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NOTE: Asterisks (*) indicate which fields are required on the page. If required information is missing, an error message displays at the top of the page after saving the data. |
Use this tutorial to record DMA-410 information on the DMA Notification page.
Complete the following steps to perform this tutorial:
Display the DMA Notification page.
Enter the notification details:
In Notification Type, select the type of notification from the drop-down list.
Enter the Co-Payment Notification details if Co-Payment is selected from the drop-down list.
In No EOB Available. Coverage is through, enter when the coverage is through.
In Insurance/benefit plan. The co-payment for their service is, enter the amount for the co-pay.
Enter the COB Non-Coverage Affidavit details if COB Non-Coverage Affidavit is selected from the drop-down list.
In I Submitted my claim(s) to, enter the name of the insurance carrier to whom the claims were submitted.
In (date) Of Payment, enter the date on which the claim payment was made. For more information about entering dates, see the Calendar Controls topic.
In (date) for confirmation, enter the date on which the insurance carrier was contacted. For more information about entering dates, see the Calendar Controls topic.
In Insurance Representative, enter the name of the insurance representative.
In Telephone #, enter the contact telephone number.
Select the Cancelled On (date) check box to enter the date on which coverage was cancelled. For more information about entering dates, see the Calendar Controls topic.
Select the Service is non-covered, annual/lifetime service limits exceeded check box if the service claimed is not covered or the policy limits have been exceeded.
Select the Member not covered under this policy check box if the individual is not covered under the insurance policy.
Select the Out-of-Network Provider, No In-Network provider available to provide Medicaid covered services (explain below) check box and enter a detailed explanation in the text box if no in-network provider was available and an out-of-network provider was used.
Select the Other (explain) check box and enter a detailed explanation in the text box if the service was not covered for another reason.
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NOTE: Asterisks (*) indicate which fields are required on the page. If required information is missing, an error message displays at the top of the page after saving the data. |
Click Save.
Version 1.6
