Idpa Form PDF Details

In navigating the complex terrain of health insurance claims, the DPA 2360 health insurance claim form emerges as a vital tool for medical providers, particularly those associated with school-based or linked health centers as outlined in the October 2002 IDPA Appendix S-1. This document serves not only as a billing instrument but also as a means to streamline the processing and reimbursement procedures for various medical services. Key instructions for completing the form range from ensuring legibility and avoiding the use of any form of punctuation to the meticulous process of entering service codes and patient information precisely within designated areas. The guidelines specify the usage of black ink, the avoidance of any handwriting unless absolutely necessary, and the requirement that all attachments must be properly aligned and attached without the use of staples to aid in efficient imaging processing. The stipulated conditions under which each section must be filled, encompassing both mandatory and optional entries, are delineated to facilitate the provider's task in claiming services rendered, whether they pertain to medical care, surgery, diagnostics, or family planning. Furthermore, it delves into specifics such as the formatting of dates, the detailing of service types via codes, and the accurate reporting of charges without deduction for third-party payments. The ultimate goal is to ensure that health centers are reimbursed accurately and promptly for the indispensable services they offer, thereby underscoring the critical nature of adhering to these technical guidelines in claim preparation.

QuestionAnswer
Form NameIdpa Form
Form Length10 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 30 sec
Other nameswhat is r16 override on idpa form, order form for idpa envelopes, idpa 2360 form, idpa technical form online

Form Preview Example

Handbook for School Based/Linked Health Centers

Chapter S-200 Appendices

APPENDIX S-1

TECHNICAL GUIDELINES FOR CLAIM PREPARATION FORM DPA 2360, HEALTH INSURANCE CLAIM FORM

Please follow these guidelines in the preparation of claims for imaging processing to assure the most efficient processing by the Department:

Claims that are illegible will be returned to the provider.

Claims with extreme print qualities, either light or dark, will not image.

Use only one font style on a claim. Do not use bold print, italics, script, or any font that has connecting characters.

Claims should be typed or computer-printed in capital letters. The character pitch must be 10-12 printed character per inch, the size of most standard pica or elite typewriters. Handwritten entries should be avoided.

Do not use punctuation marks, slashes, dashes or any special characters anywhere on the claim form.

All entries must be within the specified boxes. Do not write in the margins.

Red ink does not image. Use only black ink for entries on the billing form, attachments and provider signature.

If corrections need to be made, reprinting the claim is preferred. Correction fluid should be used sparingly.

Remove the pin-feed strips on claims at the perforations only. Do not cut the strips, as it may alter the document size.

Attachments containing a black border as a result of photocopying with the copier cover open cannot be imaged. Attachments must have a minimum one- half inch white border at the top and on the sides to ensure proper imaging of the document.

For attachments containing gray areas, either as part of the original or as a result of photo-copying a colored background, print in the gray area is likely to be unreadable. If information in this area is important, the document should be recopied to eliminate the graying effect as much as possible without making the print too light.

Attachments should be paper-clipped or rubber-banded to claims. Do not fold invoices or fasten attachments with staples.

October 2002

IDPA Appendix S-1 (1)

Handbook for School Based/Linked Health Centers

Chapter S-200 Appendices

Appendix S-1a is a copy of Form DPA 2360, Provider Invoice. Instructions for completion of the Provider Invoice follow in the order entries appear on the form and addresses only those fields required by the Department. Mailing instructions follow the claim preparation instructions.

The left hand column of the following instructions identifies mandatory and optional items for form completion as follows:

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

37B. TPL Status - A two-digit code indicating the disposition of the third party billing must be entered. The TPL Status Codes are:

01 - TPL Adjudicated - total payment shown: TPL Status Code 01 is to be entered when payment has been received from the patient or patient's third party resource. The amount of payment received must be entered in the TPL amount box.

02 - TPL Adjudicated - patient not covered: TPL Status 02 is to be entered when advised by the third party resource that the patient was not insured at the time goods or services were provided.

03 - TPL Adjudicated - service not covered: TPL Status Code 03 is to be entered when advised by the third party resource that goods or services provided are not covered.

04 - TPL Adjudicated - spenddown met: TPL Status Code 04 is to be entered when the patient's Form 2432, (Split Billing transmittal), shows $0.00 liability.

05 - Patient not covered: TPL Status Code 05 is to be entered when a patient informs the provider that the third party resource identified on the Medical Eligibility Card is not in force.

06 - Services not covered: TPL Status Code 06 is to be entered when the provider determines that the identified resource is not applicable to the service provided.

07 - Third Party Adjudication Pending: TPL Status Code 07 may be entered when an invoice has been submitted to the third party and 30 days have elapsed since the third party was billed and reasonable follow-up efforts to obtain payment have failed.

10 - Deductible not met: TPL Status Code 10 is to be entered when the provider has been informed by the third party resource that non-payment of the service was because the deductible was not met.

October 2002

IDPA Appendix S-1 (7)

Handbook for School Based/Linked Health Centers

Chapter S-200 Appendices

37C. TPL Amount - If there is no TPL amount, enter 0 00. Enter the amount of payment received from the third party resource. A dollar amount entry is required if TPL Status Code 01 was entered in the “Status” box.

37D. TPL Date - A TPL date is required when any status code is shown in Item 37B. Use the following date for the specific TPL status codes;

01 = Third Party Adjudication Date or the date from the DPA 2432

02 = Third Party Adjudication Date

03 = Third Party Adjudication Date

04 = Date from DPA 2432

05 = Date of Service

06 = Date of Service

07 = Date of Service

10 = Third Party Adjudication Date

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

MAILING INSTRUCTIONS

The Provider Invoice is a two-part form. The provider is to submit the original to the Department as indicated below. The copy of the claim is to be retained by the provider.

The pin-feed guide strip should be detached from the sides of continuous feed forms.

Routine claims are to be mailed to the Department in pre-addressed mailing envelopes, Form DPA 1444, Provider Invoice Envelope, provided by the Department.

Claims with attachments must be mailed to the Department in the pre-addressed mailing envelope, DPA 1414, Special Approval Envelope.

To order the envelopes mentioned in this topic, refer to Chapter 100, General Appendix 10.

October 2002

IDPA Appendix S-1 (9)