| [FL 50-53] Blank if Medicare Primary | 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). |
| [FL54] Prior Payment | One of the following options displays prior payment:
- Blank
- Blank if Medicare is Prim
- Prior Payer Payments
|
| [FL55] Estimated Amount Due | One of the following options displays estimated amount that is due:
- 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
|
| [FL64] Document Control Number | One of the following options displays document control number:
- Default – No selection
- Blank – Use to remove a selection or no selection.
- Resub Ref - 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– 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.
|
