Project link in the Other Links section of the window 3 Select the Enrollment Information option The ePEAP Enrollment Information window opens 4 Click the Base Information link The ePEAP Basic Enrollment Information window opens To Enter Enrollment Changes Step 1 Action To change the Birth Date select new values for the month day and year from the corresponding drop down lists Result The provider s birth da
240. ion Preference for Indicates provider s preference Radio Buttons N A Aggregation of for aggregation Possible values Remittance Data are e Provider Tax Identification Number TIN e National Provider Identifier NPI Preference for Tax ID Number to be used for Numeric 9 Aggregation of aggregation Remittance Data Required when TIN is selected Provider Tax cisions Identification Number P j TIN Preference for NPI number to be used for Numeric 10 Aggregation of aggregation Remittance Data Required when NPI is selected National Provider reference Identifier NPI P Method of Retrieval Indicates provider s method of Radio Buttons N A retrieving ERA Possible values are e Clearinghouse e PA PROMISe Provider Electronic System PES e Other Method of Retrieval Description of the means that Alpha numeric 50 Other provider will use to retrieve ERA Required when Other is the PROMISe Provider Internet User Manual docx July 3 2014 66 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Description Data Type Length selected preference Electronic Remittance Advice Clearinghouse Information Clearinghouse Name Name of the Clearinghouse Alpha numeric 50 Required when Clearinghouse is the selected Method of Retrieval Clearinghouse Contact Name of a contact in Alpha numeric 50 Name Clearinghouse office for handling
241. ion Code 0 Report Type Code 0 State Accident 0 1 2 PROMISe Provider Internet User Manual docx Error Message To Correct X is not a valid Recipient Enter a valid 10 ID Recipient ID is a required field Referring Provider ID must be 9 characters Referring Provider ID must numeric Release of Medical Data for OI is a required field Rendering Provider ID must be 9 characters Rendering Provider ID must be numeric character Recipient ID Enter a valid 10 character Recipient ID Enter a numeric 9 character provider ID Enter a numeric 9 character provider ID Select Release of Medical Data Enter a numeric 9 character provider ID Enter a numeric 9 character provider ID Rendering Provider ID is a Enter a numeric 9 required field Report Transmission Code when Report Type Code is selected Report Type Code is required when Report Transmission Code is selected When Accident Ind Auto Y Accident State is required Accident State can only contain alphabetic character s spaces not allowed Accident State must be 2 character s in length 106 character provider ID Select a Report Transmission Code when a Report Type Code is entered Select a Report Type Code when a Report Transmission Code is selected Enter a state Enter a valid 2 character state Enter a valid 2 character state July 3 2014 Provider Internet User Manual PROMISe
242. ion Code that contains only alphanumeric characters Enter 2 characters for the Condition Code Enter a Condition Code that contains only alphanumeric characters Enter 2 characters for the Condition Code Enter a Condition Code that contains only alphanumeric characters Enter 2 characters for the Condition Code Enter a Condition Code that contains only alphanumeric characters Enter a Patient date of birth that is a valid date less than or equal to today s date Enter a Patient date of death that is a valid date less than or equal to today s date Enter a valid 24 hour time for the Discharge July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field First Name Patient From Date From DOS Last Name Patient Medical Record Medicare Approved Amount Middle Initial Patient Modifier 1 Modifier 2 NPI Attending Provider NPI Facility NPI Operating Provider NPI Other Provider Occurrence Code 1 Error Code 0 Error Message First name for Patient is a required field First name for Patient can only contain Alphanumeric character s Date must be of format MM DD YYYY From DOS must be less than or equal to today s date Last name for Patient is a required field Last name for Patient can only contain Alphanumeric characters Medical Record may not contain or Approved Amount for OI must be numeric an
243. ion Identifies provider s financial Numeric 9 PROMISe Provider Internet User Manual docx July 3 2014 54 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Description Data Type Length Routing Number institution Type of Account at Indicates the type of account Radio buttons N A Financial Institution provider will use to receive EFT payments Possible values are Checking Savings Provider s Account Identifies provider s account that Alpha numeric 17 Number with Financial will receive payments at the Institution financial institution Account Number Indicates provider s preference Radio Buttons N A Linkage to Provider for grouping of payments Identifier Possible values are Provider Tax Identification Number TIN National Provider Identifier NPI Account Number Tax ID Number to be used for Numeric 9 Linkage to Provider grouping of payments Tientiner Poytug Required when TIN is selected Tax Identification reference Number TIN P l Account Number NPI number to be used for Numeric 10 Linkage to Provider grouping of payments ina Saona Required when NPI is selected Provider Identifier ref renc NPI P i Submission Information Reason for Submission Indicates provider s reason for Radio Buttons N A submitting the EFT form Possible values are New Enrollment Change Enrollment Cancel Enrollment Authorized Signa
244. ist 0 Assignment Other Box Insurance Benefits Indicates if benefits are to be assigned Drop Down List 0 Assignment Valid values are Box e Yes e No e Not Applicable Bill Type Three digit value that indicates the type of bill Drop Down List 0 Box Billed Amount Amount requested by a provider as payment for Number 9 services rendered Billed Amount Amount requested by a provider as payment for Number 9 Service Lines List services rendered Box Billing Note Free form field for comments or special Character 80 instructions Carrier Code Other Other insurance carrier Character 3 Insurance List Box Carrier Code Other Other insurance carrier Drop Down List 0 Insurance Box Claim Filing Code Type of claim Drop Down List 0 Other Insurance Box Claim Type Type of institutional claim Valid values are Drop Down List 0 Inpatient Outpatient and Long Term Care Box Code Type ICD type indicator for this claim Drop Down List 0 Box Condition Code 1 First condition s related to this claim or to the Drop Down List 0 patient Box Condition Code 2 Second condition s related to this claim or to 0 Drop Down List the patient Press the underlined Add to add Box this field PROMISe Provider Internet User Manual docx July 3 2014 116 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Condition Code 3 Third condition s related to this claim or to the 0 patie
245. it value Changes must be made for the page to submit At least one taxonomy code checkbox must be selected for the page to submit Re enter the NPI N A N A N A N A July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Error Field Code 5665 5666 5667 5669 5675 County 4 Effective Date 5 6 10 Effective End Date 2 3 End Date 7 8 9 Fax 5 Fax 1 PROMISe Provider Internet User Manual docx Error Message This service location already is associated with a different NPI Only one NPI is allowed per service location during the same time period The taxonomy is not associated with the provider types and specialties for this service location The NPI Taxonomy Zip combination is already being used End date must be greater than effective date Individuals can only have one NPI number Tax ID cannot be changed to SSN You must select a county when adding a Pennsylvania address Effective date must be numeric Effective date must be 8 numbers in length Effective date is not a valid date Valid date range is 1966073 1 22991231 Enter a Complete Date Enter a date in the future End date must be numeric End date must be 8 numbers in length End date is not a valid date Valid date range is 1966073 1 22991231 Fax number must be numeric Fax number must 10 digits Fax number must be numeric 282 N A N A N
246. ked 7 The Provider Identifiers Section National Provider Identifier NPI field represents the Federally assigned 10 digit number for the Assigned service location This information is auto filled from the data available in PROMISe The user may not update this information via the ERA Enrollment Application window This information is auto filled from the data available in PROMISe The user may not update this information via the ERA Enrollment Application window 8 The Other Identifiers Section 1 Assigning Authority field represents PA PROMISe 9 The Other Identifiers Section Trading Partner ID field s represents PA PROMISe will be auto filled in this field The user may not update this information via the ERA Enrollment Application window This information is partially auto filled from the data available in PROMISe PROMISe Provider Internet User Manual docx 59 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation the provider s assigned 9 digit Medical Assistance ID number will be auto filled The 4 digit Service Location is initially blank The user must update the 4 digit Service Location An automatic edit will verify that the entered Service Location is active for the submitting provider legal entity Note Only the first Trading Partner ID selection will be partially auto filled with
247. l numbers ACNs The ACN is used by the provider community to allow paper attachment forms to be submitted in reference to an electronic claim A batch cover form with the ACN is present on all paper attachment batches The ACN on the paper batch must match the ACN entered on the related electronic claim If a provider searches on an ACN the details of that ACN are displayed if it exists for the provider Searching without populating the ACN box returns all attachment numbers for that provider The Request button returns a new claim ACN as a link in a group box that appears at the bottom of the window To print the associated Paper Attachment to Electronic Cover Sheet click on the linked ACN The cover sheet opens in an Adobe PDF format and can be printed from the Adobe page The Search button returns all records associated with the Recipient ID identified for the search This window is accessed from the Provider Main Page by selecting the Search Request Attachment Control Number option from the Claims drop down menu This window is also accessed from the Provider Main Page by clicking the Claim Submission link to open the Claims Menu Click on the Search Request Attachment Control Number link Note The user must have the Adobe Acrobat Reader application to print the cover sheet If not already installed on the user s system a free copy of Adobe Acrobat Reader is available by clicking the Adobe icon on the window PROMISe Provider Internet
248. lication is complete and accurate and made subject to the penalties of 18 Pa C S 4904 relating to unsworn falsification to authorities In addition I acknowledge that misstating my identity or assuming the identity of another person may subject me to misdemeanor or felony criminal penalties for identity theft pursuant to 18 Pa C S 4120 or other sections of the Pennsylvania Crimes Code By entering my full name in the space provided below and transmitting this form electronically I state that I am the person whom I represent myself to be herein and I acknowledge that I have read and understand the User Agreement and agree to the terms and conditions as described about the role that I will perform Please sign by typing your full name here PROMISe Provider Internet User Manual docx July 3 2014 19 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 7 The Display Name field is already populated with the first and last name you entered in the first Registration window 8 Create and enter a User ID into the User ID field e The User ID must be 6 to 20 characters in length and contain only letters and numbers e The User ID and Password cannot be the same e Once you ve entered text in the User ID field click the Check Availability button to see whether the User ID you selected is already in use If it is not in use the first confirmation message will app
249. lick the Clear The entered text is erased Message button 4 To send the message to DPW click the The message is forwarded to DPW for Send Message button review Cancel Requests Step Action Result 1 Click the Cancel link next to the request to The request you selected will be cancelled be cancelled Other Options Step Action Result 1 Click the ePEAP Menu button Opens the ePEAP Menu 2 Click the Help button Describes the fields on the Recent Requests window 3 Click the Exit button Opens the PA PROMISe Provider Main Page Field Descriptions Field Description Data Type Length Cancel Cancels the selected request Hyperlink 0 Contact Displays a message area at bottom of window Hyperlink 0 Through message area user may submit a message to DPW regarding the selected request Exit Exit ePEAP Button 0 Help Describes the fields on the ePEAP window Button 0 Options Options available for request Character 4 Status Recent Identifies the current status of a request A request may Character 10 Rqst have the status of Received In Process Complete Rejected or Withdrawn PROMISe Provider Internet User Manual docx July 3 2014 252 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Submit Date Date request was submitted Date 8 CCYYMMDD Tracking Identifies requests submitted through
250. ll be blank when EFT Status is Not Enrolled Provider s Account Service location s account number with Alpha numeric 17 Number the Financial Institution Only last 4 digits of the account number will be displayed other digits will be masked Field will be blank when EFT Status is Not Enrolled Type of Account Type of financial account Possible values Alpha 8 are e Checking e Savings Field will be blank when EFT Status is Not Enrolled Most Recent Online Submission Date of most recent EFT Numeric 8 EFT Enrollment Enrollment request submitted on the Request Submission Portal for the service location mae Format is CCYYMMDD Field will be blank if an online EFT Enrollment request has never been submitted for the service location Most Recent Online Current status of the EFT Enrollment Alpha 9 EFT Enrollment Request Possible values are Request Request Siang e Accepted e Pending e Rejected Field will be blank if an online EFT Enrollment request has never been submitted for the service location EFT Enrollment Opens EFT Enrollment Application Button N A Request Window Electronic Remittance Advice PROMISe Provider Internet User Manual docx July 3 2014 44 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Description Data Type Length ERA Status Service location s ERA activity Statusin Alpha 15 PROMISe Possibl
251. lment field indicates not auto filled The user must enter the the name of the individual who is name of the individual submitting the submitting the ERA application form ERA application form 27 In the Submission Information The Printed Title of Person Submitting Section the Printed Title of Person Submitting Enrollment field indicates the title of the individual who is submitting the ERA application form Enrollment field is a required field and is not auto filled The user must enter the title of the individual submitting the ERA application form PROMISe Provider Internet User Manual docx 62 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 28 In the Submission Information The Submission Date field is auto filled Section the Submission Date field with the current date in Format indicates the date on which the CCYYMMDD The user may not specify enrollment is submitted a past date 29 Click the Submit ERA Enrollment The Electronic Remittance Advice ERA Form option to submit the ERA Agreement window opens enrollment Application 30 Click the Cancel option The Cancel option will discard any data entered and return the User to the EFT and ERA Enrollment window I certify the foregoing information is true accurate and complete under penalty of perjury If the signatory is a preparer and not the provider identified by the Medica
252. lp Review Submit Eg The following error message is displayed if there is a conflict between your provider type and specialty and the group being added for fee assignment If this happens and it is not a data entry error please send an email to promise state pa us with the subject line Enrollment Fee Assignment detailing the assignment you are trying to complete This fee assignment is not allowed because your provider type and specialty do not correspond to the provider type and specialty of the Group 6 29 1 Accessibility and Use To access the ePEAP Add a Group for Fee Assignment window and add a group complete the steps in the following step action tables PROMISe Provider Internet User Manual docx July 3 2014 234 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Access the Add A Group for Fee Assignment Window Step Action Result Sign on to the PA PROMISe Internet The Provider Main Page appears on the 1 application using instructions provided in desktop Section 2 9 of this manual Click on the ePEAP Provider Enrollment 2 Automation Project link in the Other The ePEAP Menu window opens Links section of the window 3 Select the Enrollment Information option a PE rg pent mrormytion window opens 4 Click the Fee Assignment Information The ePEAP Fee Assignment Information link window opens 5 Click the Add A Group For Fee
253. lphanumeric characters Surgical Code is a required when Surgical Date has been entered Surgical Code can only contain alphanumeric characters Surgical Code is a required when Surgical Date has been entered Surgical Date is a required field Surgical Date must be between From DOS date and To DOS date Surgical Date is a required field Surgical Date must be between From DOS date and To DOS date Surgical Date is a required field Surgical Date must be between From DOS date and To DOS date Surgical Date is a required field Surgical Date must be between From DOS date and To DOS date Surgical Date is a required field Surgical Date must be between From DOS date and To DOS date Surgical Date is a required field Surgical Date must be between From DOS date and To DOS date Date must be of format MM DD Y YYY PROMISe Provider Internet User Manual docx 140 To Correct Enter the Surgical Code Enter a Surgical Code that contains only alphanumeric characters Enter the Surgical Code Enter a Surgical Code that contains only alphanumeric characters Enter the Surgical Code Enter the Surgical Date Enter a Surgical Date that is between From DOS date and To DOS date Enter the Surgical Date Enter a Surgical Date that is between From DOS date and To DOS date Enter the Surgical Date Enter a Surgical Date that is between From DOS date and To DOS date Enter the Surg
254. m Documentation To Enter Contact Information Step Action Result 1 Enter the following information in the Contact Information window e Name required e Phone required e Fax e E mail required 2 If the displayed information is correct click the Submit button 3 To clear the entered information click the Reset button 4 To cancel the requested changes click the Cancel button Field Descriptions The message Changes Are Complete is displayed The previous maintenance window is displayed Field Description Data Type Length Cancel Cancels the update process Button 0 Cancel All Cancels all entered ePEAP change requests Button 0 Changes Continue Continues the update process Button 0 Continue to Make Continues the ePEAP update process Button 0 Changes Email The email address of the contact person for the ePEAP Character 35 change request Exit Exits ePEAP Button 0 Fax The fax number of the contact person for the ePEAP Character 10 change request Help Describes the fields on the ePEAP window Button 0 Name The name of the contact person for the ePEAP change Character 35 request Phone The phone number of the contact person for the Character 10 ePEAP change request Reset Resets the form Button 0 Submit Changes Submits all entered ePEAP change requests Button 0 ePEAP Menu Navigates to the ePEAP Menu Window Button 0 PROMISe Provider I
255. m to DPW Button 0 Surgical Code 1 Surgical ICD procedure code most relevant to Character 7 the care being rendered Surgical Code 2 Surgical ICD procedure code most relevant to Character 7 the care being rendered Press the underlined Add to add this field Surgical Code 3 Surgical ICD procedure code most relevant to Character 7 the care being rendered Press the underlined Add to add this field Surgical Code 4 Surgical ICD procedure code most relevant to Character 7 the care being rendered Press the underlined Add to add this field Surgical Code 5 Surgical ICD procedure code most relevant to Character 7 the care being rendered Press the underlined Add to add this field Surgical Code 6 Surgical ICD procedure code most relevant to Character 7 the care being rendered Press the underlined Add to add this field Surgical Code Date Requested anticipated or actual date of Date 8 1 surgery MM DD CCYY PROMISe Provider Internet User Manual docx July 3 2014 123 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Surgical Code Date Requested anticipated or actual date of Date 8 2 surgery MM DD CCYY Surgical Code Date Requested anticipated or actual date of Date 8 3 surgery MM DD CCYY Surgical Code Date Requested anticipated or actual date of Date 8 4 surgery MM DD CCYY Surgical Code Date Requested anticipated or actual date of Date 8 5 surgery
256. mation is cleared and the original information to its original values information is restored 3 Click the Review Submit button to review The Review Your Changes window opens and submit all changes to the information 4 Click the Enrollment Information button The update is cancelled and the Enrollment Information window opens 5 Click the ePEAP Menu button Returns to the ePEAP Menu window 6 Click the Help button Describes the fields on the ePEAP window 7 Click the Exit button The ePEAP Main window opens Field Descriptions Field Description Data Type Length ACH Indicates whether provider service Character 1 location receives payment electronically Possible values are Y yes or N no Birth Date Provider s date of birth Drop Down List Box 0 Cancel Cancel transaction clear contents Button 0 Click here Contact information when a Medicare HyperLink 0 number needs to be updated Comment do not use Add relevant supporting information to Character 200 this box to request justify a request changes Continue Moves to the next logical page or form Button 0 DEA Provider s DEA number indicates the Character 9 Effective Date provider is a prescribing physician Beginning date for a Medicare billing Date CCYYMMDD 8 number Read only as of 2 1 2008 End Date Ending date for a Medicare billing Date CCYYMMDD 8 number Read only as of 2 1 2008 Enrollment Returns to the Enrollment Information Button 0
257. me First Last Current Roles Provider In Network Contact Information Display Name First Last Phone Number 1 717 777 7777 Current Email flast hp com Preferences Primary Language English US Challenge Questions Challenge Question 1 What is the name of your favorite school teacher Answer to 1 Mr Smith Challenge Question 2 Who was your first employer Answer to 2 My father Challenge Question 3 What is the name of your favorite pet Answer to 3 Rover Site Key Token Site Key Q Passphrase I love balloons Change Password Password 1 Click the Change Password button located at the bottom of the screen Change Password ie 2 The Change Password page displays PROMISe Provider Internet User Manual docx July 3 2014 33 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Yeo pennsylvania DEPARTMENT OF PUBLIC WELFARE My Home gt My Profile gt Change Password Thursday 04 22 2010 08 26 AM EST Change Password 1 The Password cannot be the same Indicates a required field as your User ID Enter your Current Password New Password New Password Confirmation and click the Submit button 2 The Password must be between 8 20 characters Current Password 3 The Password can only contain New Password letters and numbers 4 Th
258. mo of new PROMISe Internet Portal e Learning courses a PA PROMISe Internet ePrescribe Demo CMS 1500 08 05 CMS 1500 08 05 Waivers e UB 04 Outpatient Speer The Commonwealth of Pennsylvania Department of Public Welfare offers state of the i art technology with PROMISe the claims processing and management information These courses require the Flash player system Please take advantage of online training to use the system to its full advantage Provider Electronic Solutions Software Department of Public Welfare This site requires at minimum Internet Explorer version 6 with 128 bit encryption PROMISe Provider Internet User Manual docx July 3 2014 35 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation It is from this window that you initially log on to the PA PROMISe application Providers with more than one service location may create more than one account However only one account can be created per service location To continue follow the steps outlined below Helpful information can be accessed from this page by clicking the Use the Internet Help Manuals here link Users may also take the online e Learning course titled PROMISe Internet a link to this course is located on this page 1 Enter your user ID in the User ID field 2 Click the Log In button 3 The Challenge Question window displays rey pennsylvania DEPARTMENT OF P
259. n the default setting the Challenge Question window will appear and have to be completed during future logons Click the Continue button 7 The Site Token Password window displays PROMISe Provider Internet User Manual docx July 3 2014 36 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation N pennsylvania DEPARTMENT OF PUBLIC WELFARE Home Home gt Challenge Question gt Site Token Password Thursday 04 29 2010 12 37 PM EST Confirm Site Key Token and Make sure your site key token and passphrase are correct Passphrase Confirm that your site key token and If the site key token and passphrase are correct type your password and click Sign In passphrase are correct If this is not your site key token or passphrase do not type your password If you recognize your site key token Call the customer help desk to report the incident and passphrase you can be more comfortable that you are at the valid HealthCare Portal site and therefore is safe to enter your password Sine Tokan re 4 Passphrase A cup of tea Password Forgot Password 8 Verify that the site key token and passphrase shown are correct e Enter your password in the Password field If the site key token and passphrase shown are not yours contact the Provider Assistance Center 9 Click the Sign In button 10 The Provider Home Page appears PROMISe
260. n Occurrence Code is entered Span Thru Date must be less than or equal to today s date Occurrence Span Code must be 2 characters in length To Correct Enter a Span From Date that is less than or equal to Span To Date Enter the Span Thru Date Enter a Span Thru Date that is less than or equal to today s date Enter 2 characters for the Occurrence Span Code Occurrence Span Code can only Enter a Occurrence Span Code contain alphanumeric characters Span From Date is a required field when Occurrence Code is entered Span From Date must be less than or equal to today s date Span From Date must be less than or equal to Span To Date Span Thru Date is a required field when Occurrence Code is entered Span Thru Date must be less than or equal to today s date The first two characters of Operating Provider ID must be alpha that contains only alphanumeric characters Enter the Span From Date Enter a Span From Date that is less than or equal to today s date Enter a Span From Date that is less than or equal to Span To Date Enter the Span Thru Date Enter a Span Thru Date that is less than or equal to today s date Enter alphabetic characters for the first two characters of the Operating Provider ID Operating Provider ID must be 8 Enter a Operating Provider ID or 9 characters in length The ICN entered for the Original Claim number is an encounter Encounters may not be adjusted or voided through the PROMISe
261. n Page window the General User Manual opens 2 Click the Claims tab The Claims window opens Claims The Claims window opens opens PROMISe Provider Internet User Manual docx July 3 2014 142 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Step Action Response 3 Click the Submit Institutional link The Provider Institutional Claim window opens To Complete Claim Billing Information Note Claims should be completed in accordance with DPW s guidelines policies and procedures Refer to the DPW web site for more specific information on completing a claim submission Step Action Response 1 In the Billing Information section in the Claim Type and Bill Type drop down lists select a value 2 Type a value in the Original Claim Recipient ID Patient Account Last Name First Name Middle Initial Attachment Control Medical Record and Prior Authorization fields 3 In the Report Type Code and Report Transmission Code drop down lists select a value 4 Type a value in the Gross Patient Pay and Patient Pay Amount fields To Complete Claim Service Information Step Action Response 1 In the Service Information section type a value in the Patient Status Attending Provider ID Location Operating Provider ID Location Other Provider ID Location Referral Number Facility ID Facility Name and Billing Note fields
262. n accordance with DPW s guidelines policies and procedures Refer to the DPW web site for more specific information on completing a claim submission Step Action Response 1 In the Billing Information section in the Claim Type drop down lists select a value 2 Type a value in the Cardholder ID Last Name First Name and Date of Service fields 3 In the Patient Location Pregnancy Indicator and Eligibility Clarification Code drop down lists select a value To Add Claim Details Information Step Action Response 1 In the Details section type a value in the Prescriber ID field 2 In the Rx Qualifier drop down list select a value 3 Type a value in the Prescription field 4 In the NDC Qualifier drop down list select a value 5 Type a value in the NDC Quality Dispensed New Refill and Days Supply fields 6 In the Compound Indicator and Dispense As Written drop down lists select a value 7 Type a value in the Billing Note and Date Prescribed fields 8 In the Other Coverage Code drop down list select a value 9 Type a value in the Usual and Customary Charge field 10 In the Submission Clarification Level of Service and Prior Authorization Type drop down lists select a value 11 Type a value in the Prior Authorization Number and Ingredient Cost fields 12 In the Basis of Cost Determination and Unit of Measure drop down lists select a value 13 Type a value in the Patient Paid Amount field To Complete Claim DUR PPS Information Step Action Re
263. n or Enter an Admission Date less equal to today s date than or equal to today s date Anesthesia must be at least three valid Enter a valid anesthesia code characters When Accident Date is entered a related cause Employment Other Accident or Auto Accident must be chosen Date is entered Billed Amount may not be negative Enter a valid Billed Amount and must be of the format 999999 99 using only numbers Billing Note may not contain or Remove and from Billing Note Code Type field is required Select an ICD code type Both ICD 9 and ICD 10 codes have Select the correct ICD code type been found within this inquired claim for that claim Please choose the correct ICD code type Accident country can only contain Enter alphanumeric Accident alphanumeric characters Country Accident country cannot be less than 2 Enter 3 charactera Accident characters in length Country Accident Date must be entered when Enter a Accident Date when Employment Other Accident or Auto Employment Other Accident or Accident is populated Auto Accident is populated Date of Birth must be less than or Enter a date that is less than or equal to today s date equal to today s date Patient date of death for Patient must Enter Date of Death that is less be a valid date less than or equal to than or equal to today s date today s date Diagnosis code can only contain alphanumeric characters Select a related cause Employmen
264. naeenaees 230 Other Option Sto ee deen E ed cde ate nue tend ves aan Seen eat teed 230 6 28 ePEAP Fee Assignment Information cc cccescceesccssstcessssesssnsessnsccessnseseneceeees 231 6 28 1 Accessibility and Use svt netaa E ood esbigent ved ee seekleaete E E TEER 232 To Access the ePEAP Fee Assignment Information Window eeceeceeseeeneeeseeeneeeseeeneees 232 Field Descriptions ssc erecta ses e taae e Cael reas A A tae ace tras a a eE 233 6 29 ePEAP Add a Group for Fee Assignment ceeeeeesceceeneeceeeeeceeeeeceeeeecseeeeeeaeeeees 233 6 29 71 Accessibility and Use estate cute 2eba te cesde e ea ea Suan resus e e E E aea eat 234 To Access the Add A Group for Fee Assignment Window ceceecceeceeeeeeeeeeseeeneeeneeensees 235 To Add a Group for Fee Assignment Information 2000 00 ceeceeceseeeseceseeeeeeeeeeeeaeeeaeesaaeesaees 235 Other Option sieves ever chests tetas tal a ah tesssen e eeee wee eased A 235 6 30 ePEAP Manage Fee Assignments cic tsvieilsountacteteiaiel pede enicnd ams aatarnseede 236 6 301 Accessibility and Use cosirer eiar a AEA ET EE E A enous 238 To Access the Manage Fee Assignment Window sssseseseereeseereesesrreserrissrrsrssresresressesrrsseee 238 Terminate a Fee Assignment minien n e iaee a a eia a areia 238 Other Options aone eee E ea E ee lee eee a a a a 238 6 31 ePEAP Manage NPI Taxonomy sssessssssesssesesesesseeessessessseesseresseeesseesseesseesseesseee 239 PROMISe Prov
265. nature Pregnancy Indicator and Contract Type drop down lists select a value 7 Type a value in the Contract Code and Contract Version fields To Complete Claim Accident Information Step Action Response 1 In the Accident section in the Employment Related Other and Auto drop down lists select a value 2 Type a value in the Date State and Country fields To Complete Claim Ambulance Information Step Action Response 1 In the Ambulance section in the Transport Code and Transport Reason Code drop down lists select a value 2 Type a value in the Transport Distance and Patient Weight fields 3 Type up to 5 values in the Condition Code field s PROMISe Provider Internet User Manual docx July 3 2014 175 PROM Provider Internet User Manual ISe Internet Portal PA PROMISe System Documentation To Add Patient Information Newborn Only 176 Step Action Response 1 In the Patient Information Newborn Only section type a value in the Patient ID Last Name First Name and Middle Initial 2 In the Gender drop down list box select a value 3 Type a value in the Date of Birth and Date of Death fields 4 Click the Add button to add additional Patient Information To Remove Patient Information Step Action Response 1 Click the Remove button To Add Claim Other Insurance Information Step Action Response In the
266. nature when Signature Benefits Assignment is Yes Benefits Assignment Patient Weight 0 Patient Weight must be numeric and Enter a positive numeric Patient ambulance may not contain a negative value Weight Pregnancy 0 Maternity Care Indicator must be Yes Select Yes for Maternity Care Indicator when submitting Patient Information Indicator when submitting Patient Information 1 Patient information is required when Enter Patient information Newborn Maternity Care Indicator is Newborn Maternity Care Yes Indicator is Yes Prior 0 Prior Authorization must be 10 Enter a 10 character Prior Authorization characters in length Authorization Procedure 0 At least 5 alphanumeric characters Enter a valid Procedure Code must be entered containing at least 5 alphanumeric characters RecipientID 0 Recipient ID is a required field Enter valid Recipient ID 1 Recipient ID must be 10 characters in Enter at least a 10 character length Recipient ID Referral Code 1 Referral Code must be 2 characters in Enter a Referral Code that is two length characters in length 2 Referral Code can only contain Enter a Referral Code that alphanumeric characters contains only alphanumeric characters Referring 0 Referring Provider ID must be less Enter a provider ID that is less Provider ID than 10 or 13 characters in length than 10 or enter a 13 digit Referring Provider ID 1 13 digit Referring Provider ID must be Enter a 13 digit numeric Provider numeric ID Rendering 0 Rende
267. nce Ambulance Condition Code 1 is Condition Code is entered entered Transport 0 Ambulance Transport Reason Code is Enter Ambulance Transport Reason Code a required field Enter Ambulance Reason Code when Ambulance ambulance Transport Reason Code when Transport Code or Ambulance Ambulance Transport Code or Transport Distance or Ambulance Transport Distance or Ambulance Condition Code is Ambulance Condition Code is entered entered Units 0 Units may not be negative and must Enter the units using the format be in the format 999999 99 999999 99 6 13 1 Accessibility and Use To access and use the Provider Professional Claim window complete the steps in the step action table s Note The following step action tables are organized to coincide with information as it is grouped in the online claim submission form window Billing Information is presented first then Claim Service information and on through the subsequent groups ending with Service Lines information To Access Provider Professional Claim Window Step Action Response 1 Logon to PA PROMISe using the steps presented The Provider Main Page window in the General User Manual opens 2 Click the Claims tab The Claims window opens 3 Click the Submit Professional link The Provider Professional Claim window opens PROMISe Provider Internet User Manual docx July 3 2014 174 Provider Internet User Manual
268. nce Code Date Button 0 Code Date X Occurrence Span Removes the Occurrence Span Code Date Button 0 Code Date X Condition Code Removes the Condition Code Button 0 X Value Code Removes Value Code Amount fields Button 0 Amount Zip Attending Zip for Attending Provider ID Character 9 Provider Zip Billing Zip for Billing Provider ID Character 9 Provider Zip Operating Zip for Operating Provider ID Character 9 Provider Zip Other Provider Zip for Other Provider ID Character 9 PROMISe Provider Internet User Manual docx July 3 2014 128 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Edits Field Adjustment Group Code Service Line Adjustment Admission Date Admission Hour Admission Source Admission Type Attending Provider ID Benefits Assignment Other Insurance Billed Amount Carrier Code Other Insurance Code Type Condition Code 1 Error Code 0 Error Message Adjustment Group Code is a required field Admission Date must be less than or equal to today s date Admission Hour is a required field To Correct Enter the Adjustment Group Code is a required field Enter a Admission Date that is less than or equal to today s date Enter the Admission Hour Admission Hour must be a valid Enter a valid 24 hour time for 24 hour time Admission Source is a required field Admission Source can only contain alphanumeric ch
269. ndered Box Place of Service Location code for the place where a health care Drop Down List 0 Service Lines service was rendered for a service line This field Box list is auto populated with a code when a value is selected from the drop down box in the Place of Service field below Placement Initial placement or replacement for prosthesis Drop Down List 0 Indicator crown or inlay code Box Policy Holder First Name of Policy Holder Character 25 First Name Other Insurance Policy Holder ID Identification number of the policy holder Character 12 Code Other Insurance PROMISe Provider Internet User Manual docx July 3 2014 98 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Policy Holder Last name of policyholder This field is auto Character 35 Last Name populated by the value entered in the Policy Other Insurance Holder Last Name field below list Policy Holder Last name of policyholder Character 35 Last Name Other Insurance Prior Prior authorization number submitted on the claim Number 10 Authorization Prior Placement Date that the prosthesis being replaced was Date 8 Date originally placed MM DD CCYY Procedure Description that clarifies the product service Character 5 Service Lines procedure code and related data elements Procedure Description that clarifies the product service Character 5 Service Lines procedure code and relate
270. ne number of the not auto filled The user must enter the contact in the Clearinghouse office for telephone number of the Clearinghouse handling ERA issues contact 23 In the Electronic Remittance Advice The Email Address field is a required field Clearinghouse Information Section when Clearinghouse is the selected the Email Address field indicates the Method of Retrieval The information is email address of the contact in the not auto filled The user must enter the Clearinghouse office for handling ERA email address of the Clearinghouse issues contact 24 In the Submission Information The Reason for Submission is a required Section the Reason for Submission field and is not auto filled The user must field indicates the provider s reason for select one of the valid values by clicking submitting the ERA form Valid the Radio Button next to the value values are e New Enrollment e Change Enrollment e Cancel Enrollment 25 In the Submission Information This information is auto filled from the Section the Authorized Signature data available in PROMISe The user field indicates the name of the may not update this information via the PROMISe Portal user ID of the ERA Enrollment Application window individual who is submitting the ERA application form 26 In the Submission Information The Printed Name of Person Submitting Section the Printed Name of Person Enrollment field is a required field and is Submitting Enrol
271. nefit Percent Eligibility Detail Benefit Related Entity Eligibility Detail Card Number input City State and Zip Recipient Clear Coverage Description Eligibility Detail Date of Birth Input Date of Birth Recipient Description Data Type Recipient s second address line Character Indicates if authorization or certification is Character required Begin date of the eligibility or period for the Date summary line Only provided when the value MM DD CCYY appears within the range of dates supplied on the request Monetary amount qualifier of benefit such as a Number deductible amount Percent qualifier of a benefit such as co Number insurance Type name address and phone number for the Character primary entity associated with this eligibility or benefit detail The length is variable depending on the eligibility detail status and quantity of entity information available on EVS ACCESS card number Number Recipient s city state and zip code A Character maximum of 30 characters for city 2 characters for state and 15 characters for zip code can be displayed Clears or resets the search fields back to Button default values Description of the eligibility being provided Character Used only in the Medicaid eligibility detail to communicate the program status category of assistance and service program code Recipient s date of birth Present twice in the Date input area for search grouping
272. net User Manual PROMISe Internet Portal PA PROMISe System Documentation Yeow pennsylvania DEPARTMENT OF PUBLIC WELFARE My Home gt Manage Alternates Thursday 06 24 2010 09 29 AM EST Alternate Assignment Back to My Home Add New Alternate Add Registered Alternate Indicates a required field Enter the fields below and click Submit to generate the alternate code for the new alternate to register First Name Last Name Birth Date Unique PIN Alternates Click the Alternate s name to change the status of the alternate Namea Birth Date Unique PIN Alternate Code Status 1 User Sample 01 01 1918 1234 00000 Active Adding a New Alternate 1 The Add New Alternate tab is selected by default 2 Enter the alternate s first name last name birth date and a unique four digit number into the specified fields 3 Click the Submit button 4 A confirmation window appears PROMISe Provider Internet User Manual docx July 3 2014 22 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation pennsylvania DEPARTMENT OF PUBLIC WELFARE My Home gt Manage Alternates Thursday 04 22 2010 12 57 PM EST Alternate Assignment Back to My Home p Add New Alternate Click Confirm to confirm the request Click Cancel to cancel it First Name Alt Last Name Standin Birth Da
273. new Condition Code Add new Occurrence Code Date Add new Occurrence Span Code Date Add new POA diagnosis line to claim up to 24 Add new other insurance line to claim Add new service line to claim Add new Surgical Code Date Add new Value Code Amount First adjustment group code Second adjustment group code Third adjustment group code Data Type Button Button Button Button Button Button Button Button Drop Down List Box Drop Down List Box Drop Down List Box Date the recipient was admitted into the facility Date Diagnosis code at admission for this claim MM DD CCYY Character Time the recipient was admitted into the facility Character Source of the admission Priority of this admission First amount of adjustment group Second amount of adjustment group Third amount of adjustment group PROMISe Provider Internet User Manual docx 115 Drop Down List Box Drop Down List Box Number Number Number Length July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Attachment Control Attachment control number ACN used to Number 20 relate attachments to this claim Attending Provider ID of the physician responsible for the care of Character 9 ID the patient Basis of Type units used for a value Drop Down List 0 Measurement Box Benefits Indicator or Assignment of Benefits code Drop Down L
274. ng your full name here field and click the Submit button to submit the form electronically If all required information is present you will be able to gain access to the PA PROMISe Web application PROMISe Provider Internet User Manual docx July 3 2014 12 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation The following confirmation message should appear v User Successfully Registered You have successfully registered as a provider for the PROMISe Internet Portal A confirmation email containing your login information has been sent to the email address provided Email notifications can take 15 to 30 minutes to be delivered 2 2 Process for Registering and Obtaining a Password Billing Agents Providers who are DPW billing agents formerly known as business partners must follow the instructions in this section to log on to the PA PROMISe Internet site A billing agent is an entity with whom an organization exchanges data electronically The billing agent may send or receive information electronically Billing agents include the following provider types who do business with DPW e HCSIS e PH e BHMCO On the PROMISe Welcome Page click the Register Now link The Registration Selector window displays pennsylvania DEPARTMENT OF PUBLIC WELFARE rN PROMISe Internet Home gt Registration Selector Thursday 07 22 201
275. nge a service location address click the New Service Location Request Form from the Provider Address Information window to download a copy of the form This form must be printed filled out and submitted to DPW for approval and processing PROMISe Provider Internet User Manual docx July 3 2014 221 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout Add New Pay To Mail To and or Home Office Address Instructions You may use the form below to specify an address and assign it to replace the current Pay to Mail to and or Home Office address for your Service Location After completing the form please click Continue Address City State Zip Code County for Pennsylvania Addresses Phone Ext Fax Handicap Access Oves ONo Assign to Service Location 0001 as Check all that apply Payto Address Mailto Address C Home Office Address C Continue Required 6 25 1 Accessibility and Use To access the Add a New Address window and perform address maintenance tasks complete the steps in the following step action tables To Access the Add a New Address Information window Step Action Result 1 Sign on to the PA PROMISe Internet The Provider Main Page appears on the application using instructions provided in desktop S
276. nload File Download Current Files Avail lable for Download Cl s igibili Trade Files LGE Wednesday 11 09 2011 01 45 PM EST Filename downloadiwavi3301 200084104 070526 010334 zip download wav13301 200084104 070524 142101 zip download wav13301 200084104 070524 111952 zip MISCELLNAEOUS 2007 05 26 _ MISCELLNAEOUS 2007 05 24 MISCELLNAEOUS 2007 05 24 download wav13301 200084104 070524 105817 zip Idownloadiwav13301 200084104 070523 090309 zip MISCELLNAEOUS 2007 05 24 IMISCELLNAEOUS 2007 05 23 download wav13301 200084104 070519 010234 zip download wav13301 200084104 070505 010247 zip MISCELLNAEOUS 2007 05 19 IMISCELLNAEOUS 2007 05 05 download wav13301 200084104 070503 124223 zip download wav13301 200084104 070502 104258 zip IMISCELLNAEOUS 2007 05 03 MISCELLNAEOUS 2007 05 02 download wav13301 200084104 070427 141509 zip download wav13301 200084104 070421 010251 zip MISCELLNAEOUS 2007 04 27 IMISCELLNAEOUS 2007 04 21 Idownload wav13301 200084104 070416 104204 zip MISCELLNAEOUS 2007 04 16 download wav13301 200084104 070306 Mar5605 zip MISCELLNAEOUS 2007 03 06 downloadiwav13301 200084104 070306 Mar3215 zip MISCELLNAEOUS 2007 03 06 downloadiwav13301 200084104 060213 124947 zip idownloadiwav13301 200084104 070306 Mar1622 zip MISCELLNAEOUS 2007 03 06 MISCELLNAEOUS 2006 02 13 Type 3 Date Available Date Downloa
277. ns Step Action Result 1 Click the ePEAP Menu button Opens the ePEAP Menu window 2 Click the Help button Describes the fields on the Recent Requests window 3 Click the Exit button Opens the PA PROMISe Provider Main Page Field Descriptions Field Description Data Type Length Cancel End termination request Button 0 Continue Opens the Review Your Changes window Button 0 Effective End Date provider officially terminates enrollment asa Drop down 14 Date Medical Assistance provider List Box Exit Exit ePEAP Button 0 Help Describes the fields on the ePEAP window Button 0 ePEAP Menu Returns the user to the ePEAP menu window Button 0 Provider ID Nine digit provider number Character 9 Service Location Four digit service location number Character 4 PROMISe Provider Internet User Manual docx July 3 2014 255 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 35 ePEAP Manage Remittance Advice The Manage Remittance Advice window is used by providers to suppress or reinstate mail delivery of paper Remittance Advices RAs This window is accessed by clicking the Manage Remittance Advice link in the ePEAP Menu Layout Manage Remittance Advice Only PENNS VIMANAL iz DEAP Office of Medical Assistance Programs OMAP Your Provider ID 300180963 DOGOOD JAMES L Status Active NPI 1234567893 View Taxonomy ePEAP Access Full Access Service Location 0001 123 HOPE RD
278. ns only alphanumeric character s Enter the Reason Code 3 for OI that contains only alphanumeric characters Enter a Reason Code that contains only alphanumeric character s Enter a Recipient ID Enter 10 characters for the Recipient ID Enter a Referral Code that is two characters in length Enter a Referral Code that contains only alphanumeric characters July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Release of Medical Data Release of Medical Data Other Insurance Error Code 0 0 Report Transmission 0 Code Report Type Code Revenue Code State Surgical Code 1 Surgical Code 2 Surgical Code 3 Surgical Code 4 Error Message Release of Medical Data is a required field Release of Medical Data for OI is a required field Report Transmission Code is required when Report Type Code is entered Report Type Code is required when Report Transmission Code is entered Revenue Code must be 3 or 4 characters in length Revenue Code must be numeric and may not contain a negative value Accident state must be 2 alpha characters in length Surgical Code can only contain alphanumeric characters Surgical Code is a required when Surgical Date has been entered Surgical Code is required when Operating Physician is entered Surgical Code can only contain alphanumeric characters Surgical Code is a required when
279. nstitutional link in the Claims option in the menu bar of the Provider My Home Page window Section 5 10 Provider Institutional Claim provides step by step information for submitting or adjusting an Institutional claim 2 10 3 About Pharmacy Claims Providers can access the online Pharmacy claim form by clicking on the Submit Pharmacy link in the Claims option in the menu bar of the Provider My Home Page window Section 5 12 Provider Pharmacy Claim provides step by step information for submitting or adjusting a Pharmacy claim 2 10 4 About Professional Claims Providers can access the online Professional claim form by clicking on the Submit Professional link in the Claims option in the menu bar of the Provider My Home Page window Section 5 14 Provider Professional Claim provides step by step information for submitting or adjusting a Professional claim PROMISe Provider Internet User Manual docx July 3 2014 40 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 2 10 5 About the Copy Function Providers can duplicate a paid claim using the Copy function The Copy button can be used if a provider is resubmitting a previously denied claim or performing an adjustment or void on a previously paid claim Service Adjustments for Service Line 1 dd Reason Code 2 Coinsurance amount Amount 5 40 Adjustment Group Code PR Patient Responsibility Paid Date 05 31 2012 P
280. nsylvania UBLIC WELFARE Home gt Registration Selector gt Registration Monday 06 21 2010 12 07 PM EST Registration Step 2 of 2 Security Informati Indicates a required field The User ID and Password cannot be the same and the password must be 8 20 characters in length contain a minimum of 1 numeric digit 1 uppercase letter and 1 lowercase letter User ID eck Availability Password Confirm Password Please provide your contact information below Display Name Sample Name Phone Number _ lt k Email Confirm Email Please choose a personalized Site Key and enter a passphrase that will be used to verify your identity upon logging into the PROMISe Internet portal 99 oF Site Key Apple Balloon O Balloons Baseball Billiards Passphrase Please select a unique challenge question and provide an answer for each of the question groups below Challenge Question 1 what is your mother s maiden name v Answer to 1 Challenge Question 2 who was your first employer v Answer to 2 Challenge Question 3 what is the name of your favorite school teacher y Answer to 3 User Agreement By checking the box provided below and transmitting this form electronically I state I am the person whom I represent myself to be herein and I affirm the information within this web app
281. nt Paid Date is a required field Service Adjustment Paid Date must be a date less than or equal to today s date To Correct Enter a Fee For Service claim number Enter a valid Service Adjustment paid Amount Enter a valid Service Adjustment Paid Date Enter a Service Adjustment Paid Date that is less than or equal to today s date Patient Pay Amount must Enter a Patient Pay be a number greater than 0 Amount that is Prior Authorization Number must be 10 characters Service Line Prior Placement Date must be less than or equal to today s date Service Line Procedure is a required field Service Line greater than 0 Enter a 10 character Prior Authorization Number Enter a Placement Date that is not in the future Enter a procedure code Enter a valid Procedure can only contain procedure code alphanumeric characters Service Line Procedure must be 5 characters in length Reason Code is a required field Reason Code can only contain alphanumeric character s Enter a valid procedure code Enter a valid Reason Code Enter a valid alphanumeric Reason Code July 3 2014 Provider Internet User Manual PA PROMISe System Documentation PROMISe Internet Portal Error Code Field Recipient ID 0 1 Referring Provider ID 0 1 Release of Medical Data Other Insurance 0 Rendering Provider ID 0 1 2 Report Transmiss
282. nt Press the underlined Add to add this field Condition Code 4 Fourth condition s related to this claim or to the patient Press the underlined Add to add this field Condition Code 5 Fifth condition s related to this claim or to the patient Press the underlined Add to add this field Condition Code 6 Sixth condition s related to this claim or to the patient Press the underlined Add to add this field Condition Code 7 Seventh condition s related to this claim or to Drop Down List 0 the patient Press the underlined Add to add Box Drop Down List Box Drop Down List Box Drop Down List Box Drop Down List Box this field Copy Copies a paid claim s data to a new Button 0 unprocessed claim Covered Days The number of covered days Number 3 Date of Birth Patient s date of birth Date 8 MM DD CCYY Date of Death Patient date of death Date 8 MM DD CCYY Date of Service Date this service line was rendered Date 8 Service Lines List MM DD CCYY Box Delete Other Remove existing other insurance line from Button 0 Insurance claim Delete Service Remove existing service line from claim Button 0 Lines Discharge Hour Hour patient was discharged Character 4 E Code Emergency code for this claim Character 6 Emergency Indicates whether the service was provided as a Drop Down List 0 result of an emergency Box Facility ID Service facility location ID Character 9 Facility Name Service facility location name Charac
283. nt Responsibility Qualifier Button 0 Responsibility Qualifier PROMISe Provider Internet User Manual docx July 3 2014 149 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Add Reject Code Add Submission Clarification Code Additional Patient Info Ind Additional Prescriber Info Ind Address Amount Amount Paid Amount Paid Qualifier Attachment Control Basis of Cost Determination Billing Note City Cardholder DOB Cardholder ID Compound Indicator Copy Coupon Amount Coupon Number Coupon Type Coverage Type Description Add a Reject Code Add Submission Clarification Code Additional patient information indicator Additional prescriber information indicator Valid values are e 1 No e 2 Yes Address of the patient Amount of Patient Responsibility Amount Paid Amount Paid Qualifier Attachment control number Method by which the ingredient cost submitted was determined Description or special notation regarding the billing for this claim City where the patient lives Date of birth of the cardholder ID number issued to recipients who are authorized to receive Medicaid services The recipient ID verification digit and ACCESS card number are all entered in this same field Indicates if the prescription is a compound Copies a paid claim s data to a new unprocessed claim Amount of coupon Number of coupon Type of
284. nter a valid email address Enter in a 5 digit zip code number Enter in a 5 digit zip code number July 3 2014
285. nter the Fax Number Enter the fax number if available 8 Enter Yes or No for Handicap Access 9 Assign to Current Location nnnn as Check all boxes that apply Pay to Address Mail to Address Home Office Address 10 Click the Continue button The Review Your Changes window opens Other Options Step Action Result 1 Click the Cancel button The update is cancelled and returns to the Manage Pay to Mail to and or Home PROMISe Provider Internet User Manual docx 223 July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Step Action Result Office Address window Click the Reset button The contents on this page are cleared 3 Click the Address Menu button Returns to the Provider Address Information window Click ePEAP Menu Returns to the ePEAP Menu window Click the Help button Click the Review Submit button Describes the fields on the ePEAP window The Review Your Changes window opens 4 5 6 7 Click the Exit button Returns to the ePEAP Menu window Field Descriptions Field Address Address Menu Cancel City Continue County Exit Ext Fax Handicap Access Help Home Office Address Mail to Address Pay to Address Phone PROMISe Provider Internet User Manual docx Description Data Type Length New street address Character 60 Returns to the Address Menu window Button 0 Update
286. nter the Provider ID and Service Location in the corresponding fields 2 Click the Check button The verification is displayed Other Options Step Action Result 1 Click the ePEAP Menu button Opens the ePEAP Menu window 2 Click the Help button Describes the fields on the Recent Requests window 3 Click the Exit button Opens the PA PROMISe Provider Main Page Field Descriptions Field Description ia Length Check Verify a provider is in a specific group Button 0 Exit Exit ePEAP Button 0 Help Describes the fields on the ePEAP window Button 0 Provider ID Provider ID of the individual provider whose group Number 9 membership is being verified Service Service location of the individual provider whose group Character 4 Location membership is being verified ePEAP Menu Opens the ePEAP menu window Button 0 6 39 ePEAP Provider Group Members The Provider Group Members window is used to view a provider s group enrollment This is a view only window and the information it displays cannot be modified by the user This window is accessed by clicking the View Provider Group Members link in the ePEAP Menu When the results for this window exceed 1000 records only the first 1000 records are displayed and the Displaying results drop down list appears to specify the range group being displayed Results beyond the first 1000 are viewed by selecting a range of results from the drop down list and pressing the View Results button
287. nternet User Manual docx July 3 2014 249 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 33 ePEAP Recent Request Window The ePEAP Recent Request window is used to track a provider s open requests in the ePEAP system The details of individual requests can be viewed open requests can be cancelled and messages can be sent to DPW requesting information regarding the status of a request This window can be accessed from the PA PROMISe Internet Provider Main Page and then select ePEAP Provider Enrollment Automation Project From here select Recent Requests to display the Recent Requests window Layout PENNSYLMANIO a PEAP Your Provides ID 300 180863 DOGOCO JAMES L Stans Actin HPI 1234507039 iew Taxonomy PEAP Access Ful Access Service Lecation 001 123 HOPE RD HARRIESSURG PA 17011 Provider Type 31 PHYSICIAN Mew Specisties Recent Requests Options Tracking Submit Date Ststus View Cortact 6326 64096 28 2005 3 08 20 Pt In Process View Contact 6327 64097 1042005 3 29 47 PM In Process View Contact 6239 64098 1072005 3 26 02 AM In Process View Cortact 7771 64145 4 24 2006 4 06 50 Pt In Process View 921 64220 11202006 3 35 46 PM Compbte View 9272 64231 AVAWI0G 2 4217 PM Complte View 923 64232 TVN22006 2 43 37 PM Complete View 947 64240 11212006 1 16 51 PM Comphte Vies 949 64241 1212006 1 19 36 PM Compbte View 954 64243 11 21 2006 230 20PM Comphte View 9956 642
288. om the selected paid claim is copied to a new claim PROMISe Provider Internet User Manual docx July 3 2014 109 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 8 Provider Help Provider Help The PROMISe Internet manual contains assistance for using the PROMISe Internet windows that are available to Provider Internet users The manual contains information about the use of each window and field edit information for correcting errors The PROMISe Internet Manual is accessed by selecting the Help link from the Main logon page Layout ry pennsylvania DEPARTMENT OF PUBLIC WELFARE PROMISe Internet Home Wednesday 11 02 2011 11 35 AM EST Provider Login User ID The Pennsylvania Medical Assistance EHR Incentive Program is now available Forgot User ID s a P s s e 3 If you applied at CMS s EHR Incentive Program Registration and Attestation R amp A website you will see a link to the Register Now Medical Assistance Provider Incentive Repository MAPIR after you log on with your PROMISe Internet Portal User ID If you do not have a PROMISe Internet Portal User ID please register by following the Quick Links on the left of this Where do I enter my password page Quick Links wil phates guia i Dovm he Internet Help Manuals A le P Adobe Acrobat aik ra VIEOE 6 8 1 Accessib
289. on Provider Contact Name field the name of the provider contact for handling EFT issues This information is partially auto filled from the data available in PROMISe The user must update the 4 digit Service Location An automatic edit will verify that the entered Service Location is active for the submitting provider legal entity Note Only the first Trading Partner ID selection will be partially auto filled with the service location information of the service location you log into the portal with This information cannot be updated All subsequent service location entries must be submitted by the provider and then confirmed by the system Each new row begins with a minus sign that the user may click to remove the row from the application form The maximum number of service locations that may be added is 100 The first time a user clicks this link on a new application a pop up message appears to caution the user about adding service locations WARNING Please be advised that each location entered will be enrolled for EFT Please confirm all service locations listed are accurate prior to submission s The Provider Contact Name field is a required field and is not auto filled The User must enter the name of the provider contact for handling EFT issues 11 In the Provider Contact Information Section Telephone Number field the provider contact phone number for EFT issues PR
290. on No 0815600000001 06 04 2008 i Recipient Name GAS Recipient D GED Date ot Brh SD Gender SD Eligibility Summary m o o Meme Begn Ena F Cotegory PMA Medicaid Program Stetus 00 0604 2008 0604 2008 Service Program HCBO2 Services Restricted to Folowing Provider PODIATRIST 06104 2008 060412003 Eligibility Detail status Medicaid Service Type Health Benefit Pian Coverage Insurance Type Medicaid 5 Coverage Description Category PNY Program Stetus 00 Service Program HCBO2 Service 0604 2008 Bigiblty 0604 2008 IBeneft Related Entty MA Service Program Information Contact Telephone SD Eligibility Detail Stetus Services Restricted to Following Provider Service Type Heath Benett Plan Coverage Service 05012008 Period Steet 05 04 2008 Period End losos2a08 Message Text PODIATRIST 4 Message Text Restrictions do not apply to emergency services 4 Benefit Related Entty Contracted Service Provider 5 Information Contact Telephone S lt Field Descriptions Address Line 1 Recipient s first address line Recipient PROMISe Provider Internet User Manual docx July 3 2014 189 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Address Line 2 Recipient Authorization Indicator Eligibility Detail Begin Eligibility Summary Benefit Amount Eligibility Detail Be
291. on Section Street field represents the number and street name where the provider service location is located This information is auto filled from the data available in PROMISe The user may not update this information via the ERA Enrollment Application window if appropriate 3 The Provider Information Section City field represents the city associated with the provider service location s street address This information is auto filled from the data available in PROMISe The user may not update this information via the ERA Enrollment Application window 4 The Provider Information Section State Province field represents the two character code associated with the state name This information is auto filled from the data available in PROMISe The user may not update this information via the ERA Enrollment Application window 5 The Provider Information Section Zip Code Postal Code field represents the full 9 digit zip code associated with the service location s address This information is auto filled from the data available in PROMISe The user may not update this information via the ERA Enrollment Application window 6 The Provider Identifiers Section Provider Federal Tax Identification Number TIN or Employer Identification Number EIN field represents the Tax ID of the provider legal entity Note Only the last 4 digits of the Tax ID will be displayed the other digits will be mas
292. one number Enter a 10 digit phone number Enter in a 10 digit phone number Enter in a 10 digit phone number Enter in a 10 digit fax number Enter in a 10 digit fax number Enter in a 9 digit provider number Enter in a 9 digit provider number Provider Number must be 9 Enter in a 9 digit provider digits This Provider ID is the same one signed on to ePEAP Provider ID must be numeric Provider ID must be nine digits Enter Provider ID to continue Service Location must be 4 characters 283 number Enter a new 9 digit group provider number Enter a 9 digit provider number Enter a 9 digit provider number Enter a 9 digit provider number Enter a 4 character service location July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Error Field Code State 10 Your e mail address for 1 messages from etc Zip Code 11 12 PROMISe Provider Internet User Manual docx Error Message You must enter a state before continuing Enter an Email address to continue Email Address you typed was invalid Email destination is invalid Email address appears incorrect must end in a three letter domain or two letter country Zip code must be numeric Zip code must be 5 digits 284 To Correct Select a valid state from drop down list Enter an email address Enter a valid email address Enter a valid email address E
293. onic Funds Transfer Enrollment Application window complete the steps in the following step action tables PROMISe Provider Internet User Manual docx July 3 2014 46 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout Fe Say pennsylvania Q D oi PROMISe Internet MyHome Claims Eligibility Trade Files Reports aa aaa Help Enroted Provider Search EFT and ERA Enrotiment My Home gt EFT and ERA Enrollment Wednesday 12 11 2013 08 42 AM EST Electronic Funds Transfer EFT ESA Enrollment Application Provider Information Provider Name Provider Address Payment Address Street D23 MAPLE STREET City aTown Stete Province Pa I ZIP Code Postal Code 2345 Provider Identifiers Provider Identifiers Provider Federal Tax Identification Number TIN or Employer Identification Number EIN National Provider Identifier NPI Other Identifiers Assigning Authority PA PROMISE Trading Partner ID 2032 9 digt Provider ID and 4 digt Service Location ie New Service Location Provider Contact Information Provider Contact Name Contact MARY SMITH Telephone Number E55 Telephone Number Extension Tr Email Address Marys mith ourtownhospital org Financial Institution Information Financial Institution Name PURTOWN NATIONAL BANK Financial Institution Address Street 1717 WEST MAIN STREET
294. opy button is only available on paid claims Step Action Response 1 Using Claim Inquiry inquiry asp If a match is found the search results list is complete a claim search displayed 2 Select a paid claim The paid claim displays 3 Click the Copy button All data from the selected paid claim is copied to a new claim 6 12 Provider ProDUR Warning Provider ProDUR Warning The Provider ProDUR Warning window is a pop up alert window to warn the provider that the claim being submitted contains a ProDUR conflict The provider can take two actions Selecting OK overrides the alert and submits the claim Selecting Cancel returns the provider to the claim form for correction Multiple conflicts may appear on the alert If a conflict appears that prohibits override only the Cancel option is displayed PROMISe Provider Internet User Manual docx July 3 2014 158 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout Microsoft Internet Explorer gt x 22 ProDUR Warning Drug NDC 00001730000 conflicts with NDC 00001649630 Do you wish continue with your claim submission Field Descriptions Field Description Data Type Length Cancel Returns to the claim form for correction Button 0 OK Overrides the alert Button 0 Field Edits Field Error Code Error Message To Correct No Error Code Messages found for this window 6 13 Provider Professional Claim Pro
295. or Auto is Yes x is not a valid day in Enter a valid date month Use a value in the range l days in month Service Line Date of Enter a date of Service is a required field service Service Line Date of Enter a date of Service must be less than service less than or or equal to today s date equal to today s date Service Line Date of Enter a date of Service is a required field service Service Line inx 1 Date of Service must be less than or equal to today s date Service Line 1 Enter a number Diagnosis pointer must be between 1 and 4 between and 4 x is not a valid day in Enter a valid date month Use a value in the range 1 days in month July 3 2014 103 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Facility ID Modifier 1 Modifier 2 Modifier 3 Modifier 4 NPI Referring Provider ID NPI Rendering Provider ID Original Claim PROMISe Provider Internet User Manual docx Error Code 0 0 Error Message Facility ID must be 9 characters Service Line Modifier 1 must be 2 characters Service Line Modifier 1 can only contain alphanumeric characters Service Line Modifier 2 must be 2 characters Service Line Modifier 2 can only contain alphanumeric characters Service Line Modifier 3 must be 2 characters Service Line Modifier 3 can
296. ovider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout PENNS VIMANAD i PEAP Starus Action 0E7770 DIGAR MEDISAL ASSOCIATES PEAP Access Your Provider I RPI 13745523 View Taxonomy Service Location 7331 123 E htt ST CAMP HILL FA 17011 5312 Provider Type ot FI SICLIAN Wiss Speciales Verify Provider Membership in My Group instructions To chec lt wether Proe der is member 9 your Group 1 Enter the Proe der s ID and Service Lecation 2 Cicek the Chec buron Provider ID 217137353 Service Location 000 Provider ID 300180963 Service Loc 0001 is a member of your Group Provider ID Sve Lee Provider Name Membership Dates 321133363 cco COGIOD JAMES L O 242007 12131 2299 Perea wens Preis Pex 6 38 1 Accessibility and Use To access the ePEAP Verify Provider Membership in My Group window and verify membership complete the steps in the following step action tables To Access the ePEAP Verify Provider Membership in My Group Window Result The Verify Provider Membership in My Step Action 1 Select the Verify Provider Membership link in the ePEAP Menu Group window opens July 3 2014 PROMISe Provider Internet User Manual docx 269 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Verify Provider Membership in My Group Step Action Result 1 E
297. ovider Report Index Provider Report Index The provider Report Index window shows the online reports that are available to the user Reports are displayed in one or more groupings The Provider and MCO groupings are shown in the window mockup Users can only see reports in groupings that are appropriate for them For example a provider sees only the Provider report grouping A managed care organization can see both the MCO and Provider grouping as a managed care organization can view reports in both of those groupings Other groupings such as Drug Manufacturer can be added as well based on need Within each grouping is a list of available reports for that grouping Selecting one of the reports takes the user to the Provider Report Request web page where the user can query the COLD system for versions of that report Layout Yoo pennsylvania N n D DEPARTMENT OF PUBLIC WELFARE PROMIS e Internet MyHome Claims Eligibility Trade Files Outpatient Fee Schedule ePEAP Hospital Assessment Help Reports Friday 11 11 2011 01 37 PM EST This page provides access to reports that your organization is eligible to access online This information is confidential to your organization To access reports for online viewing or offline download you will need to install the Acrobat Reader Software NI Provider Reports Adobe the Adobe logo Acrobat and the Acrobat logo are either registered trademarks or trademarks of Adobe Systems Incorpora
298. ovider Report Request The Provider Report Request window is used to retrieve more than one version of the report that is available from the web The user may enter a start date and an end date and select the Request Reports button to be presented with a list of the dates for which the report is available The date range entered must not be greater than 90 days apart but may start at any time in the past A user wishing to see the reports generated over a given year would submit four queries each for a different 90 day period PROMISe Provider Internet User Manual docx July 3 2014 198 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout E pennsylvania DEPARTMENT OF PUBLIC WELFARE PROMIS e Internet Aa Ceo Reports Meer as ea T a occa Reports Friday 11 11 2011 01 38 PM EST Provider ID 123456789 Location 0001 You have selected to request output from the following report Enter a date range to view your organization s information from FIN O000 W NOTES You may not view more than 90 days of reports at one time List Reports From 03 01 2010 ia Required To 05 01 2010 EE Required Request Reports Weekly Remittance Advice Reports generated between Monday March 1 2010 and Saturday May 1 2010 03 08 2010 03 27 2010 04 01 2010 Field Descriptions Field Description Data Type Length Report Text description of the selected report Character
299. ow opens 4 Review the entered information If ready to process click Submit Changes The Contact Information window opens 5 Complete the requested contact information fields Name Phone and E Mail are required fields Click Submit The following Changes are Complete window is displayed Changes Are Complete Your provider information has been updated as you requested If you wish to view your request again please select Recent Requests from the ePEAP Menu The Tracking Number for this Request was 956 64244 Thank you for using ePEAP Continue 3 Click the Continue button The ePEAP Main Menu window opens Other Options Step Action Result 1 Click the Enrollment Information button Return to the Enrollment Information window 2 Click the ePEAP Menu button Return to the ePEAP Menu window 3 Click the Help button Describes the fields on the ePEAP window 4 Click the Exit button The ePEAP Main window opens 5 Click the Cancel button Cancels all entries changes and returns to the Enrollment Information window PROMISe Provider Internet User Manual docx 244 July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Step Action 6 Click the Reset button Result Cancels all entries changes but leaves the Manage NPI and Taxonomy Codes window open Field Descriptions
300. own list select a value n Optional Type a value in the Procedure Drug Code field Optional Type a value in the Modifier 1 field Optional Type a value in the Modifier 2 field Optional Type a value in the Modifier 3 field Optional Type a value in the Modifier 4 field O CO YI QD Nn Click the Search button If a match is found the search result is displayed To Search by Recipient ID and Date of Birth Step Action Response 1 Type a value in the Recipient ID and Date of Birth fields 2 In the Date of Service From and To drop down lists select a value PROMISe Provider Internet User Manual docx 195 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Step Action Response 3 Optional In the Procedure Drug Type drop down list select a value 4 Optional Type a value in the Procedure Drug Code field 5 Optional Type a value in the Modifier 1 field 6 Optional Type a value in the Modifier 2 field 7 Optional Type a value in the Modifier 3 field 8 Optional Type a value in the Modifier 4 field 9 Click the Search button If a match is found the search result is displayed To Search by SSN Step Action Response 1 Type a value in the SSN field 2 In the Date of Birth drop down list select a value 3 In the Date of Service From and To drop down lists s
301. provider can enter all of the required information to submit a pharmacy claim in this window including multiple detail lines This window is accessed by selecting the Submit Pharmacy link from the Claims option on the Menu Bar or by clicking the Pharmacy link in the Claims Menu window Note Maximum field lengths for this window are limited by HIPAA NCPDP guidelines Differences may appear between fields on this window and fields on other windows that are based on different underlying HIPAA transaction formats PROMISe Provider Internet User Manual docx July 3 2014 147 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation The first window Layout below shows the initial viewable display the following Layouts show the remaining data viewable by scrolling Layout Pharmacy Claim Billing Information Billing Provider NPI Transaction Code B1 Biling iM m Cardholder ID is required A m Cardholder ID Last Name First Name Date of Service Date of Service is Required Patient Information Taxonomy Zip MM DDIYYYY Patient Residence 0 NOT SPECIFIED Patient Gender Code 0 NOT SPECIFIED Details Prescriber ID NPI Prescriber ID is required Additional Prescriber Info Ind 1 No v Date Prescribed Date Prescribed is Required 1 RX BILLING Rx Qualifier Prescription Prescription is Required
302. ption The ePEAP Menu window opens The ePEAP Enrollment Information window opens 4 Click the Address Information link The ePEAP Provider Address Information window opens 5 Click the Change Email link PROMISe Provider Internet User Manual docx 229 The Manage E mail Address window July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Step Action Result opens To Add or Modify E mail Address Step Action Result 1 If an existing email address needs to be Old e mail address is deleted from the changed highlight the existing e mail field address and press the Delete key 2 Type in your new e mail address Click the Continue button The Review Your Changes window opens 4 Click the Continue To Make Changes A confirmation window opens Click button to continue with the change Continue to return to the Enrollment Information window Other Options Step Action Result 1 Click the Cancel button to cancel the Opens the Provider Address Information change window 2 Click the Reset button Clears the e mail field 3 Click the Address Menu button Opens the Provider Address Information window 4 Click ePEAP Menu Opens the ePEAP Menu window 5 Click the Help button Describes the fields on the ePEAP window 6 Click the Review Submit button Opens the Review Your Changes window 7 Click the Exit button Opens th
303. purpose Name Dr James DoGood Phone 717 555 1212 Fax i E mail jdogood medical com En oo Required 4 Enter a contact name phone number and email address 5 Click the Submit button Your request is submitted Changes Are Complete Your provider information has been updated as you requested If you wish to view your request again please select Recent Requests from the ePEAP Menu The Tracking Number for this Request was 3555 64942 Thank you for using ePEAP Continue PROMISe Provider Internet User Manual docx July 3 2014 264 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Remove Service Location from the Directory Step Action Result Click to place a checkmark next to I wish 1 to be included in the SelectPlan for Women Directory Office of Medical Assistance Programs OMAP P ENNSYIUANID Welfare DEAp Your Provider ID 300276278 DOGOOD MEDICAL ASSOCIATES Active NPI 1384654368 View Taxonomy ePEAP Access Full Access Service Location 0001 123 E MAIN ST CAMP HILL PA 17011 6312 Provider Type 31 PHYSICIAN View Specialties SelectPlan for Women Directory SelectPlan for Women Directory SelectPlan for Women is an MA benefit that covers family planning and related services to help women stay healthy SelectPlan for Women services are provide
304. purposes A MM DD CCYY value entered in one location is copied into the other date of birth field Recipient s date of birth returned in the Date eligibility results section MM DD CCYY Date of Birth Second Recipient s date of birth Present twice in the Date Input Date of Service From input area for search grouping purposes A MM DD CCYY value entered in one location is copied into the other date of birth field From date that service provider wishes to Date verify eligibility MM DD CCYY PROMISe Provider Internet User Manual docx 190 Length 55 10 999 47 50 10 10 10 10 July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Delivery Eligibility Detail Delivery Frequency Eligibility Detail Delivery Measurement Eligibility Detail Delivery Pattern Time Eligibility Detail Delivery Period Eligibility Detail Delivery Qualifier Eligibility Detail Delivery Quantity Eligibility Detail Double Left Arrow Double Right Arrow Eligibility End Eligibility Detail End Eligibility Summary Errors Eligibility Detail First Name input Gender Recipient Group Number Eligibility Detail In Plan Network Eligibility Detail Insurance Type Eligibility Detail Last Name input Description Information about the number and frequency of benefit Information about the number and freq
305. r Value Code 5010 values are e 80 Covered Days e 81 Non Covered Days e 82 Coinsurance Days e 83 Lifetime Reserves Value Code 12 Twelfth code and description of monetary data Drop Down List 0 as required by the payer organization No more Box than twelve value codes can be added to a claim 5010 values are e 80 Covered Days e 81 Non Covered Days e 82 Coinsurance Days e 83 Lifetime Reserves Value Code Amount Amount for value code 1 1 Value Code Amount Amount for value code 2 2 Value Code Amount Amount for value code 3 3 Value Code Amount Amount for value code 4 4 Value Code Amount Amount for value code 5 5 Value Code Amount Amount for value code 6 6 Value Code Amount Amount for value code 7 7 PROMISe Provider Internet User Manual docx Number 9 Number 9 Number 9 Number 9 Number 9 Number 9 Number 9 July 3 2014 127 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Value Code Amount Amount for value code 8 Number 9 8 Value Code Amount Amount for value code 9 Number 9 9 Value Code Amount Amount for value code 10 Number 9 10 Value Code Amount Amount for value code 11 Number 9 11 Value Code Amount Amount for value code 12 Number 9 12 X Diagnosis Removes the Diagnosis Other Button 0 Other X Surgical Removes the Surgical Code Date Button 0 Code Date X Occurrence Removes the Occurre
306. r Tax e National Provider Identifier Identification Number TIN or field 17 NPI National Provider Identifier NPI gt PROMISe will NOT aggregate payments This is informational only 16 The Electronic Remittance Advice The Provider Tax Identification Number Information Section the Provider TIN field is not auto filled The user Tax Identification Number TIN must enter the Tax ID Number when the field represents the Tax ID Number to Radio Button next to the value is selected be used for aggregation 17 In the Electronic Remittance Advice The National Provider Identification Information Section the National Number NPI field is not auto filled Provider Identifier NPI field The user must enter the NPI Number represents the NPI number to be used when the Radio Button next to the value is for aggregation selected 18 In the Electronic Remittance Advice The Method of Retrieval field is a Information Section the Method of required field and is not auto filled The Retrieval field indicates the provider s user must select one of the appropriate method of retrieving the ERA Valid valid values by clicking the Radio Button values are next to the value e Clearinghouse e PA PROMISe Provider Electronic System PES e Other 19 In the Electronic Remittance Advice The Method of Retrieval Other field is a Information Section the Method of required field when the radio button next Retrieval Other field is a f
307. re is a conflict between the 13 digit Provider ID number to which you are logged in and the NPI number you are entering If you receive this message please contact Provider Enrollment at PROMISe state pa us with a subject line of NPI registration problem In your email please include the error message text and number details about the entry as well as a contact name and phone number The NPI taxonomy zip code combination is already being used The same NPI taxonomy nine digit ZIP Code combination can only be associated with one service location The above error message will be displayed if you attempt to associate this same combination with another service location If you receive this error message please contact Provider Enrollment at PROMISe state pa us with a subject line of NPI registration problem In your email please include the error message text and number details about the entry as well as a contact name and phone number 6 31 1 Accessibility and Use To access the ePEAP Manage NPI and Taxonomy Codes window complete the steps in the step action table s To Access the Manage NPI and Taxonomy Codes Window Step Action Result 1 Sign on to the PA PROMISe Internet The Provider Main Page appears on the application using instructions provided in desktop Section 2 9 of this manual Click on the ePEAP Provider Enrollment The ePEAP Menu window opens Automation Project link in the Other Links sec
308. red in the Attending Provider ID field If Attending Provider ID is entered this field is required NPI for Billing Provider ID Character NPI for Facility Character Note Not enabled until a 7 or 8 digit ID is entered in the Facility ID field If Facility ID is entered this field is required NPI for Operating Provider ID Character Note Not enabled until a 7 or 8 digit ID is entered in the Operating Provider ID field If Operating Provider ID is entered this field is required NPI for Other Provider ID Character Note Not enabled until a 7 or 8 digit ID is entered in the Other Provider ID field If Other Provider ID is entered this field is required Number assigned to each other insurance detail Number line First code that defines a significant event Drop Down List related to this bill that may affect payer Box processing Second code that defines a significant event Drop Down List related to this bill that may affect payer Box processing Third code that defines a significant event Drop Down List related to this bill that may affect payer Box processing Fourth code that defines a significant event Drop Down List related to this bill that may affect payer Box processing Fifth code that defines a significant event Drop Down List related to this bill that may affect payer Box processing PROMISe Provider Internet User Manual docx 119 Length 3 10 10 10 10 10 July 3 2014 PROMISe Intern
309. ree text to the value is selected and is not auto field description of the means that the filled The user must enter the description provider will use to retrieve the ERA of the means that will be used by the provider to retrieve the ERA 20 In the Electronic Remittance Advice The Clearinghouse Name field is a PROMISe Provider Internet User Manual docx 61 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Clearinghouse Information Section the Clearinghouse Name field represents the name of the Clearinghouse required field when Clearinghouse is the selected Method of Retrieval The information is not auto filled The user must enter the name of the Clearinghouse 21 In the Electronic Remittance Advice The Clearinghouse Contact Name field is Clearinghouse Information Section a required field when Clearinghouse is the Clearinghouse Contact Name the selected Method of Retrieval The field represents the name of the contact information is not auto filled The user in the Clearinghouse office for must enter the name of the Clearinghouse handling ERA issues contact 22 In the Electronic Remittance Advice The Telephone Number field is a required Clearinghouse Information Section field when Clearinghouse is the selected the Telephone Number field Method of Retrieval The information is represents the telepho
310. relationship Last Name Last name of the Medicaid recipient Character 35 Medical Record Patient s medical record number Character 30 Middle Initial Middle initial of the Medicaid recipient Character 1 Modifier 1 First modifier code that supplies additional Character 2 information on the procedure code Modifier 2 Second modifier code that supplies additional Character 2 information on the procedure code Modifier 3 Third modifier code that supplies additional Character 2 information on the procedure code Modifier 4 Fourth modifier code that supplies additional Character 2 information on the procedure code Months Total remaining months for orthodontic treatment Character 2 Remaining Orthodontic Treatment NPI Billing NPI for Billing Provider ID Character 10 Provider NPI Referring NPI for Referring Provider ID Character 10 Provider Note Not enabled until a 7 or 8 digit ID is entered in the Referring Provider ID field If Referring Provider ID is entered this field is required NPI Rendering NPI for Rendering Provider ID Character 10 Provider Note Not enabled until a 7 or 8 digit ID is entered in the Rendering Provider ID field If Rendering Provider ID is entered this field is required New Refreshes the screen to create a new claim form Button 0 OCD 1 First designation of the quadrant s of the mouth Drop Down List 0 on which services were performed or will be Box performed PROMISe Provider Internet User Manual docx July 3 2014
311. reserved CDT is a trademark of the ADA THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT BY CLICKING BELOW ON THE BUTTON LABELED ACCEPT YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN CLICK BELOW ON THE BUTTON LABELED I DO NOT ACCEPT AND EXIT FROM THIS COMPUTER SCREEN IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION AS USED HEREIN YOU AND YOUR REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING 1 Subject to the terms and conditions contained in this Agreement you your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself employees and agents within your organization within the United States and its territories Use of CDT is limited to use in programs administered by Centers for Medicare amp Medicaid Services CMS You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement You acknowledge that the ADA holds all copyright trademark and other rights in
312. ric characters Other Diagnosis code cannot be less than 3 characters in length Other Diagnosis code can only contain alphanumeric characters Other Diagnosis code cannot be less than 3 characters in length PROMISe Provider Internet User Manual docx 136 To Correct Enter an Other Diagnosis code that contains only alphanumeric characters Enter a Other Diagnosis code that is at least 3 characters in length Enter an Other Diagnosis code that contains only alphanumeric characters Enter an Other Diagnosis code that is at least 3 characters in length Enter an Other Diagnosis code that contains only alphanumeric characters Enter an Other Diagnosis code that is at least 3 characters in length Enter an Other Diagnosis code that contains only alphanumeric characters Enter an Other Diagnosis code that is at least 3 characters in length Enter an Other Diagnosis code that contains only alphanumeric characters Enter an Other Diagnosis code that is at least 3 characters in length Enter an Other Diagnosis code that contains only alphanumeric characters Enter an Other Diagnosis code that is at least 3 characters in length Enter an Other Diagnosis code that contains only alphanumeric characters Enter an Other Diagnosis code that is at least 3 characters in length July 3 2014 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Other Provider ID Pai
313. ring Provider ID is a required Enter valid Rendering Provider Provider ID field ID 1 Rendering Provider ID cannot be less Enter a 9 character Rendering than 9 characters in length Provider ID Report 0 Report Transmission Code is required Enter valid Report Transmission Transmission when Report Type Code is entered Code when Report Type Code is Code entered Report Type 0 Report Type Code is required when Enter valid Report Type Code Code Report Transmission Code is entered when Report Transmission Code is entered PROMISe Provider Internet User Manual docx S y 2094 173 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field ae Error Message To Correct ode State accident 0 When Accident Ind Auto Y Enter valid Accident State when Accident State is required Accident Ind Auto Y 1 Accident State can only contain Enter alphabetic Accident State alphabetic character s spaces not allowed 2 Accident State must be 2 character s Enter a 2 character Accident in length State Tax ID 0 Tax ID must be numeric Enter a numeric value for Tax ID 1 Tax ID must be 9 digits in length Enter 9 digits for Tax ID Transport 0 Ambulance Transport Distance is a Enter Ambulance Transport Distance required field Enter Ambulance Distance when Ambulance ambulance Transport Distance when Ambulance Transport Code or Ambulance Transport Code or Ambulance Transport Reason Code or Transport Reason Code or Ambula
314. s 123 HOPE RD HARRISBURG PA 17011 Ts Herr Err PROMISe Provider Internet User Manual docx July 3 2014 258 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 36 1 Accessibility and Use To access the ePEAP Active Service Locations window view all service locations associated with a provider ID and review specialties or taxonomy codes associated with a service location complete the steps in the following step action tables To Access the ePEAP Active Service Locations Window Step Action Result Sign on to the PA PROMISe Internet 1 application using instructions provided in Section 2 9 of this manual The Provider Main Page appears on the desktop Click on the ePEAP Provider Enrollment 2 Automation Project link in the Other The ePEAP Menu window opens Links section of the window The ePEAP Active Service Locations 3 Select the Active Service Locations option window opens To View Specialties Associated With a Service Location Step Action Result Click on the View Specialties link for the 1 The following pop up window opens requested Service Location 8 pop up p a Specialty Microsoft Internet Explorer provided by EDS COE SE Specialties for DOGOOD JAMES L Provider ID 300180963 Service Location 0002 Provider Type 31 318 GENERAL PRACTITIONER PROMISe Provider Internet User Manual docx July 3
315. s We appreciate your patience as you may be required to take a few moments to e Learning courses make updates to your user profile Provider Awareness PROMISe Internet f f i e e CMS 1500 08 05 i f IDON q CMS 1500 08 05 Waivers gt A ie t ree VIED UB 04 Outpatient gt a Field Descriptions Field Description Data Type Try Again Returns to the log in page Button Field Edits Field Error Code Error Message To Correct o Error Code Messages found for this window 6 3 Billing Agent No Access Billing Agent No Access The Billing Agent No Access window is displayed upon logging in when a billing agent has web site access but is not authorized for access in association with any providers The user has no other access when this page displays PROMISe Provider Internet User Manual docx July 3 2014 79 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Layout Yow pennsylvania DEPARTMENT OF PUBLIC WELFARE Home Home Provider Login User ID Forgot User ID Register Now Where do I enter my password Broadcast Message PROMISe Internet Monday 08 02 2010 11 10 AM EST This is a test message for training This is addional information You do not have any providers associated with your account at this time You have been logged off and redirected back to the provider welcome page Please contact customer
316. s 144 To Remove Patient Information onssa e E E N leE 144 To Add Other Insurance Information sssssssesseesseesseesseesseesstesstesstessetsstesstessttsseesseesseesseessee 144 To Remove Other Insurance Information essesssssseessesssessseesseesstesstesstresstesstesseessesseesseessee 145 To Add Medicare Information sneren inii E EE EEN A TE E E EA EA 145 To Complete Claim Service Lines Information eeeeseseseeseeseesresresrrsresresresresrrsserrresrereesrene 145 To Submit Claim ne eine E E T EA E EEEE ETE E e 145 To Create New Claim FOLII seccccscccessveiscaeseeecseussvtsazasacd ceestbsaaaiiavedstenssadsnea ect ea Tirant ioo aaas 145 Lo Copy aPaid Clalit vacates adeteees ta hee tied i casteacsrese easel 145 6 10 Switch Provider Number tse 5 ccf eac cect cddee a etal seg te ae ated ak et 145 6 1 0a Accessibility and USC terran cneneee ENEE EEE cbusacs E daen a E E iaa 147 To Access Provider Number Management Window ceecesccssceseceeeeeseeeeneeeseeeaeeeneeenaees 147 To Switch Provider Number cennin inneoin i a ii ais 147 6 11 Provider Pharmacy Claim Pharmacy asp ccsssccssseceeeeceeeeeceeececseeeecseeeeeneeeees 147 6 11 1 Accessibility and Uses citss cnn susan asl ee il ene eee eae ae eats 156 To Access Provider Pharmacy Claim Window scsssccssecssecsseceseceseceseceseeesneeeneeeneeeaaeenaes 156 To Complete Claim Billing Information 20 0 0 cece ceecesceseceeeceseeeeeeesaeeese
317. s enrolled in the Pennsylvania An account created by a Provider for use by an individual Medicaid program as a provider of services within the provider s organization Alternate accounts can be authorized by a provider to bill for more than one 13 digit MPI and Service Location EN i Billing Agent Out of Network A third party individual or entity who is authorized to submit An individual or entity that is authorized to access specific Medicaid transactions on behalf of a Provider functionality within the PROMISe Internet Portal 2 The Registration Personal Information window for alternates displays E pennsylvania DEPARTMENT OF PUBLIC WELFARE Home gt Registration Selector gt Registration Friday 04 23 2010 07 40 AM EST Registration Step 1 of 2 Personal Information Indicates a required field Please provide the following information to get started First Name Last Name Birth Date _ ES UniquePIN Alternate Code 3 Enter first name last name date of birth the unique four digit PIN number created by the provider billing agent or OON provider and the alternate code generated when the provider created the alternate role into the applicable fields PROMISe Provider Internet User Manual docx July 3 2014 27 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 4 Click the
318. scribing Application Demo ePrescribing User Manual On the Provider Home Page click the My Profile link The My Profile window opens PROMISe Provider Internet User Manual docx July 3 2014 38 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation oN pennsylvania DEPARTMENT OF PUBLIC WELFARE My Home gt My Profile Monday 06 21 2010 03 08 PM EST My Profile Back to My Home Name Sample User Current Roles Provider In Network Display Name Sample Name Phone Number 1 717 111 1111 Current Email sample test com Preferences Primary Language English US Challenge Questions Challenge Question 1 What is your mother s maiden name Answer to 1 kli Challenge Question 2 Who was your first employer Answer to 2 kli Challenge Question 3 What is the name of your favorite school teacher Answer to 3 kli Site Key Token Site Key a Passphrase An apple a day Password Users can update contact information challenge questions and site key tokens Clicking the Edit button for each successive section causes a modified version of the My Profile page to display with accessible fields Make changes as necessary and click the Submit button Next the user will be presented with the option to edit the Edit button cancel the Cancel button or finalize the Confirm button the changes made
319. ser ID Register Now The Pennsylvania Medical Assistance EHR Incentive Program is now available If you applied at CMS s EHR Incentive Program Registration and Attestation R amp A website you will see a link to the Medical Assistance Provider Incentive Repository MAPIR after you log on with your PROMISe Internet Portal User ID If you do not have a PROMISe Internet Portal User ID please register by following the Quick Links on the left of this Where do I enter my password page Quick Links Need Help ver iis tO Dovmload the Internet Help Manuals i le i i here i gt 9 Requires Adobe Acrobat ra i we P ae Dovnload the ePrescribing User Manual here Demo of new PROMISe Internet Portal e Learning courses e PA PROMISe Internet a ePrescribe Demo e CMS 1500 08 05 CMS 1500 08 05 Waivers a UB 04 Outpatient ae The Commonwealth of Pennsylvania Department of Public Welfare offers state of the f art technology with PROMISe the claims processing and management information These courses require the Flash player system Please take advantage of online training to use the system to its full advantage Provider Electronic Solutions Software Department of Public Welfare This site requires at minimum Internet Explorer version 6 with 128 bit encryption PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PR
320. seseesseesseessessseresseesseee 253 6 34 1 Accessibility and Use sioaren eee aeta lees tere ap eetarea ete 253 To Access the ePEAP Terminate Medical Assistance Participation Window eee 254 Other Opu ONS enren ae ei aee ae lel eeance O dae iavenche sees EEE ee aee e Ee Ee EA EE 255 Field Descriptions nn eels i aaae dees dea Leanne 255 6 35 ePEAP Manage Remittance Advice 2 45655 silovisosasseareeasa ea qedeeiseasaees seas 256 6 35 Accessibility and Use isicccctesc itn eects Ree ee eae 257 To Access the ePEAP Manage Remittance Advice Window eeceeeeeeeeeeeeeeeeeneeeeeensees 257 To Discontinue Delivery of Paper Remittance Advices 0 cece ceeceseeeeeeeeeeeeeeeneeeneeesaeenaees 257 To Restart Delivery of Paper Remittance AdVIC S 0 ce ceecesceseceseceeeeeseeeeneeeaeeeaeeeaeeeaaeesaees 257 Field De scriptiOnssivets cc y eats teas rie A eel Wei niay Waa a inthe 257 6 36 ePEAP Active S rvice Locatl OM e iisc5 seed cae ell adiwaieesdaMennmneainataded 258 6 36 1 Accessibility anid Uses ccsteccetie Haves eal apelin iinet ee alee ate T 259 To Access the ePEAP Active Service Locations Window ceeeesesseeeeeeeeeeeseeeneeeaeeesaees 259 6 37 ePEAP SelectPlan for Women Directory eececessceceeneeceeeeeceeneeceeneeeneeeeenteeeees 261 6 37 Accessibility and Use sieniin enet Ee eet ee Sud a ieee 262 6 38 ePEAP Verify Provider Membership ccsccssscessccesssccesssssessscsesnecceesascesaeson
321. sis or MM DD CCYY treatment as referenced in the transaction Date of Birth Patient Date of Birth Date 8 MM DD CCYY Date of Death Patient s date of death Date 8 MM DD CCYY Delete Anesthesia Remove existing anesthesia code from claim Button 0 Code Delete Condition Remove existing condition code from claim Button 0 Code Delete Diagnosis Remove existing diagnosis code from claim Button 0 Code Delete Other Remove existing other insurance line from claim Button 0 Insurance Delete Patient Remove existing other insurance line from claim Button 0 Delete Service Remove existing service line adjustment from Button 0 Line Adjustment claim Delete Service Remove existing service line from claim Button 0 Lines Diagnosis Code Diagnosis Code Number 8 Discharge Date Date the patient was discharged Date 8 MM DD CCYY Emergency Indicates if the service was provided as aresult Drop Down List 0 of an emergency Box EPSDT Response code to indicate that this service line is Drop Down List 0 related to EPSDT Box Facility ID Service facility location ID Character 13 Facility Name Service facility location name Character 35 Family Planning Response code to indicate family planning Drop Down List 0 Box First Name First name of the Medicaid recipient Character 25 First Name Patient First name of the patient Character 25 list box First Name First name of the patient Character 25 Patient From DOS Beginning date of service Date 8 MM DD CCY
322. sistance Participation Window Step Action Result 1 Sign on to the PA PROMISe Internet The Provider Main Page appears on the application using instructions provided in desktop Section 2 9 of this manual 2 Click on the ePEAP Provider Enrollment The ePEAP Menu window opens Automation Project link in the Other Links section of the window 3 Select the Terminate MA Enrollment The ePEAP Terminate Medical Assistance option PROMISe Provider Internet User Manual docx 254 Participation window opens July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Terminate Your Participation as a MA Provider at this Service Location Step Action Result 1 Select an Effective End Date month day and year from the drop down box 2 Click the Continue button The Review Your Changes window opens to verify your request 3 Click the Cancel button This enrollment termination process will be ended and will not complete 4 Click the Continue To Make Changes Opens the ePEAP Menu button to make additional changes 3 Click the Cancel All Changes button to The message This request has been cancel all changes cancelled is displayed Click the Continue button to return to the ePEAP menu window 6 Click the Submit Changes button to submit Request for MA enrollment termination is the changes submitted Other Optio
323. sponse 1 In the DUR PPS section in the Reason for Service Service Code and Result of Code drop down lists select a value To Complete Clinical Information Step Action Response 1 In the Clinical section type up to 3 values in the Diagnosis Code field s PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Complete COB Information Step Action Response 1 In the COB section type up to 3 values in the Diagnosis Code field s To Submit Claim Step Action Response 1 Click the Submit button The claim is submitted To Bill for Compound Drugs Step Action Response 1 Complete the steps as shown above In the The Compound header box is Compound Indicator drop down lists select 2 added at the bottom of the window Compound 2 In the Dosage Form Dosage Route and Dispensing Unit drop down lists select a value 3 The ingredients box is auto filled from data typed in the previous NDC field To add additional NDCs click the Add button 4 Type a value in the NDC ID Ingredient Quantity If additional NDCs are required and Ingredient Cost fields click the Add button and repeat step 4 as needed 5 In the Basis of Cost Determination drop down list select a value 6 Click the Submit button The claim is submitted To Copy a Paid Claim Note The C
324. ss Provider Institutional Claim Window ccccccsssssssssssssesssssssssssssssesssesseseseeeseees 142 To Complete Claim Billing Information s eesseseeeseeeseseseessesreeresressesrtsserrisseesrssrenresressesreseeee 143 To Complete Claim Service Information eee cssecssecsseceseceseceseeeseeeseeeeneesaeeeaeeeneeenaeenaees 143 To Complete Admission Discharge Information ccc cesceseceseeeseeeeeeeeeeeeeeeeseeeneeenaeenaees 143 To Complete Claim Diagnosis Information cece eeseceseceseceseceseceeeeeseesseeesaeeeseeeneeesaeesaees 143 To Add Claim Surgical Code Date Information ce ceecesceseceseceseeeeeeeeneeeneesseeeseeenaeenaees 143 To Add Occurrence Code Date Information 0 cccccessesssessesssesssssssssssssssssssesssssssessseeeeees 144 To Add Occurrence Span Code Information 0 0 0 ce cesceseceseceseceeeceseeeeeeeeeeeeaeeeaeeeaeeeaaeesaees 144 To Add Condition Code Information ccccccesssesssssssssssssssssssssssssssssssssessssseesssssseseseseneees 144 To Add Value Code Amount Information 0 ccccccccesssssssssessesesssssssssssssessessssssesssssssseseeees 144 To Add Days Information s acuesiai eset ee a eee a ete ee 144 PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Add Patient Information Newborn Only 0 ce ceeceesseceseeeceeeeecsaeceeaeeceeneeceeeeeaeceeaeeceeee
325. ssage should appear v User Successfully Registered You have successfully registered as a provider for the PROMISe Internet Portal A confirmation email containing your login information has been sent to the email address provided Email notifications can take 15 to 30 minutes to be delivered 2 4 About Alternates An alternate is an account created by a Provider for use by an individual within the provider s organization Alternate accounts can be authorized by a provider to bill for more than one 13 digit MPI and Service Location The alternate is responsible for ensuring patient privacy information accessed via this Web site is used only for legitimate business reasons Important Note After creating a new alternate account the provider OON provider and billing agent must supply the alternate with the unique four digit PIN and five digit Alternate Code generated during the alternate account creation process The alternate needs these codes in order to register in the PROMISe Provider Portal 2 4 1 Creating an Alternate Providers OON providers and billing agents can create alternates Follow the steps below to assign an alternate to your account These steps are identical for providers OON providers and billing agents 1 On the Provider My Home Page click the Manage Alternates link to open the Manage Accounts window PROMISe Provider Internet User Manual docx July 3 2014 21 Provider Inter
326. st 0 as required by the payer organization Press the Box underlined Add link to add another Value Code 5010 values are e 80 Covered Days e 81 Non Covered Days e 82 Coinsurance Days e 83 Lifetime Reserves Value Code 8 Eighth code and description of monetary data Drop Down List 0 as required by the payer organization Press the Box underlined Add link to add another Value Code 5010 values are e 80 Covered Days e 81 Non Covered Days e 82 Coinsurance Days e 83 Lifetime Reserves Value Code 9 Ninth code and description of monetary data as Drop Down List 0 required by the payer organization Press the Box underlined Add link to add another Value Code 5010 values are e 80 Covered Days e 81 Non Covered Days e 82 Coinsurance Days e 83 Lifetime Reserves PROMISe Provider Internet User Manual docx July 3 2014 126 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Value Code 10 Tenth code and description of monetary data as Drop Down List 0 required by the payer organization Press the Box underlined Add link to add another Value Code 5010 values are e 80 Covered Days e 81 Non Covered Days e 82 Coinsurance Days e 83 Lifetime Reserves Value Code 11 Eleventh code and description of monetary Drop Down List 0 data as required by the payer organization Box Press the underlined Add link to add anothe
327. stment Group Code 8 In the Adjustment 1 row select a value 9 Enter the amount of the adjustment for this claim in the Amount box at the end of the Adjustment 1 row 10 Select a value from the Carrier Code drop down box 11 To add another adjustment to this claim click the Add Adjustment button to activate the Adjustment 2 row Repeat Steps 7 through 10 in the Adjustment 2 row Up to eleven additional adjustments can be added 12 Click the Submit button The adjustment s for this claim is are submitted 4 3 Recipient Eligibility Verification You can use the Recipient Eligibility Verification window to perform inquiries about PA PROMISe recipient data You can make inquiries based on the following information e Recipient ID and Card Issuance Number e Recipient ID Date of Birth e Social Security Number Date of Birth e Recipient Name Date of Birth You must enter a single date or range of up to 31 days to limit the search results A procedure drug code or modifier may optionally be provided When you provide the drug or service EVS returns information on the recipient s eligibility to receive the drug or service This feature is supported only for fee for service recipients The first window Layout below shows the initial viewable display the following Layouts show the remaining data viewable by scrolling PROMISe Provider Internet User Manual docx July 3 2014 72 PROMISe Internet Portal Provider Int
328. swer for each of the question groups below Challenge Question 1 what is your mother s maiden name v Answer to 1 Challenge Question 2 l Who was your first employer v Answer to 2 Challenge Question 3 What is the name of your favorite school teacher v Answer to 3 User Agreement By checking the box provided below and transmitting this form electronically I state I am the person whom I represent myself to be herein and I affirm the information within this web application is complete and accurate and made subject to the penalties of 18 Pa C S 4904 relating to unsworn falsification to authorities In addition I acknowledge that misstating my identity or assuming the identity of another person may subject me to misdemeanor or felony criminal penalties for identity theft pursuant to 18 Pa C S 4120 or other sections of the Pennsylvania Crimes Code By entering my full name in the space provided below and transmitting this form electronically I state that I am the person whom I represent myself to be herein and I acknowledge that I have read and understand the User Agreement and agree to the terms and conditions as described about the role that I will perform Please sign by typing your full name here PROMISe Provider Internet User Manual docx July 3 2014 11 Provider Internet User Manual PROMISe Internet Portal PA PROMISe Syst
329. t Other Accident or Auto Accident when Accident Enter alphanumeric Diagnosis Codes Diagnosis code cannot be less than 3 Enter at least a 3 character characters in length Diagnosis Codes Discharge Date must be greater than or Enter a Discharge Date greater equal to Admission Date than or equal to Admission Date July 3 2014 171 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field ae Error Message To Correct ode Employment 0 When Accident Date is entered a Select a related cause accident related cause Employment Other Employment Other Accident or Accident or Auto Accident must be Auto Accident when Accident chosen Date is entered First Name 0 First name for Patient is a required Enter valid First Name patient field 1 First name for Patient can only Enter alphanumeric First Name contain Alphanumeric character s Last Name 0 Last name for Patient is a required Enter valid Last Name patient field 1 Last name for Patient can only Enter alphanumeric Last Name contain Alphanumeric character s Middle Initial 0 Middle name for Patient can only Enter alphanumeric Middle patient contain Alphanumeric character s Initial 1 Newborn Maternity Care Indicator Select Yes for must be Yes when submitting Patient Newborn Maternity Care Information Indicator when submitting Patient Information NPI Facility 0 NPI must be 10 digits Enter a 10 digit NPI NPI
330. t User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Release of Medical Indicates whether the provider has informed Drop Down List 0 Data consent to release medical info For conditions Box Release of Medical Data Other Insurance Rendering Provider ID Report Transmission Code Report Type Code or diagnosis regulated by federal status or a signed statement on file to permit the release of medical data to other organizations Valid Values are e I Informed Consent to Release Medical Info For conditions or diagnoses regulated by Federal Statutes e Y Yes the provider has a signed statement permitting the release of medical billing data related to a claim Indicates whether the provider has informed Drop Down List 0 consent to release medical info For conditions Box or diagnosis regulated by federal status or a signed statement on file to permit the release of medical data to other organizations Valid Values are e I Informed Consent to Release Medical Info For conditions or diagnoses regulated by Federal Statutes e Y Yes the provider has a signed statement permitting the release of medical billing data related to a claim Number of the provider who performed the Character 13 service Timing transmission method or format by Drop Down List 0 which reports are to be sent Box Title or contents of a document report or Drop Down List 0 supporting item Box
331. t Version Service Lines Copy Description Other insurance carrier Other insurance carrier Service line adjustment carrier Service line adjustment carrier Carrier name of other insurance carrier Type of claim Data Type Character Drop Down List Box Character Drop Down List Box Character Drop Down List Box Specifies the frequency of the claim to identify if Drop Down List it is original an adjustment or voided ICD type for this claim Comment Condition Code Specific contract established by the payer Specific contract established by the payer Contract type Contract type Additional or supplemental contract provisions or a particular version of modification of contract Additional or supplemental contract provisions or a particular version of modification of contract Copies a paid claim s data to a new unprocessed claim Country Accident Country in which the automobile accident occurred PROMISe Provider Internet User Manual docx 164 Box Drop Down List Box Character Character Character Character Drop Down List Box Drop Down List Box Character Character Button Character Length 3 14 20 14 30 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Date Accident Date of the accident related to charges the Date 8 patient s current condition diagno
332. t by the system during a selected time period From this list you can select a date from which to download and view an individual RA in Adobe Acrobat PDF format Note The Provider Report Index window does not display reports created prior to the inception of PROMISe Layout Ey pennsylvania DEPARTMENT OF PUBLIC WELFARE PROMIS e Internet aC OCS ar C Reports Meenas eee Mes O LE a a E Reports Friday 11 11 2011 01 38 PM EST Provider ID 123456789 Location 0001 You have selected to request output from the following report Enter a date range to view your organization s information from FIN 0000 W NOTES You may not view more than 90 days of reports at one time List Reports From 03 01 2010 ca Required To 05 01 2010 Eg Required Request Reports Weekly Remittance Advice Reports generated between Monday March 1 2010 and Saturday May 1 2010 03 08 2010 03 27 2010 04 01 2010 For detailed information about this window see Section 5 18 Provider Report Index window PROMISe Provider Internet User Manual docx July 3 2014 75 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 PA PROMISe Internet Windows This section of the Provider Internet User Manual contains detailed information regarding the windows within the PA PROMISe Internet application to help users better understand how each window is used Windows presented in this se
333. t supplies additional information on the procedure code Click to add a new claim NPI for Billing Provider ID PROMISe Provider Internet User Manual docx 166 Data Type Date MM DD CCYY Drop Down List Box Character Character Character Character Drop Down List Box Character Character Character Number Character Character Character Character Character Character Character Button Character Length 8 14 14 17 17 35 35 35 10 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length NPI Facility NPI for Facility ID Character 10 Note Not enabled until a 7 or 8 digit ID is entered in the Facility ID field If Facility ID is entered this field is required NPI Referring NPI for Referring Provider ID Character 10 Provider Note Not enabled until a 7 or 8 digit ID is entered in the Referring Provider ID field If Referring Provider ID is entered this field is required NPI Rendering NPI for Rendering Provider ID Character 10 Provider Note Not enabled until a 7 or 8 digit ID is entered in the Rendering Provider ID field If Rendering Provider ID is entered this field is required Ol Number assigned to each other insurance detail Number 2 line Original Claim Original claim number for the claim Required Character 13 when the claim frequency code is a number other than one
334. t the date to terminate the fee assignment 3 Review your Pay to Address and change if needed Active Fee Assignments Group ID Sve Loc Group Name Begin Date End Date 001155484 0006 MANRIQUE SHROFF ASSOC 04 16 2007 12 31 2299 PROMISe Provider Internet User Manual docx July 3 2014 237 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 6 30 1 Accessibility and Use To access the ePEAP Manage Fee Assignment window and terminate an active fee assignment complete the steps in the step action table s To Access the Manage Fee Assignment Window Step Action Result 1 Sign on to the PA PROMISe Internet application using instructions provided in Section 2 9 of this manual The Provider Main Page appears on the desktop 2 Click on the ePEAP Provider Enrollment The ePEAP Menu window opens Automation Project link in the Other Links section of the window 3 Select the Enrollment Information option The ePEAP Enrollment Information window opens 4 Click the Fee Assignment Information The ePEAP Fee Assignment Information link window opens 5 Click the Manage Fee Assignments link The ePEAP Manage Fee Assignments window opens Terminate a Fee Assignment Step Action Result 1 Click the Select link next to the fee assignment to be terminated from the list in the Active Groups box The window expands to include fields in
335. te 00 00 0000 Unique PIN 9876 a c No alternates are assigned to you 5 To change the information displayed click the Edit button To cancel the request click the Cancel button To confirm the request click the Confirm button 6 A confirmation message will appear v Alternate Assignment The alternate has been added to your alternate list The alternate code for the new alternate is 00000 The alternate code is required to be communicated to the new alternate for registering with the portal PROMISe Provider Internet User Manual docx July 3 2014 23 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 7 Click the OK button The Manage Alternates screen appears again however a Delegates sub window appears at the bottom listing the alternate s name birth date unique PIN alternate code and status r pennsylvania DEPARTMENT OF PUBLIC WELFARE My Home gt Manage Alternates Thursday 04 22 2010 01 03 PM EST Alternate Assignment Back to My Home Add New Alternate Add Registered Alternate Indicates a required field Enter the fields below and click Submit to generate the alternate code for the new alternate to register First Name Last Name Birth Date E Unique PIN Delegates Click the Alternate s name to change the status of the alternate Name a Birth Date
336. te is changed 2 To change the Gender select a new value The gender information is changed from the corresponding drop down list 3 To change the Medical Degree The medical degree information is information select a new value from the changed corresponding drop down list 4 For Service Locations having a validated The Medicare Indicator for Medicare NPI number the Medicare Indicator may crossover claims is associated with the be associated with the Service Location or current Service Location or removed from removed from it by clicking on the check it as requested box in the Medicare Indicator Information display Note Medicare numbers can no longer be updated via ePEAP Beginning May 23 2008 NPI numbers will be used to process Medicare carrier crossover claims instead of Medicare numbers 5 Click the Continue button to review any The Review Your Changes window opens changes Click the Continue To Make Changes button to return to the Enrollment Information window PROMISe Provider Internet User Manual docx 212 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Other Options Step Action Result 1 Click the Cancel button to cancel all The update is cancelled and the Enrollment changes and restore the original Information window opens information 2 Click the Reset button to reset the New infor
337. ted in the United States and or other countries Field Descriptions Data Field Description Length ies peta Type oe Report Below the each report name is a description of the report Character 250 Pe a Report Reports are collected in to one or more Grouping This field Character 50 Grouping displays the name of each report grouping available to the Report Name Within each report grouping the report name is displayed as a Hyperlink 150 hyperlink for the user to select Selecting the hyperlink takes the user to the Provider Report Request window PROMISe Provider Internet User Manual docx July 3 2014 197 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Edits Field Error Code Error Message To Correct No Error Code Messages found for this window 6 17 1 Accessibility and Use To access and use the Provider Report Index window complete the steps in the step action table s To Access Provider Report Index Window Step Action Response 1 Logon to PA PROMISe using the steps presented in The Provider Main Page the General User Manual window opens 2 Click the Reports tab The Provider Report Index window opens To View Provider Reports Step Action Response 1 Click the hyperlink for the desired report The Provider Report Request window opens 6 18 Provider Report Request Pr
338. ter 20 First Name First name of the Medicaid recipient Character 25 First Name Patient First name of the patient Character 25 From Date Earliest beginning date for service lines Date 8 MM DD CCYY From DOS Earliest beginning date of service found on the Date 8 claim MM DD CCYY PROMISe Provider Internet User Manual docxsss i s sSS y 2094 117 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Full Medicare Days Gender Gross Patient Pay Group Name Other Insurance List Box Group Name Other Insurance Group Number Other Insurance List Box Group Number Other Insurance Individual Relationship Last Name Last Name Patient Lifetime Reserve Days Medical Record Medicare Approved Amount Medicare Coinsurance Days Middle Initial Middle Initial Patient Modifier 1 Modifier 2 Modifier 3 Modifier 4 New Description Number of full Medicare days Gender of the patient Amount of patient responsibility for payment prior to other deductions Group name of other insurance carrier Group name of other insurance carrier Group number of other insurance carrier Group number of other insurance carrier Patient s relationship to the policyholder Last name of the Medicaid recipient Last name of the patient Number of Lifetime Reserve days Number assigned to the patient by the provider This number is used by the provid
339. tes whether or not user s Character service location is authorized to update enrollment information through ePEAP Possible values Full Access or Read Only ePEAP Menu Returns to the ePEAP Menu Button 0 6 41 ePEAP Upload Attestation Form Section 1202 of the Patient Protection and Affordable Care Act Pub L 111 148 as amended by the Health Care and Education Reconciliation Act of 2010 Pub L 111 152 collectively the ACA and the implementing regulations require state Medicaid programs to pay increased fees for certain primary care services to qualifying physicians that are no less than the Medicare rates in effect in Calendar Year CY 2013 and 2014 You may view the federal implementing regulation by accessing the following website link http www gpo gov fdsys pkg FR 2012 11 06 pdf 2012 26507 pdf To qualify for the increased fees among other things you must complete and submit a signed Attestation Form in which you self attest to a specialty or subspecialty designation of family medicine general internal medicine or pediatric medicine recognized by the American Board of Physician Specialties ABPS the American Board of Medical Specialties ABMS or the American Osteopathic Association AOA and that a You are board certified with a specialty or subspecialty of family medicine general internal medicine or pediatric medicine or a subspecialty recognized by the ABMS the ABPS or the AOA or b
340. the Continue button The Review Your Changes window opens 4 Review the entered information If ready to The Contact Information window process click Submit Changes opens 5 Complete the requested contact information The following confirmation window fields Name Phone and E Mail are required is displayed fields Click Submit PROMISe Provider Internet User Manual docx July 3 2014 242 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Step Action Result fa TY E ENNY ELANLA Wellare PEAP Yom Provider ID 300180563 DOGOOD JAMES L Stams Acma Peodimg NPI 1234567683 View Taxonomy e PEAP Access Ful Access Service Location con 123 HOPE RD HARRISBURG PA 17011 Provides Type 31 PHYSICIAN Mew Spociatiea Changes Are Complete Your prowder information has been updated as you requested Ifyou vesh to vwaw your request agan please select Racert Requests from the ePEAP Meru ching Number for s Reques 190 564324 Thank you for using ePEAP Notice when Associating an NPI with your Service Location Itwill be nec fonwerd the NPI documentation received from NPPES in order to vabdate the NPI number just entered The documentation must de mailed to the following address Bureau of FeeFor Service Programs Division of Operations Provider Enrollment Section PO BOX 8045 Harrisburg PA 17105 6045 Until your NPI number validation from NPPE
341. the Diagnosis section in the Code Type drop down list select code type 1 from drop down 2 Select Add to open a diagnosis field 3 Enter diagnosis in diagnosis field To Complete Claim Accident Information Step Action Response 1 In the Accident section in the Employment Related Other and Auto drop down lists select a value 2 Type a value in the Date State and Country fields To Add Claim Other Insurance Information Step Action Response 1 In the Other Insurance section click the Add button 2 In the Other Insurance 1 section type a value in the Group Number Group Name Carrier Code Carrier Name Policy Holder ID Code Policy Holder Last Name and Policy Holder First Name fields 3 In the Release of Medical Data Benefit Assignment and Claim Filing Code drop down lists select a value To Remove Other Insurance Information Step Action Response 1 In the Other Insurance section click the Remove button To Add Claim Service Lines Information Step Action Response 1 In the Service Lines section click the Add button PROMISe Provider Internet User Manual docx July 3 2014 108 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Step Action Response 2 In the Service Line 1 section type a value in the Date of Service field 3 In the Place of
342. the service location information of the service location you log into the portal with This information cannot be updated All subsequent service location entries must be submitted by the provider and then confirmed by the system Each new row begins with a minus sign that the user may click to remove the row from the application form The maximum number of service locations that may be added is 100 The first time a user clicks this link on a new application a pop up message appears to caution the user about adding service locations ex OOOO WE WARNING Please be advised that each location entered will be enrolled for EFT Please confirm all service locations listed are accurate prior to submission 10 The Other Identifiers Section znd PA PROMISe EDI Unit will be auto Assigning Authority field represents filled in this field The user may not PA PROMISe EDI Unit update this information via the ERA Enrollment Application window 11 The Other Identifiers Section This information is auto filled from the Trading Partner ID field represents data available in PROMISe The user the 9 digit Submitter ID number for must enter the 9 digit Submitter ID for ANSI X12 Transactions ANSI X12 Transactions if the information does not auto fill from PROMISe 12 The Provider Contact Information The Provider Contact Name field is a Section Provider Contact Name field represents the nam
343. tion of service Alpha numeric 10 Code Postal Code location s pay to address Full 9 digit zip code with a dash inserted between first 5 and last 4 numbers Provider Identifier Information Provider Identifiers Tax ID of provider legal entity Numeric 9 Provider Federal Tax Identification Number or Employer Identification Number Only the last 4 digits of the Tax ID will be displayed the other digits will be masked Provider Identifiers National Provider Identifier Numeric 10 National Provider assigned to the service location Identifier NPI Other Identifiers PA PROMISe Alpha 10 Assigning Authority PA PROMISe Other Identifiers 13 digit PROMISe Provider ID Numeric 9 4 Trading Partner ID selected for the Portal user PA PROMISe Formatted as 9 digit MPI and 4 digit Service Location Code Other Identifiers Adds a new row for Trading Link N A Trading Partner ID Partner ID 9 digit MPI is auto PA PROMISe filled the same as the first row Y Add New Service and may not be updated Location 4 digit Service Location is initially blank and must be updated by the user An automatic edit will verify that the user entered Service Location is an active service location for the submitting provider legal entity Each new row begins with a minus sign that the user may click to remove the row from the form PROMISe Provider Internet User Manual
344. tion of the window Select the Enrollment Information option The ePEAP Enrollment Information window opens Click the Manage NPI Taxonomy link The ePEAP Manage NPI and Taxonomy Codes window opens PROMISe Provider Internet User Manual docx July 3 2014 241 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Add an NPI National Provider Identifier Code Available only if an NPI Code has not been previously associated with a provider and service location combination Once you have associated an NPI number with your Provider ID and Service Location it cannot be updated or removed via ePEAP Instead you must mail a written request to DPW with supporting documentation for review Step Action Result l Enter a valid NPI number in the Manage NPI and Taxonomy Codes window Note If an NPI number has already been added the NPI field will be read only and not accessible 2 Click the applicable check box es to select one or more taxonomy codes This window will only display the taxonomies valid for the registered Provider Type and Specialty combination If the taxonomy related to your provider type specialty does not appear contact Provider Enrollment via email at PROMISe state pa us with a subject line Taxonomy Discrepancy to verify the provider type and specialty codes associated with this service location 3 Click
345. tion window if appropriate 6 In the Provider Identifiers Section This information is auto filled from the Provider Federal Tax Identification data available in PROMISe The user Number TIN or Employer may not update this information via the Identification Number EIN field EFT Enrollment Application window if the Tax ID of the provider legal entity appropriate Note Only the last 4 digits of the Tax ID will be displayed the other digits will be masked 7 In the Provider Identifiers Section This information is auto filled from the National Provider Identifier NPI field the Federally assigned 10 digit number for the Assigned service location PROMISe Provider Internet User Manual docx 48 data available in PROMISe The user may not update this information via the EFT Enrollment Application window if appropriate July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation 8 In the Other Identifiers Section Assigning Authority field PA PROMISe PA PROMISe will be auto filled in this field The user may not update this information via the EFT Enrollment Application window 10 In the Other Identifiers Section Trading Partner ID field s the provider s assigned 9 digit Medical Assistance ID number will be auto filled The 4 digit Service Location is initially blank In the Provider Contact Information Secti
346. ts list is displayed 6 Click the claim link The detailed claim is displayed To Search for A Fee for Service Claim by Patient Account Number Step Action Response 1 Type a value in the Patient Account field 2 In the Claim Status drop down list select a value 3 In the Date of Service section enter a value in the From Date field 4 In the Date of Service section enter a value in the Thru Date field 5 Click the Submit button If a match is found the search results list is displayed 6 Click the claim link The detailed claim is displayed PROMISe Provider Internet User Manual docx S uyg 2014 89 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Search for A Fee for Service Claim by ICN Step Action Response 1 Type a value in the ICN field 2 In the Claim Status drop down list select a value 3 In the Date of Service section enter a value in the From Date field 4 In the Date of Service section enter a value in the Thru Date field 6 Click the Submit button If a match is found the search results list is displayed 7 Click the claim link The detailed claim is displayed To View Next Fee for Service Claim Step Action Response 1 Complete a claim search If a match is found the search results list is displayed 2 Click the Next button The next claim is displayed 3 Click the associated ICN link to view the The detailed claim is displayed desired
347. tton to submit the form electronically If all required information is present you will be able to gain access to the PA PROMISe Web application The following confirmation message should appear PROMISe Provider Internet User Manual docx July 3 2014 16 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation v User Successfully Registered You have successfully registered as a provider for the PROMISe Internet Portal A confirmation email containing your login information has been sent to the email address provided Email notifications can take 15 to 30 minutes to be delivered 2 3 Process for Registering and Obtaining a Password OON Providers An OON provider is defined as an out of network business entity that is enrolled in the Healthcare program as a provider of services To register as an OON provider click the Register Now link on the PROMISe Welcome Page 1 The Registration Selector window displays Yoo ennsylvania ahead blerratne PROMISe Internet Home gt Registration Selector Thursday 07 22 2010 07 58 AM EST Registration Select one of the following options that best describes your role EA 98 Provider Alternate An individual or entity that is enrolled in the Pennsylvania An account created by a Provider for use by an individual Medicaid program as a provider of services within the provider s organization Altern
348. ture PROMISe Portal User ID of Alpha numeric 50 Electronic Signature of PROMISe Provider Internet User Manual docx July 3 2014 55 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Description Data Type Length Person Submitting person submitting enrollment Enrollment Printed Name of Person Name of the submitter Alpha numeric 50 Submitting Enrollment Printed Title of Person Title of the submitter Alpha numeric 50 Submitting Enrollment Submission Date The date on which the enrollment Numeric 8 is submitted Auto filled with current date Format CCY YMMDD Requested EFT Date on which the requested Numeric 8 Start Change Cancel action is to begin Date Auto filled with current date User may not specify a past date Format CCY YMMDD Submit EFT Enrollment Opens EFT Agreement Window Button N A Form Cancel Discards any data entered and Button N A returns user to the EFT and ERA Enrollment Window 3 3 Electronic Remittance Advice ERA Enrollment Application Window This window allows registered PROMISe provider service locations to enroll for Electronic Remittance Advice ERA delivered as ANSI X12 835 This window is accessed from the PA PROMISe Internet Provider My Home Page and clicking on the EFT and ERA Enrollment menu option in the menu bar and then clicking the ERA Enrollment Request button PROMISe Provider
349. uccessor codes and or the toxoid vaccine product codes currently used by the MA Program for purposes of vaccine administration payment found on page 01 of the instructions for this form CURRENT PA MA PHYSICIAN PROVIDERS enrolled for at least 1 full calendar year attest that am an eligible primary care physician or subspecialist but do not have a certification recognized by the ABMS ABPS or AOA I attest that at least 60 of the procedure codes billed to Mevicaid in the previous calendar year as of the signature date of this attestation form were for the E amp M vaccine administration and or vaccine product codes as set forth above oe ne T ee E PA MA PHYSICIAN PROVIDERS enrolled 1 full calendar month or more but less than the full previous calendar year more than 31 days billing history and enrolled in the previous calendar year attest that am an eligible primary care physician or subspecialist but do not have a certification recognized by the ABMS ABPS bys attest that at least 60 of the procedure codes billed to Medicaid in the prior calendar year s billings as of the signature date of this attestation form through the current CY month were for the E amp M vaccine administration and or vaccine product codes as set forth above attest that the information submitted in this attestation is true and accurate understand that any false statements made herein are subject to the penalties contained in 18 PA C S 4904
350. uency of benefit Information about the number and frequency of benefit Information about the number and frequency of benefit Information about the number and frequency of benefit Type of quantity of benefit Quantity of benefit Used to remove Service Type Location from Selected list Data Type Character Character Character Character Character Character Number Button Used to add Service Type Location to Selected Button list Last date of eligibility for the given eligibility Date detail segment The eligibility end date is not returned by EVS if it falls outside the range of dates specified on the EVS request End date of the eligibility or period for the summary line Only provided when the value is within the range of dates supplied on the request Any errors returned in processing details Recipient s first name used to search by name Recipient s gender Group number associated with this other or additional payer eligibility detail line Indicates if benefits are in or out of Plan Network or not HIPAA code value expanded here with a description that identifies the type of insurance described in this eligibility detail Recipient s last name used to search by name PROMISe Provider Internet User Manual docx 191 MM DD CCYY Date MM DD CCYY Character Character Character Character Character Character Character Length 0 10 10 999 25 30 150 35
351. und by this signature NOTICE Anyone who misrepresents or falsifies essential information to receive payment utilizing this form may upon conviction be subject to fine and or imprisonment under applicable State and or Federal laws The EFT Agreement displays the terms and conditions for EFT enrollment and allows the user to accept or decline the terms 1 Click the ACCEPT option to submit The Electronic Funds Transfer EFT data the EFT Enrollment data is added to the PROMISe database for review and processing 2 Click the Decline option The user will be returned to the EFT Enrollment Application window Field Descriptions Field Description Data Type Length Provider Information Provider Name Name associated with the service Alpha numeric 50 location s pay to address Provider Address Street address lines 1 and 2 of the Alpha numeric 50 Street service location s pay to address Provider Address City City portion of service location s Alpha numeric 18 pay to address Provider Address State portion of service location s Alpha 2 State Province pay to address 2 character postal PROMISe Provider Internet User Manual docx July 3 2014 52 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length abbreviation code Provider Address Zip Zip code por
352. updated by the user An automatic edit will verify that the user entered Service Location is an active service location for the submitting provider legal entity Each new row begins with a minus sign that the user may click to remove the row from the form The maximum number of service locations that may be added is 100 The first time the user clicks this link on a new application a pop up message will appear to caution the user about adding service locations DPW will provide the wording for this pop up message Other Identifiers PA PROMISe EDI Unit Alpha 19 Assigning Authority PA PROMISe EDI Unit Other Identifiers Trading 9 digit Submitter ID for ANSI Numeric 9 Partner ID PA X12 Transactions PROMISe EDI Unit Provider Contact Information Provider Contact Name Name of contact in provider Alpha numeric 50 Contact office for handling ERA issues Provider Contact Name Phone number of contact Numeric 10 Telephone Number person PROMISe Provider Internet User Manual docx July 3 2014 65 PROMISe Internet Portal Provider Internet User Manual PA PROMISe System Documentation Field Description Data Type Length Provider Contact Name Phone number extension of Numeric 4 Telephone Number contact person Extension Provider Contact Name Email Address of contact Alpha numeric 50 Email Address person Electronic Remittance Advice Informat
353. urance Delete Service Deletes the service lines Button 0 Line list Diagnosis Code Diagnosis Code Character 8 Diagnosis Pointer Diagnosis Pointer Character 1 Discharge Date Date recipient was discharged Date 8 MM DD CCYY Emergency Indicates whether the service was provided on an Drop Down List 0 emergency basis Box Facility ID Service facility location ID Character 9 Facility Name Service facility location name Character 35 First Name First name of the Medicaid recipient Character 25 Group Name Group name of other insurance carrier This field Character 14 Other Insurance is auto populated by the value entered in the list Group Name field below Group Name Group name of other insurance carrier Character 14 Other Insurance Group Number Group number of other insurance carrier This Character 17 Other Insurance field is auto populated by the value entered in the list Group Number field below Group Number Group number of other insurance carrier Character 17 Other Insurance PROMISe Provider Internet User Manual docx July 3 2014 96 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Description Data Type Length Individual Patient s relationship to policy holder Drop Down List 0 Relationship Valid Values are Box e 01 Spouse e 18 Self e 19 Child e 20 Employee e 21 Unknown e 39 Organ Donor e 40 Cadaver Donor e 53 Life Partner e G8 Other
354. user accounts for others alternates in their organization e Review the status of claims submitted to DPW for payment and review specific Error Status Codes ESC and HIPAA Adjustment Reason Codes for rejected claims PROMISe Provider Internet User Manual docx July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Submit claims for payment or adjustments for services and prescriptions directly through the secure Web site s Claims Menu or search for prescriber ID numbers Pharmacy claims are automatically reviewed for ProDUR Prospective Drug Utilization Review alerts and overrides at the time of entry and corrections can be made before final submission Assuming successful completion of a claim submission the total allowed amount of the claim and any adjustment information will be displayed to the submitting provider This prompt response to a claim s submission significantly reduces the time required for providers to submit properly completed claims and allows faster processing Review information for eligibility limitation information ePEAP and provider information from the Provider My Home Page Verify the eligibility status of recipients Inquiries can be made by Recipient ID SSN Date of Birth or Recipient Name Date of Birth Download MA Program Outpatient Fee Schedules from the Provider My Home Page Providers can download or review Provider manuals claim forms etc
355. ut 0 SSN must be 9 characters Enter a numeric 9 character Social Security Number 1 SSN must be a number Enter a numeric 9 character Social Security Number To Input 0 To Date of Service is an invalid Enter a valid date date x PROMISe Provider Internet User Manual docx a yB 2094 194 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field maa Error Message To Correct 1 Please Enter Date of Service Enter a valid Date of Service 2 value is an invalid month of the Enter a valid month year Use a value in the range of 1 12 3 value is a not a valid day in Enter a valid day of the month Use a value in the range month of 1 31 6 16 1 Accessibility and Use To access and use the Provider Recipient Eligibility Verification window complete the steps in the step action table s To Access Provider Recipient Eligibility Verification Window Step Action Response 1 Logon to PA PROMISe using the steps The Provider Main Page window presented in the General User Manual opens 2 Click the Eligibility Verification link The Provider Recipient Eligibility Verification window opens To Search by Recipient ID and Card Number Step Action Response 1 Type a value in the Recipient ID and Card Number fields 2 In the Date of Service From and To drop down lists select a value Optional In the Procedure Drug Type drop d
356. value in the From Date field 4 In the Date of Service section enter a value in the Thru Date field 5 Click the Submit button 6 Click the claim link To View Recipient Eligibility If a match is found the search results list is displayed The detailed claim is displayed Step Action Response 1 Complete a claim search If a match is found the search results list is displayed 2 Click the Recipient ID link The Recipient Eligibility Verification window opens and displays information for the requested Recipient ID To Submit a Claim Adjustment Step Response 1 Type a value in the Recipient ID field or ICN or Patient Account fields 2 Select a value from the Claim Status drop down box 3 If the date of service is known enter values in the From Date and Thru Date fields 4 Press the Submit button 5 Click on the ICN link for which an adjustment is to be made 6 Scroll down the claim window to the Service Adjustments for Service Line 1 group 7 In the Adjustment 1 row select a value PROMISe Provider Internet User Manual docx 71 Claim records that match the search criteria are displayed in the lower portion of the window Note that all ICNs and Recipient IDs are hyperlinked The original claim is displayed July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Step Action Response from the Adju
357. ve successfully logged into the Provider Internet Application and accessed the ePEAP Menu you can access each sub application as explained in this section The following documentation describes how to navigate to the various parts of the ePEAP system By clicking on the following links in the Provider Options box the windows described below are accessed Enrollment Information ePEAP Enrollment Information window Recent Requests ePEAP Recent Requests window Terminate MA Enrollment ePEAP Terminate Medical Assistance Participation window Manage Remittance Advice ePEAP Manage Remittance window Active Service Locations Active Service Locations window SelectPlan for Women Directory ePEAP SelectPlan for Women Directory window Upload PDF Upload PDF window By clicking on the following links in the For Groups Only box the windows described below are accessed Verify Provider Membership ePEAP Verify Provider Membership In My Group window View Provider Group Members Pop up window listing the provider s group members PROMISe Provider Internet User Manual docx July 3 2014 202 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Please note The For Groups Only box is only displayed if you are logged on with a Group Provider ID Click the View Helpful Hints link to view a printable list of helpful tips Layout Yeo pennsylvania DEPARTMENT OF PUB
358. w Taxonomy ePEAP Access Full Access Service Location 0001 123 HOPE RD HARRISBURG PA 17011 Provider Type 31 PHYSICIAN View Specialties Manage NPI and Taxonomy Codes 1 Select one or more applicable taxonomy codes 2 Click Continue 3 Review Request and Submit NPI 1234567893 193200000X GROUP MULTFSPCLTY DEFAULT SPCLTY cD 193400000X GROUP SINGLE SPCLTY DEFAULT SPCLTY cD 202K00000X ALLOPATHIC amp OSTEO PHYSICIANS PHLEBOLOGY DEFAULT SPCLTY CD 208DO0000 ALLOPATHIC amp OSTEO PHYSCNS GENERAL PRACTICE DEFAULT SPCLTY CD O 8 Wf K Note Once you have associated an NP with your Provider ID and Service Location it cannot be updated or removed via ePEAP Instead it will be necessary to mail a written request to DPW with supporting documentation for review so reset Enrollment Information ePEAP Menu Help f Exit Error Messages The number entered is not a valid NPI number Please verify and re enter The above error message is displayed if the NPI number you entered is invalid this would occur if the number was keyed in error The entered NPI cannot be associated with the service location to which you are logged in Please refer to your ePEAP Manual for handling PROMISe Provider Internet User Manual docx July 3 2014 240 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation The above error message is displayed if the
359. w opens PROMISe Provider Internet User Manual docx 232 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Update Fee Assignment Information Step Action Result 1 To add a fee assignment to a group click The Add a Group for Fee Assignment the Add a Group for Fee Assignment link window opens 2 To edit fee assignment information already The Fee Assignments window opens assigned to a group click the Manage Fee Assignment link Other Options Step Action Result 1 Click the Enrollment Information button Opens the Enrollment Information window 2 Click the ePEAP Menu button Opens the ePEAP Menu 3 Click the Help button Describes the fields on the ePEAP window 4 Click the Review Submit button Opens the Review Your Changes window 5 Click the Exit button Opens the PA PROMISe Provider Main Page Field Descriptions Field Description Data Type Length Add a Group for Fee Opens the ePEAP Add a Group for Fee Hyperlink 0 Assignment Assignment window used to add fee assignments for the current provider service location Enrollment Opens the Enrollment Information window Button 0 Information Exit Exits ePEAP Button 0 Help Describes the fields on the ePEAP window Button 0 Manage Assignment Removes a group to end the fee assignment Hyperlink 0 Info Review Submit Opens the Review Your Ch
360. w service location or modify a service location s physical address To add a new service location or change a service location address click the New Service Location Request Form to download a copy of the form that must be printed filled out and submitted to DPW for approval and processing PROMISe Provider Internet User Manual docx July 3 2014 215 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout PENN SVLUAMID rons Provider Enrolment Automation Program SULE PEAP Provider Address Information Instructions The address information for your Service Location is displayed below To change any of the information please click the corresponding Change button The addition of NEW SERVICE LOCATIONS and changes to the physical address of a service location MAY NOT be completed through ePEAP They must be requested on the NEW SERVICE LOCATION REQUEST FORM 6 23 1 Accessibility and Use To access the ePEAP Provider Address Information window and perform address maintenance tasks complete the steps in the step action table s PROMISe Provider Internet User Manual docx July 3 2014 216 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation To Access the ePEAP Provider Address Information Window Step Action Result Sign on to the PA PROMISe Internet The Provider Main Page appears on the
361. which this information can be edited 2 Highlight the Fee Assignment you wish to terminate 3 Select the End Date on which to terminate The End Date is displayed the fee assignment 4 Click the Continue button The Review Your Changes window opens Click Continue to return to the Enrollment Information window Other Options Step Action Result 1 Click the Fee Assignment Menu button Return to the Fee Assignment Menu window 2 Click the ePEAP Menu button Return to the ePEAP Menu window Click the Help button Describes the fields on the ePEAP window 4 Click the Review Submit button Opens the Review Your Changes window PROMISe Provider Internet User Manual docx 238 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Step Action Result 5 Click the Exit button The ePEAP Main window opens Field Descriptions Field Description Data Type Length Begin Date Date when current provider service location Date 8 began fee assignment to the group CCYYMMDD End Date Date when current provider service location Date 8 will end fee assignment to the group CCYYMMDD Exit Exits ePEAP Button 0 Fee Assign Menu Opens the Fee Assignment window Button 0 Group ID Provider ID number of the group Number 9 Group Name Actives a provider group name Character 50 Help Describes the fields on the ePEAP window Button 0 Review
362. xplorer window Button 0 on which the user can select the PDF file to upload Comments About Optional Comments Alphanumeric 1800 the PDF Contact Name Name of person uploading the file Alphanumeric 50 Email Address Email address of the person Alphanumeric 35 uploading the file Exit Ends the user s ePEAP session Button NPI User s NPI Number Phone Number Phone number of person uploading Number 10 the file Please select a Description corresponding to a Drop Down List Box 0 description PEAP Document Type Select either Attest 60 Percent Board Certification or PCP Board Certification corresponds to PEAP Document Type ePEAP Upload Provider Type User s Provider Type code and Alphanumeric 0 description Send Uploads the file Button Service Location User s service location code and Alphanumeric address PROMISe Provider Internet User Manual docx July 3 2014 278 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Status Status of user s service location in PROMISe Possible values are Active or Closed Character 0 Upload Form Path name of file selected for upload Alphanumeric View Specialties Opens a new window that displays specialty codes assigned to the user s service location Hyperlink View Taxonomy Opens a new window that displays taxonomy codes assigned to user s service location Hyperlink
363. y 3 2014 76 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Layout Yoo pennsylvania DEPARTMENT OF PUBLIC WELFARE My Home Claims Eligibility Trade Files Reports Outpatient Fee Schedule ePEAP Help My Home gt My Profile Tul My Profile Back to My Home Name Dental Provider Current Roles Provider In Network Contact Information Display Name Dental Provider Phone Number 1 717 763 5932 Current Email tim leitzel hp com Primary Language English US Challenge Questions Challenge Question 1 What is your mother s maiden name Answer to 1 uati23 Challenge Question 2 What street did you grow up on Answer to 2 uati23 Challenge Question 3 What is your city of birth Answer to 3 uati23 Site Key Token Site Key Passphrase wuati23 Edit Password Change Password PROMISe Provider Internet User Manual docx July 3 2014 77 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation Field Descriptions Field Description Data Type Length Window Level Edits Window level edit messages N A 0 Field Edits Field Error Code Error Message To Correct Window Level Edits 0 6 1 1 Accessibility and Use To access and use the My Profile window complete the steps in the step action table s To Access My Profile window Step Action Response 1 Logon
364. y Holder Last Name Other Insurance Pregnancy Indicator Primary Diagnosis Prior Authorization Procedure Reason Code 1 Other Insurance Reason Code 2 Other Insurance Reason Code 3 Other Insurance Recipient ID Referral Code Release of Medical Data Description ID of policyholder Last name of policyholder Last name of policyholder Indicator if patient is pregnant Primary diagnosis code for this claim PA number submitted on the claim Prior authorization number submitted on the claim Clarification of the product service procedure code and related data elements Detailed reason for the adjustment Detailed reason for the adjustment Detailed reason for the adjustment ID number issued to recipients who are authorized to receive Medicaid services The field accepts the 9 digit recipient ID and the single verification digit Referral code provided for referring provider Indicates whether the provider has informed consent to release medical info For conditions or diagnosis regulated by federal status or a signed statement on file to permit the release of medical data to other organizations Valid Values are e I Informed Consent to Release Medical Info For conditions or diagnoses regulated by Federal Statutes e Y Yes the provider has a signed statement permitting the release of medical billing data related to a claim PROMISe Provider Internet User Manual docx 122 Data
365. y and Use To access the ePEAP Review Your Changes window and review approve and submit your changes complete the steps in the following step action tables To Access the Review Your Changes Window Step Action Result 1 Sign on to the PA PROMISe Internet application using instructions provided in Section 2 9 of this manual The Provider Main Page appears on the desktop 2 Click on the ePEAP Provider Enrollment Automation Project link in the Other The ePEAP Menu window opens Links section of the window 3 Select and process one of the Menu options to change provider information After requesting and submitting changes this window will open The Review Your Changes Window opens To Review Approve and Submit Your Changes Step Action Result 1 Review the displayed information for accuracy 2 If displayed information is correct and no The Contact Information window is other changes are required click the displayed Submit Changes button 3 If additional changes are required click the The previous maintenance window will be Continue to Make Changes button displayed 4 To cancel all entered changes click the The message This request has been Cancel button cancelled is displayed PROMISe Provider Internet User Manual docx 248 July 3 2014 PROMI Provider Internet User Manual Se Internet Portal PA PROMISe Syste
366. yment rates in 2014 If your board certification expires prior to the end of 2014 you must submit a new attestation and updated board certification to continue to qualify for the increased primary care fees If you attest that you qualify for the increased fees because your claims meet the 60 threshold you should note that e If you were enrolled as an MA provider for the entire previous CY you are attesting that at least 60 of Medicaid billed codes during the entire previous calendar year are qualifying E amp M vaccine administration and or vaccine product codes e If you have been enrolled as an MA provider for less than one full calendar month or if you newly enroll as an MA Provider during 2013 or 2014 you must submit claims to the MA Program for a minimum of one full calendar month before submitting an Attestation Form You are attesting that at least 60 of Medicaid billed codes from your enrollment date through the calendar month of the date in which you attest are qualifying E amp M vaccine administration and or vaccine product codes o If you have been enrolled as an MA provider for one full calendar month or more in 2013 but less than the full calendar year in 2012 you are attesting that at least 60 of Medicaid billed codes billed from your enrollment date in 2012 to the day in which you attest are the qualifying E amp M and vaccine administration or product codes PROMISe Provider Internet User Manual docx July 3 2014 276
367. yments Valid values are into Checking Saving 19 In the Financial Institution The Provider s Account Number with Information Section Provider s Account Number Financial Institution field the account number at the financial institution to which EFT Financial Institution field is a required field and is not auto filled The User must enter the account number at the provider s financial institution to which PROMISe Provider Internet User Manual docx 50 July 3 2014 Provider Internet User Manual PROMISe Internet Portal PA PROMISe System Documentation payments are to be deposited EFT payment is to be deposited 20 In the Financial Institution The Account Number Linkage to Provider Information Section Account Identifier field is not auto filled The Number Linkage to Provider User may enter the provider s preference Identifier field s the preference for for grouping claim payments Valid grouping bulking claim payments values are Note this is collected for Provider Tax Identification Number TIN informational purposes only PA National Provider Identifier NPI PROMISe does NOT bulk NOTE If TIN is the selected preference payments the provider s Tax Identification Number is required to be entered If NPI is the selected preference the provider s NPI is required to be entered 21 In the Submission Information The Reason for Submission field is a S

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