Identifies the type of payer. This setting comes from the Payer edit screen.
Patient Insured ID. When the claim is primary, this data comes from the Primary Insured screen. When the claim is secondary, this data comes from the Secondary Insured screen.
Patient Name.
Patient Birthdate. This data comes from the Patient demographic screen.
Insured Name. When the claim is primary, this data comes from the Primary Insured screen. When the claim is secondary, this data comes from the Secondary Insured screen.
Patient Address. This data comes from the Patient demographic screen.
Patient relationship to insured. This data comes from the Patient demographic screen.
Insured Address. When the claim is primary, this data comes from the Primary Insured screen. When the claim is secondary, this data comes from the Secondary Insured screen.
Patient Status. This information comes from the Patient Demographic screen and Patient Notes screen.
Secondary Insured Name. When the claim is primary, this data comes from the Secondary Insured screen. When the claim is secondary, this data comes from the Primary Insured screen.
Claim Patient Condition. This information is entered in the popup window when creating claims.
Insured Policy or Group FECA number. When the claim is primary, this data comes from the Primary Insured screen. When the claim is secondary, this data comes from the Secondary Insured screen.
Patient Signature. SIGNATURE ON FILE will print as long as a date has been entered in the Patient Notes screen. The date entered in this box will either be the posting date of the claim, or the date that the form was printed. To set this option, see the HCFA Settings under the Edit Menu - Preferences.
Insured Signature. SIGNATURE ON FILE will print as long as a date has been entered in the Patient Notes screen.
Date of current illness. This information is entered in the popup window when creating claims. If the date is not set, the current illness date is automatically set to the earliest date entered in th Box 24 service dates. To hide box 14, see the section on payer filing setup.
Date of similar illness. By default, this box is blank. This information is entered in the popup window when creating claims. If the date is not set, then the field is left blank.
Dates Patient unable to work. By default, this box is blank. This information is entered in the popup window when creating claims. If the dates are not set, then the field is left blank.
Referring Physician. The name of the referring physician is entered when the Patient Claim is created. You can assign a referring physician to a patient so that the referring physicians name automatically appears when claims are created. The patients referring physician is entered in the Patient Demographic screen.
Box 17a contains the referring physicians UPIN number along with a 1G qualifier. Box 17b contains the referring physicians NPI number.
The physicians UPIN number and NPI are entered in the Physician screen.
Hospitalization Dates. These dates come from the Patient Claim screen. Check the 'Hospital Visit' check box and enter the Admitted and Discharge dates.
Reserved for local use. This box is normally blank. However, you can have the claim notes printed in this box if you check the Show notes on Claim Form box when entering Patient Claims.
Outside lab and lab charges. By default, this box is blank. This information is entered in the popup window when creating claims.
Diagnosis codes. The patient diagnosis is entered when the Patient Claim is created. You can assign a diagnosis to a patient so that the diagnosis code automatically appears when claims are created. The patients diagnosis is entered in the Patient Demographic screen.
Not used
Prior authorization number. This data comes from the Patient Claim screen. When creating claims, box 23 data will automatically fill in based on the Payer filing setup. From the claim screen, you can add, edit, or remove the data in this field as claims are created.
Typically, this box will either show the Practice CLIA number from the Practice Information screen, or the Patient Precertification number from the Patient Notes screen.
Box 24A - Shows the Service dates From/To.
Box 24B - Place of Service.
Box 24C - EMG. By default, this box is blank. This information is entered in the popup window when creating claims.
Box 24D - Procedure code and Modifiers
Box 24E - Diagnosis Pointers
Box 24F - Claim Charges
Box 24G - Units
Box 24H - EPSDT. By default, this box is blank. This information is entered in the popup window when creating claims.
Box 24I - Legacy Qualifier. Typically, the qualifier will print '1C' for medicare claims, and '1D' for medicaid claim. The qualifier is used when you are printing the legacy pin numbers as a secondary identifier.
Box 24J (shaded) - The data in this field is determined in the payer filing setup screen. Typically, this field will show the rendering provider pin number.
Box 24J - The data in this field is determined in the payer filing setup screen. Typically, this field will show the rendering provider NPI.
Federal Tax ID number. This information comes from the Provider screen.
Patients Account Number. The data for this field will default to the internal ID number maintained by MDC. You have the option to show the patient chart number in this field. To set this option, see the MDC Settings screen under the Edit Menu - Preferences.
Accept Assignment. By default, this box is checked Yes. This information is entered in the popup window when creating claims.
Total Charge. The total of all the charges from Box 24.
Amount Paid. This box is typically $0.00. When filing to secondary, this box will show the amount paid by primary.
Balance Due.
This box always shows the name of the rendering provider. The date entered in this box will be the Posting Date of the claim.
Facility Name. The name of the Facility is entered when the Patient Claim is created. You can assign a Facility to a patient so that the Facility name automatically appears when claims are created. The patients Facility is entered in the Patient Demographic screen.
For most practices, you should assign a default facility that represents the office where most services are performed.
Box 32A will show the Facility NPI. The facility NPI is entered in the Facility setup screen. Practices should not enter their Billing Provider NPI or Rendering Provider NPI in this field. These NPI's are entered in the Practice Information screen and the Provider setup screen.
Box 32B will show the secondary ID number assigned in the Facility setup screen.
Billing Provider Information. By default, the Practice Name/Address appears in this box. You can setup this box to show other names. See the Payer filing setup screen.
Box 33A - Typically shows the Billing Provider NPI from the Practice Information screen.
Box 33B - Typically shows the Billing Provider Pin number from the Payer information screen.
For both these boxes, you should see the options from the Payer filing setup screen.