Box Number: 1 - Insurance Name
Where this populates from: Billing Info > Billing Preferences > Insurance Type
Description: Where the type of health insurance coverage applicable to this claim is selected. There are seven plan types to select from, by checking the appropriate box. Only one plan type is allowed to be selected.
Box Number: 1a - Insured’s ID Number
Where this populates from: Patient File > Insurance tab > Card Info, ID on Card (patient can fill this out during onboarding if you are accepting insurance info).
Description: Where the insured's ID number is entered as shown on their ID card for the payer to which the claim is being submitted.
Box Number: 2 - Patient’s Name
Where this populates from: Personal tab of Patient File
Description: Where the patient's full name is entered as Last Name, First Name, Middle Initial, separated by commas.
Box Number: 3 - Patient’s Birthdate and Sex
Where this populates from: Personal tab of Patient File
Description: Where the patient's 8-digit birth date is entered in the format MMDDYYYY. As well, the appropriate box should be marked indicating the sex (gender) of the patient. Only one box can be marked.
Box Number: 4 - Insured’s Name
Where this populates from: Personal tab of Patient File OR if covered under someone else, Patient File > Insurance Tab > Card Info > ID on Card (patient can fill this out during onboarding if you are accepting insurance info).
Description: Where the insured's full name is entered as Last Name, First Name, Middle Initial, separated by commas.
Box Number: 5 - Patient’s Address
Where this populates from: Personal tab of Patient File
Description: Where the patient's address information is entered. This is the patient's permanent residence. The first line is for the street address. The second line is for the city and state. The third line is for the zip code and phone number.
Box Number: 6 - Patients relationship to Insured
Where this populates from: Insurance tab of the Patient File (If "Covered under someone else's insurance plan?" is switched to Yes OR patient can fill out during onboarding).
Description: Where the patient's relationship to the insured is entered. Only one box can be marked.
Box Number: 7 - Insured Address
Where this populates from: Personal tab of Patient File OR Patient File > Insurance Tab > Insured under someone else fields.
Description: Where the patient's address information is entered. This is the patient's permanent residence. The first line is for the street address. The second line is for the city and state. The third line is for the zip code and phone number.
Box Number: 8 - Reserved for NUCC Use
Where this populates from: can not be modified within Unified Practice
Description: Reserved field. It was previously used to report Patient Status. Patient Status no longer exists, so this field has been eliminated.
Box Number: 9 - Other Insured’s Name
Where this populates from: Insurance tab must have Primary/Secondary/other insurance info filled out. Then in Billing Info > Billing Preferences, select Primary and Secondary insurances from the drop-down boxes.
Description: Indicates that there is a holder of another policy that may cover the patient. The insured's name is entered as Last Name, First Name, Middle Initial, separated by commas. If Box 11d is marked, complete boxes 9, 9a, and 9d, otherwise leave blank.
Box Number: 9a - Other Insured's Policy or Group Number
Where this populates from: Insurance tab must have Primary/Secondary/other insurance info filled out. Then in Billing Info > Billing Preferences, select Primary and Secondary insurances from the drop-down boxes.
Description: The other insured's policy or group number as it appears on the insured's health care identification card for secondary insurance. If Box 11d is marked, complete boxes 9, 9a, and 9d, otherwise leave blank.
Box Number: 9b - Reserved for NUCC Use
Where this populates from: can not be modified within Unified Practice
Description: Box 9b is now a reserved field. It was previously used to report Other Insured's Date of Birth, Sex. Other Insured's Date of Birth, Sex no longer exists, so this field has been eliminated.
Box Number: 9c - Reserved for NUCC Use
Where this populates from: can not be modified within Unified Practice
Description: Box 9c is now a reserved field. It was previously used to report Employer’s Name or School Name. Employer’s Name or School Name no longer exists, so this field has been eliminated.
Box Number: 9d - Insurance Plan Name or Program Name
Where this populates from: can not be modified within Unified Practice
Description: Box 9d is the name of the insurance plan or program of the other insured as indicated in Box 9. If Box 11d is marked, complete boxes 9, 9a, and 9d, otherwise leave blank.
Box Number: 10 - Is Patient's Condition Related To
Where this populates from: Billing Info > Billing Preferences > Is Patient's condition related to (this carries over from treatment to treatment).
Description: Indicate whether the patient’s illness or injury is related to employment, auto accident, or other accident. Only one box on each line can be marked. Any item marked “YES” indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Box 11.
Box Number: 10a - Employment
Where this populates from: Employment (current or previous) would indicate that the condition is related to the patient’s job or workplace.
Description: Indicate whether the patient’s illness or injury is related to employment, auto accident, or other accident. Only one box on each line can be marked. Any item marked YES indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Box 11.
Box Number: 10b - Auto Accident
Where this populates from: Auto accident would indicate that the condition is the result of an automobile accident. The state postal code where the accident occurred must be reported if YES is marked in 10b for “Auto Accident.”
Description: Indicate whether the patient’s illness or injury is related to employment, auto accident, or other accident. Only one box on each line can be marked. Any item marked YES indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Box 11.
Box Number: 10c - Other Accident
Where this populates from: Other accident would indicate that the condition is the result of any other type of accident.
Description: Indicate whether the patient’s illness or injury is related to employment, auto accident, or other accident. Only one box on each line can be marked. Any item marked YES indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Box 11.
Box Number: 10d - Reserved for Local Use
Where this populates from: can not be modified within Unified Practice
Description: Used to identify additional information about the patient’s condition or the claim. When required by payers to provide the sub-set of Condition Codes approved by the NUCC, enter the Condition Code in this field.
Box Number: 11 - Insured Policy Group or FECA Number
Where this populates from: Billing Info > Billing Preferences > select which company is being used as Primary for this visit.
Description: The insured's policy or group number as it appears on the insured's health care identification card.
Box Number: 11a - Insured Date of Birth and Sex
Where this populates from: Personal tab of Patient File
Description: Where the insured's 8-digit date of birth in the format MMDDYYYY is entered and a box indicating the insured's gender is marked.
Box Number: 11b - Other Claim ID (Designated by NUCC)
Where this populates from: can not be modified within Unified Practice
Description: The other claim ID. Claim identifiers are designated by the NUCC.
Box Number: 11c - Insurance Plan Name Or Program Name
Where this populates from: Insurance tab of Patient File by selecting the Insurance Plan (goes for all types).
Description: The name of the insurance plan or program of the insured. Some payers require an identification number of the primary insurer rather than the name in this field.
Box Number: 11d - Is there another Health Benefit Plan
Where this populates from: Billing Info > Billing Preferences > Secondary Insurance
Description: If Box 11d is marked, complete boxes 9, 9a, and 9d, otherwise leave blank. This specifies if there is another health benefit plan attached to this claim. Mark the appropriate box (Yes or No). Only one box can be marked.
Box Number: 12 - Patients or Authorized Person’s Signature
Where this populates from: Billing Info > Billing Preferences > Signature Date. If switched to Yes, you can enter the date. Otherwise, this is left blank.
Description: Where the signature and date indicating authorization to release any medical information needed to process and/or adjudicate the claim. This can be done by entering Signature on File, SOF or the actual signature.
Box Number: 13 - Insured’s or Authorized Person’s Signature
Where this populates from: This is automatically populated by Unified Practice with Signature on File.
Description: Where the signature indicating authorization of payment for medical benefits to the provider of service. This can be done by entering Signature on File, SOF or the actual signature.
Box Number: 14 - Date of Current Illness, Injury, or Pregnancy
Where this populates from: Billing Info > Billing Preferences > Onset Date
Description: Identifies the first date of onset of illness, the actual date of injury, or the LMP for pregnancy. Enter the 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) date of the first date of the present illness, injury, or pregnancy. For pregnancy, use the date of the last menstrual period (LMP) as the first date. Enter the applicable qualifier to identify which date is being reported.
Box Number: 15 - Other Date
Where this populates from: Billing Info > Billing Preferences > Other Date
Description: Where another date related to the patient’s condition or treatment is entered. Enter the applicable qualifier to identify which date is being reported. 454 Initial Treatment, 304 Latest Visit or Consultation, 453 Acute Manifestation of a Chronic Condition, 439 Accident, 455 Last X-ray, 471 Prescription, 090 Report Start (Assumed Care Date), 091 Report End (Relinquished Care Date), 444 First Visit or Consultation.
Box Number: 16 - Dates patient unable to work in current occupation
Where this populates from: can not be modified within Unified Practice
Description: Where the time span the patient is, or was, unable to work is entered if the patient is employed and is unable to work in their current occupation. A 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) date must be shown for the “from–to” dates that the patient is unable to work. An entry in this field may indicate employment-related insurance coverage.
Box Number: 17 - Name of Referring Provider or other Source
Where this populates from: [1.] Patient File > Personal Tab > Edit > Referring Provider [2.] Billing Info > Billing Preferences > Fill in referring providers details toggle switched to Yes
Description: Where the name of the referring provider, ordering provider, or supervising provider who referred, ordered or supervised the service(s) or supply(ies) on the claim. The qualifier indicates the role of the provider being reported. Enter the name (First Name, Middle Initial, Last Name) followed by the credentials of the professional who referred or ordered the service(s) or supply(ies) on the claim. Enter the applicable qualifier to the left of the vertical dotted line to identify which provider is being reported. DN Referring Provider, DK Ordering Provider
Box Number: 17a
Where this populates from: This field can not be populated from Unified Practice
Box Number: 17b - NPI
Where this populates from: Patient File > Personal Tab > Edit > Referring Provider > Add new provider > NPI
Description: Where the NPI number of the referring, ordering, or supervising provider is entered. The NPI number refers to the HIPAA National Provider Identifier number.
Box Number: 18 - Hospitalization dates related to current services
Where this populates from: can not be modified within Unified Practice
Description: Where you would refer to an inpatient stay and indicates the admission and discharge dates associated with the service(s) on the claim. Enter the inpatient 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) hospital admission date followed by the discharge date (if discharge has occurred). If not discharged, leave discharge date blank. This date is when a medical service is furnished as a result of, or subsequent to, a related hospitalization.
Box Number: 19 - Additional Claim Information
Where this populates from: Billing Info > Billing Preferences, Additional Claim Information
Description: Used to identify additional information about the patient’s condition or the claim. Please refer to the most current instructions from the public or private payer regarding the use of this field. Some payers ask for certain identifiers in this field. If identifiers are reported in this field, enter the appropriate qualifiers describing the identifier.
Box Number: 20 - Outside Lab, $ charges
Where this populates from: Billing Info > Billing Preferences > Outside Lab
Description: Used to indicate that services have been rendered by an independent provider.
Box Number: 21- Diagnostic or Nature of Illness or Injury (ICD Ind)
Where this populates from: Billing Info > ICD codes
Description: Used to identify the applicable ICD indicator to specify which version of ICD codes are being reported.
9 ICD-9
0 ICD-10
Box 21, Lines A through L, are used to indicate the sign, symptom, complaint, or condition of the patient relating to the service(s) on the claim. Up to 12 ICD-9-CM or ICD-10-CM diagnosis codes can be entered.
Box Number: 22 - Resubmission Code, Original Ref No.
Where this populates from: Billing Info > Billing Preferences > Resubmission code (left), Original reference number (right)
Description: Used to list the original reference number for resubmitted/corrected claims. When resubmitting a claim, enter the appropriate bill frequency code left justified in the left-hand side of the field.
6 Corrected Claim
7 Replacement of prior claim
8 Void/cancel of prior claim
Box Number: 23 - Prior Authorization number
Where this populates from: Patient File > Insurance tab > Prior authorization turned on > Authorization #
Description: Used to show the payer assigned number authorizing the service(s).
Box Number: 24
Description: Used to list the completed services for the claim. The six service lines in section 24 have been divided horizontally to accommodate submission of both the NPI and another/proprietary identifier and to accommodate the submission of supplemental information to support the billed service. The top area of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 lines of service. The supplemental information is to be placed in the shaded section of 24A through 24G as defined in each Item Number. Providers must verify requirements for this supplemental information with the payer.
Box Number: 24a - Dates of Service
Where this populates from: Appointment Date
Description: Indicates the actual month, day, and year the service(s) was provided.
Box Number: 24b - Place of service
Where this populates from: Locations & Rooms > Edit Location > Facility Code
Description: Used to identify the location where the service was rendered. Enter the appropriate two-digit code from the Place of Service Code list for each item used or service performed.
Box Number: 24c - EMG
Where this populates from: can not be modified within Unified Practice
Description: Identifies if the service was an emergency. Check with payer to determine if this information (emergency indicator) is necessary. If required, enter Y for “YES” or leave blank if “NO” in the bottom, unshaded area of the field. The definition of emergency would be either defined by federal or state regulations or programs, payer contracts, or as defined in 5010A1.
Box Number: 24d - Procedures, services, or supplies
Where this populates from: Appointment bill, CPT codes -or- CPT Fee Schedule [on iPad]
Description: Used to identify the medical services and procedures provided to the patient. Enter the CPT code(s) and modifier(s) (if applicable) from the appropriate code set in effect on the date of service. This field accommodates the entry of up to four two-digit modifiers. The specific procedure code(s) must be shown without a narrative description.
Box Number: 24e - Diagnostic pointer
Where this populates from: Appointment bill, CPT codes, ICD pointer -or- Chief Complaint & ICD [on iPad]
Description: Used to indicate the line letter from Box 21 that relates to the reason the service(s) was performed. Enter the diagnosis code reference letter (pointer) as shown in Box 21 to relate the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow. The reference letter(s) should be A – L or multiple letters as applicable. ICD-9-CM (or ICD-10-CM, once mandated) diagnosis codes must be entered in Box 21 only. Do not enter them in 24e.
Box Number: 24f - Charges
Where this populates from: Fee Schedule (or if changed, charge in billing info screen)
Description: The total billed amount for each service line. Enter the charge for each listed service, right justified in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in cents area if the amount is a whole number.
Box Number: 24g - Days or Units
Where this populates from: Appointment Billing Info
Description: Used to indicate the number of days corresponding to the dates entered in 24A or units as defined in CPT coding manual(s). Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia units or minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered. Enter numbers left justified in the field. No leading zeros are required. If reporting a fraction of a unit, use the decimal point.
Box Number: 24h - EPSDT Family Plan
Where this populates from: cannot be modified within Unified Practice
Description: Box 24h is used to identify certain services that may be covered under some state plans.
Box Number: 24i - ID Qualifier
Where this populates from: Clinic Staff > Details > Taxonomy Code OR Account > My Account > Taxonomy Code, if it is entered, 'ZZ' will appear in the grey area of column 24i
Description: Indicate the appropriate qualifier and identifying number in the shaded area.
Box Number: 24j - Rendering Provider ID#
Where this populates from:
Clinic Staff > Details > Practitioner NPI, if it is entered (even if the toggle Use this NPI….. is turned off)
If Practitioner NPI is empty it takes the NPI configured in Clinic Settings >Billing Information
If both are empty, the field remains empty
Clinic Staff > Details > Taxonomy Code, if it is entered, it will appear in the grey area of column 24j
Description: Indicates the individual performing/rendering the service.
Box Number: 25 - Federal TAX ID number
Where this populates from: Account > My Account > Personal Tax ID > switch Use this ID as the Tax ID for my Superbills and Claim forms for billing toggle to Yes.
Description: Indicates the unique identifier assigned by a federal or state agency. Enter the Federal Tax ID Number (employer ID number or SSN) of the Billing Provider identified in Box 33. This is the tax ID number intended to be used for 1099 reporting purposes. Enter an X in the appropriate box to indicate which number is being reported. Only one box can be marked.
Box Number: 26 - Patient Account Number
Where this populates from: cannot be modified within Unified Practice
Description: Indicates the identifier assigned by the provider.
Box Number: 27 - Accept Assignment?
Where this populates from: Billing Info > Billing Preferences > Accept Assignment
Description: Indicates that the provider agrees to accept assignment under the terms of the payer’s program. Enter an X in the correct box. Only one box can be marked. Report Accept Assignment? for all payers.
Box Number: 28 - Total Charge
Where this populates from: Service balance due in Billing Info
Description: Indicates the total billed amount for all services entered in Box 24f (lines 1–6). Enter total charges for the services (i.e., total of all charges in 24F). Enter the number right justified in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in cents area if the amount is a whole number.
Box Number: 29 - Amount Paid
Where this populates from: Billing Info > Billing Preferences > switch Amount Paid - fill-in amount paid by patient for services to Yes and fill in the amount. This will auto-fill from payment received/applied.
Description: Indicates the payment received from the patient or other payers. Enter total amount the patient and/or other payers paid on the covered services only. Enter the number right justified in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in cents area if the amount is a whole number.
Box Number: 30 - Balance Due
Where this populates from: Total charge minus balance due that is listed on the CMS-1500 form.
Box Number: 31 - Signature of Physician or Supplier
Where this populates from: Name in My Account & the Date of Service - or - Clinic Settings then Clinic Staff and click Details to the right to the Practitioner's name.
Box Number: 32 - Service Facility Location Information
Where this populates from: Clinic Settings > Locations & Rooms > Edit Location
Description: Indicates the name and address of facility where services were rendered identifies the site where service(s) were provided. Enter the name, address, city, state, and ZIP code of the location where the services were rendered.
Box Number: 32a
Where this populates from: Clinic Settings > Locations & Rooms > Edit Location > Service Facility NPI
Box Number: 32b
Where this populates from: cannot be modified within Unified Practice
Description: Indicates the non-NPI ID number of the service facility as assigned by the payer for the facility. Enter the 2-digit qualifier identifying the non-NPI number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number.
Box Number: 33a - Billing Information > Billing NPI
Where this populates from: Clinic Settings > Clinic Staff > Details -or- My Account if Use this NPI. is turned on.
Description: Indicates the HIPAA National Provider Identifier number. Enter the NPI number of the billing provider in 33a.
Box Number: 33b
Where this populates from: Billing Info > Billing Preferences > Group ID
Description: Indicates the payer-assigned unique identifier of the professional.