MO HealthNet Help
Drug Claim Suspense/Exam Entry
Allows for entering or changing the Drug Claim. ICN
The Internal Control Number assigned to the claim. Status
This code identifies the status of the claim. A list of valid values is located in the Tables Manual and can be viewed by clicking the following link:
http://systemmanuals.momed.com/collections/Tables/Tables%20PDF%20Files/Tables_Claim_St atus_Codes_Claims_Processing.pdf
Image
The one-digit indicator identifies if the claim has an image available. The valid values are Y - Yes and N - No.
Split Ind
Indicates the claim as it was billed by the provider was split into one or more claims. A list of valid values is located in the Tables Manual and can be viewed by clicking the following link: http://systemmanuals.momed.com/collections/Tables/Tables%20PDF%20Files/Tables_Split_Cla im_Indicator.pdf
Form Number
The pre-printed number (used as the invoice number) on the upper right hand corner of the claim form.
Bottom Button
Click on the Bottom button to go to the bottom of the page. Abbreviated Name (Provider)
The first two letters of the provider's last name followed by the system generated provider name.
ID/NPI
The nine-digit MO HealthNet legacy provider identification or the National Provider Identifier (NPI) is a unique 10-digit identification number for covered health care providers. When a NPI is entered, the system will populate the field with the provider ID.
Name (Provider)
Provider's full name (system generated). Provider Specialty
The provider specialty code generated from the provider file. A list of valid values is located in the Tables Manual and can be viewed by clicking the following link:
http://systemmanuals.momed.com/collections/Tables/Tables%20PDF%20Files/Tables_Provider _Specialty.pdf
Prior Authorization Number
Abbreviated name (Participant)
The first two letters of the participant's last name and the first letter of the participant's first name.
Name (Participant)
Participants last name and first name (system generated). DCN
The eight-digit participant MO HealthNet identification number keyed from the claim unless a presumptive ID was billed. In that instance, the participant ID on-line may be a cross reference ID, which replaces the presumptive ID keyed.
Diagnosis Code
The diagnosis code entered is used for tracking therapeutic drugs. Medicare D Ind
Indicates the participant's Medicare Part D status on the Date of Service (DOS) billed. Valid values are:
Blank - Participant does not have Medicare Part A, B, or D on the DOS
D - Participant has Medicare Part D on the DOS or is QMB-only on DOS and has MoRx coverage
P - Participant has Medicare Part A and B, but does not have Part D on the DOS O - Participant has Medicare Part D override for the DOS
Q - Participant is SLMB on DOS and has MoRx coverage S - Participant is QI on DOS and has MoRx coverage Mo-Rx Ind
Indicates when the Missouri Prescription Plan (MoRx) Process Control Number (PCN) is used during billing. Valid values: Y - MoRx PCN was used for billing and N - MO HealthNet PCN was used for billing.
Submitted Charge Ind
A code indicating if the submitted usual and customary charge or the gross amount due was populated for the total charge. If the usual and customary charge and the gross amount due are submitted with the claim, the system will select the lower of the two and set this indicator to indicate what amount was populated in this field. If the field is left blank then only one amount was submitted. Valid values are:
Blank
G - Gross Amount
U - Usual and Customary Eligibility Clarification Code
This is a code indicating that the pharmacy is clarifying eligibility based on receiving a denial. Valid values are:
0 - Not Specified 1 - No Override 2 - Override
3 - Full Time Student 4 - Disabled Dependent 5 - Dependent Parent 6 - Significant Other
Compound Ind
The compound indicator. A 2 indicates additional ingredients of a compound prescription. Submission Ind
The code indicates how the claim was submitted. Valid values are: B - 837 Internet Batch
C - COBC (GHI) if clerk ID and submission indicator is on system parameter SUBI the submission indicator is updated to C
F - Internet Form P - Paper
X - 837 NDM or POS
Blank - Anything that is not 837 compliant other than paper Frequency Ind
The code indicates how the claim is being processed. Valid values are: 1 - Original
7 - Replacement 8 - Void
Nursing Home Ind
This code indicates whether the drug was dispensed to a nursing home participant. Valid values are:
Y - Participant is a nursing home resident N - Participant is not a nursing home resident EPSDT Ind
This information indicates whether this drug was dispensed to a participant under the Early Periodic Screening and
Diagnostic Treatment (EPSDT) Program. Valid values are: Y - EPSDT related
N - Not EPSDT related Third Party Liability Ind
This code indicates whether the participant has other insurance and if it is applicable to the claim.
Valid values for NCPDP v5.1 drug claims only with dates of service after 9/9/2005 are: 0 - Not specified
1 - No other coverage identified
2 - Other coverage exists-payment collected 3 - Other coverage exists-this claim not covered 4 - Other coverage exists-payment not collected 5 - Managed Care plan denial
6 - Other coverage denied-not a participating provider 7 - Other coverage exists-not in effect at time of service 8 - Claim is a billing for a copay
Valid values for NCPDP vD.0 drug claims are: 0 - Not specified
1 - No other coverage identified
2 - Other coverage exists-payment collected 3 - Other coverage exists-this claim not covered 4 - Other coverage exists-payment not collected Rx Number
The number assigned by the pharmacy for the prescription filled or refilled. Originator Indicator
The code indicates the origin of the claim into the system. Valid values are: BTCNCPDP 5.1 or 837 Adjustment/Credit
PCCPOS Capture PDCPOS Drug Claim PDGPaper Drug
PRVPOS Adjustment/Credit Code Set Version Ind
The code indicates the version of the code set applicable to the claim. Valid values are: I9 ICD-9
IXICD-10
Prescribing Provider ID
The MO HealthNet number of the physician that prescribed the prescription. This number can also be the Drug Enforcement Administration (DEA) number.
Prescribing Provider Name
Prescribing provider's name (system generated). Dispense Date
The date the prescription was dispensed. Thru Date
The end date the prescription was dispensed. National Drug Code
The universal product identifier for the product being billed. Drug Name
The name of the drug dispensed. Generic Drug Code
The generic code associated with the prescription. Generic Drug Name
The generic name of the drug dispensed. Metric Quantity Dispensed
Quantity dispensed. Decimal Quantity Dispensed
Quantity dispensed in decimal units. Days Supply
This indicates the number of days the dispensed amount should last. Total Charge Amount
The amount to be paid for the procedure billed. If the procedure is to be manually priced, the amount is entered by the user.
Submitted Charge Amount
The amount the provider is billing for the dispensed prescription. Allowed Amount
The amount to be paid for the procedure billed. If the procedure is to be manually priced, the amount is entered by the user.
Other Insurance Amount
The amount paid by an other payer toward this claim. Patient Responsibility Amount
The amount the previous payer has reported as the participant's responsibility. Net Charge
The amount remaining after the other insurance payment has been deducted from the total charge.
Dispensing Fee Amount
The dispensing fee amount paid for the claim. Spenddown Incurred Amount
The amount of spenddown incurred on the claim. This amount is applied to the A/R for this claim.
Spenddown Withheld Amount
The dollar amount applied to reduce the reimbursement amount. Charge Source Code
The claim charge source is the pricing action code. A list of valid values is located in the Tables Manual and can be viewed by clicking the following link:
http://systemmanuals.momed.com/collections/Tables/Tables%20PDF%20Files/Tables_Pricing_ Action_Codes_Drug.pdf
Dispensing Status Code
This code indicates if the quantity dispensed is a partial fill or the completion of a partial fill. Valid values are:
P - Partial Fill
C - Completion of Partial Fill Lockin Provider ID
The lockin provider number of the participant. Refill Code
This code indicates if the prescription if an original or a refill. Valid values are: O - Original Prescription
R - Refill Prescription Current Location
The code indicates the current location of the claim. Current Location Date
System EOB
The header Explanation of Benefits (EOB) codes. If present, the system displays two EOBs. The first EOB is taken from the Exception Control File during claims processing, the second EOB is entered on the claim during claim resolution.
Manual EOB
The EOB that was manually keyed by the resolution clerk. Override Location
The override location code to be overridden. This information is placed on the claim during resolutions and causes the claim to be placed into a location other than the original location that was posted during claims processing.
Override Exception
The override exception code to be overridden. This information is placed on the claim during resolutions and causes the claim to be placed into a location other than the original location that was posted during claims processing.
Previous ICN
The Internal Control Number (ICN) of this claim when it was previously submitted and denied. This ICN is used in conjunction with timely filing.
Remittance Advice Number
The Remittance Advice number on which this claim was reported. This is system generated and contains no data while in suspense.
Reimbursement Amount
The total reimbursement amount for all lines on this claim. This is system generated and contains no data while in suspense.
Paid Date
The Remittance Advice (RA) date the claim was reported on in MM/DD/CCYY format. This is system generated and contains no data while in suspense.
Adjustment ICN
The Adjustment Internal Control Number (ICN) assigned to the adjustment. Adjustment Reason Code
The Adjustment Reason Code assigned to the adjustment. A list of valid values is located in the Tables Manual and can be viewed by clicking the following link:
http://systemmanuals.momed.com/collections/Tables/Tables%20PDF%20Files/Tables_Adjustm ent_Reason_Codes.pdf
Line
The line that applies to the exception code. Exception Code
The exception code number(s) which was posted to the claim. Exception Status
The status for the exception code on the claim. A list of valid values is located in the Tables Manual and can be viewed by clicking the following link:
n_Status_Codes.pdf Clerk ID
The identification number of the clerk who resolved the suspended exception or overrides the exception.
Scroll Button
Click on the Scroll button to scroll through the exceptions on the claim. Top Button
Click on the Top button to go to the top of the page. Back Button
Click on the Back button to go back to the key panel. Previous Claim Button
Click on the Previous Claim button to go to the previous claim in exam entry. Not valid in suspense mode.
Next Claim Button
Click on the Next Claim button to go to the next claim in exam entry. Not valid in suspense mode.
Full Description Button
Select a field with the cursor and then click on the Full Description button to display a screen with a full description of the field selected. This button applies to Provider ID, NPI, DCN, NDC, etc.
Name Lookup Button
Click on the Name Lookup button to go to Claim Provider and Participant Key Panel (GAV0841).
