CMS 1500 (2012) Form Print Options for All Payers

CMS 1500 (2012) Options	Description
Do not print payer address on HCFA	Prevents the payer address from appearing on the CMS 1500 (2012) form.
Payer Name at top of form	Displays the name of the payer using one of the following options: Blank Payer Alias Payer Alias - Upper Case Payer Name Payer Name - Upper Case Use Contents of Box 19
Print payer address in old location	Displays the payer address in the header of the CMS 1500 (2012) form.
Print page numbers on multiple page claims	Displays page numbers on claims having two or more pages.
[1] Insured's program	Displays the availed insured's program through one of the following options: Blank Use Legacy Standards Current Program with X Current Program with P
[1a] Insured's ID number	Displays the identification number of the insured through one of the following options: Blank Use Legacy Standards Current payer's insured's policy # Insured's override # if not blank; else insured's policy # Social Security Nbr Current payer's policy # + Plan Code
[1a] Convert value to upper case	Converts all lower case letters to upper case letters.
[10bc] Force 10b & 10c to No	Sets boxes 10b and 10c as No under the Worker's Comp claims. Only 10a employment box is checked.
[10d] Claim Codes	Displays the additional information about the condition of patient or the claim through one of the following options: Blank Other Payer's Provider Individual number Other Payer's Provider Individual number if other payer is Medicare Claim Codes This reports the Medi-Cal Share of Cost (SOC) similar to a copayment in box 10d of the claims form. You can enable this option by entering the Medi-Cal SOC value without decimal point or dollar sign in the Claims Code field of the Encounter Maintenance window. Condition Code Category - WC You must select the Condition Code Category - WC option on the Encounter Maintenance window to use this option. "MCD" + Insured ID if any Other Payers Medicaid "01" Sum of Other Payers Amount Paid "Y" if Emergency CPT4 "ATTACHMENT" Insured ID if any Other Payers Medicaid EPSDT Referral Codes Referring Physician UPIN
[11a] Date format for insured's date of birth	Displays the date of birth of the insured through one of the following options: Blank MMDDYY MMDDYYYY
[11a] Display insured's sex	Displays the gender of the insured in box 11a.
[11b] Other Claim ID	Displays the qualifier Y4 and the identifier number Property Casualty Claim Number in box 11b.
[14] Populate Accident Date & Qualifier	Displays the date of accident and the qualifier 439 in box 14. Note: This option is for the non-HIPAA carriers, for example, Auto Accident and Workers Compensation.
[15] Date format for patient same illness	Displays the date and the qualifier that identifies the reported date through one of the following options: Blank MMDDYY MMDDYYYY N/A Note: The selection you make in the Occurrence Code field of the Encounter Maintenance window identifies the qualifier that displays in box 15.
[17] Name of referring physician or other source	Displays the name of the referring physician through one of the following options: Blank First, MI, Last Name of Referring Provider (no commas) First, MI, Last Name of Referring Provider plus state (no commas) Last First Last First Middle Initial Last First Middle Initial State Last First State Last, First Last, First State Ordering provider This displays DK in the first column and provider's name in the second column. Referring name, else 'None' This displays DN in the first column of box 17. It either displays the provider's name or NONE in the second column if the Referring Provider field is empty. Self Referral if no referring doctor Supervising provider This displays DQ in the first column and the provider's name in the second column. Box 17 fetches the provider's name from the Supervisor field of the Encounter Maintenance window. UCASE(First MI Last Name of Referring Provider (no commas)) UCASE(First MI Last Name of Referring Provider plus state (no commas)) UCase(Last First MiddleInitial) UCase(Last First MiddleInitial) State UCase(Last First) UCase(Last First) State Note: Box 17 fetches the name of the provider from the Referring Provider field of the Encounter Maintenance window.
[17] Replace MI with referring physician full middle name	Displays the full middle name of the referring physician instead of the middle initials of the referring physician. Note: This claim print option is applicable only if you select an option in the [17] Name of referring physician or other source print option that can display the middle initial of the referring provider's name in box 17.
[17a] ID of physician reported in Box 17	Displays the non-National Provider Identifier (NPI) ID number of the referring provider mentioned in the [17] Name of referring physician or other source print option through one of the following options: Blank Georgia Better Health Nbr Physician State License Nbr Physician Taxonomy Code Physician UPIN, else none Prior Authorization Nbr Referral Number Use Legacy Standards Note: The selection you make in the 17a - Referring Prov Qualifier field of the Payer Information window in Payer Master, identifies the qualifier that displays in the first column of the box 17a.
[17b] Display NPI of physician reported in Box 17	Displays the NPI number of the provider mentioned in [17] Name of referring physician or other source print option.
[19] Display qualifier	Displays the Physician Taxonomy code and the qualifier ZZ in this field. Note: If you are billing by a group, this claim print option displays the group taxonomy code, whereas if you are billing as an individual provider, then the rendering provider taxonomy code displays.
[19] Reserved for Local Use	Displays additional claim information in box 19 through one of the following options: Anesthesia (Start/Stop) and/or Prior Deductible and/or Narrative Anesthesia Time (24h format), else Narrative Anesthesia Time (CAPS with Total), else Narrative Anesthesia Time (with Start/Stop), else Narrative Authorization Number, else Narrative Blank Claim attachments for WC This displays data that you select in the following fields of the Attachments sub tab of the Encounter Maintenance window: Attachment Report Type Report Transmission Code Attachment Control Number Demonstration Project Identifier, else Narrative This displays the following information when the Claim Print library is attached in Libraries Practice Preferences: Displays demonstration project ID with the prefix CT when it is entered on General sub-tab of the Encounter Maintenance window. Displays narrative when the Narr/Dunn field is filled in Charge Entry and the Demonstration Project ID is not entered. Displays blank when both, the narrative and the Demonstration Project ID are not entered. EPSDT Referral Condition Codes, else Narrative Legacy Option Narrative only NDC code, else Narrative Phys Taxonomy Code Prior Deductible Prior Deductible and Narrative Referral Number Referring UPIN and Date Last Seen, else Narrative Supervisor ID and NPI Supervisor ID and NPI; else narrative Note: If an option is selected and it does not exist on the encounter or no option is selected, then by default, the value is set to narrative.
[19] Use two lines for text	Sets the application to use two lines for free text in box 19.
[21] Diagnosis or nature of illness or injury	Displays the ICD code that identifies the condition of the patient related to the service on the claim through one of the following options: Blank Code This can display one of the following options: A total of 12 diagnosis codes can display in boxes A - L that relate to the lines-of-service selected in box 24E. Note: If there are more than 12 ICD codes on the claim, the application creates a second Continuation Claim with the additional ICD codes. ICD Ind. box displays 9 for ICD-9 codes ICD Ind. box displays 0 for ICD-10 codes Description
[22] Medicaid resubmission code	Displays the assigned code that indicates a previously submitted claim or encounter through one of the following options: Blank Deductible Amount for all line items if primary/secondary is MCR; else Blank Prov ID ResubCode (from Claim Maintenance) Supervising Prov ID UCase(ResubCode) UCase(ResubRefNbr) (from Claim Maintenance) UCase(ResubCode) (from Claim Maintenance) Note: This box can contain 11 characters.
[22] Original Ref No	Displays the original reference number that indicates a previously submitted claim or encounter through one of the following options: Blank Paid amount if primary/secondary is MCR; else Blank Prov ID Resub Ref # (from Claim Maintenance) Supervising Prov ID
[23] Authorization number	Displays the payer assigned number that authorize the services through one of the following options: Authorization Number Authorization Number - Upper Case Blank CLIA Number CLIA Number - Upper Case Legacy Option Medicare Provider Number Medicare Provider Number - Upper Case Referral Number Rendering Provider Name (Supervisor Billing only)
[24] Display supplemental data qualifier	Displays the supplemental data qualifier.
[24] Supplemental charge-related data to display above line	Displays the supplemental charge-related data through one of the following options: Anesthesia Begin/End (7) Anesthesia Begin/End/Time (7) Blank Charge Narrative (ZZ) NDC basis of measure/charge units(N4)(Column D) NDC desc/basis of measure/drug units(N4) NDC desc/basis of measure/drug units(N4) else Anesthesia begin/end(7) else Narratice(ZZ) NDC desc/basis of measure/drug units(N4) else Anesthesia begin/end/time(7) else Narrative (ZZ) Service Item Description (ZZ) Note: When a National Drug Code (NDC) option is selected, the NDC, Drug Unit Count, and Basis of Measure populates the paper CMS 1500 (2012) claim with the NDC, Basis of Measure, and National Drug Unit values in the Claims Maintenance Detail for the charge service line when the Claim Print Library is set to a default practice library or attached to the payer for the encounter.
[24a] Date format for dates of service	Displays the date on which the services were provided through one of the following options: MM DD YY MM DD YYYY MMDDYY MMDDYYYY
[24a] Force 2 digit year on output to file	Displays the year of service as two digits while printing to a file.
[24c] EMG Indicator	Displays Y or N that identifies whether the service provided was an emergency or not through one of the following options: Actual Value (Y/N) Blank Delay Reason Code fills either the Encounter Delay Reason Code or the payer's Auto Delay Reason Code. The Encounter Delay Reason Code field is on the Billing & Collections tab of the Encounter Maintenance window. The Auto Delay Reason Code field is on the Other sub-tab of the Practice tab of the Payer Master window. Remap Y =1, N=Blank Remap Y = 1, N =N Remap Y = X, N = Blank Remap Y = X, N = N Remap Y = Y, N = Blank Note: The Remap options enable you to substitute a specific character in place of the Y or N.
[24d] Modifier Options for Box 24d	Displays the modifiers that identifies the medical services and procedures provided to the patient through one of the following options: Blank Print 99 in 24d and modifiers in Box 19 when more than one modifier Print 99 in 24d when more than one modifier Print all modifiers Print only 3 modifiers Print xx 99 in 24d and modifiers in Box 19 when more than two modifiers Print xx 99 in 24d when more than two modifiers Note: When Blank is selected, all modifiers display on the claim.
[24e] Diagnosis code	Displays the Diagnosis Pointer from box 21 that identifies the reason for the service performed through one of the following options: All Pointers All Pointers without commas Blank Diag Code Diag Code without decimals Frmttd Code (nnn/nnn.n/nnn.nn) Primary Pointer
[24f] Suppress commas in amount	Removes the commas in the amount in box 24f. It also removes the commas in box 28. Box 28 is the sum of box 24f charges.
[24g] Display days/units	Displays the number of anesthesia days or units through one of the following options: Anes Min if Anes SIM else Quantity (Units) Anes Time (HMM) if Anes SIM else Quantity (Units) Anes Units if Anes SIM else Quantity (Units) Anesthesia Min if Anes SIM and Alt Code populated else Anes Units if Anes SIM else Quantity (Units) Blank Quantity (Units) Time Units if Anes SIM else Quantity (Units)
[24h top] EPSDT	Displays the code that identifies certain services that may be covered under the state plans through one of the following options: Blank EPSDT Legacy Option
[24h bottom] Family Planning	Displays Y or N depending on the requirement to report the referral as a Family Planning service or not through one of the following options: Blank Family Planning: If checked print "Y", if unchecked print "N" Family Planning: If checked print "Y", if unchecked print Blank Legacy Option Note: You must set up the Other option to Y or N in the EPSDT Encounter Code - Paper field of the Claims tab on the Encounter Maintenance window.
[24i] ID Qualifier	Displays the qualifier for the provider's ID number who does not have an NPI number.
[24j TOP - Enable group logic] If Prov ID is selected in box 24j TOP 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.	Displays the ID number of the individual rendering the services.
[24j TOP] Rendering Provider ID	Displays the provider ID of the rendering physician through one of the following options: Prov ID Prov ID (excluding DME) Prov Taxonomy Code Right 6 digits of Prov ID (excluding DME) UCASE(Prov ID) (excluding DME) UCASE (Prov St Lic #) (excluding DME) UPIN
[24j Bottom] Rendering NPI	Displays the NPI ID of the rendering physician through one of the following options: Blank Rendering NPI Rendering NPI if provider belongs to a group, else blank
[25] Federal tax id number	Displays the ID number assigned by a federal or state agency to the employer through one of the following options: Blank Prov ID Tax ID UCase(Tax ID)
[25] Federal tax ID number type	Displays the type of ID number assigned to the employer in box 25 through one of the following options: Blank EIN Read from claim (standard) SSN
[27] Accept Assignment/Worker's Comp	Displays an 'X' that indicates whether the provider agrees to accept the assignment under the terms of the payer's program through one of the following options: Blank No Use Legacy Options uses previous settings. Yes
[29] Amount Paid - Include Adjustments for payers?	Displays the amount adjustments paid by the payers.
[29] Amount Paid - Include refunds for payers?	Displays the refund amount adjustments made to the payers.
[29] Amount Paid - When zero dollar amount, display:	Displays the zero dollar amount through one of the following options: 0.00 Blank
[29] Amount Paid - Format	Displays the amount paid by the payer through one of the following options: 999,999.99 999999.99
[30] Balance Due - When zero dollar amount, display:	Displays the due zero dollar amount through one of the following options: 0.00 Blank Note: This field is reserved for NUCC use.
[30] Balance Due - Format	Displays the due amount using one of the following options: 999,999.99 999999.99 Note: This field is reserved for NUCC use.
[30] Balance Due - Include Adjustments	Displays the due amount with adjustments from payers through one of the following options: Ignore Adjustments Include Adjustments of All Payers Include Adjustments of Current Payer Include Adjustments of Prior and Current Payer Include Adjustments of Prior Payer Use Box 29 setting Note: This field is reserved for NUCC use.
[30] Balance Due - Include Refunds	Displays the due amount with refund amount from payers through one of the following options: <None> Ignore Refunds Include Refunds for All Payers Use Box 29 setting Note: This field is reserved for NUCC use.
[29 & 30] Amount Paid & Balance Due - Total Location	Indicates where to display the total amount paid for a multi-page claim through one of the following options: Grand total on first page only; blank on other pages Grand total on last page only; 'page X of Y' on other pages Grand total on last page only; blank on other pages Total each page separately; no grand total
[31-1] Signature of physician or supplier	Displays the signature of the physician and the date on which the form was signed through one of the following options: ‘Agreement on File’ 'COMPUTER-GENERATED MM/DD/YY' ‘signature on file’ ‘SIGNATURE ON FILE’ (Upper Case) Blank Current Date (mm/dd/yy) Current Date (mm/dd/yyyy) Group Name Name of facility/location Original Date (mm/dd/yy) Original Date (mm/dd/yyyy) Physician License Number Provider Individual Number Rendering name (Display As) RENDERING NAME (Display As - Upper Case) Rendering name (Last, First MI) Rendering name (Last, First MI - Upper Case) Note: The claim print option must not be left blank.
[31-2] Signature of physician or supplier	Displays the signature of another physician, if any and the date on which the form was signed through one of the following options: ‘Agreement on File’ 'COMPUTER-GENERATED MM/DD/YY' ‘signature on file’ ‘SIGNATURE ON FILE’ (upper case) Blank Current Date (mm/dd/yy) Current Date (mm/dd/yyyy) Original Date (mm/dd/yy) Original Date (mm/dd/yyyy) Physician License Number Provider Individual Number Rendering name (Display As) RENDERING NAME (Display As - Upper Case) Rendering name (Last, First MI) Rendering name (Last, First MI - Upper Case)
[31-3] Signature of physician or supplier	Displays the signature of another physician, if any and the date on which the form was signed through one of the following options: ‘Agreement on File’ 'COMPUTER-GENERATED MM/DD/YY' ‘signature on file’ ‘SIGNATURE ON FILE’ (upper case) Blank Current Date (mm/dd/yy) Current Date (mm/dd/yyyy) Original Date (mm/dd/yy) Original Date (mm/dd/yyyy) Physician License Number Provider Individual Number Rendering name (Display As) RENDERING NAME (Display As - Upper Case) Rendering name (Last, First MI) Rendering name (Last, First MI - Upper Case)
[32] COB1 Recent Paid Date or Batch Nbr below box	Displays the date and batch number to identify on which Coordination Of Benefits (COB) 1 was paid through one of the following options: Batch Nbr Blank Recent Date Recent Date & Batch Nbr
[32] Convert values to upper case	Coverts all values of box 32, lines 1-4, to appear in upper case.
[32-1] Name/Addr where services rendered	Displays the name of the facility where the services were provided through one of the following options: Blank Blank if phys addr = fac/loc addr; else Name of fac/loc Blank if phys name/addr = fac/loc name/addr; else Name of fac/loc Blank if POS is office; else Name of fac/loc Blank if POS is office; Facility Name if not blank; else Practice Name Facility Name if not blank; else Practice Name If POS 12 print HOME If POS is 99, Name of POS Location Name of facility/location SAME if phys addr = fac/loc addr; else Name of fac/loc SAME if phys name/addr = fac/loc & POS is office/inpat hosp; else Name of fac/loc SAME if phys name/addr = fac/loc name/addr; else Name of fac/loc
[32-2] Name/Addr where services rendered	Displays the address of the facility where the services were provided through one of the following options: Addr1 Addr2 of facility/location Blank Blank if phys addr = fac/loc addr; else Addr1 Addr2 of fac/loc Blank if phys name/addr = fac/loc & POS is office/inpat hosp; else Addr1 Addr2 of fac/loc Blank if phys name/addr = fac/loc name/addr; else Addr1 Addr2 of fac/loc Blank if POS is office; else Addr1 Addr2 of fac/loc If POS 12 Addr 1 Addr 2 of patient If POS is 99, Address of POS Location
[32-3] Name/Addr where services rendered	Displays the name of city, state, and zip of the facility where the services were provided through one of the following options: Blank Blank if phys addr = fac/loc addr; else City State Zip of fac/loc Blank if phys name/addr = fac/loc & POS is office/inpat hosp; else City St Zip of fac/loc Blank if phys name/addr = fac/loc name/addr; else City State Zip of fac/loc Blank if POS is office; else City State Zip of fac/loc City State Zip of facility/location If POS 12 City, State, Zip of patient If POS is 99, City, State, and ZIP of POS Location
[32-a] NPI	Displays the NPI number of the service facility location through one of the following options: Blank Blank if phys addr = fac/loc addr; else Fac NPI Blank if phys name/addr = fac/loc & POS is office/inpat hosp; else Fac NPI Blank if phys name/addr = fac/loc; else Fac NPI Blank if POS is office; else Fac NPI Facility NPI
[32-b] Facility ID	Displays the non-NPI ID number of the service facility through one of the following options: Blank Blank if phys addr = fac/loc addr; else Fac ID (if present), else Mammography Cert of loc Blank if phys name/addr = fac/loc & POS is office/inpat hosp; else Fac ID, else Mam Cert Blank if phys name/addr = fac/loc; else Fac ID (if present), else Mammography Cert of loc Blank if POS is office; else Fac ID (if present) ; else Mammography Cert of loc Facility ID (if present), else Mammography Cert of location Facility Taxonomy
[32-b & 33-b] Add space between qualifier and data	Adds a space between the qualifier and the data in boxes 32-b and 33-b.
[33] Display group phone #	Displays the group phone number in box 33.
[33-1] Physician's/Supplier's information	Displays the name of the billing provider through one of the following options: Group Name UCase (Group Name) Group Phone SAME Supervising Name if supervising exists and is not blank; else Rendering Name Supervising Phone if supervising exists and is not blank; else Rendering Phone Bill to Loc Name else Group name
[33-2] Physician's/Supplier's information	Displays the address of the billing provider through one of the following options: Group Addr1 & Addr2 UCase(Group Addr1 & Addr2) UCase(Group Name) Blank Supervising Addr1 & Addr2 if supervising exists and is not blank; else Rendering Addr1 & Addr2 Supervising Name if supervising exists and is not blank; else Rendering Name Bill to Loc Addr 1 & 2 else Grp Addr 1 & 2
[33-3] Physician's/Supplier's information	Displays the name of the city, state, and zip of the billing provider through one of the following options: Group City & St & Zip UCase(Group City & St & Zip) UCase(Group Addr1 & Addr2) Blank Supervising City & St & Zip if supervising exists and is not blank; else Rendering City & St & Zip Supervising Addr1 & Addr2 if supervising exists and is not blank; else Rendering Addr1 & Addr2 Bill to Loc City, St & Zip else Grp City, St & Zip
[33-4] Physician's/Supplier's information	Displays the details of the billing provider group through one of the following options: Blank UCase(Group City & St & Zip) Group Phone Supervising City & St & Zip if supervising exists and is not blank; else Rendering City & St & Zip Supervising Phone if supervising exists and is not blank; else Rendering Phone Bill to Loc Phone else Grp Phone
[33-a] Display NPI	Displays the NPI number of the billing provider through one of the following options: Blank NPI (Group NPI if group billing, else provider individual NPI if billing as an individual)
[33-GRP Enable group logic] If group # or Prov ID is selected in box 33 (GRP Physician's Supplier's), display group # only if the provider belongs to a group (Group # selected) or Prov ID only if the provider does not belong to a group (Prov ID selected).If the provider is in a group and Prov ID is selected, display nothing. If the provider is not in a group and Group # is selected display nothing.	Displays the ID number of the provider.
[33-GRP] Physician's/Supplier's information	Displays the non-NPI ID number and the taxonomy code of the provider through one of the following options: Group # Prov ID & OptClaimValue1 Blank OptClaimValue1 OptClaimValue2 Prov ID & OptClaimValue2 Group Opt Val Prov Taxonomy code Group Taxonomy code Phys Billing Taxonomy code UCase(Group #) Trim(Group #) UCase(Trim(Group #) Prov ID Trim(Prov ID) UCase(Trim(Prov ID)) Prov ID & Prov Tax ID Prov ID & Group #

Do not print payer address on HCFA

Prevents the payer address from appearing on the CMS 1500 (2012) form.

Payer Name at top of form

Displays the name of the payer using one of the following options:

Blank
Payer Alias
Payer Alias - Upper Case
Payer Name
Payer Name - Upper Case
Use Contents of Box 19

Print payer address in old location

Displays the payer address in the header of the CMS 1500 (2012) form.

Print page numbers on multiple page claims

Displays page numbers on claims having two or more pages.

[1] Insured's program

Displays the availed insured's program through one of the following options:

Blank
Use Legacy Standards
Current Program with X
Current Program with P

[1a] Insured's ID number

Displays the identification number of the insured through one of the following options:

Blank
Use Legacy Standards
Current payer's insured's policy #
Insured's override # if not blank; else insured's policy #
Social Security Nbr
Current payer's policy # + Plan Code

[1a] Convert value to upper case

Converts all lower case letters to upper case letters.

[10bc] Force 10b & 10c to No

Sets boxes 10b and 10c as No under the Worker's Comp claims. Only 10a employment box is checked.

[10d] Claim Codes

Displays the additional information about the condition of patient or the claim through one of the following options:

Blank
Other Payer's Provider Individual number
Other Payer's Provider Individual number if other payer is Medicare
Claim Codes
This reports the Medi-Cal Share of Cost (SOC) similar to a copayment in box 10d of the claims form. You can enable this option by entering the Medi-Cal SOC value without decimal point or dollar sign in the Claims Code field of the Encounter Maintenance window.
Condition Code Category - WC
You must select the Condition Code Category - WC option on the Encounter Maintenance window to use this option.
"MCD" + Insured ID if any Other Payers Medicaid
"01"
Sum of Other Payers Amount Paid
"Y" if Emergency CPT4
"ATTACHMENT"
Insured ID if any Other Payers Medicaid
EPSDT Referral Codes
Referring Physician UPIN

[11a] Date format for insured's date of birth

Displays the date of birth of the insured through one of the following options:

Blank
MMDDYY
MMDDYYYY

[11a] Display insured's sex

Displays the gender of the insured in box 11a.

[11b] Other Claim ID

Displays the qualifier Y4 and the identifier number Property Casualty Claim Number in box 11b.

[14] Populate Accident Date & Qualifier

Displays the date of accident and the qualifier 439 in box 14.

Note: This option is for the non-HIPAA carriers, for example, Auto Accident and Workers Compensation.

[15] Date format for patient same illness

Displays the date and the qualifier that identifies the reported date through one of the following options:

Blank
MMDDYY
MMDDYYYY
N/A

Note: The selection you make in the Occurrence Code field of the Encounter Maintenance window identifies the qualifier that displays in box 15.

[17] Name of referring physician or other source

Displays the name of the referring physician through one of the following options:

Blank
First, MI, Last Name of Referring Provider (no commas)
First, MI, Last Name of Referring Provider plus state (no commas)
Last First
Last First Middle Initial
Last First Middle Initial State
Last First State
Last, First
Last, First State
Ordering provider
This displays DK in the first column and provider's name in the second column.
Referring name, else 'None'
This displays DN in the first column of box 17. It either displays the provider's name or NONE in the second column if the Referring Provider field is empty.
Self Referral if no referring doctor
Supervising provider
This displays DQ in the first column and the provider's name in the second column. Box 17 fetches the provider's name from the Supervisor field of the Encounter Maintenance window.
UCASE(First MI Last Name of Referring Provider (no commas))
UCASE(First MI Last Name of Referring Provider plus state (no commas))
UCase(Last First MiddleInitial)
UCase(Last First MiddleInitial) State
UCase(Last First)
UCase(Last First) State

Note: Box 17 fetches the name of the provider from the Referring Provider field of the Encounter Maintenance window.

[17] Replace MI with referring physician full middle name

Displays the full middle name of the referring physician instead of the middle initials of the referring physician.

Note: This claim print option is applicable only if you select an option in the [17] Name of referring physician or other source print option that can display the middle initial of the referring provider's name in box 17.

[17a] ID of physician reported in Box 17

Displays the non-National Provider Identifier (NPI) ID number of the referring provider mentioned in the [17] Name of referring physician or other source print option through one of the following options:

Blank
Georgia Better Health Nbr
Physician State License Nbr
Physician Taxonomy Code
Physician UPIN, else none
Prior Authorization Nbr
Referral Number
Use Legacy Standards

Note: The selection you make in the 17a - Referring Prov Qualifier field of the Payer Information window in Payer Master, identifies the qualifier that displays in the first column of the box 17a.

[17b] Display NPI of physician reported in Box 17

Displays the NPI number of the provider mentioned in [17] Name of referring physician or other source print option.

[19] Display qualifier

Displays the Physician Taxonomy code and the qualifier ZZ in this field.

Note: If you are billing by a group, this claim print option displays the group taxonomy code, whereas if you are billing as an individual provider, then the rendering provider taxonomy code displays.

[19] Reserved for Local Use

Displays additional claim information in box 19 through one of the following options:

Anesthesia (Start/Stop) and/or Prior Deductible and/or Narrative
Anesthesia Time (24h format), else Narrative
Anesthesia Time (CAPS with Total), else Narrative
Anesthesia Time (with Start/Stop), else Narrative
Authorization Number, else Narrative
Blank
Claim attachments for WC
This displays data that you select in the following fields of the Attachments sub tab of the Encounter Maintenance window:
- Attachment Report Type
- Report Transmission Code
- Attachment Control Number
Demonstration Project Identifier, else Narrative
This displays the following information when the Claim Print library is attached in Libraries Practice Preferences:
- Displays demonstration project ID with the prefix CT when it is entered on General sub-tab of the Encounter Maintenance window.
- Displays narrative when the Narr/Dunn field is filled in Charge Entry and the Demonstration Project ID is not entered.
- Displays blank when both, the narrative and the Demonstration Project ID are not entered.
EPSDT Referral Condition Codes, else Narrative
Legacy Option
Narrative only
NDC code, else Narrative
Phys Taxonomy Code
Prior Deductible
Prior Deductible and Narrative
Referral Number
Referring UPIN and Date Last Seen, else Narrative
Supervisor ID and NPI
Supervisor ID and NPI; else narrative

Note: If an option is selected and it does not exist on the encounter or no option is selected, then by default, the value is set to narrative.

[19] Use two lines for text

Sets the application to use two lines for free text in box 19.

[21] Diagnosis or nature of illness or injury

Displays the ICD code that identifies the condition of the patient related to the service on the claim through one of the following options:

Blank
Code
This can display one of the following options:
- A total of 12 diagnosis codes can display in boxes A - L that relate to the lines-of-service selected in box 24E.
  Note: If there are more than 12 ICD codes on the claim, the application creates a second Continuation Claim with the additional ICD codes.
- ICD Ind. box displays 9 for ICD-9 codes
- ICD Ind. box displays 0 for ICD-10 codes
Description

[22] Medicaid resubmission code

Displays the assigned code that indicates a previously submitted claim or encounter through one of the following options:

Blank
Deductible Amount for all line items if primary/secondary is MCR; else Blank
Prov ID
ResubCode (from Claim Maintenance)
Supervising Prov ID
UCase(ResubCode) UCase(ResubRefNbr) (from Claim Maintenance)
UCase(ResubCode) (from Claim Maintenance)

Note: This box can contain 11 characters.

[22] Original Ref No

Displays the original reference number that indicates a previously submitted claim or encounter through one of the following options:

Blank
Paid amount if primary/secondary is MCR; else Blank
Prov ID
Resub Ref # (from Claim Maintenance)
Supervising Prov ID

[23] Authorization number

Displays the payer assigned number that authorize the services through one of the following options:

Authorization Number
Authorization Number - Upper Case
Blank
CLIA Number
CLIA Number - Upper Case
Legacy Option
Medicare Provider Number
Medicare Provider Number - Upper Case
Referral Number
Rendering Provider Name (Supervisor Billing only)

[24] Display supplemental data qualifier

Displays the supplemental data qualifier.

[24] Supplemental charge-related data to display above line

Displays the supplemental charge-related data through one of the following options:

Anesthesia Begin/End (7)
Anesthesia Begin/End/Time (7)
Blank
Charge Narrative (ZZ)
NDC basis of measure/charge units(N4)(Column D)
NDC desc/basis of measure/drug units(N4)
NDC desc/basis of measure/drug units(N4) else Anesthesia begin/end(7) else Narratice(ZZ)
NDC desc/basis of measure/drug units(N4) else Anesthesia begin/end/time(7) else Narrative (ZZ)
Service Item Description (ZZ)

Note: When a National Drug Code (NDC) option is selected, the NDC, Drug Unit Count, and Basis of Measure populates the paper CMS 1500 (2012) claim with the NDC, Basis of Measure, and National Drug Unit values in the Claims Maintenance Detail for the charge service line when the Claim Print Library is set to a default practice library or attached to the payer for the encounter.

[24a] Date format for dates of service

Displays the date on which the services were provided through one of the following options:

MM DD YY
MM DD YYYY
MMDDYY
MMDDYYYY

[24a] Force 2 digit year on output to file

Displays the year of service as two digits while printing to a file.

[24c] EMG Indicator

Displays Y or N that identifies whether the service provided was an emergency or not through one of the following options:

Actual Value (Y/N)
Blank
Delay Reason Code fills either the Encounter Delay Reason Code or the payer's Auto Delay Reason Code.
- The Encounter Delay Reason Code field is on the Billing & Collections tab of the Encounter Maintenance window.
- The Auto Delay Reason Code field is on the Other sub-tab of the Practice tab of the Payer Master window.
Remap Y =1, N=Blank
Remap Y = 1, N =N
Remap Y = X, N = Blank
Remap Y = X, N = N
Remap Y = Y, N = Blank

Note: The Remap options enable you to substitute a specific character in place of the Y or N.

[24d] Modifier Options for Box 24d

Displays the modifiers that identifies the medical services and procedures provided to the patient through one of the following options:

Blank
Print 99 in 24d and modifiers in Box 19 when more than one modifier
Print 99 in 24d when more than one modifier
Print all modifiers
Print only 3 modifiers
Print xx 99 in 24d and modifiers in Box 19 when more than two modifiers
Print xx 99 in 24d when more than two modifiers

Note: When Blank is selected, all modifiers display on the claim.

[24e] Diagnosis code

Displays the Diagnosis Pointer from box 21 that identifies the reason for the service performed through one of the following options:

All Pointers
All Pointers without commas
Blank
Diag Code
Diag Code without decimals
Frmttd Code (nnn/nnn.n/nnn.nn)
Primary Pointer

[24f] Suppress commas in amount

Removes the commas in the amount in box 24f. It also removes the commas in box 28. Box 28 is the sum of box 24f charges.

[24g] Display days/units

Displays the number of anesthesia days or units through one of the following options:

Anes Min if Anes SIM else Quantity (Units)
Anes Time (HMM) if Anes SIM else Quantity (Units)
Anes Units if Anes SIM else Quantity (Units)
Anesthesia Min if Anes SIM and Alt Code populated else Anes Units if Anes SIM else Quantity (Units)
Blank
Quantity (Units)
Time Units if Anes SIM else Quantity (Units)

[24h top] EPSDT

Displays the code that identifies certain services that may be covered under the state plans through one of the following options:

Blank
EPSDT
Legacy Option

[24h bottom] Family Planning

Displays Y or N depending on the requirement to report the referral as a Family Planning service or not through one of the following options:

Blank
Family Planning: If checked print "Y", if unchecked print "N"
Family Planning: If checked print "Y", if unchecked print Blank
Legacy Option

Note: You must set up the Other option to Y or N in the EPSDT Encounter Code - Paper field of the Claims tab on the Encounter Maintenance window.

[24i] ID Qualifier

Displays the qualifier for the provider's ID number who does not have an NPI number.

[24j TOP - Enable group logic] If Prov ID is selected in box 24j TOP 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.

Displays the ID number of the individual rendering the services.

[24j TOP] Rendering Provider ID

Displays the provider ID of the rendering physician through one of the following options:

Prov ID
Prov ID (excluding DME)
Prov Taxonomy Code
Right 6 digits of Prov ID (excluding DME)
UCASE(Prov ID) (excluding DME)
UCASE (Prov St Lic #) (excluding DME)
UPIN

[24j Bottom] Rendering NPI

Displays the NPI ID of the rendering physician through one of the following options:

Blank
Rendering NPI
Rendering NPI if provider belongs to a group, else blank

[25] Federal tax id number

Displays the ID number assigned by a federal or state agency to the employer through one of the following options:

Blank
Prov ID
Tax ID
UCase(Tax ID)

[25] Federal tax ID number type

Displays the type of ID number assigned to the employer in box 25 through one of the following options:

Blank
EIN
Read from claim (standard)
SSN

[27] Accept Assignment/Worker's Comp

Displays an 'X' that indicates whether the provider agrees to accept the assignment under the terms of the payer's program through one of the following options:

Blank
No
Use Legacy Options uses previous settings.
Yes

[29] Amount Paid - Include Adjustments for payers?

Displays the amount adjustments paid by the payers.

[29] Amount Paid - Include refunds for payers?

Displays the refund amount adjustments made to the payers.

[29] Amount Paid - When zero dollar amount, display:

Displays the zero dollar amount through one of the following options:

0.00
Blank

[29] Amount Paid - Format

Displays the amount paid by the payer through one of the following options:

999,999.99
999999.99

[30] Balance Due - When zero dollar amount, display:

Displays the due zero dollar amount through one of the following options:

0.00
Blank

Note: This field is reserved for NUCC use.

[30] Balance Due - Format

Displays the due amount using one of the following options:

999,999.99
999999.99

Note: This field is reserved for NUCC use.

[30] Balance Due - Include Adjustments

Displays the due amount with adjustments from payers through one of the following options:

Ignore Adjustments
Include Adjustments of All Payers
Include Adjustments of Current Payer
Include Adjustments of Prior and Current Payer
Include Adjustments of Prior Payer
Use Box 29 setting

Note: This field is reserved for NUCC use.

[30] Balance Due - Include Refunds

Displays the due amount with refund amount from payers through one of the following options:

<None>
Ignore Refunds
Include Refunds for All Payers
Use Box 29 setting

Note: This field is reserved for NUCC use.

[29 & 30] Amount Paid & Balance Due - Total Location

Indicates where to display the total amount paid for a multi-page claim through one of the following options:

Grand total on first page only; blank on other pages
Grand total on last page only; 'page X of Y' on other pages
Grand total on last page only; blank on other pages
Total each page separately; no grand total

[31-1] Signature of physician or supplier

Displays the signature of the physician and the date on which the form was signed through one of the following options:

‘Agreement on File’
'COMPUTER-GENERATED MM/DD/YY'
‘signature on file’
‘SIGNATURE ON FILE’ (Upper Case)
Blank
Current Date (mm/dd/yy)
Current Date (mm/dd/yyyy)
Group Name
Name of facility/location
Original Date (mm/dd/yy)
Original Date (mm/dd/yyyy)
Physician License Number
Provider Individual Number
Rendering name (Display As)
RENDERING NAME (Display As - Upper Case)
Rendering name (Last, First MI)
Rendering name (Last, First MI - Upper Case)

Note: The claim print option must not be left blank.

[31-2] Signature of physician or supplier

Displays the signature of another physician, if any and the date on which the form was signed through one of the following options:

‘Agreement on File’
'COMPUTER-GENERATED MM/DD/YY'
‘signature on file’
‘SIGNATURE ON FILE’ (upper case)
Blank
Current Date (mm/dd/yy)
Current Date (mm/dd/yyyy)
Original Date (mm/dd/yy)
Original Date (mm/dd/yyyy)
Physician License Number
Provider Individual Number
Rendering name (Display As)
RENDERING NAME (Display As - Upper Case)
Rendering name (Last, First MI)
Rendering name (Last, First MI - Upper Case)

[31-3] Signature of physician or supplier

Displays the signature of another physician, if any and the date on which the form was signed through one of the following options:

‘Agreement on File’
'COMPUTER-GENERATED MM/DD/YY'
‘signature on file’
‘SIGNATURE ON FILE’ (upper case)
Blank
Current Date (mm/dd/yy)
Current Date (mm/dd/yyyy)
Original Date (mm/dd/yy)
Original Date (mm/dd/yyyy)
Physician License Number
Provider Individual Number
Rendering name (Display As)
RENDERING NAME (Display As - Upper Case)
Rendering name (Last, First MI)
Rendering name (Last, First MI - Upper Case)

[32] COB1 Recent Paid Date or Batch Nbr below box

Displays the date and batch number to identify on which Coordination Of Benefits (COB) 1 was paid through one of the following options:

Batch Nbr
Blank
Recent Date
Recent Date & Batch Nbr

[32] Convert values to upper case

Coverts all values of box 32, lines 1-4, to appear in upper case.

[32-1] Name/Addr where services rendered

Displays the name of the facility where the services were provided through one of the following options:

Blank
Blank if phys addr = fac/loc addr; else Name of fac/loc
Blank if phys name/addr = fac/loc name/addr; else Name of fac/loc
Blank if POS is office; else Name of fac/loc
Blank if POS is office; Facility Name if not blank; else Practice Name
Facility Name if not blank; else Practice Name
If POS 12 print HOME
If POS is 99, Name of POS Location
Name of facility/location
SAME if phys addr = fac/loc addr; else Name of fac/loc
SAME if phys name/addr = fac/loc & POS is office/inpat hosp; else Name of fac/loc
SAME if phys name/addr = fac/loc name/addr; else Name of fac/loc

[32-2] Name/Addr where services rendered

Displays the address of the facility where the services were provided through one of the following options:

Addr1 Addr2 of facility/location
Blank
Blank if phys addr = fac/loc addr; else Addr1 Addr2 of fac/loc
Blank if phys name/addr = fac/loc & POS is office/inpat hosp; else Addr1 Addr2 of fac/loc
Blank if phys name/addr = fac/loc name/addr; else Addr1 Addr2 of fac/loc
Blank if POS is office; else Addr1 Addr2 of fac/loc
If POS 12 Addr 1 Addr 2 of patient
If POS is 99, Address of POS Location

[32-3] Name/Addr where services rendered

Displays the name of city, state, and zip of the facility where the services were provided through one of the following options:

Blank
Blank if phys addr = fac/loc addr; else City State Zip of fac/loc
Blank if phys name/addr = fac/loc & POS is office/inpat hosp; else City St Zip of fac/loc
Blank if phys name/addr = fac/loc name/addr; else City State Zip of fac/loc
Blank if POS is office; else City State Zip of fac/loc
City State Zip of facility/location
If POS 12 City, State, Zip of patient
If POS is 99, City, State, and ZIP of POS Location

[32-a] NPI

Displays the NPI number of the service facility location through one of the following options:

Blank
Blank if phys addr = fac/loc addr; else Fac NPI
Blank if phys name/addr = fac/loc & POS is office/inpat hosp; else Fac NPI
Blank if phys name/addr = fac/loc; else Fac NPI
Blank if POS is office; else Fac NPI
Facility NPI

[32-b] Facility ID

Displays the non-NPI ID number of the service facility through one of the following options:

Blank
Blank if phys addr = fac/loc addr; else Fac ID (if present), else Mammography Cert of loc
Blank if phys name/addr = fac/loc & POS is office/inpat hosp; else Fac ID, else Mam Cert
Blank if phys name/addr = fac/loc; else Fac ID (if present), else Mammography Cert of loc
Blank if POS is office; else Fac ID (if present) ; else Mammography Cert of loc
Facility ID (if present), else Mammography Cert of location
Facility Taxonomy

[32-b & 33-b] Add space between qualifier and data

Adds a space between the qualifier and the data in boxes 32-b and 33-b.

[33] Display group phone #

Displays the group phone number in box 33.

[33-1] Physician's/Supplier's information

Displays the name of the billing provider through one of the following options:

Group Name
UCase (Group Name)
Group Phone
SAME
Supervising Name if supervising exists and is not blank; else Rendering Name
Supervising Phone if supervising exists and is not blank; else Rendering Phone
Bill to Loc Name else Group name

[33-2] Physician's/Supplier's information

Displays the address of the billing provider through one of the following options:

Group Addr1 & Addr2
UCase(Group Addr1 & Addr2)
UCase(Group Name)
Blank
Supervising Addr1 & Addr2 if supervising exists and is not blank; else Rendering Addr1 & Addr2
Supervising Name if supervising exists and is not blank; else Rendering Name
Bill to Loc Addr 1 & 2 else Grp Addr 1 & 2

[33-3] Physician's/Supplier's information

Displays the name of the city, state, and zip of the billing provider through one of the following options:

Group City & St & Zip
UCase(Group City & St & Zip)
UCase(Group Addr1 & Addr2)
Blank
Supervising City & St & Zip if supervising exists and is not blank; else Rendering City & St & Zip
Supervising Addr1 & Addr2 if supervising exists and is not blank; else Rendering Addr1 & Addr2
Bill to Loc City, St & Zip else Grp City, St & Zip

[33-4] Physician's/Supplier's information

Displays the details of the billing provider group through one of the following options:

Blank
UCase(Group City & St & Zip)
Group Phone
Supervising City & St & Zip if supervising exists and is not blank; else Rendering City & St & Zip
Supervising Phone if supervising exists and is not blank; else Rendering Phone
Bill to Loc Phone else Grp Phone

[33-a] Display NPI

Displays the NPI number of the billing provider through one of the following options:

Blank
NPI (Group NPI if group billing, else provider individual NPI if billing as an individual)

[33-GRP Enable group logic] If group # or Prov ID is selected in box 33 (GRP Physician's Supplier's), display group # only if the provider belongs to a group (Group # selected) or Prov ID only if the provider does not belong to a group (Prov ID selected).If the provider is in a group and Prov ID is selected, display nothing. If the provider is not in a group and Group # is selected display nothing.

Displays the ID number of the provider.

[33-GRP] Physician's/Supplier's information

Displays the non-NPI ID number and the taxonomy code of the provider through one of the following options:

Group #
Prov ID & OptClaimValue1
Blank
OptClaimValue1
OptClaimValue2
Prov ID & OptClaimValue2
Group Opt Val
Prov Taxonomy code
Group Taxonomy code
Phys Billing Taxonomy code
UCase(Group #)
Trim(Group #)
UCase(Trim(Group #)
Prov ID
Trim(Prov ID)
UCase(Trim(Prov ID))
Prov ID & Prov Tax ID
Prov ID & Group #

CMS 1500 (2012) Form Print Options for All Payers

Recommendations

CMS 1500 (2005) Options

UB(92) Options

UB(04) Form Print Options for All Payers

CMS 1500 (2012) Form Print Options for All Payers

CMS 1500 (2005) Options

1500 CMS Options (2012)

CMS 1500 (2005) Options

UB(92) Options

UB(04) Form Print Options for All Payers

CMS 1500 (2012) Form Print Options for All Payers

CMS 1500 (2005) Options

1500 CMS Options (2012)