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Routine: IBCF3TP

IBCF3TP.m

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