| Assignment of Benefits | Select one of the following options:
- No
- Patient Refuses to assign
- Yes
|
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| Release of Information | Select one of the following options to identify the release of information status:
- Approp Rel on File at Svc Prov
- Inf Consent to Rel Med Info
- Limited Ability to Rel Data
- No, Provider Not Allowed
- On File at Payer or Plan Sponsor
- Yes, Signed Stmt Perm Rel
|
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| Notified by | Enter the name of the person who sent the notification. |
|---|
| Notification date | Enter or select the date of notification. |
|---|
| Verified by | Enter the name of the person who verified the insurance. |
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| Verification date | Enter or select the date the insurance was verified. |
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| Claim Level Authorizations | Do one of the following:
- In the Claim Level Authorization list (displays only active authorizations):
- Select the applicable claim-level authorization to link to the encounter.
- Clear the applicable claim-level authorization to remove from the encounter.
- Select open menu
 and select one of the following options:
- Open to access the Authorization Listing window and open, create, or delete a claim level authorization.
- Show all Authorizations to display a list of all active and inactive authorizations attached to the payer.
|
|---|
| Use remaining encounter authorizations | Select this check box to apply an existing claim-level authorization to an encounter. |
|---|
| Claim Level Referrals | Do one of the following:
- In the Claim Level Referral list (displays only active referrals):
- Select the claim-level referral that you want to link to the referral.
- Clear the claim-level referral that you want to remove from the referral.
- Select open menu and select one of the following options:
- Open to access the Referral Listing window and open, create, or delete a claim-level referral.
- Show all Refunds to display a list of all active and inactive authorizations attached to the payer.
|
|---|
| Use remaining encounter referrals | Select this check box to apply an existing claim-level referral to an encounter. |
|---|
| Line Level Authorizations | Do one of the following:
- Select the applicable line-level authorization to attach it to the encounter.
- Clear the applicable line-level authorization to remove it from the encounter.
- Select open menu to access the Authorization Code Tracking window and create or modify a line-level authorization.
|
|---|
| Line Level Referrals | Do one of the following:
- Select the applicable line-level referral to attach it to the line-level charge.
- Clear the applicable line-level authorization to remove it from the line-level charge.
- Select the open menu button to access the Referral Code Tracking window and create or modify a line-level referral.
|
|---|
| PRO Procedure | Select one of the following options:
- (look up in book)
- Extraction of lens
- Extraction of lens - 30
- Extraction of lens - 40
- Removal of lens material
- Removal of lens material - 50
- Remove cataract - 84, insert lens
|
|---|
| PRO State | Enter or select the PRO state. |
|---|
| PRO Date | Enter or select the PRO date. |
|---|
| Certificate of Medical Necessity | Do one of the following:
- Select the applicable certificate of medical necessity.
- Select
 to access the Certificates of Medical Necessity Information window.
|
|---|
| Property/Casualty Number | Enter the property or casualty number. |
|---|
| Date Appliance Placed | This field appears only when the primary payer on the encounter is a dental payer. Enter the date the patient had a dental appliance placed. The date prints on paper ADA claims and is included on electronic 837D claims.
Note: The Dental payer check box must be enabled in File Maintenance on the Payer Information window Defaults-2 tab.
|
|---|
| Date Appliance Removed | This field appears only when the primary payer on the encounter is a dental payer. Enter the date the patient had a dental appliance removed. The date is not included on paper ADA or electronic 837D claims.
Note: The Dental payer check box must be enabled in File Maintenance on the Payer Information window Defaults-2 tab.
|
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