The Detail Claim Item window is used to maintain detail claim item information. The Detail Claim Item window displays the claim number, line and version. The DHHS office, the case person, the service description, service dates, service frequency, charges, status and effective date of the status also display. Use this window to browse or update a claim item or more than one claim item, when multiple detail claim item lines are selected from the Detail Claim window.
Claim Group Box:
Number: This field displays the unique system assigned claim identification number.
Line: This field displays the line number from the claim on which the claim item appears
Version: This field displays the version number for the claim item.
DHHS Office: This field displays the name of the office assigned to this claim item.
Case Person Group Box:
Number: Enter the unique system assigned case person identification number associated with this claim item.
Name: This field displays the name of the case person associated with this claim item.
|
|
Select the search arrow to go to the Person Search window to find the case person associated with the claim item. |
Svc Auth Nbr: This field displays the service authorization number associated with the case person, claim item and service type. When the system does not find the service authorization number and service authorization number is known, the number can be entered.
Service Group Box:
Code: This field displays the code number used to uniquely identify the service type provided on this claim item.
Description: This field displays the description of the service type associated with the service type code number shown above.
|
|
Select the search arrow to go to the Search Service Type Criteria window to find the appropriate service type to assign to this claim. |
Service Dates Group Box:
Begin: Enter the date the service started on this claim item.
End: Enter the date the service on this claim item ended.
Service Frequency: Open the drop down list and select the appropriate frequency.
Relative Provider Check Box: This check box indicates the provider of the service is related to the recipient of the service. This information is set on the Service Authorization window.
Reduction Reasons Button: Select this button to view the Claim Item Reduction Reasons window to review the reason(s) for reducing the dollar amount paid.
Adjustment Reasons Button: Select this button to view the Claim Item Adjustment Reasons window to view the reason(s) for adjusting the dollar amount paid.
Program: This field displays the program that is attached to the claim item.
Fund: This field displays the fund attached to the claim item.
OP Amt: This field displays the overpayment amount, if any
UP Amt: This field displays the underpayment amount, if any
Status: This field displays the current status of the claim
As On: This field displays the date the system established the current status.
Reason Drop Down List Box: Open this drop down list to display the reason for the current status.
Charges Group Box:
This group box has two columns. Complete the first column “Submitted”. The submitted amounts are found on the claim form, billing document or other document sent in to establish the provider’s claim. The system completes the second column “Validated”.
Units Provd: Enter the number of service units submitted for payment in this field.
Rate: Enter the rate for this type of service in this field.
Total Chrg: Enter the total charge of the claim item from the billing document. Manually multiply the units provided by the rate to arrive at the total charge.
Note: The total charge entered may not always be the units provided multiplied by the rate. Consider special circumstances when entering the total charge.
Cust Oblig: Enter the amount of the claim obligated to be paid by the recipient of the service.
Net Charge: This field displays the automatic calculation of the net charge. The system calculates the net charge by subtracting the customer obligation from the total charge.
FICA: This field displays the FICA amount withheld.
Note: Set the FICA withholding status on the Detail Organization window. The system automatically deducts the FICA amount when the identified service provider is an organization that should have federal income tax withheld and the service type is identified for FICA withholding.
Backup Withholding: This field displays the amount of backup withholding deducted from the claim.
Approved Payment Amount: This field displays the automatically calculated approved payment amount.
|
Select the OK button to save the changes and return to the Detail Claim window. |
|
Select the previous line button to save the changes and display the previous claim item. |
|
Select the next line button to save the changes and display the next claim item. |
|
Select the Help button to return to the Detail Claim window without saving the changes. |
|
Select the Help button to display windows help. |
NFO4072H
(12-2011)