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1. coal 13 DENTAL HEADER ONE ENTRY INSTUCTIONS 14 DBNTAEHEADER ro d prc c A aa ete E DE LA E rdi 17 DENTAL HEADER TWO ENTRY INSTRUCTIONS tette treten 19 DENTAL HEADER THREE Ma certis e A RA p RR P 21 DENTAL HEADER THREE ENTRY INSTRUCTIONS ettet treten treten 22 DENTAL SERVICE ONE SCREEN petet cci hsc ae pe E e a FRU t e I E T RC Eg 24 DENTAL SERVICE ONE ENTRY INSTRUCTIONS 25 DENTAL SERVICE TWO SCREEN cccccccsccsscsssssscssessucsscssscssessecesessessucsucssscssecsussusssessussseceusasecsucssesseeaseesecs 27 DENTAL SERVICE TWO ENTRY INSTRUCTIONS ceteetete teet 28 OTHERINSUB ANDE cds mw aestu Rr XE E tana e e ede i 29 OTHER INSURANCE ENTRY INSTRUCTIONS eet tette tette 30 HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 2 DENTAL CLAIMS BILLING INSTRUCTIONS INTRODUCTION Now that you have installed and become familiar with the functionality of the Hewlett Packard Enterprise PROVIDER ELECTRONIC SOLUTIONS software it s time to begin claims data entry The claim entry screen consists of six sections Three Headers Two Service and Other Insurance screens following instructions detail requirements and general information for each of these sections In the following sections each data entry field is defined with the appropriate requirements Edits have been built into the software to assi
2. MI Enter the middle initial of the client who received services Client DOB Enter the date the client was born Gender Select the appropriate value from the drop down list to enter the client s gender Code Description F Female M Male U Unknown Subscriber Address Line 1 Enter the street address of the party being referenced The address is required for providers clients and policyholders Line 2 Enter additional address information of the party being referenced such as suite or apartment number if applicable City Enter the city of the party being referenced The address is required for providers clients and policyholders State Enter the state of the address of the party being referenced The address is required for providers clients and policyholders Zip Enter the 9 digit zip code of the party being referenced The address is required for providers clients and policyholders HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 6 DENTAL CLAIMS BILLING INSTRUCTIONS BILLING PROVIDER SCREEN HP Provider Electronic Solutions HIPAA NCPDP OYOpPaOeK OBX SE SHS 4p Billing Provider Provider ID Provider ID Code Qualifier Add Taxonomy Code Entity Type Qualifier Delete Last Org Name First Name SSN Tax ID SSN 7 ID Qualifier 2070 Provider Address vie oe Jaye Find City State Zip Print P
3. DENTAL CLAIMS BILLING INSTRUCTIONS PAID AMOUNT 9 R N POLICY HOLDER GROUP 17 O X POLICY HOLDER GROUP NAME 14 R A CARRIER CODE 3 R X POLICY HOLDER LAST NAME 35 R A POLICY HOLDER FIRST NAME 25 R A ALPHA N NUMERIC X ALPHANUMERIC OTHER INSURANCE ENTRY INSTRUCTIONS Providers are required to submit other insurance information when another payer is known to potentially be involved in paying or denying a claim The following fields are required when a Y is indicated in the Other Insurance Indicator field on the Header Three Screen Release of Medical Data Select the appropriate value from the drop down box that indicates whether the provider has on file a signed statement by the client authorizing the release of medical data to other organizations Remarks Required Format A Benefits Assignment Select the appropriate value from the drop down box that identifies that the client or authorized person authorizes benefits to be assigned to the provider This field defaults to Y Remarks Required Format A Claim Filing Ind Code Select the appropriate value from the drop down box that identifies the type of other insurance claim that is being submitted Select MB when the denial is from Medicare Remarks Required Format XX Adjustment Group Cd Select the appropriate value from the drop down box that identifies the general category of payment adjustment by the other insurance carrier Remarks Requir
4. Last Name Enter the last name of the policyholder of the other insurance or Medicare First Name Enter the first name of the policyholder of the other insurance or Medicare ID Code Enter the policyholder s identification number assigned by the other insurance company ID Qualifier Select the appropriate value from the drop down box that identifies the ID that is being used Date of Birth Enter the date the policyholder was born Gender Select the appropriate value from the drop down box that identifies the sex of the individual Policy Holder Address Line 1 Enter the street address of the party being referenced The address is required for providers clients and policyholders Line 2 Enter additional address information of the party being referenced such as suite or apartment number if applicable City Enter the city of the party being referenced The address is required for providers clients and policyholders State Enter the state of the address of the party being referenced The address is required for providers clients and policyholders Zip Code HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 11 DENTAL CLAIMS BILLING INSTRUCTIONS Enter the zip code of the party being referenced The address is required for providers clients and policyholders Patient ID Enter the other insurance identification number of the Connecticut Medical Assistance Program client to whom services were rendered ID
5. 5 OTHER INSURANCE INDICATOR 1 R A ALPHA N NUMERIC X ALPHANUMERIC DENTAL HEADER THREE ENTRY INSTRUCTIONS Diagnosis Code 1 4 Enter the diagnosis code s from the International Classification of Diseases 9 Revision Clinical Modification ICD 9 CM manual Up to 4 diagnosis codes may be entered NOTE DO NOT key the decimal point It is already assumed Remarks Optional Format XXXXX Accident Related Causes 1 2 If this claim is the result of an accident select the appropriate code to indicate the type of accident Remarks Situational Format AA Date Indicate the date of the accident Required if the claim is the result of an accident Remarks Situational Format MM DD CCYY State Enter the state where the accident occurred Use state postal codes CT Connecticut etc Required if Accident Related Causes value is AA Auto Accident Remarks Situational Format AA Country Enter the country in which the accident occurred Required if an auto accident occurred outside of the United States Remarks Situational Format AA Rendering Provider ID HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 22 gt gt gt Z DENTAL CLAIMS BILLING INSTRUCTIONS Select the Connecticut Medical Assistance Program rendering provider number from the drop down window The other provider information will be populated once you select enter Used only when the provider rendering services is different
6. 8 the Original Claim field will be required Remarks Required Format N Original Claim This field is populated when the claim frequency is a 7 or 8 When a claim is replaced or voided indicate the original Internal Control Number as it appears on the remittance advice Remarks Situational Format NNNNNNNNNNNNN Provider ID Enter your NPI or Connecticut Medical Assistance Program Provider Number with two leading zeros Remarks Required Format NNNNNNNNN Alternatively click the down arrow at the right side of the field to display the list of saved providers and select the desired provider from the list Double click the Provider ID field to open the provider list and add a new entry if needed HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 14 DENTAL CLAIMS BILLING INSTRUCTIONS Taxonomy Code This field will be auto plugged once you enter your provider number and contains an alphanumeric code that consists of a combination of the provider type classification area of specialization and education training requirements Note The health care provider taxonomy code list is available on the Washington Publishing Company web site http www wpc edi com Remarks Required Format NNNANNNNNA Last Org Name This field will be auto plugged once you enter your provider number and contains the provider s name or the first two letters of the provider s last name as enrolled in the Connecticut Medical Ass
7. Appliance Placement Date Enter the placement date of the appliance if applicable Remarks Situational Format MM DD CCY Y Rendering Provider ID Select the Connecticut Medical Assistance Program rendering provider number from the drop down window The other provider information will be populated once you select enter Used only when the provider rendering services is different from the billing provider on the Header One tab Remarks Situational Format NNNNNNNNN Rendering Provider Taxonomy Code Enter an alphanumeric code that consists of a combination of the provider type classification area of specialization and education training requirements This field will be populated once you select a rendering provider provider ID Note The health care provider taxonomy code list is available on the Washington Publishing Company web site http www wpc edi com Remarks Situational Format NNNANNNNNA Rendering Provider Last Org Name Enter provider s name or the first two letters of the provider s last name as enrolled in the Connecticut Medical Assistance Program This field will be populated once you select a rendering provider provider ID Example THOMPSON or Remarks Situational Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA or AA Rendering Provider First Name HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 28 DENTAL CLAIMS BILLING INSTRUCTIONS Enter the first name of the provider when they are an
8. Last Org Name This field will be auto plugged once you enter the provider number This field contains the last name of an individual provider or the business name of a group or facility when the Entity Type Qualifier is a 2 Remarks Optional Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA First Name This field will be auto plugged once you enter the provider number This field contains the first name of the provider when they are an individual Required when the Entity Type Qualifier is a 1 Cannot be used when the Facility Type Qualifier is a 2 Remarks Optional Format AAAAAAAAAAAAAAAAAAAAAAAAA Referral Number Enter the referral number if applicable Remarks Optional Format AAAAAAAAAAAAAAAAAAAAAAAAA Place of Service Enter the appropriate code from the drop down list that reflects where the services for this claim were performed Code Description Code Description 03 School 33 Custodial care facility 04 Homeless Shelter 34 Hospice 05 Indian health service free 41 Ambulance land standing facility 42 Ambulance air 06 Indian health service 50 Federally qualified health center provider based facility 51 Inpatient psychiatric facility HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 19 DENTAL CLAIMS BILLING INSTRUCTIONS 07 Tribal 638 free standing facility 52 Psychiatric facility partial hospital 08 Tribal 638 provider based facility 53 Community mental health center 11 Office 54 Intermediate care facility me
9. OBX OHMS Client ID ID Qualifier MI Issue Date 00 00 0000 Add Accout Ciemt S N 00 Delete Last Name First Name Client DOB 00 00 0000 Gender v m Subscriber Address Save Line 1 Line 2 Find City State 2 Print Client ID Undo All Last Name First Name Help 987654321 SMITH 123456789 NAMELAST FIRST 111111111 JONES Select Close The Client list requires you to collect detailed information about your clients which are then automatically entered into forms All of the fields are required except Issue Date Middle Initial and Subscriber Address Line 2 CLIENT ENTRY INSTRUCTIONS Client ID Enter the Client identification number assigned by the Connecticut Medical Assistance Program ID Qualifier This field has been preloaded with the information which identifies the type of client This field will be by passed Issue Date Enter the issue date found on the patient s Medical Assistance Program Identification Card Account Enter the unique number assigned by your facility to identify a client Client SSN Enter the client s social security number Last Name Enter the last name of the client who received services First Name HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 5 DENTAL CLAIMS BILLING INSTRUCTIONS Enter the first name of the client who received services
10. Qualifier Select the appropriate value from the drop down box that identifies the ID that is being used CLAIM ENTRY INSTRUCTIONS Use the following instructions to complete the claim screens When data entry is complete click SAVE The saved claim will appear in the list below the data entry screen If the claim data hits edits a message window will appear with error messages Click SELECT to move to the highlighted error and correct the data Once all error messages have been resolved you can save the claim Newly saved claims are in Status R Ready Status R claims can be edited and saved multiple times prior to submission Be sure to click ADD before beginning to enter the data for each new claim Note The Select Command button is not visible on the List window unless it has been invoked by double clicking an autoplug field from a claim screen Once a List entry has been either added or edited the Select button must be clicked in order for the data to populate the claim screen with the selected List entry HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 12 DENTAL CLAIMS BILLING INSTRUCTIONS DENTAL HEADER ONE HP Provider Electronic Solutions HIPAA NCPDP File Edit View Forms Tools Window Help vYQhrSOOXR OBX XH SHAG 0 9f 837 Dental Total Charge 0I Amount SS Billed Amount WI Services 88 Header 1 Header 2 Header 3 Service 1 Service 2 Claim Frequency v Provider ID Taxonomy Co
11. from the billing provider on the Header One tab Remarks Situational Format NNNNNNNNN Rendering Provider Taxonomy Code Enter an alphanumeric code that consists of a combination of the provider type classification area of specialization and education training requirements This field will be populated once you select a rendering provider provider ID Note The health care provider taxonomy code list is available on the Washington Publishing Company web site http www wpc edi com Remarks Situational Format NNNANNNNNA Rendering Provider Last Org Name Enter provider s name or the first two letters of the provider s last name as enrolled in the Connecticut Medical Assistance Programs This field will be populated once you select a rendering provider provider ID Example THOMPSON or Remarks Situational Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA or AA Rendering Provider First Name Enter the first name of the provider when they are an individual Required when the entity type qualifier is a1 Cannot be used when the entity type qualifier is 2 This field will be populated once you select a rendering provider provider ID Example THOMPSON or Remarks Situational Format AAAAAAAAAAAAAAAAAAAAAAAAA or AA Other Insurance Indicator This field indicates whether the client has other insurance This field is defaulted to for no When this is changed to a for yes the Other Insur
12. individual Required when the entity type qualifier is a 1 Cannot be used when the entity type qualifier is a 2 This field will be populated once you select a rendering provider provider ID Example THOMPSON or Remarks Situational Format AAAAAAAAAAAAAAAAAAAAAAAAA or AA OTHER INSURANCE hy HP Provider Electronic Solutions HIPAA NCPDP File Edit View Forms Tools Window Help Qe Qs 5085 e OBXOHN 5 meg mH YU Sf 537 Dental Total Charge 01 Amount Billed Amount NT Services Header 1 Header 2 Header3 OI Service 1 Service 2 Release of Medical Data Benefits Assignment Y v Add Claim Filing Ind Code v Adjustment Group v Payer Responsibility v IS Reason Codes Amts 1 00 2 cxx 0 Paid Date Amount 00 00 0000 00 3 10 Delete M Policy Holder Group F3 Group Carrier Code _ Undo All Last Name O First Save Add 01 Srv Carrier Code Group Group Name Last Name 01 Delete 01 Last Name Billed Amount Last Submit Dt 1 111111111 JONES JANE OTHER INSURANCE INFORMATION FIELD REQUIRED ALPHA DESCRIPTION LENGTH OPTIONAL NUMERIC SITUATIONAL RELEASE OF MEDICAL DATA 1 R A BENEFITS ASSIGNMENT 1 R A CLAIM FILING IND CODE 2 R X ADJUSTMENT GROUP CD 2 R X PAYER RESPONSIBILITY 1 R A REASON CODES 1 3 3 R x REASON AMTS 1 3 9 R N PAID DATE 8 R N HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 29
13. AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA or AA First Name This field will be auto plugged once you enter the client s Connecticut Medical Assistance Program identification number This field contains the client s first name or the first character of the client s first name There are no spaces allowed in this field Example JOHN or J Remarks Required Format AAAAAAAAAAAAAAAAAAAAAAAAA or A MI This field will be auto plugged once you enter the client s Connecticut Medical Assistance Program identification number This field contains the first character of the client s middle name Example JOHN or J Remarks Optional Format A Release of Medical Data This code indicates whether the provider has on file a signed statement by the client authorizing the release of medical data to other organizations Enter the value that corresponds to the release of medical data Yes is the default value Y Yes N No Remarks Required Format A Benefits Assignment Code identifying that the client or authorized person authorizes benefits to be assigned to the provider Enter one of the values below to indicate assignment of benefits Y Yes N No Remarks Required Format A HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 16 DENTAL CLAIMS BILLING INSTRUCTIONS Report Type Code Code indicating the title or contents of a document report or supporting item for this claim Enter the two digit value that corre
14. CE ONE ENTRY INSTRUCTIONS Enter the date of service on which services were provided for this claim in MM DD CCYY format Date Sve Remarks Required Format MM DD CCYY Place of Service Select the appropriate code that reflects where the services for this claim were performed This field is required if a place of service code is not entered on Header Two Code Description 03 School 04 Homeless Shelter 05 Indian health service free standing facility 06 Indian health service provider based facility 07 Tribal 638 free standing facility 08 Tribal 638 provider based facility 11 Office 12 Home 15 Mobile unit 20 Urgent care facility 21 Inpatient 22 Outpatient 23 Emergency room 24 Ambulatory surgical center 25 Birthing center 26 Military treatment facility 31 Skilled nursing facility 32 Nursing facility Remarks Required Format NN Procedure Description Custodial care facility Hospice Ambulance land Ambulance air Federally qualified health center Inpatient psychiatric facility Psychiatric facility partial hospital Community mental health center Intermediate care facility mentally retarded Psychiatric substance abuse treatment facility Psychiatric residential treatment center Mass immunization center Comprehensive inpatient rehabilitation Comprehensive outpatient rehabilitation End stage renal disease treatment facility State or local public health clinic Rural health clinic Independent
15. DENTAL CLAIMS BILLING INSTRUCTIONS HPE Provider Electronic Solutions Billing Instructions Cc Hewlett Packard Enterprise Provider Electronic Solutions Dental Claims Important Update This software will not be supported after October 1 2015 Current PES users are encouraged to transition to an alternative method of claim submission by October 1 2015 to avoid a disruption in electronic claims processing HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 1 DENTAL CLAIMS BILLING INSTRUCTIONS Table of Contents PITT OTIC eng ek M 3 VOR RING WIPED E Aa eel red Mat 4 CLIENT SCREEN nae 5 CLIENT ENTRY INSTRUCTIONS 555 5 BILE ING PROVIDER SCREEN 7 BILLING OTHER PROVIDER ENTRY 242240404 7 TFAXONONIY SCREBNS 2222 Ao Gos ren ws Seah A E E oS 9 8 9 POLICY HOLDER SCREEN eed 10 POLICY HOLDER ENTRY INSTRUCTIONS cccscssccsucsssssscssecssessecsusssessscssessecsusssesrecssessscssessecessssesseeasecses 10 CLAIM ENTRY INSTRUCTIONS 55sec ain 12 DENTAEHEADERIONES d E
16. LAIMS BILLING INSTRUCTIONS Delay Reason Code Select the appropriate code from the drop down list to identify the reason for delay in submitting the claim Code Description 1 Proof of eligibility unknown or unavailable 2 Litigation 3 Authorization delays 4 Delay in certifying provider 5 Delay in supplying billing forms Remarks Optional Format N DENTAL HEADER THREE hy HP Provider Electronic Solutions HIPAA NCPDP File Edit View Forms Tools Window Help OBXCHX amp SHt Get 9f 837 Dental Total Charge 01 Amount SS Billed Amount Services Header 1 Header2 Header 3 Service 1 Service 2 M Diagnosis Codes 1 2 3 4 M Accident 1 Related Causes 1 2 x Delete Date 0070070000 State Country Undo All Rendering Provider Save Provider ID Taxonomy Code Last Org Name First Name Other Insurance Ind N Last Name First Name Billed Amount Last Submit Dt 1 111111111 JONES er on DENTAL HEADER THREE INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL O NUMERIC SITUATIONAL S DIAGNOSIS CODES 1 4 3 O X ACCIDENT RELATED CAUSES 1 2 2 5 DATE 8 5 N STATE 2 5 COUNTRY 3 5 HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 21 DENTAL CLAIMS BILLING INSTRUCTIONS RENDERING PROVIDER 10 5 PROVIDER ID RENDERING PROVIDER 10 5 TAXONOMY CODE RENDERING PROVIDER 35 5 LAST ORG RENDERING PROVIDER FIRST 25
17. Other Provider if applicable Taxonomy Policy Holder If these lists are not completed prior to keying your transaction the list will open in the transaction form Some of the lists contain preloaded information that is available for auto plugging as soon as you install Provider Electronic Solutions Other lists require you to enter the information you will use for auto plugging You should enter your data in these lists soon after you set up Provider Electronic Solutions to take advantage of the auto plug feature To create or edit a list select List from the Main Menu and then select the appropriate item WORKING WITH LISTS From the Lists option on the menu bar select the list you want to access Perform one of the following To add a new entry select Add To edit an existing entry select the entry and then enter your changes The command buttons for Delete Undo All Find Print and Close work as titled Note The Select Command button is not visible on the List window unless it has been invoked by double clicking an autoplug field from a claim screen Once a List entry has been either added or edited the Select button must be clicked in order for the data to populate the claim screen with the selected List entry HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 4 DENTAL CLAIMS BILLING INSTRUCTIONS CLIENT SCREEN Ar HP Provider Electronic Solutions HIPAA NCPDP File Edit View Forms Tools Window Help OY Qs OAR
18. S MANUAL 9 DENTAL CLAIMS BILLING INSTRUCTIONS POLICY HOLDER SCREEN n HP Provider Electronic Solutions HIPAA NCPDP File Edit View Forms Lists Tools Window Help mt DORK c 26 CAS NE hp Policy Holder Client ID f Group Carrier Code Add Carrier Name Other Insurance Group Delete Insurance Type Code Relationship to Insured m Policy Holder Information FasNam Save IDCode cD Qualifier Find Date Of Birth 0070070000 Gende Policy Holder Address Linel S Awe Ciy Stef 0 Zp Undo All Print Patient Information Patient ID En ID Qualifier Client ID Group Carrier Code Last Name First Name 111111111 664 JONES 123456789 001 LAST 987654321 MPB SMITH The Policy Holder list requires you to list the information for the policyholder of the other insurance policies and Medicare policies As with the provider and client lists this list must be completed before completing a claim with other insurance or Medicare Complete a separate list for each policy when a client has both other insurance and Medicare Like the other lists once the code is entered into the list it may be accessed by the drop down window and will automatically populate into the claim All fields are required except Policy Holder Address Line 2 POLICY HOLDER ENTRY INSTRUCTIONS This tab is required if an indicator of Y is enter
19. ance Tab is added to the claim form for entry Y Yes N No Remarks Required Format A HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 23 DENTAL CLAIMS BILLING INSTRUCTIONS DENTAL SERVICE ONE SCREEN Ay HP Provider Electronic Solutions HIPAA NCPDP File Edit View Forms Tools Window Help GYOprPSOGR OBX XH amp SKC 837 Dental Total Charge OI Amount ET Billed Amount WE Services J Header 1 Header 2 Header3 Service 1 Service 2 Date Svc 10 00 0000 Place Of Service Add Procedure Modifiers 1 I j 2 3 emn 4 Copy Tooth Surfaces 1 2 i 3f 4 15 z Quadrants 1 2 z z 4 zs Placement Ind z Prior Placement Date 00 00 0000 Undo All Unts 0 Rate 00 Billed Amount 00 Add Srv Srv From DOS To DOS OS Procedure Units Billed Amount 00 00 0000 00 00 0000 Srv Delete Srv Last Name Billed Amount Last Submit Dt 1 111111111 JONES JANE SERVICE ONE INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL NUMERIC SITUATIONAL S DATE SVC 8 R N PLACE OF SERVICE 2 R N PROCEDURE 5 R X MODIFIERS 1 4 2 5 X TOOTH 2 5 X SURFACES 1 5 1 5 X QUADRANTS 1 5 2 5 X PLACEMENT IND 1 5 x PRIOR PLACEMENT DATE 8 5 N UNITS 8 R N UNIT RATE 9 R N BILLED AMOUNT 9 R N A ALPHA N NUMERIC X ALPHANUMERIC HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 24 DENTAL CLAIMS BILLING INSTRUCTIONS DENTAL SERVI
20. ase letters are automatically converted to upper case Note The health care provider taxonomy code list is available on the Washington Publishing Company web site http www wpc edi com Entity Type Qualifier Select the appropriate value to indicate if the provider is an individual performer or corporation HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 7 DENTAL CLAIMS BILLING INSTRUCTIONS Last Org Name Enter the last name of an individual provider or the business name of a group or facility when the Entity Type Qualifier is a 2 First Name Enter the first name of the provider when the provider is an individual Required when the Entity Type Qualifier is a 1 Field will not be available when the Entity Type Qualifier is a 2 SSN Tax ID Enter the Social Security Number SSN or Federal Employee Identification Number FEIN of the provider being referenced SSN Tax ID Qualifier Select the appropriate code from the drop down box that identifies what value is being submitted in the SSN Tax ID field Provider Address Line 1 Enter the street address of the party being referenced The address is required for providers subscribers and policyholders Line 2 Enter additional address information of the party being referenced such as suite or apartment number if applicable City Enter the city of the party being referenced The address is required for providers clients and policyholders State Enter the state o
21. de Last OrgName FssName ooo Delete Undo All Client ID Account LastName O FastNam o Mil Save Release of Medical Data v Benefits Assignment v Report Type Code x Report Transmission Code m Attachment Ctl Last Name Biled Amount Last Submit Dt Ene 1 111111111 JONES JANE Print Close DENTAL HEADER ONE INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL O NUMERIC SITUATIONAL S CLAIM FREQUENCY 1 R N ORIGINAL CLAIM 13 5 PROVIDER ID 10 R N TAXONOMY CODE 10 R X LAST ORG NAME 35 R A FIRST NAME 25 R A CLIENT ID 16 R X ACCOUNT 38 R X LAST NAME 35 R A FIRST NAME 25 5 MI 1 O A RELEASE OF MEDICAL DATA 1 R A BENEFITS ASSIGNMENT 1 R A REPORT TYPE CODE 2 O X REPORT TRANSMISSION CODE 2 O A HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 13 DENTAL CLAIMS BILLING INSTRUCTIONS ATTACHMENT CTL 30 5 N NUMERIC X ALPHANUMERIC DENTAL HEADER ONE ENTRY INSTRUCTIONS Special Note All data entry will default to capital letters Header Field Definition Dollars cc Cents Alpha Numeric X Alphanumeric Claim Frequency Select the appropriate code specifying the frequency of the claim to identify original adjustment or void Code Description 1 Original Admit thru discharge claim 7 Replacement Replacement of prior claim 8 Void Void Cancel of prior claim Note If the claim frequency is a 7 or
22. ed Format XX Payer Responsibility Select the code that describes the order of insurance carrier s level of responsibility for a payment of a claim Remarks Required Format A Reason Codes 1 3 HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 30 DENTAL CLAIMS BILLING INSTRUCTIONS Enter the code identifying the reason the adjustment was made by the other insurance carrier At least one reason code and amount is required or use this field to indicate the reason Medicare denied the claim Reason codes can be found in the Implementation Guide by clicking on the following site www wpc edi com http www wpc edi com Follow the instructions below to retrieve the reason codes e Click on HIPAA e Click on Code Lists e Click on Claim Adjustment Reason Codes Use this list of codes to indicate if a payment was made by OI or denied by OI Remarks Required Format XXXXX Reason Amounts 1 3 Enter the amount associated with each reason code At least one reason code and amount is required Remarks Required Format Paid Date Enter the date that the other insurance carrier paid the claim remittance advice date Use this field to enter the date Medicare denied the claim Remarks Required Format MM DD CCYY Paid Amount Enter the amount paid by the other insurance carrier An amount of zero 0 may be entered This field is required if a value is entered in the Reason Code field on the other insurance screen and a
23. ed in the other insurance indicator field on the Header Three screen The information on this screen must be entered before you enter the Group Number from the Other Insurance screen Client ID Enter the Client identification number assigned by the Connecticut Medical Assistance Program Group Number Enter group number for the other insurance or Medicare If a group number is not applicable please enter the policy number of the client For Medicare clients please enter the client s Health Insurance Claim HIC number Carrier Code Select the three digit other insurance carrier code from the drop down box HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 10 DENTAL CLAIMS BILLING INSTRUCTIONS Note Provider must maintain an Explanation of Benefits EOB on file for audit purposes Carrier Name This field is auto plugged by the system once the carrier code is entered and contains the name of the other insurance company listed for the client Other Insurance Group Name Enter the name of the group that the other insurance is listed under and coincides with Group number Insurance Type Code Select the appropriate value from the drop down box that identifies the type of insurance listed Relationship to Insured Select the appropriate value from the drop down box that identifies the client s relationship to the policy holder for the other insurance or Medicare listed If the client is the policyholder self will be listed
24. f the address of the party being referenced The address is required for providers clients and policyholders Zip Code Enter the 9 digit zip code of the party being referenced The address is required for providers clients and policyholders HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 8 DENTAL CLAIMS BILLING INSTRUCTIONS TAXONOMY SCREEN 4g HP Provider Electronic Solutions HIPAA NCPDP File Edit View Forms Lists Tools Window Help C Qs iO Ox 06 the eae 4 Taxonomy Taxonomy Code Description Delete Undo All Save Taxonomy Code Description Find 111 00000 lt Chiropractor 101 08005 Counselor Mental Health 207500000 Physician Allergy amp Immunology 208U 00000 Physician Clinical Pharmacology 2072F0201 Physician Pathology Forensic Pathology 103 0700 Psychologist Clinical 16300000 Registered Nurse Print The Taxonomy list requires you to list the taxonomy code which is then automatically entered into the Provider List All fields are required TAXONOMY BILLING INSTRUCTIONS Taxonomy Code Enter the alphanumeric code that consists of a combination of the provider type classification area of specialization and education training requirements Note The health care provider taxonomy code list is available on the Washington Publishing Company web site http www wpc edi com Description Enter the description of the code listed HPE PROVIDER ELECTRONIC SOLUTIONS USER
25. he services performed for this procedure This should include the charge for all units listed Remarks Required Format DENTAL SERVICE TWO SCREEN Ag HP Provider Electronic Solutions HIPAA NCPDP File Edit View Forms Tools Window Help YOpraGOBK OBX Hea 5 SHAS aH Sf 837 Dental Total Charge SI 01 Amount SS Billed Amount SE Services J Header 1 Header 2 Header 3 Service 1 Service 2 DiagPt 1 2 0 4 Appliance Placement Date 00 00 0000 o lt Rendering Provider Provider ID Taxonomy Code Undo All Last Org Name First Save From DOS To DOS OS Procedure 00 00 0000 00 00 0000 Last Name First Name Billed Amount Last Submit Dt 1 111111111 JONES JANE r RR SERVICE TWO INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL NUMERIC SITUATIONAL S DIAG PTR 1 4 1 R N APPLIANCE PLACEMENT 8 5 N DATE RENDERING PROVIDER 10 S N PROVIDER ID RENDERING PROVIDER 10 S X TAXONOMY CODE RENDERING PROVIDER 35 S A LAST ORG NAME HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 27 DENTAL CLAIMS BILLING INSTRUCTIONS RENDERING PROVIDER 25 5 FIRST N NUMERIC X ALPHANUMERIC DENTAL SERVICE TWO ENTRY INSTRUCTIONS Diag Ptr Enter the diagnosis pointer that corresponds to the diagnosis code on the Header Three tab Up to four 4 diagnosis pointers may be entered Remarks Required Format N
26. istance Program Example THOMPSON or Remarks Required Format AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA or AA First Name This field will be auto plugged once you enter your provider number and contains the provider s name or the first letter of the provider s first name as enrolled in the Connecticut Medical Assistance Program Required when the Entity Type Qualifier is a 1 There are no spaces allowed in this field Example THOMPSON Remarks Situational Format AAAAAAAAAAAAAAAAAAAAAAAAA or A Client ID Enter the client s nine digit Connecticut Medical Assistance Program identification number Remarks Required Format Account This field will be auto plugged once you enter the client s Connecticut Medical Assistance Program identification number and contains the patient s account number Provider assigned this field may be alphabetic or numeric and is used for the provider s own accounting purposes Remarks Required Format XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 15 DENTAL CLAIMS BILLING INSTRUCTIONS Last Name This field will be auto plugged once you enter the client s Connecticut Medical Assistance Program identification number This field contains the client s last name or the first two characters of the client s last name Example THOMPSON or Remarks Required Format AAAA
27. laboratory Other unlisted facility Enter the five 5 digit HCPCS or American Dental Association ADA service procedure code which best describes the services rendered Remarks Required Format XXXXX HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 25 DENTAL CLAIMS BILLING INSTRUCTIONS Modifiers Enter the modifier if applicable Up to four 4 modifiers may be entered for each detail Remarks Situational Format XX Tooth Select the appropriate tooth number 1 32 A T if applicable Remarks Situational Format XX Surfaces Enter the tooth surface if applicable Up to five 5 surfaces may be entered for each detail Remarks Situational Format X Quadrants Enter the quadrant if applicable Up to five 5 quadrants may be entered for each detail Remarks Situational Format XX Placement Ind Select the appropriate placement indicator code if applicable Remarks Situational Format X Prior Placement Date Enter the date of the prior placement if services are for a replacement appliance Required if Placement Ind R Remarks Situational Format MM DD CCY Y Units Enter the number of units performed for the service being billed Remarks Required Format NNNNNNNN Unit Rate Enter the rate per unit billed Remarks Required Format HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 26 DENTAL CLAIMS BILLING INSTRUCTIONS Billed Amount Enter the total amount for t
28. me Delete Referral Number Undo All Place Of Service Facility ID Copay Amount 00 M Orthodontic Treatment Total Months Months Remaining EPSDT N Delay Reason Code v Last Name First Name Billed Amount Last Submit Dt 1 111111111 JONES Save HEADER TWO INFORMATION FIELD REQUIRED R ALPHA DESCRIPTION LENGTH OPTIONAL NUMERIC SITUATIONAL S REFERRING PROVIDER ID 10 O N REFERRING TAXONOMY CODE 10 O X REFERRING LAST ORG NAME 35 O A REFERRING FIRST NAME 25 O A REFERRAL NUMBER 30 O X PLACE OF SERVICE 2 R N FACILITY ID 9 O N COPAY AMOUNT 9 S N TOTAL MONTHS 2 S N MONTHS REMAINING 2 S N EPSDT 1 R A DELAY REASON CODE 2 O N A ALPHA N NUMERIC X ALPHANUMERIC HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 18 DENTAL CLAIMS BILLING INSTRUCTIONS DENTAL HEADER TWO ENTRY INSTRUCTIONS Referring Provider ID Select the NPI or Connecticut Medical Assistance Program identification number from the drop down list for the referring physician Remarks Optional Format NNNNNNNNN Taxonomy Code This field will be auto plugged once you enter your provider number and contains an alphanumeric code that consists of a combination of the provider type classification area of specialization and education training requirements Note The health care provider taxonomy code list is available on the Washington Publishing Company web site http www wpc edi com Remarks Optional Format NNNANNNNNA
29. ntally retarded 12 Home 55 Psychiatric substance abuse treatment facility 13 Assisted Living Services 56 Psychiatric residential treatment center 15 Mobile unit 60 Mass immunization center 16 Temporary lodging 61 Comprehensive inpatient rehabilitation 20 Urgent care facility 62 Comprehensive outpatient rehabilitation 21 Inpatient 65 End stage renal disease treatment facility 22 Outpatient 71 State or local public health clinic 23 Emergency room 72 Rural health clinic 24 Ambulatory surgical center 81 Independent laboratory 25 Birthing center 99 Other unlisted facility 26 Military treatment facility 31 Skilled nursing facility Remarks Required Format XX Facility ID Select the appropriate facility provider identification number from the drop down list Required when Place of Service values are 21 22 31 or 25 Remarks Optional Format NNNNNNNNN Copay Amount Enter the copay amount if applicable Remarks Situational Format cec Total Months Enter the number of months for the orthodontia treatment plan if applicable Remarks Situational Format NN Months Remaining Enter the number of months remaining in the orthodontia treatment plan if applicable Remarks Situational Format NN EPSDT Select or select Y if the patient is part of the Early Periodic Screening Diagnosis and Treatment EPSDT program Remarks Required Format A HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 20 DENTAL C
30. payment has been received towards the claim from a third party Remarks Required Format Policy Holder Group Select the group number for the other insurance from the drop down list If a group number is not applicable please enter the policy number of the client For Medicare clients please enter the client s Health Insurance Claim HIC number Remarks Optional Format XXXXXXXXXXXXXXXXX Policy Holder Group Name This field is auto plugged when a group number is selected and contains the name of the group that the other insurance is listed under and coincides with Group number Remarks Required HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 31 DENTAL CLAIMS BILLING INSTRUCTIONS Format AAAAAAAAAAAAAA Policy Holder Carrier Code This field is auto plugged when a group number is selected and contains the carrier code identifying the Other Insurance carrier from the drop down list Remarks Required Format XXX Policy Holder Last Name This field is auto plugged when a group number is selected and contains the last name of the policyholder of the other insurance Remarks Required Format AAAAAAAAAAAAAAAAAAAAAA Policy Holder First Name This field is auto plugged when a group number 15 selected and contains the first name of the policyholder of the other insurance Remarks Required Format AAAAAAAAAAAAAAAAAAAAAA HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 32
31. rovider ID Taxonomy Last Org Name Type Qualifier 0987654321 123456000 PROVIDER2 Help 1234567890 5 00000 PROVIDER 4564564565 5 00000 PROVIDERS Select Close The Provider lists require you to collect information about service providers which are then automatically entered into forms These can be individual providers or organizations Use the Billing Provider list to enter all billing rendering and facility identification provider numbers Use the Other Provider list to enter referring provider numbers All fields are required except Provider Address Line 2 and First Name when the Entity Type Qualifier is a 2 Facility BILLING OTHER PROVIDER ENTRY INSTRUCTIONS Provider ID Enter the National Provider Identifier NPT or the Connecticut Medical Assistance Program billing provider number with two leading zeros if the provider is a Non Covered Entity NCE An NCE is a Medicaid service provider who is not included in the National Provider Identifier requirement Provider ID Code Qualifier Enter the code that identifies if the Provider ID submitted is the Medical Assistance Provider number or the Health Care Financial Administration HCFA National Provider Identifier NPI Taxonomy Code An alphanumeric code that consists of a combination of the provider type classification area of specialization and education training requirements Only numeric characters 0 9 and alphabetic characters A Z are accepted Lower c
32. sponds to the report type Code Description B4 Referral form DA Dental models DG Diagnostic report EB Explanation of benefits OB Operative Notes OZ Support data for claim P6 Periodontal charts RB Radiology films RR Radiology reports Remarks Optional Format XX Report Transmission Code Code defining timing transmission method or format by which reports are to be sent Enter the two digit value that defines the transmission method under which reports will be sent Code Description AA Available on request at provider s site BM By mail EL Electronically only EM E mail FX By fax Note If the values BM EL EM or FX are used the Attachment Control field will be required Remarks Optional Format AA Attachment Ctl This field is enabled when the Report Transmission Code is a BM EL or FX Enter the control number of the attachment Remarks Situational Format XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX DENTAL HEADER TWO HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 17 DENTAL CLAIMS BILLING INSTRUCTIONS 4g HP Provider Electronic Solutions HIPAA NCPDP File Edit View Forms Tools Window Help OY OBX OHA 5 9f 837 Dental Total Charge 01 Amount DSi Billed Amount Services J Headeri Header 2 Header3 service 1 Service 2 gt ron Referring Provider dd Provider ID Taxonomy Code Last Org First Na
33. st you in correct data entry however READ THESE SECTIONS CAREFULLY Payment or denial of your claims depends on the data you supply to Hewlett Packard Enterprise Please reference your billing manual for detailed Connecticut Medical Assistance Program billing requirements unique to your provider type Important Update This software will not be supported after October 1 2015 Current PES users are encouraged to transition to an alternative method of claim submission by October 1 2015 to avoid a disruption in electronic claims processing HPE PROVIDER ELECTRONIC SOLUTIONS USER S MANUAL 3 DENTAL CLAIMS BILLING INSTRUCTIONS Provider Electronic Solutions contains reference lists of information that you commonly use when you enter and edit screens For example you can enter lists of common diagnosis codes procedure codes and modifiers All of the lists are available from the data entry section as a drop down list where you can select previously entered data to speed the data entry process and help ensure accuracy of the form There are several lists that you are required to complete prior to entering a transaction Because this software uses the HIPAA compliant transaction format there is certain information which is required for each transaction To assist you in making sure that all required information is included and save time entering your information some of the lists are required These lists are Client Billing Provider and

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