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Provider Electronic Solutions User Guide

Provider Electronic Solutions User Guide R E V I S E D : S E P T E M B E R 1 3 , 2 0 1 1 V E R S I O N 2 . 1 2


Table of Contents 0BIntroduction to Provider Electronic Solutions ............................................................... 1 9BUsing This Guide .......................................................................................................... 1 10BSystem Requirements (minimum) ............................................................................. 1 11BInstalling Provider Electronic Solutions .................................................................... 2 12BLogging On the First Time .......................................................................................... 2 13BInstalling Upgrades ...................................................................................................... 3

1BSetting Up Provider Electronic Solutions ...................................................................... 4 14BConnection Tab ............................................................................................................ 4 15BBatch Tab ...................................................................................................................... 4 16BPayer/Processor Tab ................................................................................................... 4 17BRetention Tab ............................................................................................................... 4

2BNavigating Through Provider Electronic Solutions .................................................... 5 18BUsing Lists ..................................................................................................................... 5 19BUsing the Mouse........................................................................................................... 5 20BMenus............................................................................................................................. 5 21BToolbars ......................................................................................................................... 5 22BCommand Buttons ....................................................................................................... 5 23BUsing the Keyboard ..................................................................................................... 6 24BUsing the Online Help .................................................................................................. 6

3BCustomizing Provider Electronic Solutions .................................................................. 7 25BCreating Lists ................................................................................................................ 7 26BUsing Lists ..................................................................................................................... 7

4BSubmitting Forms ............................................................................................................. 8 27BEntering Forms ............................................................................................................. 8 28BSubmitting Forms ......................................................................................................... 9 29BModifying and Resubmitting Forms ........................................................................... 9

5BOther Features ................................................................................................................ 10 30BCreating a Claim Status Inquiry Batch .................................................................... 10 31BSubmission Reports ................................................................................................... 10 32BBatch Response Reports .......................................................................................... 11 33BDownloading and Viewing Responses ................................................................... 12 34BUsing the Edit All Feature ......................................................................................... 12

6BUsing Provider Electronic Solutions Tools ................................................................. 13 35BDatabase Recovery ................................................................................................... 13 36BCreating New Users ................................................................................................... 13 37BChanging Passwords ................................................................................................. 14 38BArchiving Submissions .............................................................................................. 14 39BRestoring Archives ..................................................................................................... 15

7BAppendix I Frequently Asked Questions .................................................................... 16 8BAppendix II Commonly Requested Form Walkthroughs .......................................... 18


Revised:09/13/2011 1 Version: 2.12

0BIntroduction to Provider Electronic Solutions

Provider Electronic Solutions (PES) is an application that can be installed on a hard disk or a network drive and can be installed on as many personal computers (PCs) as necessary. PES can also be installed for use by multiple computers in a network environment. The network administrator should be contacted to set up a shared database location for network installations.

9BUsing This Guide

The purpose of this user guide is to provide the general information needed to use the PES software. This user guide does not provide specific billing information. Providers should use the Kansas Medical Assistance Program (KMAP) provider manuals for program-specific claim filing instructions. These can be found at 2TUhttps://www.kmap-state-ks.us/Public/providermanuals.aspU2T.

10BSystem Requirements (minimum) Pentium II with CD-ROM Windows 98/2000/XP MS Internet Explorer 5.5 or greater 64 megabytes RAM 800 X 600 resolution 100 MB hard drive space available 28.8 kbps modem (or faster) Printer with 8pt MS Sans Serif font (optional)

Provider Electronic Solutions User Guide Introduction to Provider Electronic Solutions

Revised: 09/13/2011 2 Version: 2.12

11BInstalling Provider Electronic Solutions

Do not use the installation program if PES is already installed and needs to be upgraded. See the next page for upgrade instructions.

1. If installing from a compact disk (CD), insert the program CD into the computer. Note: If the Windows AutoPlay feature is active, skip to step 6.

2. Open the Start menu and select Run.

3. Click Browse and select the CD drive or the folder that the installation program was downloaded to and highlight KS_vxxxx_Setup.exe.

4. Click Open.

5. Click OK. The Welcome window displays.

6. Click Next. The License Agreement window displays.

7. Click Yes.

8. Select the type of setup needed. Select Typical Setup if only installing on one PC or if this is the first installation for a network. Otherwise, select Workstation Setup. Click Next.

9. Click Next to accept the default destination for the software.

10. Click Next to accept the default destination for the database or click Browse to change the destination directory to where the database is to reside. For workstation installations, click Browse and select the shared directory in which the database was initially installed.

Warning: When selecting a typical installation, an empty database will be placed in the folder. If there is already a PES database in the folder, the existing information will be erased.

11. Click OK. A graphic displays showing the progress of the installation. The installation can be cancelled at any time by clicking Cancel.

12. When the installation is complete, click Finish to exit the installation.

12BLogging On the First Time When logging on for the first time, the only user available is pes-admin. The password default is eds-pes. When installing a workstation, use the user identification (ID) and password set up by the administrator.

After entering the user ID and password, click OK. A new password along with a question and answer must be entered after the initial logon.

Provider Electronic Solutions User Guide Introduction to Provider Electronic Solutions


13BInstalling Upgrades Periodically, upgrades are required to improve the quality of the application or to keep up with policy changes. When an upgrade is available, follow the instructions below.

1. Click Tools from the main menu and select Get Upgrades. PES connects to the KMAP website to download the upgrade(s). Since the upgrade files are sometimes fairly large, the download may take up to several hours depending on the speed of the PC’s Internet connection. Do not be concerned if the application becomes unresponsive for a period of time.

2. When the download is complete, exit the application.

3. Open the Start menu and select Program Files > KS EDS Provider Electronic Solutions > Upgrade.

4. Select Yes to accept installation. PES expands the upgrade and begins the installation. Follow the instructions.

5. Click Finish to complete the installation.

Note: When applying an upgrade in a network environment, make sure all PCs with PES installed also apply the upgrade. This will ensure all copies of the application remain synchronized with the database.

6. If the installed version is more than one version behind the current version, for example upgrading version 2.03 to version 2.12, repeat steps 4 through 6 until the message is received that there are no upgrades available.



1BSetting Up Provider Electronic Solutions

Once logged on, the initial settings for PES need to be entered. When all of the information has been entered, click OK to save. Click Tools in the main menu and select Options to access this window in the future.

14BConnection Tab The Connection tab is used to set up the method for submitting information. If connecting to the Internet through a LAN or the default ISP, verify the box labeled Use Microsoft Internet Explorer Pre-config Settings is selected.

15BBatch Tab The Batch tab is used to enter information for submitting forms using the web server. In the Web Logon ID and Web Password fields, enter the user information used to log on to the KMAP MMIS on the Internet. This information is required to log on to the KMAP website to submit claims. If the password is changed on the website, it must be updated here as well. The contact information and trading partner ID must also be entered on this tab.

16BPayer/Processor Tab The Payer/Processor tab is used to identify who will be receiving the information submitted from PES. The fields will be prepopulated with the information for KMAP. These fields should never be altered.

17BRetention Tab The Retention tab is used to specify how PES handles various options such as storage of forms and password changes. For specific information about each field, access the online help by clicking on the field and then clicking Help.



2BNavigating Through Provider Electronic Solutions

Navigating through the PES software is similar to other Windows-compatible applications. There are a variety of ways different utilities can be accessed.

18BUsing Lists All of the list utilities in PES work the same. When a list is first opened, a new entry is created. To save the entry, click the corresponding Save button. Once saved, select Add or Copy to create a new entry. To change a previous entry, click the left mouse button on the item to be changed. The data populates automatically for that entry.

19BUsing the Mouse Use the mouse as you do in any other software. Move the mouse cursor over a field or option and click the left mouse button once to position the cursor at that location or to select the option. To double click on a feature, press the left mouse button twice in quick succession. The right mouse button will allow use of the Cut, Copy, Paste, or Select All options the same as the menu or toolbar options. Just click the right mouse button over the field and select the option from the menu.

20BMenus PES uses menus for navigation throughout the application. The menu options change depending on which features are being used. When first opening PES, the main menu is visible. Menus can be used by clicking on them with the mouse or by pressing ALT on the keyboard.

21BToolbars Toolbars are designed to work as shortcuts for frequently used menu items. A toolbar consists of small pictures or buttons representing different menu commands. To execute a command using the toolbar, click on the button with the mouse. To see a name or brief description of each button, move the arrow over the button, but do not click the mouse. The description appears just below the button.

22BCommand Buttons Activate command buttons by clicking them with a mouse or using the hot key associated with that button. An underlined letter on the button identifies the hot key. Press this hot key along with the ALT key to activate the button.

Provider Electronic Solutions User Guide Navigating Through Provider Electronic Solutions


23BUsing the Keyboard To navigate using just the keyboard, use the following list of keys:

To do this Press this key Go to the next field TAB or ENTER Go to the previous field SHIFT+TAB Move backward within a field Left Arrow Move forward within a field Right Arrow Scroll up through a list Up Arrow Scroll down through a list Down Arrow Open online help when the cursor is on a data entry field

F1

24BUsing the Online Help PES has an extensive set of online documentation available. To get information about a field, click the left mouse button over the field and then press F1.

For additional information about all of the features of PES, access the help index by clicking Help Topics in the upper left corner of the help window.



3BCustomizing Provider Electronic Solutions

PES contains reference lists for information frequently used when entering and editing forms. For example, common diagnosis codes and procedure codes can be entered for use later. All of the lists are available from the form entry section as a drop-down list.

25BCreating Lists Since this software uses the Health Insurance Portability and Accountability Act (HIPAA) compliant transaction format, there is certain information required for each transaction. To ensure all required information is included and to save time, some of the lists must be entered before using the information in a form. If the necessary information has not been completed prior to entering a form, open the list entry window from the transaction by double clicking on the corresponding drop-down list.

To add information to a list, select Lists from the main menu and then select the appropriate list. Enter any necessary information and then click Save. As always, additional information about each field can be found by clicking on the field and pressing F1 or by clicking Help. To create additional entries, click Add and repeat the process.

26BUsing Lists The information entered is available in drop-down lists when completing a form. When a selection is made from one of the drop-down lists, other fields may be populated automatically to match the selection. If a selection is not available in a drop-down list, double click on the list to access the list entry window. Once the information is entered, click Save and close the window. The information will be available for future use.



4BSubmitting Forms

PES may be used to create, edit, and submit forms. For example, instead of filling in a form on paper, forms may be completed and saved on a PC. The forms can then be submitted electronically for processing by KMAP.

PES provides the following form types:

Form Type Button

837 Professional

837 Institutional Inpatient

837 Institutional Outpatient

837 Institutional Nursing Home

270/271 Eligibility Inquiry and Response

276/277 Claim Status Request and Response

278 Prior Authorization Request and Response

NCPDP Pharmacy

NCPDP Pharmacy Reversal

NCPDP Pharmacy Eligibility

NCPDP Pharmacy PA Inquiry

NCPDP Pharmacy PA Request

27BEntering Forms To enter a form, click Forms from the main menu and then select the type of form to submit. Forms can also be selected by clicking on the corresponding icon in the toolbar.

The information on each form is separated into several tabs. Be sure to enter the necessary information for each tab. For a description of information for each field, press F1. Also, see Appendix II for commonly requested claim walkthroughs. When finished, click Save.

Many of the fields in forms have drop-down lists available to select commonly used information. Selecting from some drop-down lists may cause other fields to automatically populate. If an item in a list needs to be added or changed, double click on the list to access the list editor.

Some information is required to comply with HIPAA standards. If there is required information missing when attempting to save the form, another window appears indicating the missing information. Choose to save the incomplete form (status I) or go back to the fields listed and enter the missing information.

Provider Electronic Solutions User Guide Submitting Forms


When finished, click Save again. Once the form is saved successfully, it appears in the list at the bottom of the window with a status of R (Ready).

28BSubmitting Forms PES allows multiple forms (a batch) to be saved for submission at the same time. All forms saved with a status of R (Ready) are included in a batch.

1. After filling out all of the forms to be submitted in a batch, close the form window.

2. Click Communication from the main menu and select Submission. The Batch Submission window displays.

3. Select the method to use when submitting the batch of claims from the Method drop-down list. Claims can be submitted either through the web server (includes dial-up) or to a diskette.

4. Highlight the types of forms to submit. Multiple types of forms can be submitted at the same time.

5. Click Submit. After submission, the forms that were in R status are changed to F (Final). Forms in F status will not be resent and cannot be altered but can be copied and edited for future submissions. To remove old forms in F status, use the Archive feature.

29BModifying and Resubmitting Forms PES allows the resubmission of an entire batch or just a portion of a batch. A batch can be resubmitted exactly as it was or can be copied and modified.

1. Click Communication and select Resubmission from the main menu. The Batch Resubmission window displays with a list of previously submitted batches.

2. Select a batch and then highlight the claims within that batch to resubmit.

3. To resubmit the claims without changing them, click Resubmit to be taken to the Batch Submission window. Otherwise, click Copy to replicate the forms. The selected forms are placed with the current batch in R status to be reviewed or edited.

If the batch was copied, do not attempt to use the Resubmission option to send the modified batch. The Submission option must be used instead.



5BOther Features

PES offers many useful reports and other tools such as global date changes and a claim status inquiry batch creation.

30BCreating a Claim Status Inquiry Batch Once a batch of claims has been submitted, PES allows users to create a claims status inquiry batch from previously submitted claims.

1. Select 276 Claim Status Inquiry from the Forms menu.

2. Click Select Batch. A window containing previously submitted batches appears.

3. Click the batch to check on, and then click Copy. An inquiry is created for each claim in the batch.

4. Close the form window and use the Submission option in the Communication menu to send the 276 batch transaction. See the Batch Response Reports section for information to retrieve the response.

31BSubmission Reports Reports can be created for almost any of the data in PES. These reports are available under the Reports option in the main menu. Reports can also be created for batch transactions either before or after they are submitted.

1. From the Reports menu, select either Detail Forms or Summary Forms. Detail reports display all of the information for each form and usually take up a lot of space. Summary reports are shorter and display the most commonly used information.

2. Select the form type to view.

3. If the batch has already been submitted, enter the batch number in the Batch Number field. To view forms that have not been submitted, select Ready from the Form Status field. Click OK on the right side of the window.

4. To print reports, click Print on the right side of the window. When finished viewing the report, click Close.

Provider Electronic Solutions User Guide Other Features

Revised: 09/13/2011 11 Version: 2.12

32BBatch Response Reports PES will download responses to batch submissions. The following response transactions are available from KMAP. Each response is normally available approximately an hour after the request.

277 Claim Status Response

The claim status report is only sent in response to a 276 claim status inquiry request.

278 Prior Authorization Response

The prior authorization response is only sent in response to a 278 prior authorization request.

NCPDP-Pharmacy Response

The pharmacy response transactions are sent in reply to any of the NCPDP transactions available in PES.

835 Electronic Remittance Advice

The electronic remittance advice is only available if requested on the trading partner application. The 835 transaction is made available for download every Monday.

997 Acknowledgment

Batch acknowledgments are sent in response to the 270, 276, 278, and 837 transactions. If there is an error processing the transaction, the 997 contains detailed technical data about the error.

Batch Submit Report

Submit reports are created in response to the 270, 276, 278, and 837 transactions. The report contains a confirmation that all transactions received were processed.

271 Eligibility Response

The eligibility response transaction is only sent in response to a 270 eligibility request transaction.

277 Pended Claims

The 277 pended claims report is sent with the 835 electronic remittance advice. The 835 transaction only contains data about paid and denied claims. The pended claims report includes claims received but not processed.

Provider Electronic Solutions User Guide Other Features

Revised: 09/13/2011 12 Version: 2.12

33BDownloading and Viewing Responses Response transactions are not downloaded automatically. Follow these steps to check for response files waiting to be downloaded.

1. Click Communication from the main menu and select Submission. The Batch Submission window appears.

2. Responses supported by PES are listed in the Files to Receive box on the right side of the window. Click on each type of transaction to download.

3. Click Submit. PES connects to the KMAP website and downloads any waiting response files.

4. Once the submission is successful, close the Form Submission window. Batch submit reports can be viewed by selecting View Submit Report from the Communication menu. All other responses can be viewed by selecting the View Batch Response/835 ERA/997s option from the Communication menu.

34BUsing the Edit All Feature The professional and nursing home claim forms have an additional option to modify the dates on all claims in a batch while retaining information in the claim. To modify all R (Ready) status claims, select Edit All on the right side of the form window and enter new dates of service and covered days (nursing home claims only). To resubmit a batch after using the Edit All feature:

1. Click Communication and select Resubmission from the main menu. The Batch Resubmission window displays with a list of previously submitted batches.

2. Select a batch to resubmit and click Copy on the right side of the window. Click Yes when prompted to copy the batch.

3. Open the Form window (837 professional or nursing home form).

4. Click Edit All and enter the new information. Click Yes when prompted to modify claims in R status.

5. After making any other necessary changes, close the Form window and click the Submission option in the Communication menu to send the claims. Do not use the Resubmission option after copying a previous batch.



6BUsing Provider Electronic Solutions Tools

PES has several options available for managing information. These tools can help conserve disk space, protect data, and make PES easier to use.

35BDatabase Recovery PES has several tools available to maintain the stability of the database. These options can be accessed from the Database Recovery submenu of Tools in the main menu.

Compact: When information is removed from the database, there is unused space. The Compact option deletes these gaps, freeing the disk space.

Repair: The Repair option attempts to validate the information in the database.

This option is helpful when having trouble accessing information. The feature can be used at any time.

Unlock: Sometimes errors can cause the database to lock information. The

database should be locked when submitting forms, archiving forms, restoring forms, and sometimes when adding or editing forms. If data is locked in error, use the unlock option to allow access.

36BCreating New Users When logged on as an administrator, other user accounts can be created to help control access to the PES application.

1. Click Security Maintenance in the main menu and select Security.

2. Enter the new user ID and a password.

3. Select the security level for the user. Nonadministrative users can do everything except access the Security menu.

4. Click Save.

5. Click Add and repeat the process to add additional users.

Provider Electronic Solutions User Guide Using Provider Electronic Solutions Tools

Revised: 09/13/2011 14 Version: 2.12

37BChanging Passwords The logon password for PES can be changed at any time.

1. Click Tools and then select Change Password from the main menu.

2. Enter the old password and then enter a new password twice. Passwords in PES must be between 5 and 10 characters in length.

3. Change the question and answer if necessary. The question and answer can be left the same.

4. Select OK. A message displays indicating the password has been updated.

When logged on to PES as an administrator, passwords for other user names can also be reset. If a user forgets the password:

1. Click Security and select Security Maintenance from the main menu.

2. Highlight the user and enter a new password in the Password field.

3. Select Save. The user is prompted to change the password when logging on.

38BArchiving Submissions Archiving keeps the size of the claim lists small enough to be useful, while maintaining historical records of the forms that have been entered. Choosing to create an archive will copy old forms into a compressed file and then delete them from the database. PES automatically gives a reminder to archive old claims every 30 days.

To archive:

1. Select Create from the Archive submenu under Tools.

Note: Before running the archive function, verify that no other users are logged on at any other workstation.

2. Highlight the types of forms to archive. Only forms in F status that meet the days aged (specified by the user) will be archived. The filename defaults to the current day’s date and a sequence number, but the user can override this.

Warning: Be sure to use the default file name or specify a file name that does not already exist. Additional forms cannot be appended to existing archive files.

3. Click OK. PES automatically compresses the old forms and deletes them from the database.

Provider Electronic Solutions User Guide Using Provider Electronic Solutions Tools

Revised: 09/13/2011 15 Version: 2.12

39BRestoring Archives To view a form already archived, it must first be restored from the archive.

Warning: If PES has been reinstalled, do not attempt to restore an archive created prior to the reinstallation. This could cause loss of data.

1. Select Restore from the Archive submenu. The Restore Forms window displays.

2. Click Browse and locate the file in which the form was archived.

3. Select the archive file and click Open. The field populates with the archived file name.

4. Click Next. A list of the types of forms in the archive displays.

5. Select the types of forms to restore and select Next.

6. Highlight the forms to be restored and click Finish. The selected forms are copied back into the current database.

Restored claims are placed in the Form Entry window with status A. These forms will be deleted the next time an archive is created and will not be rearchived. Archived forms can be restored as many times as needed.



7BAppendix I Frequently Asked Questions

How do I know what a certain field is used for in PES?

If you click inside the field and press F1, you will see a description of the field and also indication whether the field is required or optional.

I received a notice from KMAP indicating my diagnosis codes are changing, but when I try to put them into PES, it says the code is invalid.

All diagnosis codes need to be entered without the decimal point. The interChange MMIS is designed to process claims without decimal points.

I want to back up my database. How do I do that?

Your database is a file named ksnewecs.mdb. Perform a search on your computer (Start > Search > Find Files or Folders) for this file and copy it to another location on your computer. If you are going to rely on this file for current information, remember to make frequent copies of the file. The PES user ID and password used at the time the database is copied will be the same one used if you choose to restore PES with a previous database file. If you still have problems performing this task, contact the EDI help desk at 1-800-933-6593, option 4.

I've ruined or lost my PES database, but I have a backup. How do I restore my database?

Find your backup of the PES database and rename it to ksnewecs.mdb. Move this file into the folder your PES database resides. The location of this file defaults to C:\KShipaa if you chose a standard PES installation. Next, open your PES application and log on. Remember to use a user ID and password that existed during the time you created the database backup. If you still have problems performing this task, contact the EDI help desk at 1-800-933-6593, option 4.

I used to transmit just fine, but now PES tells me my transmission failed. What's wrong?

Check your communication log under Communication > View Communication Log. If the log says "Invalid ID/Password," you may have changed the password on your web account but haven't updated PES. To update PES, select Tools > Options > Batch and change the Web Password field to reflect what you currently use on the website. Then, try your transmission again.

Can PES be installed multiple times?

No. Only one installation of PES will work on a single PC. However, you can load it to multiple PCs within the same office. PES supports billing for as many providers as necessary with a single installation.

Provider Electronic Solutions User Guide Appendix I: Frequently Asked Questions

Revised: 09/13/2011 17 Version: 2.12

Can claims be “tagged”?

PES does not use the tag option. Instead, all claims in R status will be sent at one time.

How many beneficiaries can be loaded into a list?

An unlimited number of beneficiaries can be loaded.

How many detail lines per claim type are allowed on PES?

PES limits the number of lines to 99 for institutional and 50 for professional.

On PES pharmacy claims, where does the TPL information need to be entered?

TPL information is entered on the Other Ins/COB tab.

What operating system does PES require?

PES requires Windows 98/2000/XP. See the System Requirements section in this document.

Will there ever be electronic attachments?

PES supports the HIPAA-compliant attachment control number. Providers should submit their claims with an attachment control number assigned by them. The attachment control number is then written on the attachment and mailed or faxed to the fiscal agent who will pair it up with the electronic claim.



8BAppendix II Commonly Requested Form Walkthroughs

This appendix is for supplemental purposes only and is not intended to replace or establish any policy for KMAP. For current information on KMAP policy, refer to the KMAP provider manual for your provider specialty.

Nursing Home Claim Walkthrough

Header 1 Tab

Type of Bill Enter the type of bill that applies to this claim. Most nursing home claims use 213 (skilled nursing facility) or 613 (intermediate care facility).

Original Claim # Enter the internal control number (ICN) of the claim originally filed only if filing an adjustment or void or if you are filing the claim beyond 12 months from the date of service.

Provider ID/NPI From the drop-down list, select the billing provider. The rest of the information will populate when you press TAB. If your KMAP provider ID or national provider identifier (NPI) is not listed, double click on the drop-down list to access the Billing Provider List editor.

Beneficiary ID From the drop-down list, select the beneficiary. The rest of the information will populate when you press TAB. If the beneficiary does not appear on the list, double click on the drop-down list to access the Beneficiary List editor.

Encounter Ind Leave as “CH”.

Contract Type Leave blank.

Medical Record # Enter the beneficiary’s medical record number if applicable.

Release of Medical Data Leave as “Y” unless the beneficiary listed has not approved release of his or her protected health information to KMAP. Otherwise, select the applicable item.

Benefits Assignment Leave as “Y” unless the beneficiary has not approved the payment for the services to be assigned to your provider account. Otherwise, select option “N.”

Patient Status Enter the patient status code for this beneficiary. Refer to the KMAP Nursing/Intermediate Care Facility Provider Manual for valid codes.

Report Transmission Code Leave blank unless sending a paper attachment separate from the claim. Otherwise, select the item.

Report Type Code Leave blank unless sending a paper attachment separate from the claim. Otherwise, select the applicable item.

Provider Electronic Solutions User Guide Appendix II: Commonly Requested Form Walkthroughs

Revised: 09/13/2011 19 Version: 2.12

Nursing Home Claim Walkthrough

Attachment Ctl Leave blank unless sending a paper attachment separate from the claim. Otherwise, enter a unique ID code for the attachment that is being sent. Be sure to document this number and your provider number clearly on the attachment.

Header 2 Tab

Admission Date Enter the date the beneficiary was admitted to the facility (referred to as the first date of the billing period).

Admission Hour Enter the admission hour if applicable. Otherwise, set field to “00”.

Admission Type Enter the corresponding admit type code. (Enter “3” for elective admissions.)

From DOS Enter the first date for this claim.

To DOS Enter the last date for this claim.

Admit Source Enter the source of admission for this beneficiary. (Enter “9” if admitted from home.)

Days Covered Enter the total number of days for this claim.

Days Non-Covered Leave blank for submission to KMAP.

Coinsurance Enter the number of days covered by coinsurance for this claim if applicable.

Lifetime Reserve Enter the lifetime reserve days if applicable.

Attending Select the attending physician for the beneficiary if one is required by KMAP policy. If the physician is not on the list, double click on the drop-down box to access the Other Provider List editor.

Header 3 Tab

Diagnosis Codes Enter the applicable diagnosis codes for the beneficiary. The Primary and Admit diagnosis codes are required and may be the same.

Patient Liability Enter the patient liability only if different than the liability on record with KMAP. Do not deduct the liability from the total charges.

Comment Cd/Comment Select a comment type and enter a comment only if one is necessary to comply with KMAP policy.

Header 4 Tab

Value Codes/Amounts Enter all applicable value codes and their corresponding amounts. Leave blank if none apply.

Other Insurance/Medicare Indicator

Set to “Y” only if a third-party liability has already made a payment for this claim.


Revised: 09/13/2011 20 Version: 2.12

Service Tab

Date of Service Enter the first day for this line item.

Revenue Code Enter the revenue code indicating the type of service for this line item. PES requires four-digit revenue codes. Add a leading zero to any three-digit codes listed (“0101” instead of “101”).

Billed Amount This value is calculated automatically by multiplying the Unit Rate field by the number of units (days) for this service line.

Units Enter the total number of days for this service. The total of the units on all of the line items should equal the total days included on the claim.

Basis of Measurement Can be left as “UN”. All long-term care (LTC) revenue codes are assumed to be days.

Unit Rate Set to the daily rate for the type of service. Do not deduct the patient obligation, copay, or other insurance payment amount. These values are calculated by KMAP. The total billed amount should be set to equal the unit rate multiplied by the units.

Non-Covered Charge Enter the charges not covered if KMAP does not cover any portion of the billed amount.


Revised: 09/13/2011 21 Version: 2.12

Professional Claim Walkthrough

Header 1 Tab

Claim Frequency Leave as “1” unless filing an adjustment or voiding an existing claim.

Original Claim # Enter the ICN of the claim that was originally filed only if filing an adjustment or void or if you are filing the claim beyond 12 months from the date of service.

Provider ID/NPI From the drop-down list, select the billing provider. The rest of the information populates when you press TAB. If your KMAP provider ID or NPI is not listed, double click on the drop-down list to access the Billing Provider List editor.

Beneficiary ID From the drop-down list, select the beneficiary. The rest of the information populates when you press TAB. If the beneficiary does not appear on the list, double click on the drop-down list to access the Beneficiary List editor.

Medical Record # Enter the beneficiary’s medical record number if applicable.

Release of Medical Data Leave as “Y” unless the beneficiary listed has not approved release of his or her protected health information to KMAP. Otherwise, select the applicable item.

Benefits Assignment Leave as “Y” unless the beneficiary has not approved the payment for the services to be assigned to your provider account. Otherwise, select option “N”.

Patient Signature Select the item that applies. Select “B” if you have a signature authorization form on file (equivalent to “Signature on file”).

Report Transmission Code Leave blank unless sending a paper attachment separate from the claim. Otherwise, select the item that applies.

Report Type Code Leave blank unless sending a paper attachment separate from the claim. Otherwise, select the item that applies.

Attachment Ctl Leave blank unless sending a paper attachment separate from the claim. Otherwise, enter a unique ID code for the attachment being sent. Be sure to document this number and your provider number clearly on the attachment.

Header 2 Tab

Diagnosis Codes Enter any applicable diagnosis codes. Be sure to omit any periods that are included in the diagnosis codes.

Referring Provider Only required when necessary to comply with KMAP policy. Leave blank if billing for Home and Community Based Services (HCBS).

Encounter Ind Leave as “CH”.

Contract Type Leave blank.

Similar Illness Date Use only if necessary to comply with KMAP policy.


Revised: 09/13/2011 22 Version: 2.12


Prior Authorization Enter the prior authorization number if one applies. Leave blank when billing for a plan of care (POC).

Place Of Service Select the plan of service (POS) code that applies to the services being billed. The POS must be entered either here or on the Service 1 tab.

Comment Cd/Comment Select a comment description and enter the corresponding comment when one is necessary to comply with KMAP policy.

Header 3 Tab

Accident Enter any related causes and other information when services are a result of an accident.

Ambulance Enter applicable information if providing ambulance services.

Admission/Discharge Date Enter if services were rendered during a hospital stay.

Other Insurance/Medicare Indicator

Set to “Y” if there has been a partial payment made by a third-party liability.

Header 3 Tab Only used by physicians

Service Facility Leave blank unless the information is necessary to comply with KMAP policy.

Service 1 Tab

From/To DOS Enter the dates the service was rendered.

Emergency Ind Leave blank unless services were rendered due to an emergency.

Place Of Service Enter applicable POS code if the Place of Service field was left blank on Header 2.

Procedure Code Enter the applicable procedure code for this service.

EPSDT Change to “Y” if services rendered are part of an Early Periodic Screening Diagnosis and Treatment program (physician services only).

Modifiers Enter any applicable modifiers (after the first five digits of the procedure code).

Diag Ptr Enter a number 1-8 to indicate which diagnosis entered on Header 2 applies to this service. (“1” indicates the primary diagnosis.)

CLIA number Enter the clinical laboratory improvement amendments (CLIA) license number if applicable (lab services only).

Basis of Measurement Set to “UN” unless otherwise necessary to comply with KMAP policy.

Units Enter the number of units billed for this service.

Billed Amount Enter the total amount charged for this service. Do not deduct the patient obligation, copay, or other insurance payments.

Family Planning Ind Leave blank unless it is required by KMAP to indicate the service was rendered as part of a family planning visit.


Revised: 09/13/2011 23 Version: 2.12


Service 2 Tab

Ambulance Enter the applicable information if billing for ambulance services. Optional if the information has already been supplied on Header 3.

Rendering Provider From the drop-down list, select a rendering provider if different than the billing provider listed on Header 1. When billing targeted case management (TCM) services for a community developmental disability organization (CDDO), the CDDO should be listed as the billing provider on Header 1 and the TCM contractor as the Rendering Provider on Service 2.

RX Ind Set to “Y” if a national drug code (NDC) must be submitted to comply with KMAP policy. An RX tab appears to enter the information.

RX Tab Applies only if the RX Ind field is set to “Y”

NDC Enter or select the NDC code that applies to this service.

Quantity Enter the quantity of the drug indicated by the NDC being billed. The quantity is only required when more than one NDC is being entered for this service.

Unit Price Enter the cost per unit of the NDC indicated being billed to the patient. Leave as “.00” if the price per unit is unknown.

Unit of Measurement Select the unit used for measuring the quantity of the NDC. Leave as “F2” if the unit of measurement is not known.


Revised: 09/13/2011 24 Version: 2.12

List – Billing Provider

Provider ID Code Qualifier

Set to “01” for a NPI, or “1D” for a KMAP provider ID.

Provider ID/NPI Enter the KMAP provider ID or NPI. A KMAP ID is nine numbers followed by one letter and should not contain spaces. The NPI is 10 numbers with no spaces.

Entity Type Qualifier Set to “2” if billing as an organization. Otherwise, indicate a “1”.

Taxonomy Code Enter the provider taxonomy code associated with the provider number. Taxonomy information can be accessed on the KMAP Taxonomy Crosswalk page of the KMAP provider website, 2TUhttps://www.kmap-state-ks.usU2T. The taxonomy code should be populated with the taxonomy assigned to the provider by KMAP. If this information is not available for the provider, the field may be populated with nines.

Last/Organization Name Enter the organization name on record with KMAP if the Entity Type Qualifier is “2”. Enter the provider’s last name if the Entity Type Qualifier is “1”.

First Name Enter the provider’s first name if the Entity Type Qualifier is “1”.

SSN/Employer ID Enter the provider’s Employer Identification Number (EIN) if the Entity Type Qualifier is “2” or the Social Security number (SSN) of the provider. The EIN should have a hyphen as the third character (XX-XXXXXXX). If this information is not available, the field can be populated with nines. The correct SSN or EIN must be entered when the provider is to receive the payment for claims submitted.

SSN/Employer ID Qualifier

Set to “24” if the number listed in the SSN/Employer ID field is the EIN. Otherwise, leave the field as “34”.

Line 1 Enter the mailing address of the provider office.

Line 2 Enter any additional address information if applicable.

City Enter the city of the provider location.

State Enter the two-letter state code for the provider (for example, KS).

Zip Enter the ZIP code of the provider office. The four-digit extension may be necessary to identify the provider’s service location and should be entered.


Revised: 09/13/2011 25 Version: 2.12

List – Beneficiary

Beneficiary ID Enter the beneficiary’s 11-digit KMAP member ID.

ID Qualifier Leave set to “MI”.

Account # Enter the beneficiary’s internal account number. If the beneficiary is not assigned an account number, enter a “0”.

SSN Enter the beneficiary’s SSN.

Last Name Enter the last name of the beneficiary as it appears on the KMAP member ID card.

First Name Enter the first name of the beneficiary as it appears on the KMAP member ID card.

MI Enter the middle initial of the beneficiary if available. Otherwise, leave blank.

DOB Enter the date of birth of the beneficiary as it appears on the KMAP member ID card.

Gender Select the gender of the beneficiary.

Line 1 Enter the mailing address of the beneficiary.

Line 2 Enter any additional address information if applicable.

City Enter the city of the beneficiary’s address.

State Enter the two-letter state code for the beneficiary (for example, KS).

Zip Enter the ZIP code of the beneficiary. The four-digit extension is not required.


Revised: 09/13/2011 26 Version: 2.12

Insurance Tabs

OI/Medicare Applies only if the Other Insurance/Medicare Indicator field is set to “Y”

Release of Medical Data Leave as “Y” if there is a signed signature authorization form on file. Otherwise, select the applicable option.

Benefits Assignment Leave as “Y” unless the benefits were not payable to the billing provider on the claim.

Claim Filing Ind Code Includes “MA”, “MB”, and “MC” indicators.

Payer Responsibility Indicate the level of responsibility for this payer.

Paid Date/Amount Enter the total amount paid and the date it was paid.

Policy Holder From the drop-down list, select the policyholder. If the information is not listed, double click on the drop-down list to access the Policy Holder List editor.

TPL/Medicare Applies only if the TPL/Medicare Indicator field is set to “Y”

Deductible Enter the Medicare deductible if applicable.

Coinsurance Enter any applicable coinsurance amount.

Co-pay Enter any copayment amount.

Remarks Codes A remittance advice remark code (RARC) is used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a claim adjustment reason code (CARC). Each RARC identifies a specific message. Additionally, there are some informational RARCs starting with the word “Alert” which are used to provide general adjudication information (for example, appeal rights). These RARCs can be used without any associated CARC and /or when there is not an adjustment. Always enter RARC codes whenever possible. A complete listing of available HIPAA-compliant RARC codes can be found on the Washington Publishing Company (WPC) website at 2TUhttp://www.wpc-edi.com/content/view/711/401/U2T.


Revised: 09/13/2011 27 Version: 2.12

Insurance Tabs

Adjustment Group Cd A claim adjustment group code is used to identify the general category of the payment adjustment. A group code must always be used in conjunction with a CARC to show liability for amounts not covered or to identify a correction or reversal of a prior decision.

If entered, at least one CARC and payment adjustment amount is required for the group code.

Valid group codes for use:

CO – Contractual Obligations: This group code is used when a contractual agreement between the payer and payee or a regulatory requirement resulted in an adjustment. Generally, these adjustments are considered a write-off for the provider and not billed to the patient.

CR – Corrections and Reversals: This group code is used for correcting a prior claim. It applies when there is a change to a previously adjudicated claim.

OA – Other Adjustments: This group code is used when none of the other group codes apply to the adjustment.

PR – Patient Responsibility: This group is used when the adjustment represents an amount that should be billed to the patient or insured. This group would typically be used for deductible and copay adjustments.

PI – Payer-Initiated Reductions: This group code is used when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is not a supporting contract between the provider and the payer (for example, medical review or professional review organization adjustments).

Reason Code/Amount Reason Code: A CARC is used to communicate why a claim or service line was paid differently than it was billed (difference between the billed and paid amount). Reason codes explain the reasons for any financial adjustments, such as denials, reductions, or increases in payment. These codes can be used at the service or claim level, as appropriate. A complete listing of available HIPAA-compliant CARC codes can be found on the WPC website at 2TUhttp://www.wpc-edi.com/content/view/711/401/U2T.

If there is not an adjustment to a claim/line, then there is no need to use a CARC.

If entered, a corresponding adjustment amount and an adjustment group code must always be entered.

Note: There are certain CARC codes that always require the use of a RARC and this is identified within the description of the CARC code.

Amount: This is the payment adjustment amount for the associated CARC. If an adjustment amount is entered, then a corresponding CARC and adjustment group code must also be entered.


Revised: 09/13/2011 28 Version: 2.12

Policy Holder List Only used for third-party insurance (not KMAP)

Beneficiary ID Enter the Medicaid beneficiary ID for the patient.

Group # Enter the group code for the other insurance policy. If a group number is not applicable, enter the patient’s policy number.

Carrier Code From the drop-down list, select the carrier code. If the carrier is not listed, double click on the drop-down list to access the Carrier List editor.

Other Insurance Group Name

Enter the name of the other insurance group.

Insurance Type Code Select the type of policy.

Relationship to Insured Select the relationship of the policyholder to the beneficiary. Select “18” if the policyholder is the beneficiary.

Policy Holder Information

Last Name Enter the last name of the policyholder.

First Name Enter the first name of the policyholder.

ID Code Enter the policy number for the other insurance policy. The ID code may be the same as the beneficiary ID.

ID Qualifier Set to “MI” unless the ID code is not the member ID.

Date of Birth Enter the date of birth of the policyholder.

Gender Select the gender of the policyholder.

Policy Holder Address

Line 1 Enter the mailing address of the policyholder.

Line 2 Enter any additional address information of the policyholder if applicable.

City Enter the city of the policyholder’s address.

State Enter the two-letter state code for the policyholder (for example, KS).

Zip Enter the ZIP code of the policyholder. The four-digit extension is not required.

Patient Information

Patient ID Enter the patient’s policy number or other applicable ID.

ID Qualifier Select the type of ID that was entered in the Patient ID field.

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