Field

Description

SSN

Enter the social security number of the patient.

Referral Source

By default, in a new practice, this section is blank. Please contact support if your referral source drop-down is blank. Select the referral source from the drop down menu.

First Name

Enter/Type the first name of the patient. This is a mandatory field, or the basic information needed to record Patient Info details.

Middle Name

Enter/Type the middle name of the patient, if any.

Last Name

Enter/Type the patient’s last name. This is a mandatory field, or one of the basic information needed to record Patient Info details.

Suffix

Enter/Type additional information about the person, like letters that indicate the position held by the individual, or educational degree, accreditation, office, or honour.

Alias/Nickname

Enter/Type the patient’s nick name, pet name or any specific name used to address the person.

Address 1

Enter/Type the first line of the patient address.

Address 2

Enter/Type the second line of the patient address.

City

Enter/Type the name of the patient’s city.

State

Select the patient’s state using the drop down menu.

Zip

Enter/Type the patient’s zip code.

Pri Care Prov

Select the primary care provider from the drop down menu.

Referring Provider

Select the referring provider from the drop down menu.

Field

Description

Account

By default Automatically Assign Account number checkbox is selected under Setup - General. The system will automatically assign account number for the patient. The account number can be manually changed, if necessary.

Marital Status

Select the marital status of the patient from the drop down menu.

Chart

Enter the chart number. If the old patient chart number needs to be cross referenced to the new system, the chart number needs to be entered in this field. This is entered only for informational purpose.

Gender

Select the patient’s gender by clicking on the required radio button. This is a mandatory field, or one of the basic information needed to record Patient Info details.

Employment Status

Select the patient’s employment status from the drop down menu.

Employers

Select the employer from the drop down menu. The employers section allows to search from the employers existing list or add new employer details. To edit, or add a company, use the buttons to the right of the company drop down. Click   to modify the existing details of an employer or click to add an employer. This will open the Company dialog box. Edit or add any information as necessary.

Field

Description

Relationship to Patient

Select the guarantor’s relationship with the patient using the drop down menu. The options available in the drop down menu are:

• Self: Select Self, if the patient and the guarantor are the same person.

• Other: Use Other, if the patient is a child, spouse or if the patient’s section of the bill needs to be sent to some other person.

Guarantor

Select the guarantor from the drop down menu. Click   to modify the existing details of a guarantor or click to add a guarantor. For family billing make sure you enter the Guarantor only once and then select that Guarantor for all family members.

Field

Description

Home Phone

Enter/Type the patient’s home phone number.

Work Phone

Enter/Type the patient’s work phone number.

Mobile Phone

Enter/Type the patient’s mobile phone number.

Other Phone

Enter/Type the patient’s alternative or additional phone number.

Fax

Enter/Type the patient’s fax number.

Email

Enter/Type the patient’s email address.

Pt consents to receiving statement and/or appt reminders by email

Receive statement and reminders by email. Click the Pt consents to receive statement and/or apt reminders by email checkbox. Currently this box is for informational purposes only and does not control any statement settings.

Field

Description

Date of Birth

Enter the patient’s date of birth. This is a mandatory field, or one of the basic information needed to record Patient Info details.

Years

Enter the age, i.e., numbers of years. For example if the patient was born on 01/01/1990, then as of 07/03/2016, enter 26 in the Years field.

Months

Enter the number of months if any. For example if the patient was born on 01/01/1990, then as of 07/03/2016, enter 2 in the Months field.

Deceased

Click the deceased checkbox if the patient is deceased. The Date Deceased field gets highlighted; enter the deceased date in the appropriate field.

Field

Description

Signature on file

Click the Signature on File checkbox, if the signature of the patient is available on file. Signature on file refers to the signature of the patient or an authorized person, authorizing the release of any medical or other information necessary to process the claim. This is also used to request payment of government benefits to self or to the party who accepts the assignment.

Date

Enter the date of the signature recorded on file.

Field

Description

Ethnicity

Select the patient ethnicity from the drop down menu. The options available are:

• Hispanic or Latino

• Non-Hispanic or Latino

• Unknown: Select unknown if the patient does not know his/her ethnicity, or if the patient does not belong to any of the options mentioned above.

Race

Select the patient race from the drop down menu. Select Other, if none of the options match the patient’s race.

Language

Select the patient language from the drop down menu.

Click the Needs interpreter checkbox, if the patient requires an interpreter.

Click the Military Veteran checkbox if the patient is a retired military veteran.

Field

Description

New

Click New to record details of a new company

Open

Click Open to access the details of the existing company.

Click Open and select the required company and click OK.

Save

Click Save to save the details of the company information entered.

Previous

Click Previous to access the previously accessed company information.

Next

Click Next to access the previously accessed company information.

Delete

Click Delete to permanently remove the details of a company.

Field

Description

Company Name

Enter/Type the name of the company in the provided text box.

Address 1

Enter/Type the first line of the company address.

Address 2

Enter/Type the second line of the company address.

City

Enter/Type the name of the city where the company is located.

State

Select the state where the company is located from the provided drop down menu.

Zip

Enter/Type the company’s zip code.

Phone

Enter/Type the company’s phone number.

Fax

Enter/Type the company’s fax number.

Field

Description

First Name

Enter/Type the first name of the person representing the company in the provided text box.

Middle Name

Enter/Type the middle name of the person representing the company.

Last Name

Enter/Type the last name of the person representing the company.

Suffix

Enter/Type additional information about the person, like letters that indicate the position held by the individual, or educational degree, accreditation, office, or honour.

Phone

Enter/Type the phone number of the person representing the company. The format for entering the extension number is X1234.

Field

Description

Address 1

Enter/Type the first line of the company address.

Address 2

Enter/Type the second line of the company address.

City

Enter/Type the name of the city where the company is located.

State

Select the state where the company is located from the provided drop down menu.

Zip

Enter/Type the company’s zip code.

Phone

Enter/Type the company’s phone number.

Fax

Enter/Type the company’s fax number.

Field

Description

First Name

Enter/Type the first name of the service type contact person in the provided text box.

Middle Name

Enter/Type the middle name of the service type contact person.

Last Name

Enter/Type the last name of the service type contact person.

Suffix

Enter/Type additional information about the service type contact person, like letters that indicate the position held by the individual, or educational degree, accreditation, office, or honour.

Phone

Enter/Type the phone number of the service type contact person. The format for entering the extension number is X1234.

Click

To

View the unpaid open claim details of the patient. The Open Claim feature does not get highlighted until a patient is selected.

Clear the existing information that is displayed and enable to record new claim details of the patient.

Delete a claim which has not yet been released. A claim which has been released cannot be deleted.

Place an existing claim on hold.

Void a claim which has already been released. A claim which is not been released cannot be voided.

Field

Description

Displays information for the last patient that had a claim saved.

Patient Name

Displays the name of the existing patient.

Patient Transaction History displays the details of the claim. Select the required patient for the patient’s transaction history details to be displayed.

Claim Notes allows to enter any notes regarding the patient’s claim into the system.

Enter the necessary notes in the provided text box and click Save. The saved notes are displayed in the section below as shown above.

A/C #

Enter the account number to find a patient, or tab to the last name field, type in the last name and hit Enter. The Patient Search dialog box opens, which enables to search the patient by entering one of the fields mentioned or the required patient can be selected from the list at the bottom of the form.

: Opens the Patient Search dialog box, which is used to search for a patient using last name, first name, SSN, DOB, state, A/C#, Other A/C#, Chart #.

: Opens the Patient dialog box, which is used to view and modify the existing information of the patient.

: Opens the Patient dialog box, which is used to add new claim detail of a patient.

Facility

From the drop down menu, select the required facility, where the services were furnished.

Provider

Select the required provider from the drop down menu. Selecting a provider with an asterisk (*) next to the provider name, are called the mid-level providers or practitioners. These practitioners need a supervisor or a medical doctor’s supervision, hence the Supervising Provider field is highlighted and the required supervisor needs to be selected from the drop down menu.

Referring Provider

Referring Provider is the provider who sent the patient to another provider for services. Select the required referring provider from the providers that have already been added to the practice’s list in the drop down menu.

A new Referring Provider can be added to the list by clicking the button.

Ordering Provider

Ordering Provider is the provider who requests items or services. Select the required ordering provider from the drop down menu.

A new Ordering Provider can be added to the list by clicking the button.

EDI Exception Alert

Shown to all users when the provider that is on hold for at least one EDI service is selected as billing on Claim-General.

Field

Description

Other A/C#

Enter an Other patient account number (Other A/C#), if one is available.

Visit#

Enter a Visit #, if one is available. This number can be found of the system generated encounter form.

Field

Description

Claim ID

Enter the claim identification number in the provided text box and click GO. The claim details of the patient is displayed.

Change Claim Status

If you have an incorrect rejection, or the payer has agreed to reprocess your claim, you can use this button to update the claim and mark it as being ‘confirmed’ without resaving it.

Claim History and Preview

Allows to view the claim history of the patient and also allows to view the preview of the claim.

Condition Related Employment

Check the Condition Related Employment checkbox if the patient condition was related to employment.

Case#

Enter the case number related to the condition related to employment.

Auto Accident

Check the Auto Accident checkbox if the patient condition related to an auto accident.

State

From the drop down menu, select the state in which the auto accident took place,

Other Accident

Check the Other Accident checkbox if the patient condition is related to some other accident.

NOTE: Condition Related Employment, Case#, Auto Accident, State and Other Accident are the text boxes available on the insurance claim form.

Field

Description

Current

Select the qualifier for the current date from the list and enter the date of current illness, injury or pregnancy.

The following qualifiers are available for the Current date field:

• 431 Onset of Current Symptoms or Illness

• 484 Last Menstrual Period

Other

Select the qualifier for Other date and enter the date.

The following qualifiers are available for the Other date field:

• 454 Initial Treatment

• 304 Latest Visit or Consultation

• 453 Acute Manifestation of a Chronic Condition

• 439 Accident

• 455 Last X-ray

• 471 Prescription

• 090 Report Start (Assumed Care Date)

• 091 Report End (Relinquished Care Date)

• 444 First Visit or Consultation

Return

Enter the return date for this patient.

Unable to work from

Enter the first date that the patient was unable to work, if this is required by the employment related insurance.

Unable to work to

Enter the last date till which the patient was unable to work, if this is required by the employment related insurance.

Field

Description

Current

Enter the date of illness (first symptom) or injury (accident) or pregnancy.

Last Seen

Enter the date the patient was last seen or consulted.

First Consult

Enter the date of the first consult with this patient.

Return

Enter the return date for this patient.

Similar Symptom Date

Enter the date of any recorded similar symptoms, not required by Medicare.

Unable to work from

Enter the first date that the patient was unable to work, if this is required by the employment related insurance.

Unable to work to

Enter the last date till which the patient was unable to work, if this is required by the employment related insurance.

Field

Description

ICD-9

If the date of service of the claim is before October 1st 2015, then the ICD 9 code needs to be selected.

ICD-10

Select the nature of the patient compliant from the required ICD 10 codes. This field is a searchable field, for example: If the patient is suffering from cough, type in cough in the description field, and select the appropriate code from the search results.

The search results are sorted by their relevance to the entered text:

- Diagnoses which contain the whole entered search text in the beginning – on the top.

- Diagnoses which contain the whole entered search text - below.

- Diagnoses which contain all words from the entered search text – in the bottom.

The search starts only if at least two characters are entered.

Last Diagnoses

Displays the information of the three last diagnoses codes, the ICD codes, the diagnosis date and the charges incurred for the services.  You can add individual diagnoses from the grid by double clicking on the code.

Use GEMs

Opens the GEMs Search dialog box which converts the outdated ICD 9 codes to the current ICD 10 codes.

EPSDT

Check the EPSDT checkbox if the claim is an EPSDT claim.

Anesthesia

Check the Anesthesia checkbox if the claim is an anesthesia claim.

Dental

Check the Dental checkbox if the claim is a dental claim.

NOTE: EPSDT, Anesthesia and Dental are further explained in the document, under their respective headings.

Condition C’s

Conditions C’s are codes which are entered as per the claim.

Line

The line number is automatically displayed, based on the number of claim details entered into the system.

For example, 1 is displayed in the Line box, for the first claim details recorded for the patient. Once the details entered are saved, the line automatically reflects 2, for the second claim details to be entered.

Service From

Is the date the patient consulted the doctor, the date entered here automatically updates all the necessary dates pertaining to the claim.

Service To

Enter the Service To date, if the patient consulted the doctor on different dates. The Service To date can be the same as Service From date.

CPT

The treatment provided to the patient by the doctor is CPT, select the required CPT code from the drop down menu.

If a CPT code entered is not available in the Practice’s list, the system will allow the code to be added when you hit tab to move to the next field.

POS

Facility is selected on the Claim General screen, each facility has a place of service ID. Based on the selection made on the Claim General screen this field on Claim Detail screen gets populated automatically.

Modifiers

Modifiers are used to elaborate more on the CPT codes selected, to provide insurance companies more detail.

Multiple modifiers can be entered by typing in the code without interruption. For example: Type the first code 25, and continue typing the next code 45 and so on. The Modifier box automatically adds a comma between 25 and 45 differentiating the codes.

Diagnosis Pointers

Enter the line numbers of the ICD9 and ICD10 codes that relate to the CPT code. If multiple ICD9 and ICD10 codes relate to the CPT code, enter all the related line numbers with no spaces (e.g. ABC for ICD9 code lines 1, 2 and 3).

Drug

Check the Drug checkbox to enable the NDC field, NDC is the National Drug Code

Each NDC that is selected is linked to a certain CPT code, and the list of available NDC codes will be populated accordingly after the CPT code is selected.

Click   to modify an existing NDC code.

Click to add a new NDC code by specifying the NDC #, NDC Label, Units and Unit Type fields.

Manually added NDC codes will be marked up with gray background, while common NDC codes will not be marked up.

Manually added NDC codes are available only within the practice they had been added in.

Common NDC codes cannot be modified via the Edit NDC action. When any common NDC code is edited, a new custom code is added instead of changing the common NDC code.

Emergency

Allows to add an emergency flag-------Need clarification

Charge

Charge is calculated based on the CPT code entered as per the fee schedule, this amount can be manually entered, overriding the fee schedule.

Units

The units by default is always selected as 1, this can be manually changed by entering the required number of units.

Remarks

Refers to box 19 on the claim form, therefore box 19 needs to be entered in this field.

Hospitalization Dates

If the Place of Service (POS) is a hospital, the hospitalization dates field needs to be entered, i.e., the Admit and Discharge date.

Field

Description

Payment Type

To enter payments, select the appropriate payment type:

• Cash: Select cash when the transaction is done by cash. The payment can be made by cash in the reception.

• Check: Select check when checks are used to make payment. In the Check/Ref # field type in the check number, enter the check amount in the Payment Amount field and enter the date the amount was paid in the Payment Date field.

• Credit/Debit Card: Select credit/debit card if cards are used to make payment. In the Check/Ref # field type in the credit/debit card number, enter the payment amount in the Payment Amount field and enter the date the amount was paid in the Payment Date field.

Print Receipt on Saving

Check the print receipt on saving checkbox to enable print for receipt on saving.

Field

Description

Prior Authorization

Enter the prior authorization number issued by the payer for this claim submission.

Referral

Enter the referral number for the claim. Data entered here will be printed in the claim form for GA Medicaid.

Medicaid Resubmission Code

Enter the resubmission code for Medicaid claims.

Original Reference

Enter the original reference number for this claim.

Other Claim ID

Select the qualifier for the Other Claim ID and enter the Other Claim identification number.

Additional Claim Information

Check the additional claim information checkbox to enter the additional information about the claim.

Local Use

The claim can be reserved for local use.

Lab Work

Check the Lab work checkbox if there was an outside lab work associated with this claim.

Lab Charge

Enter the amount charged for the lab work.

Patient is Pregnant

Check the Patient is pregnant checkbox if the patient is pregnant or keep it cleared if otherwise.

Patient Weight (grams)

Enter the weight of the patient measured in grams. (Billing Applet will convert this to pounds as required for electronic claims data).

Field

Description

Attachment Report Type Code

Value in the dropdown identifies the type of attachment.

Transmission Code

Options are BM for By Mail and FX for Faxed documents.

Identification Code Qualifier

Required when Transmission code is BM or FX the value is AC by default.  

Attachment Control #

A value assigned by the provider to uniquely identify the attachment.