source: WorldVistAEHR/trunk/r/INTEGRATED_BILLING-IB-PRQ--IBD--IBQ--PRQS/IBCF3TP.m@ 1259

Last change on this file since 1259 was 613, checked in by George Lilly, 15 years ago

initial load of WorldVistAEHR

File size: 2.9 KB
Line 
1IBCF3TP ;ALB/BGA - TEST PATTERN UB92 FORM ; 12-AUG-93
2 ;;Version 2.0 ; INTEGRATED BILLING ;; 21-MAR-94
3 ;;Per VHA Directive 10-93-142, this routine should not be modified.
4 ;
5 ;This program performs a test print function. The results of this
6 ;test will align the fields of the IB routines to the field locators
7 ;on form UB92.
8 ;
9 ;
10ZIS S %ZIS="QM" D ^%ZIS G:POP END
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
12 U IO
13ENP ;
14 W "##SR",?34,"*** UB-92 TEST PATTERN ***"
15 W !,"AGENT CASHIER"
16 W !,"AGENT CASHIER STREET",?57,"BN XXX ",?77,"XXX"
17 W !,"CITY STATE ZIP"
185 W !,"PHONE #",?26,"TAX# XXXX",?37,"5/1/93",?44,"5/4/93"
19 W !
20 W !,"PATIENT NAME",?31,"PT SHORT ADDRESS"
21 W !
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
23 W !!
2411 S IBI=0 F IBJ=1:1:5 W ?IBI,"OC",?(IBI+3),"DATE" S IBI=IBI+10
25 W !!,"RESPONSIBLE PARTY'S NAME"
26 W !,"STREET ADDRESS 1",!,"STREET ADDRESS 2",!,"STREET ADDRESS 3",!,"CITY STATE ZIP"
27 W !
2819 W !,"CD1",?5,"REV CODE description",?48,"xx",?57,"xxxx.xx"
29 W !,"CD2",?5,"REV CODE description",?48,"xx",?57,"xxxx.xx"
30 W !,"CD3",?5,"REV CODE description",?48,"xx",?57,"xxxx.xx"
31 W !,?5,"Subtotal",?57,"xxxx.xx"
32 W !!,?5,"Total",?57,"xxxx.xx"
33 W !!!!!!!!!
3432 W !,"For your information, even though the patient may be otherwise eligible"
35 W !,"for Medicare, no payment may be made under Medicare to any Federal provider"
36 W !,"of medical care or services and may not be used as a reason for non-payment."
37 W !,"Please make your check payable to the Department of Veterans Affairs and"
38 W !,"send to the address listed above."
39 W !
40 W !,"The undersigned certifies that treatment rendered is not for a"
41 W !,"service connected disability."
42 W !
4343 W !,"Name of Payer 1",?26,"Provider #",?40,"x",?43,"x"
44 W !,"Name of Payer 2",?26,"Provider #",?40,"x",?43,"x"
45 W !,"Name of Payer 3",?26,"Provider #",?40,"x",?43,"x"
46 W !!
4748 W !,"Insured's Name 1",?26,"x",?29,"Insurance #",?49,"Group Name",?64,"Group #"
48 W !,"Insured's Name 2",?26,"x",?29,"Insurance #",?49,"Group Name",?64,"Group #"
49 W !,"Insured's Name 3",?26,"x",?29,"Insurance #",?49,"Group Name",?64,"Group #"
50 W !
51 W !,"Treatment Auth. Cd",?19,"x",?21,"Employer Name",?47,"Employer Location"
52 W !,?19,"x",?21,"Employer Name",?47,"Employer Location"
53 W !,?19,"x",?21,"Employer Name",?47,"Employer Location"
54 W !
5556 W !,"PDX" S IBI=7 F IBJ=1:1:8 W ?IBI,"Dx Cd" S IBI=IBI+7
56 W ?64,"ADMT DX",!!
57 S IBI=3 F IBJ=1:1:3 W ?IBI,"P-code",?(IBI+8),"mmddyy" S IBI=IBI+15
58 W ?52,"Attending Phys. ID#",!!
59 S IBI=3 F IBJ=1:1:3 W ?IBI,"P-code",?(IBI+8),"mmddyy" S IBI=IBI+15
60 W ?52,"Other Phys. ID#"
6161 W !,?7,"Patient ID#: xxx-xx-xxxx"
62 W !,"Bill Type: xxx xxxxxx"
63 W !,"UB 92 TEST PATTERN",?52,"Provider Representative DATE"
64 W !,"*** comment ***"
65 K IBI,IBJ
66 I $D(ZTQUEUED) S ZTREQ="@" Q
67 D ^%ZISC
68END Q
Note: See TracBrowser for help on using the repository browser.