IBCF2P ;ALB/ARH - PRINT HCFA 1500 12-90 FORM ; 17-JUL-93
Source file <IBCF2P.m>
Package | Total | Call Graph |
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CPT HCPCS Codes | 1 | $$MOD^ICPTMOD |
action | A | extended action | Ea | event driver | Ed | subscriber | Su | protocol | O | limited protocol | LP | run routine | RR | broker | B | edit | E | server | Se | P | screenman | SM | inquire | I |
Package | Total | Caller Graph |
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Integrated Billing | 1 | IBCF2 |
Name | Comments | DBIA/ICR reference |
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; print the form, IBFLD required
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LINE8 | ; insured's ID number
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LINE10 | ; patient name, DOB, sex; insured's name ("SAME" if patient)
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LINE12 | ; patient's address (street); pt. rel to ins.; insured's address
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LINE14 | ; patient addr city, state code, marital status; insured's city, state
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LINE16 | ; patient zip code, phone; patient employment status; insured's zip code, phone
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LINE18 | ; other insured's name; insured's policy group
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LINE20 | ; other insured's policy number; condition related to employment?; insured's date of birth and sex
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LINE22 | ; other insured's DOB, sex; patient auto accident & place; insured's employer
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LINE24 | ; other insured's employer; patient other accident; insured's insurance plan name
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LINE26 | ; other insured's plan name; is there another benefit plan *488* add box 10d
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LINE29 | ; patient's signature; insured's signature (use PL 99-272, SECTION 1729 TITLE 38)
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LINE32 | ; date of current illness; date of similar illness; dates unable to work *488*
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LINE34 | ; name of referring physician; ID# referring physician; hospitalization dates related to services
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LINE35 | ; "not for SC" note line 1
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LINE36 | ; "not for SC" note line 2; outside lab (now defaults to "no" in IBEHCFA)
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LINE37 | ; diagnosis code indicator *488*
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LINE38 | ; diagnosis codes 1-4 ; field 22 (MEDICAID) left blank *488*
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LINE39 | ; diagnosis codes 5-8 *488*
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LINE40 | ; diagnosis codes 9-12; field 23 (prior authorization #) *488*
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LINE44 | ;lines 44,46,48,50,52,54 all the same
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LINE56 | ||
LINE58 | ||
LINE69 | ||
LINE60 | ||
LINE61 | ||
END |
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Name | Line Occurrences (* Changed, ! Killed) |
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^IBE(350.9 - [#350.9] | PRINT+1 |
>> | Not killed explicitly |
* | Changed |
! | Killed |
~ | Newed |
Name | Field # of Occurrence |
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DT | LINE44+5 |
IBADDM | PRINT+1*, PRINT+2, LINE61+4, END! |
>> IBFLD( | LINE32+1 |
>> IBFLD("10A" | LINE20+1 |
>> IBFLD("10B" | LINE22+2 |
>> IBFLD("10BS" | LINE22+2 |
>> IBFLD("10C" | LINE24+3 |
>> IBFLD("10D" | LINE26+1 |
>> IBFLD("11AD" | LINE20+2 |
>> IBFLD("11AX" | LINE20+2 |
>> IBFLD("11B" | LINE22+2 |
>> IBFLD("11C" | LINE24+3 |
>> IBFLD("11D" | LINE26+1 |
>> IBFLD("16A" | LINE32+1 |
>> IBFLD("16B" | LINE32+1 |
>> IBFLD("18A" | LINE34+1 |
>> IBFLD("18B" | LINE34+1 |
>> IBFLD("1A" | LINE8+1, LINE61+4 |
>> IBFLD("21A" | LINE37+1 |
>> IBFLD("3D" | LINE10+1 |
>> IBFLD("3X" | LINE10+1 |
>> IBFLD("5S" | LINE14+1 |
>> IBFLD("5T" | LINE16+1 |
>> IBFLD("8E" | LINE16+1 |
>> IBFLD("8M" | LINE14+1 |
>> IBFLD("9A" | LINE20+1 |
>> IBFLD("9D" | LINE26+1 |
>> IBFLD(0 | PRINT+2 |
>> IBFLD(11 | LINE18+1 |
>> IBFLD(12 | LINE29+1 |
>> IBFLD(13 | LINE29+1 |
>> IBFLD(14 | LINE32+1 |
>> IBFLD(15 | LINE32+1 |
>> IBFLD(19 | LINE35+1, LINE36+1 |
>> IBFLD(2 | LINE10+1, LINE61+4 |
>> IBFLD(21 | LINE38+1, LINE39+1, LINE40+1 |
>> IBFLD(23 | LINE40+1 |
>> IBFLD(24 | LINE44+1, LINE44+2, LINE44+3*, LINE44+4, LINE44+5, LINE44+6, LINE44+7*, LINE61+2 |
>> IBFLD(25 | LINE56 |
>> IBFLD(26 | LINE56 |
>> IBFLD(28 | LINE56 |
>> IBFLD(29 | LINE56+1 |
>> IBFLD(31 | LINE69, LINE60, LINE61 |
>> IBFLD(32 | LINE58, LINE69, LINE60+1 |
>> IBFLD(33 | LINE58, LINE69, LINE60+2, LINE61 |
>> IBFLD(4 | LINE10+1 |
>> IBFLD(5 | LINE12+1, LINE14+1, LINE16+1 |
>> IBFLD(6 | LINE12+1 |
>> IBFLD(7 | LINE12+1 |
>> IBFLD(9 | LINE18+1 |
>> IBI | PRINT+2*, LINE44+1*, LINE44+2, LINE44+3, LINE44+4, LINE44+5, LINE44+6, LINE44+7, LINE61+5* |
>> IBJ | LINE44+1* |
IBPAGE | PRINT+1*, LINE61+3*, LINE61+4, END! |
IOF | LINE61+4 |
U | PRINT+1, LINE44+1, LINE44+4, LINE44+5, LINE44+6, LINE44+7 |