- IBCF3TP ;ALB/BGA - TEST PATTERN UB92 FORM ; 12-AUG-93
- ;;Version 2.0 ; INTEGRATED BILLING ;; 21-MAR-94
- ;;Per VHA Directive 10-93-142, this routine should not be modified.
- ;
- ;This program performs a test print function. The results of this
- ;test will align the fields of the IB routines to the field locators
- ;on form UB92.
- ;
- ;
- ZIS S %ZIS="QM" D ^%ZIS G:POP END
- I $D(IO("Q")) S ZTRTN="ENP^IBCF3TP",ZTSAVE("IBCF31")="",ZTDESC="PRINT TEST BILL" D ^%ZTLOAD K IO("Q") D HOME^%ZIS G END
- U IO
- ENP ;
- W "##SR",?34,"*** UB-92 TEST PATTERN ***"
- W !,"AGENT CASHIER"
- W !,"AGENT CASHIER STREET",?57,"BN XXX ",?77,"XXX"
- W !,"CITY STATE ZIP"
- 5 W !,"PHONE #",?26,"TAX# XXXX",?37,"5/1/93",?44,"5/4/93"
- W !
- W !,"PATIENT NAME",?31,"PT SHORT ADDRESS"
- W !
- W !,"DOB",?9,"X",?12,"X",?14,"DATE",?21,"HR",?25,"X",?28,"X",?30,"DR",?33,"ST",?36,"000-00-0000" S IBI=54 F IBJ=1:1:7 W ?IBI,"CC" S IBI=IBI+3
- W !!
- 11 S IBI=0 F IBJ=1:1:5 W ?IBI,"OC",?(IBI+3),"DATE" S IBI=IBI+10
- W !!,"RESPONSIBLE PARTY'S NAME"
- W !,"STREET ADDRESS 1",!,"STREET ADDRESS 2",!,"STREET ADDRESS 3",!,"CITY STATE ZIP"
- W !
- 19 W !,"CD1",?5,"REV CODE description",?48,"xx",?57,"xxxx.xx"
- W !,"CD2",?5,"REV CODE description",?48,"xx",?57,"xxxx.xx"
- W !,"CD3",?5,"REV CODE description",?48,"xx",?57,"xxxx.xx"
- W !,?5,"Subtotal",?57,"xxxx.xx"
- W !!,?5,"Total",?57,"xxxx.xx"
- W !!!!!!!!!
- 32 W !,"For your information, even though the patient may be otherwise eligible"
- W !,"for Medicare, no payment may be made under Medicare to any Federal provider"
- W !,"of medical care or services and may not be used as a reason for non-payment."
- W !,"Please make your check payable to the Department of Veterans Affairs and"
- W !,"send to the address listed above."
- W !
- W !,"The undersigned certifies that treatment rendered is not for a"
- W !,"service connected disability."
- W !
- 43 W !,"Name of Payer 1",?26,"Provider #",?40,"x",?43,"x"
- W !,"Name of Payer 2",?26,"Provider #",?40,"x",?43,"x"
- W !,"Name of Payer 3",?26,"Provider #",?40,"x",?43,"x"
- W !!
- 48 W !,"Insured's Name 1",?26,"x",?29,"Insurance #",?49,"Group Name",?64,"Group #"
- W !,"Insured's Name 2",?26,"x",?29,"Insurance #",?49,"Group Name",?64,"Group #"
- W !,"Insured's Name 3",?26,"x",?29,"Insurance #",?49,"Group Name",?64,"Group #"
- W !
- W !,"Treatment Auth. Cd",?19,"x",?21,"Employer Name",?47,"Employer Location"
- W !,?19,"x",?21,"Employer Name",?47,"Employer Location"
- W !,?19,"x",?21,"Employer Name",?47,"Employer Location"
- W !
- 56 W !,"PDX" S IBI=7 F IBJ=1:1:8 W ?IBI,"Dx Cd" S IBI=IBI+7
- W ?64,"ADMT DX",!!
- S IBI=3 F IBJ=1:1:3 W ?IBI,"P-code",?(IBI+8),"mmddyy" S IBI=IBI+15
- W ?52,"Attending Phys. ID#",!!
- S IBI=3 F IBJ=1:1:3 W ?IBI,"P-code",?(IBI+8),"mmddyy" S IBI=IBI+15
- W ?52,"Other Phys. ID#"
- 61 W !,?7,"Patient ID#: xxx-xx-xxxx"
- W !,"Bill Type: xxx xxxxxx"
- W !,"UB 92 TEST PATTERN",?52,"Provider Representative DATE"
- W !,"*** comment ***"
- K IBI,IBJ
- I $D(ZTQUEUED) S ZTREQ="@" Q
- D ^%ZISC
- END Q
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HIBCF3TP 3006 printed Jan 18, 2025@03:14:16 Page 2
- IBCF3TP ;ALB/BGA - TEST PATTERN UB92 FORM ; 12-AUG-93
- +1 ;;Version 2.0 ; INTEGRATED BILLING ;; 21-MAR-94
- +2 ;;Per VHA Directive 10-93-142, this routine should not be modified.
- +3 ;
- +4 ;This program performs a test print function. The results of this
- +5 ;test will align the fields of the IB routines to the field locators
- +6 ;on form UB92.
- +7 ;
- +8 ;
- ZIS SET %ZIS="QM"
- DO ^%ZIS
- if POP
- GOTO END
- +1 IF $DATA(IO("Q"))
- SET ZTRTN="ENP^IBCF3TP"
- SET ZTSAVE("IBCF31")=""
- SET ZTDESC="PRINT TEST BILL"
- DO ^%ZTLOAD
- KILL IO("Q")
- DO HOME^%ZIS
- GOTO END
- +2 USE IO
- ENP ;
- +1 WRITE "##SR",?34,"*** UB-92 TEST PATTERN ***"
- +2 WRITE !,"AGENT CASHIER"
- +3 WRITE !,"AGENT CASHIER STREET",?57,"BN XXX ",?77,"XXX"
- +4 WRITE !,"CITY STATE ZIP"
- 5 WRITE !,"PHONE #",?26,"TAX# XXXX",?37,"5/1/93",?44,"5/4/93"
- +1 WRITE !
- +2 WRITE !,"PATIENT NAME",?31,"PT SHORT ADDRESS"
- +3 WRITE !
- +4 WRITE !,"DOB",?9,"X",?12,"X",?14,"DATE",?21,"HR",?25,"X",?28,"X",?30,"DR",?33,"ST",?36,"000-00-0000"
- SET IBI=54
- FOR IBJ=1:1:7
- WRITE ?IBI,"CC"
- SET IBI=IBI+3
- +5 WRITE !!
- 11 SET IBI=0
- FOR IBJ=1:1:5
- WRITE ?IBI,"OC",?(IBI+3),"DATE"
- SET IBI=IBI+10
- +1 WRITE !!,"RESPONSIBLE PARTY'S NAME"
- +2 WRITE !,"STREET ADDRESS 1",!,"STREET ADDRESS 2",!,"STREET ADDRESS 3",!,"CITY STATE ZIP"
- +3 WRITE !
- 19 WRITE !,"CD1",?5,"REV CODE description",?48,"xx",?57,"xxxx.xx"
- +1 WRITE !,"CD2",?5,"REV CODE description",?48,"xx",?57,"xxxx.xx"
- +2 WRITE !,"CD3",?5,"REV CODE description",?48,"xx",?57,"xxxx.xx"
- +3 WRITE !,?5,"Subtotal",?57,"xxxx.xx"
- +4 WRITE !!,?5,"Total",?57,"xxxx.xx"
- +5 WRITE !!!!!!!!!
- 32 WRITE !,"For your information, even though the patient may be otherwise eligible"
- +1 WRITE !,"for Medicare, no payment may be made under Medicare to any Federal provider"
- +2 WRITE !,"of medical care or services and may not be used as a reason for non-payment."
- +3 WRITE !,"Please make your check payable to the Department of Veterans Affairs and"
- +4 WRITE !,"send to the address listed above."
- +5 WRITE !
- +6 WRITE !,"The undersigned certifies that treatment rendered is not for a"
- +7 WRITE !,"service connected disability."
- +8 WRITE !
- 43 WRITE !,"Name of Payer 1",?26,"Provider #",?40,"x",?43,"x"
- +1 WRITE !,"Name of Payer 2",?26,"Provider #",?40,"x",?43,"x"
- +2 WRITE !,"Name of Payer 3",?26,"Provider #",?40,"x",?43,"x"
- +3 WRITE !!
- 48 WRITE !,"Insured's Name 1",?26,"x",?29,"Insurance #",?49,"Group Name",?64,"Group #"
- +1 WRITE !,"Insured's Name 2",?26,"x",?29,"Insurance #",?49,"Group Name",?64,"Group #"
- +2 WRITE !,"Insured's Name 3",?26,"x",?29,"Insurance #",?49,"Group Name",?64,"Group #"
- +3 WRITE !
- +4 WRITE !,"Treatment Auth. Cd",?19,"x",?21,"Employer Name",?47,"Employer Location"
- +5 WRITE !,?19,"x",?21,"Employer Name",?47,"Employer Location"
- +6 WRITE !,?19,"x",?21,"Employer Name",?47,"Employer Location"
- +7 WRITE !
- 56 WRITE !,"PDX"
- SET IBI=7
- FOR IBJ=1:1:8
- WRITE ?IBI,"Dx Cd"
- SET IBI=IBI+7
- +1 WRITE ?64,"ADMT DX",!!
- +2 SET IBI=3
- FOR IBJ=1:1:3
- WRITE ?IBI,"P-code",?(IBI+8),"mmddyy"
- SET IBI=IBI+15
- +3 WRITE ?52,"Attending Phys. ID#",!!
- +4 SET IBI=3
- FOR IBJ=1:1:3
- WRITE ?IBI,"P-code",?(IBI+8),"mmddyy"
- SET IBI=IBI+15
- +5 WRITE ?52,"Other Phys. ID#"
- 61 WRITE !,?7,"Patient ID#: xxx-xx-xxxx"
- +1 WRITE !,"Bill Type: xxx xxxxxx"
- +2 WRITE !,"UB 92 TEST PATTERN",?52,"Provider Representative DATE"
- +3 WRITE !,"*** comment ***"
- +4 KILL IBI,IBJ
- +5 IF $DATA(ZTQUEUED)
- SET ZTREQ="@"
- QUIT
- +6 DO ^%ZISC
- END QUIT