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Guarantor/Program Billing Defaults - Paper UB-04 Section - Cal-PM

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Set the Paper UB-04 billing file default values.

  1. In the Horizontal Offset field, type a positive or negative 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 Address Information To Print In Form Locator 1 field, select Provider Data From 'Facility Defaults' to use the information from the Facility Defaults form. Select Program Extended Dictionary to use the address information based on the program the service was posted under.

  3. In the Form Locator 2 Pay-To Provider Name field, type the override value for form locator 2 (Pay To Provider Name).

  4. In the Form Locator 2 Pay-To Street Address field, type the override value for form locator 2 (Pay-To Street Address).

  5. In the Form Locator 2 Pay-To ZIP Code field, type the override value to include in form locator 2 (Pay-To ZIP Code).

  6. In the Form Locator 2 Pay-To City field, type the override value to include in form locator 2 (Pay-To City).

  7. In the Form Locator 2 Pay-To State field, select the override value to include in form locator 2 (Pay-To State).

  8. In the Display For Form Locator 3 (Patient Account No.) field, select the display format for the client's account number.

  9. In the Form Locator 4 (First Three Digits) field, select the override value to display in the first three digits of form locator 4.

  10. In the Information To Display For Form Locators 8b, 9, 10, And 11 field:

  • Select Client's Demographic Data to use the Client's information in these form locators.
  • Select Subscriber's Demographic Data in Financial Eligibility to use the subscriber's information in these form locators.

  1. In the Display For Form Locator 38 field, choose whether to display the Subscriber or Guarantor information in form locator 38.

  2. In the Form Locator 42 - Number Of Digits For Revenue Code field, select the number of digits for the revenue code in form locator 42.

  3. In the Form Locator 44 - Display HCPCS For The Following Revenue Code(s) field, select the ancillary revenue codes for inclusion of HCPCS information.

  4. In the Form Locator 45 - Display Dates Of Service For The Following Revenue Code(s) field, select the ancillary revenue codes for inclusion in dates of service information.

  5. In the Form Locator 47 - Charge Calculation field, select how charges are calculated in form locator 47.

  6. In the Form Locator 51 (Health Plan ID) field, type the override value for form locator 51 (Health Plan ID).

  7. In the Form Locator 56 (National Provider Identifier) field, type the override value for form locator 56 (National Provider Identifier).

  8. In the Form Locator 57 (Other Billing Provider ID) field, type the override value for form locator 57 (Other Billing Provider Number).

  9. In the Form Locator 66 (ICD Version Indicator) field, designate the ICD version number.

  10. In the Exclude Punctuation From Claim - Form Locators 67-70, 72 And 74 field, select Yes to exclude punctuation in these form locators; select No to disable this function.

  11. In the Select Type Of Information To Include In Form Locator 78 field, choose whether to include the Referring Practitioner or the Referring Provider in form locator 78, or if it should be left blank.

  12. In the Display For Form Locator 80 field, select the information to display in form locator 80.

  13. In the Form Locator 81-A-1 field, select the override value for form locator 81-A-1.

  14. In the Form Locator 81-A-2 field, type the override value for form locator 81-A-2.

  15. In the Form Locator 81-A-3 field, enter the override value to use in form locator 81-A-3.

  16. In the 'Additional Sort Based on...' field, select Date of Service (Outpatient Only) to sort records by the date of service.

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