Additional Claim Information

Information regarding accident and illness can be entered in the Additional Claim Information section. This can be either collapsed or expanded by using the +/- icon located in the top right corner of the window.

Note: This section will be collapsed by default, as it is less frequently used.

To fill in Additional Claim Information:

1.Select the Type of Accident using the drop-down menu.
2.Enter the Date of Accident.
Note: All dates in this section can also be selected from the Calendar by clicking the INSYNC~1_img29 icon.
3.Select the State where the accident took place using the drop-down menu.
4.Enter the Current Illness Date.
5.Enter the past illness date (Date patient had same illness).
6.Enter the date range the Patient was Unable to Work, if applicable.
7.Enter the Admission and Discharge dates, if applicable.
8.Enter the Date Last Seen.
9.Enter the Initial Treatment Date.
10.Click in the Generate Claim radial button to indicate whether or not you want to generate a claim from this charge. The selection is defaulted to “Yes.”
Note: If “No” is selected, the charge will not appear in the Claims Processing queue.
11.Enter additional claim information, if necessary, in the Reserved for Local Use box.
Note: This information will appear in Field 19 on a claim form.
12.Select the Outside Lab check box to indicate services provided by an outside lab.
Note: This corresponds to box 20 on an HCFA/CMS-1500 form.
13.Select the delay reason using the drop-down list.
14.Select the Medicaid Special Program Indicator from the drop-down list.
15.Enter the Referral Number.