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Number
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Field description
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Location of the preprinted logo on the paper form, which must conform to the following requirements:
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No closer than 0.5 inches (1.27 cm) to the left and top edge of the form.
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No further than 4.8 inches (12 cm) from the left edge of the form.
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No further than 1.9 inches (4.8 cm) from the top edge of the form.
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Heading of the form.
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Agency address, city, state, ZIP Code, and phone and fax numbers, according to the MBA rules as defined at the insurance plan, insurance company, insurance code, branch, or business unit level.
If MBA rules are not defined, the agency address is shown as defined in Administration > Configuration > Business Units > Address.
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Insured's address, depending on the value entered in the Rel (Patient's Relationship to Insured Person) column in Patient > General > Payers > Pay Source > General:
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01 - Prints patient's address.
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Other values - Prints resource's address.
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Branch name, phone number and extension, and e-mail address, as defined in Administration > Configuration > Business Units > Branches.
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End date of the claim cycle (ageing date).
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Invoice number (claim ID).
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Patient's first, middle, and last name, as defined in Patient > General > Basic.
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Patient's code, as defined in Patient > General > Basic.
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Federal Tax ID, as defined in the Federal Tax ID field in the Legal Entities section in Administration > Configuration > Business Units > Teams and Legal Entities for the legal entity selected in the Legal Entity field in Administration > Financial > Insurance Codes > General.
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Service details for the appropriate claim. The data in the table is sorted by service date, then by service performed, and then by employee name. This section contains the following information:
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Service Date – Shows the following information, depending on the type of claim:
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For regular (fee-for-service) and benefit (physician service) claims – Date of the conducted service, as defined in the Schedule or Transactions module.
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For benefit (per diem and continuous care) claims – Start and end dates in the appropriate acuity level.
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For benefit (room and board) claims – Start and end date in the facility or at home.
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Employee Name – Shows the following information, depending on the type of claim:
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For regular (fee-for-service) claims, except supplies, and benefit (physician services) claims – Name of the resource that provided the service.
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For regular (fee-for-service) claims for supplies and benefit (per diem and continuous care) claims – Blank.
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For benefit (room and board) claims – Facility name, if it is defined in Patient > General > Payers or Patient > General > Admissions & Status; otherwise, this field is blank.
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Service Performed – Shows the following information, depending on the type of claim:
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For regular and benefit (physician service) claims – Service code description, as defined for staff, contractors, physicians, or supplies.
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For benefit (per diem and continuous care) claims – Acuity level description, as defined in Administration > General Patient Acuity Levels for the acuity selected in the Acuity field in Patient > General > Admissions & Status > Status.
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For benefit (room and board) claims – Room and board billing rate description, as defined in Administration > Financial > Billing Rates for the items selected in Patient > General > Payers.
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Hours – Shows the following information, depending on the type of claim:
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For regular (fee-for-service) claims, except supplies – Direct duration of the service as entered in the Schedule or Transactions component.
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For regular (fee-for-service) claims for supplies and benefit (room and board, per diem, and continuous care) claims – Blank.
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For benefit (physician service) claims – Hours spent on conducting the service.
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Units – Shows the following information, depending on the type of claim:
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For regular (fee-for-service) claims – Number of units for supplies or number of units for services with different basis.
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For benefit (per diem and continuous care) – Number of days spent at the appropriate acuity level.
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For benefit (room and board) – Number of days spent in the appropriate facility or at home.
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For benefit (physician service) – Units as set for the service.
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Rate – Actual net amount, as defined in Administration > Financial > Billing Rates.
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Amount – Amount to be paid for each service given in the table.
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Payments – Shows the total amount paid for the service. This field is used only for CSP payers.
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Balance Due – Sum of the amounts to be paid for the conducted services.
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Notes – Notes for the claim as entered in Claims > Process > Annotate Claims.
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Remittance section – Remittance information that is always printed at the bottom of the form and that contains the following information:
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Make checks payable to – This line prints on the claim if the Make checks payable to field is specified in Administration > Financial > Insurance Codes > Billing Rules.
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Payment Details section – Contains blank fields with labels for payment details.
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Right section of the remittance – Contains the following details:
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Patient Name – Patient's first, middle, and last names, as defined in Patient > General> Basic.
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Patient ID Number – Patient's code.
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Invoice Number – Claim ID.
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Invoice Total – Sum of the amounts to be paid for the conducted services.
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Amount Enclosed – Blank.
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To make a payment online, visit – This line prints on the claim if the To make a payment online, visit field is specified in Administration > Financial > Insurance Codes > Billing Rules.
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