| [FL 50-53] Blank if Medicare Primary | Select this option to suppress primary payer information in these fields if Medicare is primary. When this option is selected, the secondary and tertiary payer information in FL 50-66 moves to the primary and secondary positions (Lines A & B). |
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| [FL54] Prior Payment | Select one of the following options:
- Blank
- Blank if Medicare is Prim
- Prior Payer Payments
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| [FL55] Estimated Amount Due | Select one of the following options:
- Blank
- Charge Amt minus Box 54
- Charge Amt minus Box 54 minus Value Code amounts (Deductible and Coinsurance only)
- Charge Amt minus first Value Code amt (share of cost only)
- Charge Amt minus Value Code amounts (Deductible and Coinsurance only)
- Enc Rate SIM amount
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| [FL64] Document Control Number | Select one of the following options:
- Default – No selection
- Blank – Use to remove a selection or no selection.
- Resub Ref # (from Claim Maintenance) - Select to print the Resubmission Reference Number in the Claims Maintenance Claims Detail “Resubmission Code field. This is an alpha numeric field with a maximum length of 26 characters.
- Prior Payer Ref # (from Claim Maintenance) – When this is selected the Prior Payer Resubmission Reference Number will print from the new field “Prior Payer Reference Number” in Claims Maintenance>Claim Detail field when populated. This is an alpha numeric field with a maximum length of 26 characters.
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