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Handbook for School Based/Linked Health Centers

Chapter S-200 Appendices

October 2002

IDPA Appendix S-1 (1)

Handbook for School Based/Linked Health Centers

Chapter S-200 Appendices

Required

=

Entry always required.

Optional

=

Entry optional - In some cases failure to include an entry will

result in certain assumptions by the Department and will

preclude corrections of certain claim errors by the

Department.

Conditionally

=

Entries which are required only under certain circumstances.

Required

Conditions of the requirement are identified in the instruction

text.

COMPLETION

ITEM EXPLANATION AND INSTRUCTIONS

Required

1. Recipient Name - Enter the participant's name exactly as it

appears on the MediPlan Card or Temporary MediPlan Card

or KidCare Card. Separate the components of the name

(first, middle initial, last) in the proper sections of the name

field.

Conditionally

2. Birthdate - Enter the month, day and year of birth of the

Required

participant as shown on the MediPlan Card or Temporary

MediPlan Card or KidCare Card. An entry is required when

charges are being billed when Form DPA 1411 does not

contain a recipient number. Use the MMDDYY format.

October 2002

IDPA Appendix S-1 (2)

Handbook for School Based/Linked Health Centers

Chapter S-200 Appendices

Required

8.

Recipient No. - Enter the nine digit number assigned to the

individual as copied from the MediPlan Card or Temporary

MediPlan or KidCare Card. Use no punctuation or spaces.

Do not use the Case Identification Number.

If the Temporary MediPlan Card does not contain the

recipient number, enter the patient name and birthdate on

the Provider Invoice and attach a copy of the Temporary

MediPlan Card to the Provider Invoice. The Department will

review the claim and determine the correct recipient number.

See "Mailing Instructions" in this Appendix when a copy of

the Temporary MediPlan Card is attached.

Conditionally

23a.

Healthy Kids - If a provider completed a heathly kids

Required

screening or if diagnostic and treatment services were

provided because of a Healthy Kids screening, enter an “X”

in the “YES” BOX.

Conditionally

23b. Family Planning - If services were rendered for family

Required

planning purposes, enter an “X” in the “YES” box.

Required

23e. Type of Service - Enter the code corresponding to the

type of service for which the charges submitted on the claim

apply.

Only one type of service can be included on a single claim.

A separate claim must be prepared for each type of service

for which charges are made. However, labs and x-rays do

not have to be separated out. Use T.O.S. 1 and bill together.

The following codes are to be used.

1 - Medical Care - Attending Physician

2 - Surgery - Surgeon

Optional

23f.

Diagnosis or Nature of Injury or Illness - Enter the

diagnosis or nature of injury or illness description which

describes the condition primarily responsible for the patient’s

treatment.

Optional

24.

Repeat Code - Usage not recommended.

Required

24a. Date of Service - Enter the date the service was

performed. (Use the MMDDYY format).

October 2002

IDPA Appendix S-1 (3)

Handbook for School Based/Linked Health Centers

Chapter S-200 Appendices

Required

24b.

Place of Service - Enter the appropriate code which

identifies the place where the service was provided.

3 or 11 - Office/Clinic

Required

24c. Procedure Code/Drug Item Number - When billing for

services enter the appropriate five-digit CPT-4 or HCPCS

procedure code.

When billing for dispensed items, enter the CPT-4 procedure

code or eight-digit item number. Enter the name of the item

dispensed in the description area (24C)

Required

24d. Primary Diagnosis - Enter the specific ICD-9-CM code for

the primary diagnosis. Do not use a decimal or leave a blank

space in the decimal point's position.

Secondary Diagnosis: An entry in this field is optional. A

second ICD-9-CM code may be entered to identify a

secondary diagnosis when appropriate. Do not use a

decimal or leave a blank space in the decimal point's

position.

Required

24e. Provider Charges - Enter the total charge for the service.

Do not deduct any payment from a third party.

Conditionally

24f.

Days/Units - A four-digit entry is required only for the

Required

following:

• When billing for multiples of the same lab test, indicate

the number; (e.g., for 2 lab tests, enter 0002)

• When billing for drug items dispensed, indicate the

number; (e.g., for birth control pills, enter 0028).

Optional

Delete - When an error has been made that cannot be corrected,

enter an “X” to delete the entire service section. Only “X” will be a

valid character, all other will be ignored.

Required

25.

Signature of Physician and Date Signed - The physician

or authorized representative must sign the completed form

in black or dark blue ink. Unsigned claims will be rejected.

Only original signatures are accepted. Signatures must also

be complete (no initials), legible and entered within the

boundaries of this item. The signature should not overwrite

the date field. Use MMDDYY format.

October 2002

IDPA Appendix S-1 (4)

Handbook for School Based/Linked Health Centers

Chapter S-200 Appendices

Required

27.

Total Charge - Enter the sum of all charges shown in service

sections 1 through 7 of item 24E.

Required

28.

Amount Paid - Enter the total of all payments received from

other sources. If no payment was received, enter 0.00. The

entry must equal the sum of the amounts shown in fields 37C

and 38C.

Required

29.

Balance Due - Enter the difference between the total charge

and amount paid.

Required

30.

Your Provider Number - Enter the 12 digit provider number

of the clinic exactly as it is shown on the Provider Information

Sheet.

Required

31.

Physician's or Supplier's Name, Address, Zip Code -

Enter the clinic's name exactly as it is shown on the Provider

Information Sheet. When an address is entered, the

Department will attempt to correct claims that have been

suspended due to provider name/number errors. When no

address is entered, the Department will not attempt to make

corrections.

Conditionally

32.

Patient's Account Number - Providers may enter up to 10

Required

characters used in your accounting system to identify the

patient or transaction. This number will be included on your

IDPA Remittance Advice.

Required

33.

Payee Number - Enter the single digit number of the payee

to whom payment is to be sent. Payees are listed

numerically on the Provider Information Sheet.

Required

34.

Number of Sections - Enter the total number of service

sections in Item 24 which have been correctly completed.

October 2002

IDPA Appendix S-1 (5)

Handbook for School Based/Linked Health Centers

Chapter S-200 Appendices

Conditionally

37A. TPL Code - The TPL Code contained on the

Required

patient's MediPlan Eligibility Card (MEC) is to be entered in

this field. If payment was received from a third party

resource not listed on the MEC, enter the appropriate TPL

Code as listed in Chapter 100, General Appendix 9. If none

of the TPL codes that are listed in Chapter 100, General

Appendix 9 are applicable to the source of payment, enter

Code “999" and enter the name of the payment source in

field 9, Other Health Insurance Coverage. If there is more

than one source of other payments to report, the additional

payments are to be shown in Sections 38A-D.

Spenddown - Refer to Chapter 100, Item 133 for a full

explanation of Spenddown policy. If the client has a

Spenddown obligation, they will either be responsible for the

total amount of the charge or will present the provider with a

Form DPA 2432 (SPLIT BILLING TRANSMITTAL FOR

MANG SPENDDOWN PROGRAM). When a Form DPA

2432 is necessary, the Form DPA 2360 should be

completed as follows:

If Form DPA 2432, Split Billing Transmittal, shows a

recipient liability greater than $0.00 the invoice should be

coded as follows:

37A; 906

37B; 01

37C; The actual recipient liability as shown on Form

DPA 2432.

37D; The issuance date on the bottom right hand corner

of the DPA 2432. This is in MMDDYY format.

If Form DPA 2432, Split Billing Transmittal, shows a recipient

liability of $0.00 the invoice should be coded as follows:

37A; 906

37B; 04

37C; 0 00

37D; The issuance date on the bottom right hand corner

of the DPA 2432. This is in MMDDYY format.

October 2002

IDPA Appendix S-1 (6)

Handbook for School Based/Linked Health Centers

Chapter S-200 Appendices

October 2002

IDPA Appendix S-1 (7)

Handbook for School Based/Linked Health Centers

Chapter S-200 Appendices

Conditionally

38A.

(See 37A above)

Required

38B.

(See 37B above)

38C.

(See 37C above)

38D.

(See 37D above)

October 2002

IDPA Appendix S-1 (8)

Handbook for School Based/Linked Health Centers

Chapter S-200 Appendices

October 2002

IDPA Appendix S-1 (9)