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Health PAS Web Portal Provider User Guide Date of Publication: January 13, 2016

Document Version: 5.0

This user guide is a draft document and will continue to be updated to reflect

new functionality and user interface changes as a result of future releases to

Health PAS.

Health PAS Web Portal Provider User Guide


Privacy and Security Rules

The Health Insurance Portability and Accountability Act of 1996 (HIPAA – Public Law 104-

191), the HIPAA Privacy Final Rule1, and the American Recovery and Reinvestment Act

(ARRA) of 2009 requires that covered entities protect the privacy and security of individually

identifiable health information.

Protected health information (PHI) includes demographic information and other health

information and confidential information, whether verbal, written, or electronic; created,

received, or maintained by Molina Healthcare about members and patients. It is healthcare data

plus identifying information that would allow the data to tie the medical information to a

particular person. PHI relates to the past, present, and future physical or mental health of any

individual or recipient; the provision of healthcare to an individual; or the past, present, or future

payment for the provision of healthcare to an individual. Claims data, prior authorization

information, and attachments such as medical records and consent forms are all PHI.

1 45 CFR Parts 160 and 164, Standards for Privacy of Individually Identifiable Health Information; Final Rule



Table of Contents

Privacy and Security Rules .......................................................................................................... 2

Table of Contents .......................................................................................................................... 3

Table of Figures and Tables ......................................................................................................... 6

1. Introduction ........................................................................................................................... 9

2. Information You Will Need ................................................................................................ 10

3. System Requirements ......................................................................................................... 11

4. Getting Started .................................................................................................................... 12

4.1 Home Page ................................................................................................................................. 12

4.1.1 Breadcrumbs ......................................................................................................................... 13

4.2 Command Buttons ..................................................................................................................... 14

4.3 Announcements ......................................................................................................................... 14

4.4 Contact Us ................................................................................................................................. 15

4.5 Provider Directory ..................................................................................................................... 16

4.6 References ................................................................................................................................. 18

4.6.1 Companion Guides ................................................................................................................ 18

4.6.2 Forms..................................................................................................................................... 19

4.6.3 Frequently Asked Questions ................................................................................................. 20

4.6.4 Newsletters ............................................................................................................................ 20

4.6.5 Provider Manual .................................................................................................................... 20

4.6.6 User Guides ........................................................................................................................... 21

4.7 Training ..................................................................................................................................... 21

4.7.1 Training Calendar .................................................................................................................. 21

4.7.2 USVI Medicaid Training Center Information ....................................................................... 22

5. Ending Your Session ........................................................................................................... 23

6. Secure Health PAS-Online Portal ..................................................................................... 24

6.1 Secure Health PAS-Online Banner ............................................................................................ 25

6.2 Trading Partner Window ........................................................................................................... 27

6.2.1 Alert Feature .......................................................................................................................... 29

6.3 Sign Out of Your Trading Partner Account ............................................................................... 31

7. Claim Submission ................................................................................................................ 32

8. Claims Search ...................................................................................................................... 36

8.1 Professional Claim, CMS 1500 ................................................................................................. 37

8.1.1 Claim Information for Professional Claim ............................................................................ 37

8.1.2 Diagnoses for Professional Claim ......................................................................................... 37

8.1.3 Services for the Professional Claim ...................................................................................... 38

8.1.4 Additional Information for the Professional Claim ............................................................... 43

8.1.5 Submit the Professional Claim .............................................................................................. 44

8.2 Dental Claim .............................................................................................................................. 44



8.2.1 Claim Information for the Dental Claim ............................................................................... 44

8.2.2 Services for the Dental Claim ............................................................................................... 45

8.2.3 Additional Information for the Dental Claim ........................................................................ 48

8.2.4 Submit the Dental Claim ....................................................................................................... 48

9. Institutional Claim .............................................................................................................. 50

9.1.1 Claim Information for the Institutional Claim ...................................................................... 50

9.1.2 Admission Data for the Institutional Claim .......................................................................... 52

9.1.3 Diagnosis, Visit, and Injury Codes for the Institutional Claim ............................................. 53

9.1.4 Procedures for the Institutional Claim .................................................................................. 54

9.1.5 Condition, Occurrence, and Value Codes for the Institutional Claim ................................... 56

9.1.6 Service Codes for the Institutional Claim ............................................................................. 59

9.1.7 Submit the Institutional Claim .............................................................................................. 61

9.2 ‘Copy Last Claim’ feature ......................................................................................................... 61

9.2.1 Search for Last Claim Submitted .......................................................................................... 61

9.3 Submit and Process a Claim ...................................................................................................... 66

9.3.1 Adjudicate Claim .................................................................................................................. 67

9.3.2 Edit Claim ............................................................................................................................. 67

10. Eligibility Search ............................................................................................................. 69

10.1 Access Eligibility Verification .................................................................................................. 69

10.2 Search for a Member ................................................................................................................. 69

10.3 Eligibility Inquiry ...................................................................................................................... 71

10.4 Eligibility Verification Response .............................................................................................. 72

10.4.1 Enrollments ....................................................................................................................... 72

10.4.2 Other Insurance ................................................................................................................. 74

10.4.3 Share of Cost (SOC) ......................................................................................................... 74

10.4.4 PCP Assignment ............................................................................................................... 75

10.5 Lock-In ...................................................................................................................................... 75

10.5.1 Print Receipt ..................................................................................................................... 75

11. Patient Roster .................................................................................................................. 77

11.1 Add New Member ..................................................................................................................... 78

11.1.1 Diagnosis .......................................................................................................................... 80

11.1.2 Service Codes ................................................................................................................... 80

11.1.3 Claim Submit Confirmation .............................................................................................. 81

12. Submit Request for DHS Authorization ....................................................................... 82

13. Viewing Authorizations .................................................................................................. 89

14. Common Functionality ................................................................................................... 93

14.1 Add Attachments ....................................................................................................................... 93

14.1.1 Type of Attachments ......................................................................................................... 95

14.2 View Attachments ..................................................................................................................... 97

14.3 Export to Excel .......................................................................................................................... 98

14.4 Print List .................................................................................................................................... 99



14.5 Diagnosis Entry ....................................................................................................................... 100

14.6 Service/Revenue Code Entry ................................................................................................... 101

Glossary of Acronyms............................................................................................................... 103



Table of Figures and Tables

Figure 4.1 – Web Address ............................................................................................................ 12

Figure 4.1.1 – Home Page............................................................................................................. 12

Figure 4.1.2 - Tabs ........................................................................................................................ 13

Figure 4.1.1.1 – Breadcrumbs ....................................................................................................... 13

Figure 4.1.1.2 - Back and Forward Arrows Seen in the Browser Tool Bar .................................. 13

Figure 4.1.1.3 - Browser Pull-down Options ................................................................................ 13

Figure 4.2.1 – Command Buttons ................................................................................................. 14

Figure 4.3.1 – Announcement on Home Page .............................................................................. 15

Figure 4.4.1 - Contact Information ............................................................................................... 15

Figure 4.5.1 – Provider Search Window ....................................................................................... 16

Figure 4.5.2 – Map Results Window ............................................................................................ 17

Figure 4.5.3 - Get Directions Window .......................................................................................... 17

Figure 4.6.1 – Reference Tile ....................................................................................................... 18

Figure 4.6.1.1 - X12 Companion Guides ...................................................................................... 18

Figure 4.6.1.2 Companion Guide Example .................................................................................. 19

Figure 4.6.2.1 Forms ..................................................................................................................... 19

Figure 4.6.3.1 - Frequently Asked Questions ............................................................................... 20

Figure 4.6.4.1 - USVI Monthly Provider Newsletters .................................................................. 20

Figure 4.6.5.1 - Provider Manual .................................................................................................. 21

Figure 4.6.6.1 - User Guides ......................................................................................................... 21

Figure 4.7.1.1 - Training Calendar................................................................................................ 22

Figure 4.7.2.1 – Medicaid Training Center................................................................................... 23

Figure 5.1 - Sign Out Hyperlink ................................................................................................... 23

Figure 6.1 – Sign In Hyperlink ..................................................................................................... 24

Figure 6.2 – Sign In Window ........................................................................................................ 25

Figure 6.1.1 – Secure Health PAS-Online Banner ....................................................................... 26

Figure 6.2.1 – Navigation Toolbar, Messages & Alerts, Training, and LMS Help Sections ....... 27

Table 6.2.1 – Medical Provider Command Buttons and Descriptions ......................................... 29

Figure 6.2.1.1 – Alert Feature ....................................................................................................... 30

Figure 6.2.1.2 – Document Title Hyperlinks ................................................................................ 30

Figure 6.3.1 – Sign Out ................................................................................................................. 31

Figure 7.1 – View & Submit Claims Tile ..................................................................................... 32

Figure 7.2 – Submit New Claim ................................................................................................... 32

Figure 7.3 – Find Member Search Area........................................................................................ 33

Figure 7.4 – Member Located ....................................................................................................... 33

Figure 7.5 – Claim Submission Window ...................................................................................... 34

Figure 7.6 – Completed Form ....................................................................................................... 35

Figure 8.1 – View & Submit Claims Tile ..................................................................................... 36

Figure 8.1.3.1 – Services for the Professional Claim ................................................................... 39

Figure 8.1.3.2. – Available Fields for Entry ................................................................................. 40



Figure 8.1.3.3 – COB Information Button .................................................................................... 41

Figure 8.1.3.4 – By Claim or By Service Line ............................................................................. 41

Figure 8.1.3.5 – COB Information Screen .................................................................................... 42

Figure 8.1.4.1 – Additional Information Section (Auto Accident) ............................................... 43

Figure 8.1.5.1 – Submitting the Professional Claim ..................................................................... 44

Figure 8.2.1.1 – Dental Claim Information ................................................................................... 45

Figure 8.2.2.1 – Total $ and Total Units Display ......................................................................... 46

Figure 8.2.2.2 - COB Hyperlink ................................................................................................... 47

Figure 8.2.2.3 – COB Information Entered by Claim or Service Line ......................................... 47

Figure 8.2.3.1 – Additional Information for Dental Claim ........................................................... 48

Figure 8.2.3.2 – Miscellaneous Information ................................................................................. 48

Figure 8.2.4.1 – Successful Submission of Dental Claim............................................................. 49

Figure 9.1.1.1 – Claim Information for the Institutional Claim (Top) ......................................... 51

Figure 9.1.1.2 – Claim Information for the Instituional Claim (Bottom) ..................................... 52

Figure 9.1.2.1 – Admission Data for the Institutional Claim ....................................................... 53

Figure 9.1.3.1 – Codes for the Institutional Claim ....................................................................... 54

Figure 9.1.4.1 – Principle Procedure Code ................................................................................... 54

Figure 9.1.4.2 – Search for Procedure Code ................................................................................. 55

Figure 9.1.4.3 – Search for Description ........................................................................................ 56

Figure 9.1.5.1 – Condition, Occurrence, and Value Codes .......................................................... 57

Figure 9.1.5.2 – Condition Codes ................................................................................................. 58

Figure 9.1.5.3 – Code ID .............................................................................................................. 58

Figure 9.1.6.1 – Services Codes for Institutional Claim ............................................................... 60

Figure 9.1.6.2 - COB Link ............................................................................................................ 60

Figure 9.1.6.3 – COB Information ................................................................................................ 61

Figure 9.2.1.1 – Selecting the Member ......................................................................................... 62

Figure 9.2.1.2 – Last Copy Claim Option is Chosen .................................................................... 62

Figure 9.2.1.3 – Last Submitted Claim Opens (Top) .................................................................... 63

Figure 9.2.1.4 – Last Submitted Claim Opens (Middle)............................................................... 63

Figure 9.2.1.5 - Last Submitted Claim Opens (Bottom) ............................................................... 64

Figure 9.2.1.6 – Copied Claim Submitted Successfully ............................................................... 64

Figure 9.2.1.1.1 – Edit Window (Top).......................................................................................... 65

Figure 9.2.1.1.2 – Edit Window (Middle) .................................................................................... 66

Figure 9.3.1 – Submit and Process a Claim .................................................................................. 67

Figure 9.3.2.1 - Add/Delete Claim Lines, Services ...................................................................... 68

Figure 9.3.2.2 - Options after Correcting Claim ........................................................................... 68

Figure 10.1.1 - Accessing Eligibility Verification ........................................................................ 69

Figure 10.2.1 - Eligibility Verification Screen ............................................................................. 70

Figure 10.2.2 - Member Information ............................................................................................ 71

Figure 10.3.1 - Eligibility Inquiry ................................................................................................. 72

Figure 10.4.1.1 - Enrollment Tab.................................................................................................. 74

Figure 10.4.2.1 - Other Insurance ................................................................................................. 74



Figure 10.4.3.1 - Share of Cost ..................................................................................................... 75

Figure 10.4.4.1 - PCP Assignment ............................................................................................... 75

Figure 10.5.1 - Lock-In ................................................................................................................. 75

Figure 10.5.1.1 - Eligibility Response for Printing ....................................................................... 76

Figure 11.1 - Accessing the Patient Roster ................................................................................... 77

Figure 11.2 - Search ...................................................................................................................... 78

Figure 11.3 - Print and Excel Options .......................................................................................... 78

Figure 11.1.1 - Find Member ........................................................................................................ 79

Figure 11.1.2 – Delete Member .................................................................................................... 79

Figure 11.1.3 – Initiating the Form ............................................................................................... 80

Figure 11.1.1.1 - Diagnosis Code Review .................................................................................... 80

Figure 11.1.2.1 - Service Code Review ........................................................................................ 81

Figure 11.1.3.1 - Confirmation Notice.......................................................................................... 81

Figure 12.1 – View & Submit Authorizations Tile....................................................................... 82

Figure 14.2 – Authorization Member Search Window ................................................................. 82

Figure 12.3 – Prior Authorization Details..................................................................................... 83

Table 12.1 – Explanation of Prior Authorization Details ............................................................. 87

Figure 12.4 – Cancel Button Message .......................................................................................... 87

Figure 12.5 – Submit Button Message .......................................................................................... 87

Figure 13.1 – List of Authorizations ............................................................................................. 89

Table 13.1 – Explanation of Authorization Details ...................................................................... 90

Figure 13.2 – Provider Authorization Window ............................................................................ 91

Table 13.2 – Explanation of Provider Authorization Fields ......................................................... 92

Figure 14.1.1 – Adding Attachments ............................................................................................ 93

Figure 14.1.2 – Uploading Attachments ....................................................................................... 94

Figure 14.1.3 – File Name Box ..................................................................................................... 94

Figure 14.1.4 – Successful Attachment ........................................................................................ 95

Figure 14.1.1.1 – Document Types ............................................................................................... 96

Figure 14.2.1 – View Documents Page ........................................................................................ 97

Figure 14.2.2 – Internet Explorer Version 11 Example ................................................................ 97

Figure 14.3.1 – Export to Excel Hyperlink ................................................................................... 98

Figure 14.4.1 – Print List .............................................................................................................. 99

Figure 14.4.2 – Print Window....................................................................................................... 99

Figure 14.4.3 – Saving PDF ........................................................................................................ 100

Figure 14.5.1 – Search Window ................................................................................................. 101

Figure 14.6.1 – Service Code Column ........................................................................................ 102



1. Introduction

The Health PAS-Online portal contains protected health information (PHI). Providers are

required to become registered trading partners to view and submit healthcare information. Once

the provider becomes a registered trading partner, they are bound by the Health Insurance

Portability and Accountability Act (HIPAA) of 1996.



2. Information You Will Need

To access the Healthcare Payer Administration Solution-Online (Health PAS-Online) secure

portal, you must have a registered trading partner user name and password.

This user guide is provided for everyone using the United States Virgin Island (USVI) Health

PAS-Online web portal. Health PAS-Online is a Web-based Medicaid administration system that

permits real-time completion of healthcare transactions over the Internet. This portal includes a

secured provider site for registered trading partners allowing them access to submit claims

online. The Health PAS-Online portal also permits the general public an easily accessible

location to view the USVI Department of Human Services (DHS) approved information by

means of a public Internet portal.



3. System Requirements

To successfully use all features of the Health PAS-Online portal, ensure that your computer

system meets the following minimum requirements:

Reliable online connection

Web browser

Internet Explorer 11

Mozilla Firefox 33 and 34

Google Chrome 41, 42, 43, and 44

Adobe Reader

Microsoft Excel



4. Getting Started

The Home tab is the first step to accessing the rest of the portal. Open the browser used to access

the Internet and enter the USVI Medicaid Web address in the browser address area as seen in

Figure 4.1. The Web address is www.vimmis.com.

Figure 4.1 – Web Address

4.1 Home Page

The Home page appears automatically upon loading. Refer to Figure 4.1.1.

Figure 4.1.1 – Home Page

http://www.vimmis.com/



The top part of the screen, containing the DHS logo, is called the title area. The bar directly

beneath the title area contains the tabs which take users to various places on the portal. Refer to

Figure 4.1.2.

Figure 4.1.2 - Tabs

Clicking on any tab will take you directly to that information.

4.1.1 Breadcrumbs

When a hyperlink is clicked, the related window displays. The breadcrumbs shown in Figure

4.1.1.1 indicate the current position within the site. Breadcrumbs are a visual representation of

the windows and sub-windows accessed to reach the current window.

Figure 4.1.1.1 – Breadcrumbs

To go back to the previous page or to move forward to the next page, you can use the Back and

Forward arrow icons associated with your browser. Refer to 4.1.1.2 for a sample of the back and

forward arrows seen in the far left side of the browser tool bar. The pull-down option allows you

to cancel the navigation or see your past browser history. Refer to Figure 4.1.1.3.

Figure 4.1.1.2 - Back and Forward Arrows Seen in the Browser Tool Bar

Figure 4.1.1.3 - Browser Pull-down Options



4.2 Command Buttons

Command buttons, located below the fields of each functional window, enable you to perform

certain actions. The available actions depend on the purpose of the window. The most common

command buttons associated with Eligibility Verification include:

Submit – Submit information entered for a specific form.

Reset – Clear a form and navigate back to the Trading Partner window.

Cancel – Cancel a form.

Continue – Continue to the next window.

Refer to Figure 4.2.1 to view an example of the command buttons.

Figure 4.2.1 – Command Buttons

4.3 Announcements

Announcements will be posted here by the portal administrator. These will vary as needed. Refer

to Figure 4.3.1 for a sample of where the announcements will be placed.



Figure 4.3.1 – Announcement on Home Page

4.4 Contact Us

The Contact Us tile provides departmental contact information as seen in Figure 4.4.1.

Figure 4.4.1 - Contact Information



4.5 Provider Directory

The Provider Directory window allows you to search for enrolled providers. Refer to Figure

4.5.1.

Two or more criteria are required to perform a provider search.

When searching with name alone, you must enter at least five characters.

The more provider search criteria entered, the narrower results returned.

To search for enrolled providers, follow the steps below:

1. Enter at least two search criteria. Click SEARCH.

Figure 4.5.1 – Provider Search Window

The results of your search display. Refer to Figure 4.5.2.



Figure 4.5.2 – Map Results Window

2. Click the Plus icon to expand the Details section.

3. Details such as telephone number, handicap accessibility, age restrictions that may be

present, gender restrictions, and hours of operation display.

4. The Provider Directory can offer detailed street directions. Click GET DIRECTIONS.

5. The Get Directions window displays.

6. In the Enter your location field, enter your starting location and click SUBMIT. Refer

to Figure 4.5.3.

Figure 4.5.3 - Get Directions Window

7. Detailed directions display if you click on the Details hyperlink.

8. To begin a new provider search, click SEARCH AGAIN.



4.6 References

Reference materials are accessible for all users as displayed in Figure 4.6.1. Each resource is

discussed in the sections below.

Figure 4.6.1 – Reference Tile

4.6.1 Companion Guides

Clicking the Companion Guides link brings up a list of several X12 Transaction Vendor

Specification Guides as seen in Figure 4.6.1.1.

Figure 4.6.1.1 - X12 Companion Guides

Selecting any of these links will open the specification guide for review. Each guide has the

instructions for setting up that electronic transaction. The HIPAA X12 Electronic Data

Interchange (EDI) companion guides are supplied to complement the national standards X12

implementation guides with United States Virgin Islands (USVI) and Molina specific

requirements. Refer to these guides for answers to transaction questions related to format or

value questions associated with fields in the submissions. Refer to Figure 4.6.1.2 for a sample

title page of the 837 Vendor Specifications. Each guide is in a PDF format which may be read,

saved to another location, or printed.



Figure 4.6.1.2 Companion Guide Example

4.6.2 Forms

The Forms hyperlink contains information divided into folders for easier classification. The

current grouping of forms is seen in Figure 4.6.2.1. The Supplemental Agreements and

Additional Terms folder contains agreements and forms used by providers and USVI. Other

folders have been added by the site administrator for Claims, Prior Authorization, Provider

Enrollment, and Provider Maintenance.

Figure 4.6.2.1 Forms



4.6.3 Frequently Asked Questions

Frequently Asked Questions (FAQs) as seen in Figure 4.6.3.1 are noted as a list of answers to

FAQs grouped by categories. Clicking the name of any of the FAQs within one of the categories

will open the FAQ including any pertinent URLs.

Figure 4.6.3.1 - Frequently Asked Questions

4.6.4 Newsletters

Once the USVI determines to utilize the Newsletters hyperlink, a record of all newsletters may

be located here via links to their PDF documents as seen in Figure 4.6.4.1. As with other PDF

files, these can be opened, read, printed, or saved to other locations if you have Adobe’s Acrobat

Reader installed.

Figure 4.6.4.1 - USVI Monthly Provider Newsletters

4.6.5 Provider Manual

This area provides the entire provider manual, not just the billing instructions. It is grouped into

categories offering detailed information critical to all providers. Refer to Figure 4.6.5.1.



Figure 4.6.5.1 - Provider Manual

4.6.6 User Guides

The user guides section of the Reference area is a collection of user guides. Refer to Figure

4.6.6.1. This list of documents will be added to and updated as appropriate.

Figure 4.6.6.1 - User Guides

4.7 Training

Medicaid training will be updated as requested and/or required by DHS due to various changes

and/or updates to the USVI Medicaid system.

4.7.1 Training Calendar

The Training Calendar hyperlink displays a public calendar showing monthly scheduled

provider training sessions. Refer to Figure 4.7.1.1.



Figure 4.7.1.1 - Training Calendar

4.7.2 USVI Medicaid Training Center Information

The USVI Medicaid Training Center Registration hyperlink takes users to the Medicaid

Training Center User Registration information. This information is to complete the one-time

form which generates the user profile. The profile allows providers an opportunity to access the

USVI Medicaid Training Center (LMS) 24/7 to see scheduled training and to self-register for

upcoming sessions. Refer to Figure 4.7.2.1.



Figure 4.7.2.1 – Medicaid Training Center

5. Ending Your Session

If you are on the Home tab, click the in the upper right corner of the page to exit the USVI

Medicaid portal. If you are logged into the Provider secure portal, click Sign Out from the

Trading Partner pull-down menu as seen in Figure 5.1 to securely log off the portal.

Note: If you have taken no action on the Website for 30 minutes, your session will be closed

automatically.

Figure 5.1 - Sign Out Hyperlink



6. Secure Health PAS-Online Portal

To sign in to the secure section of the Health PAS-Online trading partner Website, navigate to

the Territory’s Medicaid Website home page at www.vimmis.com.

1. In the Health PAS-Online banner, click the Sign In hyperlink. Refer to Figure 6.1.

When signing in to your trading partner account, if the incorrect

password is entered five times, you will be locked out of the trading

partner account indefinitely. To have the account unlocked, contact the

EDI Help Desk at 1-888-483-0793 and select option 6.

When contacting the EDI Help Desk, please have the following

information available: NPI, Username, and TP ID.

Figure 6.1 – Sign In Hyperlink

2. The Sign In window displays.

3. In the User Name field, enter your user name.

4. In the Password field, enter your password.

5. Read and accept the Attention HIPAA PHI: Special Handling Required statement by

selecting the I have read and accept HIPAA PHI privacy policy check box.

6. Click SIGN IN. Refer to Figure 6.2.

http://www.vimmis.com/



Figure 6.2 – Sign In Window

Once you are signed in to your trading partner account, the secure Trading Partner window

displays.

6.1 Secure Health PAS-Online Banner

Located at the top of the window, the banner provides a full list of functions available to you

from the current window. Refer to Figure 6.1.1. The functions include the following:

Enable Accessibility – When the Enable Accessibility hyperlink is clicked, this enables the

Website to present information in a way that is more understandable for accessibility

software like Job Access With Speech (JAWS).

A A A A – This is the font size hyperlink that allows you to enlarge or decrease the font size

on the portal.

Help – This is basic Website functionality help.

Trading Partner drop-down list – This drop-down list allows you to change your password

or sign out.

Search this site field – This allows you to enter search criteria and complete a basic Website

functionality search.

In Health PAS-Online, all search fields perform partial search without

wildcards.



Figure 6.1.1 – Secure Health PAS-Online Banner



6.2 Trading Partner Window

The Trading Partner window has several sections of information, including the navigation

toolbar as well as Messages & Alerts, Training, and Learning Management System (LMS) Help

sections. Refer to Figure 6.2.1.

Figure 6.2.1 – Navigation Toolbar, Messages & Alerts, Training, and LMS Help Sections

Home – Returns you to the Home window.

Form Entry – Provides access to Health PAS-Online functions, including authorizations,

claims, verify eligibility, Provider Incentive Payments, and Electronic Health Record (EHR).

Account Maintenance – Provides access to manage users, provider associations, reset

password, trading partner status, and provider enrollment.

File Exchange – Provides access to upload, download, and view X12 files and reports.

Contact Us – Contains contact information for Molina Medicaid Solutions (MMS) and the

Territory.

Provider Directory – Allows you to search for an enrolled provider.

Reference Material – Contains useful hyperlinks and documentation for the provider

community.



Messages & Alerts – Allows you to send secure messages to MMS and receive alerts.

Beneath the navigation toolbar on the Trading Partner window, you will see a row of provider

command buttons. The provider command buttons allow you to perform several tasks. Refer to

Table 6.2.1.

Medical Button Description

Allows you to view medical authorizations and submit requests for

medical authorizations if the service cannot be addressed within

the PCP clinic.

Allows you to view and submit medical, dental, and institutional

claims.

Allows you to verify a member’s eligibility.

Allows you to view your patient roster.

Allows you to view a primary care clinic roster of members

assigned to your primary care clinic.

Allows you to view payments.



Medical Button Description

Allows you to view referrals and submit referrals.

Note: This function will be available on or after March 1, 2016.

Allows you to view the Provider Incentive Payment System for the

Medicaid EHR Incentive Program document.

Allow you to view dental authorizations and submit requests for

dental authorizations.

Note: This function will be available on or after March 1, 2016.

Table 6.2.1 – Medical Provider Command Buttons and Descriptions

The order in which the buttons are displayed may vary.

Depending on your security settings, you may not see all of the buttons in

Table 6.2.1.

6.2.1 Alert Feature

The Alert feature displays and alerts a provider that there are unread documents such as

Remittance Advices (RAs) or claim reports. There is an alert box on the secured home page for

providers where this information can be found. Refer to Figure 6.2.1.1.



Figure 6.2.1.1 – Alert Feature

The provider is able to view these documents by clicking on each document title hyperlink or by

placing a check in each box at the left-hand side of each row. There is also the ability to perform

a download so the document can be saved for later reference. If documents exceed one page you

can use the arrows at the bottom left-hand side to scroll through the pages. Refer to Figure

6.2.1.2.

Figure 6.2.1.2 – Document Title Hyperlinks

6.2.1.1 Pended Claim Report

This is a weekly report that pulls all pended or in-process claims that have not been finalized in

some way. This is a companion report for the RA; it lets you know where your claims are in the

adjudication process. The RA and an in-process claim report together equal all claims submitted

and processed by the MMIS system.



6.3 Sign Out of Your Trading Partner Account

To sign out of your trading partner account, click the Trading Partner drop-down list in the

upper right-hand corner of the window and select Sign Out. Refer to Figure 6.3.1.

When signing out of your trading partner account, do not click the X in

the upper right-hand corner of the browser window. This closes the

window but leaves your trading partner ID signed in and it will remain

signed in. If your trading partner account is locked, you can either wait

20 minutes or contact the EDI Unit at 1-888-483-0793 and select option

6 to request the account be signed out.

Figure 6.3.1 – Sign Out



7. Claim Submission

To submit a claim, click the View & Submit Claims tile. Refer to Figure 7.1. The Billing

Provider field can be populated from the pull-down list. To submit a new claim, click the New

Claim button. Refer to Figure 7.2.

Figure 7.1 – View & Submit Claims Tile

Figure 7.2 – Submit New Claim

After clicking the New Claim button, the Find Member search area opens at the bottom of the

window. Refer to Figure 7.3. Select which type of claim you want to submit. Your choices

include: Professional, Dental, or Institutional. You must include information in two of the rows

in order to complete a member search to attach to the new claim. This can include any

combination of the following four: Member ID, Last Name and First Name, Date of Birth, or

SSN. Once the two rows have been filled in, click the Submit button to perform the search.

Provider Name | Provider ID



Figure 7.3 – Find Member Search Area

Once the member has been located, the new claim can be added. Refer to Figure 7.4.

Figure 7.4 – Member Located





Click the radio button beside the desired member to select. Then, click the Continue button to

proceed. The Claim Submission window opens. Refer to Figure 7.5.

Figure 7.5 – Claim Submission Window

Provider Name




There must be at least one diagnosis code added to the claim. To add a diagnosis code simply

type it in the field and click the magnifying glass to search for the description. If you are unsure

of the correct code, you can simply click the magnifying glass and the Diagnosis Codes window

will open. You can type part of the descriptive name in the Description field. Note: Ensure that

you have selected ICD-9 or ICD-10 upon which to base the search. The process is the same to

add Service Codes also. Refer to Figure 7.6. Once the desired fields have been filled in, you can

click the Submit button.

Figure 7.6 – Completed Form



8. Claims Search

To perform a claims search, click the View &Submit Claims tile.

Refer to Figure 8.1.

Figure 8.1 – View & Submit Claims Tile

Reminder: All fields with a red asterisk (*) are required fields

On the first screen, identify the Billing Provider. The field may have filled automatically. If not,

click the down arrow to open the drop-down menu. Click the appropriate provider name.

If this a New Claim, press the New Claim button. On the next line, click the radio button next to

the type of claim to be entered:

Professional

Dental

Institutional

Identify the member who received the services associated with this claim using the fields in the

Find Member screen. Note: If member is not located, but presented a VI Medicaid member ID

card or Notice of Decision reflecting coverage on date of service, please contact the Medicaid

Program office at (340) 713-6929.




8.1 Professional Claim, CMS 1500

The CMS 1500 is used for non-institutional providers (generally group or individual provider

practices) or suppliers. There are four sections to the claim screen:

Claim Information

Diagnosis

Services

Additional Information

Reminder: Any fields with a red asterisk (*) are required. An error message will be displayed if

these values are left blank at time of submission.

8.1.1 Claim Information for Professional Claim

The member information will auto-fill based upon the participant identified using the Find

Member screen.

The Patient Account #, the number assigned to the patient in your billing system, is a required

field. The Medical Record # (as used by your office) may be entered if your office chooses to

do so.

The Rendering Provider, a required field, can be entered using the down arrow which opens a

drop-down menu. Click the name of the rendering provider and the field will fill.

Please note: The rendering provider must be enrolled, credentialed, and affiliated to the billing

provider in order for them to appear in the drop-down menu.

The Service Location will automatically default with the correct service location for the

rendering provider for this particular service. The field will fill automatically.

8.1.2 Diagnoses for Professional Claim

This screen is used to enter all the diagnoses for the member for this claim. As many diagnoses

as needed may be entered. To add a new line, press the Tab key at the end of the last line and a

new line will appear. There are five fields in the diagnosis section:

Line #

Code

Description

ICD Version

Type: whether the diagnosis is primary or secondary

The only field you can edit is Code. The Line # will increase automatically as each line is added.

The Description and Type will appear once the code is entered. If the code cannot be used

currently for billing, an error message will appear in the description field. The first line entered

will be the primary diagnosis. The primary diagnosis must be closely related to the procedure.

All lines entered after that will be considered secondary diagnoses.



To delete a line from the list, click the Delete icon, at the end of the Line # field. A diagnosis

line cannot be deleted if it will be listed in one of the Related Diagnosis fields on a Service

Code line on the claim.

To search for a Diagnosis Code, click in the Code field then click the Search icon, , near the

Line # and a search window will open.

8.1.3 Services for the Professional Claim

Refer to Figure 8.1.3.1. The fields for entering Services are as follows:

Line #

Dates of Service (From and To)*: Format: MM/DD/YYYY

Place of Service*

Code*

Code Description

Modifier(s)

Related Diagnosis*

Charge*

Units*

Minutes*(This field is grayed out as it is not required at this time)

EPSDT (Early Periodic Screening, Diagnosis and Treatment)

Emergency

Authorization #

Rendering Provider



Figure 8.1.3.1 – Services for the Professional Claim

Note - Total charges and also total units will need to be entered.

Do not submit the claim with a PA number. A PA number is not required on the claim form. The

system will automatically fill in the authorization number on each service line.

When you press the Tab key through all these fields without entering anything, some of the

fields will fill automatically. The following information will display:

Dates of Service (From and To): Current date

Place of Service: 11

Charge: $0.00

Units: 1

EPSDT:

Provider Name




Rendering Provider: Same rendering provider listed above in the Claim Information

section at the top of the screen.

When a Service Code is entered, the description will appear below in the CPT Code

Description box. If the code cannot be used currently for billing, an error message will appear in

the description field.

As in the diagnosis area, to add more lines, press the Tab key at the end of the last line and a

new line will appear. Up to 99 service lines are available for entry. If any required field has not

been entered, the cursor will jump back to that field before displaying a new line.

The Total $ and Total Units will appear underneath the Services area.

If the service is for a drug product, click the Enter NDC Codes check box (Enter NDC Codes)

at the middle of the line, refer to Figure 8.1.3.2; the applicable fields will be available for entry at

the right-end of the array. The fields are:

National Drug Code (NDC)

Unit of Measure

Qty/Units

Rx Number

Figure 8.1.3.2. – Available Fields for Entry

To search for any service code, click first the Code field, then click the Search icon and a new

search window will open.

Coordination of Benefits (COB) Information

COB information may be added to the claim by clicking the button at the bottom of the claim

form entry screen. Refer to Figure 8.1.3.3.



Figure 8.1.3.3 – COB Information Button

In the COB Information screen, refer to Figure 8.1.3.4, click the applicable radio button to have

the COB information entered by Claim or Service Line. The data should represent the amount

already paid to the provider either by Medicare or by Commercial. Medicare and Commercial

information can be entered either by the claim line or claim header for each COB type. If COB is

entered at the line, totals are displayed at the top of the data-entry grid. Up to four action codes

may be entered for Medicare.

Figure 8.1.3.4 – By Claim or By Service Line

There are six options available for entry. The Medicare line contains the following fields. Note

that the first three fields do not display if the By Claim radio button was chosen:

Click the Details icon to open the Medicare: COB Details

section at the bottom.



Line #/Total

Service Code

DOS (Date(s) of Service): Format: MM/DD/YYYY

Allowed Amount

Paid Amount

Deductible Amount

Coinsurance Amount

Adjustment Reason Code (Action Code)

Paid Date: Format: MM/DD/YYYY

Third Party Liability (TPL) has the same fields with the exception of the Action Code.

All dollar amounts can be entered without the dollar sign. Whole dollars can be entered without

the decimal and the additional zeros. For example, the following entry conventions apply:

For $100 even, enter 100, the field will display 100.00

For $54.35, enter 54.35, the field will display 54.35


(Note that it is not necessary to enter the last 0)

Enter/update information on this page, click Continue at the bottom of the page, and then either

Save or Adjudicate the claim in order to store the information. Refer to Figure 8.1.3.5.

Figure 8.1.3.5 – COB Information Screen



8.1.4 Additional Information for the Professional Claim

The Additional Information section contains information about whether these services are

related to any kind of accident. The choices are:

Employment

Auto Accident

Other Accident

If the claim relates to an Auto Accident, enter the State in which the accident occurred in the

field just below Auto Accident. Refer to Figure 8.1.4.1.

Figure 8.1.4.1 – Additional Information Section (Auto Accident)



8.1.5 Submit the Professional Claim

When all the information has been entered, review your entries for accuracy, and click the

Submit button, , to submit the claim. Any error messages will appear at the top

of the page in a red font and must be corrected before the claim will actually be submitted. Refer

to Figure 8.1.5.1 for a confirmation page that a claim has been submitted.

Figure 8.1.5.1 – Submitting the Professional Claim

8.2 Dental Claim

This claim is used for dental providers. There are five parts to the claim:

Claim Information

Diagnosis

Services

Additional Information

Submit the Dental Claim

Any entry fields with a red asterisk (*) are required. An error message will be displayed if these

fields are left blank.

8.2.1 Claim Information for the Dental Claim

Refer to Figure 8.2.1.1 for the Claim Information for the dental claim. The Member Name will

fill automatically based on the member identified using the process from Find Member.



do so.

Rendering Provider, a required field, can be entered by clicking the down arrow which opens a

drop-down menu. Click the name of the dentist and the field will auto fill.



Please note: The rendering provider must be enrolled, credentialed, and affiliated to the billing

provider in order for them to appear in the drop-down menu.

The Service Location will automatically default with the correct service location for the

rendering dentist for this particular service. The field will fill automatically.

Figure 8.2.1.1 – Dental Claim Information

8.2.2 Services for the Dental Claim

Dental Service fields include:

Line #

DOS (Date(s) of Service-From and To): Format: MM/DD/YYYY

Place of Service

Provider Name

Provider Name |Provider ID




CDT Code (Current Dental Terminology)

Code Description

Tooth

Related Diagnosis

Units

Fee

Quantity

Fee

Authorization Number (Predetermination Number)

Rendering Provider (With a drop-down arrow)

CDT Code Description

Totals

Note: A predeterminiation number is not required on the claim form. The system will

automatically fill in the authorization number on each service line.

Note: If you press the Tab key through all these fields without entering anything, some of the

fields will fill automatically. The information to appear is as follows:

Dates of Service (From and To): Current date

Place of Service: 11

Quantity: 1

Fee: $0.00

Rendering Provider: Same rendering provider listed above in the Claim Information

section at the top of the screen

When a service code is entered, the description will appear below in the CDT Code Description

box. If the code cannot be used currently for billing, an error message will appear in the

description field.

The Total $ and Total Units are calculated and displayed underneath the Services portion of the

Dental Claim window. Refer to Figure 8.2.2.1.

Figure 8.2.2.1 – Total $ and Total Units Display

To add more lines press the Tab key at the end of the last line and a new line will appear. To

delete a line from the list, click the Delete button, , at the end of Line #.



To search for a Service Code, first click the Code field, then click the Search icon, , in the

Code field and a new search window will open.

Coordination of Benefits (COB) for the Dental Claim

More information for Coordination of Benefits (COB) may be added by clicking the link for

COB information. Refer to Figure 8.2.2.2.

Figure 8.2.2.2 - COB Hyperlink

Click the applicable radio button to have the COB information entered by Claim or by Service

Line. The data should show the amount(s) already paid to the provider from the third party,

Refer to Figure 8.2.2.3. Note that the first three fields do not display if the By Claim radio button

was clicked. The fields include:

Line #

Service Code

DOS (Date(s) of Service): Format MM/DD/YYYY

Allowed Amount

Paid Amount

Deductible Amount

Coinsurance Amount

CoPayment Amount

Paid Date: Format MM/DD/YYYY

Figure 8.2.2.3 – COB Information Entered by Claim or Service Line


the decimal and the additional zeros. For example the following entry conventions apply:









8.2.3 Additional Information for the Dental Claim

The Additional Information section, refer to Figure 8.2.3.1, contains information about whether

these services are related to any kind of accident. The choices are:

Employment

Auto Accident

Other Accident

If the claim relates to an auto or other accident, enter the State in which the accident occurred in

the State field.

Figure 8.2.3.1 – Additional Information for Dental Claim

The miscellaneous area contains Is Orthodontics and Initial Prosthesis. Enter the applicable

month, day, and year or click on the Calendar icon. Refer to Figure 8.2.3.2.

Figure 8.2.3.2 – Miscellaneous Information

8.2.4 Submit the Dental Claim

When all the information has been entered, review your entries for accuracy and then click the

button to submit the claim. Any errors will appear at the top of the page in a red



font and must be corrected before the claim can be submitted. When submitted successfully, a

confirmation window will appear. Refer to Figure 8.2.4.1.

Figure 8.2.4.1 – Successful Submission of Dental Claim



9. Institutional Claim

This claim, comparable to the paper UB-04, is used for all providers who bill Medicare fiscal

intermediaries. There are six parts to this claim:

Claim Information

Admission Data

Diagnosis, Visit, and Injury

Procedures

Condition, Occurrence, and Value Codes

Service Codes

Any input fields with a red asterisk (*) are required. An error message will display if these values

are left blank.

9.1.1 Claim Information for the Institutional Claim

For Claim Information for the Institutional Claim, Refer to Figure 9.1.1.1 and Figure 9.1.1.2.

The Billing Provider is automatically filled in based on the user sign-on.

The Member Name, Date of Birth, and Member ID will be pre-populated based on the

member chosen. To edit the information or find a different member, use the same processes.



do so.

A PA number is not required on the claim form. The system will automatically fill in the

applicable authorization number on each service line.

Rendering Provider is a required value. Rendering Provider and Service Location can be

selected by clicking the drop-down menu arrow, then clicking an item in the list.

Bill Type is a required value. Click the down arrow for the drop-down menu; click the

appropriate type.

The Attending and Operating provider fields may be required depending on the Bill Type or

the Service Codes entered.

Enter Covered Days, Non-Covered Days, Lifetime Reserve, and Co-insured Days as needed.

The Encounter Claim box is optional. It is used when a claim is being submitted for

management/tracking purposes and no reimbursement is expected.



Figure 9.1.1.1 – Claim Information for the Institutional Claim (Top)


Provider Name



Figure 9.1.1.2 – Claim Information for the Instituional Claim (Bottom)

9.1.2 Admission Data for the Institutional Claim

This section of the claim form has six data fields:

Admission Date: Format MM/DD/YYYY

Admission Source Code

Admission Time*: Format: hh-mm

Discharge Time*: Format: hh-mm

Admission Type Code

Patient Status Code



*Enter times using a 24-hour format. For example:

8:32 am would be entered as 08-32

7:25 pm would be entered as 19-25 (note that 12 + 7=19)

Enter as much information as possible in the applicable fields. Refer to Figure 9.1.2.1.

Figure 9.1.2.1 – Admission Data for the Institutional Claim

9.1.3 Diagnosis, Visit, and Injury Codes for the Institutional Claim

This section of entry for the institutional claim has four sets of fields, refer to Figure 9.1.3.1. For

all four fields when the code is entered, tab to the next field and the system will confirm that the

entry is currently an active code; if the code is not active an error message will display in the

description field.

Diagnosis

Admitting Diagnosis

Reason for Visit

External Cause of Injury

Except for Reason for Visit, each has four fields:

Code: editable

Description: information will fill automatically once the code is entered

Type: primary or secondary, filled in automatically once the code is entered

POA (Present on Admission): can be edited, , use one of the following codes:

o Y for Yes

o N for No

o U for Unknown/Undetermined

o Field does not appear for Reason for Visit

Up to 12 diagnosis codes may be entered. Press the Tab key at the end of the last line entered

and a new line will appear. To delete a line from the list, click delete, , at the end of the Line

# field.

The first line entered will be the primary type. This primary diagnosis must be closely related to

the procedure(s) associated with the claim. All subsequent lines entered will be secondary.



Figure 9.1.3.1 – Codes for the Institutional Claim

9.1.4 Procedures for the Institutional Claim

The fields for entering the principle procedure code include:

Code

Description

Date of Service: Format MM/DD/YYYY

Type: First code is considered principle, all others are secondary

Other procedures may also be entered using:

Code

Description

Type

Note the absence of date of service for the additional procedure codes. To add a new line press

the Tab key and a new line will appear.

For all Procedure Codes, the Code and the Date of Service can be entered or edited. The

Description and the Type will fill automatically. If the code cannot be used for billing, an error

message will appear in the description field. The first line entered will be the principle type. All

following lines entered will be secondary. Refer to Figure 9.1.4.1.

To delete a line from the list, click delete, , at the end of the Line # field.

Figure 9.1.4.1 – Principle Procedure Code



To search for either kind of procedure code, click the Code field under Principle Procedure for

the primary procedure or under Other Procedure for all other codes. Click the Search icon,

, near the word Code and a new window will open. Refer to Figure 9.1.4.2.

Figure 9.1.4.2 – Search for Procedure Code

Enter a description of the code in the Description box and then click the Search button, ;

a list of results will display.

If none of the options is appropriate, then click the button to clear the description field.

Clicking the Search button, , or pressing Enter with no description entered, will display

the whole list of available procedures.

The results consist of Code IDs and Descriptions, as seen in Figure 9.4.4.3. Click the

appropriate Code ID to enter that Code ID to the applicable procedure area. The Description

and the Type will fill automatically.



Figure 9.1.4.3 – Search for Description

9.1.5 Condition, Occurrence, and Value Codes for the Institutional Claim

Condition, Occurrence, and Value Codes provide additional information used in adjudicating

an institutional claim. Refer to Figure 9.1.5.1.

Condition Codes have two fields:

Code

Description

If necessary, use the Search icon, , near the Code field; see Code Search below for the

process.

Occurrence Codes have either three or four fields:

Code

Description

Date: Format: MM/DD/YYYY

o For an Occurrence Code there is one Date

o For an Occurrence Span there are From and Thru date

If necessary use the Search icon, , near the Code field; see Code Search below for the

process.

Value Codes have the three fields:

Code

Description

Amount

The Condition, Occurrence, and Value Codes are immediately checked for accuracy by the

system; if the code cannot be used, there will be an error message in the description field.




the decimal and the additional zeros. For example, the following entry conventions apply:





If necessary, use the Search icon, , near the Code field; see Code Search below for the

process.

Figure 9.1.5.1 – Condition, Occurrence, and Value Codes

Using Condition Codes as an example for these three areas, click the Code field, click the

Search icon, , and enter the description in the Description field. Refer to Figure 9.1.5.2.



Figure 9.1.5.2 – Condition Codes

Then click the Search button, , and a list of codes and descriptions will display. Refer to

Figure 9.1.5.3. Clicking the Search button or pressing Enter without having entered a

Description will display the whole list of available codes.

If necessary, click the Reset button, , to clear the description field and enter a different

description.

In the list of results, click the Code ID and that Code ID and Description will automatically fill

the fields in the Condition Codes area.

Figure 9.1.5.3 – Code ID



9.1.6 Service Codes for the Institutional Claim

Service Code fields include:

Line #

Code

HCPCS (Healthcare Common Procedure Coding System)

Modifiers

Dates of Service (From and To): Format: MM/DD/YYYY

Units

Charge

Non-Covered Charges

Referral

NDC (National Drug Code)*

Unit of Measure for NDC Code*

Quantity/Units for NDC*

Price for NDC*

Service Code Description

Note: A PA is not required on the claim form. The system will automatically fill in the

authorization number on each service line.

*NDC, Units of Measure, Quantity/Units, and Price will open and be available only when the

box to the right of Enter NDC Codes contains a check mark; click the box, a check mark will

appear, and the four fields will open.

To add more lines press the Tab key at the end of the line and a new line will appear. Up to 99

lines of service codes may be entered.

When a Revenue Code is entered, the system will check the accuracy of the code; if it matches

the list of active revenue codes active on the dates of service, the description will appear in the

Description box; if it does not match, an error message will appear. The total price and total

units will be displayed at the bottom of this area.

When a Service Code is entered, the system will check the accuracy of the code; if it matches

the list of active service codes active on the dates of service, the description will appear below in

the Description box; if it does not match, an error message will appear. The total price and total

units will be displayed in the grey area next to the CPT Code Description box. Refer to Figure

9.1.6.1.

Pressing the Tab key to move through the fields, will automatically fill the fields listed below:

DOS From and DOS To: The current date

Units: 1

Charge: $0.00

Non-Covered Charges: $0.00



Figure 9.1.6.1 – Services Codes for Institutional Claim

To search for a Service/Revenue Code, click the Code field and click the Search icon, , to

the right of the Line # and a new search window will open.

Coordination of Benefits

More information for the COB for the claim may be added by clicking the link in the lower left

of the Service Codes area. Refer to Figure 9.1.6.2.

Figure 9.1.6.2 - COB Link

The COB Information can be entered for the whole claim or for each individual claim line for

any amounts previously paid to the provider. Click the radio button to indicate how the COB

information is to be entered. Refer to Figure 9.1.6.3.



Figure 9.1.6.3 – COB Information


the decimal and the additional zeros. For example the following entry conventions apply:




(Note: that it is not necessary to enter the last 0)

9.1.7 Submit the Institutional Claim

When all the information has been entered, review your entries for accuracy and click the

button to submit the claim. Any errors will appear at the top of the page in

a red font and must be corrected before the claim will actually be submitted.

9.2 ‘Copy Last Claim’ feature

This feature allows the provider to select the most recent claim by date of service for the

Member ID entered. If there is more than one claim with the same date of service, the system

will select the most recent claim submitted based on time stamp. If the system does not find a

claim for the member entered, the provider will get message that No Claim Found. In this case,

the provider will resubmit the claim without using the Copy Last Claim feature.

9.2.1 Search for Last Claim Submitted

To search for the last claim submitted, click the View Patient Roster tile. Search for the member

either by the alphabet search feature or by clicking Search. Once the search has been completed,

select the member by clicking the radio button beside the name and click the Submit Claim

button. Refer to Figure 9.2.1.1.





Figure 9.2.1.1 – Selecting the Member

Once the member has been selected and the Submit Claim button has been clicked, the

Last copy claim option is available under the Claim Type section of the Patient Roster

window. Select the Copy Last Claim option by clicking the radio button and then click

the Submit button to begin the submission process. Refer to Figure 9.2.1.2.

Figure 9.2.1.2 – Last Copy Claim Option is Chosen

The last submitted claim will open as shown in Figures 9.2.1.3, 9.2.1.4, and 9.2.1.5. Enter

the required data and submit the claim.



Figure 9.2.1.3 – Last Submitted Claim Opens (Top)

Figure 9.2.1.4 – Last Submitted Claim Opens (Middle)

Provider Name

Provider Name

Member Name

Provider Name

Provider Name



Figure 9.2.1.5 - Last Submitted Claim Opens (Bottom)

Once the claim has been successfully submitted, a confirmation window appears. Refer to Figure

9.2.1.6.

Figure 9.2.1.6 – Copied Claim Submitted Successfully



9.2.1.1 Review Claim Information

The claim detail displays on the screen, where the provider can modify as needed before

resubmitting the claim. This can be done by clicking the Edit Claim button. The Rendering

Provider field and service location are auto-populated based on the original claim. Figures

9.2.1.1.1 and 9.2.1.1.2 identifies the fields that are required. A search can be done to find the

Referring Provider by selecting the magnifying glass, , and typing in the provider

information.

Figure 9.2.1.1.1 – Edit Window (Top)

Provider Name

Provider Name

Member Name

Provider Name



Figure 9.2.1.1.2 – Edit Window (Middle)

9.2.1.2 Diagnosis

At least one diagnosis code is required to resubmit the claim. The original diagnosis code is

displayed on the screen. The provider can update/modify the diagnosis code if needed.

9.2.1.3 Service Codes

The DOS From and DOS To fields must be entered to resubmit the claim. Use the format of

MM/DD/YYYY to enter the dates. Enter the date in the DOS From field and press the Tab

button. The DOS TO field will auto-populate with the same date entered in the DOS From field.

Ensure the DOS TO field aligns to the claim you are resubmitting. Review all fields with a red

asterisk (*), and press the Submit button, .

9.2.1.4 Claim Submit Confirmation

Once the claim is submitted the user will receive a confirmation screen.

9.3 Submit and Process a Claim

When all the information for any claim has been entered, review your entries for accuracy and

click the button near the bottom of the screen to submit the claim.

The Claim Confirmation will be displayed. The Claim ID is in the upper left corner. The

Submitted Claim screen presents the following options:

Claim View: Click Claim View to see all information that was entered on the claim

Adjudicate Claim: Click the Adjudicate Claim button; the claim is immediately

processed for payment

Edit Claim: Click the Edit Claim button if changes need to be made to the entry

Provider Name

Provider Name



Upload Attachment: Click the Upload Attachment button

New Claim: Opens a new claim form for entry

Refer to Figure 9.3.1.

Figure 9.3.1 – Submit and Process a Claim

Any entry errors will appear at the top of the page in a red font and must be corrected before the

claim can be submitted.

9.3.1 Adjudicate Claim

Adjudication processes the claim for payment and identifies the amount that will be paid to the

provider. If the claim cannot be adjudicated the screen will show the error message, There are

outstanding edits. Click the Edit Claim button at the bottom of the section to fix these errors in

order to attempt to adjudicate the claim again.

Note: You can adjudicate up to nine times and correct any errors after adjudication. However, if

you need to re-adjudicate a tenth time, then you must let Health PAS 5.0 process the claim.

9.3.2 Edit Claim

Clicking the Edit Claim button presents the list of edits needed and allows for additions or

deletions to parts of the claims. Click the radio button in front of the edit to select it for

correction.

A check box displays in front of each edit so that you can check them off and track the changes

as you make them to the claim. The Claim Type, Billing Provider, and Member are the only

fields that cannot be changed when editing a claim.




In the Diagnosis example from a Professional claim a new line can be added; press the Tab key

in each of the fields of the last active line; after pressing Tab on the last field, a new line will be

displayed. In order to delete a line, click the Delete button .

In the Services example from a Professional claim a new line, #2, has already been added. To

add more lines, press the Tab key through each of the fields in the last active line.

In order to delete a line, click the Delete button, , at the end of the line number to be deleted.

Refer to Figure 9.3.2.1.

Figure 9.3.2.1 - Add/Delete Claim Lines, Services

After entering all the corrections and revisions, there are three options:

Back: Click the Back button to return to the previous screen

Save: Click the Save button to save the changes made so far

Adjudicate: Click the Adjudicate button to adjudicate the edited claim

Refer to Figure 9.3.2.2.

Figure 9.3.2.2 - Options after Correcting Claim



10. Eligibility Search

It is a best practice to verify eligibility for all Medicaid members just before a service is rendered

by a provider. This ensures the provider that the member is eligible on that date and for the

services that will be rendered.

10.1 Access Eligibility Verification

To access Eligibility Verification, go to the Verify Member Eligibility tile. Refer to Figure

10.1.1.

Figure 10.1.1 - Accessing Eligibility Verification

10.2 Search for a Member

The window to begin the inquiry to verify eligibility for a member appears. For eligibility

verification you will need two of the following criteria

Member ID

Name (Last and First)

Date of Birth

Social Security Number

For example, you can enter the Name (Last and First) and the Date of Birth, or Name (Last and

First) and the Member ID.

After the search criteria are submitted, the Eligibility Verification screen appears, refer to

Figure 10.2.1, and the Name, Date of Birth, Medicaid ID, and Gender will automatically fill

the Member area. This information cannot be edited on this screen.




Figure 10.2.1 - Eligibility Verification Screen

Eligibility Inquiry verifies whether a member was eligible for a Medicaid program on the date(s)

of service submitted in the request. This information does not guarantee eligibility or payment

for the service rendered.

The feature for Procedure Code/Service Code/HIPAA Category Codes is available, however,

even if a HIPAA Category Code shows eligible that does not mean that every service is eligible.

The information does not guarantee payment for services rendered.

Pay close attention to the details of the coverage code listed. If further clarification is needed,

please call Provider Services between 8 am to 5 pm AST at 1 (340) 713-6929.

To see additional information about the member, including demographics, click the member’s

name. A window showing the member information will open. Refer to Figure 10.2.2.

The forms entry content doesn’t list new feature for submission of request for DHS

authorization, etc.



Figure 10.2.2 - Member Information

To go back to the Eligibility Inquiry screen, click the Verify Eligibility button.

10.3 Eligibility Inquiry

The Tracking Number is a verification number assigned by the Health PAS system to the

transaction. It is used to provide proof (when requested) that the eligibility for the member was

verified. Please refer to Figure 9.3.1 for the location of the Tracking Number, Dates of Service,

Procedure Codes/Service Codes, and HIPAA Category Codes.

The Dates of Service, both From and To, are required fields for this form. The dates can be

entered manually using the format MM/DD/YYYY or use the Calendar icon at the end of each

field.

From Date

o Automatically fills with current date

o Date can be changed but not for more than one year in the past

To Date o Automatically fills with current date

o Cannot enter a future date

To search for specific Procedure Codes/Service Codes, enter a maximum of 10 codes separated

by a comma or space, and then click the Search (magnifying glass) button.

Clicking the Reset button at the bottom of the screen, at any time, resets all the values.



Figure 10.3.1 - Eligibility Inquiry

Before submitting your inquiry, review your entries for accuracy. Then click the Submit button

to enter the request. After the request is submitted, the response will display under the Eligibility

Inquiry section.

10.4 Eligibility Verification Response

The Eligibility Verification Response screen contains multiple pieces of information for

eligibility. The following sections will always appear in the response.

Enrollments

Other Insurance

PCP Assignment

Lock-In

Share of Cost will display for the following specialties only

o Skilled Nursing Facility

o ICF/MR

o Residential Assisted Living Facility (RALF)

o Certified Family Homes

o Residential Habilitation Agency

o Adult Day Care

o Nursing Agency

o PCS/Aged and Disabled Services Agency

o Home Delivered Meals

o Emergency Response System

10.4.1 Enrollments

The Enrollments tab displays the types of coverage for which the member is eligible. Each plan

listed for the member also shows the Coverage Status (either Active or Partial), the Coverage



Level (Primary or Secondary), the Plan Type, Effective Date, and Termination Date. Refer to

Figure 10.4.1.1.

When the enrollment is active for the entire inquiry period, the coverage status is displayed as

active. Otherwise, the coverage status is displayed as partial, effective date, termination date, or

both are populated.

For an example, enrollment is active from 1/1/2010 to 12/31/2010.

If provider inquires on coverage between 3/1/2010 and 10/31/2010, then coverage status

will be displayed as active; effective and termination dates are both blank.


will be displayed as active; effective and termination dates are both blank.


will be displayed as partial; effective date is displayed as 1/1/2010 and termination date is

blank.

If provider inquires on coverage between 3/1/2010 and 2/1/2011, then coverage status is

displayed as partial and effective date is blank; termination date is displayed as

12/31/2010.


will be displayed as partial; effective date is displayed as 1/1/2010 and termination date is

displayed as 12/31/2010.

When different providers are displayed in the response, it is important to note both

which provider is the PCP for that member

and

the dates when that member is assigned to that PCP

If necessary, redo the eligibility check with a different date range to confirm the correct provider

for a given date of service.



Figure 10.4.1.1 - Enrollment Tab

10.4.2 Other Insurance

The next tab is Other Insurance; refer to Figure 10.4.1.2. This information shows the

Enrollment ID, Plan, Plan Type, Policy Type, Policy Number, Group Number, Status,

Carrier Name, Coverage Status, Effective Date, and Termination Date. Should COB

information be found, this area of the page would explain it in detail.

Figure 10.4.2.1 - Other Insurance

10.4.3 Share of Cost (SOC)

The Share of Cost tab, refer to Figure 10.4.3.1, shows the SOC Start Date, SOC End Date,

Monthly SOC Amount, Rate Code, and the Last update date.



Figure 10.4.3.1 - Share of Cost

10.4.4 PCP Assignment

The PCP Assignment tab, refer to Figure 10.4.4.1, displays the information for the member’s

PCP including the Effective Date, PCP Name, Address, Office Number, Office Hours,

Termination Date, Provider ID, and the Coverage Status. Should the member have a PCP

assigned, the full detail would be explained in this section of the page.

Figure 10.4.4.1 - PCP Assignment

10.5 Lock-In

The Lock-In tab, refer to Figure 10.5.1, displays any Lock-In information that was found for the

member. Should the member have this information, it would be detailed here.

Figure 10.5.1 - Lock-In

10.5.1 Print Receipt

The request from the Eligibility Verification Response screen can be printed in order to have a

paper record of the request. Click the Print Receipt button found at the bottom of the screen

below the eligibility response information; refer to Figure 10.5.1.1. A new window displays the

entire Eligibility Response that can be printed.



Figure 10.5.1.1 - Eligibility Response for Printing



11. Patient Roster

You can create a custom roster or a list of members associated with a particular billing provider.

One advantage of creating a Patient Roster is that you can verify eligibility, or submit a claim

directly from the Patient Roster screen. To access the Patient Roster which is a list of members

associated with a particular billing provider, click the View Patient Roster tile. Refer to Figure

11.1.

Figure 11.1 - Accessing the Patient Roster

The Patient Roster screen appears. Click the drop-down arrow in the Billing Provider field,

and then click the name of your Billing Provider. The Patient Roster will display with

members sorted alphabetically by last name.

The result lists the following information:

Last Name

First Name

Date of Birth

Member ID

To view the information about the member, click the Last Name hyperlink.

To search for a specific member, select one of the highlighted letters. Refer to Figure 11.2.




Figure 11.2 - Search

Note two tabs: Print List and Export to Excel. Refer to Figure 11.3.

Click Print List to print all members.

Click Export to Excel to send all members to an Excel spreadsheet.

Figure 11.3 - Print and Excel Options

11.1 Add New Member

To add a member to the Patient Roster, click Add New Member. The fields display to allow you

to search for the new member as shown in Figure 11.1.1. You must use two of the following

items to search:

Member ID

Name (Last and First)

Date of Birth

Social Security Number

Click the Submit button and the member’s information displays. Click the radio button in front

of the member's name and then click the Add to Roster button. The name of the member will be

added to your patient roster.




Figure 11.1.1 - Find Member

If you want to delete a member from your roster, click the Delete button next to the last name oat

the beginning of the line of the member. Refer to Figure 11.1.2.

Figure 11.1.2 – Delete Member

To create one of the forms for submission, first click the radio button in front of the name of the

member. Then click one of the buttons at the bottom of the screen to initiate the form. Refer to

Figure 11.1.3.

Submit Claim

Verify Eligibility




Figure 11.1.3 – Initiating the Form

11.1.1 Diagnosis

At least one diagnosis code is required to submit the claim. The original diagnosis code is

displayed on the screen. Refer to Figure 11.1.1.1. The provider can update or modify the

diagnosis code if needed.

Figure 11.1.1.1 - Diagnosis Code Review

11.1.2 Service Codes

The DOS From and DOS To fields must be entered to submit the claim, shown in Figure

11.1.2.1. Use the format of MM/DD/YYYY to enter the dates. Enter the date in the DOS From

field and press the Tab key. The DOS TO field will auto-populate with the same date entered in

the DOS From field. Ensure the DOS TO field aligns to the claim you are submitting. Review

all fields with a red asterisk (*), and click the Submit button.




Figure 11.1.2.1 - Service Code Review

11.1.3 Claim Submit Confirmation

Once the claim is submitted the user receives a confirmation screen similar the message shown

in Figure 11.1.3.1.

Figure 11.1.3.1 - Confirmation Notice



12. Submit Request for DHS Authorization

1. Select the View & Submit Authorizations tile. Refer to Figure 12.1.

2. Select the New Authorization button.

Figure 12.1 – View & Submit Authorizations Tile

3. If Billing Provider does not default, select the appropriate Billing Provider.

4. Search for the member that needs the services.

5. Select the Submit button.

6. From the Search Results grid, select the appropriate member by selecting the radio

button next to the member’s name.

7. Select the Continue button. Refer to Figure 14.2.

Figure 14.2 – Authorization Member Search Window




8. Entry of the prior authorization details. Refer to Figure 12.3 and Table 12.1.

Figure 12.3 – Prior Authorization Details



Member Information

Name Displays the name of the selected member.

Date of Birth Displays the selected member’s date of birth.

Member ID Displays the selected membr’s member identification.

Authorization Information

Authorization

Type Drop-down list of the available authorization types.

Pay To/Billing

Provider Displays the selected Pay-To or Billing provider’s name.

Requesting

Provider

Provides the list of Providers associated with the Pay-To or

Billing provider’s to select from.

Requested Length

of Stay

Required for authorizations that requires the member to stay at a

facility.

Start Date Provides entry of the Service start date.

End Date Provide entry for the Service end date.

Number of Units Enter in the number of service units.



Referring Provider

Renderring

Provider or Group

Provides a default provider.

Or

Ability to search for a provider.

Select the magnifying glass to display the Provider Search

screen.

1. Enter provider information to search for the provider.

2. Select Search button.

3. Select the radio button next to the correct provider.

4. Select Continue button to return to the Authorization page

and the provider selected displays.

Pay To/Billing

Provider Defaults to the Pay To/Billing Provider selected.

Diagnosis

Diagnosis

Provides functionality to enter the member’s diagnosis.

Refer to Diagnosis Entry section.



Services

Services

Provides functionality to enter the member’s services.

Refer to Service Entry section.

Miscellaneous Information

Accident Type

Optional

Select the appropriate accident option.

Accident Date

Oprional

Enter the accident date by either:

Manually typing the date in the field

Selecting the Calendar icon to display an electronic

calendar. Find the appropriate year and month then use the

mouse to select the day. The system will fill the date field

with your selection.

Investigation

Required

Optional

Checkbox to indicate if investigation is required.

Pregnancy

Information

Last Menstrual

Period Date

Optional

Enter the last menstrual period date by either:

Manually typing the date in the field.

Selecting the Calendar icon to display an electronic

calendar. Find the appropriate year and month then use the

mouse to select the day. The system will fill the date field

with your selection.

Pregnancy

Informaiton

Estimated

Delivery Date

Oprional

Enter the estimated delivery date by either:

Manually typing the date in the field.

Select the Calendar icon to display an electronic calendar.

Find the appropriate year, month and day and use the

mouse to select the day. System will fill the date field with

your selection.

Notes

Notes Entry of any desired comments that needs to be seen by reviewers

and specialists.

Notes are viewable by multiple people.

Take care with sensitive and private

information.

Number, special characters, and alphabet are allowed.



Allows up to 300 characters.

Note: This information is viewable by other providers and

authorized DHS personnel who have access to Health PAS-Online

and Health PAS-Adminstrator, so please ensure you do not share

HIPAA-protected information in this field.

Table 12.1 – Explanation of Prior Authorization Details

9. Select the Submit or Cancel button

a. Cancel button displays the following message. Refer toFigure 12.4.

If OK selected, authorization is erased and returned to Authorization

Member Search page.

If cancel, current page continues to display.

Figure 12.4 – Cancel Button Message

b. Submit button displays the following message. Refer to Figure 12.5.

If Cancel: authorization is not created and returned to Authorization

Submission page with all fields blank.

If OK: authorization is created and process continues to Step 10.

Figure 12.5 – Submit Button Message

10. Review Authorization submission status



a. The authorization submission status displays on the top of the Authorization

screen.

b. A successful creation of an authorization generates an Authorization Number and

an authorization status and displays on the screen.



13. Viewing Authorizations

The section provides an explanation of the screens that display submitted authorizations.

1. Select the View & Submit Authorizations tile.

2. Bill Provider Field

a. If the Billing Provider field is not filled, then select your Bill Provider by selecting

the down arrow on the Billing Provider field to show the list of billing providers you

are assigned to. Select the Provider by highlighting the provider’s name with the

mouse pointer and selecting.

b. If the Billing Provider field is filled, the application defaulted to your assigned

Billing Provider.

3. List of Authorization display. Refer to Figure 13.1 and Table 13.1.

Figure 13.1 – List of Authorizations



Screen Component Action

Example of the authorization hyperlink. Select this to display the

authorization details.

Functionality to search for a authorization.

Enter search criteria.

Select the Search button.

Authorization grid updated with search results.

Functionality to place the referrals found into an Excel spreadsheet. See

Export to Excel section for instructions.

Functionality to Print the referrals found. See Print List section for

instructions.

Table 13.1 – Explanation of Authorization Details



4. Select Authorization hyperlink to display Provider Authorization Detail page. Refer to

Figure 13.2 and Table 13.2.

Figure 13.2 – Provider Authorization Window

Screen Component Activity

Functionality to add attachments to the referral. Attachments are

stored on your computer. See Add Attachments section for

instructions.

Functionality to print out the authorization details. Below is a cut-out

of the screen. When the button is selected, the authorization details



opens in another window.

Select Print button to send to the printer that you are

connected to.

Select Close to close window.

Functionality to view the documents that are attached to the

authorization. See View Attachment section for instructions.

Returns you to the View Authorization page.

Table 13.2 – Explanation of Provider Authorization Fields



14. Common Functionality

This section provides the instructions for functions that are common between Referrals and

Authorizations screens.

14.1 Add Attachments

Selection of the Add Attachment button to attach a document to the referral. The system will

accept documents that are GIF, JPEG, Microsoft Excel, Microsoft Word, PDF, and TIFF. The

file size must be less than 4 megabytes. Refer to Figure 14.1.1.

1. Select the Type of Attachment from the drop-down field.

Figure 14.1.1 – Adding Attachments

2. Select Browse button to display the Choose File To Upload window.

3. Select the desired file.

4. Select Open. Refer to Figure 14.1.2.



Figure 14.1.2 – Uploading Attachments

5. Verify that the file name appears in the File name box. Refer to Figure 14.1.3.

6. Select the Attach button to attach the file to the referral. If it not selected, the file will not

saved to the referral.

Figure 14.1.3 – File Name Box



Successful attachment is shown below. Note the message and the

clearing of the file name box. Refer to Figure 14.1.4.

Error message displays if file can’t be found or loaded. Check if file type

is valid and/or file size.

Figure 14.1.4 – Successful Attachment

7. Repeat steps to attach additional documents.

8. Select the Back button to return to the Provider Referral page.

14.1.1 Type of Attachments

Below are the documents types. Refer to Figure 14.1.1.1. Please follow DHS document

attachment policies.



Figure 14.1.1.1 – Document Types



14.2 View Attachments

On the Referrals Details page, the View Attachment button was selected.

1. Select the View Attachment button that displays the View Documents page. Refer to

Figure 14.2.1.

2. Select the Document ID hyperlink.

Figure 14.2.1 – View Documents Page

3. You are asked if you want to open the file. The question will display based on your

brower and brower version. Figure 14.2.2 reflects Internet Explorer version 11.

Figure 14.2.2 – Internet Explorer Version 11 Example

4. Selecting Open opens another window to display the attachment.



No changes can be saved when the document is opened even if it seems

to provide the options. Any changes made will need to be saved on your

computer and execute the Add Attachments functionality.

5. Select the Back button to return to the Provider Referral page.

14.3 Export to Excel

This functionality allows you to save the information in Microsoft Excel format and save the file

on your computer.

The presentation of the dialog boxes is based on your browser and its

version of it. The dialog boxes below are based on Internet Explorer

version 11.

1. Select the Export to Excel hyperlink. Refer to Figure 14.3.1.

Figure 14.3.1 – Export to Excel Hyperlink

a. Open the file

i. Selecting the Open option will open up the file in Excel. You will use the

Excel Save As/Save functionality.

b. Saving the File

i. It is recommended that the Save As functionality be used. This allows you to

control where the file is saved.



14.4 Print List

This functionality creates a PDF of the referral or authorization listing in a new window. Refer to

Figure 14.4.1. The Viewer provides the options to print or to save a copy.

When finished, select the ‘X’ in the upper right-hand corner to close the

window.

Figure 14.4.1 – Print List

To Print:

Select the Printer icon to print the information to the printer you have configured to your

computer. Refer to Figure 14.4.2.

Figure 14.4.2 – Print Window



To Save the PDF:

Select the Disk icon and follow the instructions to save a copy of the PDF to your PC. Refer to

Figure 14.4.3.

Recommend modifying File Name to a name that is meaningful to you.

Figure 14.4.3 – Saving PDF

14.5 Diagnosis Entry

This section provides instruction when selecting the magnifying glass to search for a diagnosis

code. The use of ICD-9 and ICD-10 can be used.

1. Enter the partial or full name of the diagnosis description or enter in the code. Example

used “soccer.”

Click in the entry box to display a list of prior search values


3. Select the value from the Code ID column to select the diagnosis. Diagnosis will display

on the entry page. Refer to Figure 14.5.1.

The search window will remain open until the Close Window button is

selected.



Figure 14.5.1 – Search Window

14.6 Service/Revenue Code Entry

This section provides instructions to search for service or revenue codes after selecting the

magnifying glass on the field.

1. Enter the partial or full name of the service or revenue description or enter in the code.

Example used “Asthma.”

Click in the entry field to provide the list of prior search values.


3. Select the value from the Service Code column to select the diagnosis. Selected code will

display on the entry page. Refer to Figure 14.6.1.

The window will remain open until the Close Window button is

selected.



Figure 14.6.1 – Service Code Column



Glossary of Acronyms

Acronym Definition

ARRA American Recovery and Reinvestment Act of 2009

CDT Current Dental Terminology

COB Coordination of Benefits

CPT Current Procedural Terminology

DHS Department of Human Services

DLP Desk Level Procedure

DME Durable Medical Equipment

EDI Electronic Data Interchange

EHR Electronic Health Record

EPSDT Early Periodic Screening, Diagnosis, and Treatment

FAQ(s) Frequency Asked Question(s)

HCPCS Healthcare Common Procedure Coding System

HIPAA Health Insurance Portability and Accountability Act of 1996

ICF/MR Intermediate Care Facility/Mental Retardation

JAWS Job Access with Speech

LMS Learning Management System

MMIS Medicaid Management Information System

MMS Molina Medicaid Solutions

NDC National Drug Code

PA Prior Authorization



Acronym Definition

PCP Primary Care Provider/Physician

PCS Procedure Coding System

PDF Portable Document Format

PHI Protected Health Information

RA(s) Remittance Advice(s)

RALF Residential Assisted Living Facility

TPL Third Party Liability

UM Utilization Management

URL(s) Universal Resource Locator(s)

USVI United States Virgin Islands