| [FL54] Prior Payment | Select one of the following options:
- Blank
- Prior Payer Payments
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| [FL55] Estimated Amount Due | Select one of the following options:
- Blank
- Charge Amt minus Box 54
- Medicare Primary: Charge Amt minus Box 54 minus Box 39 if value codes are A1 or A2.
- Non-Medicare Primary: Charge Amt minus Box 54 minus Box 39 if value codes are B1, B2, C1, or C2.
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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) - When this is selected, 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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