Intellect™
INSTITUTIONAL UB92 SAMPLE PAPER CLAIMS
Box 1 - Provider or Clinic information: Examples one through three indicate available set up options.
Box 4 - Bill Type: Example four indicates available set up options.
Box 38 - Insurance Company name and address: Examples five and six indicate available set up options.
Boxes 42 - 49 - Charge information: Examples seven through twelve indicate the different formats available for data, along with instructions for data entry, form type, and set up options.
Boxes 50a through 62a, and 65 through 66 - Primary and Secondary insurance information: Examples thirteen and fifteen indicate set up options.
Boxes 65 and 66 - Employer Name and Address: Examples sixteen through eighteen indicate where the information may be printed from.
Boxes 82 and 83 - Attending and Other Physician ID: Examples nineteen through twenty one indicate where the data is pulled from.
Box 84 - Remarks: Examples twenty two and twenty three indicate the different programming options available.
Box 1 - Provider or Clinic information:
Examples one through three indicate available set up options for all form types.
Utility --►Set Up --►Parameter
The <Billing Method> field = C.
The name and address pull from the Utility --►Set Up --►Clinic screen <Name> and <Address> fields.
Utility --►Set Up --►Parameter
The <Billing Method> field = D.
AND
Utility --►Provider
The <Organization> field is completed.
The name is pulled from the <Organization> field.
Utility --►Set Up --►Parameter
The <Billing Method> field = D.
AND
Utility --►Provider
The <Organization> field is blank.
The name is pulled from the Utility --►Provider <Provider First Name>, <Middle Initial>, <Last Name> and <Title> fields.
Example four indicates available set up options for all form types.
Example Four:
Charges --► Encounter --►UB Encounter
If the <Bill Type> field is completed and the charges are linked to the encounter, the Bill Type prints.
Utility --►Set Up --►Clinic
If the <Facility Identification Number> field is completed and either an encounter is NOT linked to the charges, or the Encounter Bill Type is blank, the number entered in the <Facility Identification Number> prints:
Box 38 - Insurance Company name and address:
Examples five and six indicate available set up options for all form types.
Utility --►Insurance
If <Print Name on Claim> = Y (yes), the name and address from the insurance record prints in Box 38:
Utility --►Insurance
If <Print Name on Claim> = N (no), Box 38 is left blank:
Boxes 42 through 49 - Charge information:
Examples seven through twelve indicate the different formats available for data, along with instructions for data entry, form type, and set up options.
NOTE: The order in which the charges print on Form Types V and U are determined by the Utility --► Set Up --► Parameter screen <Itemization> field. The options available are:
H Highest charge amount to lowest charge amount
L Lowest charge amount to highest charge amount
E Order in which charges were posted
S Date of Service order, then Entry order
Form Type 8 ALWAYS prints in Revenue Code order from lowest to the highest.
Example Seven - Form Type V and U
Example Eight - Form Type V and U
Example Nine - Form Type V and U
Example Ten - Form Type V and U
Form Type: V (laser generated form) and U (red and white form).
Charges --►Charge
Services for a date range were posted on a single line. In this example, charges are posted for From Date = 09/01/2006 and To Date = 09/30/2006. To post charges in this manor, set up Utility --►Procedure --►Procedure as follows:
<Global> = X
<Qty (Y/N/X)> = X
In Utility --►Insurance, set up:
<UB92 Special Handling> = Y (yes)
<Comment on Bill> = N (no) or there are no Charge Remarks entered
Form Type: V (laser generated form) and U (red and white form)
Charges --►Charge
Services for a date range were posted on a single line. In this example, charges are posted for From Date = 09/01/2006 and To Date = 09/30/2006. To post charges in this manor, set up Utility --►Procedure as follows:
<Global> = X
<Qty (Y/N/X)> = X
In Utility --►Insurance, set up:
<UB92 Special Handling> = Y (yes)
<Comment on Bill> = Y (yes) and there are Charges Remarks entered
Form Type: V (laser generated form) and U (red and white form).
Charges --►Charge
A separate charge is posted for each Date of Service within the date range billed.
In Utility --►Insurance, set up:
<UB92 Special Handling> = Y (yes)
<Comment on Bill> = N (no) or there are no Charge Remarks entered
Form Type: V (laser generated form) and U (red and white form).
A separate charge is posted for each Date of Service within the date range billed.
In Utility --►Insurance, set up:
<UB92 Special Handling> = Y (yes)
<Comment on Bill> = Y (yes) and there are Charges Remarks entered
Form Type: 8 (laser generated form summarized by Revenue Code and DOS).
Charges --►Charge
A separate charge is posted for each Date of Service within the date range billed.
In Utility --►Insurance, note:
<UB92 Special Handling> does NOT affect this section of Form 8. This field is used only when charges are posted as a date range.
<Comment on Bill> does NOT affect this section of Form 8. Regardless of whether or not Charge Remarks are entered, they do NOT print on Form 8.
Form Type: 8 (laser generated form summarized by Revenue Code and DOS)
Charges --►Charge
Services for a date range were posted on a single line. In this example, charges are posted for From Date = 09/01/2006 and To Date = 09/30/2006. To post charges in this manor, set up Utility --►Procedures as follows:
<Global> = X
<Qty (Y/N/X)> = X
In Utility --►Insurance, set up:
<UB92 Special Handling> = Y (yes)
Note: The <Comment on Bill> field does NOT affect this section of Form 8. Regardless of whether or not Charge Remarks are entered they do NOT print on Form 8.
Boxes 50a through 62a, and 65 through 66 - Primary and Secondary insurance information:
Examples thirteen and fifteen indicate set up options.
Example Thirteen - Form Type 8
Example Fourteen - Form Type 8
Example Fifteen - Form Type U and V
Form Type: 8 (laser generated form summarized by Revenue Code and DOS)
This setting only applies to Form Type 8 when printing the secondary insurance claim, and was designed for use when billing Medi-Cal as secondary to Rural Health Medicare.
Utility --►insurance
If the <Print Prim Ins on Sec> field is set to Y (yes), when printing the secondary ins claim, the Secondary insurance information prints in Boxes 50a, 51a, 52a, 60a and 62a in place of the Primary insurance information.
Box 54a (where the Primary Insurance payment would normally print) is left blank.
The total charges print in Box 55a in place of the balance.
Form Type: 8 (laser generated form summarized by Revenue Code and DOS)
This setting only applies to Form Type 8, and was designed for use when billing Medi-Cal as secondary to Rural Health Medicare.
Utility --►insurance
If the <Print Prim Ins on Sec> is set to N (no), Insurance information for the Primary Insurance is NOT printed on the form. Instead, the Secondary Insurance information is printed on the first line, and Box 54 is left blank.
Form Type: U and V
NOTE: The Utility --►Insurance <Print Prim Ins on Sec> field does not apply to Form Types V (laser generated form) and U (red and white form).
Boxes 65 and 66 - Employer Name and Address:
Examples sixteen through eighteen indicate where the information may be printed from.
NOTE: Where the data is printed from is dependent upon the Relationship to Insured.
Example Sixteen - All Form Types
Example Eighteen - Form Type 8
All Form Types
Registration --►Regular --►Patient - Insurance screen
If the <Relation to Insured> field is 18 (self), the data is printed from the Patient screen's <Employer Name> and <Address> fields when the Utility --►Category screen <Type> field is other than W (worker compensation) or F (worker compensation with first report of injury). See line one of the following example.
If the <Relation to Insured> field is other than 18, the data is printed from the Patient Insurance screen <Employer Name> and <Employer Address> fields. See line two of the following example.
NOTE: If the Relationship to Insured is other than 18, and the <Insured Name> or <Address> is left blank on the insurance screen, the field is left blank on the printed form, even if the employer information is completed on the patient demographic screen. In the following example, for the second line of Boxes 65 and 66, the insured <Employer Name> was completed and printed, but the <Address> was left blank and therefore the second line Box 66 is blank.
Form Type 8
Primary Insurance information may be excluded by setting the following; the other criteria regarding the Relationship to Insured still applies:
In Utility --►Insurance, set up:
<Print Prim on Sec Ins> = N
Boxes 82 and 83 - Attending and Other Physician ID:
Examples nineteen through twenty one indicate where the data is pulled from.
NOTE: The information printed in Boxes 82 and 83 are dependent on the Utility --►Insurance screen <Insurance Type> field.
NOTE: If the Utility --►Referring screen <Doctor/Other> field is set to O (other), the referring provider (a.k.a. ordering physician) information does NOT print.
Example Nineteen - All Form Types
Example Twenty - All Form Types
Example Twenty One - All Form Types
All Form Types
In Utility --►Insurance, set up:
<Insurance Type> = D (usually Medi-Cal or Medicaid). The referring doctor’s (a.k.a. ordering physician's) number prints, depending on Utility --►Insurance Box 17a.
NOTE: If there was no Referring Doctor posted, the Billing Provider’s Utility --►Provider --►Facility HCFA Box 24K prints. If none, the Utility --►Provider --►Provider-Provider HCFA Box 24K number prints. If none, the Utility --►Provider --►Provider HCFA Box 24K1, HCFA Box 24K 2, or HCFA Box 24K 3 print, dependent on the Utility --►Insurance --►Insurance <Selection (1/2/3)>.
NOTE: When the Utility --►Insurance --►Insurance screen <Insurance Type> field is set to D, the Referring Doctor or Billing Doctor name does NOT print.
All Form Types
In Utility --►Insurance, set up:
<Insurance Type> = C or 1 (usually Medicare or Medi-Medi). The referring doctor's (a.k.a. ordering physician's) number, depending on the Utility --►Insurance --►Insurance screen <Box 17a> field, and Name print.
NOTE: If there was no Referring Doctor posted, the Billing Provider’s Utility --►Provider screen <UPIN No> and <Name> print.
All Form Types
In Utility --►Insurance <Insurance Type>, for all types other than D, C, or 1, the Billing Provider’s Utility --►Provider --►Provider-Facility table number prints HCFA Box 24K.
If none, the Utility --►Provider --►Provider-Provider screen <Prov No> prints.
If none, the Utility --►Provider --►Provider screen HCFA Box 24K 1, HCFA Box 24K 2, or HCFA Box 24K 3 prints, depending on the Utility --►Insurance --►Insurance screen <Selection (1/2/3)> field.
The Billing Provider’s Name prints
Examples twenty two and twenty three indicate the different programming options available.
All Form Types or only V and U
Report Designer set up:
The program default prints Claim Notes entered in the UB Encounter screen, but may be modified to print the Charge Remark entered in either the Charges --►Charge or Charges --►Modify screen. To have this changed, please contact Prime Clinical Systems, Inc.
Claim notes entered in the Charges --►Encounter --►UB Encounter screen <Claim Notes> field.
Remarks entered in Charges --►Charge or Charges --►Modify
