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 Apr 09, 2024@21:20:46 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
