Professional
Claim Information Professional
Claim Information The information specific to a Professional claim is entered on this tab. Approximately one-third of the data elements are unique to this claim type and will not be seen on other 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.
Place of Service: Enter the Place of Service from the CMS Place of Service code list that is most appropriate for the service location type.
Provider Signature on File?: Select 'Yes' or 'No' depending on whether or not the Provider Signature is on file with the Payer. This field is required for all Professional 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.
Signature Source: Select either patient or other on how subscriber authorization signature was obtained.
Exempt from Copay? Select Yes or No on whether the member is exempt from copay.
Is Patient Pregnant? Select Yes or No on whether the member is pregnant.
Patient Amount Paid: The sum of all amounts paid, if any, on the claim by the patient or his/her representative.
Prior Authorization: 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 and should not be used for Predetermination of Benefits.
Mammography Certification Number: When entering a claim where mammography services were rendered, the Mammography Certification Number must be entered.
CLIA Number: The Clinical Laboratory Improvement Amendment Number is required on all claims containing laboratory tests covered by the CLIA Act.
Certification Category: If applicable, select the appropriate certification category. Options are: Homebound-Functional, Vision-Spectacle Lense, Vision-Contact Lense, Vision Spectacle Frame or EPSDT Referral.
Condition Codes: Enter the appropriate condition code based on the certification category selected.
The format for all date values is MM/DD/YYYY and may be entered in the field or selected from the calendar available by pressing the button to the right of the field.
Admission Date: If applicable, enter the date of admission.
Discharge Date: If applicable, enter the discharge date.
Onset of Current Illness or Injury Date: If applicable, enter the date the illness/injury began.
Last X-Ray Date: If applicable, enter the date of the last x-ray.
Last Menstrual Period Date: If applicable, enter the last menstrual period date.
Hearing and Vision Prescription Date: If applicable, enter date for hearing or vision prescription.
Disability From Date: If applicable, enter date member started disability.
Disability Through Date: If applicable, enter date member stopped disability.
Assumed Care Date: If applicable, enter date care was assumed.
Relinquished Care Date: If applicable, enter date care was relinquished.
Acute Manifestation Date: If applicable, enter date of acute manifestation.
Initial Treatment Date: If applicable, enter date initial treatment started.
Last Seen Date: If applicable, enter date member was last seen.
Related Causes: You may select up to two related causes for this claim. If one or more of the options applies to the situation, mark the appropriate check box(es) and enter the Accident Date. If Auto Accident is selected as a Related Cause, enter the state and country in which the accident occurred, 'NY' and 'USA' are the corresponding default values.
Accident Date: If any of the Related Causes boxes are checked, the date of the accident must be entered. The date may not be greater than the current date. The format of 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.
Ambulance Transport
Patient Weight: The weight, in pounds, of the patient at the time of transport via ambulance.
Ambulance Transport Reason: Enter or select a Transport Reason Code from the provided list of valid values. If any information is entered in the "Ambulance Transport Information" section, this data element is required.
Transport Distance: Enter the distance, in miles, traveled during transport of the patient. If any information is entered in the "Ambulance Transport Information" section, this data element is required.
Ambulance Condition Codes: Up to 5 Condition Codes may be entered for an individual claim, however if any information is entered in the "Ambulance Transport Information" section at least 1 Condition Code must be entered. Select the desired code value from the provided list of valid values. You may either select from the available list or type the code directly into the field. Note: Condition Code values may not be entered more than once on an individual claim.
Non-Emergency Transport
Driver License: If billing for non-emergency transportation (Ambulette), enter the driver license of the driver.
License Plate Number: If billing for non-emergency transportation (Ambulette), enter the license plate number of the vehicle.
If billing for transportation, enter the drop off and pick up locations of the trip.
Pick UP
Address Line 1/Line 2: Enter the street address of where the member was picked up.
City: Enter the city where the member was picked up.
State: Enter the state where the member was picked up.
Zip Code: Enter the zip code where the member was picked up.
Drop Off
Address Line 1/Line 2: Enter the street address of where the member was dropped off.
City: Enter the city where the member was dropped off.
State: Enter the state where the member was dropped off.
Zip Code: Enter the zip code where the member was dropped off.
Service Authorization Exception Code: Enter an exception code if service is exempt from utilization threshold.
Special Program Indicator: If applicable, enter a special program indicator. Options are:
02 Physically Handicapped Children's Program
03 Special Federal Funding
05 Disability
09 Second Opinion or Surgery
Delay Reason: If claim is over the timely filing limits, enter the appropriate delay reason for the claim. Options are:
1 Proof of Eligibility Unknown or Unavailable
2 Litigation
3 Authorization Delays
4 Delay in Certifying Provider
5 Delay in Supplying Billing Forms
7 Third Party Processing Delay
8 Delay in Eligibility Determination
9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules
10 Administration Delay in the Prior Approval Process
11 Other
15 Natural Disaster
Patient Weight (EPO patients): If applicable, enter the weight of the patient.
Code: If billing for a sterilization or abortion, select the appropriate condition code from the list.
Group Provider Number: If payment is to go to the group, enter the group NPI in this field.
Click here for the controls located at the bottom of the page or continue to the Physician Information tab.
