Intellect™
SAMPLE BILLING INSURANCE FORMS
Click on the alphabetized report titles below, OR scroll through the report samples (in the order shown on the <Form Type> drop-down list).
HCFA Colorado: Sample not available.
INGENIX MESSAGE: Sample not available. When this option is selected, the same information is gathered as for billing reports, only it is saved in a special format, like HL7. The file name begins with IMF, and is saved under ut_path/ingenix.
UB04: Laser-generated form if Utility/Insurance <Form Type> = C or V
UB04 RED: Prints a laser-generated Red form if Utility/Insurance <Form Type> = B or U
UB04 SUMMARY: Laser-generated form
CHDP6: Set Utility/Insurance <Form Type> = 6
CHDP7: Set Utility/Insurance <Form Type> = 7
INGENIX MESSAGE: Sample not available. When this option is selected, the same information is gathered as for billing reports, only it is saved in a special format, like HL7. The file name begins with IMF, and is saved under ut_path/ingenix.
HCFA Colorado: Sample not available.
HCFA Illinois - Claim Form (Form F)
HCFA Illinois Crossover (Secondary Claim)
Second Bill Review - Provider's Request for Second Bill Review
Note: Where 
displays in the following sample, solid light gray displays on the printed copy.
NEW HCFA RED - HCFA 1500(02-12) RED FORM - For use starting January 2014
Note: Where displays in the following sample, solid light gray displays on the printed copy.
NEW HCFA TRACER RED - Prints on a HCFA 1500 (02-12) Tracer Red Form
RURAL UB04 - Effective version 13.12.12
This claim form is similar to UB04 SUMMARY, and generates when the Utility --►Insurance --►Insurance <Form Type> = C and 8. The RURAL UB04 form type differs from the UB04 Summary as follows:
Box 18 always prints "80"
Boxes 42 through 47 print 2 lines for EACH charge
Box 43 prints the Utility --►Insurance --►Insurance <Rural Procedure Description>
Box 44 prints the Utility --►Procedure --►Procedure <Code O> on the top line and <Code C> on the bottom line
Box 50 only prints for the billed insurance when billing the Secondary or Tertiary insurance
Boxes 58 through Box 62 are Blank
DISPUTE RESOLUTION REQUEST - Effective version 16.02.22
Before a dispute resolution form may be requested:
• Each provider for whom a dispute resolution form is generated must have his/her own PDR code set up in <Message Code> on the Utility --►Messages --►Message screen.
• The appropriate PDR code must be added in the Message column on either the Payment --►Open Item screen or the Ledger --►Open Item screen for the charge/payment in dispute.
See <Form Type> Billing --►Insurance --►Batch of Patients for additional information for this form.
