Insurance > Claim Form Codes

Key Info  
Purpose:

Configure claim form codes which are used to indicate the claim form and associated settings for use in creating claims for insurance companies.
Related Module(s):

Insurance
Accessed From:

Maintenance > Insurance > Claim Form Codes
Window(s):

Claim Form Codes

Dependencies: None.

Claim Form Codes Window

Claim Form codes are used to indicate the claim form and associated settings for use in creating claims for insurance companies.

The Claim Form Codes window allows you to manage the list of claim form codes used by insurance companies available in axiUm.

Field Description
Code

A text field that indicates the code that identifies the claim form.
Form

A drop-down list that indicates the claim form.

Note: This list is hard-coded into axiUm.

Tip: Based on the Form selected, axiUm enables/disables the following fields as they relate to the form code.

Description A text field that indicates the full name of the claim form.
Laser Drawn Form

A check box that, when selected, indicates that this form must be laser drawn and printed on plain paper (rather than a pre-printed form).
Claim Inquiry Form

A check box that, when selected, indicates that the form is used to make a claim inquires, and not for submitting claims.
Multi-page claim A check box that, when selected, indicates that this is a multi-page claim form.
Print Patient Signature Date (where applicable) A check box that, when selected, indicates that the form should display the date that the patient's signature was captured, if possible.
Block out Assignment of Payment (for non-assignment claims) A check box that, when selected, indicates that the that the signature field for claim forms that are printed for non-assignment patients will display 'XXXXXXXX' in field to prevent the patient from signing it.
Default Ortho Information from Attached Txs (Ortho Billing Process)

A check box that, when selected, indicates that form should display the default ortho information from the billing treatment that is assigned to the ortho plan when running ortho billings.

Examples: Replacement date, total months, months left (calculated).
Use Approval Faculty On Claim (where applicable)

A check box that, when selected, indicates that axiUm will use the approval users' Billing ID information (other than the fee schedule) when the claim is generated. The fee will still be based on the rendering provider (or other overrides).
Use Treating Dentist as Billing Entity A check box that, when selected, indicates that axiUm should use the first billing provider found on the claim form as the billing entity for the claim and also for the EDI submission. If there is no billing provider on the claim form, axiUm will use the non-billing provider (e.g. hygienist) shown on the first treatment.
Mark Missing Teeth Information A check box that, when selected, indicates that missing teeth are marked with an X on the claim form.
Print Claim Number A check box that, when selected, indicates that the axiUm claim number is printed on the upper right corner of the form.
Use NPI

A drop-down list that controls the use of NPI:

  • No: NPI numbers are not printed on this form.
  • Yes: NPI numbers are printed on the form, when applicable.
  • NPI Only, not other IDs: Only the NPI number is used, no other IDs like provider #, license, etc. are used.
Suppress Punctuation

A drop-down list that controls the use of punctuation:

  • No: None of the punctuation is suppressed.
  • Decimals Only: Decimals are filtered from the text sent to the form.
  • Decimals, Commas, and others: Most punctuation is filtered form the text sent to the form.
Dentist Sig.

A drop-down list that controls the signature of the dentist:

  • Print Dentist Name: The name of the dentist is displayed in the dental signature field.
  • Use Digital Sig. (if applicable): The digital signature is printed on the claim form.
  • Print "Signature on File": 'Signature on File' is printed on the claim form.
  • Leave as Blank: The signature field is left blank.

Total Paid (Assignment)

A drop-down list that is used for HCFA forms only and affects what is printed in boxes 29 and 30:

  • Both (Insurance + Patient): Display amounts paid by both insurance and patient (in box 29) when calculating the balance due (box 30).
  • Insurance Only: Display amounts paid by insurance (in box 29) when calculating the balance due (box 30).
  • Patient Only: Display amounts paid by the patient (in box 29) when calculating the balance due (box 30).
Total Paid (Non-Assign)

A drop-down list that is used for HCFA forms only and affects what is printed in boxes 29 and 30:

  • Both (Insurance + Patient): Display amounts paid by both insurance and patient (in box 29) when calculating the balance due (box 30).
  • Insurance Only: Display amounts paid by insurance (in box 29) when calculating the balance due (box 30).
  • Patient Only: Display amounts paid by the patient (in box 29) when calculating the balance due (box 30).
Task Procedure
Add Claim Form Codes
  1. Click the Clear Data () icon.
  2. Complete the fields as necessary and click the Add a new Record () icon.
Edit Claim Form Codes
  1. Select a listed entry.
  2. Make any necessary changes and click the Modify Record () icon.
Delete Claim Form Codes
  1. Select a listed entry and click the Delete Record () icon.
  2. When prompted, click Yes to confirm the deletion.
Preview/Print Report
  1. (Optional) To preview the Claim Form Codes report, click the Preview Report () icon.
  2. To print the Claim Form Codes report, click the Print Report () icon.

    3. Note: The Claim Form Codes report uses the ClaimCode.rpt file