MDHIN Encounter Documentation and Reimbursement Form

Complete this form to document Encounter and submit for payment to MDHIN

Member Name * First Middle Last
Member Number (Member ID) *
Group Number *
MDHIN Provider ID *
Payer ID *
Program *

Program RxDirectCare MDDPC MDDPC Weight Loss
MDHIN Provider Submitter Name *
MDHIN Provider Submitter NPI *
Rendering Provider Name * Title First Middle Last Suffix
Service Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Service Details

Details of the actual service, actual date of service and number of units used
Eligibility Confirmation Number

If you do not have an eligibility confirmation number you risk the member not being eligible for this service or submission.
Date of Service * / MM / DD YYYY
Start Time * : HH MM AM/PM
End Time * : HH MM AM/PM
The start and end time must correspond with the total number of Units submitted below when Selecting the Visit Code
Service Type *
Pharmacy Direct Primary Care (RxDirectCare) Provider Direct Primary Care (MDDPC) Specialty Direct Primary Care (MDDPC) Point-of-Care Test (POCT) (RxDirectCare) E-Visit (RxDirectCare or MDDPC)
Visit Procedure/Encounter Code *
1, 30 Min Unit Provider DPC: 99212 1, 30 Min Unit Provider DPC: 99212 1, 30 Min Unit Pharmacy DPC: 99429 1, 30 Min Unit Pharmacy DPC: 99429 1, 30 Min Specialty DPC: 99499 1, 30 Min Specialty DPC: 99499 1 POCT: 99000 1 POCT: 99000 E-Visit Code (if applicable and only 1 unit available) 99423 PGX Test (RxDirectCare Program Tiers and only Combined with 1 99429 and 1 99000)
Select One for each complete 30 minutes of service for 99212, 99499 or 99429 and up 2 POCT 99000 for each Date of Service. You can only select one Code number based on license and only up to 2 per encounter. Select Only 99423 if Encounter was done as an e-visit. If you select 99423, you cannot select any other code. Select PGX test is the test was administered and submitted ot the lab for processing.
Total Units (Count One for each complete 30 minutes of service for 99212, 99499 or 99429 and up count One POCT 99000 for each Date of Service. Count Only 99423 if Encounter was done as an e-visit. Do not include the PGX Test. *

The total number in this box excluding the PGX test can only be 2. So, the number should be 1 or 2 only. Any billed encounter will reduce the number of available visits or POCT tests available to the member.
ICD-10 Code *
Second ICD-10 Code
Encounter Notes / Summary

1. General Encounter Summary (Default)
Discussed health symptoms, and provided brief counseling; no issues noted.
2. Pharmacy Direct Primary Care
Completed pharmacy consultation with medication review, adherence check, and brief clinical guidance.
3. Provider Direct Primary Care
Performed focused evaluation, reviewed concerns, and provided brief counseling with a follow-up plan.
4. Provider E-Visit (99423)
Reviewed patient-submitted information asynchronously and provided brief clinical guidance and recommendations.
5. Specialty Direct Primary Care
Conducted brief specialty assessment with targeted recommendations based on symptoms and history.
6. Point-of-Care Test (POCT)
Completed point-of-care test, reviewed results with patient, and provided brief follow-up guidance.
Description/Note/Summary of the Encounter *
Discussed health symptoms, and provided brief counseling; no issues noted.
Please see the guidelines above.
Attestation *
I attest this encounter was provided and this form is for documentation only and may be used to generate a payment request.

MDHIN Encounter Documentation and Reimbursement Form

MDHIN Encounter Documentation and Reimbursement Form

Service Details

Encounter Notes / Summary