| [613] | 1 | IBCF3TP ;ALB/BGA - TEST PATTERN UB92 FORM ; 12-AUG-93
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| 2 | ;;Version 2.0 ; INTEGRATED BILLING ;; 21-MAR-94
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| 3 | ;;Per VHA Directive 10-93-142, this routine should not be modified.
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| 4 | ;
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| 5 | ;This program performs a test print function. The results of this
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| 6 | ;test will align the fields of the IB routines to the field locators
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| 7 | ;on form UB92.
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| 8 | ;
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| 9 | ;
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| 10 | ZIS S %ZIS="QM" D ^%ZIS G:POP END
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| 11 | I $D(IO("Q")) S ZTRTN="ENP^IBCF3TP",ZTSAVE("IBCF31")="",ZTDESC="PRINT TEST BILL" D ^%ZTLOAD K IO("Q") D HOME^%ZIS G END
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| 12 | U IO
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| 13 | ENP ;
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| 14 | W "##SR",?34,"*** UB-92 TEST PATTERN ***"
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| 15 | W !,"AGENT CASHIER"
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| 16 | W !,"AGENT CASHIER STREET",?57,"BN XXX ",?77,"XXX"
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| 17 | W !,"CITY STATE ZIP"
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| 18 | 5 W !,"PHONE #",?26,"TAX# XXXX",?37,"5/1/93",?44,"5/4/93"
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| 19 | W !
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| 20 | W !,"PATIENT NAME",?31,"PT SHORT ADDRESS"
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| 21 | W !
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| 22 | 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
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| 23 | W !!
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| 24 | 11 S IBI=0 F IBJ=1:1:5 W ?IBI,"OC",?(IBI+3),"DATE" S IBI=IBI+10
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| 25 | W !!,"RESPONSIBLE PARTY'S NAME"
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| 26 | W !,"STREET ADDRESS 1",!,"STREET ADDRESS 2",!,"STREET ADDRESS 3",!,"CITY STATE ZIP"
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| 27 | W !
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| 28 | 19 W !,"CD1",?5,"REV CODE description",?48,"xx",?57,"xxxx.xx"
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| 29 | W !,"CD2",?5,"REV CODE description",?48,"xx",?57,"xxxx.xx"
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| 30 | W !,"CD3",?5,"REV CODE description",?48,"xx",?57,"xxxx.xx"
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| 31 | W !,?5,"Subtotal",?57,"xxxx.xx"
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| 32 | W !!,?5,"Total",?57,"xxxx.xx"
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| 33 | W !!!!!!!!!
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| 34 | 32 W !,"For your information, even though the patient may be otherwise eligible"
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| 35 | W !,"for Medicare, no payment may be made under Medicare to any Federal provider"
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| 36 | W !,"of medical care or services and may not be used as a reason for non-payment."
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| 37 | W !,"Please make your check payable to the Department of Veterans Affairs and"
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| 38 | W !,"send to the address listed above."
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| 39 | W !
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| 40 | W !,"The undersigned certifies that treatment rendered is not for a"
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| 41 | W !,"service connected disability."
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| 42 | W !
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| 43 | 43 W !,"Name of Payer 1",?26,"Provider #",?40,"x",?43,"x"
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| 44 | W !,"Name of Payer 2",?26,"Provider #",?40,"x",?43,"x"
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| 45 | W !,"Name of Payer 3",?26,"Provider #",?40,"x",?43,"x"
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| 46 | W !!
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| 47 | 48 W !,"Insured's Name 1",?26,"x",?29,"Insurance #",?49,"Group Name",?64,"Group #"
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| 48 | W !,"Insured's Name 2",?26,"x",?29,"Insurance #",?49,"Group Name",?64,"Group #"
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| 49 | W !,"Insured's Name 3",?26,"x",?29,"Insurance #",?49,"Group Name",?64,"Group #"
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| 50 | W !
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| 51 | W !,"Treatment Auth. Cd",?19,"x",?21,"Employer Name",?47,"Employer Location"
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| 52 | W !,?19,"x",?21,"Employer Name",?47,"Employer Location"
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| 53 | W !,?19,"x",?21,"Employer Name",?47,"Employer Location"
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| 54 | W !
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| 55 | 56 W !,"PDX" S IBI=7 F IBJ=1:1:8 W ?IBI,"Dx Cd" S IBI=IBI+7
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| 56 | W ?64,"ADMT DX",!!
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| 57 | S IBI=3 F IBJ=1:1:3 W ?IBI,"P-code",?(IBI+8),"mmddyy" S IBI=IBI+15
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| 58 | W ?52,"Attending Phys. ID#",!!
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| 59 | S IBI=3 F IBJ=1:1:3 W ?IBI,"P-code",?(IBI+8),"mmddyy" S IBI=IBI+15
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| 60 | W ?52,"Other Phys. ID#"
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| 61 | 61 W !,?7,"Patient ID#: xxx-xx-xxxx"
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| 62 | W !,"Bill Type: xxx xxxxxx"
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| 63 | W !,"UB 92 TEST PATTERN",?52,"Provider Representative DATE"
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| 64 | W !,"*** comment ***"
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| 65 | K IBI,IBJ
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| 66 | I $D(ZTQUEUED) S ZTREQ="@" Q
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| 67 | D ^%ZISC
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| 68 | END Q
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