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Guarantor/Program Billing Defaults - Paper UB-92 Section - Cal-PM

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Set default values for the Paper UB-92 billing file.

  1. In the Horizontal Offset (UB-92) 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 Additional Sort Based on Following myAvatar PM Treatment String Value(s) field, check Date of Service (Outpatient Only) to sort records by the date of service.

  3. In the Address Information To Print In Form Locator 1 field, select Provider Data From 'Facility Defaults' to retrieve provider address information from the Facility Defaults form; select Program Extended Dictionary to retrieve provider address information from the extended dictionary data elements associated with the Program data element. This information is from Form Locator 1 of the UB-92 paper bill. When a selection is not made, the information is retrieved from the Program Extended Dictionary.

  4. In the Display For Form Locator 3 field, select the display format for the client's account number.

  5. In the UB-92 Form Locator 4 (First Two Digits) field, select the value to be included in the bill type column of the UB-92 billing file.

  6. In the Display Logic For Form Locator 7 (Outpatient Only) field, select Blank to leave the form locator blank; select R&B Days to include number of Room and Board days in the form locator; select Total Units From Form Locator 46 to include total number of service units in the form locator.

  7. In the Information To Display For Form Locators 12, 13, 14, and 15 field, select the source for the information that will display in these form locators.

  8. In the Form Locator 42 - Number Of Digits For Revenue Code field, select the number of digits to allow for the revenue code.

  9. In the Form Locator 44 - Display HCPCS For The Following Revenue Code(s) field, select the ancillary revenue codes for inclusion of HCPCS information. This is a multiple selection data element.

  10. In the Form Locator 45 - Display Dates Of Service For The Following Revenue Code(s) field, select the ancillary revenue codes for inclusion of dates of service information. This is a multiple selection data element.

  11. In the Form Locator 47 - Charge Calculation field, select Use Service Fee Table to use the service charge from the Service Code Fee Table; select Use Client's Treatment Information to use the service charge from the Treatment History Table.

  12. In the Form Locator 51 (Provider No) field, enter the value for form locator 51 (Provider No).

  13. In the Leave Form Locator 83 (Other Phys. ID) Blank field, select Yes to leave the form locator blank; select No to include the practitioner in the bill.

  14. In the Display For Form Locator 84 field, select Blank to leave the form locator blank; select Guarantor Address Information to include this information in the form locator.

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