PCA Claim
Review MHCP Billing Policy for general billing requirements and guidance when submitting claims.
Refer to additional billing requirements in the PCA section of the MHCP Provider Manual before you submit the claim for
services.
Log in to MN–ITS
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Log in to MN–ITS
From the left menu:
a) Select “MN–ITS”
b) Select “Submit DDE Claims (837)”
c) Select “Professional (837P)”
Submit the Claim
To submit the claim follow the instructions in the tables below for each of the following claim screens:
Billing Provider
Subscriber
Claim Information
Coordination of Benefits (COB) (complete only when the recipient has other/private insurance)
Services
Billing Provider
The billing provider screen auto-populates with the information in the enrollment profile for the NPI/UMPI used to login to
MN–ITS. If changes are needed, use the Change of Enrollment Information to notify MHCP Provider Enrollment.
Refer to the table below for instruction and information about each field on this screen.
Field Name *
(X12 Loop & element)
Field Instruction
Organization
(Loop: 2010AA, NM103 (last or
organization)
NM104 (first)
Taxonomy
(Loop: 2000A, PRV03)
The field auto-populates with the name of the PCA agency.
Address 1
(Loop: 2010AA, N301)
This field auto-populates with the first line of your address in your provider file.
Address 2
(Loop: 2010AA, N302)
This field auto-populates with the second line of your address in your provider file.
City
(Loop: 2010AA, N401)
This field auto-populates with the city listed in the address of your provider file.
State
(Loop: 2010AA, N402)
This field auto-populates with the state listed in the address of your provider file.
Zip
(Loop: 2010AA, N403)
Telephone
(Loop: 2010AA, PER04)
This field auto-populates with the zip code listed in the address of your provider file.
Action Button
Select Continue to proceed to the next screen.
This field only displays information when a Health care provider specialty/location code
has been added to the provider file.
This field auto-populates with the telephone number reported on the provider file.
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Subscriber
Use the Subscriber screen to report the recipient who received the service(s) reported on this claim.
Refer to the table below for instruction and information about fields to complete on this screen when entienrg PCA claims.
Field Name*
(X12 loop & element)
Field Instruction
Subscriber ID
(Loop: 2010BA, NM109)
Birth Date
(Loop: 2010BA, DMG02)
Enter the 8-digit MHCP ID for the subscriber (recipient) indicated on the MHCP
member identification card.
Enter the birth date of the subscriber.
Select the Search action button in this section to have MN-ITS find and display the
subscriber associated with the subscriber ID and date of birth entered.
The following fields auto-populate based on the information entered in the Subscriber ID and Birth Date fields
Subscriber First Name
The first name of the subscriber.
(Loop: 2010BA, NM104)
Middle Initial
The middle initial of the subscriber.
(Loop: 2010BA, NM105)
Last Name
The last name of the subscriber.
(Loop: 2010BA,NM103)
Gender
The gender of the subscriber.
(Loop: 2010BA, DMG03)
Select Delete to remove the subscriber information if the incorrect recipient.
Screen Action Button
Select one of the following screen action buttons:
 Continue to proceed to the next screen.
 Back to go back to the previous screen
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Claim Information
Use the Claim Information screen(s) to report header (claim) level information that will identify the type of claim and details
about the service(s). Information entered on the claim information screen will apply to all lines of the claim.
Refer to the table below for instruction and information about each field on this screen.
Field Name*
(X12 Loop & element)
Field Instruction
Claim Frequency Code
(Loop: 2300, CLM05-3)
Leave original if not submitting a Replacement or Void claim. The default is Original.
Select replacement if you are replacing a claim that MHCP previously paid for this
recipient.
Select void if you are voiding a claim that MHCP previously paid for this recipient.
This field only displays if you selected the replacement or void claim frequency code.
Enter the claim you want to replace or void.
Select from the drop down menu “12-Home” for all PCA claims.
Payer Claim Control Number
(Loop: 2300, REF02)
Place of Service
(Loop: 2300 CLM05-1)
Patient Control Number
(Loop: 2300, CLM01)
Assignment/ Plan
Participation
(Loop: 2300, CLM07)
Benefits Assignment
(Loop: 2300, CLM08)
Release of Information
(Loop: 2300, CLM09)
Enter words, numbers, letters or a combination to report a unique code to identify this
claim for this recipient in your records. This can be anything you want. MHCP will
report this back to you on the remittance advice (RA).
Select the code to report whether the provider accepts payment from MHCP if different
than the default. The default is Assigned.
The options are:
 Assigned - provider has a participation agreement with MHCP
 Assignment Accepted - provider accepts assignment only for clinical lab services
 Not Assigned - neither assigned nor assignment accepted apply
Select the benefit assignment to report the policy holder or person authorized to act on
their behalf, gives MHCP permission to pay the provider directly if different than the
default. The default is Yes.
The options are:
 Yes - Benefits assigned to the provider
 No - Benefits not assigned to the provider
 Not Applicable - Patient refuses to assign benefits
Select the correct response if different than the default to report The determination of
whether the provider has a signed statement by the recipient on file, authorizing the
release of medical data to other organizations. The default is Yes.
The options are:
 Yes - Signature collected or required
 Informed Consent - Signature not collected and not required
Select the correct response if different than the default to report whether the provider’s
signature is on file, certifying services were performed by the provider. The default is
Signature on File.
Diagnosis Code
Enter the diagnosis code (ICD) that is listed on your service authorization (SA) or
(Loop: 2300, HI01-2, HI02-2,
Assessment and Service Plan document.
HI03-2, HI04-2)
Select the Add action button in this section to include the diagnosis code on the claim.
Once a diagnosis code is entered it will display in the table below. Select the Delete
button next to a diagnosis code to remove it from the claim.
Situational Claim Information - Select this accordion panel to report service agreement number.
Prior Authorization Number
Enter the service agreement number from your service authorization (SA) letter.
(Loop: 2300, REF02)
Other Providers (Claim Level) – Select this accordion panel to report other providers when required
Rendering Provider
NPI/UMPI
1. Enter the UMPI of the individual PCA provider
(Loop: 2310B, NM109)
2. Select Add to add the individual PCA provider’s information
3. Select the radio button to select this individual PCA provider for all lines on the
claim; otherwise leave blank
Screen Action Button
Select Continue to proceed to the next screen.
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Provider Indicator
(Loop: 2300, CLM06)
Coordination of Benefits (COB)
Use the COB screen to report other payers, private insurance (TPL) or Medicare’s financial responsibility for all or a
portion of the claim. If no other payers are involved with this claim, select the Continue button at the bottom of this screen
to proceed to the next screen.
To report each type of other payer information at the claim/header level use the tables below:
TPL/Private Insurance (non-Medicare)
Complete the following fields to report adjustment, payments and denials from the private insurance (Non-Medicare)
carrier.
Field Name*
(X12 Loop & Element)
Field Instruction
Other Payer Name
(Loop: 2330B, NM103)
Other Payer Primary ID
(Loop: 2330B, NM109)
Enter the full name of the insurance carrier/other insurance.
Claim Filing Indicator
(Loop: 2320, SBR09)
Payer Responsibility
(Loop: 2320, SBR01)
Insured ID
(Loop: 2330A, NM109)
Relationship Code
(Loop: 2320, SBR02)
Claim Adjustment Group
Code
(Loop: 2320, CAS01)
Enter the Identifier of the insurance carrier.
This is reported as the carrier ID for the insurance coverage, in the Other Insurance
section of the eligibility reponse for this recipient.
Select from the drop down menu, the code identifying the type of insurance.
The type of insurance is usually reported in the Other Insurance section of the eligibility
response for this recipient.
Once the claim filing indicator is selected, additional fields will display to report
payments made by the TPL/other insurance.
Select the code identifying the insurance carrier’s level of responsibility for payment of
the claim, from the drop down menu.
Scenarios:
 If this insurance is the first payer and you sent the claim to and then MHCP second
then this insurance is the primary payer
 If this insurance is the second insurance you sent the claim to and now MHCP
third, then this insurance is the secondary payer
Enter the policy holder’s policy number with this other insurance.
Select from the drop down menu, the relationship of the MHCP subscriber (recipient) to
the policy holder.
Example: Recipient is the child to the person who holds this other insurance policy.
Complete this field only if you want to report the claim adjusments at the claim level
instead of line per line at the service line level.
To report claim adjustments: select the adjustment code from the drop down menu, to
report the type of adjustment reported by the other insurance.
Adj Reason Code
(Loop: 2320, CAS02, CAS05,
CAS08, CAS11, CAS14,
CAS17)
Adj Amount
(Loop: 2320, CAS03, CAS06,
CAS09, CAS12, CAS15
CAS18)
Adj Quantity
(Loop: 2320, CAS04, CAS07,
CAS10, CAS13, CAS16,
CAS19)
Action Button
Use the Washington Publishing Company link, on right, to find the HIPAA compliant
code that matches the adjustment response on the other payer’s EOB.
This field is used only when reporting TPL/private insurance at the claim (header) level
rather than at the service line.
Enter the code identifying the reason the other payer adjusted the payment.
Use the Washington Publishing Company link, on right, to find the HIPAA compliant
code that matches the adjustment response on the other payer’s EOB.
This field is used only when reporting TPL/private insurance at the claim (header) level
rather than at the service line.
Enter the dollar amount of the adjustment.
This field is used only when reporting TPL/private insurance at the claim (header) level
rather than at the service line.
Enter the number of units not paid when the units paid are different than the number of
units submitted on the claim.
Select the Add action button in this section to include the adjustment entries on the
claim.
Action Button
Payer Paid Amount
(Loop: 2320, AMT02)
Repeat the Claim Adjustment entries to report all adjustments as noted on the EOB
from the TPL/private insurance.
Select the Delete action button next to an adjustment to remove it from the claim.
This field is used only when reporting TPL/private insurance at the claim (header) level
rather than at the service line.
Non-Covered Charge Amount
(Loop: 2320, AMT02)
Benefits Assignment
(Loop: 2320, O103)
Enter the total dollar amount paid by ther other payer.
This field is used only when reporting TPL/private insurance at the claim (header) level
rather than at the service line.Enter the total dollar amount the other payer did not pay.
The determination of the policy holder, or person authorized to act on their behalf, to
give the other payer permission to pay the provider directly.
Release of Information
(Loop 2320, O106)
Default is Yes.
Select the correct response if different than the default.
The determination of whether the provider has a signed statement by the recipient on
file, authorizing the release of medical data to other organizations.
Section Action Button
Screen Action Button
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Default is Yes.
Select the correct response if different than the default.
Select one of the following screen action buttons:
 Save to save the entry
 Delete to remove this entry
 Add to save this entry and add another payer.
After you save the entry, select Continue to proceed to the next screen.
Services
Use the Services screen to enter each date of service you provided PCA services for the recipient. Information reported
on a service line will override information reported at the header (claim) level for that line.
Refer to the table below to compelte each field in the services screen for instruction and information about each field on
this screen.
Field Name*
(X12 Loop and element)
Field Instruction
Date of Service (From)
(Loop: 2400, DTP03)
Procedure Code
(Loop: 2400, SV101-2)
Enter the date the service was provided.
Enter the HCPCS code from your service authorization letter.
Procedure Code Modifier(s)
(Loop: 2400, SV101-3, SV1014, SV101-5, SV101-6)
Diagnosis Pointer
(Loop: 2400, SV107-1, SV1072, SV107-3, SV107-4)
Line Item Charge
(Loop: 2400, SV102)
Service Unit Count
(Loop: 2400, SV104)
Enter the modifier that clarifies or further identifies the service indicated in the
procedure code field.
PCA claims only require the most current, most specific diagnosis code for the service
provided on this claim line.
Review to ensure the diagnosis code is displaying in the first field.
If the code is not visible, use the drop down menu to select the correct diagnosis code
for this line of the claim.
Enter your total charge for all units on this line.
To determine the total charge, multiply the number of units for this line to your usual
and customary charge for this service.
If you report other payers in the COB or line COB sections, your total charge must be
the same as the amount you submitted or would have submitted to the other payer.
Enter the number of units for this service line.
Other Payer – Use this section only if reporting other payer (TPL) COB payments or denials at the service (line) level.
To complete this section, select the Other Payer accordion panel and complete the fields. If the recipient does not have
other/private insurance to report, skip this accordion section and move on to the Other Provider accordion section.
Other Payer Primary Identifier From the drop down menu, select the identifier of the TPL/private insurance carrier,
(Loop: 2430, SVD01)
HMO Medicare Risk or the NPI of the Medicare contractor.
Service Line Paid Amount
Enter the total dollar amount the other payer paid for this service line.
(Loop: 2430, SVD02)
Adjudication - Payment Date
Enter the date of payment or denial determination by the Medicare payer for this
(Loop: 2430, DTP03)
service line.
Paid Unit Count
(Loop: 2430,SVD05)
Claim Adjustment Group
Code
(Loop: 2430, CAS01)
Adjustment Reason Code
(Loop: 2430, CAS02)
Adjustment Amount
(Loop: 2430, CAS03)
Adjustment Quantity
(Loop: 2430, CAS04)
Action Button
This field is not required for TPL/private insurance reporting.
Enter the number of units identified as being paid from the other payer’s EOB/EOMB
for this service line.
From the drop down menu, select the adjustment code identifying the general category
of payment adjustment for this service line.
Use the Washington Publishing Company link, on right, to find the HIPAA compliant
code that matches the adjustment response on the other payer’s EOB.
Enter the code identifying the reason the other payer adjusted the payment for this
service line.
Use the Washington Publishing Company link, on right, to find the HIPAA compliant
code that matches the adjustment response on the other payer’s EOB.
Enter the dollar amount of the specific adjustment for this service line.
Enter the number of units not paid when the units paid are different than the number of
units submitted for this service line.
Select the Add action button in this section to include the adjustment entries on the
service line.
Repeat the Other Payer COB Line Adjustment Entries to report all adjustments for this
service line as noted on the EOB/EOMB.
Select the Delete action button next to an adjustment to remove it from the service line.
Section Action Button
To remove the entire COB line entry, select the delete action button afer adding the
information.
Select the Save action button in this section, below the display of adjustments, to save
the COB information for the payer to this service line.
Once saved, the COB Line Payments/Adjustments screen will appear with the
following information:
 Other Payer Primary identifier
 Line Paid Amount
 Total Adjustment for the service line
Section Action Button as
needed
Section Action Button as
needed
Select the Edit action button next to a payer to change the adjustment entries for the
payer (the totals on this screen should equal the charge you sent to the primary payer).
Select the Add action button in this section, below the display of payers, to report
another payer to this service line. Repeat the same steps to add additional payer
information for this service line.
Other Providers – Use this accordion section to report the individual PCA provider who provided the service on each
service line.
Rendering Provider
NPI/UMPI
If different than the provider reported on the claim information screen:
(Loop: 2420A, NM109)
 Enter the NPI of the provider who provided the service
 Select the action button in this section to add the other provider information
 Select the radio button to add the other provider to the claim
Section Action Button
Select one of the following:
 Save/ View Line(s): to save the line item if only one line item is entered or if not
using the Copy or Add action button for the next line.
 Copy: to save and copy the service line information that was just entered so that
you can make changes to the copied service line.
 Delete: to remove the service line information that is displayed.
 Add: to add a new service line to the claim. A new service line will display for you
to enter new information for your next service line.
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Select Save/View Line(s) once all entries are complete.
Service Line Recap Table
Each time you select save/view line, a summary table will display providing a summary
for each line, showing:
 Line number
 From and to Date
 Procedure Code
 Modifier
 Charge
 Units
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Select the Edit button next to the line item if changes are needed to that service line.
Finish the Claim
Select Add below the service line summary table to add additional service line(s).
Select one of the following action buttons to finish the claim:
 Back to go back to the previous screen
 Cancel to cancel the claim entry
 Validate to determine if the claim has met the HIPAA-compliant and certain basic
requirements at both the claim and line level information.
 Submit to submit the claim for adjudication. The submit response will identify if the
claim will be paid, denied or suspended for review at the claim level and the line
level of the claim.
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Use the Washington Publishing Company (WPC) health care codes lists to identify the
claim status category and claim status codes displayed on the claim response.
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Review the Copy, Replace or Void User Guide for step-by-step instructions when completing these transactions.