CLAIMGEAR  CMS-1500 SPECS

BOX            DESCRIPTION OF FIELD ON FORM AND IN CLAIMGEAR

                   LOCATION OF FIELD IN CLAIMGEAR

1

 1

Payer/Carrier Type

Payer -F6 tab, Find or Add, Payer Type

a

Insured's ID Number

*Patient -F2 tab, Search or Add, 2 Insured tab, Payers tab, Set Payer 1, enter Member Id#

2

Patient's last name, first name, and middle initial

Patient -F2 tab, 1 Patient tab, enter Last Name, First, MI

3

Patient's Date of Birth

Patient -F2 tab, 1 Patient tab, enter Birth date

4

Enter the Insured's last name, first name, and middle initial

Patient -F2 tab, 2 Insured tab, enter Last Name, First, MI

5

Patient's Address

*Patient -F2 tab, 1 Patient tab, enter Address

6

Patient Relationship to Insured

*Patient -F2 tab,  2 Insured tab, enter Patient Relationship to the Insured?

7

Insured's Address

*Patient -F2 tab, 2 Insured tab, enter Address

8

Patient Status: Single, Married, Other, Employed, Full-Time Student, Part-Time Student

Patient -F2 tab, 1 Patient tab, Defaults tab, enter Marital Status or Student Status or Employed Status

9

Other Insured's Name (Last, First, MI).  2 ways:

*1) Patient -F2 tab, 2 Insured tab, enter Last Name, First, MI

*2) Patient -F2 tab, 3 Other Insured tab, enter Last Name, First, MI

9a

Other Insured's Policy AND Group number

*1) Patient -F2 tab, 2 Insured tab, Payers tab, Payer 2, enter Group Number AND Member ID#

*2) Patient -F2 tab, 3 Other Insured tab, Payer 3, enter Group Number AND Member ID#

9b

Other Insured's Date of Birth

*1) Patient -F2 tab, 2 Insured tab, enter Birth date

*2) Patient -F2 tab, 3 Other Insured tab, enter Birth date

9c

Other Insured's Employer's Name

*1) Patient -F2 tab, 2 Insured tab, Employer tab, enter Employer Name

*2) Patient -F2 tab, 3 Other Insured tab, enter Employer Name

9d

Insurance Plan Name

*1) Patient -F2 tab, 2 Insured tab, Payers tab, Payer 2, enter Payer 2 by 'New Payer' or 'Find Payer'

*2) Patient -F2 tab, 3 Other Insured tab, Payer 3, enter Payer 3 by 'New Payer' or 'Find Payer'

10

Patient's Condition; Type of Accident

1) Claim -F1 tab, 3 Additional Info tab, enter Yes for specific accident type (10b requires state abbreviation)

11

Insured's Policy Group Number

*Patient -F2 tab, 2 Insured tab, Payers tab, Payer 1, enter Group Number

11a

Insured's Date of Birth

*Patient -F2 tab, 2 Insured tab, enter Birth date

11b

Enter the Employer's name

*Patient -F2 tab, 2 Insured tab, Employer tab, enter Employer Name

11c

Insurance Plan Name

*Patient -F2 tab, 2 Insured tab, Payers tab, enter Payer 1 by 'New Payer' or 'Find Payer' button

11d

Is there another health benefit plan?

System defaults this information.  If wrong, see Box 9 and complete correctly.

12

Patient's or Auth Signature

*Patient -F2 tab, 2 Insured tab, enter 'Signed signature authorization form for both Block 12 and 13 are on file'

13

Insured's or Auth Signature

*Patient -F2 tab, 2 Insured tab, enter 'Signed signature authorization form for both Block 12 and 13 are on file'

14

Date of Current Illness/Injury/Pregnancy

1) Claim -F1 tab, 3 Additional Info tab, enter Date of Onset of Illness or Accident or LMP

15

Date of Same or Similar Illness

Claim -F1 tab, 3 Additional Info tab, enter Date of Similar Illness

16

Dates Patient Unable to Work in Current Occupation

Claim -F1 tab, 3 Additional Info tab, enter Unable to Work From Date and To Date

17

Name of Referring Physician

b

Referring Physician NPI

1) Claim -F1 tab, 1 Claim tab, enter Select Referring/PCP Provider

18

Hospitalization Dates Related to Current Services

Claim -F1 tab, 3 Additional Info tab, enter Hospitalized From Date and To Date

19

Reserved For Local Use

Not applicable

20

Outside Lab and Charges

Claim -F1 tab, 3 Additional Info tab, enter Lab Charges

21

Diagnosis

Claim -F1 tab, 2 Charges tab, enter ICD#

22

Medicaid Resubmission Code

Claim -F1 tab, 3 Additional Info tab, enter Resubmit Reason Code

23

Prior Authorization Number

Claim -F1 tab, 1 Claim tab, enter Authorization # and press 'Copy Authorization to Claim' button

24

Charges

a-g

Claim -F1 tab, 2 Charges tab, enter Information

24a

Dates of Services - From and To Date

24b

Place of Service (POS)

24d

Procedure code (CPT)

24f

Total Charges

24g

Units

24

Rendering ID Qualifier

i

Automatically populate based on payer information

24

Non-NPI number

j

Payer- F6 tab, Select Payer, Provider ID Numbers tab, enter Individual number

24

NPI Number

j

Claim F -1 tab, 1 Claim tab, and Select Rendering Provider and Select Billing Provider

24

Payment Information - InsPay  InsAdj  InsAllow

x

Payment -F3 tab, 3 EOB Posting tab, Find, Search, Select Patient,

correct insurance payment, adjustment, or allowed

25

Federal Tax ID Number

Claim F -1 tab, 1 Claim tab, and Select Rendering Provider and Select Billing Provider

26

Patient's Account No.

Automatically generated by ClaimGear

27

Accept Assignment?

*Patient -F2 tab, 2 Insured tab, enter 'Yes, The provider accepts the assignment of benefits'

28

Total Charge

Claim -F1 tab, 2 Charges tab, enter Total Charges (= Unit Price X Units)

29

Amount Paid

Payment -F3, enter 1 Line Item Posting (co-pay) OR 3 EOB Posting (Insurance payment) tab

30

Balance Due

Claim -F1 tab, 2 Charges tab, enter Information [= Adjustments + Money Due (by Patient or Insurance)]

31

Signature Of Physician or Supplier

Claim -F1 tab, 1 Claim tab, and Select Rendering Provider and Select Billing Provider

32

Name and Address of Facility

Claim -F1 tab, 1 Claim tab, enter Select Facility

a

Facility NPI

Claim -F1 tab, 1 Claim tab, enter Select Facility

33

Physicians or Suppliers Billing Information

Claim -F1 tab, 1 Claim tab, enter Billing Provider

a

Billing NPI

Claim -F1 tab, 1 Claim tab, enter Billing Provider

b

Billing Other ID

Claim -F1 tab, 1 Claim tab, enter Billing Provider

*

Information on the Patient -F2 tab, 1 Insured tab OR 2 Other Insured tab

If any information on these two screens have been changed after its initial entry,

update the information and go to 4 Misc. Info tab, check B, and click Save.

NA

Claim - Not Found

One or more are incorrect, fix and rescore.  Patient Name (box 2), DOB (box 3), and DOS (box 24a).

See page 71 of this manual for a detailed description.

NA

Charge – Not Found

1 or more are incorrect, fix and rescore.  DOS (box 24a) and Charges (24d).

See page 70 of this manual for a detailed description.