HCFA Box 1 - Insurance Type : Select the appropriate "HCFA Type" for each insurer

[365 & v4] Office Setup Wizard --> Insurance Carriers: HCFA Type (or go to Insurer tab and edit a carrier)

HCFA Box 1a - Insurance ID # : Select the insurance policy and enter the Ins ID# for each insurance policy

[365] Patient Wizard Page 1 --> Insurance Policy: Ins ID#
[v4] Patient Wizard --> Insurance Policy: Ins ID#

HCFA Box 2 - Patient Name

[365] Patient Wizard Page 1 --> Personal Information: Patient Name
[v4] Patient Wizard --> Personal Information: Patient Name

HCFA Box 3 - Patient DOB (Date of Birth)

[365] Patient Wizard Page 1 --> Personal Information: DOB
[v4] Patient Wizard --> Personal Information: DOB

HCFA Box 4 - Insured's Name - name of the policy holder which can be different from the patient's name.

[365] Patient Wizard Page 2 --> Insurance Policy: Name
[v4] Patient Wizard --> Insurance Policy: Name

hint - if in Box-6 "spouse, child or other" was selected then the insured's "name, address, city, state, zip and telephone" must be included in ChiroPulse in the insurance policy.

HCFA Box 5 - Patient Address : Three lines for 1. Address; 2. City, State; 3. Zip code & home phone number

[365] Patient Wizard Page 1 --> Personal Information: Address fields
[v4] Patient Wizard --> Personal Information: Address fields

hint - Medicare patients require a number or claim will be denied. If in doubt use 111-111-1111

HCFA Box 6 - Relation : This is the relation of the patient to the insured policy holder

[365] Patient Wizard Page 2 --> Insurance Policy: Relation (choose relation)
[v4] Patient Wizard --> Insurance Policy: Relation (choose relation)

HCFA Box 7 - Insured Address

[365] Patient Wizard Page 2 --> Insurance Policy: Insured Address
[v4] Patient Wizard --> Insurance Policy: Insured Address

  1. Insured's Address
  2. City, State
  3. Zip code & home phone number

    hint     - if in Box-6 "spouse, child or other" was selected then the insured's "name, address, city, state, zip and telephone" must be added in the insurance policy info.

HCFA Box 8 - Patient Status (Maritial Status & Employment Status)

[365] Patient Wizard Page 1 --> Personal Information: Marital Status & Employment Status
[v4] Patient Wizard --> Personal Information: Marital Status & Employment Status

HCFA Box 9 - Other Insured's Name : A secondary policy must be entered with the level of "2 - secondary".

[365] Patient Wizard Page 2 --> Insurance Policy: Name
[v4] Patient Wizard --> Insurance Policy: Name

For Secondary Medigap Policies - the Medigap button must be checked. When checked the Box 9 prints the Patient's Name, 9a prints "MGAP-policy#", 9b prints DOB & gender and 9c prints the claims processing address of the Medigap insurer. 9d enter insurance company co-code (Office Setup Wizard --> Insurance Carriers: Medigap code)

HCFA Box 9a - Other Ins. Policy / Group #

[365] Patient Wizard Page 2 --> Insurance Policy: Ins. Policy #
[v4] Patient Wizard --> Insurance Policy: Ins. Policy #

hint - A second policy must be entered with the level of "2 - secondary".

For Secondary Medigap Policies - the Medigap button must be checked. 9a prints "MGAP" plus the "policy#". For example "MGAP-1234321

HCFA Box 9b - Other Ins DOB & Gender

[365] Patient Wizard Page 2 --> Insurance Policy: DOB & Gender
[v4] Patient Wizard --> Insurance Policy: DOB & Gender

hint - A second policy must be entered with the level of "2 - secondary".

For Secondary Medigap Policies - the Medigap button must be checked. 9b prints DOB & gender

HCFA Box 9c - Employer's Name

[365] Patient Wizard Page 2 --> Insurance Policy: Employer
[v4] Patient Wizard --> Insurance Policy: Employer

hint - A second policy must be entered with the level of "2 - secondary".

For Secondary Medigap Policies - the Medigap button must be checked. 9c prints the address of the Medigap insurer.

HCFA Box 9d - Insurance Plan / Program Name

[365] Patient Wizard Page 2 --> Insurance Policy Level: Carrier (select the carrier)
[v4] Patient Wizard --> Insurance Policy: Carrier (select the carrier)

hint - A second policy must be entered with the level of "2 - secondary".

For Secondary Medigap Policies - 9d enter insurance company co-code
Office Setup Wizard --> Insurance Carriers: Medigap code

HCFA Box 10a - Employment Y/N : Select Yes to check if the patient's condition is related employment.

[365] Claim Wizard Page 2 --> Employment (check yes or no)
[v4] Claim Wizard --> HCFA 2) Numbers and IDs: Employment (check yes or no)

HCFA Box 10b - Auto accident Y/N : Select Yes to check if the condition is related auto accident & enter state.

[365] Claim Wizard Page 2 --> Auto Accident (check yes or no)
[v4] Claim Wizard --> HCFA 2) Numbers and IDs: Auto Accident (check yes or no)

 

HCFA Box 10c - Other accident Y/N : Select Yes to check if the patient's condition is related to another accident.

[365] Claim Wizard Page 2 --> Auto Accident (check yes or no)
[v4] Claim Wizard --> HCFA 2) Numbers and IDs: Auto Accident (check yes or no)

HCFA Box 10d - Reserved for Local Use
If needed enter the data for the HCFA 10d "Local Use Field". This is used when an insurance carrier requests specific information that is not specified on the HCFA claim form. For example, Xact Medicare Services requires this field to be used when the patient has a Medigap Policy.

[365] Claim Wizard Page 2 --> Local Use & Lab: Local Use 10d
[v4] Claim Wizard --> HCFA 4) Local Use & Lab: Local Use 10d

 

HCFA Box 11 - Ins Policy Group FECA #

[365] Patient Wizard Page 2 --> Insurance Policy: Group #
[v4] Patient Wizard --> Insurance Policy: Group #

hint - Medicare patients leave blank.

HCFA Box 11a - Ins. DOB & Gender

[365] Patient Wizard Page 2 --> DOB (date of birth) and Gender
[v4] Patient Wizard --> Insurance Policy: DOB (date of birth) and Gender

hint - Medicare patients leave blank.

HCFA Box 11b - Employer Name

If the patient and insured are not the same person go here:
     [365] Patient Wizard Page 2 --> Employer
     [v4] Patient Wizard --> Insurance Policy: Employer

If the patient and insured are the same then go here:
     [365] Patient Wizard Page 1 --> Employer
     [v4] Patient Wizard -> Personal Info: Employeer

hint - Medicare patients leave blank.

HCFA Box 11c - Insurance Plan Name

[365] Patient Wizard Page 2 --> Carrier (select the carrier)
[v4] Patient Wizard --> Insurance Policy: Carrier (select the carrier)

hint - Medicare patients leave blank.

HCFA Box 11d - Another Health Benefit

Automated based number of policies present. On standard policies (ie. not Medicare) if there is two policies Yes will be checked and Box 9a,b,c,d will be printed if supplied.

HCFA Box 12 - Signature on File & Date

[365] Claim Wizard Page 2 --> Authorize Records checkbox and date
[v4] Claim Wizard --> HCFA 1) Dates of Record: Authorize Records checkbox and date

Select for authorization of records. If checked enter the date. This authorizes the release of any medical or other information necessary to process this claim. If selected, the text "Signature on File" will appear in the HCFA box 12

If unselected, the signature of the patient must appear in HCFA box 12

HCFA Box 13 - Insurance Authorize Signature

[365] Claim Wizard Page 2 --> Direct Payment checkbox and date
[v4] Claim Wizard --> HCFA 1) Dates of Record: Direct Payment checkbox and date

Select for direct physician payment. If checked enter the date the patient signed the Signature on File form. This authorizes payment of medical benefits to the physician. If selected, the text "Signature on File" will appear in the HCFA box 13.

If unselected and the physician is to receive direct payment, the patient's signature must appear in the HCFA box 13.


HCFA box 14 - Dates of Current illness : Enter the date of the current illness, injury or pregnancy.

[365] Claim Wizard Page 2 --> Current Illness
[v4] Claim Wizard --> HCFA 1) Dates of Record: Current Illness

Please note, as of January 1, 1996 , Xact Medicare Services requires this box to be completed. Without the current illness date your claim is likely to be rejected.

 

HCFA box 15 - Dates of Similar illness

[365] Claim Wizard Page 2 --> Similar Illness
[v4] Claim Wizard --> HCFA 1) Dates of Record: Similar Illness

Enter the date of any similar illness.

HCFA box 16 - Unable to work from/to

[365] Claim Wizard Page 2 --> Unable to Work
[v4] Claim Wizard --> HCFA 1) Dates of Record: Unable to Work

From - Enter the start date of disability of the patient.
To - Enter the end date of the disability of the patient.

HCFA Box 17 - Referring physician : Enter the name of the referring physician.

[365] Claim Wizard Page 2 --> Referring Physician name
[v4] Claim Wizard --> HCFA 2) Numbers and IDs: Referring Physician name

 

HCFA Box 17a - UPIN/ID # of Referring physician
HCFA Box 17b - NPI of of Referring physician

[365] Claim Wizard Page 2 --> Referring Physician ID #
[v4] Claim Wizard --> HCFA 2) Numbers and IDs: Referring Physician ID #

Enter the UPIN number of the referring physician for Box 17a
Enter the NPI number of the referring physician for Box 17b

HCFA Box 18 - Hospitalized from/to

[365] Claim Wizard Page 2 --> Hospitalized
[v4] Claim Wizard --> HCFA 1) Dates of Record: Hospitalized

From - Enter the start date of hospitalization of the patient.
To - Enter the end date of the hospitalization of the patient.

HCFA Box 19 - Reserved for Local Use

[365] Claim Wizard Page 2 --> Local Use 19
[v4] Claim Wizard --> HCFA 4) Local Use & Lab: Local Use 19

Enter the data for the HCFA box 19 "Local Use Field". This is used when an insurance carrier requests specific information that is not specified on the HCFA claim form. For example, Xact Medicare Services requires this field to be used to indicate that x-rays, to demonstrate a vertebral subluxation, have been taken of the patient. Therefore, the date the x-rays were taken would be entered in this field.

hint - Medicare x-ray date must be filled in here

 

HCFA Box 20 - Outside Lab and Charges

[365] Claim Wizard Page 2 --> Outside Lab charge
[v4] Claim Wizard --> HCFA 4) Local Use & Lab: Outside Lab charge

hint - if a lab is entered it will check Yes on the HCFA, if no lab is entered it will check NO. If lab is present enter charge amount.

HCFA Box 21 - ICD #1, 2, 3 & 4

[365] Claim Wizard Page 2 --> ICD Codes selected
[v4] Claim Wizard --> Required Fields & ICD Codes : ICD Codes selected

HCFA Box 22 - Medicaid resubmission # and Original reference #

[365] Claim Wizard Page 2 --> Medicaid Resub # and Original Ref #
[v4] Claim Wizard --> HCFA 2) Numbers and IDs: Medicaid Resub # and Original Ref #

HCFA Box 23 - ICD #3 - Prior authorization #

[365] Claim Wizard Page 2 --> Prior Auth #
[v4] Claim Wizard --> HCFA 2) Numbers and IDs: Prior Auth #

Enter the prior authorization number.

HCFA Box 24a - Date of Service

[365 & v4] Ledger

"Visit Date" as added from the visit autologic or visit editor (viewed/edited in the Ledger)

HCFA Box 24b - Place of Service

Setup Defaults here:
     [365] Office Setup Wizard --> Doctors: Default Location
      [v4] Office Setup Wizard --> Doctors: Default Location

To Override/Change the default location for a patient claim:
     [365] Visit Wizard --> LOC
     [v4] Visit Wizard --> Step 2: LOC

HCFA Box 24c - TOS Type of Service

Setup Defaults here:
    [365] Office Setup Wizard --> Doctors: TOS
     [v4] Office Setup Wizard --> Doctors: TOS

To Override/Change the default location for a patient claim:
     [365] Claim Wizard Page 2 --> TOS
     [v4] Claim Wizard --> HCFA 2) Assignments & TOS: TOS

HCFA Box 24d - CPT (modifier optional) : HCFA2007 form allows up to 4 modifiers now.

[365] "CPT" and "modifier" as added from the visit autologic or visit editor (edited in the Ledger)
[v4] "CPT" and "modifier" as added from the visit autologic or visit editor (edited in the Ledger).

HCFA Box 24e - ICD code

[365] "ICD-9s" as added from the visit autologic or visit editor (description does not print) (edited in the Ledger)
[v4] "ICD-9s" as added from the visit autologic or visit editor (description does not print) (edited in the Ledger).

hint - to override/change the ICD codes assigned per CPT use the Visit Wizard:
[365] Ledger --> Visit Wizard Step 2: ICD (deselect inappropriate ICDs)
[v4] Ledger --> Visit Wizard Step 2: ICD (deselect inappropriate ICDs)

Requirements for several states: Alaska (AK), Arizona (AZ), Colorado (CO), Hawaii (HI), Iowa (IA),Nevada (NV), North Dakota (ND), Oregon (OR), South Dakota (SD), Washington (WA), Wyoming (WY) & perhaps others:

In the states listed above, no matter how many ICD codes are printed in box 21, HCFAs will print first ICD only in box 24E.

[365] MyOffice --> Preferred Global Options --> "Your Office" tab, select your STATE. Press OK to save and exit the correct setting
[v4] From the SETUP menu, select Global Preferences. In the Global Preferences "Your Office" tab, select your STATE. Press OK to save and exit the correct setting.

Medicare typically requires only the number "1" in Box 24e. That "1" ICD also needs to correspond with a subluxation code (i.e. 739.1) or it will be rejected. For example even though four codes may be selected in the claim wizard when the HCFA prints you will only see the number "1".

HCFA Box 24f - Charges

"Charges/Fees" as added from the visit autologic or visit editor (viewed/edited in the Ledger)

hint - to override the above default location use:
[365] Visit Wizard --> Fee (check the fee box and enter the new fee)
[v4] Visit Wizard --> Step 1: Fee (check the fee box and enter the new fee)

HCFA Box 24g - D/U Days/Units

This will print "1" unless you change it, regardless of the charges entered

hint - to override the D/U (change to "2" for example) use the Visit Wizard:
[365] Ledger (or popup menu from Px finder) --> Visit Wizard Step 2: D/U
[v4] Ledger (or popup menu from Px finder) --> Visit Wizard Step 2: D/U

HCFA Box 24h - EPSDT Family Plan

This will be left blank (not print) unless you change it

hint - to override the EPSDT use the Visit Wizard:
[365] Ledger --> Visit Wizard: EPSDT
[v4] Ledger --> Visit Wizard Step 2: EPSDT

HCFA 2007 Box 24i - ID Qualifier - this field is typically used with the new HCFA 2007 form, unlike in the past where it was typically left blank.

In the Dr. Editor (Dr tab) press the [PIN Numbers] button. Select the carrier and choose the "Attending Physician Type" (for example 1C Medicare, 1D Medicaid). You must select "-none-" to leave it blank.

HCFA Box 24i OLD FORM - EMG : This will be left blank unless you change it

hint - to override the EPSDT use the Visit Wizard: Ledger --> double-click date, Visit Wizard Step 2: EMG

HCFA 2007 Box 24j - Attending Physicians PIN (top shaded) & NPI (bottom)

Step 1. In the Dr. Editor (Dr tab) press the [PIN Numbers] button. Select the carrier and enter the "Attending Physician PIN" (for example 12345).

Step 2. In the Dr. Editor (Dr tab) press the [Licenses and other IDs] button. Enter the NPI (example 123456789).

Note - these are enabled for all carriers

HCFA Box 24j OLD FORM - COB : This will be left blank unless you change it

hint - to override the COB use the Visit Wizard:
    [365] Ledger --> Visit Wizard: COB
     [v4] Ledger --> Visit Wizard Step 2: COB

 

HCFA Box 24k - Reserved for Local use (box 24K does NOT appear on the HCFA2007 Form)

This will be left blank (not print) unless you enable it by following the instructions below. When setup, it works only when you bill from the Group Practice (Step 3 of the Billing Wizard). Some insurers require a PIN in box 24K.

hint - this field can be used for "Attending Physicians PIN#s" when required by an insurance carrier. To enable PIN# printing in this box you must do this:

Step 1. In the Dr. Editor (Dr tab) press the [PIN Numbers] button. Select the carrier and enter the "Billing PIN" and "Attending PIN" as needed.
Step 2. In the Insurance Carrier Editor, check "Enable HCFA box24 Pin logic"
Step 3. In the Billing Wizard select "Group Practice" as the "billing doctor".

HCFA Box 25 - Federal Tax ID#
The TaxID (ie. EIN) or SSN will appear on the printed HCFA depending on how the doctor or group practice is setup.

hint - setup each doctor or group in the Doctor Setup:
[365] Doctors Tab --> Enter SSN, Enter TaxID/EIN then select the "Fed Tax Id" to use by default from the combobox (either your SSN or TaxID/EIN).
[v4] Doctors Tab --> Enter SSN, Enter TaxID/EIN then select the "Fed Tax Id" to use by default from the combobox (either your SSN or TaxID/EIN).

HCFA Box 26 - Patient Account # : If a patient is assigned a chart number (Patient Wizard) this will print here.

hint - setup the chart number via the :
[365] Patient Wizard Page 1 --> Chart #
[v4] Patient Wizard --> Personal Info: Chart #

HCFA Box 27 - Accept assignment

Check if the doctor will accept assignment on this claim. This means the doctor will accept the insurance carriers fee limits and thus cannot balance bill above this except for copays and deductible.

hint - setup each doctor's default or group in the Doctor Setup:
[365] Setup Wizard --> Doctors : Accept Assignment select if yes
[v4] Office Setup Wizard --> Doctors : Accept Assignment select if yes

to override the default value for a doctor - setup each doctor's default or group in the Doctor Setup:
[365] Claim Wizard Page 2 --> Accept Assignment select yes (or no).
[v4] Claim Wizard --> HCFA 3) Assignments & TOS: Accept Assignment select yes (or no).

HCFA Box 28 - $ Charges

Total charges (dollar amount billed) for each individual HCFA form.

hint - this is based on which procedures are selected in the Billing Wizard, editable in Ledger

HCFA Box 29 - $ Paid

Total payments for the CPTs listed on each individual HCFA form.

hint - this is based on which procedures are selected in the Billing Wizard, editable in Ledger

HCFA Box 30 - $ Balance

This is the balance due. Total charges minus payments for the CPTs listed on each individual HCFA form.

hint - this is based on which procedures are selected in the Billing Wizard, editable in Ledger

HCFA Box 31 - Physician Signature & Date

Prints the Name of the billing physician with today's date as determined by the Billing Wizard

hint - this goes along with Box33 and can be changed here
[365] Billing Invoice Wizard --> Step 3: Select Billing Doctor
[v4] Billing Invoice Wizard --> Step 3: Select Billing Doctor

Idaho HCFA Notice (Dec. 2000): BC and BS of Idaho, each have been rejecting claims unless the Doctor PIN# is included in Box 31. There now is an option in the Insurer Editor to "Show Box31 Pin#". When checked, HCFA and Electronic Claims files will include this logic in Box31.

 

HCFA 2007 Box 32a - NPI goes here (enabled for all carriers)

[365] In the Dr. Editor (Dr tab) enter the NPI (example 123456789)
[v4] In the Dr. Editor (Dr tab) press the [Licenses and other IDs] button. Enter the NPI (example 123456789).

HCFA 2007 Box 32b - Billing PIN goes here (enabled for all carriers)

[365] In the Dr. Editor (Dr tab) press the [PIN Numbers] button. Select the carrier and enter the "Attending Physician PIN" (for example 12345)
[v4] In the Dr. Editor (Dr tab) press the [PIN Numbers] button. Select the carrier and enter the "Attending Physician PIN" (for example 12345).

HCFA 2007 - more info on how Box 32b & 33b (shaded boxes) is used in ChiroPulse properly:

HCFA Box 32 OLD HCFA - Name & Address of Service Facility:
Used if you refer a patient to an outside service facility if the doctor pays the facility (instead of the patient paying) then the doctor will bill the insurer to be reimbursed. You can enable this insurer by insurer, doctor by doctor as follows:

Step 1. In the Dr. Editor (Dr tab) press the [Setup Alternate HCFA Pobox Address ] button. Now enter the info and save.

Step 2. In the insurance carrier editor (Insurer tab) of the appropriate carrier, check the box "Enable HCFA box 32/33 Pobox logic".

Idaho HCFA Notice (Dec. 2000): Medicare of Idaho has been rejecting claims unless the word "Same" is located in Box 32. ChiroPulse HCFA logic now looks to see if insurer type is Medicare and if the insurer state is "ID (Idaho)". In this scenario, the word "Same" will appear in box 32.

HCFA 2007 Box 33a - NPI goes here (enabled for all carriers)

[365] In the Dr. Editor (Dr tab) enter the NPI (example 123456789)
[v4] In the Dr. Editor (Dr tab) press the [Licenses and other IDs] button. Enter the NPI (example 123456789).

HCFA 2007 Box 33b - Billing PIN goes here (enabled for all carriers)

[365] In the Dr. Editor (Dr tab) press the [PIN Numbers] button. Select the carrier and enter the "Attending Physician PIN" (for example 12345)
[v4] In the Dr. Editor (Dr tab) press the [PIN Numbers] button. Select the carrier and enter the "Attending Physician PIN" (for example 12345).

HCFA 2007 - more info on how Box 32b & 33b (shaded boxes) is used in ChiroPulse properly:

HCFA Box 33 OLD HCFA FORM - Physicians Name Address & Phone

Step 1. In the Dr. Editor (Dr tab) press the [PIN Numbers] button.

Step 2. Select the insurer (or Edit an existing carrier) and enter the "Billing PIN" for box 33 (and/or "Attending PIN" for box 24). Select GROUP to print the PIN on the right side of box33 . Leave GROUP unchecked to print the PIN on the left side of box33.