DWC Provider Claim Submission User Manual By: PCE Systems
Contents
1. Enter the COB Paid Date date the 3rd party insurance company paid Enter the COB HIPAA Claim Adjustment Reason Code the standard HIPAA Medicaid adjustment reason code for this COB payment 0 fe To enter the Staff who performed the service if applicable Click the button to the right of the Staff field Search for and select the Staff Member 0 Enter the notes in the Notes field if applicable Click the button to collapse the data entry field or click the Contract All link above the detail lines Although hidden the information will remain in the screen until deleted by the User e DWC has a Copy link to assist entering data the Copy link will allow you to copy a service detail line and make it applicable to multiple service dates To use the copy function e Complete the service line e Click the Copy link to the left of the line A calendar will appear All February 2015 Unselect All CREATE DETAIL LINES CANCEL COPY e Place a checkmark in the days you wish to populate e Detail lines will be created for the dates indicated e Click the SAVE button e The Claim is now saved Continue to add claims to the batch by selecting the next Consumer Once all claims for the Provider have been entered proceed to DWC Step 2 Send Batch of Claims for Processing How to Enter Hospital Institutional Claims that Require an Authorization Use this link to view authorized servic2. Click the Print Remittance Advice link to the right of the check EFT information e A separate window will open with a Processing Request message The Remittance Advice will appear in this window e Click the Print icon to send the report to a local printer Partial or zero paid denied e Click this link to display where a partial or no payment was made e Click the Print icon to send the report to a local printer 12 To Print Explanation of Benefits e Click the Print EOB link to the right of the check EFT information e A separate window will open with a Processing Request message The Remittance Advice will appear in this window e Click the Print icon to send the report to a local printer How to View all Batches and Claims Use this link to view all batches and claims submitted by you the Provider regardless of the batch status e Click the Claim Submission AP link in the Main Menu e Click the View all Batches and Claims link to the right of the Main Menu e All of the batches will display You may filter the list by batch status dates and number Affiliate PIHP MCPN All w Provider cle Batch Status All Unsent Data Entry Sent to MCPN for Payment Adjudicated O Approved for Payment Sent to GL Paid For Batch Dates 01 01 2015 thru 02 26 2015 SEARCH Batch Number Affiliate PIHP MCPN 142793 Detroit Wayne BILLING PROVIDER Mental Health at aid O
3. DWC will automatically indicate that this claim pertains to the diagnosis listed in section 21 box 1 above Charges Enter the total charges for this service line Units Enter the total number of units for this service line Family Plan EMG Local Use read only fields COB Coordination of Benefits This field is not used See below for COB information e For services that require you to report the time of service and or to enter COB information Click the LE button to left of the service line or click the Expand All link above the detail lines to expand the detail lines re a aa SS ee oS From te 0 CPI HCPCS Mods sd an a A BE EU 90791 vom eT pt H HY ee I a Bike BE Click here to expand the detail lines PEN RE SEE VE ER EEE EEE EE SE ER ER BR N RE DT RT DS fara foal con on Fe we fa CPT HCPCS ae eas Plan Use JE eis 1 Tor it Te Time of Service COB From TAM Allowed Amount sat lookup clear i T AM Paid Amount _ Check to specify Rendering Provider not in the system Paid Date Notes HIPAA Adjustment Reason Code 0 Enter the begin and end time of the service if required applicable O Enter the COB Allowed Amount amount that is allowed by the 3rd party insurance company for this line of service 0 Enter the COB Paid Amount amount that was paid by the 3rd party insurance company for this line of service 0
4. Take Over Batch View Batch Info How to Create an Adjudication Report You may run a preliminary adjudication report for a batch prior to sending the batch to the MICPN for adjudication and payment The adjudication report can determine whether there are any data entry errors e Click the Adjudication Report link to the right of the batch The following message will appear at the top of the screen Your request is being processed Once the file has been generated you can access it by clicking on the message icon at the top of the screen e Click the icon in the upper left corner of MH WIN to retrieve the report e Click the link of the report The report will open in a separate window Review the results MH WIN System Message 02111 2015 Adjudication Report for Batch Nu Click here to view the Re port co Once you make changes to the claim you must re run the adjudication report for the most up to date information 10 How to View and Correct Claims in a Batch The Change and Delete options described below are only available if you are the owner of a batch If you do not own the batch and need to change or delete claims within a batch see the instructions labeled To Take Over Batch e Click the View Claims in Batch link to access all claims in the batch and the following screen will display Click here to view correct claims in a batch Billing Provider SERVICE PROVIDER 1415 02 e To
5. in your MH WIN password and click Finalize Upload Password Finalize Upload Cancel After uploading batches click on View Uploaded 837 Files on the Claims Submission AP menu to see the results of the files that have been uploaded The following screen will appear 14 Affiliate PIHP MCPN Select Affiliate PIHP MCPN Provider File Type EDI 637 Claims File FileID OO Fie i Provider DateTime cratus lly Click here to download the ILL error report 5 ER 1 Batches PROVIDER Download 837 Error Report Download Uploaded 537 Claims File If errors exist click Download 837 Error Report to view the details of the errors Correct the errors in your system recreate the 837 file and upload it again to MH WIN Once the file is accepted follow the guide above How to Adjudicate Claims Make Changes and Send a Batch of Claims for Processing using Claim Submission option 2 Send Batch of Claims for Processing How to Access a Batch which has been Returned to the Provider As a practice please always re visit Step 2 after submitting batches to the MCPN In this manner you can check whether any claims have been reviewed by DWMHA and returned to you for any reason If you submitted a batch of claims which subsequently was returned to you by DWMHA you the sender will receive an email alert Additionally a link View Comments will appear in the MH WIN list screen alongside the claim de
6. view the details of the claim click the View link to the right of the claim e To correct or edit the claim click the Change link to the right of the claim The Change link is only available if you are the person that entered the batch Make the necessary corrections to the claim and click the button to save the changes e authorized users only To delete a claim from the batch click the Delete link to the right of the claim The claim will then display in a read only format click the button to confirm the deletion How to Take Over a Batch If you are not the owner of a batch you cannot change or delete the claims within the batch You also cannot submit the batch to the MCPN for payment There may be times where it is necessary to transfer ownership of a batch e Click the Take Over Batch link to the right of the batch you wish to work Batch Affiliate PIHP tatus Total Billec Click here to take Number MCPN Billing Provider Claims ig ahle over batch Detroit Wayne Mental Health Authority TEST PROVIDER Take Over Batch View Batch Info e The batch then becomes assigned to you You can now follow the preceding steps to modify it as needed How to Submit Claims to the Agency Once the batch is ready i e all claims have been entered and all corrections have been made send the batch to the MCPN for payment Click the Submit Claims to the Agency link to the right of the batch you wish to send 11 Batch
7. Adjudication i in Authority Progress Direct View Batch Info Contract Detroit wame BILLING PROVIDER 71201 1 Billed 890 00 View Claims in Batch Paid 890 00 Adjudication Report View Batch Info Tota Billed d Billing Provider oe 1 Billed 1453 00 View Claims in Batch Detroit Wayne Mental Health ca f Paid 1453 00 Ad uudication Report View Batch Info 13 How to Upload the EDI 837 Claims File e Click the Claim Submission AP link in the Main Menu Click the Upload EDI 837 Claims Files link to the right of the Main Menu The following screen will open Step 1 Click on the Browse button to select the file to upload Click the Upload button to begin Upload EDI STEP 1 Select the file to upload Select a file to upload from your local PC by clicking Browse Files to be uploaded cannot exceed 30MB Try compressing ZIP large files Browse I Click Upload to begin uploading the file you ve selected This may take several minutes depending on the file size Upload Step 2 Provide a file description in the File Description Notes textbox STEP 2 File Information To identify the file that you are uploading please complete the following information File Type EDI 837 Claims File File Description Notes Step 3 Enter your password below and click the button Finalize Upload The upload is complete STEP 3 Authentication For authentication purposes type
8. Affiliate PIHP ren Total Billed Number MCPN ek ne ne Detroit Wayne Mental 5 1 Click here to Submit Claims to the Agency Health Authority TEST PROVIDER Submit Claims to Agency Take Over Batch View Batch Info e To view the batch once it has been sent click the link titled View all Batches and Claims How to View Payments Follow the steps below to view checks or electronic fund transfers and view or print the remittance advice and explanation of benefits e Click the Claim Submission AP link in the Main Menu e Click the 3 View Payments link to the right of the Main Menu and the following screen will display Provider _ clear Starting Check Number SEARCH Starting Check Date 11 26 2014 Show Out Of Balance Only 8 Checks TEST PROVIDER View Change Print Pumice Short Print Remittance Advice Other An 50 00 Print Remittance Partial ero aid Print EOB Download EOB in Excel View Payment Requests The checks EFT will display You can filter the list by check number and or check date To Print Remittance Advice Short e Click the Print Remittance Short link to the right of the check EFT information e A separate window will open with a Processing Request message The Remittance Advice will appear in this window e Click the Print icon to send the report to a local printer To Print Remittance Advice This link will provide more payment detail than the previous link e
9. Covers Period From To The dates from the MH WIN authorization will automatically fill change date s as needed to reflect the actual dates for this claim Note the dates must fall within the authorization date range e Box 17 Admission Date Enter the inpatient admission date associated with this claim e Facility Billing and consumer demographic information will automatically be filled e Detail Lines Enter the following information in the applicable boxes Enter a detail line for each date of service or date range of service PLEASE NOTE Only services with a day unit can be reported in date ranges All other service units i e 15 minute hour and encounters are reported per date or service From To Dates Enter the first date of the service in the From field Enter the discharge date in the To field REV CD MH WIN will automatically enter the Revenue Code listed in the authorization Note if the authorization uses the generic Service Package Inpatient Day code 01X change it to the appropriate code that is being billed for example 0124 Mod add modifier s as needed HCPCS Not used on the UB 04 in MH WIN Professional service must be reported on a separate HCFA 1500 form SERV UNITS Enter the total number of units days for this service line Note Since the discharge date is not paid the number of units should represent the number of nights in the date range Charges
10. DWC Provider Claim Submission User Manual By PCE Systems February 2015 Table of Contents How to Enter a Professional Claim that Requires an Authorization ccsscsee 3 How to Enter the DEF AI 0er een 4 How to Enter Hospital Institutional Claims that Require an Authorization 7 How to Enter NI DA ee ee een E E 8 How to Adjudicate Claims Make Changes and Send a Batch of Claims for PROCES SUNG sera san nn E tea haare tens 10 HOW to Create an Adjudication Report ee 10 How to View and Correct Claims in a Batch 22222222uuusseeeeessennnnnnnnnnnnnnnnnnnnnnnnnennnnnnnnnnnnnnnnnnnnnnnn 11 HOW LO EIKE OVEL GB AUC N ea era en re een er ke er ee 11 How to Submit Claims to the AQ ncy csscccsssssrecsonssscncnssscnecsssceecussectoussscneussscneoussesteussseneussscnenussense 11 FIOWIONV EWEIV BIENEN 12 To Print Remittance Advice SHOrt ccccccccsessseccccceesseccccceessecceeeeeeeeceeeeeeeeeceeeeeneceeeseeneeeeseaegeeeeeeas 12 10 Print Remittance Aavice un eek 12 Partislorzero Bald denied ee era 12 To Print Explanation of Bene fits cccccccsssccccesseccceesecceceesecessusececeeeecceseusecessunecessensceesseaecetsenecetsenes 13 How to View all Batches and Claims uuussssssneonsnseneeennnnnnnnnennnnnnnnnnnnnnnnnnnnnnnnnnnsnnnnnnnnnnnnsnnnnnnnnnnsnnssnnnn 13 How to Upload the EDI 837 Claims File cccsccscsccsccsceccsccscnccsceccnccsceccnsess 14 How to Access a Batc
11. Enter the total charges for this service line Diagnosis principal and code diagnoses are required fields If a diagnosis exists in the Consumer s record MH WIN will automatically pre fill the PRIN field If no diagnosis exists in either field click the L UP_ button to search for and select the diagnosis Total Prior Paid Amount COB Enter the amount owed or previously paid on this claim by 3rd party insurance etc Co Insurance Amount Enter the co pay amount owed or previously paid by the Consumer 9 Remarks Enter notes as needed e Click the button e The Claim is now saved Continue to add claims to the batch by selecting the next Consumer Once all claims for the Provider have been entered proceed to Step 2 How to Adjudicate Claims Make Changes and Send a Batch of Claims for Processing Use this link to view a list of claim batches entered You can review the claims in each batch and send forward to request payments Each step below builds on the previous step e Click the Claim Submission AP link in the Main Menu e Click the 2 Send Batch of Claims for Processing link to the right of the Main Menu and the following screen will display Batch Affiliate PIHP EEE 1 Total Billed Number MCPN a acacia ne Payable Detroit Wayne Mental 2 Billed 960 00 View Claims in Batch Health Authority TEST PROVIDER aid 0 View Comments Adjudication Report submit Claims to Agency
12. RCH button to generate the list of authorizations for the hospital you chose e You may now see authorization s listed per the example below Affiliate PIHP MCPN All Authorization Number Check this box to show a history of all authorizations By default the list will display all current authorizations and authorizations which have expired within the last 12 months Provider 23363 UNIVERSITY PEDIATRICIANS AUT lookup SEARCH To enter a claim find the approved authorization you wish to base the claim on in the list below and click Enter HCFA 1500 or Enter UB 04 If you need to bill against an Authorization and cannot find the Authorization in the list or if there are no more available units for you to claim on an authorization contact DWMHA to issue an Authorization If you don t need an Authorization please use the links below to enter your claims 0 Authorizations Authorization Provider Name Consumer Name Authorization Effective E e An authorizations list will appear If there are several authorizations you can narrow your search by using the following fields Member ID enter the Consumer ID Last Name enter partial or the entire Consumer last name Authorization Number enter the authorization number in the textbox provided Check this box if this box is unchecked MH WIN will display current authorizations as well as those that have expired within one year If you wish to see olde
13. ere are numerous authorizations you can use the filter above green shaded section to narrow your search for a particular authorization as follows e Member ID enter the Consumer ID number e Last Name enter partial or the entire Consumer last name e Authorization Number enter the authorization number e Check this box if this box is unchecked DWC will display current authorizations as well as those that have expired within one year If you wish to see older authorizations those that have expired over one year ago place a checkmark in the checkbox Click the SEARCH button e To enter a claim click the Enter HCFA 1500 to the right of the authorization for which you want to bill How to Enter the HCFA 1500 Following the steps outlined above DWC will display the HCFA 1500 Claim form below Health Insurance Claim Form Claim Batch NEW BATCH N Patient s Name 3 Patient Birthdate Sex 4 Insured s Name 00000011 DOE p 92 10 1959 male Female DOE e Verify you have the correct authorization Consumer etc Several fields are read only and cannot be modified below are the descriptions for the sections that are to be entered Claim Batch Use the drop down menu to select the batch number for the claim If no batch exists the only option will be NEW BATCH You may use the NEW BATCH option to begin a new batch at any time Section 21 Diagnosis Codes Diagnosis Codes may pre populate i
14. es and enter claims e Click the Claim Submission AP link in the Main Menu e Click the 1 Enter Claims link to the right of the Main Menu and the following screen will display Affiliate PIHP MCPN hi All Vv Provider clear SEARCH To enter a claim find the approved authorization you wish to base the claim on in the list below and click Enter HCFA 1500 or Enter UB 04 If you need to bill against an Authorization and cannot find the Authorization in the list or if there are no more available units for you to claim on an authorization contact DWMHA to issue an Authorization If you don t need an Authorization please use the links below to enter your claims Authorization Provider Name Consumer Name Authorization fective e To search for a Hospital if you know the hospital ID enter it alongside Provider If not click on the L KUP_ button to search for and select the hospital DWC will display the following screen Select a Provider Name or Other Identifier Address SEARCH CANCEL Type Classification Any lype Classification v Provider Name Address Provider Type e When entering search criteria above remember less is more For example enter only the first few letters of the hospital name and click SEARCH pwc will return results matching the search criteria Next click Select next to the hospital you need You will return to the Claim Entry screen Click the SEA
15. h which has been Returned to the Provider 15 CLAIMS SUBMISSION AP This help guide is divided into two sections entering professional claims and entering institutional claims The final section is a guide for providers needing to enter claims using the 837 How to Enter a Professional Claim that Requires an Authorization e Click the Claim Submission AP link in the Main Menu e Click the 1 Enter Claims link to the right of the Main Menu and the following screen will display Affiliate PIHP MCPN f All v Provider ooo clear SEARCH To enter a claim find the approved authorization you wish to base the claim on in the list below and click Enter HCFA 1500 or Enter UB 04 If you need to bill against an Authorization and cannot find the Authorization in the list or if there are no more available units for you to claim on an authorization contact DWMHA to issue an Authorization If you don t need an Authorization please use the links below to enter your claims Authorization Provider Name Consumer Name Authorization Effective e To search for the Provider if the provider ID is known enter it alongside Provider If not click the Lookup button to search for and select the provider Select a Provider Name or Other Identifier En Address SEARCH CANCEL Type Classification Any Type Classification Provider Name Address Provider Type e When entering search c
16. n this section from the Consumer s record There must be an entry in the first 1 box at least Use the lookup button as needed to select the diagnosis code Add More Detail Lines Expand All Contract All these links adjust the rows below Section 24 Detail Lines Some information may pre populate in this section Add and or modify information as needed Enter a detail line for each date of service or date range of service PLEASE NOTE Only services with a day unit can be reported in date ranges All other service units i e 15 minute hour and encounters are reported per date or service u SS HE SS SS AT A A of TOS Procedures Service ne Local Pos 105 Suse ey TI IT Thon I ee IT Te E pt M EN de Te ross e SC mm EEE u BE BE BE a E p Dates of Service Enter the first date of the service in the From field Enter the last date of the service in the To field If this service is to be reported per date of service enter the same date in the From and To fields POS Place of Service Enter the numeric value of the place of service Click on the question mark to display a list of options from which to choose TOS Type of Service may be left blank CPT HCPCS DWC will automatically enter the CPT HCPCS code s listed in the authorization Mod s add modifier s as needed Diagnosis
17. r authorizations those that have expired over one year ago place a checkmark in the checkbox Click the button e Click the Enter UB 04 link to the right of the authorization for which you are billing and follow the steps below Authorization A Authorization h ee Name Consumer Name Eff ective 1120513410174 DETROIT RECEIVING S 05 03 12 05 06 12 View Authorization HOSPITAL Enter HCFA 1500 1 Enter UB 04 Authorized Service Units Authorized Units Claimed Units Paid Units Available m ur e m raw iia EERE ZA m ee SS LjENBEN Diar Fin tis 47 u u l i AUTEUR PLE IE TIL E Hi 12 i How to Enter the UB 04 Following the steps outlined above the UB 04 Claim Form will now be displayed e Verify and update the following information several fields are read only UBH HCFA 1450 MCPN 7 Affiliate Claim Baich NEW BATCH Hame and Address of Facility Billing Harme and Address e Claim Batch Use the drop down menu to select the batch number for the claim If no batch exists the only option will be NEW BATCH You may use the NEW BATCH option to begin a new batch at any time Contract Click leekup and select the appropriate contract that this claim is charged against e Box 3 Patient Control Number This is the consumer s MH WIN member ID and it will be automatically filled in No entry is required here e Box 6 Statement
18. riteria above remember less is more For example enter only the first few letters of the provider name and click the SEARCH button DWC will return a list of providers matching the search criteria Click Select next to the provider you need You will return to the Claim Entry screen and you will see DWC has entered the provider you chose Click the SEARCH button e You may now see authorization s listed per the example below Affiliate PIHP MCPN All Authorization Number Po Check this box to show a history of all authorizations By default the list will display all current authorizations and authorizations which have expired within the last 12 months Provider 28789 Centra Healthcare LLC To enter a claim find the approved authorization you wish to base the claim on in the list below and click Enter HCFA 1500 or Enter UB 04 If you need to bill against an Authorization and cannot find the Authorization in the list or if there are no more available units for you to claim on an authorization contact DWMHA to issue an Authorization If you don t need an Authorization please use the links below to enter your claims Authorization Provider Name Consumer Name Authorization Effective 141040000017 Centria Healthcare LLC John P Doe 10 01 14 11 01 14 View Authorization 00000011 Enter HCFA 1500 Authorized Service Description Units Authorized Units Claimed Units Paid Units Available e Inthe event th
19. tails below To access the batch and learn the reason s it was returned to you follow these steps e Click on the Claim Submission AP link in the main menu e Click on the Send Batch of Claims for Processing link and the following screen will appear Batch Affiliate PIHP ee tatus Total Billed Number MCPN nn er aims Payable Detroit Wayne Mental 2 Billed 960 00 View Claims in Batch Health Authority TEST PROVIDER aid 0 View Comments Adjudication Report Submit Claims to Agency Take Over Batch View Batch Info Batch number 142674 has been retumed for the following reason s Vendor GL information not found e Asneeded modify your claim s adjudicate and re submit to the MCPN 15
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