| [1] Insured's program | Select one of the following options:
- <none>
- Blank
- Use Legacy Standards
- Current Program with X
- Current Program with P
- Other if Medicare is Primary or Secondary
- Check Medicare when Tertiary payer is Medicaid else Payer Claim Type
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| [1a] Insured ID number | Select one of the following options:
- <none>
- Blank
- Use Legacy Standards
- Current payer's insured's policy #
- Insured's override # if not blank; else insured's policy #
- Social Security Nbr
- Tertiary payer's policy # + Plan Code
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| [2 and 4] Enable Commas | Select this option to separate first name, last name, and middle initial by commas in boxes 2 and 4 on the 2012 form. |
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| [4] Insured's name | Select one of the following options:
- 'SAME' if Medicare 2nd and patient addr = insured addr; else LastName FirstName MI of insured
- 'SAME' if patient and insured are same; else Blank
- 'SAME' if patient and insured are same; else LastName FirstName MI of insured
- 'SAME' if patient and insured are same; else UCase(LastName FirstName MI of insured)
- 'SAME' if patient and primary insured are same; else LastName FirstName MI of primary insured
- Blank
- Blank if patient and insured are same; else LastName FirstName MI of insured
- Blank if patient and primary insured are same; else LastName FirstName MI of insured
- If patient = insured, Blank if Medicare 1st, else 'SAME'; else LastName FirstName MI of insured
- Insured employer name
- LastName FirstName MI of insured
- Name of payer
- UCase(LastName FirstName MI of insured)
- UCase(LastName FirstName of insured)
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| [7] Insured's address and phone number | Select one of the following options:
- Blank
- Payer addr, city, state, zip, phone
- Blank if patient and primary insured are same; else addr, city, state, zip, phone of primary insured
- Blank if patient and primary insured are same; else UCASE (addr, city, state, zip, phone of primary insured)
- Blank if primary insured and secondary insured are the same; else addr, city, state, zip, phone of primary insured)
- Blank if Medicare is 2nd and patient addr = tertiary insured addr, city, state, zip, phone of tertiary insured
- <none>
- Addr, city, state, zip, phone of tertiary insured
- UCASE (city, state, zip, phone of tertiary insured)
- Addr, city, state, zip, phone of tertiary insured's employer
- UCASE (Addr, city, state, zip, phone of tertiary insured's employer)
- Blank if patient and tertiary insured are same; else addr, city, state, zip, phone of tertiary insured
- Blank if patient and tertiary insured are same; else UCASE (addr, city, state, zip, phone of tertiary insured)
- Blank if patient and primary insured are same; else addr, city, state, zip, phone of tertiary insured
- Blank if patient and primary insured are same; else UCASE (addr, city, state, zip, phone of tertiary insured)
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| [9] Other insured's name | Select one of the following options:
- <none>
- Blank
- Insured's name from secondary payer
- Use Legacy Standards
|
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| [9a] Other insured's group number | Select one of the following options:
- <none>
- Blank
- Current insured's policy number
- Insured's policy number from secondary payer
- TPL Code
- When Medicare is tertiary, this setting prints the secondary payer's TPL code.
- Use Legacy Standards
|
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| [9b] Other insured's DOB | Select one of the following options:
- <none>
- Blank
- Insured's DOB and Sex from Secondary payer
- Use Legacy Standards
Note: This is the [9b] Reserved for NUCC Use field on the 2012 form.
|
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| [9c] Employer's name or school name | Select one of the following options:
- Addr1 Addr2 of MG if MG is 1st/2nd; else Blank
- Blank
- Insured's Emp Name of primary
- Insured's Emp Name of primary if primary insured diff from tertiary insured; else Blank
- Insured's Emp Name of primary if primary is not Medicare; else Blank
- Insured's Emp Name of primary if secondary is not Supplemental; else Blank
- Insured's Emp Name of secondary
- Insured's Emp Name of tertiary
- Primary Amt Paid if primary is Medicare; else Insured's Emp Name of primary
- UCase(Insured's Emp Name of primary)
- UCase(Insured's Emcp Name of secondary)
- UCase(Insured's Emp Name of tertiary)
Note: This is the [9c] Reserved for NUCC Use field on the 2012 form.
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| [9d] Insurance plan name or school name | Select one of the following options:
- '620' if primary is Medicare; else Name of primary payer
- Blank
- Name of MG if 1st/2nd; else Addr2 of primary payer
- Name of primary payer
- Name of primary payer if primary insured diff from tertiary insured; else Blank
- Name of primary payer if primary is not Medicare; else Blank
- Name of secondary payer
- Name of primary payer if secondary is not Supplemental; else Blank
- Name of tertiary payer
- Other insured's group number - TPL Code
- UCase(Name of primary payer)
- UCase(Name of secondary payer)
- UCase(Name of tertiary payer)
Note: This is the [9d] Insurance Plan Name or Program Name field on the 2012 form.
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| [10d] Reserved for Local Use | Select one of the following options:
- <none>
- Other Payer's Provider Individual number if other payer is Medicare
- ATTACHMENT if Tertiary Medicaid
- If EPSDT print 8 otherwise print 3
- "1" if Primary is Medicare and Primary Amount Paid = 0
- "2" if Primary is BCBS
- "6" if Primary is Central Certification, Other Fed. Program, or Self Pay
- "3" if Primary is Champus, Commercial, or Workers Comp
- Primary policy number
- "3" if Primary Amount Paid > 0; else "S"
- Tertiary policy number
- Other Payer's Provider Individual number
Note: This is the [10d] Claim Codes (Designated by NUCC) field on the 2012 form.
|
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| [11] Insured's policy group or FECA number | Select one of the following options:
- Blank
- Blank if primary payer is Medicare else Insured ID # from primary payer
- Group # from primary payer
- Group # from primary payer & Insured ID # from primary payer
- Group # from tertiary payer
- Insured ID # from primary payer
- Insured ID # from primary payer if not blank else Group # from primary payer
- Insured ID # from tertiary payer if not blank; else Group # from tertiary payer
- NONE
- NONE if 2nd or 3rd is Medicaid or Medigap; else Insured ID # from primary payer
- NONE if Insur status is retired; else Ins ID # from primary payer if not blank; else Group # from Primary
- UCase(Group # from tertiary payer)
- UCase(Insured ID # from primary payer) if Group # is blank; else UCase(Group # from primary payer)
- UCase(Insured ID# from primary payer) if not blank; else UCase(Group # from primary payer)
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| [11b] Other Claim ID | Select this option to print the"Y4" qualifier and the Property Casualty Claim Number.
Note: Y4 prints only if Y4 is selected on the Master Files System > Payers > Select Payer or New > System Tab > Provider Payer Qualifiers box > 11 b Property Casualty Claim > Qualifier drop-down box.
The Property Casualty Claim Number prints only if this number is entered on the Patient Chart window > Insurance Tab > Verification> Patient Insurance - Encounter window > Property / Casualty Number field.
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| [11c] Insurance plan name or program name | Select one of the following options:
- Blank
- Insured ID's # from tertiary
- Primary payer name
- Primary payer name 'of' primary payer state if primary is BCBS; else primary payer name
- Primary payer name if insured is patient
- Primary payer name if primary payer is not Medicare
- Tertiary payer name
- Tertiary payer name if secondary insurance exists and insured is patient
- UCase (primary payer name)
|
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| [11d] Is there another health plan? | Select one of the following options:
- Blank
- Blank if secondary is Medicare; else No
- No
- Yes
|
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| [22] Original Ref No | Select one of the following options:
- Blank
- Prior Payer Ref # - Prints the Prior Payer Reference Number from the window in box 22 Document Control Number.
- Resub Ref # - Pints the Resubmission Code from the window if the claim is a replacement (7) or Void/Cancel of Prior claim (8). Prints the ICN in box 22 of the paper CMS 1500 (2005 and 2012) claim.
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| [24j - Enable group logic] If Prov ID is selected in box 24k BELOW, display Prov ID only if the provider belongs to a group. If the provider is not in a group and Prov ID is selected, display nothing. | Select this option to enable the following logic:
- If the Prov ID option is selected in box 24k, listed below, display Prov ID only if the provider belongs to a group.
- If the provider is not in a group and Prov ID is selected, display nothing
|
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| [24j] Reserved for local use | Select one of the following options:
- <none>
- Allow or Deduct Amt $$.==/$$== (excluding DME)
- For example: if the allowed amount is $100 and deductible amount is $200, 100.00/20000 will print; or if the allowed amount is zero, 0.00/20000 will print.
- Allowed Amt Only (excluding DME)
- Blank
- Group Number
- Group Number (excluding DME)
- Group Taxonomy
- Narrative (excluding DME)
- OptClaimValue1 (excluding DME)
- OptClaimValue2 (excluding DME)
- Prior Paid Amt ($$.==) (excluding DME)
- Prior Paid Amt ($$== - no'.') (excluding DME)
- Prior Paid Amt Other Than Medicare ($$¢¢ - no'.') (excluding DME)
- Prov ID
- Prov ID (excluding DME)
- Provider Taxonomy Code
- Right 6 digits of Prov ID (excluding DME)
- UCase(Prov ID) (excluding DME)
- UCase(Prov St Lic #) (excluding DME)
- UPIN
|
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| [29] Amount Paid | Select one of the following options:
- Blank
- Pat paid amt
- Pri (if not Medicare) + Sec (if not Medicare) + Pat paid amt if enc has non-MCR/MCD payers; else Blank
- Pri (if not Medicare) + Sec (if not Medicare) paid amt
- Pri + Sec + Pat paid amt
- Pri + Sec + Ter + Pat paid amt
- Pri + Sec + Ter paid amt
- Pri + Sec paid amt
- Pri + Sec paid amt if Pri not Medicaid; else Blank
- Pri + Sec paid amt if Pri not Medicare/Medicaid; else Blank
- Pri + Sec paid amt if total paid amt > 0; else 1.00
- Pri paid amt
- Pri paid amt if paid amt > 0; else 1.00
- Pri paid amt if Pri is Medicare; else Blank
- Pri paid amt if Pri not Medicare/Medicaid; else Blank
|
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| [30] Balance Due | Select one of the following options:
- Blank
- Blank if primary payer is Commercial and secondary payer is Medicare; else Box 28 minus Box 29
- Blank if primary payer is Medicare and secondary payer is MCD/MGP/Supl; else Box 28 minus Box 29
- Box 28 minus [Pri (if Medicare) + Sec (if Medicare) + Pat paid amt]
- Box 28 minus all pymts (ins and pat) + common rules adj and ref settings
- Box 28 minus Box 29
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