Below is the program logic used for printing data in the following boxes:
Box 1
Selected in the ‘Payer Library’.
Box 9a
When printing a Primary claim, this box will be populated by the secondary Group # field. When printing a Secondary (or Tertiary) claim, this box will contain both the primary insured’s ID and the primary group number.
Box 10abc
To populate box 10 fields, enter the information in the fields in the claim grid. Info can also be defaulted in ‘Initial Claim Values’ at the patient level. If added there, remember to update existing claims as needed. Two-letter state code is required on all Auto Accident claims.
Box 10d
Claim Codes identify additional information about the patient’s condition or the claim itself. Please refer to current NUCC guidelines for valid codes and to payer guidelines as to their requirements. This field allows for 19 characters.
Box 11b
This box is populated with the ‘Workers Compensation Claim Number’. Other names include Workman’s Compensation, Worker’s Compensation, Work Comp, and WC. This field is available as a custom column on the claim screen’s vertical grid. If a WC Claim Number is entered, the qualifier will automatically be set to ‘Y4’. There is no option to change the qualifier.
Box 11d
If there are 2 or more payers attached to the claim, the program will automatically check the ‘Yes’ box. Otherwise, the box is checked ‘No’.
Box 14
On the 02-12 version of the 1500 form, different dates can be represented by this box. The qualifier will print in the QUAL box to the right of the date. The program has the following qualifiers and dates available. If both dates are entered, the Date of Current will take precedent. CAUTION: If the Payer Name field of your Payer Library entry contains the words MEDICARE, MEDI-CAL, OR MEDICAL – the qualifier will NOT print along with the date in Box 14. You may need to edit the Payer Name field accordingly. MEDICARE can be changed to NOVITAS or NGS, for example, and MEDI-CAL or MEDICAL can be truncated to MED.
• 431 – Date of Current
• 484 – Last Menstrual Period – This field can be added to the claim grid as needed using the Customize Grid feature.
Box 15
1500 02-12 Version: In the 02-12 version of the 1500 form, different dates can be represented by this box. The program has the following qualifiers and dates available. These fields can be added to the claim grid as needed. Please note only one date will be printed:
• 454 - Initial Treatment Date
• 304 – Date Last Seen
• 453 – Acute Manifestation Date
• 439 – Accident Date
• 455 – Last X-Ray Date
• 090 – Assumed Care Date
• 091 – Relinquished Care Date
Box 17
If multiple providers are entered, only the Referring Provider will be printed. For printed claims, the Referring Provider must be removed for the Ordering or Supervising Provider to print in Box 17. The following qualifiers are auto generated by the program and will print in Box 17 and export in the appropriate loop on ANSI electronic claims.
• DN – Referring
• DK – Ordering
• DQ – Supervising
If the qualifier is missing on printed claims, go to your Payer Library entry for the insurance company in question and confirm that the payer name does not include Medi-Cal or Medical. Abbreviating the name to “Med” is a good workaround.
If both Ordering and Supervising Provider providers are entered, Ordering will override Supervising for printed claim purposes. On ANSI claims, both Ordering and Supervising loops will be generated.
Box 19
Box 19 is commonly used on paper claims for data not otherwise accommodated by the CMS-1500 claim form. Data entered in this field will print but will NOT export electronically. Please contact your payer to determine where the data is expected. For example, some payers expect the data in Loop 2400 NTE*ADD – in which case the data should be entered at the service line level in the ‘Service Line Description’ field.
Box 22
On paper claims, any resubmission code may be entered from the drop-down menu per payer requirements. However, Medicare does not allow any code other than “1” indicating Original claim. Please contact Medicare directly to determine specific requirements for flagging resubmitted claims.
Resubmission code “6” indicating a Corrected claim is generally not a valid option for electronic claims (again per payer requirements) and may need to be edited to “7” for Replacement or “8” for Void.
On both paper and electronic claims, remember to include the Original Ref Number assigned by the payer to the originally submitted claim. During ERA auto posting, this number auto-populates in the field. Otherwise, you may need to refer to a payer report or contact the payer directly to obtain this number.
If needed, a Box 22 Code Override field is available and can be added to the claim grid via the Column Chooser.
Box 24c
EMG indicator (also called emergency indicator) is a carryover from the older CMS-1500 form and is unlikely to be required on current claims. If needed, however, you can add the ‘EMG’ field via the service line Column Chooser. Acceptable values are Y or N.
Box 24d
If the procedure code is the word ‘BLANK’, the program will treat it as truly being blank and will leave 24d empty.
Box 26
The patient account number typically contains the patient account number found on the patient screen. This setting can be changed in the Program Setup > Printing Claims section.
See Account Number (Box 26) for more information.
Box 29
Box 29 normally shows payments only. If the option ‘Include Adjustments with Payments in Box 29’ is checked in the Payer Library, both payments AND adjustments will appear in Box 29. Uncheck ‘Include Adjustments with Payments in Box 29’ in Payer Library to edit.
There is also an option on the claim screen ‘Ignore Applied Amount’ which will cause $0.00 to print in box 29. This is an optional field that can be added to the claim vertical grid.
Box 30
Box 30 is not normally printed per CMS rules. If your payer requires the balance in Box 30, check the ‘Print Box 30’ option in the Payer Library. See Payer Library for more information.
Box 31
The Rendering provider name displayed on the Claims screen will print in Box 31 if the Payer selected on the claim does not have the ‘Ignore Rendering Provider’ option checked in the Payer library.
SIGNATURE ON FILE will print if the claim’s Billing Provider has the ‘Signature on File’ option checked in the ‘Physician/Facility Library’. See Signature on File for more information. The signature on file setting is stored with the billing provider and not the rendering provider because a rendering provider may not be set on the claim.
Bill Date will print when the ‘Print Claim Bill Date’ is checked on the patient record.
Box 32
The claim facility will print in Box 32. If the ‘Address Line 2’ is populated in the physician library, it will print in Box 32.
Box 33
The claim billing provider will print in Box 33. If the ‘Address Line 2’ is populated in the physician library, it will print in Box 33.
Box 33b
Box 33b can come from two different location. Typically, this field contains the ‘Additional ID Number’ found in the Billing Provider record in the Physician/Facility library. There is also a field available on the claim grid called ‘Box 33b Override’ which allows the user to enter a value into Box 33b.
