AGENCY: Department of Health. Division of Medicaid and Health Financing. Bureau of Authorization and Community Based Services

SERIES: 8155
TITLE: Medicaid Management Information System remittance statement
DATES: 1981-
ARRANGEMENT: None

DESCRIPTION: This is a COM report prepared weekly showing claims paid, denied, and in process. It includes the report date, the name of the health care provider, the provider's identification number, and the category of service. Other information is as follows: Claims paid: gives name and client identification number of the recipient, the transaction control number, the first date of service, the amount of total charges, the amount of recipient co-payment, the amount of payment from other sources, the claim amount paid, the dates of service, the units of service, the amount of submitted charges, the amount of allowed charges, an explanation for the allowed charges, and a total of all payments to that provider for that category of service. Claims in process: gives the recipient name and claim identification number, the transaction control number, the dates of service, the total charges, and the total of all charges for that provider for that category of service. Claims denied: gives recipient name and client identification number, the transaction control number, the dates of service, the total charges, and the reasons for the denial.

RETENTION

Retain for 1 year(s)

DISPOSITION

Destroy.

RETENTION AND DISPOSITION AUTHORIZATION

These records are in Archives' permanent custody.

APPROVED: 08/1986

FORMAT MANAGEMENT

Computer output microfiche master: Retain in Office for 1 year and then destroy.

APPRAISAL

Administrative

Besides the bureau's copies of the fiche, there are one master and 14 other duplicates produced. The bureau's copies need not be kept past their administrative usefulness.

PRIMARY DESIGNATION

Private

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