Institutional Claim Information

The information specific to an Institutional claim is entered on this tab. Approximately half the data elements are unique to this claim type and will not be seen on the tabs when entering other types of claims. The page is visually separated into sections using different shading. Each section/field is discussed below, click on the section name to view the details of the fields in that section.

Facility Type: Enter the Type of Facility and Bill Classification. This value identifies the type of facility where services were performed. The Claim Frequency is defaulted for all claims by ePACES and therefore is not entered as a part of this code. Required for all claims.

Assignment of Benefits?: Select 'Yes' if the insured or authorized person authorizes benefits to be assigned to the provider. Select 'No' if benefits have not been assigned to the provider. This will default to 'Yes'.

Release of Information?: Enter or select the code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations.

Accept Assignment?: Enter or select the appropriate value from the provided list to indicate whether the provider has a participation agreement with the payer. This field is required on all claims.

Auto Accident State: If this claim is related to a vehicular accident please choose the state the accident occurred in.

Admission Information

At a minimum, the admission type, patient status and the date range that is covered by the statement must be entered.

Admission Type: Please select an admission type.

Patient Status A code describing a specific condition or status of the patient as of the last date of service. For further information, see the appropriate provider manual. : Code representing the patient status as of the 'Statement Covers To' or Discharge date. Enter or select the appropriate value from the list of available codes. This a required field.

Admission Source: Indicates the source of the admission covered by this claim. Enter or select the appropriate Admission Source Code from the list. A value must be selected for all inpatient services.

Statement Covers (From/To): The date range that is being billed for in the claim. The dates may not be greater than the current date. The format for each date is: MM/DD/YYYY and may either be entered in the field or selected from the calendar available by pressing the button to the right of the field. A date range must be entered for all claims.

Admission Date The date on which the patient was first admitted. : The date on which the patient was admitted to the facility. The date may not be greater than the current date. The format for the date is: MM/DD/YYYY and may either be entered in the field or selected from the calendar available by pressing the button to the right of the field. An Admission Date is required for all inpatient.

Admission Hour Indicates the hour when the patient was admitted. For further information, see the appropriate provider billing manual. : The 4-digit military time, HHMM, associated with the time the patient was admitted to the facility. The value must be between 0001 and 2400 and must be entered directly into the field. An Admission Hour must be entered for all hospital inpatient services.

Discharge Hour The hour when the patient was discharged. For further information, see the appropriate provider billing manual. : The 4-digit military time, HHMM, associated with the time the patient was discharged from the facility. The value must be between 0001 and 2400 and must be entered directly into the field. The Discharge Hour is required for all final inpatient claims. If a Discharge Hour is entered, the Discharge Date must also be captured when the discharge date is different than the statement through date.

Medical Record Number: Allows the provider to identify the actual medical record of the patient. Free-form text field, used as reference only for Hospital Inpatient claims.

Prior Authorization Number If the provider is billing for a service that requires prior authorization, the 8-digit prior authorization number which was assigned by the NYS Department of Health Area Office. : If Prior Authorization has been received for the services associated with this claim, enter the prior approval number in the field. Prior Authorization numbers are assigned by the payer to authorize a service prior to its being performed. This number is specific to NY Medicaid.

Certification Information

Certification Category: If billing for a well care visit for a child, please select EPSDT-Referral Mutual in the drop down.

Condition Codes: Enter the appropriate condition code for EPSDT billing.

Value Codes

Rate Codes (24), Birth Weight (54), LTR Amounts (08 or 10), Surplus Amount (22), Catastrophic Amount (21), Net Available Monthly Income (NAMI) (23), Covered Days (80), Non-covered Days (81), Coinsurance Days (82), LTR Days (83) and Patient Paid Amount (FC) are

If it is necessary to enter Value codes and their corresponding values, you will notice there are 6 sets of fields visible in which to enter the information. If more than 6 Value Codes need to be entered, simply click 'Add'... and you will be able to enter an additional six Value Codes.

NOTE: You may not enter the same code multiple times, even if the corresponding values are different.

Code: Enter or select the desired code from the provided list of valid values. You may either type the code directly into the field or select the value from the pop-up window.

Value: This is a free-form field and becomes required if a corresponding code is selected. Depending on the code selected, the value entered may be an integer or a decimal value, however it must always be numeric.

Condition Codes

Up to 24 Condition Codes may be selected for an individual Institutional Claim.

NOTE: You may not select the same Condition Code multiple times.

Code: Enter or elect the desired code value from the provided list of valid values. You may either type the code directly into the field or select the value from the pop-up window.

Occurrence Span

If it is necessary to enter Occurrence Spans or Codes for this claim, you are able to enter 12 values. The tab displays 12 sets of codes and corresponding dates, however clicking 'Add'... will allow you to enter an additional 12 values if needed. Occurrence Codes are used on Hospital Inpatient claims to indicate the Discharge Date (code = 42). The Stay Deny Effective Date is now reported as the Date Active Care Ended (code = 22).

NOTE: You may select the Code 75 multiple times for the same claim. For all other codes, you may not select the same code multiple times, even if the date ranges associated with the codes differ.

Code: Enter or select the desired value from the provided list of valid values. You may either type the code directly into the field or select the value from the pop-up window.

From/Through: If an Occurrence Code is entered (code values 01-69 and A0-L9), only a From date may be entered. However if an Occurrence Span is entered (code values 70-99 and M0-Z9), then both a From and Through date must be entered. If a Through date is entered, it must be greater than the From date entered. The date(s) may not be greater than the current date. The format is: MM/DD/YYYY and may either be entered in the field or selected from the calendar available by pressing the button to the right of the field.

Service Authorization Exception Code: Enter the Service Authorization Code if the service you are billing is exempt from utilization threshold. You may either type the code directly into the field or select the value by pressing the button to the right of the field.

Delay Reason: If a claim will be submitted beyond the 90-day filing limitations, enter or select a reason code from the available list of valid values. If the delay reason is for interrupted maternity care or an IPRO denial/reversal, use "11 - Other".

Click here for the controls located at the bottom of the page or continue to the Physician Information tab.