Case Information - Claim Data

The Claim Data section of the patient's Case Information contains several fields that will map to a printed CMS-1500 insurance claim form or its electronic equivalent. It is not necessary to always fill out all of the fields in Claim Data in order to have your insurance bills accepted. However, certain insurance carrier's have their own requirements as to what is and what isn't required on the claim.

! IMPORTANT: A QuickPractice representative cannot always give you a definitive answer as to what an insurance carrier specifically requires on the claims that you send them. It is the client's responsibility to contact the carrier to confirm what is needed on the claim (such as a "ate of current illness or C.L.E.A. number). After you are sure of what needs to be included on the claims you send, you may always contact a technical support technician to inquire as how to use the program to populate that information to the insurance form.

Refer to the following screenshot and table as a reference for how each field in Claim Data maps to your insurance claims.  

Facility Type Code - Enter the code for the type of facility the services are rendered at (Example: 11 for office, 21 for inpatient hospital, etc). (BOX 24b). Submission Code - Enter the code for the type of claim being submitted (Example: 1 for "original", 6 for "corrected", etc). (electronic only). Provider Accepts Assignment? - Check if "yes" (BOX 27). Insured Authorizes Assignment of Benefits? - Check if "yes" (BOX 13). Patient Signed Statement for Release of Info? - check if "yes". (BOX 12).   Date Signed - Enter the date on which the patient signed the release statement (BOX 12). Patient Signature Source - Select the appropriate source for the patient's signature (BOX 12). Date of Current Illness - Enter the patient's date of current illness/first symptom/injury (BOX 14). Current Illness (Related To) - Place check into appropriate field (BOX 10). CMS-1500 Box 10d - Reserved for local use (BOX 10d). Same or Similar Illness Date - Enter the same or similar illness date (BOX 15).   Dates Unable to Work - Enter any dates the patient has been unable to work. (BOX 16). Referring Physician/Other Source - select the name of the referring physician or provider (BOX 17). ID# - Secondary ID# for referring provider. To input, click on lists>referring providers>secondary identifiers (BOX 17a). Last Seen - Enter the date the patient was last seen by the referring provider (electronic billing only). Hospitalization Dates Related to Current Services - If required, enter the hospitalization dates related to the diagnosis. (BOX 18). CMS-1500 Box 19 - Reserved for local use (BOX 19). Any Outside Lab Work Performed? - Check if "yes" (BOX 20). Charges - Enter total charges for outside lab work (Box 20). Medicaid Resubmission Code - Enter the authorized resubmission code given to you by Medicaid (BOX 22). Prior Authorization Number - Enter a prior authorization number (BOX 22)

At the bottom of your Claim Data screen you will notice an "Additional" button. Click on this button to view the screen containing fields for less common requirements for electronically submitted insurance claims.

Refer to the following screenshot and table as a reference for how each field in Claim Data maps to your insurance claims.   Initial Treatment Date-   If required, enter an initial treatment date. * Date of Last X-ray - If required, enter a date of last x-ray.* Date Last Worked - If required, enter a last date worked.* Nature of Condition - Select an appropriate nature of condition.* Date of Manifestation - If required, enter a date of manifestation for illness/symptom.* Clinical Laboratory Improvement Amendment - If required, enter a "C.L.I.A." number.* Special Program Code - If the patient belongs to a special program, select the appropriate category.*  Provider Agreement Code - If required, select the provider agreement code. * Delay Reason Code - If required by the insurance company, enter reason code for the delay of the transmitted claim.* Supervising Provider - If required, add a supervising provider for the billed service/procedure code.* Ordering Provider - If required, specify an ordering provider for the billed service/procedure code.* * Used for electronic billing only.