Quick Resources


HCFA Form, Effective January 6, 2014


Effective version 14.11.19:

In prior software versions for Medicare paper claims, if the <Ref Prv> field on the Charges--►Charge screen was not populated, and the <Referring Name> field was not filled on the Registration--►Regular--►Patient screen, the rendering provider was used as the referring provider on the EB file, as well as printed on Box 17 of the HCFA claims.


As of this update, the referring provider only populates the EB file and the HCFA Box 17 if the Utility--►Insurance--►Insurance <Insurance Type> field is set to  'D', 'C', '1', '5' (WI Medicaid), or 'O' and a referring provider is added in the <Ref Prv> field on the Charges--►Charge screen at the time of posting charges, or when the Registration--►Regular--►Patient <Referring Name> field is filled.


ATTENTION: This IMMEDIATELY affects billing and other daily tasks.



Effective version 14.04.15

In regard to the new HCFA 1500 (02-12) Form, as of this update:


• When a patient (or insured) does not have a middle name, Intellect removes the comma after the first name.

• When there is no insured’s name in Box 9, ", ," has been removed.



Effective version 14.03.20
This update includes a change affecting the HCFA, BOX 9A for claims for Medi-Medi insurance patients. When the patient has MediCal as the secondary, Intellect now pulls the subscriber ID from the secondary MediCal insurance.



Effective Version 14.02.04
Prime Clinical Systems has made the necessary requirements for the new HCFA 1500 Form (02/12), scheduled for mandate on 4/1/2014.

For your office to implement the new HCFA 1500 Form (02/12):

1. Intellect must be on version 13.12.12 or greater.

2. If your office has the HCFA 1500 forms set up as an Automated Task, you must contact our PCS Support Team at (, or by phone at 626-449-1705, to make the necessary changes to the Tasks for the new form.

    a. In the Subject Line of the email:  New HCFA Task Changes
    b. In the Body of the email: Client Id, Contact person and direct phone number.

3. If your office uses the Red and White HCFA Form, you may purchase them from Prime Clinical Systems. For more information on purchasing the New HCFA Form, please email

    a. In the Subject Line of the email: Order New HCFA
    b. In the Body of the email:  Client Id, contact name and direct phone number.

NOTE: Before doing this, please be sure to test the NEW FORM by updating the Utility/Insurance/Form = NEW HCFA (For the Black and white form), NEW HCFA RED (for the Red and white form.



Efective Version 13.10.29

A new Health Insurance Claim Form (HCFA) has been released, which goes into effect January 6, 2014. Some of the changes to be aware of include:


Use commas to separate the last name, first name, and middle initial. A hyphen can be used for hyphenated names. Do not use periods within the name.

8-digit dates must be used in all date-of-birth fields (items 3, 9b, and 11a).

Leave Box 8 blank


Also please note the following for individual boxes on the form:


Box 11 Insured’s Policy Group or FECA Number:


11b Other Claim ID (Designated by NUCC)

Enter the “Other Claim ID”. Applicable claim identifiers are designated by the NUCC. The following qualifier and accompanying identifier has been designated for use:


Y4 Property Casualty Claim Number


Enter the qualifier to the left of the vertical dotted line.

Enter the identifier number to the right of the vertical dotted line. For example:




Box 14 Date of Current Illness, Injury, or Pregnancy (LMP)



To the right of the vertical dotted line, enter the applicable qualifier to identify which date is being reported (431), onset of current symptoms or illness (484), or last menstrual period.


Box 15 Other Date



To the right of the vertical dotted line, enter the applicable qualifier to identify which date is being reported:


454 Initial Treatment

304 Latest Visit or Consultation

453 Acute Manifestation of a Chronic Condition

439 Accident

455 Last X-ray

471 Prescription

090 Report Start

091 Report End

444 First Visit or Consultation


Box 17 Name of Referring Provider or Other Source

Before the vertical dotted line, enter the applicable qualifier to identify which provider is being reported:


DN Referring Provider

DK Ordering Provider

DQ Supervising Provider


Effective version 14.07.01, see additional information for Box 17.


Box 21 Diagnosis or Nature of Illness or Injury

Between the vertical dotted lines, enter the applicable ICD indicator to identify which version of ICD codes is being reported:


9 ICD-9-CM

0 ICD-10-CM


Relate lines A - L to the lines of service in 24E by the letter of the line.