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Professional Web Portal

Tutorial Revised 5/11/17

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Contents PROFESSIONAL CLAIMS ........................................................................................................................................................... 3

PROVIDER INFORMATION ................................................................................................................................................... 8

SUBSCRIBER/CLIENT INFORMATION ................................................................................................................................... 9

CLAIM INFORMATION ....................................................................................................................................................... 10

DIAGNOSIS CODES ............................................................................................................................................................ 11

BASIC LINE ITEM INFORMATION ....................................................................................................................................... 11

EDITING OR DELETING A LINE ITEM .................................................................................................................................. 12

ENTERING A NATIONAL DRUG CODE (NDC) ...................................................................................................................... 12

Entering Rendering, Referring, Ordering, or Supervising Provider Information .............................................................. 13

SUBMITTING AN ATTACHMENT TO A CLAIM SUBMITTED THROUGH THE WEB PORTAL ................................................ 13

MEDICARE SECONDARY/CROSSOVER ............................................................................................................................... 14

TPL (OTHER THAN MEDICARE) .......................................................................................................................................... 17

ADJUSTING A CLAIM ......................................................................................................................................................... 19

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PROFESSIONAL CLAIMS

Navigate to http://wymedicaid.acs-inc.com and select Provider

Select Provider Portal from the left hand navigation bar.

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Enter your User ID and Password.

Note: If you have not yet registered for the Web Portal, you must do this first. Reference the Registration Tutorial or

contact EDI Services at 800.672.4959 for assistance.

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Select Claims.

Select Create Professional Template

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Name the template

o If making a template for each client, it is recommended that you name the template after each client –

i.e. Jane Smith.

o If making a template for a code, it is recommended that you name the template after the code – i.e.

99212 or Office Visit.

Note: When creating a template only fill out those selections that are not going to change from claim to claim such as

NPI and taxonomy.

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NOTE: If using this tutorial to create a claim to submit, make a selection at each and fill out the necessary additional

information.

Note: There are red + signs before certain areas that allow additional information to be entered. Selecting the red + sign

will expand the area. Only expand and enter information that is required, as entering invalid/incorrect information can

cause a claim to reject. The below information will instruct you in which areas are required to be completed.

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PROVIDER INFORMATION

Are you resubmitting this claim?

o Select Yes to submit a claim adjustment

o Select No if creating a template or submitting an original claim.

BILLING/PAY-TO PROVIDER

o Provider ID dropbox - Select the Billing/Pay-To Provider’s NPI

o Select the red + sign for Additional Billing Provider Information and enter the Billing/Pay-To Provider’s

taxonomy code in the Taxonomy Code box

Note: Entering any additional information in this section may cause your claim to reject.

Is the Billing Provider or Pay-To Provider also the Rendering Provider?

o Select Yes if the Billing Provider is also the Rendering Provider

o Select No if the Billing Provider is different from the Rendering Provider

a. Provider ID box – Enter the Rendering Provider’s NPI

b. Select XX: National Provider Identifier from the dropdown box

c. Select the red + sign for Additional Rendering (Performing) Provider Information and enter the

Rendering Provider’s taxonomy code in the Taxonomy Code box

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SUBSCRIBER/CLIENT INFORMATION

Is this service the result of a referral?

o Select Yes if this claim is the result of a referral

a. Enter the Provider information for the referring provider

o Select No if this claim is not the result of a referral

Recipient ID box - Enter the Wyoming Medicaid Client ID

Does the subscriber have insurance other than Medicaid?

o Select Yes if the client has insurance other than Medicaid

a. Please refer to the Medicare/Secondary Crossover or TPL (Other than Medicare) section for

directions on how to complete this section

o Select No if the client does not have insurance other than Medicaid

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CLAIM INFORMATION

Select the red + sign for Prior Authorization

o Prior Authorization number box – Enter the prior authorization number if necessary

Is this claim accident related?

o Select Yes if claim is accident related

a. Related Causes dropdown-Select the related cause

b. Auto Accident State box-Enter the state where the accident took place

c. Accident Date box-Enter the date the accident took place

o Select No if the claim is not accident related

Does this claim have backup documentation?

o Select Yes if the claim has backup documentation i.e. invoice, op notes, etc.

a. Select BM: By Mail if sending the backup documentation by mail

i. If BM: By Mail is selected, enter the most appropriate selection in the Type Attachment

dropdown box

b. Select EL: Electronic Attachment Only if sending the backup documentation electronically

o Select No if the claim does not have backup documentation

Patient Account No. box – Enter the patient account number

Select the red + sign for Additional Claim Data.

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o Place of Service – Select the appropriate place of service from the list

o Provider Signature on File – Select Yes

o Medicare Assignment Code: Select the appropriate assignment code

o Benefits Assignment Certification – Select Yes

o Release of Information Code – Select Y:Provider Has Signed Release

o Patient Signature Source Code – Select P: Signature generated by provider; patient not present for

services

DIAGNOSIS CODES

Enter all appropriate diagnosis codes. DO NOT use points (periods) when entering the diagnosis code

BASIC LINE ITEM INFORMATION

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Enter Service From To dates

Place of Service dropdown – Select the appropriate place of service

Procedure Code/Modifiers – Enter the procedure code and any appropriate modifiers

Submitted Charges box – Enter the submitted charges

Diagnosis Pointers – drop down box – Choose the appropriate pointers

Units – Enter the number of units

Select the Add Service Line Item button

EDITING OR DELETING A LINE ITEM

To edit a line item

o Select the number next to the line item that needs edited

The information will repopulate under the Basic Service Line Items section

o Make any necessary changes

o Select the Update Service Line Item button

To delete a line item

o Select the Delete link for the line item that needs deleted

ENTERING A NATIONAL DRUG CODE (NDC) Select the Other Svc Info link for the service line which needs an NDC

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Select the red + sign next to DRUG IDENTIFICATION

o National Drug Code box – Enter the NDC

o National Drug Unit Count box – Enter the unit count

o Unit Code dropdown – Select the unit code

Entering Rendering, Referring, Ordering, or Supervising Provider Information Select the Other Svc Info link for the service line which needs an NDC

Select the red + sign next to the type of provider information to be added

o Enter the Provider’s NPI in the Provider ID

o Select XX: National Provider Identifier from the dropdown box if a dropdown box is available

SUBMITTING AN ATTACHMENT TO A CLAIM SUBMITTED THROUGH THE WEB PORTAL

Does this claim have backup documentation?

o Select Yes if the claim has backup documentation i.e. invoice, op notes, etc.

Once the claim is keyed, select the Verify Claim button. This will help identify any errors that exist with the

claim.

Once any errors are corrected if there are any, select the Submit Claim button.

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MEDICARE SECONDARY/CROSSOVER

Does the subscriber have insurance other than Medicaid?

o Select Yes.

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Select the red + sign for Additional Other Subscriber Information

o Claim Filing Code dropdown - Select MB: Medicare Part B

o Payer Responsibility Sequence Number Code dropdown - Select P: Primary

Note: The Wyoming Medicaid Web Portal was only built to allow one additional insurance besides Medicaid. If the client

has more than one additional insurance, please submit the claim on paper as an appeal stating why it cannot be billed

through the Wyoming Medicaid Web Portal along with all necessary paperwork to process the claim.

o Select the red + sign for Other Insurance Coverage

o Benefits Assignment Certification - Select Yes

o Release of Information Code dropdown - Select Y:Provider Has Signed Release

o Signature Source Code dropdown - Select P: Signature generated by provider since patient was not

physically present

o Payer/Insurance Organization Name box – Enter Medicare

o Entity Qualifier dropdown - Select 2: Non-Person Entity

o Other Payer Primary ID box - Enter Medicare

o ID Type dropdown - Select PI:Payor Identification

o Adjudication Date box - Enter the adjudication date

o COB Payer Paid Amount box - Enter the COB payer paid amount

Select the Other Svc Info link for each line separately

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Select the red + sign for Service Line Adjudication

o Other Payer Primary ID box - Enter Medicare

o Service Line Paid Amount box - Enter the service line paid amount

o Adjudicated or Pay Date box - Enter the adjudication date

o Paid Service Unit(s) box - Enter the units

o Procedure Qualifier dropdown - Select the appropriate procedure qualifier

o Procedure Code box - Enter the procedure code

Select eh red + sign for Service Adjustment

o Adjustment Group Code dropdown - Select PR: Patient Responsibility

o Adjustment Amount box - Enter the adjustment amount

o Adjustment Reason box - Enter the adjustment reason code

a. 1 – Deductible

b. 2 – Coinsurance

c. 122 – Psych Deductible

o Select the Add Line item button

Select the Basic Claim Form button to return to the Basic Claim Info page

Note: When verifying a claim, if the error code 265 “The recipient has TPL on file and no TPL amount is indicated on the

claim” posts and the above information has been entered, please submit the claim.

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TPL (OTHER THAN MEDICARE)

Does the subscriber have insurance other than Medicaid?

o Select Yes

Select the red + sign for Additional Other Subscriber Information under Other Subscriber Information

o Claim Filing Code dropdown – Select the appropriate insurance type

o Payer Responsibility Sequence Number Code dropdown – Select P: Primary

Note: The Wyoming Medicaid Web Portal was only built to allow one additional insurance besides Medicaid. If the client

has more than one additional insurance, please submit the claim on paper as an appeal stating why it cannot be billed

through the Wyoming Medicaid Web Portal along with all necessary paperwork to process the claim.

Other Payer Information

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o Payer/Insurance Organization Name box – Enter the name of the insurance

Additional Other Payer Information

o Entity Qualifier dropdown – Select 2:Non-Person Entity

o Other Payer Primary ID box-Enter the name of the insurance

o ID Type dropdown – Select PI:Payor Identification

COB Monetary Amounts

o COB Payer Paid Amount box-Enter amount paid by the insurance

Select the Other Svc Info link for the 1st line on the claim

Select the red + sign for SERVICE LINE ADJUDICATION

o Other Payer Primary ID box – Enter the name of the insurance

o Service Line Paid Amount box – Enter the amount paid by the insurance for this line item

o Adjudicated or Pay Date box – Enter the paid date from the insurance’s EOB

o Paid Service Unit(s) box – Enter the number of units paid by the insurance

o Procedure Qualifier dropdown – Select HC:HCPCS

o Procedure Code box – Enter the procedure code on this line item

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Select the Basic Claim Form button from the bottom of the page and repeat the above for each line item

ADJUSTING A CLAIM

Are you resubmitting this claim?

o Select Yes to submit a claim adjustment

o Resubmission Type Code box – Select 6:Adjustment

o ICN to Credit/Adjust box – Enter the ICN/TCN from the claim to be adjusted

Note: If 7:Replacement is selected from the Resubmission Type Code box, this will void the original claim and submit a

clean new claim. This should only be used when the originally paid claim needs voided or the originally paid claim’s paid

date is past the six month timely filing adjustment limit.