Service Line Details
Service Line DetailsEach service line on a Professional Claim will have information available in addition to what is displayed in summary on the main page. This information is accessed by clicking the More icon on the main Service Line(s) page.
The format for all date values 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. The dates may not be greater than the current date unless otherwise specified.
Last X-Ray Date: If the claim involves spinal manipulation and an X-Ray was taken, enter the date of the X-Ray here. Not necessary if same as date entered at claim level.
Product Shipped Date: If the Service Line involves the billing/reporting of shipped goods, enter the date on which the goods were shipped.
Initial Treatment Date: If patient has previously experienced similar symptoms/illness, enter the initial treatment date here, only if it differs from the value entered at the claim level.
Prescription Date: When billing for a drug and a prescription was written, enter the date the prescription was written.
Test Performed: Using the drop down, indicate what type of test was performed.
Test Results: Enter the numeric results of the specified test. If Test Results are entered, an Identifier and Qualifier must also be selected.
Measurement Identifier: Select the manner in which the results are measured. If an Identifier is selected, a Qualifier and Test Results must also be specified.
Test Performed Date: Enter the date on which the test selected above was performed. 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. The date may not be greater than the current date.
If any information is entered into this section, all pieces of data must be populated.
National Drug Code: Enter the NDC for the drug associated with this Service Line. An 11 digit value must be entered without the hyphens.
National Drug Unit Count: Enter the number of units prescribed of this medication. Also, select the proper Unit of Measure to be associated with this value. Defaults to 'Unit' but any valid value may be selected.
Prescription Number or Compound Drug Association Number: Pick whether you are entering a Prescription Number or Link Sequence Number. Then enter the Prescription Number or Link Sequence Number associated with the drug in the field below.
Prior Authorization #: If Prior Authorization has been received for the procedures associated with this Service Line and the number is different from that entered on the Professional Claim Information tab, enter the 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.
CLIA Number: The Clinical Laboratory Improvement Amendment Number is required on all service lines containing laboratory tests covered by the CLIA Act, assuming the value differs from that entered at the claim level.
Sales Tax Amount: If sales tax applies to the services rendered on this line, enter the dollar value of the sales tax amount here.
Services a result of EPSDT Referral: Select 'Yes' or 'No' to indicate whether or not the procedures were related to the Early and Periodic Screen for Diagnosis and Treatment of Children.
Family Planning Service? Select 'Yes' or 'No' to indicate the involvement of Family Planning services.
Obstetric Anesthesia Addtl Units: If there are additional units for anesthesia, enter them in this field.
If applicable, enter the purchased service provider here. For each type of provider, there are three ways in which to enter the name onto the claim, you may select an existing provider, search for a Medicaid provider, or enter a new non-Medicaid provider. See Appendix for details.
Use an Existing Provider
Select a Name: If using an existing provider, you can select the name of the provider in the list.
Last Name: You can also enter the last name of the provider and click "Go".
Provider Number: You can also enter the provider's MMIS ID and click "Go".
Enter a New Non-Medicaid Provider
If you are entering a new non-Medicaid provider, you can enter the NPI # and/or the State License # here.
If applicable, enter the ordering provider here. For each type of provider, there are three ways in which to enter the name onto the claim, you may select an existing provider, search for a Medicaid provider, or enter a new non-Medicaid provider. See Appendix for details. DME services require an ordering provider.
Use an Existing Provider
Select a Name: If using an existing provider, you can select the name of the provider in the list.
Last Name: You can also enter the last name of the provider and click "Go".
Provider Number: You can also enter the provider's MMIS ID and click "Go".
Enter a New Non-Medicaid Provider
If you are entering a new non-Medicaid provider, you can enter the NPI # and/or the State License # here.
Length of Medical Necessity: Enter the number of days for which the medical equipment is medically necessary to the patient. A value is required if any information is entered in the DME section.
DME Rental Price: If there is a rental fee involved with the DME represented on this Service Line, enter the dollar value here. If a HCPCS code is entered, either a Rental Price or Purchase Price must be entered.
DME Purchase Price: If the DME was purchased, enter the purchase price here. If a HCPCS code is entered, either a Rental Price or Purchase Price must be entered.
Rental Unit Price Indicator: If a Rental Price is entered, you must select the unit by which the Rental Price is based. Valid values are 'Daily', 'Weekly', or 'Monthly'.
If Ambulance Transport Information was entered at the claim level, it does not need to be re-entered here, unless details are different, in which case all data elements are required.
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 box, 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 box, this data element is required.
Ambulance Condition Codes: Up to 5 Condition Codes may be selected for an individual claim, however if any information is entered in the Ambulance Transport Information box 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.
Plate License: If billing for non-emergency transportation (Ambulette), enter the license plate number of the vehicle.
Enter the pickup and dropoff location for the transport.
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.
Procedure Description: Enter additional comments on the procedure being billed.
Other Payer Name: The Payer Name selected must match one of those entered on the Other Payer tab. All subsequent data entered applies to the Adjudication for this Service Line and Payer combination.
Service Line Paid Amount: The dollar amount paid towards this Service Line by this Payer.
Paid HCPCS Code: This is the procedure code processed/priced by the payer.
Modifiers: Optionally, up to 4 modifiers identifying special circumstances related to the performance of the service may be entered for each code. Note: If entered, the Modifier must be a 2 character code.
Paid Service Unit Count: The units of service paid by the Other Payer.
Bundled Line Number: If applicable, enter the number of the line bundled or unbundled by the other payer.
Date Claim Paid: Service adjudication or payment date must be entered. The date 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.
Remaining Patient Liability: This is the amount the provider believes is due and owing after the Other Payer’s adjudication.
Claim Adjustment Group: Enter the Group Code as received from the other payer.
Reason Code: Enter the Claim Adjustment Reason Code as received from the other payer. The Claim Adjustment Group/Reason Code combination may not be entered more than once. If an Adjustment Amount or Adjustment Quantity is entered, a Reason Code is required.
Adjustment Amount: Enter the Adjustment Amount as received from the other payer. An Adjustment Amount is required when a Reason Code is entered.
Adjustment Quantity: Enter the Quantity Adjusted as received from the other payer.
If Other Payers have been included on the claim and they have adjudicated this line or you need to maintain the adjudication details, you may view/maintain the individual Line Adjudication Information or view a summary of all adjudication information for this line.
