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Guarantor/Program Billing Defaults - Paper CMS-1500 Section - Cal-PM

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Set the default Paper HCFA billing file values.

  1. In the Horizontal Offset (HCFA-1500) field, type the positive or negative number value for shifting the printed form right or left. Example: A positive one (1) shifts the print to the right one character space. A negative one (-1) shifts the print to the left.

  2. In the Print Address On Top Of Form field, select Yes to print the provider address on the top of the form; select No to leave this form locator blank. The provider address defaults from the Facility Defaults form.

  3. In the Date Of Illness, Injury, Or Pregnancy Code Qualifier (Form Locator 14) field, select the qualifier that will appear in Form Locator 14. 

    • Onset of Current Symptoms or Illness - the first date of service from the claim will appear

    • Last Menstrual Period - the bill will use the value in the field Date Of Last Menstrual Period (2300-DTP-03) on the HCFA-1500/837P Maintenance Screen for the client

  4. In the Date Format field, select Two Digit Year to print the date as MM DD YY; select Four Digit Year to print the date as MMDDYYYY. This date format is used wherever a date is printed on the form.

  5. In the Form Locator 10-D field, enter the value for form locator 10-D (Reserved for Local Use).

  6. In the Form Locator 11-C field, enter the value for form locator 11-C (Insurance Plan Name or Program Name).

  7. In the Form Locator 19 field, enter the value for form locator 19 (Reserved for Local Use). This is individually overridden by the value entered in the Form Locator 19 field of the HCFA 1500 Maintenance Screen for clients where this form is filed.

  8. In the Print Diagnosis on 21-1 Only field, select Yes to include only the principle diagnosis on the bill; select No to include up to three additional diagnoses in form locator 21.

  9. In the Include Spaces In Form Locator 24-A (Two Digit Years Only) field, select whether or not to add spaces (for alignment purposes) to the date field in Form Locator 24-A of a Paper HCFA-1500 paper bill, if the bill uses two-digit years.

  10. In the Form Locator 24-B field, type the override value (location code) to include in form locator 24B (Place of Service).

  11. In the Form Locator 24-C field, type the override value (service code) to include in form locator 24C (Type of Service).

  12. In the Form Locator 24-C (EMG) (HCFA-1500-NPI Version Only) field, type the override value for form locator 24-C (EMG).

  13. In the Form Locator 24-H field, enter the value for form locator 24H (EPSDT Family Plan).

  14. In the Form Locator 24-I field, enter the value for form locator 24I (EMG).

  15. In the Form Locator 24-J field, enter the value for form locator 24J (COB).

  16. In the Form Locator 27 (Accept Assignment) field, select Yes to place a Yes in the accept assignment form locator 27; select No to place a No in the accept assignment form locator 27.

  17. In the Form Locator 31 For Non Sorted HCFA-1500 field, enter the value for form locator 31 (Signature of Physician or Supplier).

  18. In the Print Supervising Practitioner in Form Locator 31 For Sorted HCFA-1500-NPI Version Only field, select Yes to list the supervisor in form locator 31.

  19. In the Practitioner Information To Print In Form Locator 31 For Sorted HCFA-1500 field, select whether to populate form locator 13 with a practitioner's category or discipline.

  20. In the Facility Name To Print In Form Locator 32 field, select Provider Name from 'Facility Defaults' to place the Facility Name in form locator 32 for sorted HFCA-1500 from the Facility Defaults form; select Program Name to use the program information based on the program that the service was posted under.

  21. In the Form Locator 32-A (NPI #) (HCFA-1500-NPI Version Only) field, type the override value for Form Locator 32-A (NPI #).

  22. In the Form Locator 32-B (Other ID Qualifier) (HCFA-1500-NPI Version Only) field, select the override value for form locator 32-B (Other ID).

  23. In the Form Locator 32-B (Other ID #) (HCFA-1500-NPI Version Only) field, type the override Form Locator.

  24. In the Address Information To Print In Form Locator 33 field, select Provider Data from 'Facility Defaults' to place the address information in form locator 33 for sorted HFCA-1500 from the Facility Defaults form; select Program Extended Dictionary to use the program information based on the program that the service was posted under.

  25. In the Form Locator 33 (PIN #) field, enter the value for form locator 33 (Physician's Supplier's PIN#).

  26. In the Form Locator 33 (GRP #) field, enter the value for form locator 33 (Physician's Supplier's GRP #).

  27. In the Form Locator 33-A (NPI #) (HCFA-1500-NPI Version Only) field, type the override value for form locator 33-A (NPI#).

  28. In the Override Form Locator 33-A (NPI #) (HCFA-1500-NPI Version Only) field, select Yes to override the default value for form locator 33-A (NPI #).

  29. In the Form Locator 33-B (Other ID Qualifier) (HCFA-1500-NPI Version Only) field, select the override value for form locator 33-B (Other ID Qualifier).

  30. In the Form Locator 33-B (Other ID #) (HCFA-1500-NPI Version Only) field, select the override value for form locator 33-B (Other ID #).

  31. In the Override Form Locator 33-B (Other ID Qualifier And #) (HCFA-1500-NPI Version Only) field, select Yes to override the default value for form locator 33-B (Other ID Qualifier And #).

  32. In the Exclude Punctuation From Claim field, select whether or not to omit punctuation from the bill.

  33. In the Display Prior Payment(s) For Other Guarantor(s) field, select Yes to include the prior payments from other guarantors in the bill; select No to exclude prior payments from other guarantors in the bill.

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