web claims submission user guide

Web Claims Submission User Guide Version 1.0

December 2, 2008

Confidential and Proprietary © Coventry Health Care, Inc and affiliated companies. 2008. All rights reserved.

Web Claims Submission User Guide

HIPAA Privacy Rules The Health Insurance Portability and Accountability Act of 1996 (HIPAA – Public Law 104-191) and the HIPAA Privacy Final Rule1 provides protection for personal health information. The regulations became effective April 14, 2003. First Health Services developed HIPAA Privacy Policies and Procedures to ensure operations are in compliance with the legislative mandated.

Protected health information (PHI) includes any health information whether verbal, written, or electronic, that is created, received, or maintained by First Health Services Corporation. It is health care data plus identifying information that allows someone using the data to tie the medical information to a particular person. PHI relates to the past, present, and future physical or mental health of any individual or recipient; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual. Claims data, prior authorization information, and attachments such as medical records and consent forms are all PHI.

The Privacy Rule permits a covered entity to use and disclose PHI, within certain limits and providing certain protections, for treatment, payment, and health care operations activities. It also permits covered entities to disclose PHI without authorization for certain public health and workers’ compensation purposes, and other specifically identified activities.

1 45 CFR Parts 160 and 164, Standards for Privacy of Individually Identifiable Health Information; Final Rule

Confidential and Proprietary Page 2

Revision HistoryDocument

Version Date Name Comments

1.0 4/04/08 Training & Development Department

Initial Creation of Document

Page 3 First Health Services Corporation


Table of Contents HIPAA Privacy Rules ..................................................................................................................2 Revision History..........................................................................................................................3 Table of Contents........................................................................................................................4 1.0 Introduction .....................................................................................................................6

1.1 Payer Specification Document ......................................................................................6 2.0 Logging In/Out.................................................................................................................8

2.1 Log In ............................................................................................................................8 2.2 Log Out..........................................................................................................................8

3.0 Submitting a Claim..........................................................................................................9 4.0 Claim Submission Response.......................................................................................34 5.0 Searching for a Claim ...................................................................................................35

5.1 Reversing a Claim.......................................................................................................37 5.2 Resubmitting a Claim ..................................................................................................38


First Health Services Corporation


1.0 Introduction The Web Claims Submission tool will allow pharmacy staff members to enter, reverse, rebill, and search for claims via the First Health Services state specific web site. The staff members will also be able to check a client’s eligibility.

To gain access to the Web Claims Submission tool, a designated staff member will have to complete registration via the User Administration Console application. Once this person has successfully registered, he/she can then set-up the remaining staff members and grant them access to the tool.

1.1 Payer Specification Document A Payer Specification document which, outlines the necessary information (fields) and valid field values, exists for all programs. All valid field entry data is located in the Payer Specification document and may vary across clients. Data fields are also displayed on the Claims Entry Template in the same segments that they are listed under in the Payer Specification document.

For Example: The following fields are listed under the Request Header Segment in the Payer Specification document: Bin Number, Version/Release Number, Transaction Code, Processor Control Number, Transaction Count, Service Provider ID Qualifier, Service Provider ID, Date Filled, and Software Vendor/Certification ID. The same fields are located on the Sample Claims Entry template under the Request Header Segment. Refer to Figure 3.0.3.



2.0 Logging In/Out

2.1 Log In Log In instructions vary by user. Please refer to the Login/Logout handout and/or instructions you were provided.

If you have additional questions in regards to logging in to the application please speak with your manager.

2.2 Log Out Log Out instructions vary by user. Please refer to the Login/Logout handout and/or instructions you were provided.

If you have additional questions in regards to logging out of the application please speak with your manager.



3.0 Submitting a Claim To submit a claim:

1. From the Service Provider List page, select the Provider ID from the drop-down menu. See to Figure 3.0.1.

Figure 3.0.1 - Web Claim Submission, Service Provider List

2. Click the Select button. The Adjudicated Claims Search page displays. See Figure 3.0.2.

Figure 3.0.2 - Adjudicated Claims Search

3. Click the NCPDP_51_Claim template from the listing. Refer to Figure 3.0.2. The Claim Submission Data Entry page displays. See Figure 3.0.3.

The Claim Entry template times out after 15 minutes of inactivity.



Figure 3.0.3 - Claim Entry Template

The Claim Entry template has both optional and required fields depending upon client specifications. Non-editable fields are unavailable (grayed) and cannot be populated. Mandatory or required fields are noted with a red asterisk following the field name.

Searches may also be performed to populate certain field values. If the Search icon displays directly following the field, a search may be performed.

A calendar may be used to populate dates wherever the Calendar icon displays. See Figure 3.0.4.

Figure 3.0.4 - Calendar



To use the Calendar: Click the drop-down menu to select a month, type the appropriate year, and click the appropriate day.

Claim Submission Data Entry

Field Description

Template Name Name of claim submission data entry template.

Template Description Description of claim submission data entry template.

Host Web site form is submitted to First Health Services.

Port Computer connection.

Trial Adjudication Click to adjudicate claim without committing it to production.

Date format Format of date to be used in the claim submission data entry template.

Figure 3.0.5 - Claim Submission Data Entry

Click Trial Adjudication to submit a test claim.

Click the Cancel button to return to the Claims Submission Main page. Refer to Figure 3.0.2.

If the Back button is used to return to the Claims Submission Main page, changes made on the page are not applied. It is recommended to use the Cancel button.

Click the Reset button to clear all entered information and start over.

Click the Submit button to submit the claim as entered. The Claim Submission Response page displays. See Figure 6.0.1.

Click the New Claim button to submit a new claim.

Click the Result button to view the result of the claim.



To use the Result button the claim must have been previously submitted.

Click the Print button to print the submitted claim.

Request Header Segment

NCPDP Designations

Field Description

Bin Number Assigned client specific number.

Version Release Number Version Release Number.

Transaction Code Valid values are: B1 - Rx/Service Billing B2 - Reversal B3 - Rebilling E1 - Eligibility

Processor Control Number Number assigned to plan to allow submission of claims through First Health Services.

Transaction Count Must match the number of claims. Valid values are: 1, 2, 3, or 4

Service Provider ID Qualifier Identifies required data for Provider ID field.

Service Provider ID Service Provider ID (NCPDP/NABP#).

Date Filled Date filled MM/DD/YYYY format.

Software Vendor /Certification ID Assigned once software vendor is certified by First Health Services.

Figure 3.0.6 - Request Header Segment

4. Enter the BIN Number.

5. Enter the Processor Control Number.

6. Select a Transaction Count from the drop-down menu.



7. The Service Provider ID Qualifier and Service Provider ID populate based on the Provider ID you selected from the drop-down menu on the Service Provider List page.

8. Enter the Date Filled. You can type it in or use the calendar to select the appropriate date.

9. Enter the Software Vendor/Certification ID.

Request Patient Segment

NCPDP Designations

Field Description

Patient ID Qualifier Valid values are: 01 - Social Security Number 02 - Drivers License Number 03 - U.S. Military ID 99 - Other

Patient ID Patient ID.

Date of Birth Date of Birth; YYYYMMDD format.

Sex Code Valid values are: 0 - Unknown 1 - Male 2 - Female

Patient First Name Patient First Name.

Patient Last Name Patient Last Name.

Patient Street Address Patient Street Address.

Patient City Address Patient City Address.

Patient State Address Patient State Address.

Patient Zip Zone Patient Zip Zone.

Patient Phone Number Patient Phone Number.



Field Description

Patent Location Valid Values are: 0 - Not Specified 1 - Home 2 - Inter-Care 3 - Nursing Home 4 - Long Term/Extended care 5 - Rest Home 6 - Boarding Home 7 - Skilled Care Facility 8 - Sub-Acute care Facility 9 - Acute Care Facility 10 - Outpatient 11 - Hospice

Employer ID ID assigned to employer.

Smoker /Non-Smoker Code Valid values are: Blank - Not Specified 1 - Non Smoker 2 - Smoker

Pregnancy Indicator Valid values are: Blank - Not Specified 1 - Not Pregnant 2 - Pregnant

Figure 3.0.7 - Patient Search

10. Select a Patient ID Qualifier from the drop-down menu.

11. Type the Patient ID.

12. Enter or use the Calendar to select the Date of Birth.

13. Select the Sex Code from the drop-down menu.



Required fields for the Request Patient Segment may vary depending upon plan guidelines therefore, you should refer to the Payer Specification document for all required fields and valid field values. The most common required fields on the Request Patient Segment are: Patient ID Qualifier, Patient ID, Date of Birth, and Sex Code.

Request Insurance Segment

NCPDP Designations

Field Description

Cardholder ID Number Cardholder ID Number.

Cardholder First Name Cardholder First Name.

Cardholder Last Name Cardholder Last Name.

Home Plan Functionality not utilized at this time.

Plan Identification Plan Identification.

Eligibility Clarification Code Valid values are: 0 – Not Specified 1 – No Override 2 – Override 3 – Full Time Student 4 – Disabled Dependent 5 – Dependent Parent 6 – Significant Other

Facility ID Functionality not utilized at this time.

Group Number Group Number.

Person Code Person Code should be “0”.

Relationship Code Valid values are: 1 – Subscriber 2 – Spouse 3 – Dependent 4 - Other



Figure 3.0.8 - Request Insurance Segment

14. Type the Cardholder ID Number.

Required fields for the Request Insurance Segment may vary depending upon plan guidelines therefore, you should refer to the Payer Specification document for all required fields and valid field values. The most common required field on the Request Insurance Segment is Cardholder ID Number.

Request Claim Segment

NCPDP Designations

Field Description

Prescription Reference Number Qualifier

Valid values are: 1 - RX billing 2 - Service Billing

Prescription Reference Number Service Provider assigned Rx number.

Product/Service ID Qualifier Type of Drug.

Product Service ID NDC number.

Associated Prescription Reference Number

Associated Prescription Reference.

Associated Prescription Date Associated Prescription Date.

Quantity Dispensed Quantity dispensed.

New/Refill Code Code indicating whether prescription dispensed was a new prescription or a refill. Valid values are: 00 - New prescription 01-XX - Refill

Days Supply Number of days the medication is being dispensed.

Compound Code Valid values are:



Field Description 0 - Not Specified 1 - Not a compound 2 - Compound

Dispense As Written Valid values are: 0 - No Product Selection Indicated (Default) 1 - No Substitution - Prescriber 2 - Dispensed Patient Request 3 - Dispensed Pharmacist Select 4 - Generic Drug Not In Stock 5 - Dispensed Brand As Generic 6 - Override 7 - No Substitution - Brand by Law 8 - Generic Drug Unavailable 9 - Other

Date Prescription Written Date prescription written by prescriber.

Number Refills Authorized Number of Refills Authorized.

Prescription Origin Code Valid values are: 0 - Not Specified 1 - Written Prescription 2 - Telephone Prescription 3 - Emergency Room 4 - Facsimile

Submission Clarification Code Valid values are: 0 - Not Specified, Default 1 - No Override 2 - Other Override 3 - Vacation Supply 4 - Lost Prescription 5 - Therapy Change 6 - Starter Dose 7 - Medically Necessary 8 - Process Compound for Approved Ingredient 9 - Encounters 99 - Others

Quantity Prescribed This is blank most of the time. Quantity of medication to be dispensed as indicated on prescription by prescriber.



Field Description

Other Coverage Code Enter the appropriate other coverage code, if applicable. Valid values are: 0 - Not specified 1 - No Other Coverage Identified 2 - Other Coverage, Payment Collected 3 - Other Coverage, Claim Not Covered 4 - Other Coverage, Payment Not Collected 5 - Managed Care Plan Denial 6 - Not A Participating Provider 7 - Other Coverage, Not In Effect 8 – Copay Billing

Unit Dose Indicator Code indicating if drug is packaged in a unit dose by the manufacturer (pulled from drug file by NDC). Valid values are: 1 - Not Unit Dose 2 - Manufacturer Unit Dose 3 - Pharmacy Unit Dose 4 - Custom Packaging

Originally Prescribed Product Type

Originally Prescribed Product Type.

Originally Prescribed Product Code

Originally Prescribed Product Code.

Originally Prescribed Metric Decimal Quantity

Originally Prescribed Metric Decimal Quantity.

Alternate ID Alternate ID.

Scheduled Prescription ID Number

Scheduled Prescription ID Number.

Unit of Measure Valid values are: EA - Each GM - Grams ML - Milliliters

Level of Service Valid values are: 0 - Not Specified 1 - Patient Consultation 2 - Home Delivery 3 - Emergency 4 - 24 Hour Service



Field Description 5 - Patient Generic Selection Cons

Prior Authorization Type Code Prior Authorization Type Code.

Prior Authorization Number Submitted

Prior Authorization Number Submitted.

Intermediary Authorization Type ID

Intermediary Authorization Type ID.

Intermediary Authorization ID Intermediary Authorization ID.

Dispensing Status Valid values are: C - Completion of Partial Fill P - Partial Fill

Quantity Intended to be Dispensed Quantity Intended to be Dispensed.

Days Supply Intended to be Dispensed

Days Supply Intended to be Dispensed.

Figure 3.0.9 - Request Claim Segment

15. Select a Prescription Reference Number Qualifier.

16. Type the Prescription Reference Number (Rx Number).

17. Select a Product/Service ID Qualifier.

18. Type the Product/Service ID (NDC number of the product on the claim).

If the NDC is unknown, a search may be performed.



Required fields for the Request Claim Segment may vary depending upon plan guidelines therefore, you should refer to the Payer Specification document for all required fields and valid field values. The most common required fields on the Request Claim Segment are: Prescription Reference Number and Qualifier, Product/Service ID and Qualifier, Quantity Dispensed, New/Refill Code, Day Supply, Compound Code (if applicable), Date Prescription Written, Number Refills Authorized and Submission Clarification Code.

Request Prescriber Segment

NCPDP Designations

Field Description

Prescriber ID Qualifier 12 - Drug Enforcement Administration (DEA) or Medicaid ID #.

Prescriber ID Prescriber ID.

Prescriber Location Code Prescriber Location Code.

Prescriber Last Name Prescriber Last Name.

Prescriber Phone Number Prescriber Phone Number.

Primary Care Provider ID Qualifier Primary Care Provider ID Qualifier.

Primary Care Provider ID Primary Care Provider ID.

Primary Care Provider Location Code

Primary Care Provider Location Code

Primary Care Provider Last Name Primary Care Provider Last Name.

Figure 3.0.10 - Request Prescriber Segment

19. Select a Prescriber ID Qualifier from the drop-down menu.

20. Type the Prescriber ID.



Required fields for the Request Prescriber Segment may vary depending upon plan guidelines therefore, you should refer to the Payer Specification document for all required fields and valid field values. The most common required fields on the Request Prescriber Segment are: Prescriber ID Qualifier and Prescriber ID.

Request COB (Coordination of Benefits) Segment

NCPDP Designations

Field Description

COB/Other Payment Count Number of third party payers.

Other Payer Coverage Type Valid values are: 01 - Primary 02 - Secondary 03 - Tertiary 98 - Coupon 99 - Composite

Other Payer ID Qualifier Valid values are: 01 - National Payer ID (NPI) 02 - Health Industry Number (HIN) 03 - Bank Information Number (BIN) 04 - National Association of Insurance Commissioners 09 - Coupon 99 - Other

Other Payer ID Payer ID.

Other Payer Date Other Payer Date YYYYMMDD format.

Figure 3.0.11 - Request COB Segment

21. Select the Other Payer Coverage Type using the drop-down menu.

22. Select 99-Other using the Other Payer ID Qualifier drop-down menu.

23. Type the Other Payer ID.

24. Type or use the Calendar to select the Other Payer Date.



Other Payer Amount Paid Count Segment

NCPDP Designations

Field Description

Other Payer Amount Paid Count Other Payer Amount Paid Count.

Other Payer Amount Paid Qualifier Valid values are: 01 - Delivery Cost 02 - Shipping Costs 03 - Postage Claimed 04 - Administrative Costs 05 - Incentive 06 - Cognitive Service 07 - Drug Benefit 08 - Sum of all Reimbursement 98 - Coupon 99 - Other

Other Payer Amount Paid Other Payer Amount Paid.

Figure 3.0.12 - Other Payer Amount Paid Count Segment

25. Select 08-Sum of all Reimbursement using the Other Payer Amount Paid Qualifier drop-down menu.

26. Type the Other Payer Amount Paid.

The Request COB and Other Payer Segments should only be populated if other coverage exists and is being billed for the patient.



Other Payer Reject Count Segment

Designations NCPDP

Field Description

Other Payer Reject Count Other Payer Reject Count.

Other Payer Reject Code Valid values are: 01 - M/I Bin 02 - M/I Version number 03 - M/I Transaction code 04 - M/I Processor Control Number 05 - M/I Pharmacy number 06 - M/I Group number 07 - M/I cardholder ID number 08 - M/I Person Code 09 - M/I Birthday 10 - M/I Sex code

Figure 3.0.13 - Other Payer Reject Count Segment

Select the Other Payer Reject Code using the drop-down menu.

The Other Payer Reject Count Segment should only be populated if other coverage exists but the claim was rejected/denied.



DUR PPS CD Counter Segment

NCPDP Designations

Field Description

DUR/PPS Code Counter Counts number of DUR performed.

Reason for Service Code (previously Conflict Code)

Reason for Service Code identifies the type of conflict that was detected. Examples of valid values are: HD - High Dose Alert ER - Overuse Precaution LR - Under use Precaution LD - Low Dose DD - Drug-Drug Interaction MC - Drug Disease (reported) Precaution PA - Patient Age Precaution PG - Drug Pregnancy Alert TD - Therapeutic Duplication

Professional Service Code (previously Intervention code)

Professional Service Code is the pharmacist interaction when a conflict code has been identified. Examples of valid values are: 00 - No Intervention M0 - Prescriber Consulted P0 - Patient Consulted R0 - Pharmacist Consulted PE - Patient education/instruction CC - Coordination of care PH - Patient History

Result of Service Code (previously Outcome Code)

Result of Service taken by the dispensing pharmacist. Examples of valid values are: 1A - Filled As Is, False Positive 1B - Filled Prescription As Is 1C - Filled with Different Dose 1D - Filled with Different Direction 1F - Filled with different Quantity 1G - Filled with Prescriber Approval 2A - Prescription not filled 3B - Recommendation not accepted 3C - Discontinued drug



Field Description

DUR /PPS Level of Effort Valid values are: 0 - Not Specified 11 - Level 1 (Lowest 12 - Level 2 13 - Level 3 14 - Level 4 15 - Level 5 (Highest)

DUR Co-Agent ID Qualifier Examples of valid values: ‘’ - Not Specified 01 - UPC 02 - HRI 03 - NDC 20 - ICD9 99 - Other

DUR Co-Agent ID DUR Co-Agent ID.

Figure 3.0.14 - DUR PPS CD Counter Segment

The DUR PPS CD Counter Segment should only be populated if there is a DUR Encounter with the claim being submitted.

27. Select the Reason for Service Code using the drop-down menu.

28. Select the Professional Service Code using the drop-down menu.

29. Select the Result of Service Code using the drop-down menu.

If the DUR Co-Agent ID is unknown, a search may be performed. A DUR Co-Agent ID Qualifier is required before proceeding.



Required fields for the DUR PPS CD Counter Segment may vary depending upon plan guidelines therefore, you should refer to the Payer Specification document for all required fields and valid field values. The most common required fields on the DUR PPS CD Counter Segment are: Reason for Service Code, Professional Service Code, and Result of Service Code.

Request Pricing Segment

NCPDP Designations

Field Description

Ingredient Cost Submitted Ingredient Cost Submitted.

Dispensing Fee Submitted Dispensing Fee Submitted.

Professional Service Fee Submitted Professional Service Fee Submitted.

Patient Paid Amount Submitted Patient Paid Amount Submitted.

Incentive Amount Submitted Incentive Amount Submitted.

Flat Sales Tax Amount Submitted Flat Sales Tax Amount Submitted.

Percentage Sales Tax Amount Submitted Percentage Sales Tax Submitted.

Percentage Sales Tax Rate Submitted Percentage Sales Tax Rate Submitted.

Percentage Sales Tax Basis Submitted Valid values are: ‘’ - Not Specified 01 - Gross Amount Due 02 - Ingredient Cost 03 - Ingredient Cost + Dispensing Fee

Usual and Customary Charge Usual and Customary Charge.

Gross Amount Due Gross Amount Due.

Basis of Cost Determination Valid values are: 00 - Not Specified 01 - AWP 02 - Local Wholesaler 03 --Direct 04 - EAC 05 - Acquisition 06 - MAC 07 - Usual and Customary 08 - Other



Field Description 09 - Unit Dose Use on Tape/Disk 6X - Brand Medically Necessary

Figure 3.0.15 - Request Pricing Segment

30. Type the Ingredient Cost Submitted.

31. Type the Usual and Customary Charge.

32. Type the Gross Amount Due.

33. Select the Basis of Cost Determination using the drop-down menu.

Required fields for the Request Pricing Segment may vary depending upon plan guidelines therefore, you should refer to the Payer Specification document for all required fields and valid field values. The most common required fields on the Request Pricing Segment are: Ingredient Cost Submitted, Usual and Customary Charge, Gross Amount Due, and Basis of Cost Determination.



Other Amount Claimed Count Segment

NCPDP Designations

Field Description

Other Amount Claimed Submitted Count Other Amount Claimed Submitted Count.

Other Amount Claimed Submitted Qualifier Valid values are: 01 - Delivery 02 - Shipping Costs 03 - Postage Claimed 04 - Administrative Cost 99 - Other

Other Amount Claimed Submitted Other Amount Claimed Submitted.

Figure 3.0.16 - Other Amount Claimed Count Segment

34. Select the Other Amount Claimed Submitted Qualifier using the drop-down menu.

35. Type the Other Amount Claimed Submitted.

The Other Amount Claimed Count Segment is typically not used.



Request Compound Segment

NCPDP Designations

Field Description

Compound Dosage Form Description Code Compound Dosage Form Description Code.

Compound Dispensing Unit Form Indicator Compound Dispensing Unit Form Indicator.

Compound Route of Administration Compound Route of Administration.

Compound Ingredient Component Count Segment

Compound Ingredient Component Count Compound Ingredient Component Count.

Compound Product ID Qualifier Compound Product ID Qualifier.

Compound Product ID Compound Product ID.

Compound Ingredient Quantity Compound Ingredient Quantity.

Compound Ingredient Drug Cost Compound Ingredient Drug Cost.

Compound Ingredient Basis Of Cost Determination Compound Ingredient Basis Of Cost Determination.

Figure 3.0.17 - Request Compound Segment

Compounds should be processed on-line using “multiple ingredient functionality.”



To submit compound claims on the Claim segment:

Figure 3.0.18 - Request Claim Segment

36. Type 8 into the Submission Clarification Code field. Refer to Figure 3.0.18 for steps 35 - 39.

The “8” allows the claim to continue processing if at least one ingredient is covered.

37. Type 00000000000 into the Product Code/NDC field.

The “0000000000” identifies the claim as a multi-ingredient compound.

38. Type 2 into the Compound Code field.

39. Type the Quantity Dispensed for the entire product.

40. Type the Gross Amount Due for the entire product.

To submit compound claims on the Compound segment:

41. Select the Compound Dosage Form Description Code using the drop-down menu. Refer to Figure 3.0.17 for steps 40 - 42.

42. Select the Compound Dispensing Unit Form Indicator using the drop-down menu.

43. Select the Compound Route of Administration using the drop-down menu.



To submit compound ingredients on the Compound Ingredient Component Count segment:

44. Select the Compound Product ID Qualifier using the drop-down menu. Refer to Figure 3.0.17 for steps 43 – 48.

45. Type the Compound Product ID.

The Compound Product ID is the NDC of the product.

46. Type the Compound Ingredient Quantity.

47. Type the Compound Ingredient Drug Cost.

The Product ID Qualifier, Product ID, Ingredient Quantity, and Ingredient Drug cost are all relative to individual ingredients, not the entire product.

48. Select the Compound Ingredient Basis of Cost Determination using the drop-down menu.

49. Click the right arrow to enter the next ingredient(s) and complete all required fields.



Diagnosis CD Count Segment

NCPDP Designations

Field Description

Diagnosis Code Count Diagnosis Code Count.

Diagnosis Code Qualifier Valid values are: 00 - Not Specified 01 - ICD9 02 - ICD10 03 - NCCI 04 - SNOMED 05 - CDT 06 - Medi Span Diagnosis Code 07 - DSM IV 99 - Other

Diagnosis Code Diagnosis Code.

Figure 3.0.19 - Diagnoses CD Count Segment

50. Select the Diagnosis Code Qualifier using the drop-down menu.

51. Type the Diagnosis Code.

The Diagnosis CD Count Segment is typically not used.

End of Claim Buttons

Figure 3.0.20 - End of Claim Buttons

Click the Cancel button to return to the Adjudicated Claims Search page.

If the Back button is used to return to the Adjudicated Claims Search page, changes made on the page do not apply. It is recommended to use the Cancel button.



Click the Reset button to clear all entered information and start over.

Click the Submit button to submit the claim as entered. The Claim Submission Response page displays. See Figure 4.0.1.


Click the Result button to view the result of the claim.

To use the Result button the claim must have been previously submitted.

Submitting a Multi-Claim Transaction

Up to four claims can be submitted with one transaction.

To submit a multi-claim transaction:

1. Click the right arrow to enter the next transaction. Another request transmission segment displays.

Figure 3.0.21 - Sample Claim Entry Template

2. Complete the additional segment with claim information.

3. Click the Submit button to process the additional claim(s). The Claim Submission Response displays. Refer to Figure 4.0.1.

The Transaction Count field must match the number of claims.

When submitting multiple claims in one transaction, the Patient, Prescriber, and Service Provider must be the same.



4.0 Claim Submission Response

Figure 4.0.1 - Claim Submission Response

The Claim Submission Response page shows the status of the claim once submitted. If the claim did not “pay,” the Reject Code(s) and descriptions are listed on the Claim Submission Results page.

− The Claims Submission Data Entry hyperlink displays the Claim Entry template.

− The Claim Submission Results hyperlink displays Reject Code(s) and descriptions.


Click the Cancel button to return to the Claim Submission Data Entry page.

Click the Print button to print the Claim Submission Response page.



5.0 Searching for a Claim To search for a claim:

1. Enter the Cardholder ID.

2. Enter the Date of Service or click the Calendar icon to select the date.

All dates should be entered DDMMYYYY.

A calendar may be used to populate dates wherever the Calendar icon displays. See Figure5.0.1.

Figure 5.0.1 - Calendar

To use the Calendar: Click the drop-down menu to select a month, type the appropriate year, and click the appropriate day.

3. Click the Search button. The Adjudicated Claims Search Result page displays. See Figure 5.0.2.



Figure 5.0.2 - Adjudicated Claims Search Result

To view the claim, click on the Internal Claim Number. The Claim Information page displays. See Figure 5.0.3.



Figure 5.0.3 - Claim Information

To return to the Adjudicated Claims Search Results page, click the Cancel button.

To print the claim information, click the Print button.

5.1 Reversing a Claim

To reverse the claim, click on the Reverse hyperlink. The Reverse template will display with the claims information filled in based on the original claim submitted.



5.2 Resubmitting a Claim

To resubmit the claim, click on the Resubmit hyperlink. The Rebill template will display with the claims information filled in based on the original claim submitted. You can update the fields and then resubmit the claim.


web claims submission user guide

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