HCFAs

The HCFA's Tab of Visit Entry accepts HCFA-1500 Insurance Form information to be billed on the Visit.

Visit Type	Displays Visit Type from the main Visit form
Visit Date	Displays Visit Date (Service Date) from the main Visit form

Condition Related To (Box 10)

Not Applicable	Will check the Not Applicable option of Box 10 on the HCFA-1500
Employment	Will check the Employment option of Box 10 on the HCFA-1500
Auto Accident	Will check the Auto Accident option of Box 10 on the HCFA-1500
State	Enter the Auto Accident State Code to be printed in Box 10 on the HCFA-1500
Other Accident	Will check the Other Accident option of Box 10 on the HCFA-1500

Reserved form Local User (Box 10d)

(Text)

Enter applicable text that is required by a carrier in Box 10d on the HCFA-1500

Release Information/Date (Box 12)

Authorized Signature	Indicates that an authorized signature to approve release of information to the carrier is on file
Date	Authorized signature date for Box 12 of the HCFA-1500

Benefits Assigned (Box 13)

Authorized Signature

Indicates that an authorized signature to approve assignment of benefits to the physician is on file

Current (Box 14)

Illness	Will check the Illness option of Box 14 on the HCFA-1500
Injury	Will check the Injury option of Box 14 on the HCFA-1500
LMP	Will check the LMP option of Box 14 on the HCFA-1500
Date	Enter print the date entered as the date of the current Injury, Illness, or LMP on the HCFA-1500

Similar Illness (Box 15)

Date	Prints the date of any similar illness in Box 15 on the HCFA-1500

Unable to Work (Box 16)

From	Will print the date entered in the Unable to Work From Date in Box 16 on the HCFA-1500
Thru	Will print the date entered in this field in the Unable to Work Thru Date in Box 16 on the HCFA-1500

Hosp Dates (Box 18)

From	Will print the date entered in this field in the Hospitalization From Date in Box 18 on the HCFA-1500
Thru	Will print the date entered in this field in the Hospitalization Thru Date in Box 18 on the HCFA-1500

Local Use (Box 19)

(Text)

Enter applicable text that is required by a carrier in Box 19 on the HCFA-1500

Outside Lab (Box 20)

Lab Used	Will check the Outside Lab Used option in Box 20 on the HCFA-1500
Amount	Will print the amount entered into this field in the Outside Lab Amount field in Box 20 on the HCFA-1500

Prior Auth No (Box 23)

(Text)

Enter the number to be printed as the Prior Authorization Number in Box 23 on the HCFA-1500.

The prior authorization number may be maintained in two different locations; one is in the Insurance Demographic and the other is on the Visit - HCFA Tab. Please check with your system administrator to determine where you should be maintaining this value.

Claim Delay Reason Code

(Text)

Select the reason to be report on on paper and electronic claims for NY MCD when there is a delay in reporting the claim.

EClaim Attachment - Additional Paperwork

This table allows you to define paperwork attachments that will be reported on electronic claims in the PWK (Paperwork) segment. This feature does NOT send these attachments electronically. However, it will allow you to send "notice" that an attachment is to be forwarded separately from the claim and how the attachment will be sent.

Patient Policy	Select the policy (primary, secondary, etc.) that the PWK segment will be sent to..
Report Type Code	Select the type of attachment that will be sent. This list is defined in the ANSI claim specification.
Transaction Code	Select how the attachment will be sent (Mail, e-Mail, or Fax). This list is defined in the ANSI claim specification.
Identification Code	Enter a number or code that uniquely defines the attachment,. Some payers provide pre-numbered blank forms to use while others rely on the provider to define the attachment number. This code will help the payer identify which claim an inbound attachment belongs with when it is received.