| About Field Prefixes | Fields can have a prefix of UCase, LTrim, RTrim, or Trim. All fields with a prefix of:
- UCase - display in upper case
- LTrim - all leading spaces are removed
- RTrim - all trailing spaces are removed
- Trim - all leading and trailing spaces are removed
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| Do not print payer address on CMS | Select this option to prevent the payer address from printing on the CMS form. |
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| Payer Name at top of form | Select one of the following Payer Name format options:
- Blank
- Payer Alias
- Payer Alias - Upper Case
- Payer Name
- Payer Name - Upper Case
- Use Contents of Box 19
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| Print payer address in old location | Select this option to print the address in the upper-right corner of the form. |
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| Print page numbers on multiple page claims | Select this option to print the page numbers in the format of Page XX of YY at the top of multiple page claims. Page numbers do not print on single page claims. |
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| [1] Insured's program | Select one of the following options:
- Blank
- Use Legacy Standards
- Current Program with X
- Current Program with P
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| [1a] Insured's ID number | Select 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
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| [10bc] Force 10b & 10c to No | Select this option for Worker's Comp claims to force box 10b and 10c to be set to No. Only box 10a Employment will be checked. |
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| [10d] Reserved for Local Use | Select one of the following options:
- Blank
- Other Payer's Provider Individual number
- Other Payer's Provider Individual number if other payer is Medicare
- "MDC" + 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
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| [11a] Date format for insured's date of birth | Select one of the following date format options:
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| [11a] Display insured's sex | Select this option to display the insured's sex in box 11a. |
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| [15] Date format for patient same illness | Select one of the following date format options:
- Blank
- MMDDYY
- MMDDYYYY
- N/A
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| [17] Name of referring physician or other source | Select 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
- Referring name, else 'None'
- Self Referral if no referring doctor
- 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 Middle Initial)
- UCase(Last First Middle Initial) State
- UCase(Last First)
- UCase(Last First) State
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| [17a] ID number of referring physician | Select one of the following options:
- Referring Phys Taxonomy Code
- Blank
- Georgia Better Health Nbr
- Physician State License Nbr
- Prior Authorization Nbr
- Referral Number
- Referring Physician ID Nbr
- Referring UPIN, else 'None'
- Use Legacy Standards
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| [17b] NPI | Select one of the following options:
- Blank
- Referring Provider's NPI
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| [19] Display qualifier | Select this option to print the qualifier before the data with no spaces between the qualifier and the data. |
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| [19] Reserved Local Use | Select 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
- EPSDT Referral Condition Codes, else Narrative
- Legacy Option
- Narrative only
- NDC code, else Narrative
- If you enable this claim print option and the NDC information is in the SIM Library, then the National Drug Code prints only in Box 19 of the 1500 claim form followed by the line it is referencing. For example, 00169706101 Line 2. However, if you enable this option and the NDC information is not in the SIM Library, then any existing charge narrative prints in Box 19. For complete information about enabling NDC for electronic and paper claims, see NDC Coding in the Claims User Guide for NextGen® Enterprise PM.
- Prior Deductible
- Prior Deductible and Narrative
- Referral Number
- Referring UPIN and Date Last Seen, else Narrative
- Supervisor ID and NPI (prints with one space between the numbers)
- 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, the narrative is the default value.
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| [19] Use two lines for text | Select this option to force the application to use two lines for text in box 19. |
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| [21] Diagnosis or nature of illness or injury | Select one of the following options:
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| [22] Medicaid resubmission code | Select 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)
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| [22] Original ref. no. | Select 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
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| [23] Authorization number | Select 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)
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| [24] Display supplemental data qualifier | Select this option to print the qualifier. If this option is checked, but there is no supplemental information to print on the claim, the qualifier does not print. The default value is checked. |
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| [24] Supplemental charge-related data to display above line | Select one of the following options:
- Anesthesia Begin/End (7)
- Anesthesia Begin/End/Time (7)
- Blank
- Charge Narrative (ZZ)
- NDC desc/basis of measure/drug units(N4)
- NDC desc/basis of measure/drug units(N4), else Anesthesia begin/end(7), else Narrative(ZZ)
- NDC desc/basis of measure/drug units(N4), else Anesthesia begin/end/time(7), else Narrative(ZZ)
- Service Item Description (ZZ)
The supplemental description information prints in the shaded area above the charge line. The qualifier in parentheses prints in front of the information without any spaces between the qualifier and the information. |
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| [24a] Date format for dates of service | Select one of the following formats:
- MM DD YY
- MM DD YYYY
- MMDDYY
- MMDDYYYY
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| [24a] Force 2 digit year on output to file | Select this option to format the year as two digits when printing to a file. |
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| [24c] EMG Indicator | Select one of the following options for the Emergency Indicator:
- Actual Value (Y/N)
- Blank
- 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.
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| [24d] Modifier Options for Box 24d | Select 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 print on the claim.
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| [24e] Diagnosis code | Select one of the following options:
- All Pointers (each line item contains pointers (1-4) to all the primary diagnoses selected in the encounter)
- All Pointers without commas
- Blank
- Diag Code (listed for each line item)
- Diag Code without decimals
- Frmttd Code (nnn/nnn.n/nnn.nn) (each line item shows the diagnosis formatted as a 3 digit code without decimals or a 4 or 5 digit code with decimals)
- Primary Pointer (each line item contains a pointer (1-4) to the primary diagnosis in box 21)
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| [24f] Suppress commas in amount | Select this option to suppress the commas in the amount in box 24f. It also suppresses the commas in box 28. Box 28 is the sum of box 24f charges. |
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| [24g] Display days/units | Select one of the following options to display the number of anesthesia days or units in Box 24g:
- Anes Min if Anes SIM else Quantity (Units)
- Anes Time (HMM) if Anes SIM else Quantity (Units) – For example, 30 minutes would be 030, 60 minutes would be 100, and 75 minutes would be 115.
- 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)
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| [24h top] EPSDT | Select one of the following options:
- Blank
- EPSDT Code
- Legacy Option
Note: If you want a Y or N to print in box 24h, you must set this up on the Claims tab on the Encounter Maintenance window. In the EPSDT Encounter Code - Paper field, select Other. A text box displays to the right of this field. Enter Y or N in this box.
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| [24h bottom] Family Planning | Select one of the following options:
- Blank
- Family Planning Code
- Legacy Option
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| [24i] ID qualifier | Select this option to print the two-character qualifier that identifies the rendering provider in box 24j. If the rendering provider ID # in box 24j is blank, the qualifier is also blank. The qualifier is populated from the payer master file. |
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| [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. | Select this option to do the following: If the Prov ID option is selected in box 24j TOP, 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 TOP] Rendering Provider ID | Select one of the following information options:
- Allow or Deduct Amt $$.==/$$== (excluding DME)
- Allowed Amt Only (excluding DME)
- Blank
- Group Number
- Group Number (excluding DME)
- 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)
- Prov 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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| [24j Bottom] Rendering NPI | Select one of the following options:
- Blank
- Rendering NPI
- Rendering NPI if provider belongs to a group, else blank
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| [25] Federal tax ID number | Select one of the following options:
- Blank
- Prov ID
- Tax ID
- UCase(Tax ID)
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| [25] Federal tax ID number type | Select one of the following options:
- Blank
- EIN
- Read from claim (standard)
- SSN
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| [27] Accept Assignment/Worker's Comp | Select one of the following options to indicate how to select the Accept Assignment box (Box 27):
- Blank – select nothing
- No – select No
- Use Legacy Options – use previous settings
- Yes – select Yes
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| [29] Amount Paid - Include adjustments for payers? | Select this option to display adjustments for payers on the CMS 1500 claim. |
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| [29] Amount Paid - Include refunds for payers? | Select this option to include refunds in payer amount. |
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| [29] Amount Paid - When zero dollar amount, display: | Select one of the following options:
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| [29] Amount Paid - Format | Select one of the following options:
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| [30] Balance Due - When zero dollar amount, display: | Select one of the following options:
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| [30] Balance Due - Format | Select one of the following options:
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| [30] Balance Due - Include Adjustments | Select 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 |
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| [30] Balance Due - Include Refunds | Select one of the following options:
- <None>
- Ignore Refunds
- Include Refunds for All Payers
- Use Box 29 setting
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| [29 & 30] Amount Paid & Balance Due - Total Location | Select one of the following options to indicate where to print the total amount paid for multi-page claims:
- 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
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| [31-1] Signature of physician or supplier | This claim printing option must have an option selected from the drop-down list. The option that is selected prints on the CMS 1500 box 31. The options available include:
- ‘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)
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| [31-2] Signature of physician or supplier | This claim printing option must have an option selected from the drop-down list. The option that is selected prints on the CMS 1500 box 31. The options available include:
- ‘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)
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| [31-3] Signature of physician or supplier | This claim printing option must have an option selected from the drop-down list. The option that is selected prints on the CMS 1500 box 31. The options available include:
- ‘Agreement on File’
- 'COMPUTER-GENERATED MM/DD/YY'
- ‘signature on file’
- ‘SIGNATURE ON FILE’ (upper case)
- Blank
- Current Date (mm/dd/yy - right justified}
- 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)
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| [32] COB1 Recent Paid Date or Batch Nbr below box | Select one of the following options:
- Batch Nbr
- Blank
- Recent Date
- Recent Date & Batch Nbr
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| [32] Convert values to upper case | Select this option to force all values in box 32, lines 1-4, to appear in upper case on the CMS1500 claim. |
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| [32-1] Name/Addr where services rendered | Select one of the following options:
- '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
- 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
- Name of facility/location
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| [32-2] Name/Addr where services rendered | Select 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
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| [32-3] Name/Addr where services rendered | Select 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
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| [32-a] NPI | Select 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
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| [32-b] Facility ID | Select 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
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| [32-b & 33-b] Add space between qualifier and data | Select this option to add a space between the qualifier and the data for boxes 32-b and 33-b. |
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| [33] Display group phone # | Select this option to print the group phone number of the billing provider in the top right corner of box 33. |
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| [33-1] Physician's/Supplier's information | Select 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
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| [33-2] Physician's/Supplier's information | Select 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
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| [33-3] Physician's/Supplier's information | Select 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
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| [33-4] Physician's/Supplier's information | Select 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
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| [33-a] Display NPI | Select one of the following options:
- Blank
- NPI (group NPI if group billing, else provider individual NPI if billing as an individual)
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| [33-b Enable group logic] If Group # or Prov ID is selected in Box 33-b BELOW, display Group # only if the provider belongs to a group (Group # selected) or Prov ID 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. | Select this option to activate the following logic: If Group # or Prov ID is selected in box 33 b BELOW, display Group # only if the provider belongs to a group (Group # selected) or Prov ID 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. |
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| [33-b] Physician's/Supplier's information | Select 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
- State License Nbr
- UCase(Group #)
- Trim(Group #)
- UCase(Trim(Group #)
- Prov ID
- Trim(Prov ID)
- UCase(Trim(Prov ID)
- Prov ID & Prov Tax ID
- Prov ID & Group #
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