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Replace Dropdown Menu Fields to the Accident Medical Claim Form

Replace Dropdown Menu Fields to the Accident Medical Claim Form

Aug 6th, 2022

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How to Replace Dropdown Menu Fields to the Accident Medical Claim Form

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In this tutorial, the presenter demonstrates how to create a dependent drop-down form field in a fillable form. The example involves two questions: the first asks about the employee's status, allowing selections of either "active" or "inactive." Based on the answer to question one, different options will appear for question two. The tutorial guides viewers through the process of setting this up, ensuring that the selections for the second question depend on the user's previous choice in the first question.

Got questions?

Below are some common questions from our customers that may provide you with the answer you're looking for. If you can't find an answer to your question, please don't hesitate to reach out to us.

What is box 14 on the CMS 1500 claim form?

Box 14 - Date of Current Illness, Injury, or Pregnancy (LMP) Enter the applicable qualifier to identify which date is being reported.

What goes in box 33b on claim form?

33b Required Billing Provider Info Phone # (Pay-To) - Used for atypical providers only. Enter the Medi-Cal provider number for the billing provider.

What goes in box 15 on UB 04?

Box 15 Source of Referral for Admission: (Required if applicable) Indicate the source using the one digit code that represents the source of referral for admission. Required on Hospital claims.

What goes in box 17 on HCFA 1500 form?

What does the referring box 17 mean on the CMS 1500 form? Box 17 of the CMS 1500 form derives from the selected employees Claims Settings area in the contact. Provide the referring providers name and the NPI number.

How do you fill out a diagnosis pointer on CMS 1500?

Enter the diagnosis reference number (pointer) in the unshaded area. The diagnosis pointer references the line number from field 21 that relates to the reason the service(s) was performed (ex. 1, 2, 3, or 4, or multiple numbers if the service relates to multiple diagnosis from field 21).

What is box 15 on a HCFA 1500 form?

A point of origin code discloses to the payer the source or method of the patients referral for admission. The point of origin code is similar to a place of service code on a professional claim/HCFA-1500 form.

What is Box 39 on ub04?

Box 39-41; a-d Value codes and amounts: (Optional) Use these locators to indicate codes and amounts essential to the proper adjudication of the submitted claim. Each form locator contains a three digit field in which to key the indicator code, and a larger free text field in which to designate an applicable amount.

What goes in box 15 on a HCFA 1500?

Box 15 - Other Date Enter the applicable qualifier to identify which date is being reported.

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