| [2] Preauthorization Number | Select one of the following:
- Authorization Number
- Authorization Number - Upper Case
- Blank
- Referral Number
|
|---|
| [8] Other Insurance Subscriber ID | Select one of the following:
- Blank
- Payer Policy number
- Subscriber SSN
|
|---|
| [15] Subscriber ID | Select one of the following:
- Blank
- Payer Policy number
- Subscriber SSN
|
|---|
| [20] Patient Name / Address | Select one of the following:
- Blank
- None
- Populate patient regardless of the subscriber
|
|---|
| [23] Patient ID / Account Nbr | Select one of the following:
- Blank
- Medical record number
- Patient control number
|
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| [25] Area of Oral Cavity | Select one of the following:
|
|---|
| [26] Tooth System | Check to print this box on claims. Uncheck to not print this box on claims. |
|---|
| [27] Tooth Numbers | Select one of the following:
|
|---|
| [28] Tooth Surface | Select one of the following:
Note: If multiple surface values are present, all values are printed with no separators.
|
|---|
| [29a] Diagnosis Pointer | Select one of the following:
- All Pointers
- Blank
- Primary Pointer
|
|---|
| [29b] Quantity | Select one of the following:
- Always Quantity (Units)
- Blank
- Only when quantity is greater than 1 (one)
|
|---|
| [31a &32] Other Fee(s) Line 1 & Total Fee - Total Location | Select one of the following:
- Default to Total each page separately; no grand total
- 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
|
|---|
| [34] Diagnosis Code List Qualifier | Select one of the following:
- For ICD-9. Print B in second space
- Blank
|
|---|
| [35] Remarks | Select one of the following:
- Blank
- Charge Narrative
- Medical Record Nbr and charge narrative
- Patient Control Number
- Patient Control Number and Charge Narrative
|
|---|
| [43] Replacement for prosthesis | Select one of the following:
|
|---|
| [49] Provider ID/NPI | Select one of the following:
- Blank
- Phys Billing ID
- Phys Billing NPI
|
|---|
| [50] License Number | Select one of the following:
|
|---|
| [51] SSN or TIN | Select one of the following:
|
|---|
| [52a] Addl Provider ID | Select one of the following:
- Blank
- Group ID Number
- Group Taxonomy
- Individual ID Number
- Phys Billing ID
|
|---|
| [53] Certification | Select one of the following:
- Blank
- Rendering Name
- Signature on File
- UCASE [Signature on File]
|
|---|
| [54] Provider ID/NPI | Select one of the following:
- Blank
- NPI number
- Provider ID number
|
|---|
| [55] License Number | Select one of the following:
- Blank
- License Number
- Payer Provider ID
|
|---|
| [56] Address | Select one of the following:
- Addr City St Zip of billing dentist
- Addr City St Zip of fac/loc where treatment performed if diff than of billing dentist; else Blank
- Addr City St Zip of facility/location where treatment was performed
- Blank
|
|---|
| [56a] Prov Specialty Code | Select one of the following:
|
|---|
| [57] Phone Nbr | Select one of the following:
- Blank
- Phone number of billing dentist
- Phone number of fac/loc where services performed if diff than billing dentist, else blank
- Phone number of facility/location where services performed
|
|---|
| [58] Addl Provider ID | Select one of the following:
- Blank
- Opt Claim Value 1
- Opt Claim Value 2
- Payer Provider ID
|
|---|
