Insurance Form Pull Fields

Owned by Dylan Nigh
Apr 27, 2023
168 min read

Claims pull fields are to be used with the 'Insurance' Form Type and will pull data onto paper form templates. Claims pull field categories include:

  • ADA 2006

  • CMS 1500

  • Charges

  • Charges Referral

  • Claim

  • Custom Fields

  • Diagnosis

  • Facility

  • Incident

  • Office

  • Other Insurance

  • Other Policy Holder

  • Patient

  • Patient Referral 1

  • Patient Referral 2

  • Patient Referral 3

  • Policy Holder

  • Provider

  • This Insurance

ADA 2006

  • ADA Box 12: This will display the patient's Name (Last, First, MI, Suffix) and street address.  This data will pull from the 'Last Name', 'First Name', 'Middle', 'Suffix', 'Street Address', 'Suite', 'City', 'State', and 'Zip Code' fields located in Patients > Patient.

  • ADA Box 13: This will reflect the date as entered in the 'Birth Date' field located in Patients > Patient.

  • ADA Box 14 Is Male: This is a "True/False" pull field that will display an 'X' respective to having selected "Male" from the 'Sex' popup located in Patients > Patient.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Male" is selected. If formatted for "False" an 'X' will display when "Male" is not selected.]

  • ADA Box 34 Position 1: This is a diagnosis Pointer.  When a diagnosis has been added to the first 'Diagnosis' field located in the Charge Window > Diagnosis for any procedure selected to be on the claim, this field will display an 'A'.

  • ADA Box 34 Position 2: This is a diagnosis Pointer.  When a diagnosis has been added to the first 'Diagnosis' field located in the Charge Window > Diagnosis for any procedure selected to be on the claim, this field will display an 'B'.

  • ADA Box 35: This will reflect the data as entered in the Notes field located in the Charge Window > Notes for any procedure selected to be on the claim.
    [Note: The 'Print as Remarks on Claim (Box 35)' checkbox MUST be selected.]

  • ADA Box 42 Remaining: This will display the data as entered in the 'Box 42 Months of Treatment Remaining' field located in Patients > Ledger > Incident Menu > ADA Claims.

  • ADA Box 48 Name: This will reflect the data as entered in the 'Name on Line 1 of ADA Box 48 (optional)' field located in References > User > Provider (DDS Only) for the provider selected from the 'Provider Shown on Claim' popup located in the Charge Window for the procedure(s) selected to be on the claim.

IF DATA HAS NOT BEEN ADDED TO THE ABOVE FIELD:

  • This will then reflect the Office Name of the office selected from the 'Office' popup located in the Charge Window for the procedure(s) selected to be on the claim. This data will pull from the 'Office Name' field located in the selected office's Reference. [Note: This field is inaccessible and can only be changed or updated by the Accounting Department.]

  • ADA Total Months Treatment: This will reflect the data as entered in the 'Total Months of Treatment' field located in Patients > Ledger > Incident Menu > ADA Claims. 

CMS 1500

  • CMS 1500 Box 10d Data: When the patient's primary insurance is Medicare and secondary insurance is Medicaid (as determined by the 'Plan' popup located in the selected insurance's Reference > Claims, or References > Claims > Plans if the patient has an insurance plan) this will display "MCD" followed by the patient's Medicaid Subscriber ID as entered in the 'Subscriber ID' field of the Medicaid Insurance record located in Patients > Patient > Insurance.[Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

  • CMS 1500 Box 11d Data: This will display "NONE" when the patient's primary insurance is Medicare. This data is determined by the 'Plan' popup located in the selected insurance's Reference > Claims, or References > Claims > Plans if the patient has an insurance plan.
    [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

  • CMS 1500 Box 11a DOB Data: This will reflect the date as entered in the 'Birth Date' field (located in Patients > Primary/Secondary; dependent upon the insurance carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window) for the policy holder of the selected insurance carrier.
    [Note: 1) The patient's Primary and Secondary Insurance Carriers are determined by the first and second Insurance records listed in Patients > Patient > Insurance (respectively). 2) If the Secondary Guarantor is the policy holder of the patient's primary insurance the DOB will NOT display.]

  • CMS 1500 Box 11a is Male Data: This is a "True/False" pull field that will display an 'X' respective to having selected "Male" from the 'Sex' popup located in Patients > Primary or Secondary (depending on the insurance carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window).
    [Note: 1) Pull field formatting MUST be set to "True". 2) The patient's Primary and Secondary Insurance Carriers are determined by the first and second Insurance records listed in Patients > Patient > Insurance (respectively). 3) If the Secondary Guarantor is the policy holder of the patient's primary insurance the data will NOT display.]

  • CMS 1500 Box 11b Data: [Nonfunctional]

  • CMS 1500 Box 11c Carrier Data: This will display the Name of the Insurance Carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window. This data will pull from the 'Insurance Company' field located in the selected insurance carrier's Reference > Company Info.

  • CMS Box 11c Data: This will display the Name of the Insurance Carrier selected from the 'Insurance Carrier' popup located in the Claim Creation window. This data will pull from the 'Insurance Company' field located in the selected insurance carrier's Reference > Company Info.

IF THE PATIENT HAS AN INSURANCE PLAN:

  • This will then display the Name of the patient's insurance plan selected from the 'Plan' popup of the Insurance Carrier record (located in Patients > Primary/Secondary) selected from the 'Insurance Carrier' popup located in the Claim Creation Window. This data will pull from the 'Plan Name' field found in the Insurance Plan table located in the selected insurance carrier's Reference > Plans.

  • CMS Box 11c Plan Data: This will display the Name of the patient's insurance plan selected from the 'Plan' popup of the Insurance Carrier record (located in Patients > Primary/Secondary) selected from the 'Insurance Carrier' popup located in the Claim Creation Window. This data will pull from the 'Plan Name' field found in the Insurance Plan table located in the selected insurance carrier's Reference > Plans.

  • CMS 1500 Box 11d Data: This is a "True/False" pull field that will display an 'X' respective to the following insurance combinations found in the Insurance table located in Patients > Primary.

    • If the patient has Medicare and no other insurance, no 'Xs' will be displayed.

    • If the patient has only one insurance that is NOT Medicare, a "false" 'X' (No) will be displayed.
      [Note: Pull field formatting MUST be set to "False".]

    • If the patient has more than one insurance, a "true" 'X' (Yes) will be displayed.
      [Note: Pull field formatting MUST be set to "True".]

  • CMS 1500 Box 17a Code: This will display the Charge Referral's Legacy Qualifier Code as determined by the data selected from the 'Legacy Referral Qualifier Code' popup located in the selected insurance carrier's Reference > Claims.

IF "AUTOMATIC" HAS BEEN SELECTED FROM THE 'LEGACY REFERRAL ID NUMBER' POPUP: 

  • This will then display the Legacy ID as determined by the 'Plan' popup located in the selected insurance carrier's Reference > Claims. In these cases the following items below will NOT display an ID.[Note: If "Automatic" is selected, and the patient has an insurance plan, this will instead display the data as determined by the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage.] 

    • Self Pay: [N/A]

    • Central Certification: G2 (Provider Commercial Number)

    • Other Non-Federal Programs: G2 (Provider Commercial Number)

    • Preferred Provider Organization (PPO): N5 (Provider Plan Network Identification Number)

    • Point of Service (POS): [N/A]

    • Exclusive Provider Organization (EPO): [N/A]

    • Indemnity Insurance: [N/A]

    • HMO Medicare Risk: N5 (Provider Plan Network Identification Number)

    • Automobile Medical: [N/A]

    • Blue Cross/Blue Shield: 1B (Blue Shield Provider Number)

    • Champus: 1H (CHAMPUS Identification Number)

    • Commercial Insurance Co.: G2 (Provider Commercial Number)

    • Disability: G2 (Provider Commercial Number)

    • Health Maintenance Organization: N5 (Provider Plan Network Identification Number)

    • Liability: [N/A]

    • Liability Medical: [N/A]

    • Medicare Part B: 1C (Medicare Provider Number)

    • Medicaid: 1D (Medicaid Provider Number)

    • Other Federal Program: [N/A]

    • Title V: [N/A]

    • Veteran Administration Plan: [N/A]

    • Worker's Compensation Health Claim: X5 (State Industrial Accident Provider Number)

    • Mutually Defined Unknown: [N/A]

  • CMS 1500 Box 17a ID: This will display the Charge Referral's Legacy ID as determined by the 'Legacy Referral ID Number' popup located in the selected insurance carrier's Reference > Claims. This data will pull from the corresponding field located in the charge referrer's Reference > Provider IDs.

IF "AUTOMATIC" HAS BEEN SELECTED FROM THE 'LEGACY REFERRAL ID NUMBER' POPUP: 

  • This will then display the Legacy ID as determined by the 'Plan' popup located in the selected insurance carrier's Reference > Claims. In these cases the following items below will NOT display an ID.
    [Note: If "Automatic" is selected, and the patient has an insurance plan, this will instead display the data as determined by the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage.] 

    • Point of Service

    • Exclusive Provider Organization (EPO)

    • Indemnity Insurance

    • Automobile Medical

    • Liability

    • Liability Medical

    • Other Federal Program

    • Veteran Administration Plan

    • Mutually Defined Unknown

  • CMS 1500 Box 19 Data: This will reflect the data as entered in the 'Box 19 on CMS-1500 Claim Form' field located in Patients > Ledger > Incident Menu > Incident.

  • CMS 1500 Box 22 Code: This will reflect the data as entered in the 'Resubmission Code' field located in the Claim Creation Window.

  • CMS 1500 Box 22 Reference: This will reflect the data as entered in the 'Resubmission Reference' field located in the Claim Creation Window.

  • CMS 1500 Box 23 Data: This will display the Prior Authorization Number of the Prior Authorization record selected from the 'Prior Auth' popup located in the Claim Creation Window. This will reflect the data as entered in the 'Prior Authorization' field of the selected Prior Authorization record located in Patients > Ledger > Incident Menu > Prior Auth. If the Claim does not have a Prior Authorization, this field will then display "None".
    [Note: To select the Prior Authorization record from the Claim Creation Window the following MUST be true: 1) The claim's Insurance Carrier MUST be selected from the 'Insurance' popup found in the Prior Authorization's record located in Patients > Ledger > Incident Menu > Prior Auth. 2) The Prior Authorization's record MUST have at least one remaining visit. 3) The current date MUST fall between the Prior Authorization record's Start Date and Expiration Date.]

  • CMS 1500 Box 24 Supp.: This will display an 'N4', followed by the NDC number, brand name, and dose measurement for any medication that has been added to the Charge Window > Rx for any procedure selected for the claim.
    [Note: The NDC number MUST be added to the 'National Drug Code' field located in the selected medication's Reference (Medications (FDB)) > Dose.]

  • CMS 1500 Box 24 Supp. (No N4): This will display the NDC number, followed by the brand name, and dose measurement for any medication that has been added to the Charge Window > Rx for any procedure selected for the claim.
    [Note: The NDC number MUST be added to the 'National Drug Code' field located in the selected medication's Reference (Medications (RxNorm eRx: FDB)) > Dose.]

  • CMS 1500 Box 24h Data: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Family Planning' checkbox located in Patients > Patient > Insurance.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the checkbox is selected. If formatted for "False", an 'X' will display when the checkbox is deselected.]

  • CMS 1500 Box 24i (NPI) Code: This will display the Rendering Provider's Qualifier Code as determined by the data selected from the selected provider's 'Qualifier Code (box 24)' popup located the selected insurance carrier's Reference > Provider IDs.

IF "AUTOMATIC HAS BEEN SELECTED FROM THE 'QUALIFIER CODE (BOX 24)' POPUP: 

  • This will then display the Qualifier Code as determined by the data selected from the 'Plan' popup located in the selected insurance carrier's Reference > Claims. In these cases the Qualifier Codes found below will be displayed when the following item is selected from the 'Plan' popup.

    • Self Pay: G2 (Provider Commercial Number)

    • Central Certification: G2 (Provider Commercial Number)

    • Other Non-Federal Programs: G2 (Provider Commercial Number)

    • Preferred Provider Organization (PPO): G2 (Provider Commercial Number)

    • Point of Service (POS): G2 (Provider Commercial Number)

    • Exclusive Provider Organization (EPO): G2 (Provider Commercial Number)

    • Indemnity Insurance: G2 (Provider Commercial Number)

    • HMO Medicare Risk: G2 (Provider Commercial Number)

    • Automobile Medical: G2 (Provider Commercial Number)

    • Blue Cross/Blue Shield: 1B (Blue Shield Provider Number)

    • Champus: 1H (CHAMPUS Identification Number)

    • Commercial Insurance Co.: G2 (Provider Commercial Number)

    • Disability: G2 (Provider Commercial Number)

    • Health Maintenance Organization: G2 (Provider Commercial Number)

    • Liability: G2 (Provider Commercial Number)

    • Liability Medical: G2 (Provider Commercial Number)

    • Medicare Part B: 1C (Medicare Provider Number)

    • Medicaid: 1D (Medicaid Provider Number)

    • Other Federal Program: G2 (Provider Commercial Number)

    • Title V: G2 (Provider Commercial Number)

    • Veteran Administration Plan: G2 (Provider Commercial Number)

    • Worker's Compensation Health Claim: ZZ (Provider Taxonomy)

    • Mutually Defined Unknown: G2 (Provider Commercial Number)

  • CMS 1500 Box 24i Code: This will display the Rendering Provider's Qualifier Code as determined by the data selected from the provider's 'Qualifier Code (box 24)' popup located in the selected insurance carrier's Reference > Provider IDs.

IF "AUTOMATIC" HAS BEEN SELECTED FORM THE 'QUALIFIER CODE (BOX 24)' POPUP: 

  • This will then display the Qualifier Code as determined by the data selected from the 'Plan' popup located in the selected insurance carrier's Reference > Claims. In these cases the Qualifier Codes found below will be displayed when the following item is selected from the 'Plan' popup.

    • Self Pay: G2 (Provider Commercial Number)

    • Central Certification: G2 (Provider Commercial Number)

    • Other Non-Federal Programs: G2 (Provider Commercial Number)

    • Preferred Provider Organization (PPO): G2 (Provider Commercial Number)

    • Point of Service (POS): G2 (Provider Commercial Number)

    • Exclusive Provider Organization (EPO): G2 (Provider Commercial Number)

    • Indemnity Insurance: G2 (Provider Commercial Number)

    • HMO Medicare Risk: G2 (Provider Commercial Number)

    • Automobile Medical: G2 (Provider Commercial Number)

    • Blue Cross/Blue Shield: 1B (Blue Shield Provider Number)

    • Champus: 1H (CHAMPUS Identification Number)

    • Commercial Insurance Co.: G2 (Provider Commercial Number)

    • Disability: G2 (Provider Commercial Number)

    • Health Maintenance Organization: G2 (Provider Commercial Number)

    • Liability: G2 (Provider Commercial Number)

    • Liability Medical: G2 (Provider Commercial Number)

    • Medicare Part B: 1C (Medicare Provider Number)

    • Medicaid: 1D (Medicaid Provider Number)

    • Other Federal Program: G2 (Provider Commercial Number)

    • Title V: G2 (Provider Commercial Number)

    • Veteran Administration Plan: G2 (Provider Commercial Number)

    • Worker's Compensation Health Claim: ZZ (Provider Taxonomy)

    • Mutually Defined Unknown: G2 (Provider Commercial Number)

  • CMS 1500 Box 24k (NPI) Data: This will reflect the data as entered in the Rendering Provider's 'Paper ID' field located in the selected insurance carrier's Reference > Provider ID.

  • CMS 1500 Box 24k (NPI) NPI: This will reflect the data as entered in the 'National Provider ID (NPI)' field located in the Rendering Provider's Reference > Provider > Claim Credentials.

  • CMS 1500 Box 24k Data: This will reflect the data as entered in the Rendering Provider's 'Paper ID' field located in the selected insurance carrier's Reference > Provider ID.

  • CMS 1500 Box 24k Group Data: This will reflect the data as entered in the Rendering Provider's 'Practice Group ID (Paper)' field located in the selected insurance carrier's Reference > Provider ID.

  • CMS 1500 Box 24k Pin Data: This will reflect the data as entered in the Rendering Provider's 'Paper ID' field located in the selected insurance carrier's Reference > Provider ID.

  • CMS 1500 Box 32 (NPI) Data: This will display the full Name & Address of the Office, Facility, or Lab depending on the following scenarios:

    • This will display the full Name & Address of the office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Office Name', 'Street Address', 'Suite', 'City', 'State', and 'Zip Code' fields located in the selected office's Reference > Mailing Address.
      [Note: These fields are inaccessible and can only be changed or updated by the Accounting Department.]

IF A FACILITY RECORD HAS BEEN ADDED TO THE FACILITY TABLE LOCATED IN THE SELECTED PROCEDURE'S CHARGE WINDOW:

  • This will then display the full Name & Address of the selected Facility record. This data will pull from the 'Facility Name', 'Street Address', 'Suite', 'City', 'State', and 'Zip Code' fields located in the selected facility's Reference.

IF NO FACILITY HAS BEEN ADDED, AND INSTEAD A LAB RECORD HAS BEEN ADDED TO THE LAB TABLE AND "DIAGNOSTIC LAB (PATHOLOGY)(5)" HAS ALSO BEEN SELECTED FROM THE 'TYPE OF SERVICE' POPUP LOCATED IN THE SELECTED PROCEDURE'S CHARGE WINDOW:

  • This will then display the full Lab Name & Address of the selected Lab record. This data will pull from the 'Lab Name', 'Street Address', 'Suite', 'City', 'State', and 'Zip Code' fields located in the selected lab's Reference.
     [Note: 1) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization. 2) The 'Type of Service' popup is not available in DDS.]

  • CMS 1500 Box 32 Address Line: This will either display the Street Address of the Office, Facility, or Lab depending on the following scenarios:

    • This will display the Street Address of the office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Street Address' field located in the selected office's Reference > Mailing Address.
      [Note: This field is inaccessible and can only be changed or updated by the Accounting Department.]

IF A FACILITY RECORD HAS BEEN ADDED TO THE FACILITY TABLE LOCATED IN THE SELECTED PROCEDURE'S CHARGE WINDOW:

  • This will then display the Street Address of the selected Facility record. This data will pull from the 'Street Address' field located in the selected facility's Reference.

IF NO FACILITY HAS BEEN ADDED, AND INSTEAD A LAB RECORD HAS BEEN ADDED TO THE LAB TABLE AND "DIAGNOSTIC LAB (PATHOLOGY)(5)" HAS ALSO BEEN SELECTED FROM THE 'TYPE OF SERVICE' POPUP LOCATED IN THE SELECTED PROCEDURE'S CHARGE WINDOW:

  • This will then display the Street Address of the selected Lab record. This data will pull from the 'Street Address' field located in the selected facility's Reference.
    [Note: 1) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization. 2) The 'Type of Service' popup is not available in DDS.]

  • CMS 1500 Box 32 City Line: This will either display the City, State and Zip Code of the Office, Facility, or Lab depending on the following scenarios:

    • This will display the City, State, and Zip Code of the Office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'City', 'State', and 'Zip Code' fields located in the selected office's Reference > Mailing Address.
      [Note: These fields are inaccessible and can only be changed or updated by the Accounting Department.]

IF A FACILITY RECORD HAS BEEN ADDED TO THE FACILITY TABLE LOCATED IN THE SELECTED PROCEDURE'S CHARGE WINDOW:

  • This will then display the City, State, and Zip Code of the selected Facility record. This data will pull from the 'City', 'State', and 'Zip Code' fields located in the selected facility's Reference.

IF NO FACILITY HAS BEEN ADDED, AND INSTEAD A LAB RECORD HAS BEEN ADDED TO THE LAB TABLE AND "DIAGNOSTIC LAB (PATHOLOGY)(5)" HAS ALSO BEEN SELECTED FROM THE 'TYPE OF SERVICE' POPUP LOCATED IN THE SELECTED PROCEDURE'S CHARGE WINDOW:

  • This will then display the City, State, and Zip Code of the selected Lab record. This data will pull from the 'City', 'State', and 'Zip Code' fields located in the selected lab's Reference.
    [Note: 1) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization. 2) The 'Type of Service' popup is not available in DDS.]

  • CMS 1500 Box 32 Data: This will either display the full Name & Address of the Office, the full Name/Address and Tax ID of the Facility, or the full Name/Address and Lab ID of the Lab depending on the following scenarios:

    • This will display the full Office Name & Address of the office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Office Name', 'Street Address', 'Suite', 'City', 'State', and 'Zip Code' fields located in the selected office's Reference > Mailing Address.
      [Note: These fields are inaccessible and can only be changed or updated by the Accounting Department.]

IF A FACILITY RECORD HAS BEEN ADDED TO THE FACILITY TABLE LOCATED IN THE SELECTED PROCEDURE'S CHARGE WINDOW:

  • This will then display the full Name/Address and Tax ID of the selected Facility record. This data will pull from the 'Facility Name', 'Street Address', 'Suite', 'City', 'State', 'Zip Code' and 'Facility Tax ID' fields located in the selected facility's Reference.

IF NO FACILITY HAS BEEN ADDED, AND INSTEAD A LAB RECORD HAS BEEN ADDED TO THE LAB TABLE AND "DIAGNOSTIC LAB (PATHOLOGY)(5)" HAS ALSO BEEN SELECTED FROM THE 'TYPE OF SERVICE' POPUP LOCATED IN THE SELECTED PROCEDURE'S CHARGE WINDOW:

  • This will then display the full Lab Name/Address and Lab ID of the selected Lab record. This data will pull from the 'Lab Name', 'Street Address', 'Suite', 'City', 'State', 'Zip Code' and 'Lab ID' fields located in the selected facility's Reference.
    [Note: 1) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization. 2) The 'Type of Service' popup is not available in DDS.]

  • CMS 1500 Box 32 Name Line: This will either display the Office Name, the Facility Name, or the Lab Name depending on the following scenarios:

    • This will display the Office Name of the office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Office Name' field located in the selected office's Reference.
      [Note: These fields are inaccessible and can only be changed or updated by the accounting department.]

IF A FACILITY RECORD HAS BEEN ADDED TO THE FACILITY TABLE LOCATED IN THE SELECTED PROCEDURE'S CHARGE WINDOW:

  • This will then display the Facility Name of the selected Facility record. This data will pull from the 'Facility Name' field located in the selected facility's Reference.

IF NO FACILITY HAS BEEN ADDED, AND INSTEAD A LAB RECORD HAS BEEN ADDED TO THE LAB TABLE AND "DIAGNOSTIC LAB (PATHOLOGY)(5)" HAS ALSO BEEN SELECTED FROM THE 'TYPE OF SERVICE' POPUP LOCATED IN THE SELECTED PROCEDURE'S CHARGE WINDOW:

  • This will then display the Lab Name of the selected Lab record. This data will pull from the 'Lab Name' field located in the selected lab's Reference.
    [Note: 1) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization. 2) The 'Type of Service' popup is not available in DDS.]

  • CMS 1500 Box 32a NPI: This will either display the NPI of the Facility or Lab depending on the following scenarios:

    • This will display the NPI of the Facility record selected from the Facility table located in the selected procedure's Charge Window. This data will pull from the 'National Provider ID (NPI)' field located in the selected facility's Reference.

IF NO FACILITY HAS BEEN ADDED, AND INSTEAD A LAB RECORD HAS BEEN ADDED TO THE LAB TABLE AND "DIAGNOSTIC LAB (PATHOLOGY)(5)" HAS ALSO BEEN SELECTED FROM THE 'TYPE OF SERVICE' POPUP LOCATED IN THE SELECTED PROCEDURE'S CHARGE WINDOW:

  • This will then display the NPI of the Lab record selected from the Lab table located in the selected procedure's Charge Window. This data will pull from the 'National Provider ID' field located in the selected lab's Reference.
    [Note: 1) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization. 2) The 'Type of Service' popup is not available in DDS.]

  • CMS 1500 Box 32b ID: This will display a Qualifier Code followed by either the Facility Tax ID or the Lab ID depending on the following scenarios:

    • This will display "G2" followed by the Tax ID of the Facility record selected from the Facility table located in the selected procedure's Charge Window or office Reference. This data will pull from the 'Facility Tax ID' field located in the selected facility's Reference.

IF NO FACILITY HAS BEEN ADDED, AND INSTEAD A LAB RECORD HAS BEEN ADDED TO THE LAB TABLE AND "DIAGNOSTIC LAB (PATHOLOGY)(5)" HAS ALSO BEEN SELECTED FROM THE 'TYPE OF SERVICE' POPUP LOCATED IN THE SELECTED PROCEDURE'S CHARGE WINDOW:

  • This field will then display "G2" followed by the Lab ID of the Lab record selected from the Lab table located in the selected procedure's Charge Window. This data will pull from the 'Lab ID #' field located in the selected lab's Reference.
    [Note: 1) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization. 2) The 'Type of Service' popup is not available in DDS.]

  • CMS 1500 Box 33 Group: This will reflect the data as entered in the 'Practice Group ID (Paper)' field of the rendering provider's record found in the Provider table located in the selected insurance carrier's Reference > Provider IDs.

IF NO DATA HAS BEEN ENTERED IN THE ABOVE FIELD:

  • This will then reflect the data as entered in the 'Practice Group ID (Paper)' field located in the selected insurance carrier' Reference > Company Info.

  •  CMS 1500 Box 33 National Provider ID: This will either display the Provider NPI or the Group NPI depending on the following scenarios:

    • This will display the data as entered in the 'Group National Provider ID (NPI)' field located in the rendering provider's User Reference > Provider > Claim Credentials.

IF NO DATA HAS BEEN ENTERED IN THE ABOVE FIELD:

  • This will then reflect the data as entered in the 'Group National Provider ID Number' field located in the Reference of the office selected from the 'Office' popup located in the selected procedure's Charge Window.

IF 'BILL AS INDIVIDUAL' HAS BEEN SELECTED FROM THE RENDERING PROVIDER'S RECORD FOUND IN THE PROVIDER TABLE LOCATED IN THE SELECTED INSURANCE CARRIER'S REFERENCE > PROVIDER IDs:

  • This will then reflect the data as entered in the 'National Provider ID (NPI)' field located in the rendering provider's User Reference > Provider > Claim Credentials.

  • CMS 1500 Box 33 Pin: This will display the data as entered in the 'Paper ID' field of the Rendering Provider's record found in the Provider table located in the selected insurance carrier's Reference > Provider IDs. 
    [Note: For this field to populate data the rendering provider's 'Bill as Individual' checkbox (located in the selected insurance carrier's Reference > Provider IDs) MUST also be selected.]

  • CMS 1500 Box 33 Provider Name: This will either display the office name or the rendering provider's name depending on the following scenarios:

    • This will display the Name of the office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Office Name' field located in the selected office's Reference. 
      [Note: This field is inaccessible and can only be changed or updated by the Accounting Department.]

IF 'BILL AS INDIVIDUAL' HAS BEEN SELECTED FROM THE RENDERING PROVIDER'S RECORD FOUND IN THE PROVIDER TABLE LOCATED IN THE SELECTED INSURANCE CARRIER'S REFERENCE > PROVIDER IDs:

  • This will then reflect the data as entered in the 'Name Printed in Box 53 of Insurance Form' field located in the rendering provider's User Reference > Provider > Claim Credentials.

  • CMS 1500 Box 33 Provider Phone: This will reflect the data as entered in the 'Phone' field located in the Rendering Provider's User Reference > User Information.

  • CMS Box 33b (NPI) Provider ID: This will display the Practice Group ID Number proceeded by a Group Qualifier Code as determined by the data selected from the rendering provider's 'Group Qualifier Code' popup located in the selected insurance carrier's Reference > Provider IDs.

IF "AUTOMATIC" HAS BEEN SELECTED FORM THE 'GROUP QUALIFIER CODE (BOX 33)' POPUP: 

  • This will then display the Group Qualifier Code as determined by the data selected from the 'Plan' popup located in the selected insurance carrier's Reference > Claims. In these cases the Qualifier Codes found below will be displayed when the following item is selected from the 'Plan' popup.

    • Self-pay: G2 (Provider Commercial Number)

    • Central Certification: G2 (Provider Commercial Number)

    • Other Non-Federal Programs: G2 (Provider Commercial Number)

    • Preferred Provider Organization (PPO): G2 (Provider Commercial Number)

    • Point of Service (POS): G2 (Provider Commercial Number)

    • Exclusive Provider Organization (EPO): G2 (Provider Commercial Number)

    • Indemnity Insurance: G2 (Provider Commercial Number)

    • HMO Medicare Risk: G2 (Provider Commercial Number)

    • Automobile Medical: G2 (Provider Commercial Number)

    • Blue Cross/Blue Shield: 1B (Blue Shield Provider Number)

    • Champus: 1H (CHAMPUS Identification Number)

    • Commercial Insurance Co.: G2 (Provider Commercial Number)

    • Disability: G2 (Provider Commercial Number)

    • Health Maintenance Organization: G2 (Provider Commercial Number)

    • Liability: G2 (Provider Commercial Number)

    • Liability Medical: G2 (Provider Commercial Number)

    • Medicare Part B: 1C (Medicare Provider Number)

    • Medicaid: 1D (Medicaid Provider Number)

    • Other Federal Program: G2 (Provider Commercial Number)

    • Title V: G2 (Provider Commercial Number)

    • Veteran Administration Plan: G2 (Provider Commercial Number)

    • Worker's Compensation Health Claim: ZZ (Provider Taxonomy)

    • Mutually Defined Unknown: G2 (Provider Commercial Number)

  • CMS 1500 Box 4 data: This will display the Name (Last, First MI) of the selected insurance carrier's Policy Holder. This data will pull from the 'Last Name (Guarantor)', 'First Name', and 'Middle' fields located in Patients > Primary or Secondary (depending the policy holder of the selected insurance carrier).

IF "SELF" HAS BEEN SELECTED FROM THE 'RELATIONSHIP TO PRIMARY/SECONDARY' POPUP LOCATED IN PATIENTS > PATIENT, OR IF "MEDICAID" HAS BEEN SELECTED FROM THE 'PLAN' POPUP LOCATED IN THE SELECTED INSURANCE CARRIER'S REFERENCE > CLAIMS:

  • This will then display "SAME".
    [Note: If the patient has an insurance plan this will display "SAME" when "Medicaid" has been selected from the 'Plan Type' popup located in the selected insurance carrier's Reference > Plans > Coverage.]

  • CMS 1500 Box 7 Address: This will display the Street Address and Suite Number of the selected insurance carrier's policy holder. This data will pull from the 'Street Address' and 'Suite/Apt. Number' fields located in Patients > Primary or Secondary (depending on the policy holder of the selected insurance carrier).
    [Note: If "Self" has been selected from the 'Relationship to Primary/Secondary' located in Patients > Patient, or if "Medicaid" has been selected from the 'Plan' popup located in the selected insurance carrier's Reference > Claims (Reference > Plans > Coverage if the patient has an insurance plan) NO data will display.]

  • CMS 1500 Box 7 City: This will display the City of the selected insurance carrier's policy holder. This data will pull from the 'City' field located in Patients > Primary or Secondary (depending on the policy holder of the selected insurance carrier).
    [Note: If "Self" has been selected from the 'Relationship to Primary/Secondary' located in Patients > Patient, or if "Medicaid" has been selected from the 'Plan' popup located in the selected insurance carrier's Reference > Claims (Reference > Plans > Coverage if the patient has an insurance plan) NO data will display.]

  • CMS 1500 Box 7 Phone: This will display the Phone Number of the selected insurance carrier's policy holder. This data will pull from the first "Home" 'Phone' field located in Patients > Primary or Secondary (depending on the policy holder of the selected insurance carrier).
    [Note: 1) If only one phone number has been entered, this number will display despite the selected Phone Type. 2) If "Self" has been selected from the 'Relationship to Primary/Secondary' located in Patients > Patient, or if "Medicaid" has been selected from the 'Plan' popup located in the selected insurance carrier's Reference > Claims (Reference > Plans > Coverage if the patient has an insurance plan) NO data will display.]

  • CMS 1500 Box 7 State: This will display the State of the selected insurance carrier's policy holder. This data will pull from the 'State' field located in Patients > Primary or Secondary (depending on the policy holder of the selected insurance carrier).
    [Note: If "Self" has been selected from the 'Relationship to Primary/Secondary' located in Patients > Patient, or if "Medicaid" has been selected from the 'Plan' popup located in the selected insurance carrier's Reference > Claims (Reference > Plans > Coverage if the patient has an insurance plan) NO data will display.]

  • CMS 1500 Box 7 Zip Code: This will display the Zip Code of the selected insurance carrier's policy holder. This data will pull from the 'Zip Code' field located in Patients > Primary or Secondary (depending on the policy holder of the selected insurance carrier).
    [Note: If "Self" has been selected from the 'Relationship to Primary/Secondary' located in Patients > Patient, or if "Medicaid" has been selected from the 'Plan' popup located in the selected insurance carrier's Reference > Claims (Reference > Plans > Coverage if the patient has an insurance plan) NO data will display.]

  • CMS 1500 Box 9 Data: This will display the Name (Last, First MI) of the policy holder for the insurance carrier selected from the 'Other Insurance' popup located in the Claim Creation Window. This data will pull from the 'Last Name (Guarantor)', 'First Name', and 'Middle' fields located in Patients > Primary or Secondary (depending on the policy holder of the selected insurance carrier).

  • CMS 1500 Box 9a Data: This will display the patient's Subscriber ID for the insurance carrier selected from the 'Other Insurance' popup located in the Claim Creation Window. This data will pull from the selected insurance carrier's 'Subscriber ID' field  located in Patients > Patient > Insurance.
    [Note: If the patient's Primary Insurance is Medicare, this will then display "MEDIGAP" followed by the patient's Subscriber ID.]

  • CMS 1500 Box 9b DOB Data: This will display the Date of Birth of the policy holder for the insurance carrier selected from the 'Other Insurance' popup located in the Claim Creation Window. This data will pull from the 'Birth Date' field located in Patients > Primary or Secondary (depending on the policy holder of the selected insurance carrier).

  • CMS 1500 Box 9b Is Male Data: This is a "True/False" pull field that will display an 'X' respective to having selected "male" from the 'Sex' popup located in Patients > Primary or Secondary (dependent upon the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the Claim Creation Window).
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Male" is selected. If formatted for "False" an 'X' will display when "Male" is not selected.]

  • CMS 1500 Box 9c Data: This will display the Street Address, State, and Zip Code of the insurance carrier selected from the 'Other Insurance' popup located in the Claim Creation Window. This data will pull from the 'Street Address', 'State', and 'Zip Code' fields located in the selected insurance carrier's Reference > Company Info.
    [Note: If the patient has an insurance plan this data will then pull from the selected insurance carrier's Reference > Plans > Demographic.]

  • CMS 1500 Box 9d Data: This will display the Name of the insurance carrier selected from the 'Other Insurance' popup located in the Claim Creation Window. This data will pull from the 'Insurance Company' field located in the selected insurance carrier's Reference > Company Info.

Charges

The number of transactions (procedures) to display, transactions offset, and charge amounts determined by Form Rules.
[Note: Default Form Rules: Max Transactions - 6; Transaction Offset - 24.00; Charge Amounts - Use Charge Amount]

  • Admitted Date: This will reflect the date as entered in the 'Admitted Date' field located in the selected procedure's Charge Window.[Note: Not available in DDS.]

  • Admitted Time: This will reflect the time as entered in the leftmost 'Time' field located in the selected procedure's Charge Window.
    [Note: 1) Pull field formatting MUST be set to "Text". 2) Not available in DDS.]

  • Anesthesia End 1: This will reflect the time as entered in the first 'End' field located in the selected procedure's Charge Window > Anesthesia.
    [Note: 1) The selected charge MUST have the 'Anesthesia' checkbox selected, and data MUST be entered in the 'Base Units', 'Minutes / Unit (Hour 0-4)', and 'Minutes / Unit (Hour 4+)' fields located in the selected procedure's Fee Schedule > Specialty. 2) Pull field formatting MUST be set to "Text".]

  • Anesthesia End 2: This will reflect the time as entered in the second 'End' field located in the selected procedure's Charge Window > Anesthesia.
    [Note: 1) The selected charge MUST have the 'Anesthesia' checkbox selected, and data MUST be entered in the 'Base Units', 'Minutes / Unit (Hour 0-4)', and 'Minutes / Unit (Hour 4+)' fields located in the selected procedure's Fee Schedule > Specialty. 2) Pull field formatting MUST be set to "Text".]

  • Anesthesia End 3: This will reflect the time as entered in the third 'End' field located in the selected procedure's Charge Window > Anesthesia.
    [Note: 1) The selected charge MUST have the 'Anesthesia' checkbox selected, and data MUST be entered in the 'Base Units', 'Minutes / Unit (Hour 0-4)', and 'Minutes / Unit (Hour 4+)' fields located in the selected procedure's Fee Schedule > Specialty. 2) Pull field formatting MUST be set to "Text".]

  • Anesthesia Start 1: This will reflect the time as entered in the 'Time 1 Start' field located in the selected procedure's Charge Window > Anesthesia.
    [Note: 1) The selected charge MUST have the 'Anesthesia' checkbox selected, and data MUST be entered in the 'Base Units', 'Minutes / Unit (Hour 0-4)', and 'Minutes / Unit (Hour 4+)' fields located in the selected procedure's Fee Schedule > Specialty. 2) Pull field formatting MUST be set to "Text".]

  • Anesthesia Start 2: This will reflect the time as entered in the 'Time 2 Start' field located in the selected procedure's Charge Window > Anesthesia.
    [Note: 1) The selected charge MUST have the 'Anesthesia' checkbox selected, and data MUST be entered in the 'Base Units', 'Minutes / Unit (Hour 0-4)', and 'Minutes / Unit (Hour 4+)' fields located in the selected procedure's Fee Schedule > Specialty. 2) Pull field formatting MUST be set to "Text".]

  • Anesthesia Start 3: This will reflect the time as entered in the 'Time 3 Start' field located in the selected procedur's Charge Window > Anesthesia.
    [Note: 1) The selected charge MUST have the 'Anesthesia' checkbox selected, and data MUST be entered in the 'Base Units', 'Minutes / Unit (Hour 0-4)', and 'Minutes / Unit (Hour 4+)' fields located in the selected procedure's Fee Schedule > Specialty. 2) Pull field formatting MUST be set to "Text".]

  • CDA Lab Code 1: This will display the Lab Code for the first Lab Code added to the Lab Code table located in the selected procedure's Charge Window. This data will pull from the 'Code' field located in the selected Lab Code's Reference (CDA Lab Codes), but can be edited from the Charge Window.
    [Note: The "Use Canadian Claim Fields" checkbox MUST be selected from Preferences > Localization.]

  • CDA Lab Code 2: This will display the Lab Code for the second Lab Code added to the Lab Code table located in the selected procedure's Charge Window. This data will pull from the 'Code' field located in the selected Lab Code's Reference (CDA Lab Codes), but can be edited from the Charge Window.
    [Note: The "Use Canadian Claim Fields" checkbox MUST be selected from Preferences > Localization.]

  • CDA Lab Fee 1: This will display the Lab Fee for the first Lab Code added to the Lab Code table located in the selected procedure's Charge Window. This data will pull from the 'Fee' field located in the selected Lab Code's Reference (CDA Lab Codes), but can be edited from the Charge Window.
    [Note: The "Use Canadian Claim Fields" checkbox MUST be selected from Preferences > Localization.]

  • Charge Amount: [Nonfunctional]

  • Diagnosis 1: This will display the first (checked) diagnosis code added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis 2: This will display the second (checked) diagnosis code added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis 3: This will display the third (checked) diagnosis code added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis 4: This will display the fourth (checked) diagnosis code added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis Index: This will display a maximum of four Diagnosis Pointers (1,2,3,4) reflective of the first four (checked) diagnosis code(s) added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis Index (1 Max): This will display a maximum of one diagnosis pointer (1) reflective of the first (checked) diagnosis code added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis Index (1 Max) (NPI): This will display a maximum of one diagnosis pointer (1) reflective of the first (checked) diagnosis code added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis Index (2 Max): This will display a maximum of two diagnosis pointers (1,2) reflective of the first two (checked) diagnosis code(s) added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis Index (2 Max) (NPI): This will display a maximum of two diagnosis pointers (12) reflective of the first two (checked) diagnosis code(s) added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis Index (3 Max): This will display a maximum of three diagnosis pointers (1,2,3) reflective of the first three (checked) diagnosis code(s) added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis Index (3 Max) (NPI): This will display a maximum of three diagnosis pointers (123) reflective of the first three (checked) diagnosis code(s) added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis Index (4 Max): This will display a maximum of four diagnosis pointers (1,2,3,4) reflective of the first four (checked) diagnosis code(s) added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis Index (4 Max) (NPI): This will display a maximum of four diagnosis pointers (1234) reflective of the first four (checked) diagnosis code(s) added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis Index (NPI): This will display a maximum of four diagnosis pointers (1234) reflective of the first four (checked) diagnosis code(s) added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis Letter Index (1 Max) (NPI): This will display a maximum of one diagnosis pointer (A) reflective of the first (checked) diagnosis code added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis Letter Index (2 Max) (NPI): This will display a maximum of two diagnosis pointers (AB) reflective of the first two (checked) diagnosis code(s) added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis Letter Index (3 Max) (NPI): This will display a maximum of three diagnosis pointers (ABC) reflective of the first three (checked) diagnosis code(s) added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis Letter Index (4 Max) (NPI): This will display a maximum of four diagnosis pointers (ABCD) reflective of the first three (checked) diagnosis code(s) added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Diagnosis Letter Index (NPI): This will display a maximum of four diagnosis pointers (ABCD) reflective of the first four (checked) diagnosis code(s) added to the Diagnosis Code table located in the selected procedure's Charge Window > Diagnosis.

  • Discharge Date: This will reflect the date as entered in the 'Discharge Date' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Not available in DDS.]

  • Discharge Time: This will reflect the time as entered in the rightmost 'Time' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: 1) Pull field formatting MUST be set to "Text". 2) Not available in DDS.]

  • Insurance Paid: When printing a secondary claim this will display the total payment(s) that has been applied by the Primary Insurance. This data will pull from the 'Payment' field(s) located in the Payment Window of the insurance payment(s) that has been applied to the selected procedure(s).

  • Lab Cost: This will reflect the data as found/entered in the 'Lab Costs' field located in the selected procedure's Charge Window.

  • Lab Fee: This will display the Lab Fee for the selected procedure given the following scenarios.

WHEN 'USE CANADIAN CLAIM FIELDS' (PREFERENCES > LOCALIZATION HAS NOT BEEN SELECTED:

  • This will display the Unit Fee as entered in the 'Unit Fee' field located in the selected procedure's Fee Schedule record, but can be edited from the Charge Window.

WHEN 'USE CANADIAN CLAIM FIELDS' (PREFERENCES > LOCALIZATION) HAS BEEN SELECTED:

  • This will display the sum of the Lab Code Fee that has been added to the Lab Code table and the Unit Fee of the selected procedure (both located in Charge Window). The Unit Fee will pull from the 'Unit Fee' field located in the selected procedure's Fee Schedule record, and the Lab Code Fee will pull from the 'Fee' field located in the selected (CDA) Lab Code's Reference (Both can be edited from the Charge Window).[Note: The 'Add Lab Fees To Patient Portion' checkbox (located in the Charge Window) MUST be selected.]

  • Material Cost: This will reflect the data as entered in the 'Material Costs' field located in the selected procedure's Charge Window.
    [Note: 1) The "Use Canadian Claim Fields" checkbox CANNOT be selected from Preferences > Localization. 2) This data will populate automatically when a Lab is added to the selected procedure's Fee Schedule Record > Fee >Lab with data entered in the associated 'Material Costs' field.]

  • Medication N4: This will display an "N4" when a medication has been added to the selected procedure's Charge Window > Rx.

  • Medication NDC: This will display the NDC number as found under the National Drug Code column when a medication has been added to the selected procedure's Charge Window > Rx. This data will pull from the 'National Drug Code' field located in the selected medication's Reference > Dose.

  • Medication Name: This will display the Brand Name as found under the Brand column when a medication has been added to the selected procedure's Charge Window > Rx. This data will pull from the 'Brand and Dosage' field located in the selected medication's Reference > Dose. 
    [Note: This field is inaccessible and cannot be changed.]

  • Negative Adjustment: This will display the total amount of any Negative Adjustment(s) that has been applied to the selected procedure(s). This data will pull from the 'Adjustment' field(s) of the selected procedure(s) located in the negative adjustment's Payment Window.

  • Other Number 1: This will reflect the data as entered in the 'Other 1' field located in the rendering provider's user Reference > Provider > Additional Credentials.

  • Other Number 2: This will reflect the data as entered in the 'Other 2' field located in the rendering provider's user Reference > Provider > Additional Credentials.

  • Other Number 3: This will reflect the data as entered in the 'Other 3' field located in the rendering provider's user Reference > Provider > Additional Credentials.

  • Other Number 4: This will reflect the data as entered in the 'Other 4' field located in the rendering provider's user Reference > Provider > Additional Credentials.

  • Other Number 5: This will reflect the data as entered in the 'Other 5' field located in the rendering provider's user Reference > Provider > Additional Credentials.

  • Patient Paid: This will display the total payment(s) that has been applied by a Patient Payment. This data will pull from the 'Payment' field located in the Payment Window of the patient payment(s) that has been applied to the selected procedure(s).

  • Place of Service: This will display the numeric code reflective of the data selected from the 'Place of Service' popup located in the selected procedure's Charge Window.

  • Primary Allowed Amount: This will display the Allowed Amount as found under the 'Pri Allowed' column of the Procedure table located in the Charge Window for any procedure selected to be on the claim. This data will pull from the selected procedure's 'Allowed' field found in the Procedure Code table located in the Primary Insurance Carrier's Reference > Plans > Procedures.
    [Note: 1)If the patient does NOT have an insurance plan the allowed amount will default to the selected procedure's Unit Fee. 2) The patient's Primary and Secondary Insurance Carrier is determined by the first and second Insurance records (respectively) located in Patients > Patient > Insurance.]

  • Procedure Code: This will display the Procedure Code selected for the 'Code' field located in the Charge Window for any procedure selected to be on the claim. This will reflect the data as entered in the 'Code' field located in the selected procedure's Fee Schedule > Fee at the time the procedure was added to the ledger.

  • Procedure Cross Code: This will reflect the Cross Code as entered in the 'Cross Code' field located in the selected procedure's Fee Schedule > Fee at the time the procedure was added to the ledger.

  • Procedure Code Modifier 1: This will reflect the data as entered in the first 'Modifiers' field located in the selected procedure's Charge Window.
    [Note: In DDS the 'Show Modifiers in MacPractice DDS' checkbox located in Preferences > Ledger > New Charge MUST be selected.]

  • Procedure Code Modifier 2: This will reflect the data as entered in the second 'Modifiers' field located in the selected procedure's Charge Window.
    [Note: In DDS the 'Show Modifiers in MacPractice DDS' checkbox located in Preferences > Ledger > New Charge MUST be selected.]

  • Procedure Code Modifier 3: This will reflect the data as entered in the third 'Modifiers' field located in the selected procedure's Charge Window.
    [Note: In DDS the 'Show Modifiers in MacPractice DDS' checkbox located in Preferences > Ledger > New Charge MUST be selected.]

  • Procedure Code Modifier 4: This will reflect the data as entered in the fourth 'Modifiers' field located in the selected procedure's Charge Window.
    [Note: In DDS the 'Show Modifiers in MacPractice DDS' checkbox located in Preferences > Ledger > New Charge MUST be selected.]

  • Procedure Date: This will reflect the date as entered in the 'Procedure Date' field located in the selected procedure's Charge Window.

  • Procedure Emergency: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Emergency' checkbox located in the selected procedure's Charge Window.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the checkbox is selected. If formatted for "False", an 'X' will display when the checkbox is deselected]

  • Procedure Fee: This will display the Fee for the selected procedure. This data will pull from the 'Unit Fee' field located in the selected procedure's Fee Schedule record located in References > Fee Schedule > Fee, but can be edited from the Charge Window.
    [Note: Nonfunctional.]

  • Procedure Fee Less Lab Costs: This will display the Fee for the selected procedure. This data will pull from the 'Unit Fee' field located in the selected procedure's Fee Schedule record located in References > Fee Schedule > Fee, but can be edited from the Charge Window.[Note: Nonfunctional.]

  • Procedure Fee Long Description: This will reflect the data as entered in the 'Long Description' field of the selected procedure's Fee Schedule > Long Description.

  • Procedure Modifier 1: This will reflect the data as entered in the first 'Modifiers' field located in the selected procedure's Charge Window.
    [Note: In DDS the 'Show Modifiers in MacPractice DDS' checkbox located in Preferences > Ledger > New Charge MUST be selected.]

  • Procedure Modifier 2: This will reflect the data as entered in the second 'Modifiers' field located in the selected procedure's Charge Window.
    [Note: In DDS the 'Show Modifiers in MacPractice DDS' checkbox located in Preferences > Ledger > New Charge MUST be selected.]

  • Procedure Modifier 3: This will reflect the data as entered in the third 'Modifiers' field located in the selected procedure's Charge Window.
    [Note: In DDS the 'Show Modifiers in MacPractice DDS' checkbox located in Preferences > Ledger > New Charge MUST be selected.]

  • Procedure Modifier 4: This will reflect the data as entered in the fourth 'Modifiers' field located in the selected procedure's Charge Window.
    [Note: In DDS the 'Show Modifiers in MacPractice DDS' checkbox located in Preferences > Ledger > New Charge MUST be selected.]

  • Procedure Short Description: This will reflect the data as entered in the 'Short Description' field of the selected procedure's Fee Schedule > Fee.

  • Procedure Surface: This will reflect the data as entered in the 'Surface' field located in the selected procedure's Charge Window.
    [Note: DDS only.]

  • Procedure Tax: This will display the total Tax applied to the selected procedure as determined by the Unit Fee multiplied by the Tax Rate selected from the 'Tax' popup located in the selected procedure's Charge Window.
    [Note: The 'Taxable' checkbox (located in the Charge Window) MUST be selected.]

  • Procedure To Date: This will reflect the date as entered in the 'To Date' field located in the selected procedure's Charge Window.
    [Note: Not available in DDS.]

  • Procedure To Date Filled: This will reflect the date as entered in the 'To Date' field located in the selected procedure's Charge Window.
    [Note: In DDS this data entry point is not available, however this pull field will reflect the date as entered in the 'Procedure Date' field]

  • Procedure Tooth: This will reflect the data as entered in the 'Tooth' field located in the selected procedure's Charge Window.
    [Note: DDS only.]

  • Procedure Units: This will display the number of Units being applied to the selected procedure. This data will pull from the 'Units' field located in the procedure's Fee Schedule > Fee, but can be edited from the 'Units' field located the selected procedure's Charge Window.
    [Note: The 'Fee Calculations' popup (located in the selected procedure's Fee Schedule record) MUST be set to "Units".]

  • Provider First Name: This will display the First Name of the provider selected from the 'Provider' popup located in the selected procedure's Charge Window. This will pull from the 'First' field located in the selected provider's User Reference.

  • Provider Last Name: This will display the Last Name of the provider selected from the 'Provider' popup located in the selected procedure's Charge Window. This will pull from the 'Last' field located in the selected provider's User Reference.

  • Provider Middle Name: This will display the Middle Name of the provider selected from the 'Provider' popup located in the selected procedure's Charge Window. This will pull from the 'Middle' field located in the selected provider's User Reference.

  • Provider Professional Title: This will display the Professional Title of the provider selected from the 'Provider' popup located in the selected procedure's Charge Window. This will pull from the 'Professional Title' field located in the selected provider's User Reference.

  • Provider Suffix: This will display the Suffix of the provider selected from the 'Provider' popup located in the selected procedure's Charge Window. This will pull from the 'Suffix' field located in the selected provider's User Reference.

  • Revenue Code: This will reflect the data as enter in the 'Revenue Code (UB-92)' field located in the selected procedure's Fee Schedule > Fee.

  • Secondary Allowed Amount: This will display the Allowed Amount as found under the 'Pri Allowed' column of the Procedure table located in the selected procedure's Charge Window. This data will pull from the selected procedure's 'Allowed' field found in the Procedure Code table located in the Secondary Insurance Carrier's Reference > Plans > Procedures.
    [Note: 1) The patient MUST have an insurance plan. 2) If the patient does NOT have an insurance plan the allowed amount will default to the selected procedure's Unit Fee. 3) ]

  • Total CDA Lab Fee: This will display the Lab Fee as found/entered in the 'Fee' field of the Lab Code added to the Lab Code table located in the selected procedure's Charge Window. This data will pull from the 'Fee' field located in the selected (CDA) Lab Code's Reference, but can be edited from the Charge Window.

  • Type Of Service: This will display the code reflective of the Type of Service selected from the 'Type of Service' popup located in the selected procedure's Charge Window.
    [Note: Not available in DDS.]

  • Write Off: This will display the write off amount that has been applied to the procedure via the Primary Insurance payment. This data will pull from the the selected procedure's 'Write-Off' field found in the Payment table of the Primary Insurance Payment.
    [Note: Secondary claims only.]

Charges Referral

  • BCBS: This will display BCBS Number of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'BCBS' field located in the selected referrer's Reference > Provider IDs.

  • Blue Cross: This will display Blue Cross Number of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Blue Cross' field located in the selected referrer's Reference > Provider IDs.

  • Cell Phone Number: This will display the Cell Number of the of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from a 'Phone Numbers' field located in the selected charge referral's Reference > Referrer Info.
    [Note: The adjoining "phone type" popup MUST be set to "Cell".]

  • Champus: This will display Champus Number of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Champus' field located in the selected referrer's Reference > Provider IDs.

  • City: This will display the City of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'City' field located in the selected referrer's Reference > Referrer Info.

  • Commercial: This will display Commercial Number of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.

  • Date: This will display the Referral Date of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from 'Referral Date' field of the selected referral's Record located in Patients > Patient > Referrals.

  • Department: This will display Department for the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Dept.' field located in the selected referrer's Reference > Referrer Info.

  • Disability: This will display Disability Number of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Disability' field located in the selected referrer's Reference > Provider IDs.

  • Email: This will display the Email Address of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Email' field located in the selected referrer's Reference > Referrer Info.

  • Expiration Date: This will display the Expiration Date for the charge referral (selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window) as found under the 'Expiration Date' column located in Patients > Patient > Referrals.
    [Note: The 'Use Referrals Expiration Date' checkbox MUST be selected from Preferences > Localization. 2) This date will be calculated at one year from the date the selected referrer's Record was added to the Referrals tab. 3) This date can be adjusted by toggling the 'Months' popup menu found in the selected referrer's Record located in the Referrers tab.]

  • Expiration Months: This will display the number of months until the charge referrer (selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window) expires. This data will pull from the 'Months' popup menu found in the selected referrer's Record located in Patients > Patient > Referrals.

  • Fax Number: This will display the Fax Number of the of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from a 'Phone Numbers' field located in the selected charge referral's Reference > Referrer Info.
    [Note: The adjoining "phone type" popup MUST be set to "Fax".]

  • Federal Employee: This will display Federal Employee Number of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Federal Employee' field located in the selected referrer's Reference > Provider IDs.

  • HMO: This will display the Health Maintenance Organization Number of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Disability' field located in the selected referrer's Reference > Provider IDs.

  • Home Phone Number: This will display the Home Phone Number of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from a 'Phone Numbers' field located in the selected charge referral's Reference > Referrer Info. 
    [Note: The adjoining "phone type" popup MUST be set to "Home".]

  • Managed Care: This will display the Managed Care Number of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Managed Care' field located in the selected referrer's Reference > Provider IDs.

  • Medicaid: This will display the Medicaid Number of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Medicaid' field located in the selected referrer's Reference > Provider IDs.

  • Medicare: This will display the Medicare Number of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'HMO' field located in the selected referrer's Reference > Provider IDs.

  • Name, First: This will display the First Name of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'First' field located in the selected referrer's Reference > Referrer info.

  • Name, Last: This will display the Last Name of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Last' field located in the selected referrer's Reference > Referrer info.

  • Name, Middle: This will display the Middle Name of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Middle' field located in the selected referrer's Reference > Referrer info.

  • Name, Nickname: This will display the Nickname of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Nickname (AKA)' field located in the selected referrer's Reference > Referrer info.

  • Name, Professional Title: This will display the Professional Title of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Prefix' field located in the selected referrer's Reference > Referrer info.

  • Name, Suffix: This will display the Suffix of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Suffix' field located in the selected referrer's Reference > Referrer info.

  • National Provider ID: This will display the National Provider ID for the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'National Provider ID (NPI)' field located in the selected referrer's Reference > Provider IDs.

  • Office: This will display the Office Name of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Office/Company' field located in the selected referrer's Reference > Referrer info.

  • Other: This will display the Other Non-Federal number of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Other Non-Federal' field located in the selected referrer's Reference > Provider IDs.

  • Other Federal: This will display the Other Federal number of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Other Federal' field located in the selected referrer's Reference > Provider IDs.

  • PPO: This will display the Preferred Provider Organization number of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'PPO' field located in the selected referrer's Reference > Provider IDs.

  • Phone 1 Number: This will display the Phone 1 Number of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the first 'Phone Numbers' field listed in the selected referrer's Reference > Referrer Info.

  • Phone 1 Type: This will display a numeric identifier reflective of the Phone Type of the Phone 1 Number for the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the first 'Phone Type' popup adjacent to the first 'Phone Numbers' field listed in the selected referrer's Reference > Referrer Info.

    • Home: 0

    • Work: 1

    • Cell: 2

    • Fax: 3

  • Phone 2 Number: This will display the Phone 2 Number of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the second 'Phone Numbers' field listed in the selected referrer's Reference > Referrer Info.

  • Phone 2 Type: This will display a numeric identifier reflective of the Phone Type of the Phone 2 Number for the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the second 'Phone Type' popup adjacent to the second 'Phone Numbers' field listed in the selected referrer's Reference > Referrer Info.

    • Home: 0

    • Work: 1

    • Cell: 2

    • Fax: 3

  • Phone 3 Number: This will display the Phone 3 Number of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the third 'Phone Numbers' field listed in the selected referrer's Reference > Referrer Info.

  • Phone 3 Type: This will display a numeric identifier reflective of the Phone Type of the Phone 3 Number for the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the third 'Phone Type' popup adjacent to the second 'Phone Numbers' field listed in the selected referrer's Reference > Referrer Info.

    • Home: 0

    • Work: 1

    • Cell: 2

    • Fax: 3

  • Position Title: This will display the Position Title of the referrer selected from the 'Referral' popup located in Patients > Patient > Ledger > Charge Window. This data will pull from the 'Title/Position' field located in the selected referrer's Reference > Referrer info.

  • Referral ID (NPI): [Nonfunctional]

  • Referral ID Code: This will display the Referral ID Code when a referrer has been selected from the 'Referral' popup located in the selected procedure's Charge Window. This data will pull from the 'Plan' popup located in the selected insurance carrier's Reference > Claims.
    [Note: If the patient has an insurance plan, this will instead display the data as determined by the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage.]

    • Self Pay: [N/A]

    • Central Certification: G2 (Provider Commercial Number)

    • Other Non-Federal Programs: G2 (Provider Commercial Number)

    • Preferred Provider Organization (PPO): N5 (Provider Plan Network Identification Number)

    • Point of Service (POS): G2 (Provider Commercial Number)

    • Exclusive Provider Organization (EPO): N5 (Provider Plan Network Identification Number)

    • Indemnity Insurance: G2 (Provider Commercial Number)

    • HMO Medicare Risk: N5 (Provider Plan Network Identification Number)

    • Automobile Medical: G2 (Provider Commercial Number)

    • Blue Cross/Blue Shield: 1B (Blue Shield Provider Number)

    • Champus: 1H (CHAMPUS Identification Number)

    • Commercial Insurance Co.: G2 (Provider Commercial Number)

    • Disability: G2 (Provider Commercial Number)

    • Health Maintenance Organization: N5 (Provider Plan Network Identification Number)

    • Liability: G2 (Provider Commercial Number)

    • Liability Medical: G2 (Provider Commercial Number)

    • Medicare Part B: 1C (Medicare Provider Number)

    • Medicaid: 1D (Medicaid Provider Number)

    • Other Federal Program: [N/A]

    • Title V: [N/A]

    • Veteran Administration Plan: [N/A]

    • Worker's Compensation Health Claim: [N/A]

    • Mutually Defined Unknown: [N/A]

  • Referral ID Number: This will display the Referral ID Number of the referrer selected from the 'Referral' popup located in the selected procedure's Charge Window. This data will pull from the 'Central Cert.' field located in the selected referrer's Reference > Referrer Info.

  • Referrer NPI (NPI): This will display the National Provider ID of the referrer selected from the 'Referral' Popup located in the selected procedure's Charge Window. This data will pull from the 'National Provider ID (NPI)' field located in the selected referrer's Reference > Provider IDs.

  • Referral Qualifier: This will reflect the Referral Qualifier code when a referrer has been selected from the 'Referral' popup located in the selected procedure's Charge Window. This data will pull from the 'Referral Type' popup also located in the selected procedure's Charge Window.

    • Rendering Provider: DN

    • Ordering Provider: DK

    • Supervising Provider: DQ

  • Referral Type: This will display the Referral Type of the referrer selected from the 'Referral' popup located in the selected procedure's Charge Window. This data will pull from the 'Referrer Type' popup located in the selected referrer's Reference > Referrer Info.

  • SSN/TID: This will display the Social Security Number/Tax ID of the referrer selected from the 'Referral' popup located in the selected procedure's Charge Window. This data will pull from the 'SSN/TID' field located in the selected referrer's Reference > Provider IDs.

  • Self Admin: This will display the Self Admin number of the referrer selected from the 'Referral' popup located in the selected procedure's Charge Window. This data will pull from the 'Self Admin' field located in the selected referrer's Reference > Provider IDs.

  • Self Pay: This will display the Self Pay number of the referrer selected from the 'Referral' popup located in the selected procedure's Charge Window. This data will pull from the 'Self Pay' field located in the selected referrer's Reference > Provider IDs.

  • State: This will display the State of the referrer selected from the 'Referral' popup located in the selected procedure's Charge Window. This data will pull from the 'State' field located in the selected referrer's Reference > Referrer Info.

  • State License: This will display the State License number of the referrer selected from the 'Referral' popup located in the selected procedure's Charge Window. This data will pull from the 'State License' field located in the selected referrer's Reference > Provider IDs.

  • Street Address: This will display the Street Address of the referrer selected from the 'Referral' popup located in the selected procedure's Charge Window. This data will pull from the 'Street Address' field located in the selected referrer's Reference > Referrer Info.

  • Suite: This will display the Suite number of the referrer selected from the 'Referral' popup located in the selected procedrue's Charge Window. This data will pull from the 'Suite' field located in the selected referrer's Reference > Referrer Info.

  • Taxonomy Code: This will display the Taxonomy Code of the referrer selected from the 'Referral' popup located in the selected procedure's Charge Window. This data will pull from the 'Taxonomy (Specialty Code)' field or selected from the adjoining 'Choose...' button located in the selected referrer's Reference > Referrer Info.

  • Title V: This will display the Title V number of the referrer selected from the 'Referral' popup located in the selected procedure's Charge Window. This data will pull from the 'Self Pay' field located in the selected referrer's Reference > Provider IDs.

  • Vets Admin: This will display the Vets Admin number of the referrer selected from the 'Referral' popup located in the selected procedure's Charge Window. This data will pull from the 'Vets Admin.' field located in the selected referrer's Reference > Provider IDs.

  • Work Phone Number: This will display the Work Phone Number of the referrer selected from the 'Referral' popup located in the selected procedure's Ledger > Charge Window. This data will pull from a 'Phone Numbers' field located in the selected charge referral's Reference > Referrer Info. 
    [Note: The adjoining "phone type" MUST be set to "Work".]

  • Workers Compensation: This will display the Workers Compensation number of the referrer selected from the 'Referral' popup located in the selected procedure's Charge Window. This data will pull from the 'Workers Compensation' field located in the selected referrer's Reference > Provider IDs.

  • Zip Code: This will display the Zip Code of the referrer selected from the 'Referral' popup located in the selected procedure's Charge Window. This data will pull from the 'Zip Code' field located in the selected referrer's Reference > Referrer Info.

 

Claim

  • Amount Paid: This will display the sum of any payment (Patient/Insurance/Write-Off) that has been applied to the selected procedure(s).  This data will pull from the 'Payment' and/or 'Write-Off' field(s) located in the Payment Window of the applied payment(s).
    [Note: For this field to display the payment sums the following MUST be true: 1) Primary Claims: The 'Patient Paid' checkbox located in the the primary insurance's Reference > Claims (Sum the following in Box 29 CMS-1500 for Primary Claims) MUSTbe selected. 2) Secondary Claims: The 'Patient Paid', 'Primary Paid', and/or 'Insurance Write-Off' checkbox(es) located in the secondary insurance's Reference > Claims (Sum the following in Box 29 CMS-1500 for Secondary Claims) MUST be selected).]

  • Balance Due: This will display the sum of the remaining balance for the selected procedure(s) as found under the 'Open' column located in the Ledger.

  • Charge Count: This will display the total number of selected procedures located in Patients > Ledger > Transactions.
    [Note: Currently this will only display a "1".]

  • Claim Serial Number: This will display a unique, ascending numeric identifier for each Claim that is printed.

  • Current Date: This will display the selected claim's Posted Date as found under the 'Posted Date' column located in the Ledger.

  • Date Primary Insurance Paid: For any Secondary Claim, this will display the Posted Date as found under the 'Posted Date' column of the selected procedure'(s) Primary Insurance payment located in the Ledger.

  • From Date: This will reflect the date as entered in the 'Procedure Date' field located in the Charge Window of the first selected procedure listed on the claim.

  • Is Actual Services: This is a "True/False" pull field that will display an 'X' when printing a claim from the Ledger.
    [Note: Pull field formatting MUST be set to "True"]

  • Is Treatment Plan: This is a "True/False" pull field that will display an 'X' when printing a predetermination from Patients > Ledger > Treatment Plan.
    [Note: Pull field formatting MUST be set to "True"]

  • Pay Provider Signature: This will display the selected claim's "Signature On File" when the 'Signature on File (Box 37)' checkbox has been selected. Located in Patient > Primary or Secondary (Dependent upon the policy holder of the selected insurance carrier).

  • Pay Provider Signature Date: This will display the Pay Provider Signature Date as found under the selected claim's 'Posted Date' column located in the Ledger.

  • Place Of Service Code: This will display the numeric Place of Service Code for the selected procedure(s). This data will pull selected from the 'Place of Service' popup located in the selected procedure(s) Charge Window..

  • Place Of Service - ECF: This is a "True/False" pull field that will display an 'X' respective to the Place of Service being an Extended Care Facility. This data will pull selected from the 'Place of Service' popup located in the selected procedure(s) Charge Window. The following places of service will display an 'X':
    [Note: Pull field formatting MUST be set to "True"]

    • Skilled Nursing Facility

    • Nursing Facility

    • Custodial Care Facility

    • Hospice

  • Place Of Service - Hospital: This is a "True/False" pull field that will display an 'X' respective to the Place of Service being a Hospital. This data will pull selected from the 'Place of Service' popup located in the selected procedure(s) Charge Window. The following places of service will display an 'X':
    [Note: Pull field formatting MUST be set to "True"]

    • Inpatient Hospital

    • Outpatient Hospital

    • Emergency Room

    • Ambulatory Surgical Center

    • Birthing Center

    • Military Treatment Facility

  • Place Of Service - Office: This is a "True/False" pull field that will display an 'X' respective to the Place of Service being the provider's Office. This data will pull selected from the 'Place of Service' popup located in the selected procedure(s) Charge Window. The following places of service will display an 'X':
    [Note: Pull field formatting MUST be set to "True"]

    • Office

  • Place Of Service - Other: This is a "True/False" pull field that will display an 'X' respective to the Place of Service being a location other than an Extended Care Facility, a Hospital, or the provider's Office. This data will pull selected from the 'Place of Service' popup located in the selected procedure(s) Charge Window. The following places of service will display an 'X':
    [Note: Pull field formatting MUST be set to "True"]

    • Home

    • Ambulance - Land

    • Ambulance - Air or Water

    • Federally Qualified Health Center

    • Inpatient Psychiatric Facility

    • Psychiatric Facility Partial Hospitalization

    • Community Mental Health Center

    • Residential Substance Abuse Treatment Facility

    • Psychiatric Residential Treatment Center

    • Mass Immunization Center

    • Comprehensive Inpatient Rehabilitation Facility

    • Comprehensive Outpatient Rehabilitation Facility

    • End Stage Renal Disease Treatment Facility

    • State or Local Public Health Clinic

    • Rural Health Clinic

    • Independent Laboratory

    • Other Unlisted Facility

    • Therapy Clinic

    • Assisted Living Facility

  • Thru Date: This will reflect the latest date as entered in the 'To Date' field located in Patients > Ledger > Transactions > Charge Window for any selected procedure.
    [Note: Not available in DDS.]

  • Total CDA Lab Fee: This will display the Lab Fee as found/entered in the 'Fee' field of the Lab Code added to the Lab Code table located in the selected procedure's Charge Window. This data will pull from the 'Fee' field located in the selected (CDA) Lab Code's Reference, but can be edited from the Charge Window.

  • [Note: This will currently only display "0.00".]

  • Total Charges: This will display the total charge of the selected procedure(s) as found under the 'Debit' column located in the Ledger.

  • Total Lab Costs: This will display the total lab costs of the selected procedure(s) as found under the 'Lab Cost' column located in the Ledger.
    [Note: This will currently only display "0.00".]

  • Total Tax: This will display the total tax applied to the selected procedure(s) as found under the 'Fee Tax' column located in the Ledger.
    [Note: 1) A tax rate MUST be added to References > Tax Rate. 2) The 'Taxable' checkbox located in the selected procedure's Charge Window (or Fee Schedule record) MUST be selected and a Tax Rate MUST be selected from the adjoining 'Tax Rate' popup.]

  • Type Of Service: This will display a numeric code reflective of the data selected from the 'Type of Service' popup located in the most recently posted procedure's Charge Window.  

Custom Fields

  • Custom Optional: This field will allow the User to manually type data directly onto a paper form when attempting to print said form. This field can be ignored and the form will print without data.

  • Custom Required: This field will allow the User to manually type data directly onto a paper form when attempting to print said form. This field cannot be ignored and MUST contain data before the form will be allowed to print.

 

Diagnosis

Number of Diagnosis Codes to display determined by Form Rules
[Note: Default Form Rules: Maximum Number of Diagnosis - 12]

  • Diagnosis 01 Code: This will display the selected procedure's Diagnosis Code as found in the first (checked) 'Diagnosis Code' field located in the Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis 02 Code: This will display the Diagnosis Code as found in the second (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis 03 Code: This will display the Diagnosis Code as found in the third (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis .

  • [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis 04 Code: This will display the Diagnosis Code as found in the fourth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.[Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis 05 Code: This will display the Diagnosis Code as found in the fifth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis 06 Code: This will display the Diagnosis Code as found in the sixth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the form will split.]

  • Diagnosis 07 Code: This will display the Diagnosis Code as found in the seventh (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis 08 Code: This will display the Diagnosis Code as found in the eighth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis 09 Code: This will display the Diagnosis Code as found in the ninth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis 10 Code: This will display the Diagnosis Code as found in the tenth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis 11 Code: This will display the Diagnosis Code as found in the eleventh (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis 12 Code: This will display the Diagnosis Code as found in the twelfth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis 13 Code: This will display the Diagnosis Code as found in the thirteenth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis 14 Code: This will display the Diagnosis Code as found in the fourteenth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis 15 Code: This will display the Diagnosis Code as found in the fifteenth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis 16 Code: This will display the Diagnosis Code as found in the sixteenth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis 17 Code: This will display the Diagnosis Code as found in the seventeenth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis 18 Code: This will display the Diagnosis Code as found in the eighteenth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 01: This will display the Description of the first (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 02: This will display the Diagnosis Code Description as found in the second (checked) 'Diagnosis Code' field located the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 03: This will display the Diagnosis Code Description as found in the third (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis for.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 04: This will display the Diagnosis Code Description as found in the fourth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 05: This will display the Diagnosis Code Description as found in the fifth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 06: This will display the Diagnosis Code Description as found in the sixth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 07: This will display the Diagnosis Code Description as found in the seventh (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 08: This will display the Diagnosis Code Description as found in the eighth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 09: This will display the Diagnosis Code Description as found in the ninth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 10: This will display the Diagnosis Code Description as found in the tenth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 11: This will display the Diagnosis Code Description as found in the eleventh (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 12: This will display the Diagnosis Code Description as found in the twelfth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 13: This will display the Diagnosis Code Description as found in the thirteenth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 14: This will display the Diagnosis Code Description as found in the fourteenth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis for.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 15: This will display the Diagnosis Code Description as found in the fifteenth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 16: This will display the Diagnosis Code Description as found in the sixteenth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 17: This will display the Diagnosis Code Description as found in the seventeenth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

  • Diagnosis Description 18: This will display the Diagnosis Code Description as found in the eighteenth (checked) 'Diagnosis Code' field located in the selected procedure's Charge Window > Diagnosis.
    [Note: Between all selected procedures, when the number of total Diagnosis Codes exceeds the maximum number of allowed codes, the claim will split.]

 

Facility

  • Facility (NPI) ID: [Nonfunctional]

  • Facility (NPI) National Provider ID: This will display the National Provider ID Number for the selected Lab or Facility depending on the following scenarios:

DEFAULT: 

  • This will display the National Provider ID Number for the Lab record added to the Lab table located in the selected procedure's Charge Window. This data will pull from the 'National Provider ID' field located in the selected Lab's Reference.
    [Note: 1) "Diagnostic Lab (Pathology)" MUST be selected from the 'Type of Service' popup located in the selected procedure's Charge Window. 2) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization. 3) Not available in DDS.]

IF A LAB RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW AND/OR "DIAGNOSTIC LAB (PATHOLOGY)" HAS NOTBEEN SELECTED:

  • This will then display the National Provider ID Number for the Facility record added to the Facility table located in the selected procedure's Charge Window. This data will pull from the 'National Provider ID (NPI)' field located in the selected facility's Reference.

IF A LAB/FACILITY RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW:

  • This will then display the National Provider ID Number for the Facility record added to the Facility table found in the Reference of the Office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'National Provider ID (NPI)' field located in the selected facility's Reference.

  • Facility Admission Date: This will display the date as entered in the 'Admission Date' field located in the Charge Window for the oldest (posted) selected procedure. 
    [Note: 1) A Facility/Lab record MUST be added to the Facility/Lab table located in the selected procedure's Charge Window, OR a Facility record MUST be added to the Office Reference. 2) NOT AVAILABLE DDS.]

  • Facility City: This will display the City of the selected Lab or Facility depending on the following scenarios.

DEFAULT:

  • This will display the City of the Lab record added to the Lab table located in the selected procedure's Charge Window. This data will pull from the 'City' field located in the selected lab's Reference.
    [Note: 1) "Diagnostic Lab (Pathology)" MUST be selected from the 'Type of Service' popup located in the selected procedure's Charge Window. 2) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization. 3) Not available in DDS.]

IF A LAB RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW AND/OR "DIAGNOSTIC LAB (PATHOLOGY)" HAS NOTBEEN SELECTED:

  • This will then display the City for the Facility record added to the Facility table located in the selected procedure's Charge Window. This data will pull from the 'City' field located in the selected facility's Reference.

IF A LAB/FACILITY RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW:

  • This will then display the City of the Facility record added to the Facility table found in the Reference of the Office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'City' field located in the selected facility's Reference.

  • Facility Discharge Date: This will display the date as entered in the 'Discharge Date' field located in the Charge Window for the oldest (posted) selected procedure. 
    [Note: 1) A Facility/Lab record MUST be added to the Facility/Lab table located in the selected procedure's Charge Window, OR a Facility record MUST be added to the Office Reference. 2) Not available in DDS.]

  • Facility ID: This will display the Lab ID/Facility Tax ID Number for the selected Lab or Facility depending on the following scenarios.

DEFAULT:

  • This will display the Lab ID Number for the Lab record added to the Lab table located in the selected procedure's Charge Widow. This data will pull from the 'Lab ID #' field located in the selected lab's Reference.
    [Note: 1) "Diagnostic Lab (Pathology)" MUST be selected from the 'Type of Service' popup located in the selected procedure's Charge Window. 2) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization. 3) Not available in DDS.]

IF A LAB RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW AND/OR "DIAGNOSTIC LAB (PATHOLOGY)" HAS NOTBEEN SELECTED: 

  • This will display the Facility Tax ID Number for the Facility record added to the Facility table located in the selected procedure's Charge Widow. This data will pull from the 'Facility Tax ID' field located in the selected facility's Reference.

IF A LAB/FACILITY RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW:

  • This will then display the Facility Tax ID Number of the Facility record added to the Facility table found in the Reference of the Office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Facility Tax ID' field located in the selected facility's Reference.

  • Facility ID 2: This will display the Secondary Lab ID/Secondary Facility ID Number for the selected Lab or Facility depending on the following scenarios:

DEFAULT: 

  • This will display the Secondary Lab ID Number for the Lab record added to the Lab table located in the selected procedure's Charge Window. This data will pull from the 'Secondary Lab ID #' field located in the selected lab's Reference.
    [Note: 1) "Diagnostic Lab (Pathology)" MUST be selected from the 'Type of Service' popup located in the selected procedure's Charge Window. 2) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization. 3) Not available in DDS.]

IF A LAB RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW AND/OR "DIAGNOSTIC LAB (PATHOLOGY)" HAS NOTBEEN SELECTED:  

  • This will display the Secondary Facility ID Number for the Facility record added to the Facility table located in the selected procedure's Charge Widow. This data will pull from the 'Secondary Facility ID' field located in the selected facility's Reference.

IF A LAB/FACILITY RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW: 

  • This will then display the Secondary Facility ID Number of the Facility record added to the Facility table found in the office Reference of the Office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Secondary Facility ID' field located in the selected facility's Reference.

  • Facility Name: This will display the Name of the selected Lab or Facility depending on the following scenarios.

DEFAULT: 

  • This will display the Name of the Lab record added to the Lab table located in the selected procedure's Charge Window. This data will pull from the 'Lab Name' field located in the selected lab's Reference.
    [Note: 1) "Diagnostic Lab (Pathology)" MUST be selected from the 'Type of Service' popup located in the selected procedure's Charge Window. 2) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization. 3) Not available in DDS.]

IF A LAB RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW AND/OR "DIAGNOSTIC LAB (PATHOLOGY)" HAS NOTBEEN SELECTED:

  • This will display the Name of the Facility record added to the Facility table located in the selected procedure's Charge Widow. This data will pull from the 'Facility Name' field located in the selected facility's Reference.

IF A LAB/FACILITY RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW:

  • This will then display the Facility Name of the Facility record added to the Facility table found in the office Reference of the Office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Facility Name' field located in the selected facility's Reference.

  • Facility National Provider ID: This will display the National Provider ID Number for the selected Lab or Facility depending on the following scenarios.

DEFAULT:

  • This will display the National Provider ID Number of the selected Lab record added to the Lab table located in the selected procedure's Charge Window. This data will pull from the 'National Provider ID' field located in the selected lab's Reference.
    [Note: 1) "Diagnostic Lab (Pathology)" MUST be selected from the 'Type of Service' popup located in the selected procedure's Charge Window. 2) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization. 3) Not available in DDS.]

IF A LAB RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW AND/OR "DIAGNOSTIC LAB (PATHOLOGY)" HAS NOTBEEN SELECTED:

  • This will display the National Provider ID Number of the Facility record added to the Facility table located in the selected procedure's Charge Widow. This data will pull from the 'National Provider ID (NPI)' field located in the selected facility's Reference.

IF A LAB/FACILITY RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW:

  • This will then display the National Provider ID Number of the Facility record added to the Facility table found in the office Reference of the Office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'National Provider ID (NPI)' field located in the selected facility's Reference.

  • Facility State: This will display the State of the selected Lab or Facility depending on the following scenarios.

DEFAULT:

  • This will display the State of the selected Lab record added to the Lab table located in the selected procedure's Charge Window. This data will pull from the 'State' field located in the selected lab's Reference.
    [Note: 1) "Diagnostic Lab (Pathology)" MUST be selected from the 'Type of Service' popup located in the selected procedure's Charge Window. 2) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization. 3) Not available in DDS.]

IF A LAB RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW AND/OR "DIAGNOSTIC LAB (PATHOLOGY)" HAS NOTBEEN SELECTED:

  • This will display the State of the Facility record added to the Facility table located in the selected procedure's Charge Widow. This data will pull from the 'State' field located in the selected facility's Reference.

IF A LAB/FACILITY RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW:

  • This will then display the State of the Facility record added to the Facility table found in the office Reference of the Office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'State' field located in the selected facility's Reference.

  • Facility Street Address: This will display the Street Address of the selected Lab or Facility depending on the following scenarios.

DEFAULT:

  • This will display the Street Address of the selected Lab record added to the Lab table located in the selected procedure's Charge Window. This data will pull from the 'State' field located in the selected lab's Reference.
    [Note: 1) "Diagnostic Lab (Pathology)" MUST be selected from the 'Type of Service' popup located in the selected procedure's Charge Window. 2) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization. 3) Not available in DDS.]

IF A LAB RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW AND/OR "DIAGNOSTIC LAB (PATHOLOGY)" HAS NOTBEEN SELECTED:

  • This will display the Street Address of the Facility record added to the Facility table located in the selected procedure's Charge Widow. This data will pull from the 'Street Address' field located in the selected facility's Reference.

IF A LAB/FACILITY RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW:

  • This will then display the Street Address of the Facility record added to the Facility table found in the office Reference of the Office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Street Address' field located in the selected facility's Reference.

  • Facility Suite: This will display the Suite Number of the selected Lab or Facility depending on the following scenarios.

DEFAULT:

  • This will display the Suite Number of the selected Lab record added to the Lab table located in the selected procedure's Charge Window. This data will pull from the 'Suite' field located in the selected lab's Reference.
    [Note: 1) "Diagnostic Lab (Pathology)" MUST be selected from the 'Type of Service' popup located in the selected procedure's Charge Window. 2) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization. 3) Not available in DDS.]

IF A LAB RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW AND/OR "DIAGNOSTIC LAB (PATHOLOGY)" HAS NOTBEEN SELECTED:

  • This will display the Suite Number of the Facility record added to the Facility table located in the selected procedure's Charge Widow. This data will pull from the 'Suite' field located in the selected facility's Reference.

IF A LAB/FACILITY RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW:

  • This will then display the Suite Number of the Facility record added to the Facility table found in the office Reference of the Office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Suite' field located in the selected facility's Reference.

  • Facility Zip Code: This will display the Zip Code of the selected Lab or Facility depending on the following scenarios.

DEFAULT:

  • This will display the Zip Code of the selected Lab record added to the Lab table located in the selected procedure's Charge Window. This data will pull from the 'Zip Code' field located in the selected lab's Reference.
    [Note: 1) "Diagnostic Lab (Pathology)" MUST be selected from the 'Type of Service' popup located in the selected procedure's Charge Window. 2) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization. 3) Not available in DDS.]

IF A LAB RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW AND/OR "DIAGNOSTIC LAB (PATHOLOGY)" HAS NOTBEEN SELECTED:

  • This will display the Zip Code of the Facility record added to the Facility table located in the selected procedure's Charge Widow. This data will pull from the 'Zip Code' field located in the selected facility's Reference.

IF A LAB/FACILITY RECORD HAS NOT BEEN ADDED TO THE CHARGE WINDOW:

  • This will then display the Zip Code of the Facility record added to the Facility table found in the office Reference of the Office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Zip Code' field located in the selected facility's Reference.

  • Is Lab Charges: This is a "True False" pull field that will display an 'X' respective to having added a Lab Charge to the selected procedure'(s).
    [Note: "Diagnostic Lab (Pathology)" MUST be selected from the 'Type of Service' popup located in the selected procedure's Charge Window.]

  • Lab Costs: This will reflect the data as found/entered in the 'Lab Costs' field located in the selected procedure's Charge Window.
    [Note: 1) "Diagnostic Lab (Pathology)" MUST be selected from the 'Type of Service' popup located in the Charge Window. 2) A Lab record MUST be added to the Lab table located in the Charge Window. 3) The 'Use Canadian Claim Fields' checkbox must be DESELECTED from Preferences > Localization.]

 

Incident

  • Accident Date: This will reflect the date as entered in the 'Accident Date' field, located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment.

  • Accident State: This will reflect the State selected from the 'Accident State' popup, located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment.

  • Admission Source Code: This will display the numeric code reflective of the selected Admission Source found in the 'Admission Source' popup located in Patients > Ledger > Incident Menu > Incident > Facility.

    • None: 0 

    • Non-health Care Facility Point of Origin: 1

    • Clinic or Physician's Office: 2

    • Transfer from Hospital: 3

    • Transfer from SNF, INF, or ALF/Born in Hospital: 4

    • Court/Law Enforcement: 5

    • Information Not Available: 6

    • Transfer between Distinct Units of Same Hospital (Separate Claims): 7

    • Transfer from Ambulatory Surgery Center: 8

    • Transfer from Hospice Facility: 9

  • Admission Type Code: This will display the numeric code reflective of the selected Admission Type found in the 'Admission Type' popup located in Patients > Ledger > Incident Menu > Incident > Facility.

    • None: 0 

    • Emergency: 1

    • Urgent: 2

    • Elective: 3

    • Newborn: 4

    • Trauma Center: 5

  • Auto Accident Related: This is a "True/False" pull field that will display an 'X' respective to having selected "Auto Accident" from the 'Condition Related To' popup located in Patients > Ledger > Incident Menu> Incident > Reason For Treatment.
    [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when "Auto Accident" is selected. If formatted for "False", an 'X' will display when not selected]

  • Auto Accident State: This will reflect the State selected from the 'Accident State' popup located in Patients > Ledger > Incident Menu> Incident > Reason For Treatment.
    [Note: "Auto Accident" MUST be selected from the 'Condition Related To' popup.]

  • Box 10D Claim Codes: This will reflect the data as entered in the 'Box 10D Claim Codes' field located in Patients > Ledger > Incident Menu > CMS Claims > Other Claim Data.

  • Box 11B Other Claim ID: This will reflect the data as entered in the 'Other Claim ID' field located in Patients > Ledger > Incident Menu > CMS Claims > Other Claim Data.

  • Box 11B Other Claim ID Qualifier: This will reflect the data as entered in the 'Box 11b Qualifier' located in Patients > Ledger > Incident Menu > CMS Claims > Other Claim Data.

  • Box 23B Payment Source Code: This will reflect the data as entered in the '23B Payment Source' field located in Patients > Ledger > Incident Menu > CMS Claims > Other Claim Data.
    [Note: DDS Nonfunctional.]

  • Box 25C Locator Code: This will reflect the data as entered in the 'Box 25C Locator Code' field located in Patients > Ledger > Incident Menu > CMS Claims > Other Claim Data.
    [Note: DDS Nonfunctional.]

  • Claim Other Date Type: This will display the numeric code reflective of the selected Date Type found in the 'Other Date Type' popup located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates.
    [Note: 1) "Illness" or "Last Menstrual Period" MUST be selected from the 'First Symptom Date Type' popup. 2) A valid date MUST be entered in the 'Other Date' field. 3) "Auto Accident" CANNOT be selected from the 'Condition Related To' popup located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment.]

    • Initial Treatment: 454

    • Latest Visit or Consultation: 304

    • Accident: 439

    • Acute Manifestation of a Chronic Condition: 453

    • Last X-ray: 455

    • Prescription: 471

    • Report Start (Assumed Care Date): 090

    • Report End (Relinquished Care Date): 091

    • First Visit or Consultation: 444

  • Claim Similar Symptom Date: This will reflect the date as entered in the 'Other Date' field located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates.
    [Note: 1) "Illness" or "Last Menstrual Period" MUST be selected from the 'First Symptom Date Type' popup. 2) "Auto Accident" or "None" CANNOT be selected from the 'Condition Related To' popup located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment.]

  • Claim Symptom Date: This will reflect the date as entered in the 'First Symptom Date' Field located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates.
    [Note: 1) "Illness" or "Last Menstrual Period" MUST be selected from the 'First Symptom Date Type' popup. 2) "Auto Accident" or "None" CANNOT be selected from the 'Condition Related To' popup.]

  • Claim Symptom Date Qualifier: This will display a numeric code reflective of the data selected from the 'First Symptom Date Type' popup located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates.
    [Note: 1)"Auto Accident" CANNOT be selected from the 'Condition Related To' popup located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment.]

    • Routine Service: [N/A]

    • Illness: 431

    • Last Menstrual Period: 484

  • Date Appliance Placed: This will reflect the date as entered in the 'Box 41 Date Appliance Placed' field located in Patients > Ledger > Incident Menu > ADA Claims.

  • Effective Date: This will reflect the date as entered in the 'Effective Date' field located in Patients > Ledger > Incident Menu > Military.

  • Employment Related: This is a "True/False" pull field that will display an 'X' respective to having selected "Employment" from the 'Condition Related To' popup located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment.
    [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when "Employment" is selected. If formatted for "False", an 'X' will display when not selected]

  • First Consultation Date: This will reflect the date as entered in the 'First Consultation' field located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates.

  • First Symptom: This will display a numeric code reflective of the data selected from the 'First Symptom Date Type' popup located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates.

    • Routine Service: 1

    • Illness: 2

    • Last Menstrual Period: 3

  • First Symptom Date: This will reflect the date as entered in the 'First Symptom Date' field located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates.

  • First Symptom Text: This will display the selected First Symptom depending on the following scenarios:

IF "AUTO ACCIDENT" HAS BEEN SELECTED FROM THE 'CONDITION RELATED TO' POPUP LOCATED IN PATIENTS > LEDGER > INCIDENT MENU > INCIDENT > REASON FOR TREATMENT:

  • This will then display "Accident"

IF "AUTO ACCIDENT" HAS NOT BEEN SELECTED FROM THE 'CONDITION RELATED TO' POPUP:

  • This will then display either "Illness" or "LMP" respective of having selected "Illness" or "Last Menstrual Period" from the 'First Symptom Date Type" popup located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates.

  • Has Date Prior Placement: This is a "True/False" pull field that will display an 'X' respective to having entered a valid date  in the 'Box 44 Date Prior Placement' field located in Patients > Ledger > Incident Menu > ADA Claims.

  • Has Enclosures: This is a "True/False" pull field that will display an 'X' respective to having entered data in at least one of the three fields (Radiograph(s)/Oral Image(s)/Model(s)) located in Patients > Ledger > Incident Menu > ADA Claims.

  • Has Similar Symptom Date: This is a "True/False" pull field that will display an 'X' respective to having entered a valid date in the 'Other Date' field located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates.
    [Note: 1) "Auto Accident" CANNOT be selected from the 'Condition Related To' popup located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment. 2) Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when the above conditions are true. If formatted for "False" an 'X' will display when the above conditions are NOT true.]

  • Incident Date: This will reflect the Name of the Incident selected/entered in the 'Incident Name' drop down field located in Patients > Ledger > Incident Menu > Incident.

  • Incident Name: This will reflect the Incident Name selected/entered in the 'Incident Name' drop down field located in Patients > Ledger > Incident Menu > Incident.

  • Initial Placement: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Initial Placement' checkbox located in Patients > Ledger > Incident menu > Incident > Reason For Treatment.
    [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the checkbox is selected. If formatted for "False", an 'X' will display when the checkbox is deselected. 2) DDS only.]

  • Is Orthodontics: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Orthodontics' checkbox located in Patients > Ledger > Incident menu > Incident > Reason For Treatment.
    [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the checkbox is selected. If formatted for "False", an 'X' will display when the checkbox is deselected. 2) DDS only.]

  • Military Branch: This will display a numeric code reflective of the data as selected from the  'Branch' popup located in the Patients > Ledger > Incident Menu > Military.
    [Note: Not available in DDS.]

    • None: 0

    • Army: 1

    • Air Force: 2

    • Marines: 3

    • Navy: 4

    • Coast Guard: 5

    • Public Health Service: 6

    • CHAMP/VA: 7

  • Military Branch Air Force: This is a "True/False" pull field that will display an 'X' respective to having selected "Air Force" from the 'Branch' popup located in Patients > Ledger > Incident Menu > Military.
    [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected. 2) Not available in DDS.]

  • Military Branch Army: This is a "True/False" pull field that will display an 'X' respective to having selected "Army" from the 'Branch' popup located in Patients > Ledger > Incident Menu > Military.
    [Note: 1)Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected. 2) Not available in DDS.]

  • Military Branch CHAMP/VA: This is a "True/False" pull field that will display an 'X' respective to having selected "CHAMP/VA" from the 'Branch' popup located in Patients > Ledger > Incident Menu > Military.
    [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected. 2) Not available in DDS.]

  • Military Branch Coast Guard: This is a "True/False" pull field that will display an 'X' respective to having selected "Coast Guard" from the 'Branch' popup located in Patients > Ledger > Incident Menu > Military.
    [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected. 2) Not available in DDS.]

  • Military Branch Marines: This is a "True/False" pull field that will display an 'X' respective to having selected "Marines" from the 'Branch' popup located in Patients > Ledger > Incident Menu > Military.
    [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected. 2) Not available in DDS.]

  • Military Branch Navy: This is a "True/False" pull field that will display an 'X' respective to having selected "Navy" from the 'Branch' popup located in Patients > Ledger > Incident Menu > Military.
    [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected. 2) Not available in DDS.]

  • Military Branch Public Health: This is a "True/False" pull field that will display an 'X' respective to having selected "Public Health Service" from the 'Branch' popup located in Patients > Ledger > Incident Menu > Military.
    [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected. 2) Not available in DDS.]

  • Military Date: This will reflect the date as entered in the 'Date' field located in Patients > Ledger > Incident Menu > Military.
    [Note: Not available in DDS.]

  • Military Eligibility: This will display a numeric code reflective of the data as selected from the 'Eligibility' popup located in Patients > Ledger > Incident Menu > Military.
    [Note: Not available in DDS.]

    • None: 0

    • Insurance Phone Call: 1

    • Employer Phone Call: 2

    • Payor Card Presented: 3

    • Signed Statement: 4

  • Military Status: This will display a numeric code reflective of the data as selected from the 'Status' popup located in Patients > Ledger > Incident Menu > Military.
    [Note: Not available in DDS.]

    • None: 0

    • Social Security Number: 1

    • Federal ID: 2

    • Both: 3

  • Models: This will reflect the data as entered in the 'Model(s)' field located in Patients > Ledger > Incident Menu > ADA Claims.

  • Not Accident Related: This is a "True/False" pull field that will display an 'X' respective to  not having selected "Auto Accident" or "Other Accident" from the 'Condition Related To' popup located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment.
    [Note: Functionality dependent upon pull field formatting. This field should be formatted to "True" in which case it will display an 'X' when the above items are NOT selected.]

  • Occupational Illness: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Occupational Illness/Injury' checkbox located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected.]

  • Oral Images: This will reflect the data as entered in the 'Oral Image(s)' field located in the Incident Menu > ADA Claims.

  • Other Accident Related: This is a "True/False" pull field that will display an 'X' respective to having selected "Other Accident" from the 'Condition Related To' popup located in in Patients > Ledger > Incident Menu > Incident > Reason For Treatment.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected.]

  • Other Date Type: This will display a numeric code reflective of the data selected from the 'Other Date Type' popup located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates.

    • Initial Treatment: 454

    • Latest Visit or Consultation: 304

    • Accident: 439

    • Acute Manifestation of a Chronic Condition: 453

    • Last X-ray: 455

    • Prescription: 471

    • Report Start (Assumed Care Date): 090

    • Report End (Relinquished Care Date): 091

    • First Visit or Consultation: 444

  • Partial Disability Begin Date: This will reflect the date as entered in the 'Begin Date' field of the 'Partial Disability' section located in Patients > Ledger > Incident Menu > CMS Claims > Disability.

  • Partial Disability End Date: This will reflect the date as entered in the 'End Date' field of the 'Partial Disability' section located in Patients > Ledger > Incident Menu > CMS Claims > Disability.

  • Prior Authorization (Blank): This will display the Prior Authorization Number of the Prior Authorization record selected from the 'Prior Auth' popup located in the selected procedure's Claim Creation Window.  This data will pull from the 'Prior Authorization' field found in the first Prior Authorization record listed in the Prior Authorization table located in Patients > Ledger > Incident Menu > Prior Auth.
    [Note: 1) A Prior Authorization record MUST be added to the Prior Authorization table. 2) When a Prior Authorization has NOTbeen selected from the Claim Creation Window this field will remain blank.]

  • Prior Authorization (None): This will display the Prior Authorization Number of the Prior Authorization record selected from the 'Prior Auth' popup located in the selected procedure's Claim Creation Window.  This data will pull from the 'Prior Authorization' field found in the first Prior Authorization record listed in the Prior Authorization table located in Patients > Ledger > Incident Menu > Prior Auth.[Note: 1) A Prior Authorization record MUST be added to the Prior Authorization table. 2) When a Prior Authorization has NOTbeen selected from the Claim Creation Window this field will display "None". 3) This field exhibits odd behavior. This field can only be used once per incident. Once it has been populated by a prior auth. this data can be changed and deleted, but whatever data (or lack thereof) is present will remain even if the Prior Authorization record is deleted.  Subsequently any data from a new prior auth cannot be added, and it will continue to display the deleted prior auth's data. Only by archiving said incident are you able to populate new data.]

  • Prosthesis: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Prosthesis' checkbox located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the checkbox is selected. If formatted for "False", an 'X' will display when the checkbox is not selected.]

  • Prosthesis Replacement: This is a "True/False" pull field that will display an 'X' respective of having selected the 'Initial Placement' checkbox in coordination with the 'Prothesis' checkbox located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment.
    [Note: 1) The 'Prosthesis' checkbox MUST be selected. 2) Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when when the checkbox is deselected. If formatted for "False" an 'X' will display when the checkbox is selected. 3) DDS only.]

  • Radiographs: This will reflect the data as entered in the 'Radiograph(s)' field located in the Incident Menu > ADA Claims.

  • Referral BC/BS: This will display the BCBS Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'BCBS' field located in the selected referrer's Reference > Provider IDs.

  • Referral Blue Cross: This will display the Blue Cross Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Blue Cross' field located in the selected referrer's Reference > Provider IDs.

  • Referral CHAMPUS: This will display the Champus Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Champus' field located in the selected referrer's Reference > Provider IDs.

  • Referral Central Certification: This will display the Central Certification Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Central Certification' field located in the selected referrer's Reference > Provider IDs.

  • Referral City: This will display the City of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'City' field located in the selected referrer's Reference > Referrer Info.

  • Referral Commercial: This will display the Commercial Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.

  • Referral Date: This will display the Referral Date of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Referral Date' field of the selected referrer's record located in Patients > Patient > Referrals.

  • Referral Disability: This will display the Disability Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Disability' field located in the selected referrer's Reference > Provider IDs.

  • Referral Email: This will display the Email Address of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Email' field located in the selected referrer's Reference > Referrer Info.

  • Referral Federal Employee: This will display the Federal Employee Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Federal Employee' field located in the selected referrer's Reference > Provider IDs.

  • Referral First Name: This will display the First Name of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'First Name' field located in the selected referrer's Reference > Referrer Info.

  • Referral HMO: This will display the Health Maintenance Organization Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'HMO' field located in the selected referrer's Reference > Provider IDs.

  • Referral Is Person: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Is Person' checkbox located in the Reference > Referrer Info for the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the checkbox is selected. If formatted for "False", an 'X' will display when the checkbox is deselected.]

  • Referral Last Name: This will display the Last Name of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Last Name' field located in the selected referrer's Reference > Referrer Info.

  • Referral Managed Care: This will display the Managed Care Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Managed Care' field located in the selected referrer's Reference > Provider IDs.

  • Referral Medicaid: This will display the Medicaid Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Medicaid' field located in the selected referrer's Reference > Provider IDs.

  • Referral Medicare: This will display the Medicare Part B Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Medicare Part B' field located in the selected referrer's Reference > Provider IDs.

  • Referral Middle Name: This will display the Middle Name of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Middle Name' field located in the selected referrer's Reference > Referrer Info.

  • Referral National Provider: This will display the National Provider ID of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'National Provider ID (NPI)' field located in the selected referrer's Reference > Referrer Info.

  • Referral Nickname: This will display the Nickname of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Nickname' field located in the selected referrer's Reference > Referrer Info.

  • Referral Other: This will display the Other Non-Federal Number of the referral selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Other Non-Federal' field located in the selected referrer's Reference > Provider IDs.

  • Referral Other Federal: This will display the Other Federal Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Other Federal' field located in the selected referrer's Reference > Provider IDs.

  • Referral PPO: This will display the PPO number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'PPO' field located in the selected referrer's Reference > Provider IDs.

  • Referral Phone 1: This will display the Phone 1 Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the first phone number field under the 'Phone Numbers' section located in the selected referrer's Reference > Referrer Info.

  • Referral Phone 1 Type: This will display a numeric code reflective of the Phone 1 Type (Home/Work/Cell/Fax) for the referrer selected form the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull as selected from the "Type" popup directly to the left of the first phone number field under the 'Phone Numbers' section located in the selected referrer's Reference > Referrer Info.

    • Home: 0

    • Work: 1

    • Cell: 2

    • Fax: 3

  • Referral Phone 2: This will display the Phone 2 Number for the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the second 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.

  • Referral Phone 2 Type: This will display a numeric code reflective of the Phone 2 Type (Home/Work/Cell/Fax) for the referrer selected form the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will as selected from the "Type" popup directly to the left of the second phone number field under the 'Phone Numbers' section located in the selected referrer's Reference > Referrer Info.

    • Home: 0

    • Work: 1

    • Cell: 2

    • Fax: 3

  • Referral Phone 3: This will display the Phone 3 Number for the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the third 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.

  • Referral Phone 3 Type: This will display a numeric code reflective of the Phone 3 Type (Home/Work/Cell/Fax) for the referral selected form the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull as selected from the "Type" popup directly to the left of the third phone number field under the 'Phone Numbers' section located in the selected referrer's Reference > Referrer Info.

    • Home: 0

    • Work: 1

    • Cell: 2

    • Fax: 3

  • Referral Professional Title: This will display the Professional Title of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Prefix' field located in the selected referrer's Reference > Referrer Info.

  • Referral SSN/TID: This will display the Social Security Number/Tax ID of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'SSN/TID' field located in the selected referrer's Reference > Referrer Info.

  • Referral Self Administration: This will display the Self Administration Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Self Admin' field located in the selected referrer's Reference > Provider IDs.

  • Referral Self Pay: This will display the Self Pay Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Self Pay' field located in the selected referrer's Reference > Provider IDs.

  • Referral State: This will display the State of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'State' field located in the selected referrer's Reference > Referrer Info.

  • Referral State License: This will display the State License Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'State License' field located in the selected referrer's Reference > Referrer Info.

  • Referral Street Address: This will display the Street Address of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Street Address' field located in the selected referrer's Reference > Referrer Info.

  • Referral Suffix: This will display the Suffix of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Suffix' field located in the selected referrer's Reference > Referrer Info.

  • Referral Suite: This will display the Suite Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Suite' field located in the selected referrer's Reference > Referrer Info.

  • Referral Taxonomy Code: This will display the Taxonomy Code of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Taxonomy (Specialty Code)' field located in the selected referrer's Reference > Referrer Info.

  • Referral Title V: This will display the Title V Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Title V' field located in the selected referrer's Reference > Provider IDs.

  • Referral Type: This will display the Referral Type associated with the referrer selected from the 'Referral' dropdown located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Referrer Type' drop down located in the selected referrer's Reference > Referrer Info.

  • Referral Type Emergency: This is a "True/False" pull field that will display an 'X' respective to having selected a referrer from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident with a referral type containing the word "emergency". This data pulls from the 'Referral Type' dropdown located in the selected referrer's Reference > Referrer Info.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the selected Referral Type contains the word "emergency". If formatted for "False", an 'X' will display when the selected Referral Type does not contain the word "emergency".]

  • Referral Type Patient: This is a "True/False" pull field that will display an 'X' respective to having selected a referrer from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident with a referral type containing the word "Patient". This data pulls from the 'Referral Type' dropdown located in the selected referrer's Reference > Referrer Info.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the selected Referral Type contains the word "patient". If formatted for "False", an 'X' will display when the selected Referral Type does not contain the word "patient".]

  • Referral Type Phone Book: This is a "True/False" pull field that will display an 'X' respective to having selected a referrer from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident with a referral type containing the word "Phone Book". This data pulls from the 'Referral Type' dropdown located in the selected referrer's Reference > Referrer Info.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the selected Referral Type contains the words "phone book". If formatted for "False", an 'X' will display when the selected Referral Type does not contain the words "phone book".]

  • Referral Type Provider: This is a "True/False" pull field that will display an 'X' respective to having selected a referrer from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident with a referral type containing the word "Provider". This data pulls from the 'Referral Type' dropdown located in the selected referrer's Reference > Referrer Info.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the selected Referral Type contains the word "provider". If formatted for "False", an 'X' will display when the selected Referral Type does not contain the word "provider".]

  • Referral Veterans Administration: This will display the Veterans Administration Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Vets Admin.' field located in the selected referrer's Reference > Provider IDs.

  • Referral Workers Compensation: This will display the Workers Compensation Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Workers Compensation' field located in the selected referrer's Reference > Provider IDs.

  • Referral Zip Code: This will display the Zip Code of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident. This data will pull from the 'Zip Code' field located in the selected referrer's Reference > Referrer Info.

  • Return To Work Date: This will reflect the date as entered in the 'Return To Work' field located in Patients > Ledger > Incident Menu > CMS Claims > Disability.

  •  Similar Symptom Date: This will reflect the date as entered in the 'Other Date' field located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates.

  • Termination Date: This will reflect the date as entered in the 'Termination Date' field located in Patients > Ledger > Incident Menu > Military.
    [Note: Not available in DDS.]

  • Total Disability Begin Date: This will reflect the date as entered in the 'Begin Date' field under the 'Total Disability' section located in Patients > Ledger > Incident Menu > CMS Claims > Disability.

  • Total Disability End Date: This will reflect the date as entered in the 'End Date' field under the 'Total Disability' section located in Patients > Ledger > Incident Menu > CMS Claims > Disability.

  • Unable To Work Begin Date: This will reflect the date as entered in the 'Begin Date' field under the 'Total Disability' section located in Patients > Ledger > Incident Menu > CMS Claims > Disability.

  • Unable To Work End Date: This will reflect the date as entered in the 'End Date' field under the 'Total Disability' section located in Patients > Ledger > Incident Menu > CMS Claims > Disability.

 

Office

  • City: This will display the City of the office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'City' field located in the selected office's Reference.
    [Note: This field is inaccessible and can only be changed or updated by the Accounting Department.]

  • Fax: This will display the Fax Number of the office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Fax' field located in the selected office's Reference.

  • Group NPI Number: This will display the Group NPI of the office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Group National Provider ID Number' field located in the selected office's Reference.

  • Name: This will display the Name of the office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Office Name' field located in the selected office's Reference.
    [Note: This field is inaccessible and can only be changed or updated by the Accounting Department.]

  • Office Federal Number: This will display the Tax ID of the office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Federal Tax ID' field located in the selected office's Reference.

  • Phone: This will display the Phone Number of the office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Phone' field of the selected office's Reference.

  • State: This will display the State of the office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'State' field of the selected office's Reference.
    [Note: This field is inaccessible and can only be changed or updated by the Accounting Department.]

  • Street Address: This will display the Street Address of the office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Street Address' field located in the selected office's Reference.
    [Note: This field is inaccessible and can only be changed or updated by the Accounting Department.]

  • Suite: This will display the Suite Number of the office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Suite' field of the selected office's Reference.
    [Note: This field is inaccessible and can only be changed or updated by the Accounting Department.]

  • Type Of Bill: This will display the Type Of Bill data of the office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Type Of Bill' field located in the selected office's Reference.

  • Zip Code: This will display the Zip Code of the office selected from the 'Office' popup located in the selected procedure's Charge Window. This data will pull from the 'Zip Code' field located in the selected office's Reference.
    [Note: This field is inaccessible and can only be changed or updated by the Accounting Department.]

 

Other Insurance

  • Has Other Insurance: This is a "True/False" pull field that will display an 'X' respective to the selected patient having more than one enabled insurance record.
    [Note: 1) At least two insurance records MUST be added to the Insurance table(s) located in Patients > Primary and/or Secondary. 2) At least two of theses records MUST also be enabled by selecting their respective 'Enabled' checkbox located in Patients > Patient > Insurance. 3) An Insurance Carrier record MUST be selected from the 'Other Insurance' popup located in the Claims Creation Window. 4) Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when more than one insurance record is enabled. If formatted for "False" an 'X' will display when only one insurance record is enabled.]

  • Has Third Insurance: This is a "Yes/No" pull field that will display a "YES" or a "NO" respective to the selected patient having a Tertiary Insurance record.
    [Note: 1) At least three insurance records MUST be added to the Insurance table(s) located in Patients > Primary and/or Secondary. 2) At least three of theses records MUST also be enabled by selecting their respective 'Enabled' checkbox located in Patients > Patient > Insurance. 3) An Insurance Carrier record MUST be selected from the 'Other Insurance' popup located in the Claims Creation Window. 4) Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when three insurance records are enabled. If formatted for "False" an 'X' will display when less than three insurance records are enabled/selected.]

  • Other Insurance Carrier Code: This will display the Carrier Code for the insurance carrier selected from the 'Other Insurance' popup located in the Claim Creation Window. This data will pull from the 'Carrier Code' field located in the selected carrier's Reference > Company Info.[Note: 1) At least two insurance records MUST be added to the Insurance table(s) located in Patients > Primary and/or Secondary. 2) At least two of theses records MUST also be enabled by selecting their respective 'Enabled' checkbox located in Patients > Patient > Insurance.]

  • Second Insurance Carrier: This will display the Name of the insurance carrier selected from the 'Other Insurance' popup located in the Claim Creation Window. This data will pull from the 'Insurance Company' field located in the selected carrier's Reference > Company Info.
    [Note: 1) At least two insurance records MUST be added to the Insurance table(s) located in Patients > Primary and/or Secondary. 2) At least two of theses records MUST also be enabled by selecting their respective 'Enabled' checkbox located in Patients > Patient > Insurance.]

  • Second Insurance City: This will display the City of the insurance carrier selected from the 'Other Insurance' popup located in the Claim Creation Window. This data will pull from the 'City' field located in the selected carrier's Reference > Company Info.
    [Note: 1) At least two insurance records MUST be added to the Insurance table(s) located in Patients > Primary and/or Secondary. 2) At least two of theses records MUST also be enabled by selecting their respective 'Enabled' checkbox located in Patients > Patient > Insurance. 3) If the patient's insurance record is tied to an insurance plan this data will then pull from the 'City' field located in the selected carrier's Reference > Plans > Demographic.]

  • Second Insurance Fax: This will display the Fax Number of the insurance carrier selected from the 'Other Insurance' popup located in the Claim Creation Window. This data will pull from the 'Fax' field located in the selected carrier's Reference > Company Info.
    [Note: 1) At least two insurance records MUST be added to the Insurance table(s) located in Patients > Primary and/or Secondary. 2) At least two of theses records MUST also be enabled by selecting their respective 'Enabled' checkbox located in Patients > Patient > Insurance. 3) If the patient's insurance record is tied to an insurance plan this data will then pull from the 'Fax' field located in the selected carrier's Reference > Plans > Demographic.]

  • Second Insurance Is Dental: This is a "True/False" pull field that will display an 'X' respective to the carrier selected from the 'Other Insurance' popup located in the Claim Creation Window having "Dental" selected from the 'Insurance Type' popup located in the selected carrier's Reference > Claims.
    [Note: 1) At least two insurance records MUST be added to the Insurance table(s) located in Patients > Primary and/or Secondary. 2) At least two of theses records MUST also be enabled by selecting their respective 'Enabled' checkbox located in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Dental" is selected. If formatted for "False" an 'X' will display when "Medical" is selected.]

  • Second Insurance Is Medical: This is a "True/False" pull field that will display an 'X' respective to the carrier selected from the 'Other Insurance' popup located in the Claim Creation Window having "Medical" selected from the 'Insurance Type' popup located in the selected carrier's Reference > Claims.
    [Note: 1) At least two insurance records MUST be added to the Insurance table(s) located in Patients > Primary and/or Secondary. 2) At least two of theses records MUST also be enabled by selecting their respective 'Enabled' checkbox located in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Medical" is selected. If formatted for "False" an 'X' will display when "Dental" is selected.]

  • Second Insurance Phone: This will display the Phone Number of the insurance carrier selected from the 'Other Insurance' popup located in the Claim Creation Window. This data will pull from the 'Phone' field located in the selected carrier's Reference > Company Info.
    [Note: 1) At least two insurance records MUST be added to the Insurance table(s) located in Patients > Primary and/or Secondary. 2) At least two of theses records MUST also be enabled by selecting their respective 'Enabled' checkbox located in Patients > Patient > Insurance. 3) If the patient's insurance record is tied to an insurance plan this data will then pull from the 'Phone' field located in the selected carrier's Reference > Plans > Demographic.]

  • Second Insurance Plan Name: This will display the Plan Name for the insurance carrier selected from the 'Other Insurance' popup located in the Claim Creation Window.  This data will pull from the 'Plan' popup located in the selected Carrier's record (located in the primary or secondary's insurance table) and can be edited from the 'Plan Name' field found in the Insurance Plan table located in the carrier's Reference > Plans.
    [Note: 1) At least two insurance records MUST be added to the Insurance table(s) located in Patients > Primary and/or Secondary. 2) At least two of theses records MUST also be enabled by selecting their respective 'Enabled' checkbox located in Patients > Patient > Insurance.]

  • Second Insurance Provider Paper ID: This will display the Provider Paper ID for the insurance carrier selected from the 'Other Insurance' popup located in the Claim Creation Window. This data will pull from the 'Paper ID' field located in the Provider Table of the selected carrier's Reference > Provider IDs for the rendering provider selected from the 'Provider' popup located in the selected procedure's Charge Window.
    [Note: 1) At least two insurance records MUST be added to the Insurance table(s) located in Patients > Primary and/or Secondary. 2) At least two of theses records MUST also be enabled by selecting their respective 'Enabled' checkbox located in Patients > Patient > Insurance.]

  • Second Insurance State: This will display the State of the insurance carrier selected from the 'Other Insurance' popup located in the Claim Creation Window. This data will pull from the 'State' field located in the selected carrier's Reference > Company Info.
    [Note: 1) At least two insurance records MUST be added to the Insurance table(s) located in Patients > Primary and/or Secondary. 2) At least two of theses records MUST also be enabled by selecting their respective 'Enabled' checkbox located in Patients > Patient > Insurance. 3) If the patient's insurance record is tied to an insurance plan this data will then pull from the 'State' field located in the selected carrier's Reference > Plans > Demographic.]

  • Second Insurance Street Address: This will display the Street Address of the insurance carrier selected from the 'Other Insurance' popup located in the Claim Creation Window. This data will pull from the 'Street Address' field located in the selected carrier's Reference > Company Info.
    [Note: 1) At least two insurance records MUST be added to the Insurance table(s) located in Patients > Primary and/or Secondary. 2) At least two of theses records MUST also be enabled by selecting their respective 'Enabled' checkbox located in Patients > Patient > Insurance. 3) If the patient's insurance record is tied to an insurance plan this data will then pull from the 'Street Address' field located in the selected carrier's Reference > Plans > Demographic.]

  • Second Insurance Suite: This will display the Suite Number of the insurance carrier selected from the 'Other Insurance' popup located in the Claim Creation Window. This data will pull from the 'Suite' field located in the selected carrier's Reference > Company Info.
    [Note: 1) At least two insurance records MUST be added to the Insurance table(s) located in Patients > Primary and/or Secondary. 2) At least two of theses records MUST also be enabled by selecting their respective 'Enabled' checkbox located in Patients > Patient > Insurance. 3) If the patient's insurance record is tied to an insurance plan this data will then pull from the 'Suite' field located in the selected carrier's Reference > Plans > Demographic.]

  • Second Insurance Zip Code: This will display the Zip Code of the insurance carrier selected from the 'Other Insurance' popup located in the Claim Creation Window. This data will pull from the 'Zip Code' field located in the selected carrier's Reference > Company Info.
    [Note: 1) At least two insurance records MUST be added to the Insurance table(s) located in Patients > Primary and/or Secondary. 2) At least two of theses records MUST also be enabled by selecting their respective 'Enabled' checkbox located in Patients > Patient > Insurance. 3) If the patient's insurance record is tied to an insurance plan this data will then pull from the 'Zip Code' field located in the selected carrier's Reference > Plans > Demographic.]

 

Other Policy Holder

  • Other Insurance CDA Dependent Code: This will display the Dependent Code for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window.  This data will pull from the 'Dependent Code' field found in the selected Insurance Carrier record located in Patients > Patient > Insurance.
    [Note: "Use Canadian Claim Fields" checkbox MUST be selected from Preferences > Localization.]

  • Other Insurance Division/Section: This will display the Division/Section Number for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Division/Section' field found in the selected Insurance Carrier's record located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: "Use Canadian Claim Fields" checkbox MUST be selected from Preferences > Localization.]

  • Other Insurance Group Number: This will display the Group Number for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window.  This data will pull from the 'Group #' field located in the selected Insurance Carrier record found in the Insurance table located in Patients > Primary/Secondary (dependent upon the selected insurance carrier).

  • Other Insurance Subscriber Number: This will reflect the data as entered in the 'Subscriber ID" field located in Patients > Patient > Insurance for the Insurance Carrier record selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window.

  • Insured City: This will display the City for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'City' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Insured Date of Birth: This will display the Date of Birth for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Birth Date' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Insured Division/Section: This will display the Division/Section Number for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Division/Section' field found in the selected Insurance Carrier's record located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: "Use Canadian Claim Fields" checkbox MUST be selected from Preferences > Localization.]

  • Insured Email: This will display the Email Address for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Email' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Other Insured Employer City: This will display the City of the employer selected from the 'Employer' popup found in the Insurance Carrier record (located in Patients > Primary/Secondary) that is ultimately selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'City' field located in the selected employer's Reference.
    [Note: An Employer record MUST be added Employers table located in Patients > Primary or Secondary.]

  • Other Insured Employer Name: This will display the Name of the employer selected from the 'Employer' popup found in the Insurance Carrier record (located in Patients > Primary/Secondary) that is ultimately selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Employer Name' field located in the selected employer's Reference.
    [Note: An Employer record MUST be added Employers table located in Patients > Primary or Secondary.]

  • Other Insured Employer Phone: This will display the Phone Number of the employer selected from the 'Employer' popup found in the Insurance Carrier record (located in Patients > Primary/Secondary) that is ultimately selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Phone' field of the selected Employer record found in the Employer table located in Patients > Primary/Secondary.
    [Note: An Employer record MUST be added Employers table located in Patients > Primary or Secondary.]

  • Other Insured Employer Phone Extension: This will display the Phone Extension of the employer selected from the 'Employer' popup found in the Insurance Carrier record (located in Patients > Primary/Secondary) that is ultimately selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Extension' field of the selected Employer record found in the Employer table located in Patients > Primary/Secondary.
    [Note: An Employer record MUST be added Employers table located in Patients > Primary or Secondary.]

  • Other Insured Employer State: This will display the State of the employer selected from the 'Employer' popup found in the Insurance Carrier record (located in Patients > Primary/Secondary) that is ultimately selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'State' field located in the selected employer's Reference.
    [Note: An Employer record MUST be added Employers table located in Patients > Primary or Secondary.]

  • Other Insured Employer Street Address: This will display the Street Address of the employer selected from the 'Employer' popup found in the Insurance Carrier record (located in Patients > Primary/Secondary) that is ultimately selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Street Address' field located in the selected employer's Reference.
    [Note: An Employer record MUST be added Employers table located in Patients > Primary or Secondary.]

  • Other Insured Employer Suite: This will display the Suite Number of the employer selected from the 'Employer' popup found in the Insurance Carrier record (located in Patients > Primary/Secondary) that is ultimately selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Suite' field located in the selected employer's Reference.
    [Note: An Employer record MUST be added Employers table located in Patients > Primary or Secondary.]

  • Other Insured Employer Zip Code: This will display the Zip Code of the employer selected from the 'Employer' popup found in the Insurance Carrier record (located in Patients > Primary/Secondary) that is ultimately selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Zip Code' field located in the selected employer's Reference.
    [Note: An Employer record MUST be added Employers table located in Patients > Primary or Secondary.]

  • Other Insured First Name: This will display the First Name of the policy holder for the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'First Name' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Other Insured Group Number: This will display the Group Number for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window.  This data will pull from the 'Group #' field located in the selected Insurance Carrier record found in the Insurance table located in Patients > Primary/Secondary (dependent upon the selected insurance carrier).

  • Other Insured Home Phone: This will display the Home Phone Number for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Home Phone".]

  • Other Insured Home Phone Extension: This will display the Home Extension Number for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from an 'Ext' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Home Phone".]

  • Other Insured Is Female: This is a "True/False" pull field that will display an 'X' respective to the policy holder holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window being female.  This data will pull from the 'Sex' popup located in Patients > Primary/Secondary (dependent upon the selected insurance carrier).
    [Note: Functionality dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Female" is selected. If formatted for "False" an 'X' will display when "Male" is selected.]

  • Other Insured Is Male: This is a "True/False" pull field that will display an 'X' respective to the policy holder holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window being male.  This data will pull from the 'Sex' popup located in Patients > Primary/Secondary (dependent upon the selected insurance carrier).
    [Note: Functionality dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Male" is selected. If formatted for "False" an 'X' will display when "Female" is selected.]

  • Other Insured Last Name: This will display the Last Name of the policy holder for the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Last Name (Guarantor)' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Other Insured Middle Name: This will display the Middle Name of the policy holder for the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Middle' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Other Insured Mobile Phone: This will display the Mobile Phone Number for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Mobile Phone".]

  • Other Insured Mobile Phone Extension: This will display the Mobile Extension Number for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from an 'Ext' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Mobile Phone".]

  • Other Insured Other Phone: This will display the Other Phone Number for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Other Phone".]

  • Other Insured Other Phone Extension: This will display the Other Extension Number for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from an 'Ext' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Other Phone".]

  • Other Insured Relationship Child: This is a "True/False" pull field that will display an 'X' respective to the relationship between the policy holder holder of the insurance carrier selected from the 'Other Insurance' popup (located in the selected procedure's Claim Creation Window) and the patient being parent/child.  This data will pull from the 'Relationship to Primary/Secondary' popup (dependent upon the selected insurance carrier) located in Patients > Patient .
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Child/Stepson or Stepdaughter" has been selected. If formatted for "False" an 'X' will display when "Child/Stepson or Stepdaughter" has not been selected.]

  • Other Insured Relationship Code: This will display a numeric code reflective of the relationship between the policy holder holder of the insurance carrier selected from the 'Other Insurance' popup (located in the selected procedure's Claim Creation Window) and the patient. This data will pull from the 'Relationship to Primary/Secondary' popup (dependent upon the selected insurance carrier) located in Patients > Patient .

  • Other Insured Relationship Other: This is a "True/False" pull field that will display an 'X' respective to the relationship between the policy holder holder of the insurance carrier selected from the 'Other Insurance' popup (located in the selected procedure's Claim Creation Window) and the patient being "other."  This data will pull from the 'Relationship to Primary/Secondary' popup (dependent upon the selected insurance carrier) located in Patients > Patient .
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when one of the following items has been selected. If formatted for "False" an 'X' will display when one of the following items has not been selected.]

    • Grandfather or Grandmother

    • Grandson or Granddaughter

    • Nephew or Niece

    • Foster Child

    • Ward

    • Employee

    • Unknown

    • Handicapped Dependent

    • Sponsored Dependent

    • Dependent of a Minor Dependent

    • Significant Other

    • Mother

    • Father

    • Other Adult

    • Emancipated Minor

    • Organ Donor

    • Cadaver Donor

    • Injured Plaintiff

    • Child Where Insured Has No Financial Responsibility

    • Life Partner

    • Other Relationship

    • Adopted Child

  • Other Insured Relationship Self: This is a "True/False" pull field that will display an 'X' respective to the relationship between the policy holder holder of the insurance carrier selected from the 'Other Insurance' popup (located in the selected procedure's Claim Creation Window) and the patient being "self".  This data will pull from the 'Relationship to Primary/Secondary' popup (dependent upon the selected insurance carrier) located in Patients > Patient.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Self" has been selected. If formatted for "False" an 'X' will display when "Self" has not been selected.]

  • Other Insured Relationship Spouse: This is a "True/False" pull field that will display an 'X' respective to the relationship between the policy holder holder of the insurance carrier selected from the 'Other Insurance' popup (located in the selected procedure's Claim Creation Window) and the patient being marital.  This data will pull from the 'Relationship to Primary/Secondary' popup (dependent upon the selected insurance carrier) located in Patients > Patient.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Spouse" has been selected. If formatted for "False" an 'X' will display when "Spouse" has not been selected.]

  • Other Insured Relationship Text: This will display the relationship between the policy holder holder of the insurance carrier selected from the 'Other Insurance' popup (located in the selected procedure's Claim Creation Window) and the patient in text format. This data will pull as selected from the 'Relationship to Primary/Secondary' popup (dependent upon the selected insurance carrier) located in Patients > Patient

  • Other Insured Release Of Information: This will indicate a confirmation of a "release of information" for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window by displaying "Signature On File." This data will pull respective to having selected the 'Release of Info (Box 12)' and/or the 'Signature on File (Box 13)' checkboxes located in Patient > Primary/Secondary (dependent upon the selected insurance carrier).

  • Other Insured Release Of Information (Y/N): This is a "Yes/No" pull field that will indicate a confirmation of release of information for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window by displaying a "Y" or an "N" respective to having selected the 'Release of Info (box 12)' and/or the 'Signature on File (box 13)' ('Release of Info (box 36)' / 'Signature on File (box 37)' in DDS) checkbox(es) located in Patient > Primary/Secondary (dependent upon the selected insurance carrier).

  • Other Insured Release Of Information Date: This will reflect the current date.

  • Other Insured SSN: This will display the Social Security Number for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Social Security' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Other Insured Sex: This will display a numeric code reflective of the sex for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Sex' popup located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Other Insured Signature On File: This will indicate a confirmation of the "signature on file" for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window by displaying "Signature On File." This data will pull respective to having selected the 'Signature On File (Box 13)' ('Signature on File (box 37)' in DDS) checkbox located in Patient > Primary/Secondary (dependent upon the selected insurance carrier).

  • Other Insured Signature On File (Y/N): This is a "Yes/No" pull field that will display a 'Y' or an 'N' in indication of a confirmation of the "signature on file" for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window by displaying "Signature On File." This data will pull respective to having selected the 'Signature On File (Box 13)' ('Signature on File (box 37)' in DDS) checkbox located in Patient > Primary/Secondary (dependent upon the selected insurance carrier).

  • Other Insured State: This will display the State for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'State' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Other Insured Street Address: This will display the Street Address for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Street Address' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Other Insured Subscriber Number: This will reflect the data as entered in the 'Subscriber ID" field located in Patients > Patient > Insurance for the Insurance Carrier record selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window.

  • Other Insured Suffix: This will display the Suffix of the policy holder for the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Suffix' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Other Insured Suite/Apartment: This will display the Suite/Apartment Number for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Suite/Apt. #' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Other Insured Work Phone: This will display the Work Phone Number for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Work Phone".]

  • Other Insured Work Phone Extension: This will display the Work Extension Number for the policy holder of the insurance carrier selected from the 'Other Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from an 'Ext' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Work Phone".]

  • Other Insured Zip Code: This will display the Zip Code for the policy holder of the insurance carrier selected from the 'Other Insurance' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Suite/Apt. #' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

 

Patient

  • Account ID: Upon creation, every new patient account will receive a unique numeric identifier including an additional numeric identifier for every patient tied to that account. This pull field will display the numeric account identifier that was assigned to the account at the moment of creation less the patient identifier.

  • Address State: This will reflect the data as entered in the 'State' field located in Patients > Patient.

  • Address, City: This will reflect the data as entered in the 'City' field located in Patients > Patient.

  • Address, Country: This will reflect the data as entered in the 'Country' field located in Patients > Patient.

  • Address, Street: This will reflect the data as entered in the 'Street Address' field located in Patients > Patient.

  • Address, Suite/Apt#: This will reflect the data as entered in the 'Suite/Apt. Number' field located in Patients > Patient.

  • Address, Zip Code: This will reflect the data as entered in the 'Zip Code' field located in Patients > Patient.

  • Age: This will display the Age of the patient as determined by the date of birth as entered in the 'Birth Date' field located in Patients > Patient.

  • Birthday: This will reflect the date as entered in the 'Date of Death' field located in Patients > Patient > Alerts.

  • Alert 1: This will display the first Alert record listed in the Alerts table located in Patients > Patient > Alerts. This data will pull from the 'Patient Alert Description' field located in the selected alert's Reference.

  • Alert 2: This will display the second Alert record listed in the Alerts table located in Patients > Patient > Alerts. This data will pull from the 'Patient Alert Description' field located in the selected alert's Reference.

  • Alert 3: This will display the third Alert record listed in the Alerts table located in Patients > Patient > Alerts. This data will pull from the 'Patient Alert Description' field located in the selected alert's Reference.

  • Alert 4: This will display the fourth Alert record listed in the Alerts table located in Patients > Patient > Alerts. This data will pull from the 'Patient Alert Description' field located in the selected alert's Reference.

  • Alert 5: This will display the fifth Alert record listed in the Alerts table located in Patients > Patient > Alerts. This data will pull from the 'Patient Alert Description' field located in the selected alert's Reference.

  • Alert 6: This will display the sixth Alert record listed in the Alerts table located in Patients > Patient > Alerts. This data will pull from the 'Patient Alert Description' field located in the selected alert's Reference.

  • Alert 7: This will display the seventh Alert record listed in the Alerts table located in Patients > Patient > Alerts. This data will pull from the 'Patient Alert Description' field located in the selected alert's Reference.

  • Alert 8: This will display the eighth Alert record listed in the Alerts table located in Patients > Patient > Alerts. This data will pull from the 'Patient Alert Description' field located in the selected alert's Reference.

  • Allergy Date Last Checked: This will reflect the date as entered in the 'Last' field located in Patients > Clinical > Allergy.

  • BMI: This will display the patient's Body Mass Index (rounded to the nearest decimal) for the most recent set of vital signs added to Patients > Clinical > Vitals. This data will pull from the 'BMI' field located in the selected record's Vitals Window.
    [Note: The most recent set of vitals is determined by the last record listed in the Vitals tab (most recent date entered in the 'Date Measured' field located in the Vital's Window).]

  • BP Diastolic: This will display the Diastolic Blood Pressure for the most recent set of vital signs added to Patients > Clinical > Vitals. This data will pull from the rightmost 'Blood Pressure' field (Systolic / Diastolic) located in the selected record's Vitals Window.
    [Note: The most recent set of vitals is determined by the last record listed in the Vitals tab (most recent date entered in the 'Date Measured' field located in the Vital's Window).]

  • BP Systolic: This will display the Systolic Blood Pressure for the most recent set of vital signs added to the Vitals table located in Patients > Clinical > Vitals. This data will pull from the leftmost 'Blood Pressure' field (Systolic / Diastolic) located in the selected record's Vitals Window.
    [Note: The most recent set of vitals is determined by the last record listed in the Vitals tab (most recent date entered in the 'Date Measured' field located in the Vital's Window).]

  • Birth Time: This will display the time as entered in the 'Birth Time' field located in the Details window of the 'Birth Date' field located in Patients > Patient.

  • Birthday: This will reflect the date as entered in the 'Birth Date' field located in Patients > Patient.

  • Chart #: This will reflect the data as entered in the 'Chart #' field located in Patients > Patient.

  • Custom 1: This will display the first Custom record listed in Patients > Patient > Custom. This data will pull from the 'Custom Description' field located in the selected record's Reference.

  • Custom 2: This will display the second Custom record listed in Patients > Patient > Custom. This data will pull from the 'Custom Description' located in the selected record's Reference.

  • Custom 3: This will display the third Custom record listed in Patients > Patient > Custom. This data will pull from the 'Custom Description' located in the selected record's Reference.

  • Custom 4: This will display the fourth Custom record listed in Patients > Patient > Custom. This data will pull from the 'Custom Description' located in the selected record's Reference.

  • Custom 5: This will display the fifth Custom record listed in Patients > Patient > Custom. This data will pull from the 'Custom Description' located in the selected record's Reference.

  • Custom 6: This will display the sixth Custom record listed in Patients > Patient > Custom. This data will pull from the 'Custom Description' located in the selected record's Reference.

  • Custom 7: This will display the seventh Custom record listed in Patients > Patient > Custom. This data will pull from the 'Custom Description' located in the selected record's Reference

  • Custom 8: This will display the eighth Custom record in Patients > Patient > Custom. This data will pull from the 'Custom Description' located in the selected record's Reference.

  • Display ID: Upon creation, every new patient account will receive a unique numeric identifier including a numeric identifier for every patient tied to that account. This pull field will display the full numeric account identifier and numeric patient identifier that were assigned at the moment of creation.

  • EPSTD (Early Periodic Screening Diagnosis and Treatment): This is a "True/False" pull field that will display an 'X' respective to having selected the 'EPSDT' checkbox located in Patients > Patient > Insurance.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the checkbox is selected. If formatted for "False", an 'X' will display when the checkbox is deselected.]

  • Email: This will reflect the data as entered in the 'Email Address' field located in Patients > Patient.

  • Exception: This will reflect the Exception as selected from the 'Patient Exception' popup located in Patients > Patient > CDA.
    [Note: The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization.]

  • Exception - Is Disabled: This is a "True/False" pull field that will display an 'X' respective to having selected "Disabled" from the 'Patient Exception' popup located in Patients > Patient > CDA.
    [Note: 1) The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization. 2) Pull field formatting MUST be set to "Text".]

  • Exception - Is Disabled Student: This is a "True/False" pull field that will display an 'X' respective to having selected "Disabled Student" from the 'Patient Exception' popup located in Patients > Patient > CDA
    [Note: 1) The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization. 2) Pull field formatting MUST be set to "Text".]

  • Exception - Is Full Time Student: This is a "True/False" pull field that will display an 'X' respective to having selected "Full Time Student" from the 'Patient Exception' popup located in Patients > Patient > CDA
    [Note: 1) The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization. 2) Pull field formatting MUST be set to "Text".]

  • Family Planning: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Family Planning' checkbox located in Patients > Patient > Insurance.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when the checkbox is selected. If formatted for "False" an 'X' will display when the checkbox is not selected.]

  • Fee Schedule Name: This will display the Fee Schedule Name selected from the 'Fee Schedule' popup located in Patients > Patient.

  • Formatted Age: This will display the Age of the patient followed by a 'y' as determined by the date of birth as entered in the 'Birth Date' field located in Patients > Patient. 

  • Home Phone: This will reflect the data as entered in a 'Number' field located in Patients > Patient.
    [Note: The 'Number' field's adjoining 'Type' popup MUST be set to "Home Phone".]

  • Home Phone Extension: This will reflect the data as entered in an 'Ext' field located in Patients > Patient.
    [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Home Phone".] 

  • Is Employed: This is a "True/False" pull field that will display an 'X' respective to having selected "Employed", "Self-Employed", or "Active Military" from the 'Employment' popup located in Patients > Patient.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when any of these items are selected. If formatted for "False" an 'X' will display when none of these items are selected.]

  • Is Female: This is a "True/False" pull field that will display an 'X' respective to having selected "Female" from the 'Sex' popup located in Patients > Patient.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Female" is selected. If formatted for "False" an 'X' will display when "Male" is selected.]

  • Is Full Time Student: This is a "True/False" pull field that will display an 'X' respective to having selected "Full-Time Student" from the 'Employment' popup located in Patients > Patient.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Full-Time Student" is selected. If formatted for "False" an 'X' will display when "Full-Time Student" is not selected.]

  • Is Male: This is a "True/False" pull field that will display an 'X' respective to having selected "Male" from the 'Sex' popup located in Patients > Patient.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Male" is selected. If formatted for "False" an 'X' will display when "Female" is selected.]

  • Is Marital Status Other: This is a "True/False" pull field that will display an 'X' respective to having selected "Legally Separated", "Divorced", "Widowed", "Unknown", or "Partner" from the 'Marital Status' popup located in Patients > Patient.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when any of these items are selected. If formatted for "False" an 'X' will display when none of these items are selected.]

  • Is Married: This is a "True/False" pull field that will display an 'X' respective to having selected "Married" from the 'Marital Status' popup located in Patients > Patient.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Married" is selected. If formatted for "False" an 'X' will display when "Married" is not selected.]

  • Is Part Time Student: This is a "True/False" pull field that will display an 'X' respective to having selected "Part-Time Student" from the 'Employment' popup located in Patients > Patient.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Part-Time Student" is selected. If formatted for "False" an 'X' will display when "Part-Time Student" is not selected.]

  • Is Single: This is a "True/False" pull field that will display an 'X' respective to having selected "Single" from the 'Marital Status' popup located in Patients > Patient.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Single" is selected. If formatted for "False" an 'X' will display when "Single" is not selected.] 

  • Marital Status (S/M/X/D/W/P/U): This will display a letter respective to having selected "Single (S)", "Married (M)", "Legally Separated (X)", "Divorced (D)", "Widowed (W)", "Partner (P)", or "Unknown (U)" from the 'Marital Status' popup located in Patients > Patient.

  • Medicare Expiration: This will reflect the date as entered in the 'Medicare Expiration' field located in Patients > Patient.
    [Note: "Medicare" MUST be selected from the 'SSN/Medicare' popup located in Preferences > Localization.]

  • Mobile Phone: This will reflect the data as entered in a 'Number' field located in Patients > Patient.
    [Note: The 'Number' field's adjoining 'Type' popup MUST be set to "Mobile Phone".]

  • Mobile Phone Extension: This will reflect the data as entered in an 'Ext' field located in Patients > Patient.
    [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Mobile Phone".]

  • Name (Last, First Mi): This will reflect the data as entered in the 'First Name', 'Middle Name', and 'Last Name' fields located in Patients > Patient.
    [Note: This pull field will display the data as "last name, first name, middle initial (Doe, John X.).]

  • Name, First: This will reflect the data as entered in the 'First Name' field located in Patients > Patient.

  • Name, Last: This will reflect the data as entered in the 'Last Name' field located in Patients > Patient.

  • Name, Maiden: This will reflect the data as entered in the 'Maiden Name' field located in Patients > Patient.

  • Name, Middle: This will reflect the data as entered in the 'Middle Name' field located in Patients > Patient.

  • Name, Prefix: This will reflect the data as entered in the 'Prefix' field located in Patients > Patient.

  • Name, Suffix: This will reflect the data as entered in the 'Suffix' field located in Patients > Patient.

  • New Patient Date: This will reflect the date as entered in the 'New Patient Date' located in Patients > Patient. 

  • Office ID: This will display the Office ID of the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Office ID' field located in the selected office's Reference.

  • Office Name: This will display the Name of the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Office Name' field located in the selected office's Reference.
    [Note: This field is inaccessible and can only be changed or updated by the Accounting Department.]

  • Other Phone: This will reflect the data as entered in a 'Number' field located in Patients > Patient.
    [Note: The 'Number' field's adjoining 'Type' popup MUST be set to "Other Phone".]

  • Other Phone Extension: This will reflect the data as entered in an 'Ext' field located in Patients > Patient.
    [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Other Phone".]

  • Provider First Name: This will display the First Name of the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'First' field located in the selected provider's User Reference.

  • Provider ID: This will display the Provider ID of the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'User ID' field located in the selected provider's User Reference > User Information.

  • Provider Last Name: This will display the Last Name of the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Last' field located in the selected provider's User Reference.

  • Provider Middle Name: This will display the Middle Name of the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Middle' field located in the selected provider's User Reference.

  • Provider Prof. Title: This will display the Professional Title of the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Professional Title' field located in the selected provider's User Reference.

  • Race: This will display any Race listed in the Race/Ethnicity table located in Patients > Patient > Race/Ethnicity.
    [Note: The order of the listed races is determined by dragging and dropping the entries into the desired order.] 

  • SSN: This will reflect the data as entered in the 'Social Security' field located in Patients > Patient.

  • SSN Last 4: This will reflect last 4 digits of the SSN as entered in the 'Social Security' field located in Patients > Patient.

  • School City: This will reflect the data as entered in the 'City' field located in Patients > Patient > CDA.
    [Note: The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization.]

  • School Name: This will reflect the data as entered in the 'School Name' field located in Patients > Patient > CDA.
    [Note: The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization.]

  • School State: This will reflect the data as entered in the 'State' field located in Patients > Patient > CDA.
    [Note: The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization.]

  • School Street Address: This will reflect the data as entered in the 'Street Address' field located in Patients > Patient > CDA.
    [Note: The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization.]

  • School Suite: This will reflect the data as entered in the 'Suite/Apt #' field located in Patients > Patient > CDA.
    [Note: The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization.]

  • School Zip Code: This will reflect the data as entered in the 'Zip/Postal Code' field located in Patients > Patient > CDA.
    [Note: The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization.] 

  • Sex (M/F): This will display an 'M' or an 'F' respective to having selected "Male" or "Female" from the 'Sex' popup located in Patients > Patient. 

  • Weight: This will display the Weight as found under the 'Weight' column of the most recent set of vital signs entered in the Vitals table located in Patients > Clinical > Vitals. This data will pull from the 'Weight' field located in the selected entry's Vitals Window.
    [Note: The most recent set of vitals is determined by the last record listed in the Vitals tab (most recent date entered in the 'Date Measured' field located in the Vital's Window).]

  • Work Phone: This will reflect the data as entered in a 'Number' field located in Patients > Patient.
    [Note: The 'Number' field's adjoining 'Type' popup MUST be set to "Work Phone".]

  • Work Phone Extension: This will reflect the data as entered in an 'Ext' field located in Patients > Patient.
    [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Work Phone".]

 

Patient Referral 1

[Note: For this field to populate the Referrer's record must have a "Transition To" referral category.]

  • BCBS: This will display the BCBS Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'BCBS' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Blue Cross: This will display the Blue Cross Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Blue Cross' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Cell Phone Number: This will display the Cell Phone Number for the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Central Cert: This will display the Central Cert Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Central Cert.' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Champus: This will display the Champus Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Blue Cross' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • City: This will display the City of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'City' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Commercial: This will display the Commercial Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Date: This will reflect the date as entered in the 'Referral Date' field of the patient's Referral 1 located in Patients > Patient > Referrals.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Department: This will display Department for the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Dept.' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Disability: This will display the Disability Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Disability' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Email: This will display the Email Address for the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'email' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Expiration Date: This will display the Expiration Date for the patient's Referral 1. This data will pull as found under 'Expiration Date' column located in Patients > Patient > Referrals for the selected Referrer's record. This date is calculated by beginning with the Referral Date then adding the month range selected from the 'Months' popup located in the selected Referrer record.
    [Note: 1) The 'Use Referrals Expiration Date' checkbox MUST be selected from References > Localizaion (not available in DDS). 2) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab. 3) When using this field in DDS or selecting 'Indefinite' from the 'Months' popup for other flavors, MacPractice should display the date as 12 months from the Referral date. However it displays the date as the previous month of the same year.]

  • Expiration Months: This will reflect the data selected from the 'Months' popup found in the patient's Referral 1 record located in Patients > Patient > Referrals.
    [Note: 1) The 'Use Referrals Expiration Date' checkbox MUST be selected from References > Localization. 2) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Family/Friend: [Nonfunctional]

  • Fax Number: This will display the Fax Number for the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The 'Phone Number' field's adjoining popup MUST be set to "Fax". 2) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Federal Employee: This will display the Federal Employee Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Federal Employee' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • HMO: This will display the Health Maintenance Organization Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'HMO' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Home Phone Number: This will display the Home Phone Number for the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The 'Phone Number' field's adjoining popup MUST be set to "Home". 2) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Managed Care: This will display the Managed Care Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Managed' field located in the selected referral's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Medicaid: This will display the Medicaid Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Medicaid' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Medicare: This will display the Medicare Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Medicare Part B' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Name, First: This will display the First Name of the Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'First' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Name, Last: This will display the Last Name of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Last' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Name, Nickname: This will display the Nickname of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Nickname (AKA)' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Name, Professional Title: This will display the Professional Title of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Prefix' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Name, Suffix: This will display the Suffix of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Suffix' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • National Provider ID: This will display the NPI Number for the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'National Provider ID (NPI)' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  •  Office: This will display the Company Name of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Office/Company' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Other: This will display the Other Non-Federal Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Other Non-Federal' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Other Federal: This will display the Other Federal Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Other Federal' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • PPO: This will display the PPO Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'PPO' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Phone 1 Number: This will display the Phone 1 Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the first 'Phone Numbers' field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  •  Phone 1 Type: This will display the Phone 1 Type (Home/Work/Cell/Fax) for the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull as selected from the "phone type" popup adjacent to the first phone number field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Phone 2 Number: This will display the Phone 2 Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the second 'Phone Numbers' field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Phone 2 Type: This will display the Phone 2 Type (Home/Work/Cell/Fax) for the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull as selected from the "phone type" popup adjacent to the second phone number field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Phone 3 Number: This will display the Phone 3 Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the third 'Phone Numbers' field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Phone 3 Type: This will display the Phone 3 Type (Home/Work/Cell/Fax) for the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull as selected from the "phone type" popup adjacent to the third phone number field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Position Title: This will display the Title/Position of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Title/Position' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Referral Type: This will display the Referral Type of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull as selected from the 'Referrer Type' popup located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Primary Insurance ID: This will display the Insurance ID Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • SSN/TID: This will display the Social Security Number/Tax ID for the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'SSN/TID' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Self Admin: This will display the Self Admin Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Self Admin' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Self Pay: This will display the Self Pay Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Self Pay' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • State: This will display the State of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'State' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • State License: This will display the State License Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'State License' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Street Address: This will display the Street Address of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Street Address' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Suite: This will display the Suite Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Suite' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Taxonomy Code: This will display the Taxonomy/Specialty Code of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Taxonomy (Specialty)' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Title V: This will display the Title V Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Title V' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Vets Admin: This will display the Vets Admin Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Vets Admin.' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Work Phone Number: This will display the Work Phone Number for the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The 'Phone Number' field's adjoining popup MUST be set to "Work". 2) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Workers Compensation: This will display the Workers Compensation Number of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Workers Compensation.' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

  • Zip Code: This will display the Zip Code of the patient's Referral 1 located in Patients > Patient > Referrals. This data will pull from the 'Zip Code' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 1 is determined by the first "Transition To" Referral record listed in the Referrals tab.]

 

Patient Referral 2

[Note: For this field to populate the Referrer's record must have a "Transition To" referral category.]

  • BCBS: This will display the BCBS Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'BCBS' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Blue Cross: This will display the Blue Cross Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Blue Cross' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Cell Phone Number: This will display the Cell Phone Number for the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Central Cert: This will display the Central Cert Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Central Cert.' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Champus: This will display the Champus Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Blue Cross' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • City: This will display the City of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'City' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Commercial: This will display the Commercial Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Date: This will reflect the date as entered in the 'Referral Date' field of the patient's Referral 2 located in Patients > Patient > Referrals.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Department: This will display Department for the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Dept.' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Disability: This will display the Disability Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Disability' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Email: This will display the Email Address for the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'email' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Expiration Date: This will display the Expiration Date for the patient's Referral 2. This data will pull as found under 'Expiration Date' column located in Patients > Patient > Referrals for the selected Referrer's record. This date is calculated by beginning with the Referral Date then adding the month range selected from the 'Months' popup located in the selected Referrer record.
    [Note: 1) The 'Use Referrals Expiration Date' checkbox MUST be selected from References > Localizaion (not available in DDS). 2) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab. 3) When using this field in DDS or selecting 'Indefinite' from the 'Months' popup for other flavors, MacPractice should display the date as 12 months from the Referral date. However it displays the date as the previous month of the same year.]

  • Expiration Months: This will reflect the data selected from the 'Months' popup found in the patient's Referral 2 record located in Patients > Patient > Referrals.
    [Note: 1) The 'Use Referrals Expiration Date' checkbox MUST be selected from References > Localization. 2) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Family/Friend: [Nonfunctional]

  • Fax Number: This will display the Fax Number for the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The 'Phone Number' field's adjoining popup MUST be set to "Fax". 2) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Federal Employee: This will display the Federal Employee Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Federal Employee' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • HMO: This will display the Health Maintenance Organization Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'HMO' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Home Phone Number: This will display the Home Phone Number for the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The 'Phone Number' field's adjoining popup MUST be set to "Home". 2) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Managed Care: This will display the Managed Care Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Managed' field located in the selected referral's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Medicaid: This will display the Medicaid Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Medicaid' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Medicare: This will display the Medicare Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Medicare Part B' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Name, First: This will display the First Name of the Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'First' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Name, Last: This will display the Last Name of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Last' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Name, Nickname: This will display the Nickname of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Nickname (AKA)' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Name, Professional Title: This will display the Professional Title of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Prefix' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Name, Suffix: This will display the Suffix of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Suffix' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • National Provider ID: This will display the NPI Number for the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'National Provider ID (NPI)' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  •  Office: This will display the Company Name of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Office/Company' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Other: This will display the Other Non-Federal Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Other Non-Federal' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Other Federal: This will display the Other Federal Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Other Federal' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • PPO: This will display the PPO Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'PPO' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Phone 1 Number: This will display the Phone 1 Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the first 'Phone Numbers' field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  •  Phone 1 Type: This will display the Phone 1 Type (Home/Work/Cell/Fax) for the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull as selected from the "phone type" popup adjacent to the first phone number field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Phone 2 Number: This will display the Phone 2 Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the second 'Phone Numbers' field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Phone 2 Type: This will display the Phone 2 Type (Home/Work/Cell/Fax) for the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull as selected from the "phone type" popup adjacent to the second phone number field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Phone 3 Number: This will display the Phone 3 Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the third 'Phone Numbers' field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Phone 3 Type: This will display the Phone 3 Type (Home/Work/Cell/Fax) for the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull as selected from the "phone type" popup adjacent to the third phone number field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Position Title: This will display the Title/Position of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Title/Position' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Referral Type: This will display the Referral Type of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull as selected from the 'Referrer Type' popup located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Primary Insurance ID: This will display the Insurance ID Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • SSN/TID: This will display the Social Security Number/Tax ID for the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'SSN/TID' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Self Admin: This will display the Self Admin Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Self Admin' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Self Pay: This will display the Self Pay Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Self Pay' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • State: This will display the State of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'State' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • State License: This will display the State License Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'State License' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Street Address: This will display the Street Address of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Street Address' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Suite: This will display the Suite Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Suite' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Taxonomy Code: This will display the Taxonomy/Specialty Code of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Taxonomy (Specialty)' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Title V: This will display the Title V Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Title V' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Vets Admin: This will display the Vets Admin Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Vets Admin.' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Work Phone Number: This will display the Work Phone Number for the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The 'Phone Number' field's adjoining popup MUST be set to "Work". 2) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Workers Compensation: This will display the Workers Compensation Number of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Workers Compensation.' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

  • Zip Code: This will display the Zip Code of the patient's Referral 2 located in Patients > Patient > Referrals. This data will pull from the 'Zip Code' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 2 is determined by the second "Transition To" Referral record listed in the Referrals tab.]

 

Patient Referral 3

[Note: For this field to populate the Referrer's record must have a "Transition To" referral category.]

  • BCBS: This will display the BCBS Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'BCBS' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Blue Cross: This will display the Blue Cross Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Blue Cross' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Cell Phone Number: This will display the Cell Phone Number for the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Central Cert: This will display the Central Cert Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Central Cert.' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Champus: This will display the Champus Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Blue Cross' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • City: This will display the City of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'City' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Commercial: This will display the Commercial Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Date: This will reflect the date as entered in the 'Referral Date' field of the patient's Referral 3 located in Patients > Patient > Referrals.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Department: This will display Department for the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Dept.' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Disability: This will display the Disability Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Disability' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Email: This will display the Email Address for the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'email' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Expiration Date: This will display the Expiration Date for the patient's Referral 3. This data will pull as found under 'Expiration Date' column located in Patients > Patient > Referrals for the selected Referrer's record. This date is calculated by beginning with the Referral Date then adding the month range selected from the 'Months' popup located in the selected Referrer record.
    [Note: 1) The 'Use Referrals Expiration Date' checkbox MUST be selected from References > Localizaion (not available in DDS). 2) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab. 3) When using this field in DDS or selecting 'Indefinite' from the 'Months' popup for other flavors, MacPractice should display the date as 12 months from the Referral date. However it displays the date as the previous month of the same year.]

  • Expiration Months: This will reflect the data selected from the 'Months' popup found in the patient's Referral 3 record located in Patients > Patient > Referrals.
    [Note: 1) The 'Use Referrals Expiration Date' checkbox MUST be selected from References > Localization. 2) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Family/Friend: [Nonfunctional]

  • Fax Number: This will display the Fax Number for the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The 'Phone Number' field's adjoining popup MUST be set to "Fax". 2) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Federal Employee: This will display the Federal Employee Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Federal Employee' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • HMO: This will display the Health Maintenance Organization Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'HMO' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Home Phone Number: This will display the Home Phone Number for the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The 'Phone Number' field's adjoining popup MUST be set to "Home". 2) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Managed Care: This will display the Managed Care Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Managed' field located in the selected referral's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Medicaid: This will display the Medicaid Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Medicaid' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Medicare: This will display the Medicare Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Medicare Part B' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Name, First: This will display the First Name of the Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'First' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Name, Last: This will display the Last Name of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Last' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Name, Nickname: This will display the Nickname of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Nickname (AKA)' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Name, Professional Title: This will display the Professional Title of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Prefix' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Name, Suffix: This will display the Suffix of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Suffix' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • National Provider ID: This will display the NPI Number for the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'National Provider ID (NPI)' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  •  Office: This will display the Company Name of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Office/Company' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Other: This will display the Other Non-Federal Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Other Non-Federal' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Other Federal: This will display the Other Federal Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Other Federal' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • PPO: This will display the PPO Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'PPO' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Phone 1 Number: This will display the Phone 1 Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the first 'Phone Numbers' field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  •  Phone 1 Type: This will display the Phone 1 Type (Home/Work/Cell/Fax) for the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull as selected from the "phone type" popup adjacent to the first phone number field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Phone 2 Number: This will display the Phone 2 Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the second 'Phone Numbers' field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Phone 2 Type: This will display the Phone 2 Type (Home/Work/Cell/Fax) for the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull as selected from the "phone type" popup adjacent to the second phone number field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Phone 3 Number: This will display the Phone 3 Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the third 'Phone Numbers' field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Phone 3 Type: This will display the Phone 3 Type (Home/Work/Cell/Fax) for the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull as selected from the "phone type" popup adjacent to the third phone number field listed in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Position Title: This will display the Title/Position of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Title/Position' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Referral Type: This will display the Referral Type of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull as selected from the 'Referrer Type' popup located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Primary Insurance ID: This will display the Insurance ID Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • SSN/TID: This will display the Social Security Number/Tax ID for the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'SSN/TID' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Self Admin: This will display the Self Admin Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Self Admin' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Self Pay: This will display the Self Pay Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Self Pay' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • State: This will display the State of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'State' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • State License: This will display the State License Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'State License' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Street Address: This will display the Street Address of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Street Address' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Suite: This will display the Suite Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Suite' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Taxonomy Code: This will display the Taxonomy/Specialty Code of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Taxonomy (Specialty)' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Title V: This will display the Title V Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Title V' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Vets Admin: This will display the Vets Admin Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Vets Admin.' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Work Phone Number: This will display the Work Phone Number for the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The 'Phone Number' field's adjoining popup MUST be set to "Work". 2) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Workers Compensation: This will display the Workers Compensation Number of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Workers Compensation.' field located in the selected referrer's Reference > Provider IDs.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  • Zip Code: This will display the Zip Code of the patient's Referral 3 located in Patients > Patient > Referrals. This data will pull from the 'Zip Code' field located in the selected referrer's Reference > Referrer Info.
    [Note: 1) The patient's Referral 3 is determined by the third "Transition To" Referral record listed in the Referrals tab.]

  

Policy Holder

  • Insured CDA Dependent Code: This will display the Dependent Code for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window.  This data will pull from the 'Dependent Code' field found in the selected Insurance Carrier record located in Patients > Patient > Insurance.
    [Note: "Use Canadian Claim Fields" checkbox MUST be selected from Preferences > Localization.]

  • Insured City: This will display the City for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'City' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Insured Date of Birth: This will display the Date of Birth for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Birth Date' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Insured Division/Section: This will display the Division/Section Number for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Division/Section' field found in the selected Insurance Carrier's record located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: "Use Canadian Claim Fields" checkbox MUST be selected from Preferences > Localization.]

  • Insured Email: This will display the Email Address for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Email' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Insured Employer City: This will display the City of the employer selected from the 'Employer' popup found in the Insurance Carrier record (located in Patients > Primary/Secondary) that is ultimately selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'City' field located in the selected employer's Reference.
    [Note: An Employer record MUST be added Employers table located in Patients > Primary or Secondary.]

  • Insured Employer Name: This will display the Name of the employer selected from the 'Employer' popup found in the Insurance Carrier record (located in Patients > Primary/Secondary) that is ultimately selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Employer Name' field located in the selected employer's Reference.
    [Note: An Employer record MUST be added Employers table located in Patients > Primary or Secondary.]

  • Insured Employer Phone: This will display the Phone Number of the employer selected from the 'Employer' popup found in the Insurance Carrier record (located in Patients > Primary/Secondary) that is ultimately selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Phone' field of the selected Employer record found in the Employer table located in Patients > Primary/Secondary.
    [Note: An Employer record MUST be added Employers table located in Patients > Primary or Secondary.]

  • Insured Employer Phone Extension: This will display the Phone Extension of the employer selected from the 'Employer' popup found in the Insurance Carrier record (located in Patients > Primary/Secondary) that is ultimately selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Extension' field of the selected Employer record found in the Employer table located in Patients > Primary/Secondary.
    [Note: An Employer record MUST be added Employers table located in Patients > Primary or Secondary.]

  • Insured Employer State: This will display the State of the employer selected from the 'Employer' popup found in the Insurance Carrier record (located in Patients > Primary/Secondary) that is ultimately selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'State' field located in the selected employer's Reference.
    [Note: An Employer record MUST be added Employers table located in Patients > Primary or Secondary.]

  • Insured Employer Street Address: This will display the Street Address of the employer selected from the 'Employer' popup found in the Insurance Carrier record (located in Patients > Primary/Secondary) that is ultimately selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Street Address' field located in the selected employer's Reference.
    [Note: An Employer record MUST be added Employers table located in Patients > Primary or Secondary.]

  • Insured Employer Suite: This will display the Suite Number of the employer selected from the 'Employer' popup found in the Insurance Carrier record (located in Patients > Primary/Secondary) that is ultimately selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Suite' field located in the selected employer's Reference.
    [Note: An Employer record MUST be added Employers table located in Patients > Primary or Secondary.]

  • Insured Employer Zip Code: This will display the Zip Code of the employer selected from the 'Employer' popup found in the Insurance Carrier record (located in Patients > Primary/Secondary) that is ultimately selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Zip Code' field located in the selected employer's Reference.
    [Note: An Employer record MUST be added Employers table located in Patients > Primary or Secondary.]

  • Insured First Name: This will display the First Name of the policy holder for the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'First Name' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Insured Group Number: This will display the Group Number for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window.  This data will pull from the 'Group #' field located in the selected Insurance Carrier record found in the Insurance table located in Patients > Primary/Secondary (dependent upon the selected insurance carrier).

  • Insured Home Phone: This will display the Home Phone Number for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Home Phone".]

  • Insured Home Phone Extension: This will display the Home Extension Number for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from an 'Ext' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Home Phone".]

  • Insured Is Female: This is a "True/False" pull field that will display an 'X' respective to the policy holder holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window being female.  This data will pull from the 'Sex' popup located in Patients > Primary/Secondary (dependent upon the selected insurance carrier).
    [Note: Functionality dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Female" is selected. If formatted for "False" an 'X' will display when "Male" is selected.]

  • Insured Is Male: This is a "True/False" pull field that will display an 'X' respective to the policy holder holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window being male.  This data will pull from the 'Sex' popup located in Patients > Primary/Secondary (dependent upon the selected insurance carrier).
    [Note: Functionality dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Male" is selected. If formatted for "False" an 'X' will display when "Female" is selected.]

  • Insured Last Name: This will display the Last Name of the policy holder for the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Last Name (Guarantor)' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Insured Middle Name: This will display the Middle Name of the policy holder for the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Middle' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Insured Mobile Phone: This will display the Mobile Phone Number for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Mobile Phone".]

  • Insured Mobile Phone Extension: This will display the Mobile Extension Number for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from an 'Ext' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Mobile Phone".]

  • Insured Other Phone: This will display the Other Phone Number for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Other Phone".]

  • Insured Other Phone Extension: This will display the Other Extension Number for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from an 'Ext' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Other Phone".]

  • Insured Relationship Child: This is a "True/False" pull field that will display an 'X' respective to the relationship between the policy holder holder of the insurance carrier selected from the 'Insurance Carrier' popup (located in the selected procedure's Claim Creation Window) and the patient being parent/child.  This data will pull from the 'Relationship to Primary/Secondary' popup (dependent upon the selected insurance carrier) located in Patients > Patient .
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Child/Stepson or Stepdaughter" has been selected. If formatted for "False" an 'X' will display when "Child/Stepson or Stepdaughter" has not been selected.]

  • Insured Relationship Code: This will display a numeric code reflective of the relationship between the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup (located in the selected procedure's Claim Creation Window) and the patient. This data will pull from the 'Relationship to Primary/Secondary' popup (dependent upon the selected insurance carrier) located in Patients > Patient .

  • Insured Relationship Other: This is a "True/False" pull field that will display an 'X' respective to the relationship between the policy holder holder of the insurance carrier selected from the 'Insurance Carrier' popup (located in the selected procedure's Claim Creation Window) and the patient being "other."  This data will pull from the 'Relationship to Primary/Secondary' popup (dependent upon the selected insurance carrier) located in Patients > Patient .
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when one of the following items has been selected. If formatted for "False" an 'X' will display when one of the following items has not been selected.]

    • Grandfather or Grandmother

    • Grandson or Granddaughter

    • Nephew or Niece

    • Foster Child

    • Ward

    • Employee

    • Unknown

    • Handicapped Dependent

    • Sponsored Dependent

    • Dependent of a Minor Dependent

    • Significant Other

    • Mother

    • Father

    • Other Adult

    • Emancipated Minor

    • Organ Donor

    • Cadaver Donor

    • Injured Plaintiff

    • Child Where Insured Has No Financial Responsibility

    • Life Partner

    • Other Relationship

    • Adopted Child

  • Insured Relationship Self: This is a "True/False" pull field that will display an 'X' respective to the relationship between the policy holder holder of the insurance carrier selected from the 'Insurance Carrier' popup (located in the selected procedure's Claim Creation Window) and the patient being "self".  This data will pull from the 'Relationship to Primary/Secondary' popup (dependent upon the selected insurance carrier) located in Patients > Patient.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Self" has been selected. If formatted for "False" an 'X' will display when "Self" has not been selected.]

  • Insured Relationship Spouse: This is a "True/False" pull field that will display an 'X' respective to the relationship between the policy holder holder of the insurance carrier selected from the 'Insurance Carrier' popup (located in the selected procedure's Claim Creation Window) and the patient being marital.  This data will pull from the 'Relationship to Primary/Secondary' popup (dependent upon the selected insurance carrier) located in Patients > Patient.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Spouse" has been selected. If formatted for "False" an 'X' will display when "Spouse" has not been selected.]

  • Insured Relationship Text: This will display the relationship between the policy holder holder of the insurance carrier selected from the 'Insurance Carrier' popup (located in the selected procedure's Claim Creation Window) and the patient in text format. This data will pull as selected from the 'Relationship to Primary/Secondary' popup (dependent upon the selected insurance carrier) located in Patients > Patient

  • Insured Release Of Information: This will indicate a confirmation of a "release of information" for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window by displaying "Signature On File." This data will pull respective to having selected the 'Release of Info (Box 12)' and/or the 'Signature on File (Box 13)' checkboxes located in Patient > Primary/Secondary (dependent upon the selected insurance carrier).

  • Insured Release Of Information (Y/N): This is a "Yes/No" pull field that will indicate a confirmation of release of information for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window by displaying a "Y" or an "N" respective to having selected the 'Release of Info (box 12)' and/or the 'Signature on File (box 13)' ('Release of Info (box 36)' / 'Signature on File (box 37)' in DDS) checkbox(es) located in Patient > Primary/Secondary (dependent upon the selected insurance carrier).

  • Insured Release Of Information Date: This will reflect the date as entered in the 'Procedure Date' field located in the selected procedure's Charge Window.

  • Insured SSN: This will display the Social Security Number for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Social Security' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Insured Sex: This will display a numeric code reflective of the sex for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Sex' popup located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Insured Signature On File: This will indicate a confirmation of the "signature on file" for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window by displaying "Signature On File." This data will pull respective to having selected the 'Signature On File (Box 13)' ('Signature on File (box 37)' in DDS) checkbox located in Patient > Primary/Secondary (dependent upon the selected insurance carrier).

  • Insured Signature On File (Y/N): This is a "Yes/No" pull field that will display a 'Y' or an 'N' in indication of a confirmation of the "signature on file" for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window by displaying "Signature On File." This data will pull respective to having selected the 'Signature On File (Box 13)' ('Signature on File (box 37)' in DDS) checkbox located in Patient > Primary/Secondary (dependent upon the selected insurance carrier).

  • Insured State: This will display the State for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'State' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Insured Street Address: This will display the Street Address for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Street Address' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Insured Subscriber Number: This will reflect the data as entered in the 'Subscriber ID" field located in Patients > Patient > Insurance for the Insurance Carrier record selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window.

  • Insured Subscriber Number (Guar): This will reflect the data as entered in the 'Subscriber ID" field located in Patients > Primary or Secondary dependent upon the Insurance Carrier record selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window.

  • Insured Subscriber Number (Patient): This will reflect the data as entered in the 'Subscriber ID" field located in Patients > Patient > Insurance for the Insurance Carrier record selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window.

  • Insured Suffix: This will display the Suffix of the policy holder for the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Suffix' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Insured Suite/Apartment: This will display the Suite/Apartment Number for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Suite/Apt. #' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

  • Insured Work Phone: This will display the Work Phone Number for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Work Phone".]

  • Insured Work Phone Extension: This will display the Work Extension Number for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from an 'Ext' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).
    [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Work Phone".]

  • Insured Zip Code: This will display the Zip Code for the policy holder of the insurance carrier selected from the 'Insurance Carrier' popup located in the selected procedure's Claim Creation Window. This data will pull from the 'Suite/Apt. #' field located in Patients > Primary or Secondary (dependent upon the selected insurance carrier).

 

Provider

  • ABN Number: This will display the ABN Number for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'ABN' field located in the selected provider's User Reference > Provider > Additional Credentials.

  • CLIA: This will display the CLIA data for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'CLIA' field located in the selected provider's User Reference > Provider > Claim Credentials.

  • DEA Number: This will display the DEA Number for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'DEA' field located in the selected provider's User Reference > Provider > Additional Credentials.

  • DPS Number: This will display the DPS Number for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'DPS' field located in the selected provider's User Reference > Provider > Additional Credentials.

  • Eclaim Tax ID: This is a "True/False" pull field that will display an 'X' respective to having selected "Use Federal ID Number" from the 'Provider Tax ID on Claims' popup located in References > Users > Provider > Claim Credentials for the provider selected from the 'Provider Shown on Claim' popup located in Patients > Patient.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Use Federal ID Number" is selected. If formatted for "False" an 'X' will display when "Use Social Security Number" is selected.]

  • Federal ID: This will display the Federal ID for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'Federal' field located in the selected provider's User Reference > Provider > Claim Credentials.

  • Form Name: This will display the Form Name data for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'Name Printed in Box 33 HCFA' (DDS: 'Name Printed in Box 53 of Insurance Form') field located in the selected provider's User Reference > Provider.

  • Hospital Number: This will display the Hospital Number for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull form the 'Hospital' field locate in the selected provider's User Reference > Provider > Additional Credentials.

  • ID: This will display the User ID for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'User ID' field located in the selected provider's User Reference > User Information.

  • Name, First: This will display the First Name of the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'First' field located in the selected provider's User Reference.

  • Name, Last: This will display the Last Name of the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'Last' field located in the selected provider's User Reference.

  • Name, Middle: This will display the Middle Name of the provider selected from the 'Provider Shown on Claim' popup located the selected procedure's Charge Window. This data will pull from the 'Middle' field located in the selected provider's User Reference.

  • Name, Professional Title: This will display the Professional Title for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'Professional Title' field located in the selected provider's User Reference.

  • Name, Suffix: This will display the Suffix for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'Suffix' field located in the selected provider's User Reference.

  • National Provider ID: This will display the NPI Number for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'National Provider ID (NPI)' field located in the selected provider's User Reference > Provider > Claim Credentials.

  • Other Number 1: This will display the Other 1 data for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'Other 1' field located in the selected provider's User Reference > Provider > Additional Credentials.

  • Other Number 2: This will display the Other 2 data for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'Other 2' field located in the selected provider's User Reference > Provider > Additional Credentials.

  • Other Number 3: This will display the Other 3 data for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'Other 3' field located in the selected provider's User Reference > Provider > Additional Credentials.

  • Other Number 4: This will display the Other 4 data for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'Other 4' field located in the selected provider's User Reference > Provider > Additional Credentials.

  • Other Number 5: This will display the Other 5 data for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'Other 5' field located in the selected provider's User Reference > Provider > Additional Credentials.

  • Phone: This will display the Phone Number for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'Phone' field located in the selected provider's User Reference > User Information.

  • Phone Extension: This will display the Phone Extension Number for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'Ext' field located in the selected provider's User Reference > User Information.

  • Provider Accepts Assignment: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Accepts Assignment' checkbox found in the selected provider's record located in the selected carrier's Reference > Provider IDs, OR the selected procedure's Claim Creation Window).

  • Provider CDA Accepts Assignment: [Unknown]

  • Provider Federal Tax ID Number: This will display the Federal Tax ID Number for the provider selected from the 'Provider Shown On Claim' popup located in the selected procedure's Charge Window. This data will pull from either the 'Federal/Billing Provider #' field, OR the 'SSN/Provider ID' field respective to having selected "Use Federal ID Number" or "Use Social Security Number" from the 'Provider Tax ID on Claims' popup located in the selected provider's Reference > Provider > Claim Credentials.

  • Provider Letter Head: This will display the Professional Title, First Name and Last Name of the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window; followed by the full address of the office selected from the 'Office' popup located in the selected procedure's Charge Window.  This data will pull from the 'Professional Title', 'First', and 'Last' pull fields located in the selected provider's User Reference, and the 'Street Address', 'Suite', 'City', 'State', and 'Zip Code' fields located in the selected office's Reference.
    [Note: The office fields are inaccessible and can only be changed or updated by the Accounting Department.]

  • Provider Number: This will display the Provider Number for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'Provider' field located in the selected provider's User Reference > Provider > Additional Credentials.

  • Provider Tax ID Number Is SSN: This is a "True/False" pull field that will display an 'X' respective to having selected "Use Social Security Number" from the 'SSN/Provider ID' popup located in the selected provider's (selected from the 'Provider Shown on Claim' popup located in the selected procedure's Claim Creation Window) User Reference > Provider > Claim Credentials.

  • SSN: This will display the Social Security Number of the provider selected from the 'Provider Shown on Claim' popup located inthe selected procedure's Charge Window. This data will pull from the 'SSN' field located in the selected provider's User Reference > Provider > Claim Credentials.

  • Specialty: This will display the Taxonomy Code for the provider selected from the 'Provider Shown on Claim' popup located inthe selected procedure's Charge Window. This data will pull from the 'Provider Taxonomy (Specialty)' field located in the selected provider's User Reference > Provider > Claim Credentials.

  • State License Number: This will display the State License Number for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'State License Number' field located in the selected provider's User Reference > Provider > Claim Credentials.

  • Sub ID: This will display the Sub ID for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'Sub ID' field located in the selected provider's User Reference > Provider > Claim Credentials.

  • Title XIX Exception Code: This will display the Title XIX Exception Code for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'Title SA Exception Code Box 25D' field located in the selected provider's User Reference > Provider > Claim Credentials.

  • UPIN: This will display the UPIN data for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'UPIN' field located in the selected provider's User Reference > Provider > Additional Credentials.

  • Unique Number: This will display the Unique Number for the provider selected from the 'Provider Shown on Claim' popup located in the selected procedure's Charge Window. This data will pull from the 'Unique' field located in the selected provider's User Reference > Provider > Additional Credentials.

 

This Insurance

  • Carrier: This will display the Name of the insurance carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window. This data will pull from the 'Insurance Company' field located in the selected carrier's Reference > Company Info.

  • Carrier Code: This will display the Carrier Code for the insurance carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window. This data will pull from the 'Carrier Code' field located in the selected carrier's Reference > Company Info.

  • City: This will display the City of the insurance carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window. This data will pull from the 'City' field located in the selected carrier's Reference > Company Info.
    [Note: If the patient's insurance record is tied to an insurance plan this data will then pull from the 'City' field located in the selected carrier's Reference > Plans > Demographic.]

  • Fax Number: This will display the Fax Number of the insurance carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window. This data will pull from the 'Fax' field located in the selected carrier's Reference > Company Info.
    [Note: If the patient's insurance record is tied to an insurance plan this data will then pull from the 'Fax' field located in the selected carrier's Reference > Plans > Demographic.]

  • Group ID: This will display the Group ID Number of the rendering provider selected from the 'Provider' popup located in the Claim Creation Window. This data will pull from the selected provider's 'Practice Group ID (Paper)' field located in the  insurance carrier's Reference > Provider IDs for the insurance carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window.

  • Is ChampVA Plan: This is a "True/False" pull field that will display an 'X' respective to having selected 'Veterans Administration Plan' from the 'Plan' popup located in the insurance carrier's Reference > Company Info for the carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window.
    [Note: 1) If the selected Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when 'Veterans Administration Plan' is selected. If formatted for "False", an 'X' will display when 'Veterans Administration Plan' is not selected.]

  • Is Champus Plan: This is a "True/False" pull field that will display an 'X' respective to having selected 'Champus' from the 'Plan' popup located in the insurance carrier's Reference > Company Info for the carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window.
    [Note: 1) If the selected Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when 'Champus' is selected. If formatted for "False", an 'X' will display when 'Champus' is not selected.]

  • Is Dental Insurance: This is a "True/False" pull field that will display an 'X' respective to having selected 'Dental' from the 'Insurance Type' popup located in the insurance carrier's Reference > Company Info for the carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when 'Dental' is selected. If formatted for "False", an 'X' will display when 'Medical' is selected.]

  • Is FECA Plan: This is a "True/False" pull field that will display an 'X' respective to having selected 'Other Federal Program' from the 'Plan' popup located in the insurance carrier's Reference > Company Info for the carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window.
    [Note: 1) If the selected Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when 'Other Federal Program' is selected. If formatted for "False", an 'X' will display when 'Other Federal Program' is not selected.]

  • Is Group Health Plan: This is a "True/False" pull field that will display an 'X' respective to having selected 'Preferred Provider Organization (PPO)/Exclusive Provider Organization (EPO)/Health Maintenance Organization (HMO)' from the 'Plan' popup located in the insurance carrier's Reference > Company Info for the carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window.
    [Note: 1) If the selected Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected.]

  • Is Medicaid Plan: This is a "True/False" pull field that will display an 'X' respective to having selected 'Medicaid' from the 'Plan' popup located in the insurance carrier's Reference > Company Info for the carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window.
    [Note: 1) If the selected Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when 'Medicaid' is selected. If formatted for "False", an 'X' will display when 'Medicaid' is not selected.]

  • Is Medical Insurance: This is a "True/False" pull field that will display an 'X' respective to having selected 'Medical' from the 'Insurance Type' popup located in the insurance carrier's Reference > Company Info for the carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window.
    [Note: Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when 'Medical' is selected. If formatted for "False", an 'X' will display when 'Dental' is selected.]

  • Is Other Plan Type: This is a "True/False" pull field that will display an 'X' respective to having selected any of the following items from the 'Plan' popup located in the insurance carrier's Reference > Company Info for the carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window.
    [Note: 1) If the selected Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected.]

    • Self Pay

    • Central Certification

    • Other Non-Federal Program

    • Point of Service (POS)

    • Indemnity Insurance

    • HMO Medicare Risk

    • Automobile Medical

    • Blue Cross/Blue Shield

    • Commercial Insurance

    • Disability

    • Liability

    • Liability Medical

    • Title V

    • Workers Compensation

    • Mutually Defined Unknown

  • Phone: This will display the Phone Number of the insurance carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window. This data will pull from the 'Phone' field located in the selected carrier's Reference > Company Info.
    [Note: If the patient's insurance record is tied to an insurance plan this data will then pull from the 'Phone' field located in the selected carrier's Reference > Plans > Demographic.]

  • Plan Name: This will display the Plan Name for the insurance carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window.  This data will pull from the 'Plan' popup located in the selected Carrier's record (located in the primary or secondary's insurance table) and can be edited from the 'Plan Name' field found in the Insurance Plan table located in the carrier's Reference > Plans.

  • Provider Paper ID: This will display the Provider Paper ID for the insurance carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window. This data will pull from the 'Paper ID' field located in the selected carrier's Reference > Provider IDs for the rendering provider selected from the 'Provider' popup located in the selected procedure's Charge Window.

  • State: This will display the State of the insurance carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window. This data will pull from the 'State' field located in the selected carrier's Reference > Company Info.
    [Note: If the patient's insurance record is tied to an insurance plan this data will then pull from the 'State' field located in the selected carrier's Reference > Plans > Demographic.]

  • Street Address: This will display the Street Address of the insurance carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window. This data will pull from the 'Street Address' field located in the selected carrier's Reference > Company Info.
    [Note: If the patient's insurance record is tied to an insurance plan this data will then pull from the 'Street Address' field located in the selected carrier's Reference > Plans > Demographic.]

  • Suite: This will display the Suite Number of the insurance carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window. This data will pull from the 'Suite' field located in the selected carrier's Reference > Company Info.
    [Note: If the patient's insurance record is tied to an insurance plan this data will then pull from the 'Suite' field located in the selected carrier's Reference > Plans > Demographic.]

  • Zip Code: This will display the Zip Code of the insurance carrier selected from the 'Insurance Carrier' popup located in the Claim Creation Window. This data will pull from the 'Zip Code' field located in the selected carrier's Reference > Company Info.
    [Note: If the patient's insurance record is tied to an insurance plan this data will then pull from the 'Zip Code' field located in the selected carrier's Reference > Plans > Demographic.]