| 1 | English French  Notes   Complete/Exclude
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| 2 | WAITING SINCE                   
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| 3 | MAIL MESSAGE #                  
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| 4 | MINIMUM # OF DAYS MSGS WAITING TO BE FILED:                     
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| 5 | Enter the minimum number of days a message has been waiting to be filed                 
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| 6 | before it appears on this report                        
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| 7 | REPORT OF EDI MSGS PENDING TOO LONG TO BE FILED                 
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| 8 | TOTAL # OF MESSAGES WAITING OVER                        
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| 9 |  TO BE FILED:                   
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| 10 | EDI MESSAGES WAITING TO BE FILED OVER                   
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| 11 | MESSAGE TYPE                    
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| 12 | IN CURRENT                      
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| 13 | MESSAGE #                       
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| 14 | STATUS SINCE                    
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| 15 | DO YOU WANT TO INCLUDE A LIST OF BILLS WITH EACH BATCH?:                        
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| 16 | Enter the first 10-digit batch number you want included on the report                   
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| 17 | Start with BATCH #:                     
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| 18 | Must enter a 10-digit batch #                   
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| 19 | Enter the last 10-digit batch number you want included on the report                    
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| 20 | Go to BATCH #:                  
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| 21 | Enter the first date you want to include on the report                  
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| 22 | Start with LAST TRANSMIT DATE:                  
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| 23 | Must enter a valid date                 
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| 24 | Enter the last date you want to include on the report                   
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| 25 | Go to LAST TRANSMIT DATE:                       
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| 26 | Select BATCH STATUS:                    
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| 27 | EDI 837 BATCH DETAIL LIST                       
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| 28 | Rejected?:                      
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| 29 | Resubmit:                       
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| 30 |  Batch Type :                   
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| 31 | Mail Msg:                       
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| 32 |  Received in Austin?:                   
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| 33 |  Status Date:                   
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| 34 | Date Recorded:                  
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| 35 |  First Sent :                   
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| 36 |  Last Sent  :                   
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| 37 | Number    Transmit Status            Resubmit Batch #                   
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| 38 | * = NOT RESUBMITTED                     
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| 39 | Number    Transmit Status                       
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| 40 |             Resubmit Batch #                    
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| 41 | BATCH DETAIL LIST                       
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| 42 | This report provides a list of claims held in a                 
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| 43 | Ready for Extract status.  Users can select all bills                   
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| 44 | in a Ready for extract status or only those trapped due to                      
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| 45 | the EDI Parameters being turned off.                    
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| 46 | This report requires a 132 column printer.                      
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| 47 | IB - EDI Claims in Waiting Transmission Status                  
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| 48 | Your task number                        
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| 49 |  has been queued.                       
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| 50 | There are no EDI records                        
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| 51 |  in a ready for extract status                  
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| 52 | Total EDI Bills                         
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| 53 | Total MRA Bills                         
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| 54 | Total bills                     
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| 55 | Your EDI site parameter setting is incomplete.                  
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| 56 | Please contact your coordinator.                        
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| 57 | Your site parameters are set to allow EDI transmissions                 
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| 58 | There is no need to run this report.                    
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| 59 | Trapped                         
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| 60 |  Claims Ready for Extract                       
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| 61 | Inpt/                   
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| 62 | Inst/                   
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| 63 | Opt                     
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| 64 | Prof                    
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| 65 | Statement Date                  
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| 66 | Do you want to print a list of:                 
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| 67 |      1 - All bills in Ready for Extract status                  
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| 68 |      2 - Bills trapped due to EDI paramater being turned off                    
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| 69 | IB - EDI/MRA Claims in Rescue Process                   
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| 70 | There are no records to print                   
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| 71 | Claims in Rescue Process                        
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| 72 | Stmt Date                       
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| 73 | Ins Co.                 
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| 74 | IB-HOLD                 
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| 75 | IBCE ELEC REPORT DISP                   
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| 76 | IBREP DISP                      
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| 77 | IBREP DISP1                     
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| 78 | No reports available for dispositioning                 
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| 79 | REPORT:                         
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| 80 | RACUBOTH RUCH                   
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| 81 | EDI RETURN MESSAGE ROUTER ERROR                 
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| 82 |              Return Message Code:                       
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| 83 | Return Message Date:                    
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| 84 |     Message Time:                       
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| 85 | Update Date:                    
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| 86 |      Update Time:                       
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| 87 | Return Message File #(s):                       
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| 88 | Mailman Message #:                      
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| 89 | cannot be determined                    
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| 90 | Msg Line:                       
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| 91 | Return Message Text:                    
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| 92 | ERROR+                  
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| 93 | S.IBCE MESSAGES SERVER                  
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| 94 | ***  NEW PAGE  ***                      
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| 95 | *** END OF PAGE ***                     
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| 96 | I:G.IB EDI SUPERVISOR                   
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| 97 | Status message received for batch                       
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| 98 | PAYID=                  
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| 99 | PAYER ID RETURNED IS DIFFERENT THAN PAYER ID ON FILE                    
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| 100 | BILL #     :                    
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| 101 | PAYER      :                    
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| 102 | BILL TYPE  :                    
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| 103 | ID ON FILE :                    
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| 104 | ID RETURNED:                    
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| 105 |    Please determine which id number is correct and correct the id in the                        
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| 106 | insurance file for this payer, if needed                        
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| 107 |  ALREADY EXISTS - CAN'T HAVE BOTH ON ONE BILL                   
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| 108 | IBA(355.93                      
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| 109 | N-CURRENT INS POLICY TYPE                       
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| 110 | Another user has locked this record - try again later                   
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| 111 | ONLY SELECT TO CLOSE THE TRANSMIT RECORDS IF YOU KNOW THESE ARE THE FINAL                       
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| 112 |   ELECTRONIC MESSAGES YOU WILL RECEIVE FOR ALL THE BILLS REFERENCED BY                  
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| 113 |   THESE MESSAGES                        
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| 114 | DO YOU WANT TO AUTOMATICALLY CLOSE THE TRANSMIT RECORDS FOR ANY MESSAGES                        
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| 115 |  THAT AREN'T REJECTS?:                  
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| 116 | DO YOU WANT TO SEE EACH MESSAGE BEFORE MARKING IT REVIEWED?:                    
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| 117 | IF YOU OPT TO SEE EACH MESSAGE, YOU CAN CONTROL WHETHER OR NOT THE MESSAGE                      
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| 118 |   IS MARKED AS REVIEWED                 
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| 119 |  AND, FOR NON-REJECTS, WHETHER OR NOT TO CLOSE THE                      
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| 120 |   TRANSMIT RECORD FOR THE BILL                  
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| 121 | OK TO MARK REVIEWED?:                   
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| 122 | IF YOU ENTER YES, THIS MESSAGE WILL BE MARKED REVIEWED                  
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| 123 | IF YOU ENTER NO, THIS MESSAGE WILL NOT BE ALTERED                       
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| 124 | IF YOU ENTER AN ^, THIS MESSAGE WILL NOT BE ALTERED & NONE OF THE                       
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| 125 |    REMAINING MESSAGES WILL BE PROCESSED                 
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| 126 | OK TO CLOSE THIS BILL'S TRANSMIT RECORD?:                       
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| 127 | THIS IS A REJECTION ... ARE YOU SURE YOU WANT TO MARK IT REVIEWED?:                     
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| 128 |    MESSAGES FOLLOWING THIS ONE WILL BE PROCESSED                        
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| 129 | CLAIM SENT TO PAYER                     
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| 130 | CLAIM REJECTED                  
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| 131 | Seq #:                  
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| 132 |   Bill number:                  
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| 133 | LAST SELECTION PROCESSED                        
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| 134 | N-PRIOR PAYMENTS                        
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| 135 |  PRINT CENTER                   
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| 136 | N-PATIENT STATUS                        
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| 137 | N-SOURCE OF ADMISSION                   
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| 138 | N-OTH INSURANCE PRIOR PAYMENT                   
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| 139 | N-EOB ENTRIES                   
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| 140 | Adding occurrence code 24 and primary insurance rejection date to bill                  
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| 141 | Adding value code                       
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| 142 |  for reporting of bill's prior payments                 
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| 143 | N-CURR INSURED DEMOGRAPHICS                     
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| 144 | N-OTH INSURED DEMOGRAPHICS                      
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| 145 | Adding occurrence code '                        
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| 146 |  insurance subscriber's date of birth                   
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| 147 | N-DATE LAST SEEN                        
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| 148 | Date Last Seen:                 
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| 149 | N-REFERRING PROVIDER ID                 
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| 150 | Homebound                       
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| 151 | N-ASSIGN OF BENEFITS INDICATOR                  
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| 152 | Nn0                     
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| 153 | Patient refuses to assign benefits                      
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| 154 | NOC Drug:                       
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| 155 | Testing for hearing aid                 
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| 156 | Attending physician,not hospice employee                        
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| 157 | Last Xray:                      
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| 158 | Level of Sublux:                        
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| 159 | N-SPECIAL PROGRAM                       
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| 160 | Medicare demonstration project for lung volume reduction surgery study                  
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| 161 | N-HCFA 1500 BOX 19 RAW DATA                     
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| 162 | N-BILL REMARKS                  
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| 163 | DISPLAY THE FULL HCFA 1500 BOX 19?:                     
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| 164 | Bill:                   
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| 165 | VARIABLE TO DISPLAY (IBXDATA):                  
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| 166 | BAD VARIABLE NAME                       
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| 167 |    *** NO DATA TO DISPLAY                       
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| 168 | Remember to run this for flds that set up pre-requisite data (if any) first                     
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| 169 | Form Field:                     
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| 170 | N-SPECIALTY CODE                        
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| 171 | N-ALL PROVIDERS                 
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| 172 | PRV-82                  
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| 173 | DEPT OF VETERANS AFFAIRS                        
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| 174 | SELECT 1-                       
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| 175 | Enter your selection for procedure from 1 to                    
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| 176 | There were more than                    
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| 177 |  matches found.  Please try again with more specific input                      
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| 178 | N-ATT/REND PROVIDER ID                  
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| 179 |   WANT TO CHANGE THE                    
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| 180 |  PROVIDER'S FUNCTION TO                         
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| 181 | IF YOU ANSWER YES HERE, YOU WILL MAKE THE PROVIDER FUNCTIONS CONSISTENT                 
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| 182 |   WITH THE FORM TYPE OF THE BILL                        
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| 183 |  FUNCTION DOES NOT BELONG ON THIS BILL TYPE & MUST BE DELETED                   
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| 184 | This bill is                    
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| 185 | The valid provider functions for this bill are:                 
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| 186 |  - ALREADY ON BILL                      
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| 187 |  - NOT ON BILL                  
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| 188 | Select Rx for this charge:                      
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| 189 | Enter an Rx# for this revenue code                      
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| 190 |  The Rx must not already have an associated revenue code                        
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| 191 | PROCEDURE #                     
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| 192 |  HAS BEEN ASSOCIATED WITH THIS MANUAL CHARGE                    
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| 193 | Respond YES if this revenue code charge specifically references the data for                    
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| 194 |   a particular procedure that was manually entered on the previous screen.                      
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| 195 |   For outpatient UB92 bills, associating a manual revenue code charge with                      
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| 196 |   a procedure is the only way to print a modifier in box 44                     
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| 197 | SHOULD A PROCEDURE ENTRY BE ASSOCIATED WITH THIS CHARGE?:                       
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| 198 | Respond YES if you no longer want this revenue code charge to reference a                       
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| 199 |   specific manually entered procedure                   
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| 200 | DELETE THE EXISTING PROCEDURE ASSOCIATION?:                     
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| 201 | SELECT A PROCEDURE ENTRY:                       
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| 202 | Enter a manually-added CPT procedure to associate with this charge                      
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| 203 | IBCE EXTR STATUS MANAGEMENT                     
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| 204 | Claims in need of rescue process                        
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| 205 | This function is not necessary.                 
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| 206 | No records trapped in a Ready for Extract status found                  
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| 207 | Authorizing bill...                     
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| 208 | This option will display the EDI extract data for a bill.                       
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| 209 | There is no entry in the EDI Transmit Bill file for this bill number.                   
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| 210 | There is no batch # for this bill.  It has not been transmitted.                        
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| 211 | INCLUDE FIELDS WITH NO DATA?:                   
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| 212 | Transmitted Bill Extract Data                   
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| 213 | Your task number                        
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| 214 | Inpt                    
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| 215 | Oupt                    
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| 216 |   (NO DATA - RECORD NOT SENT)                   
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| 217 | EDI Transmitted Bill Extract Data                       
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| 218 | UB-82                   
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| 219 | FOLLOW-UP AR FORM                       
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| 220 | BILL ADDENDUM FOR                       
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| 221 | BILL FORM TYPE NOT COMPLETE FOR                 
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| 222 | QUEUEING OF                     
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| 223 | DG*                     
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| 224 | *** COPY OF ORIGINAL BILL ***                   
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| 225 | *** SECOND NOTICE ***                   
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| 226 | *** THIRD NOTICE ***                    
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| 227 | MEDICARE ESRD                   
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| 228 | IB-RC                   
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| 229 | Dept. Veterans Affairs                  
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| 230 | Bill Type:                      
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| 231 | INPATIENT CARE                  
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| 232 | ADDITIONAL PROCEDURE CODES:                     
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| 233 | LESS                    
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| 234 | OP VISIT DATE(S) BILLED                                 
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| 235 | MISSING INPUT VARIABLES                 
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| 236 | BILL NON-EXISTANT                       
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| 237 | BILL CANCELLED                  
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| 238 | BILL STATUS INAPPROPRIATE                       
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| 239 | For your information, even though the patient may be otherwise eligible                 
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| 240 | for Medicare, no payment may be made under Medicare to any Federal provider                     
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| 241 | of medical care or services and may not be used as a reason for non-payment.                    
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| 242 | Please make your check payable to the Department of Veterans Affairs and                        
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| 243 | send to the address listed above.                       
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| 244 | The undersigned certifies that treatment rendered is not for a                  
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| 245 | service connected disability.                   
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| 246 | IBCF1TP-1                       
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| 247 | IB - TEST UB-82 PRINT                   
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| 248 | IBCF1TP-2                       
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| 249 | *** UB-82 TEST PATTERN ***                      
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| 250 | AGENT CASHIER                   
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| 251 | AGENT CASHIER STREET                    
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| 252 | CITY STATE  ZIP                 
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| 253 | PHONE #                 
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| 254 | BC/BS #                 
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| 255 | FED TAX #                       
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| 256 | PATIENT ADDRESS                 
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| 257 | PT DOB                  
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| 258 | ADM DT                  
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| 259 | MAILING ADDRESS NAME                    
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| 260 | STREET ADDRESS 1                        
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| 261 | STREET ADDRESS 3                        
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| 262 | 000 DAYS MEDICAL CARE                   
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| 263 | REV CODE                        
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| 264 | PAYER                   
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| 265 | INSURED NAME                    
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| 266 | POLICY #                        
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| 267 | GROUP NAME                      
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| 268 | GROUP #                         
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| 269 | EMPLOYER NAME                   
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| 270 | CITY  STATE  ZIP                        
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| 271 | PRINCIPAL DIAGNOSIS                     
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| 272 | PRINCIPAL PROCEDURE                     
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| 273 | TX. AUTH.                       
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| 274 | XXXX XXXXXXX                    
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| 275 | UB-82 TEST PATTERN                      
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| 276 | **TEST PATTERN**                        
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| 277 | UB-82 SIGNER NAME                       
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| 278 | UB-82 SIGNER TITLE                      
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| 279 | PRINT HCFA1500                  
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| 280 | N-PRINT BILL SUBMIT STATUS                      
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| 281 | ONSET OF SYMPTOMS/ILLNESS                       
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| 282 | PUBLIC LAW 99-272/SECTION 1729 TITLE 38                 
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| 283 | PUBLIC LAW 99-272                       
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| 284 | Dept. Of Veterans Affairs                       
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| 285 | THE UNDERSIGNED CERTIFIES TREATMENT IS NOT FOR A SERVICE-CONNECTED CONDITION                    
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| 286 | proc^division^basc flag^bedsection^rev code^unit chrg^Rx seq #                  
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| 287 | proc^division^basc flag^dx^pos^tos^modifier^unit chrg^Rx seq #                  
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| 288 | proc^division^basc^dx^pos^tos^modifier(s)^unit chrg^purchased chg                       
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| 289 | AUX-X                   
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| 290 | not for SC                      
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| 291 | IBCF2TP-1                       
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| 292 | IB - TEST HCFA 1500 PRINT                       
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| 293 | IBCF2TP-2                       
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| 294 | INSURANCE CARRIER NAME                  
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| 295 | CARRIER ADDRESS LINE 1                  
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| 296 | CARRIER ADDRESS LINE 2                  
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| 297 | CARRIER ADDRESS LINE 3                  
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| 298 | CARRIER CITY, STATE ZIP                 
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| 299 | SUBSCRIBER ID#                  
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| 300 | MM DD YY                        
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| 301 | INSURED'S NAME                  
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| 302 | PATIENT ADDRESS STREET                  
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| 303 | ####################    ####################    ####################    
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| 304 | ####################    ####################    ####################    
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| 305 | ####################    ####################    ####################    
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| 306 | ####################    ####################    ####################    
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| 307 | ####################    ####################    ####################    
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