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Intellect™
BILLING MENU OPTIONS
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Quick Resources
CMS 1500 Box Definitions
and
Insurance
Paper Claim Resources
CMS 1500 Box Definitions
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Worker
Sample Workers Comp Forms
CMS 1500 Box Definitions
This document is a detailed reference guide for accurately completing the CMS 1500 Claim Form (02-12), which was effective January 1, 2014. The review of each box notes the exact Intellect location of the printed information and when applicable, the billing method, insurance type, or category type criteria. (The electronic claims submission equivalent is also noted for reference purposes.)
The following <Form Type> selections use the CMS 1500 (02-12) form: NEW HCFA, NEW HCFA RED, NEW HCFA TRACER, and NEW HCFA TRACER RED.
The Charges --► Modify screen may be used to view the Encounter (EN#), Facility code (POS), CPT or HCPCS (Code), Modifier (Mod), Referring code (Rdr.), responsible party (Who) and, on the [Information] panel, Days/Units, Category code, Billing Provider code, Panel Code, and Insurance Company Code (for primary, secondary and tertiary) linked to each charge line at the time of posting on Charges --► Charge screen. NOTE: Some of the fields on the Charges --► Modify screen allow for modification, if needed for printing corrected claims.
1. Based on the Insurance (e.g., primary, secondary, or tertiary) linked to the charge(s) that you have selected to bill AND the Registration --► Regular --► Patient Insurance or Registration --► Worker --► Worker Insurance screen, the following prints in the top right corner:
1.1 When Utility --► Insurance --► Insurance <Print Name on Claim> is set to ‘Y’ or ‘X,’ the Utility --► Insurance --► Insurance <Name>, <Address>, <City>, <State>, <Zip> prints.
1.2 The Adjuster Name is available to print when all three requirements are met:
1.2.1 Utility --► Insurance --► Insurance <Print Name on Claim> is set to ‘X.’
1.2.2 The <Adjuster> field is completed on Registration --► Worker --► Worker Insurance or Registration --► Regular --► Patient Insurance screen.
1.2.3 The patient's <Category> on the Registration --► Worker --► Worker or Registration --► Regular --► Patient screen is set to 'W' or 'F' on the Utility --► Category <Type> field.
1.3 NOTE: The Adjuster Name data element is available in the programming file but has not been added to the form. Therefore, if your office wants to have the Adjuster Name printed on the Workers’ Comp paper claims, you should call Prime Clinical Systems (PCS) support and request it be added.
1.4 Professional 837 Electronic Claims Submission Equivalent: Loop 2010BB NM103, N301, N401, N402, N402
2. Box 1 MEDICARE, MEDICAID, TRICARE, CHAMPVA, GROUP HEALTH PLAN, FECA BLK LUNG, OTHER
2.1 Intellect prints ‘X’ in the appropriate box according to the type of insurance entered in the Utility --► Insurance --► Insurance <Insurance Type> field for the billed insurance. Valid field entries are:
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2.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2000B SBR09
3. Box 1a INSURED’S I.D. NUMBER
3.1 Intellect prints the insurance I.D. from the Registration --► Regular --► Patient Insurance screen <Subscriber No.> (or Registration --► Worker --► Worker Insurance <BOX 1A/CLAIM#>) field of the billed insurance.
3.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2010BA NM109
4. Box 2 PATIENT’S NAME (Last Name, First Name, Middle Initial)
4.1 Intellect prints the patient name from the Registration --► Regular --► Patient (or Registration --► Worker --► Worker) <Last Name>, <First Name>, <Middle Initial> fields separated by commas. NOTE: A hyphen can be used for hyphenated names, but periods are not allowed.
4.2 Effective version 14.04.15: When a patient does not have a middle name, Intellect removes the comma after the first name.
4.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2010CA NM103, NM104, NM105
5. Box 3 PATIENT’S BIRTHDATE | SEX
5.1 PATIENT’S BIRTHDATE
5.1.1 Intellect prints the birth date of the patient from the Registration --► Regular --► Patient (or Registration --► Worker --► Worker) <DOB> field and formats as MMDDYYYY.
5.1.2 Effective version 23.10.04: When Utility --► Insurance --► Insurance <Insurance Type> = ‘D’ (for Medicaid/Medi-Cal), Intellect prints a 6-digit date formatted as MMDDYY on NEW HCFA RED.
5.1.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2010CA DMG02
5.2 SEX
5.2.1 Intellect prints ‘X’ in the M or F box based on Registration --► Regular --► Patient (or Registration --► Worker --► Worker) <Gender> field.
5.2.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2010CA DMG03
6. Box 4 INSURED’S NAME (Last Name, First Name, Middle Initial)
6.1 The insured’s name prints based on one of the following criteria for the billed insurance:
6.1.1 If Registration --► Regular --► Patient Insurance <Related To Insured> is NOT ‘18’ (for self) or ‘20’ (for employee), then Intellect prints the Registration --► Regular --► Patient Insurance <Last Name>, <Insured First Name>, <Middle Initial> fields separated by commas.
6.1.2 If Registration --► Regular --► Patient Insurance <Related To Insured> = ‘18’ (for self), then Intellect leaves insured’s name blank since the insured is the same as the patient. Prior to version 14.07.01 Intellect printed ‘SAME’.
6.1.3 If the patient’s category is Workers’ Comp (Utility --► Category <Type> = ‘W’ or ‘F’), then Intellect prints Utility --► Business <Employer Name> for the Registration --► Worker --► Worker Insurance <Employer> field.
6.2 Effective version 14.04.15: When an insured does not have a middle name, Intellect removes the comma after the first name.
6.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2010BA NM103, NM104, NM105
7. Box 5 PATIENT’S ADDRESS | CITY | STATE | ZIP CODE |TELEPHONE
7.1 PATIENT’S ADDRESS (No., Street)
7.1.1 Intellect prints Registration --► Regular --► Patient (or Registration --► Worker --► Worker) <Address> field.
7.1.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2010CA N301
7.2 CITY
7.2.1 Intellect prints Registration --► Regular --► Patient (or Registration --► Worker --► Worker) <City> field.
7.2.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2010CA N401
7.3 STATE
7.3.1 Intellect prints Registration --► Regular --► Patient (or Registration --► Worker --► Worker) <State> field.
7.3.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2010CA N402
7.4 ZIP CODE
7.4.1 Intellect prints Registration --► Regular --► Patient (or Registration --► Worker --► Worker) <Zip Code> field.
7.4.2 837 Electronic Claims Submission Equivalent: Loop 2010CA N403
7.5 TELEPHONE (Include Area Code)
7.5.1 Intellect prints Registration --► Regular --► Patient (or Registration --► Worker --► Worker) <Home Phone No> field.
7.5.2 Professional 837 Electronic Claims Submission Equivalent: Not applicable
8. Box 6 PATIENT RELATIONSHIP TO INSURED
8.1 Intellect prints ‘X’ in the appropriate box based on the information entered on the Registration --► Regular --► Patient Insurance screen <Relation to Insured> field of the billed insurance. Valid field entries are:
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8.1.1 If ‘18’ is selected, then ‘X’ prints in the Self box.
8.1.2 If ‘1’ is selected, then ‘X’ prints in the Spouse box.
8.1.3 If ‘19’ is selected, then ‘X’ prints in the Child box.
8.1.4 For a selection other than 18, 1, or 19, the ‘X’ prints in the Other box. NOTE: The Other box is also checked for patients registered under Registration --► Worker --► Worker.
8.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2000B SBR02, Loop 2000C PAT01
9. Box 7 INSURED’S ADDRESS | CITY | STATE | ZIP CODE | TELEPHONE
The following information is based on the billed insurance.
9.1 INSURED’S ADDRESS
9.1.1 If Registration --► Regular --► Patient Insurance <Relation To Insured> is NOT 18 (for self) or 20 (for employee), then Intellect prints the Registration --► Regular --► Patient Insurance <Address> field.
9.1.2 If Registration --► Regular --► Patient Insurance <Related To Insured> = ‘18’ (for self), then Intellect leaves the insured’s address blank since the insured is the same as the patient. Prior to version 14.07.01, Intellect printed ‘SAME.’
9.1.3 If the patient’s category is Workers’ Comp (Utility --► Category <Type> = ‘W’ or ‘F’), then Intellect prints Registration --► Worker --► Worker Insurance <Address> for the employer.
9.2 CITY
9.2.1 If Registration --► Regular --► Patient Insurance <Relation To Insured> is NOT 18 or 20, then Intellect prints the Registration --► Regular --► Patient Insurance <City> field.
9.2.2 If Registration --► Regular --► Patient Insurance <Related To Insured> = ‘18’ (for self), then Intellect leaves the insured’s city blank since the insured is the same as the patient. Prior to version 14.07.01, Intellect printed ‘SAME’.
9.2.3 If the patient’s category is Workers’ Comp (Utility --► Category <Type> = ‘W’ or ‘F’), then Intellect prints Registration --► Worker --► Worker Insurance <City> for the employer.
9.3 STATE
9.3.1 If Registration --► Regular --► Patient Insurance <Relation To Insured> is NOT 18 or 20, then Intellect prints the Registration --► Regular --► Patient Insurance <State> field.
9.3.2 If Registration --► Regular --► Patient Insurance <Related To Insured> = ‘18’ (for self), then Intellect leaves the insured’s state blank since the insured is the same as the patient. Prior to version 14.07.01, Intellect printed ‘SAME’.
9.3.3 If the patient’s category is Workers’ Comp (Utility --► Category <Type> = ‘W’ or ‘F’), then Intellect prints Registration --► Worker --► Worker Insurance <State> for the employer.
9.4 ZIP CODE
9.4.1 If Registration --► Regular --► Patient Insurance <Relation To Insured> is NOT 18 or 20, then Intellect prints the Registration --► Regular --► Patient Insurance <Zip Code> field.
9.4.2 If Registration --► Regular --► Patient Insurance <Related To Insured> = ‘18’ (for self), then Intellect leaves the insured’s zip code blank since the insured is the same as the patient. Prior to version 14.07.01, Intellect printed ‘SAME.'
9.4.3 If the patient’s category is Workers’ Comp (Utility --► Category <Type> = ‘W’ or ‘F’), then Intellect prints Registration --► Worker --► Worker Insurance <Zip Code> for the employer.
9.5 TELEPHONE
9.5.1 If Registration --► Regular --► Patient Insurance <Relation To Insured> is NOT 18 or 20, then Intellect prints the Registration --► Regular --► Patient Insurance <Home Phone No> field.
9.5.2 If Registration --► Regular --► Patient Insurance <Related To Insured> = ‘18’ (for self), then Intellect leaves the insured’s telephone blank since the insured is the same as the patient.
9.5.3 If the patient’s category is Workers’ Comp (Utility --► Category <Type> = ‘W’ or ‘F’), then Intellect leaves this blank.
9.6 Professional 837 Electronic Claims Submission Equivalent: Loop 2010BA N301, N401, N402, N403
10. Box 8 RESERVED FOR NUCC USE: Left blank.
11. Box 9 OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
11.1 When billing the primary insurance, Intellect prints one of the following based on the patient’s secondary insurance (if applicable):
11.1.1 If Registration --► Regular --► Patient Insurance <Related To Insured> is NOT ‘18’ (for self) or ‘20’ (for employee), then Intellect prints the Registration --► Regular --► Patient Insurance <Last Name>, <Insured First Name>, <Middle Initial> fields separated by commas.
11.1.2 If Registration --► Regular --► Patient Insurance <Related To Insured> = ‘18’ (for self), then Intellect leaves the other insured’s name blank since the insured is the same as the patient. Prior to version 14.07.01, Intellect printed ‘SAME’.
11.2 When billing the secondary or tertiary insurance, Intellect prints Registration --► Regular --► Patient Insurance <Last Name>, <Insured First Name>, <Middle Initial> for patient’s primary insurance if Registration --► Regular --► Patient Insurance <Related To Insured> is NOT ‘18’ (for self) or ‘20’ (for employee).
11.3 If the patient’s category is Workers’ Comp (Utility --► Category <Type> = ‘W’ or ‘F’), then Intellect leaves this blank.
11.4 Effective version 14.04.15: When there is no insured’s name, the commas are removed.
11.5 Professional 837 Electronic Claims Submission Equivalent: Loop 2330A NM103, NM104, NM105
12. Box 9a OTHER INSURED'S POLICY OR GROUP NUMBER
12.1 When billing the primary insurance, Intellect prints ‘MG’ (for Medigap) followed by the Registration --► Regular --► Patient Insurance screen <Subscriber No.> field for the patient’s secondary insurance.
12.2 When billing the secondary or tertiary insurance, Intellect prints Intellect prints the Registration --► Regular --► Patient Insurance screen <Subscriber No.> field for the patient’s primary insurance.
12.2.1 If the primary insurance is the Medicare or Medicare/Medicaid crossover (Utility --► Insurance --► Insurance <Insurance Type> = ‘C’ or ‘1’), then Intellect prints ‘MG’ (for Medigap) followed by the Registration --► Regular --► Patient Insurance screen <Subscriber No.> field for the patient’s primary insurance.
12.3 If the patient’s category is Workers’ Comp (Utility --► Category <Type> = ‘W’ or ‘F’), then Intellect leaves this blank.
12.4 Professional (837) Electronic Claims Submission Equivalent: Loop 2320 SBR03
13. Box 9b RESERVED FOR NUCC USE: Left blank.
14. Box 9c RESERVED FOR NUCC USE: Left blank.
15. Box 9d INSURANCE PLAN NAME OR PROGRAM NAME
15.1 When billing the primary insurance, Intellect prints the Utility --► Insurance --► Insurance <Name> for the secondary insurance on the Registration --► Regular --► Patient Insurance screen.
15.1.1 If the primary insurance is the Medicare (Utility --► Insurance --► Insurance <Insurance Type> = ‘C’), then Intellect prints the Utility --► Insurance --► Insurance <Name> and <COBA> for the secondary insurance.
15.2 When billing the secondary or tertiary insurance, Intellect prints the Utility --► Insurance --► Insurance <Name> for the primary insurance on the Registration --► Regular --► Patient Insurance screen.
15.3 If the patient’s category is Workers’ Comp (Utility --► Category <Type> = ‘W’ or ‘F’), then Intellect leaves this blank.
15.4 Professional 837 Electronic Claims Submission Equivalent: Loop 2320 SBR04
16. Box 10 IS PATIENT'S CONDITION RELATED TO:
16.1 a. EMPLOYMENT? (Current or Previous)
16.1.1 Intellect prints ‘X’ in the YES or NO box according to:
16.1.1.1 The Charges --► Encounter --► Generic <Employment (Y/N)> field when that encounter number is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify.
16.1.1.2 The Registration --► Worker --► Worker Insurance <Employment> field when an <EN#> is not associated with the charges or <Employment (Y/N)> is blank on the associated encounter screen.
16.1.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 CLM11 EM
16.2 b. AUTO ACCIDENT
16.2.1 Intellect prints ‘X’ in the YES box and Registration --► Regular --► Patient (or Registration --► Worker --► Worker) <State> for the patient’s home address in PLACE (state) only if an A is entered in:
16.2.1.1 The Charges --► Encounter --► Generic (Ambulance or, DME) <Related: Accident (A/O/N)> field when that encounter number is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify.
16.2.1.2 The Registration --► Worker --► Worker Insurance <Related: Accident> field when an <EN#> is not associated with the charges or <Related: Accident (A/O/N)> is blank on the associated encounter.
16.2.2 Intellect prints ‘X’ in the NO box if the Related: Accident field is blank or contains a value other than A.
16.2.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 CLM11 AA
16.3 c. OTHER ACCIDENT?
16.3.1 Intellect prints ‘X’ in the YES box only if an O (for other accident) is entered in:
16.3.1.1 The Charges --► Encounter --► Generic (Ambulance or DME) <Related Accident (A/O/N)> field when that encounter number is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify.
16.3.1.2 The Registration --► Worker --► Worker Insurance <Related: Accident> field when an <EN#> is not associated with the charges or <Related: Accident (A/O/N)> is blank on the associated encounter.
16.3.2 Intellect prints ‘X’ in the NO box if the Related: Accident field is blank or contains a value other than O.
16.4 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 CLM11 OA
17. Box 10d CLAIM CODES (Designated by NUCC)
17.1 If Medicaid is primary (Utility --► Insurance --► Insurance <Insurance Type> = D) and Charges --► Encounter --► Generic (or OBGYN) <Share of Cost Amount> has an entry, then Intellect prints the share of cost amount.
17.2 For Workers’ Comp claims generated through Billing --► Worker --► Statement or Billing --► Worker --► HCFA, Intellect prints the code entered in the <Type of Report> field. Valid field entries are:
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17.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 HI
18. Box 11 INSURED’S POLICY GROUP OR FECA NUMBER
18.1 If billing Medicare or Medicare/Medicaid crossover (Utility --► Insurance --► Insurance <Insurance Type> = C or 1), Intellect prints the word "NONE".
18.2 For all other cases, Intellect prints the Registration --► Regular --► Patient Insurance <Group No.> OR Registration --► Worker --► Worker Insurance <Group> field for the billed insurance.
18.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2000B SBR03
19. Box 11a INSURED’S DATE OF BIRTH | SEX
19.1 INSURED’S DATE OF BIRTH
19.1.1 If Registration --► Regular --► Patient Insurance <Relation to Insured> is not = 18 (for self) or 20 (for employee), Intellect prints the insured’s date of birth from the Registration --► Regular --► Patient Insurance <Insured DOB> field for the billed insurance and formats as MMDDYYYY.
19.1.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2010BA DMG02
19.2 SEX
19.2.1 If Registration --► Regular --► Patient Insurance <Relation to Insured> is not = 18 (for self) or 20 (for employee), Intellect prints the insured’s gender from the Registration --► Regular --► Patient Insurance <Gender> field for the billed insurance.
19.2.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2010BA DMG03
20. Box 11b OTHER CLAIM ID (Designated by NUCC)
20.1 If the patient’s category is Workers’ Comp (Utility --► Category <Type> = W or F), Intellect prints the Registration --► Worker --► Worker Insurance <Claim No. 1> field for the billed insurance.
20.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2010BA REF01
21. Box 11c INSURANCE PLAN NAME OR PROGRAM NAME
21.1 If billing for Medicare/Medicaid crossover insurance (Utility --► Insurance --► Insurance <Insurance Type> = 1), Intellect prints Utility --► Insurance --► Insurance <Payor & Office Code > field.
21.2 If the patient’s category is Workers’ Comp (Utility --► Category <Type> = W or F), Intellect leaves this field blank.
21.3 For all other cases, Intellect prints the Registration --► Regular --► Patient Insurance screen <Claim No> field for the billed insurance.
21.4 Professional 837 Electronic Claims Submission Equivalent: Loop 2000B SBR04
22. Box 11d IS THERE ANOTHER HEALTH BENEFIT PLAN?
22.1 Intellect prints ‘X’ in the YES or NO box based on the Registration --► Regular --► Patient Insurance screens for the patient:
22.1.1 If the patient has a secondary insurance, Intellect prints ‘X’ in the YES box.
22.1.2 If the patient does NOT have a secondary insurance, Intellect prints ‘X’ in the No box.
22.2 Intellect leaves this field blank:
22.2.1 If the patient’s category is Workers’ Comp (Utility --► Category <Type> = W or F).
22.2.2 If the patient’s insurance is Medicare or Medicare/Medicaid crossover (Utility --► Insurance --► Insurance <Insurance Type> = C or 1).
22.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2320
23. Box 12 PATIENT’S OR AUTHORIZED PERSON'S SIGNATURE
23.1 SIGNED
23.1.1 Intellect prints the Utility --► Insurance --► Insurance <Message Box 12 & 13> field for the billed insurance.
23.1.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 CLM09
23.2 DATE
23.2.1 Intellect prints the Utility --► Set Up --► Clinic <Current Entry Date>.
24. Box 13 INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
24.1 Intellect prints the Utility --► Insurance --► Insurance <Message Box 12 & 13> field for the billed insurance.
24.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 CLM08
25. Box 14 DATE OF CURRENT: ILLNESS, INJURY, or PREGNANCY (LMP)
25.1 If the patient’s category is Worker's Comp (Utility --► Category <Type> = W or F), Intellect prints the date of injury with qualifier 431 based on:
25.1.1 The Charges --► Encounter --► Generic (Ambulance, DME Oxygen or Vision) <Injury Date> field when that encounter number is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify.
25.1.2 The Registration --► Worker --► Worker Insurance <DOI> field when an <EN#> is not associated with the charges or <Injury Date> is blank on the associated encounter.
25.2 If the patient’s category is NOT Workers’ Comp (Utility --► Category <Type> = W or F), Intellect prints the date and qualifier based on the patient’s Encounter screen when that encounter number is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify.
25.2.1 The Charges --► Encounter --► Generic (or Chiropractic) <First Symptom> date prints with qualifier 431.
25.2.2 The Charges --► Encounter --► OBGYN <LMP Date> field prints with qualifier 484.
25.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 DTP03
25.4 QUAL.
25.4.1 To the right of the vertical dotted line, Intellect prints the applicable 3-digit qualifier based on the field where the date was entered in Intellect, as noted in 25.1 through 25.2.2 above.
431 ONSET OF CURRENT SYSTEM/ILLNESS
484 LAST MENSTRUAL PERIOD
25.4.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 DTP01
26.1 QUAL.
26.1.1 To the right of the vertical dotted line, Intellect prints the applicable 3-digit qualifier based on where the date was entered in Intellect, as noted below.
090 REPORT START (Assumed Care Date)
091 REPORT END (Relinquished Care Date)
304 LAST VISIT OR CONSULTATION
439 Accident
444 FIRST VISIT OR CONSULTATION
453 Acute Manifestation of a Chronic Condition
454 INITIAL TREATMENT
455 LAST X-RAY
471 Prescription
26.1.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 DTP01
26.2 Intellect prints the Qualifier and Other Date based on the patient’s Encounter screen when that encounter number is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify.
26.2.1 The Charges --► Encounter --► Generic <Report Start> date prints with qualifier 090.
26.2.2 The Charges --► Encounter --► Generic <Report End> date prints with qualifier 091.
26.2.3 The Charges --► Encounter --► Generic (or Chiropractic, Physical Therapy) <Last Seen> date prints with qualifier 304.
26.2.4 If patient’s insurance is NOT Medicare, Medicare/Medicaid crossover or Medicaid (Utility --► Insurance --► Insurance <Type> is NOT C, 1 or D), the Charges --► Encounter --► Generic <First Consulted> date prints with qualifier 444.
26.2.5 The Charges --► Encounter --► Chiropractic <Acute Manifestation> date prints with qualifier 453.
26.2.6 The Charges --► Encounter --► Chiropractic <Initial Treatment> date prints with qualifier 454.
26.2.7 The Charges --► Encounter --► Generic (Chiropractic or Physical Therapy) <X-Ray Date> prints with qualifier 455.
26.2.8 The Charges --► Encounter --► Vision <Prescription Date> prints with qualifier 471.
26.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 DTP03
27. Box 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
27.1 FROM
27.1.1 Intellect prints the FROM date based on the Charges --► Encounter --► Generic <Unable to Work From> field when that encounter number is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify.
27.1.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 DTP01 = 360, DTP03
27.2 TO
27.2.1 Intellect prints the TO date based on the Charges --► Encounter --► Generic <Able to Return to Work> field when that encounter number is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify.
27.2.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 DPT01 = 361, DTP03
28. Box 17 NAME OF REFERRING PROVIDER OR OTHER SOURCE
28.1 Before the vertical dotted line, Intellect prints a 2-character qualifier to identify which provider is being reported:
28.2 For all Provider Names:
28.2.1 If the Utility --► Referring <Doctor/Other (D/O)> = D for the applicable <Referring Code>, then Intellect prints the Referring Provider, Ordering Provider, or Supervising Provider name based the Utility --► Referring fields and formats as <First Name> <Middle Initial> <Last Name>.
28.2.2 Effective 15.09.28: The <Referring Code> is invalid and will not be used if the Utility --► Referring <Last Name> field is empty.
28.3.1 If both the <Ordering Provider> and <Supervising Provider> fields are blank on the encounter screen associated with the printed charges through the <EN#> field of Charges --► Charge OR Charges --► Modify, then Intellect prints qualifier DN and the Referring Provider name as determined by the Utility --► Set Up --► Parameter <Referring> field setting. The valid choices are:
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28.3.1.1 If set to P, then Intellect prints the Referring Provider name based on the Utility --► Referring <Referring Code> associated with the referral source entered in the Registration --► Regular --► Patient <Referring Name> OR Registration --► Worker --► Worker <Referral> field.
28.3.1.2 If set to C, then Intellect prints the Referring Provider name based on the Utility --► Referring <Referring Code> entered in the Charges --► Charge <Ref Prv> OR Charges --► Modify <Rdr>.
28.3.1.3 If set to F, then Intellect prints the Referring Provider name based on the following hierarchy:
28.3.1.3.1 First, the Referring Provider entered in the Charges --► Charge <Ref Prv> OR Charges --► Modify <Rdr> field (same as ‘C’).
28.3.1.3.2 If Referring Provider for charge posting is empty, then the Registration --► Regular --► Patient <Referring Name> OR Registration --► Worker --► Worker <Referral> field (same as ‘P’).
28.3.1.3.3 If a Referring Provider is not posted in charges or entered in the patient registration screen, then the Utility --► Provider --► Provider <First Name> <Middle Initial> <Last Name> for the rendering provider entered in the Charges --►Charge (or Charge --►Modify) <Billing Prv> field is used.
28.3.2 Effective version 14.11.19: If the Utility --► Insurance --►Insurance <Insurance Type> field is set to 'D', 'C', '1', '5' (WI Medicaid), or 'O', then Intellect only prints the Referring Provider name when entered on the Charges --► Charge <Ref Prv> (or Charges --► Modify <Rdr>) field OR the Registration --► Regular --► Patient <Referring Name> field.
28.3.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2310A NM101, NM103, NM104, NM105, NM107
28.4.1 Intellect prints qualifier DK and the Ordering Provider name based on the Utility --► Referring <Referring Code> entered in the Charge --► Encounter --► Generic (Ambulance, DME or DME Oxygen) <Ordering Provider> field, when that encounter is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charge --► Modify.
28.4.2 Prior to version 15.09.28: The Ordering Provider name and qualifier only printed if the Utility --► Procedure --► Procedure <Status> field was set to ‘O’ (DME – Oxygen Procedure) or ‘D’ (DME – other than Oxygen) for one of the printed charges.
28.4.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2420E NM101, NM103, NM104, NM105, NM107
28.5.1 Intellect prints qualifier DQ and the Supervising Provider name based on the Utility --► Referring <Referring Code> entered in the Charge --► Encounter --► Generic (or Physical Therapy) <Supervising Provider> field, when that encounter is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charge --► Modify.
28.5.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2310D NM101, NM103, NM104, NM105, NM107
29.1 Intellect leaves this field blank, if billing with NPI numbers only (Utility --► Insurance --► Insurance <New form (Y/N)> = ‘X’).
29.2 If Utility --► Insurance --► Insurance <New form (Y/N)> is ‘N’ or ‘Y,’ then Intellect prints the qualifier and legacy identification number for the provider listed in Box 17 (see above).
29.2.1 In the smaller box immediately to the right of 17a, Intellect prints the 2-character qualifier based on Utility --► Insurance --►Insurance <Referring Type>. Available field entries are:
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29.2.2 In the larger box, Intellect prints the appropriate legacy identification number from the Utility --► Referring screen for the provider in Box 17 (see above) based on Utility --► Insurance --► Insurance <Box 17a> field. Valid field entries are:
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29.2.2.1 If set to ‘U,’ then Intellect prints Utility --► Referring <UPIN Number>.
29.2.2.2 If set to ‘P,’then Intellect prints Utility --► Referring <Provider No>.
29.2.2.3 If set to ‘S,’ then Intellect prints Utility --► Referring <State License>.
29.2.2.4 If set to ‘N,’ then Intellect prints Utility --►Referring <NPI>.
29.2.2.5 If set to ‘C,’ then Intellect prints Utility --►Referring <Commercial>.
29.2.2.6 If set to ‘B,’ then Intellect prints Utility --►Referring <Blue Shield>.
29.2.2.7 If set to ‘T,’ then Intellect prints Utility --► Referring <Tax ID>.
29.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2310A REF01, REF02 (Referring Provider); Loop 2310D REF01, REF02 (Supervising Provider); Loop 2420E REF01, REF02 (Ordering Provider)
30.1 If Utility --► Insurance --► Insurance <New form (Y/N)> = ‘Y’ or ‘X’, Intellect prints the Utility --►Referring <NPI> OR Utility --► Provider --► Provider <NPI> for the provider in Box 17 (see above).
30.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2310A NM109 (Referring Provider), Loop 2310D NM109 (Supervising Provider), Loop 2420E NM109 (Ordering Provider)
31. Box 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
31.1 FROM
31.1.1 Intellect prints the Charges --► Encounter --► Generic (Ambulance, Epogen, or OBGYN) <Hospitalization From> when the encounter number is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify.
31.1.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 DTP01 = 435, DTP03
31.2 TO
31.2.1 Intellect prints the Charges --► Encounter --► Generic (Ambulance, Epogen, or OBGYN) <Hospitalization To> when the encounter number is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify.
31.2.2 837 Electronic Claims Submission Equivalent: Loop 2300 DTP01 = 096, DTP03
32. Box 19 ADDITIONAL CLAIM INFORMATION (Designated by NUCC)
32.1 Intellect prints additional claim information based on the following hierarchy:
32.1.1 The Charges --► Encounter --► Generic (or OBGYN) <Box 19 Claim Notes> field appended by <HCFA Box 19 Date> when the encounter number is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify.
32.1.2 The Utility --► Insurance --► Insurance <HCFA Box 19 Comment> field.
- OR -
32.2 Intellect prints the 8-digit clinical trial registry number (CTN) preceded by ‘CT’ based on the Charges --► Encounter --► Generic <Project Identifier> field when the encounter number is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify.
32.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 NTE (for Claim Note) or Loop 2300 REF01, REF02 (for CTN)
33. Box 20 OUTSIDE LAB? | $CHARGES
33.1.1 If Utility --► Procedure --► Procedure <Status> = ‘L’ (lab procedures) for the billed charge(s) AND:
33.1.1.1 Utility --► Facility <Facility Code> was entered in the Charges --► Encounter --► Generic <Referred Lab> field when the encounter number is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify then Intellect prints ‘X’ in the YES box.
33.1.1.2 The Charges --► Encounter --► Generic <Referred Lab> field is blank OR an encounter number is not associated with the printed charges, then Intellect prints ‘X’ in the NO box.
33.1.2 If the Utility --► Procedure --► Procedure <Status> is NOT ‘L’ for the billed charge(s), then Intellect prints ‘X’ in the NO box.
33.1.3 NOTE: If ‘X’ prints in the Yes box to indicate diagnostic tests purchased from outside lab, then Box 32 (see below) prints for the outside lab name, address and NPI based on the Utility --► Facility <Facility Code> entered in the Charges --► Encounter --► Generic <Referred Lab> field.
33.2 $CHARGES:
33.2.1 If ‘X’ is in the YES box, then Intellect prints the total cost for all printed charges based on Utility --► Procedure --► Procedure <Cost>.
33.2.2 If ‘X’ is in the NO box, then Intellect prints ‘NO PURCH. SVC.’.
33.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 PS102
34. Box 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
34.1 ICD ind.:
34.1.1 Between the dotted lines, Intellect prints the ICD indicator 0 OR 9 based on the Utility --►Diagnosis --► Diagnosis <ICD9/ICD10> field for the diagnosis codes listed in A through L.
9 ICD-9-CM codes
0 ICD-10-CM codes
34.1.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 HI01-1, HI02-1, HI03-1, HI04-1, HI05-1, HI06-1, HI07-1, HI08-1, HI09-1, HI10-1, HI11-1, HI12-1.
34.2 A. through L.:
34.2.1 Intellect prints the Utility --►Diagnosis --► Diagnosis <ICD10 Code> based on the entry order at time of posting on Charges --► Charge <Diagnosis Code> field (or Charges --► Modify when updated after posting) for the printed date(s) of service.
34.2.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 HI01-2, HI02-2, HI03-2, HI04-2, HI05-2, HI06-2, HI07-2, HI08-2, HI09-2, HI10-2, HI11-2, HI12-2.
34.3 NOTE: ICD9 and ICD10 codes should NOT be reported on the same claim.
35. Box 22 RESUBMISSION CODE | ORIGINAL REF. NO.
35.1 RESUBMISSION CODE:
35.1.1 If billing Medicare or Medicare/Medicaid crossover (Utility --► Insurance --► Insurance <Insurance Type> = ‘D’ or ‘1’), then Intellect prints the Charges --► Encounter --► Generic <Medicare Status> code when the encounter number is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify.
35.1.2 Intellect prints the appropriate code for replacement or corrected claims based on the Charges --► Encounter --► Generic (Ambulance, Chiropractic, Epogen, OB/GYN, Physical Therapy, or Vision) <Claim Frequency Code> field when the encounter number is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify.
35.1.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 CLM05-3
35.2 ORIGINAL REF. NO.:
35.2.1 If printing replacement or corrected claims, then Intellect prints the Charges --► Encounter --► Generic (Ambulance, Chiropractic, DME, DME Oxygen, Epogen, OB/GYN, Physical Therapy, or Vision) <Internal Control> field when the encounter number is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify.
35.2.2 Effective version 18.08.31: If a payment was applied using the Payment --► Auto Payment screen, then the ICN (Internal Control Number) from the ERA file is printed when Charges --► Encounter <Claim Frequency Code> field is greater than 1 and the <Internal Control> field is blank.
35.2.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 REF02
36. Box 23 PRIOR AUTHORIZATION NUMBER
36.1 Intellect prints the Charges --► Encounter --► Generic (Ambulance, Chiropractic, DME, DME Oxygen, Epogen, OBGYN, Physical Therapy, or Vision) <Authorization No.> field when the encounter number is associated with the printed charges through the <EN#> field of Charges --► Charge OR Charges --► Modify.
36.1.1 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 REF01 = G1, REF02
- OR -
36.2 If Utility --► Insurance --► Insurance <Print CLIA (Y/N)> = Y AND Utility --► Procedure --► Procedure <Status> = ‘L’ then Intellect prints CLIA number based on Box 20 (see above) criteria.
36.2.1 For ‘No Purchased Services’ (‘X’ in Box 20 NO), Intellect prints the <CLIA> field on the Utility --► Provider --► Provider Facility screen to match Billing Provider, Insurance and Facility. If that field is not found, Intellect prints Utility --► Provider --► Provider <CLIA>.
36.2.2 For ‘Purchased Service, Outside Lab Billing’ (‘X’ in Box 20 YES), then Intellect prints Utility --► Facility <CLIA>.
36.2.3 NOTE: If charges are linked to an encounter, the <Authorization No.> field on the encounter screen overrides <CLIA> number (see 36.1 above).
36.2.4 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 REF01 = X4, REF02
For Boxes 24A through 24J: (lines 1 through 6)
Intellect prints up to 6 services where Utility --► Procedure --► Procedure <Parties to Bill> = ‘A,’ ‘P,’ or ‘B’ AND the <Who> field matches the insurance being billed (e.g., if <Who> = P1 then must be printing for P1 Primary Insurance). Prior to version 14.07.01, only 5 lines of service printed for the requested date(s) of service.
For Anesthesiology charges (when Utility --► Insurance --► Insurance <Insurance Type> is NOT C, 1, or D), Intellect prints the Start Time, End Time and Total Units above each charge line in the following format: Start time 00 00 End 00 00 Total Units 0
o Start time prints the time entered in Charges --► Charge OR Charges --► Modify <Time> field.
o End time prints the time entered in Charges --► Charge OR Charges --► Modify <To> field.
o Total Units = Time Units + Procedure Units + Modifier Units (if applicable)
§ Time Units: Posted time in minutes (see Box 24 G notes below) divided by the Utility --► Provider --► Provider <Anes Time Unit Calc>.
§ Procedure Units: Utility --► Procedure --► Procedure <Anes Base Unit 1>, <Anes Base Unit 2> OR <Anes Base Unit 3> determined by selection in Utility --► Insurance --► Insurance <Selection (1/2/3)> field.
§ Modifier Units: If applicable, Utility --► Procedure --► Modifier <Base Unit>.
See documentation for Anesthesiology Set Up and Charge Posting for more details.
37. Box 24A DATE(S) OF SERVICE FROM/TO
37.1 Shaded area above the date(s) of service:
37.1.1 If Utility --► Procedure --► Procedure <Status> = ‘N’ (for NDC), Intellect prints the Utility --► Procedure --► Procedure <NDC Number> proceeded by the ‘N4’ qualifier, then 3 spaces followed by <Unit of Measure> and the quantity (based on Utility --► Procedure --► Procedure <NDC Unit Value> and Charges --► Charge <QTY>).
37.1.1.1 Professional 837 Electronic Claims Submission Equivalent: Loop 2410 LIN and Loop 2410 CTP.
>-OR-
37.1.2 Intellect prints a charge remark or procedure description based on the Utility --► Insurance --► Insurance <Comment on Bill> field.
37.1.2.1 If ‘Y,’ then Intellect prints the Charges --► Charge OR Charges --► Modify <Remark> field.
37.1.2.2 If ‘D,’ then Intellect prints Charges --► Charge OR Charges --► Modify <Remark> field. If no charge remark, then Intellects prints the Utility --► Procedure --► Procedure <Description> field.
37.1.2.3 If ‘N,’ then Intellect does not print charge remarks or procedure descriptions.
-OR-
37.1.3 If Utility --► Insurance --► Insurance <Provider Name> is ‘Y’ or ‘X’ AND no charge remark exists, then Intellect prints the Utility --► Provider --► Provider <First Name> <Middle Initial> <Last Name> <Title> fields.
37.2 FROM
37.2.1 Intellect prints Charges --► Charge <From Date> (or Charges --► Modify <From> date) field and Utility --► Insurance --► Insurance <Date Format> determines if date prints as MMDDYYYY.
37.3.1 Intellect prints Charges --► Charge <To> (or Charges --► Modify <To> date) field and Utility --► Insurance --► Insurance <Date Format> determines if date prints as MMDDYYYY.
37.4 Professional 837 Electronic Claims Submission Equivalent: Loop 2400 DTP03
38.1 Intellect prints the Utility --► Facility <Place Of Service> based on Charges --► Charge <Facility> (or Charge --► Modify <POS>) code.
38.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 CLM05-1, Loop 2400 SV105
39.1 Intellect prints ‘Y’ if the Charges --► Encounter --► Generic <Emergency (Y/N)> field is set to ‘Y’ when the encounter is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify.
39.2 Intellect leaves this field blank when Charges --► Encounter --► Generic <Emergency (Y/N)> is NOT ‘Y’, UNLESS <Emergency (Y/N)> is blank, then Intellect prints Charges --► Encounter <Delay Reason Code> field.
39.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2400 SV109
40. Box 24D PROCEDURES, SERVICES OR SUPPLIES
40.1 CPT/HCPCS
40.1.1 For the <Panel> entered in the Charges --► Charge screen, Intellect prints the CPT or HCPCS code from Utility --► Procedure --► Procedure <Code R>, <Code C>, <Code E>, <Code O> or <Revenue Code> based to the Utility --► Insurance --► Insurance <Code (R/C/E/U)> field of the billed insurance.
40.1.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2400 SV101-2
40.2 MODIFIER
40.2.1 Intellect prints up to 4 modifiers based on the Utility --► Procedure --► Procedure <Modifier R>, <Modifier C>, <Modifier E>, or <Modifier O> field associated with the CPT/HCPCS code (see note above) OR entered in Charges --► Charge <To> (or Charges --► Modify) <Mod> field.
40.2.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2400 SV101-3, SV101-4, SV101-5, SV101-6
41.1 Intellect prints up to 4 diagnosis pointers per line based on Charges --► Charge (or Charges --► Modify) <RDX>.
41.2 NOTE: Although data entry for Charges --► Charge (or Charges --► Modify) <RDX> is formatted as numeric values 1 through 12 separated by commas, the values are mapped to print as alpha characters A through L (see Box 21 above).
41.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2400 SV107-1, SV107-2, SV107-3, SV107-4
42.1 Intellect prints the Charges --► Charge (or Charges --► Modify) <Charge>.
42.2 If billing the secondary or tertiary insurance AND Utility --► Insurance --► Insurance <Second Approved> = Y, then Intellect prints the primary approved amount for the charge based on:
42.2.1 Payment --► Open Item <Approved> amount entered when manually posting the primary insurance payment.
42.2.2 The approved amount from the ERA file used for posting through Payment --► Auto Payment screen.
42.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2400 SV102
43.1 Intellect prints the Charges --► Charge (or Charges --► Modify) <Qty> field, which defaults to Utility --► Procedure --► Procedure <Days/Units>.
43.2 For Anesthesiology billing, Intellect prints the total posted time in minutes based on Charges --► Charge (or Charges --► Modify) <Time> and <Time To>. For example, posting the start time of 8:00am and the ending time of 9:30am prints ‘90’ (for 90 minutes).
43.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2400 SV104
44.1 If the patient’s insurance coverage is Medicaid (Utility --► Insurance --► Insurance <Insurance Type> = D), then Intellect prints the selected code from the Charges --► Encounter --► Generic (or OBGYN) <Family Planning> field when the encounter number is associated with the printed charges using the <EN#> field of Charges --► Charge OR Charges --► Modify.
44.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2400 SV111, SV112
45.1 Intellect leaves this field blank, if billing with NPI numbers only (Utility --► Insurance --► Insurance <New form (Y/N)> = ‘X’).
45.2 If Utility --► Insurance --► Insurance <New form (Y/N)> is ‘N’ or ‘Y’, Intellect prints the qualifier for the rendering provider’s legacy number based on the Utility --► Insurance --► Insurance <Box 24J Type> field for the billed insurance.
45.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2310B REF01 or Loop 2420A REF01
46. Box 24J RENDERING PROVIDER ID #
46.1 Intellect prints the rendering provider’s ID if the Utility --► Provider --► Provider <Group Provider (Y/N)> field is set to ‘Y’ or ‘X’ for Provider Code entered on Charges --► Charge (or Charges --► Modify) <Billing Prov> field.
46.2 For LEGACY NUMBERS: (top shaded line)
46.2.1 If Utility --► Insurance --► Insurance <New form (Y/N)> = X, lntellect leaves this field blank.
46.2.2 If Utility --► Insurance --► Insurance <New form (Y/N)> = Y or N, Intellect prints the legacy number for the rendering provider entered on Charges --► Charge (or Charges --► Modify) <Billing Prov> field based on the following hierarchy, regardless of the billing method.
46.2.2.1 First looks at Utility --► Provider --► Provider Facility <HCFA Box 24 J> for a match of the Billing Provider, Insurance and Facility.
46.2.2.2 If a match is not found, the program looks at Utility --► Provider --► Provider Provider <HCFA Box 24 J> for a match of the Billing Provider and Insurance.
46.2.2.3 If a match is not found in either table, Intellect uses Utility --► Insurance --► Insurance <Selection (1/2/3)> to determine which legacy provider number (Utility --► Provider --► Provider <HCFA Box 24 J1>, <HCFA Box 24 J2>, or <HCFA Box 24 J3>).
46.2.3 If Utility --► Insurance --► Insurance <Insurance Type> = B (Workers’ Comp) and the patient’s category is Workers’ Comp (Utility --► Category <Type> = ‘W’ or ‘F’), then Intellect prints Utility --► Provider --► Provider <Taxonomy>.
46.2.4 If billing the secondary or tertiary insurance AND Utility --► Insurance --► Insurance <Second Approved> = Y, then Intellect prints the per charge payment amount on secondary & tertiary claims.
46.2.5 Professional 837 Electronic Claims Submission Equivalent Loop: 2310B REF02 or Loop 2420A REF02
46.3 For NPI NUMBERS: (bottom line)
46.3.1 If Utility --► Insurance --► Insurance <New form (Y/N)> = ‘Y’ or ‘X,’ Intellect prints Utility --► Provider --► Provider <NPI> for the rendering provider entered on Charges --► Charge (or Charges --► Modify) <Billing Prv> field.
46.3.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2310B NM109 or Loop 2420A NM109
47. Box 25 FEDERAL TAX I.D. NUMBER SSN EIN
47.1 If the Billing Method is by Clinic (Utility --► Set Up --► Parameter <Billing Method> = ‘C’, ‘T’ or ‘L’ with Utility --► Category <Billing Method> = ‘C’ or ‘T’), then Intellect prints Utility --► Set Up --► Clinic <IRS Number> and ‘X’ in EIN box.
47.2 If Billing Method is Doctor (Utility --► Parameter <Billing Method> = ‘D’ or ‘L’ with Utility --► Category <Billing Method> = D), based on the following hierarchy:
47.2.1 Intellect prints Utility --► Provider --► Provider Facility <Tax ID> and ‘X’ prints in SSN or EIN box based on <SSN/EIN> field where the record matches the Billing Provider, Insurance, and Facility for the printed charge.
47.2.2 If match not found, Intellect prints the Utility --►Provider --►Provider Provider <Tax ID> and ‘X” in SSN or EIN box based on <SSN/EIN> field where the record matches the Billing Provider and Insurance for the printed charge.
47.2.3 If a match is not found in either table, Intellect prints Utility --► Provider --► Provider <I.R.S.> with ‘X’ in EIN box OR if left blank, then Utility --►Provider --►Provider <Social Security No.> with ‘X’ in SSN box.
47.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2010AA REF01, REF02
48. Box 26 PATIENT’S ACCOUNT NO
48.1 Intellect prints the patient’s account number from the Registration --► Regular --► Patient (or Registration --► Worker --► Worker) <Patient Account No> field.
48.2 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 CLM01
49.1 Intellect prints ‘X’ in the appropriate box based on Charges --► Charge (or Charges --► Modify) Charges --► Charge (or Charges --► Modify) <ASI> which defaults to value in the Registration --► Regular --► Patient Insurance <Assignment> field.
49.1.1 If ‘N,’ then Intellect prints ‘X’ in NO box.
49.1.2 If ‘Y,’ then Intellect prints ‘Y’ in YES box.
49.2 Professional 837 Electronic Claims Submission Equivalent Loop 2300 CLM07
50.1 Intellect prints the sum of all charges in Box 24F (see notes above) lines 1 through 6.
50.2 Professional 837 Electronic Claims Submission Equivalent Loop 2300 CLM02
51.1 Intellect prints payments and/or adjustments based on Utility --► Insurance --► Insurance <Include Payment> field. Valid entries are:
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51.1.1 N prints 0.00 in Box 29
51.1.2 Y prints total of ALL (patient and insurance) payments posted to the charges in Box 24 lines 1 through 6.
51.1.3 A prints total of ALL (patient and insurance) payments plus adjustments posted to the charges in Box 24 lines 1 through 6.
51.1.4 I prints the total INSURANCE payments posted to the charges in Box 24 lines 1 through 6.
51.1.5 B prints the total INSURANCE payments plus adjustments posted to the charges in Box 24 lines 1 through 6.
51.1.6 S prints total INSURANCE payment posted to the charges in Box 24 lines 1 through 6.
51.2 EXCEPT: When billing the secondary or tertiary insurance AND Utility --► Insurance --► Insurance <Second Approved> = Y, then Intellect prints the total payments for Box 24 lines 1 through 6.
51.3 Professional 837 Electronic Claims Submission Equivalent Loop 2300 AMT02
52.1 Intellect leaves this box blank.
52.2 Effective Version 14.07.01: When billing an insurance with the Utility --► Insurance --► Insurance <Insurance Type> field set to either D or 1 (Medicaid or Medicare/Medicaid crossover), the Balance Due is based on the Utility --► Insurance --► Insurance <Include Payment> field:
52.2.1 If set to ‘N,’ ‘Y,’ ‘A,’ ‘I,’ or ‘B,’ then Intellect prints Box 28 TOTAL CHARGE minus Box 29 AMOUNT PAID.
52.2.2 If set to ‘S’, then Intellect prints Box 28 TOTAL CHARGE minus Box 29 AMOUNT PAID (Insurance Payments) and Total Insurance Adjustments posted to the charges in Box 24 lines 1 through 6.
53. Box 31 SIGNATURE OF PHYSICIAN OR SUPPLIER
53.1 SIGNED: If Utility --► Insurance --► Insurance <Provider Name (Y/N/X/Z)> = X or Z, then Intellect prints the Utility --►Provider --►Provider <First Name> <Middle Initial> <Last Name> <Title> of the rendering provider entered on Charges --► Charge (or Charges --► Modify) <Billing Prv> field.
53.2 DATE: Intellect prints the date based on Utility --► Set Up --► Clinic <Current Entry Date>.
53.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2300 CLM06
54. Box 32 SERVICE FACILITY LOCATION INFORMATION
54.1 Intellect prints the Utility --►Facility <Name>, <Address>, <City>, <State>, and <Zip Code> fields for the code entered in Charges --► Charge (or Charges --► Modify) <Facility> field.
54.2 EXCEPTIONS:
54.2.1 If Utility --► Facility <Place of Service> = 12, then Intellect prints the patient’s home address based on Registration --► Regular --► Patient <Last Name>, <First Name>, <Middle Initial>, <Address>, <City>, <State>, <Zip Code>.
54.2.2 If ‘X’ prints in YES for Box 20 (see notes above), then Intellect prints the outside lab name and address based on the Utility --► Facility <Facility Code> entered in the Charges --► Encounter --► Generic <Referred Lab> field.
54.3 Professional 837 Electronic Claims Submission Equivalent: Loop 2310C NM103, N301, N401, N4002, N403
55. Box 32a SERVICE FACILITY LOCATION INFORMATION
55.1 If Utility --► Insurance --► Insurance <New Form> = ‘Y’ or ‘X,’ then Intellect prints the Utility --► Facility <NPI> for the facility in Box 32 (see notes above).
55.2 If Utility --► Insurance --► Insurance <New Form> = ‘N,’ then Intellect leaves this blank.
55.3 Professional 837 Electronic Claims Submission Equivalent Loop 2310C NM109
56. Box 32b SERVICE FACILITY LOCATION INFORMATION
56.1 If Utility --► Insurance --► Insurance <New Form> = ‘X,’ then Intellect leaves this blank.
56.2 If Utility --► Insurance --► Insurance <New Form> = ‘Y’ or ‘N,’ then Intellect prints the legacy number for the facility in Box 32 (see notes above) where the Utility --► Insurance --► Insurance <Selection (1/2/3)> field determines Utility --► Facility <Provider 1>, <Provider 2> or <Provider 3>.
56.3 If the charges are related to Mammography (Utility --► Procedure --► Procedure <Status> = ‘M’), then Intellect prints Utility --► Procedure --► Procedure <Mammography>.
56.4 Professional 837 Electronic Claims Submission Equivalent Loop 2310C REF01, REF02
57. Box 33 BILLING PROVIDER INFO & PH#
57.1 BILLING PROVIDER INFO:
57.1.1 If Billing Method is by Clinic (Utility --► Set Up --► Parameter <Billing Method> = ‘C’ or ‘L’ with Utility --► Category <Billing Method> = ‘C’), then Intellect prints billing provider name and address in Utility --► Set Up --► Clinic <Clinic Name>, <Address>, <City>, <State>, and <Zip Code> fields.
57.1.2 If Billing Method is by Doctor (Utility --► Set Up --► Parameter <Billing Method> = ‘D’ or ‘L’ with Utility --► Category <Billing Method> = ‘D’), then Intellect prints the Utility --► Provider --► Provider <Organization Name>, <Address>, <City>, <State>, <Zip Code> based on the provider code entered on Charges --► Charge (or Charges --► Modify) <Billing Prv> field.
57.1.2.1 If Utility --► Provider --► Provider <Organization> is blank, then Intellect prints Utility --► Provider --► Provider <First Name> <Middle Initial> <Last Name> <Title>.
57.1.2.2 When both the <Organization Name> and provider’s name (<First Name> and <Last Name>) are completed, the <Organization Name> prints.
57.1.3 Professional 837 Electronic Claims Submission Equivalent Loop: 2010AA NM103, N104, NM105, NM107, N301, N401, N402, N403
57.2 PH#:
57.2.1 If Billing Method is by Clinic (Utility --► Set Up --► Parameter <Billing Method> = ‘C’ or ‘L’ with Utility --► Category <Billing Method> = ‘C’), then Intellect prints Utility --► Set Up --► Clinic <Phone> field.
57.2.2 If Billing Method is by Doctor (Utility --► Set Up --► Parameter <Billing Method> = ‘D’ or ‘L’ with Utility --► Category <Billing Method> = ‘D’), then Intellect prints Utility --► Provider --► Provider <Phone Number>.
57.2.3 Professional 837 Electronic Claims Submission Equivalent Loop: 2010AA PER04
58. Box 33a BILLING PROVIDER INFO & PH# (NPI)
58.1 If Billing Method is by Clinic (Utility --► Set Up --► Parameter <Billing Method> = ‘C’ or ‘L’ with Utility --► Category <Billing Method> = ‘C’) AND Utility --► Insurance --► Insurance <New Form> = ‘Y’ or ‘X’, then Intellect prints the Utility --► Insurance --► Insurance <Group NPI> field.
58.2 If Billing Method is by Doctor (Utility --► Set Up --► Parameter <Billing Method> = ‘D’ or ‘L’ with Utility --► Category <Billing Method> = ‘D’) AND Utility --► Insurance --► Insurance <New Form> = ‘Y’ or ‘X’, then Intellect prints for the Group NPI for the billing provider entered on Charges --► Charge (or Charges --► Modify) <Billing Prv> field based on the following hierarchy:
58.2.1 First looks at Utility --► Provider --► Provider Facility <Group NPI> for a match of the Billing Provider, Insurance and Facility.
58.2.2 If a match is not found, the program looks at Utility --► Provider --► Provider Provider <Group NPI> for a match of the Billing Provider and Insurance.
58.2.3 If a match is not found in either table, Intellect uses Utility --► Provider --► Provider <Group NPI>.
58.3 If Utility --► Insurance --► Insurance <New Form> = ‘N,’ then Intellect leaves this field blank regardless of the billing method.
58.4 Professional 837 Electronic Claims Submission Equivalent Loop: 2010AA NM109
59. Box 33b BILLING PROVIDER INFO & PH#
59.1 If Utility --► Insurance --► Insurance <New From (Y/N)>= X, lntellect leaves this field blank.
59.2 If Billing Method is by Clinic (Utility --► Set Up --►Parameter <Billing Method> = ‘C’ or ‘L’ with Utility --► Category <Billing Method> = ‘C’) AND Utility --► Insurance --► Insurance <New Form> = ‘Y,’ then Intellect prints the qualifier on the Utility --► Insurance --► Insurance <Box 33 Type> field followed by the legacy number in Utility --► Insurance --► Insurance <1500 Form Box 33 Group> field.
59.3 If Billing Method is by Doctor (Utility --► Set Up --►Parameter <Billing Method> = ‘D’ or ‘L’ with Utility --► Category <Billing Method> = ‘D’) AND Utility --► Insurance --► Insurance <New Form> = ‘Y,’ then Intellect prints for the qualifier on the Utility --► Insurance --► Insurance <Box 33 Type> field followed by the legacy number for the billing provider entered on Charges --► Charge (or Charges --► Modify) <Billing Prv> field based on the following hierarchy:
59.3.1 First looks at Utility --► Provider --► Provider Facility <HCFA Box33> for a match of the Billing Provider, Insurance and Facility.
59.3.2 If a match is not found, the program looks at Utility --► Provider --► Provider <HCFA Box33> for a match of the Billing Provider and Insurance.
59.3.3 If a match is not found in either table, Intellect uses Utility --► Insurance --► Insurance <Selection (1/2/3)> to determine which legacy provider number on Utility --► Provider --► Provider <HCFA BOX 33 1>, <HCFA BOX 33 2>, or <HCFA BOX 33 3>.
59.4 Professional 837 Electronic Claims Submission Equivalent Loop: 2000A PRV03, 2010AA REF01, REF02