Sample Printed Outputs
Use the link below to download a zip file that contains all sample outputs.
Details
Click for zip file with Sample Claim Outputs.
Current Output Types
- CMS 1500
- CMS 1500 without formatting
- Custom Printout 1
- Custom Printout 2
- Custom Printout 3
- Custom Printout 3 - Break By Facility
- Custom Printout 4 - Colorado DSS
- Custom Printout 5 - Monthly Excess Cost Billing
- Custom Printout 6 - Colorado Tuition Bill (FTE)
- Custom Printout 7 - NAFI
- General Format
- UB04 without formatting
- UB04 without formatting - one line per claim