MN–ITS Interactive COB Tab, Field Completion Guide. Minnesota Health Care
Programs (MHCP). Page 1 of 2. MN–ITS Interactive Training – 4/29/11.
MN–ITS Interactive COB Tab, Field Completion Guide This supplemental guide will help you complete the MN–ITS Interactive Coordination of Benefits tab (and a popup screen on the Services tab). Complete the fields noted and any blank field when you have the information. A = minimum required for MEDICARE A B = minimum required for MEDICARE B T = minimum required for TPL/Other Insurance
837P Prof
837D Dental
837I Long Term Care
837I Outpatient
837I Inpatient
B, T B, T
T T
A, T A, T A T
A, B, T A, B, T
A, T A, T
A, T
A, T
A
A, B
A
A, T A, T A, T
A, T A, T A, T
A, T A, T A, T
COB TAB Payer Name Primary ID Adjudication Date Prior Payment - Payer and Patient Authorization Number Referral Number Address City State Zip Code Country Code Other Payer ICN
B
Paid Amounts Box Type Amount
T T
T T
T T T
T T T
Claim Adjustment Amounts Box Group Code Reason Code Amount Quantity
Medicare Box/Medicare Outpatient Adjudication Box Reimbursement Percent HCPCS Payable ERSD Paid Amount Remarks Non-payable Component
B
B
Medicare Inpatient Adjudication Box MIA Counts MIA Amounts Remarks
A
A
A
T T T
A, T A, T A, T
A, B, T A, B, T A, B, T
A, T A, T A, T
T T T T T T
A, T A, T A, T A, T A, T A, T
A, B, T A, B, T A, B, T A, B, T A, B, T A, B, T
A, T A, T A, T A, T A, T A, T
Other Payer Subscriber Box Insured ID Insured Birth Date Last Name Insurance Type Insured Gender Relationship Benefits Assignment Release of Information Payer Responsibility Claim Filing Indicator First Name Middle Name Minnesota Health Care Programs (MHCP) MN–ITS Interactive Training – 4/29/11
B, T B, T B, T B, T B, T B, T B, T B, T B, T B, T
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MN–ITS Interactive COB Tab, Field Completion Guide A = minimum required for MEDICARE A B = minimum required for MEDICARE B T = minimum required for TPL/Other Insurance
837P Prof
837D Dental
837I Long Term Care
837I Outpatient
837I Inpatient
Other Payer Subscriber Box (cont.) Name Suffix Signature Source Group or Policy Number Group or Policy Name Address City State Country Code Zip Code
Other Payer Patient Box Primary ID Last Name
SERVICES TAB Other Payer Box Other Payer Primary ID Procedure Code Line Paid Amount Paid Units Revenue Code Procedure Description Modifiers Line Adjudication Date Bundled Line Number Authorization Number Referral Number
B B B B
B B B B B
B
B
B B B
B B B
Line Adjustment Amounts Box Group Code Reason Code Amount Quantity
Minnesota Health Care Programs (MHCP) MN–ITS Interactive Training – 4/29/11
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