Understanding your ChiroTouch-Generated CMS 1500 Health Insurance Claim Form
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- Kathleen Barnett
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1 Understanding your ChiroTouch-Generated CMS 1500 Health Insurance Claim Form Click on any box on the claim form below for a guide to entering this information into ChiroTouch. ChiroTouch cannot advise you of what information goes into any box on the claim form, as state-to-state and insurance company to insurance company requirements vary. This document is to be used as a map that will show you where to input the information as it populates on your 1500 HCFA Claim Form..
![Box 1 Policy Information for HCFA Form Box 1 can be found on the Insurance screen of the ChiroTouch Basic application. 1. From the Patient Flow screen, click [Pat Mgmt]. 2.](/docs-images/78/76843892/images/2-1.jpg "Select a patient from the list, and click [Insurance]. 3. Select the information to be placed in HCFA Form Box 1 from the drop down menu. Box 2, 3, 5, and 8 Back to Top 1.")
2 Box 1 Policy Information for HCFA Form Box 1 can be found on the Insurance screen of the ChiroTouch Basic application. 1. From the Patient Flow screen, click [Pat Mgmt]. 2. Select a patient from the list, and click [Insurance]. 3. Select the information to be placed in HCFA Form Box 1 from the drop down menu. Box 2, 3, 5, and 8 Back to Top 1. From the Patient Flow screen, click [Pat Mgmt]. 2. Select a patient from the list, and click [Pat. Info]. Page 2
3 These HCFA Form boxes can be found on the Patient Information screen here: Box 4, 6, 7, 11 Back to Top Boxes 4,6,7 and 11 refer to the insured s information. In some instances, this information may be the same as the patient information in boxes 2,3,5, and 8. In other instances, these boxes will pertain to the primary insured on the account (whether it be the parent, spouse, etc). 1. From the Patient Flow screen, click [Pat Mgmt]. 2. Select a patient from the list, and click [Insurance]. 3. From the Insurance page, select the Insured's / Other Insured's Information screen. Page 3
4 Enter the insured s information here. If the insured's information is the same as the patient information, you can copy the information by clicking [Copy Patient's Info]. Page 4
5 Box 9 Back to Top Box 9 references a secondary insurance policy. If you do not regularly input information into Box 9 on your claim form, this area may remain clear. If you regularly use Box 9 on your claim form, here you will enter the insured s information (either spouse, parent, or patient information) to inform the insurance company that this patient has a secondary insurance. If the patient has a secondary insurance plan, be sure to mark box 11-d on this Insured's / Other Insured's Information screen. 1. From the Patient Flow screen, click [Pat Mgmt]. 2. Select a patient from the list, and click [Insurance]. 3. From the Insurance page, select the Insured's / Other Insured's Information screen. Page 5
6 4. Be sure to mark 11-d, and then enter information into Box 9. Page 6
7 Box 10 Box 10 explains if the patient's condition is related to an auto accident, work injury, or any other accident. 1. From the Patient Flow screen, click [Patient Mgmt]. 2. Select your patient from the list and click [Pat. Info]. 3. Select the Condition tab. If the condition is related to an injury, select the appropriate box. If the condition is related to an auto accident, select the state where the accident occurred. If no box is selected, ChiroTouch will mark NO for these boxes on the HCFA claim form. Page 7
8 Box 14 Back to Top Box 14 refers to the Date of Current Illness. There are two places where this information is stored in ChiroTouch. The claim form pulls the Date of Current Illness from the patient's Diagnosis screen, which can be entered through the Front Desk or the Provider application. Through the Front Desk application: 1. From the Patient Flow screen, click [Patient Mgmt]. 2. Select your patient from the list and click [Dx]. You will see the date of Current Illness Box on the lower left hand corner of the Diagnosis screen. Page 8
9 3. To change the Date of Current Illness, single-click on the black box behind the date to assign a specific date. A calendar will appear, allowing you to select the exact date. 4. Select the date and click [OK] to apply a specific date. Once you have applied the Date of Current Illness, ChiroTouch will prompt you to confirm that you want to change this date. 5. Click [Yes] to confirm this change. Page 9
10 6. Click [Yes] to apply this Date of Current Illness to all future appointments for this patient. 7. If you would like to copy that Date of Current Illness and apply it to past appointments, Click [Copy]. From this dialog box, select the past appointments you would like to apply the Date of Current Illness to and click [OK]. 8. If the Date of Current Illness is gradual, select [Gradual]. Once applied, ChiroTouch will prompt you to confirm that you want to change this date. Page 10
11 9. Click [Yes] to apply the Gradual Date of Current Illness to all future appointments. Through the CT Basic Provider application: 1. Choose a patient from your patient list and click [Dx]. You will see the date of Current Illness Box on the lower left-hand corner of the Diagnosis screen. Page 11
12 2. To change the Date of Current Illness, single-click on the black box behind the date to assign a specific date. A calendar will appear, allowing you to select the exact calendar date. 3. Select the date and click [OK] to apply a specific date. Once you applied the Date of Current Illness, ChiroTouch will prompt you to confirm that you want to change this date. 4. Click [Yes] to confirm this change. Page 12
13 5. Click [Yes] to apply this Date of Current Illness to all future appointments for this patient. 6. If you would like to copy that Date of Current Illness and apply it to past appointments, Click [Copy]. From this dialog box, select the past appointments you would like to apply the Date of Current Illness to and click [OK]. 7. If the Date of Current Illness is gradual, click [Gradual]. Once applied, ChiroTouch will prompt you to confirm that you want to change this date. Page 13
![8. Click [Yes] to apply the Gradual Date of Current Illness to all future appointments. From the CT Premium Provider application 1. Select a patient by clicking [Sel].](/docs-images/78/76843892/images/14-2.jpg "The Date of Current Illness is found in the diagnosis section of the screen, underneath the diagnosis codes. 2.")
14 8. Click [Yes] to apply the Gradual Date of Current Illness to all future appointments. From the CT Premium Provider application 1. Select a patient by clicking [Sel]. The Date of Current Illness is found in the diagnosis section of the screen, underneath the diagnosis codes. 2. To change the date of current Illness, select the box pointed in the image above. Page 14
![A calendar will appear. 3. Once you choose the date of current illness, click [Select]. ChiroTouch will then ask you if you would like to use this date of injury for all future appointments. 4.](/docs-images/78/76843892/images/15-1.jpg "Click [Yes] to apply this Date of Current Illness to all future appointments. 5. If you would like to copy that Date of Current Illness and apply it to past appointments, Click [Copy].")
15 A calendar will appear. 3. Once you choose the date of current illness, click [Select]. ChiroTouch will then ask you if you would like to use this date of injury for all future appointments. 4. Click [Yes] to apply this Date of Current Illness to all future appointments. 5. If you would like to copy that Date of Current Illness and apply it to past appointments, Click [Copy]. From this dialog box, select the past appointments you would like to apply the Date of Current Illness to and click [OK]. Page 15
16 You may select one, some, or all appointments to apply the Date of Current Illness to. Click [OK] to apply. 6. If the Date of Current Illness is gradual, click [Gradual]. Once applied, ChiroTouch will prompt you to confirm that you want to change this date. 7. Click [Yes] to apply the Gradual Date of Current Illness to all future appointments. Page 16
17 The condition tab DOES NOT POPULATE THE DATE OF CURRENT ILLNESS ON THE CLAIM FORM. It is used as a reference point only. It can be found on the Conditions tab in your Patient s Information screen. 1. From the Patient Flow screen, click [Patient Mgmt]. 2. Select your patient from the list, and click [Pat. Info]. 3. Navigate to the Condition tab. Here you can enter the date of current illness or injury as a reference point. Page 17
18 Box Box 14 populates from the patient's Diagnosis screen for each appointment. Back to Top Box refers to whether the patient is unable to work; information regarding a referring physician if needed; if outside labs were performed, and gives a line for local use to enter text that is custom to that local claim form. All of these boxes can be found on the Condition tab. 1. From the Patient Flow screen, click [Patient Mgmt]. 2. Select your patient from the list and click [Pat. Info]. 3. Navigate to the Condition tab. Page 18
19 4. If this information is required for this patient, enter it on this tab. Back to Top Page 19
![Box 21 Box 21 references Diagnosis Codes which can be found in several places in ChiroTouch. In the Front Desk application: 1. From the Patient Flow screen, click [Patient Mgmt]. 2. Select your patient from the list and click [Dx].](/docs-images/78/76843892/images/20-1.jpg "This screen will give you chart notes for the day specified in the upper right hand corner, as well as the accompanying diagnosis codes. To add or change the diagnosis codes, click [Add/ Change Dx].")
20 Box 21 Box 21 references Diagnosis Codes which can be found in several places in ChiroTouch. In the Front Desk application: 1. From the Patient Flow screen, click [Patient Mgmt]. 2. Select your patient from the list and click [Dx]. This screen will give you chart notes for the day specified in the upper right hand corner, as well as the accompanying diagnosis codes. To add or change the diagnosis codes, click [Add/ Change Dx]. Page 20
![click [Post Diagnoses] to](/docs-images/78/76843892/images/21-2.jpg "apply them to the account.")
21 3. Once you have selected all of your Diagnosis Codes, click [Post Diagnoses] to apply them to the account. Page 21
22 From the CT Basic Provider application: 1. Choose the patient from your patient list and select Dx. Here you can apply diagnosis codes to the account in multiple ways: Page 22
23 Once you have chosen all of your diagnosis codes, select Post Diagnosis to apply them to your patient's account. From the CT Premium Provider application 1. From the CT Premium Provider application, pull up the patient's account to which you would like to post diagnosis codes. Page 23
24 From the All in One screen, you can apply diagnosis codes to the patient's account in several ways. Page 24
25 Box 22 Back to Top Box 22 is in reference to Medicaid patients for Medicaid Resubmission Codes and original reference numbers. This box can be found in the Insurance screen by going to patient management, selecting the patient, and selecting Insurance. Page 25
26 Box 23 Back to Top Box 23 is in reference to a Prior Authorization Number obtained from an insurance company. This box can be found in the Insurance screen by going to patient management, selecting the patient, and selecting Insurance Page 26
27 Box 24 A through I Back to Top Box 24 is where the charges for the account are listed. The 24-a box references the date of service. Boxes 24b-i reference the charge code specifically. Charges are entered in the Maintenance application of ChiroTouch. To add or edit charges: 1. Enter the Charges section of the Maintenance application. Page 27
28 Here you can edit the charges. Each charge has 2 rows of information associated with it, as described below. Page 28
![There are several ways to apply charges to the patient s account: Through the Front Desk application of ChiroTouch: 1. From the Patient Flow screen, click [Patient Mgmt]. 2.](/docs-images/78/76843892/images/29-1.jpg "Select your patient from the list and click [Ledger]. 3. Click [New], then click [Charge]. There are several ways to apply charges to the patient.")
29 There are several ways to apply charges to the patient s account: Through the Front Desk application of ChiroTouch: 1. From the Patient Flow screen, click [Patient Mgmt]. 2. Select your patient from the list and click [Ledger]. 3. Click [New], then click [Charge]. There are several ways to apply charges to the patient. See the screen shot below for a description of each method. Page 29
30 4. Once you have selected your charges, select Post Charges to apply the charges to the patients account. 5. From CT Basic Provider, Select the patient from your list and select Charges. There are several ways to apply charges to the patient's account. See the screen shot below for a description of each method. Page 30
31 6. Once you have selected your charges, select Post Charges to apply the charges to the patients account. Through the CT Premium Provider application Pull up the patient's account and enter the chart notes per usual. To enter charges, find the Charges section on your All-In-One screen. Page 31
32 There are several ways to apply charges to the patients account. See the screen shot below for a description of each method. Page 32
33 Box 24 J Back to Top Box 24 J references the Rendering Provider's ID Number. In most instances, this number is the provider's NPI Number. The NPI number can be accessed in the Providers section of the Maintenance application. Page 33
34 Box 24J is initially entered in the NPI box of the Providers information screen. Page 34
35 This box also populates box 33a on the CMS If the number in box 24J is specific to an insurance company and is not the NPI number, you can find an override field for these boxes in the Payor Information screen of the Maintenance application. 1. Select the Payor with specified information for Box 24J. Page 35
36 2. Select the Provider Pin column by clicking the [Click Here] button. 3. Enter the number specified by the insurance company into the appropriate box for the appropriate provider. Click [Exit] when complete. Page 36
37 4. Confirm that you would like to save your changes before exiting by clicking [Yes]. If Box 24J needs to be edited on a per account basis for any reason, you can find the override of the Provider NPI box and the Payor Information Override in the patient's Insurance Information screen. From the Patient Management screen in the Front Desk application: 1. Select the patient account that requires the specific information. 2. Click [Insurance]. 3. From the Insurance screen, click [Insured s/ Other Insured s Information]. Page 37
![4. Click [Billing Info] to bring up](/docs-images/78/76843892/images/38-2.jpg "the override section.")
38 4. Click [Billing Info] to bring up the override section. Back to Top Page 38
39 Box 25 Box 25 is the provider's federal Tax-Id or SSN. This information is entered in the Provider section of the ChiroTouch Basic Maintenance application. Box 26 If the SSN and Tax-Id boxes have values entered in them, ChiroTouch will populate the Tax Id number on the claim form. If you would like to use the SSN only, remove the Tax-ID number from this field in the Maintenance application. Back to Top Box 26 is the patient's account number in the ChiroTouch system. 1. From the Patient Flow screen, click [Patient Mgmt]. 2. Select your patient from the list and click [Pat. Info]. Page 39
40 The account numbers are unique to each patient file in ChiroTouch. You can assign your own account number to each person when entering the new patient information into the system, or ChiroTouch will assign an account number for you. Box 27 Back to Top Box 27 allows you to choose whether or not to accept assignment with that insurance company. This can be found in the Insurance screen by entering Patient Management, selecting the patient, and clicking [Insurance]. Page 40
41 ChiroTouch defaults to Accept Assignment automatically. If you do not wish to accept assignment, unselect this checkbox here. Box 28 Back to Top Box 28 is populated on a per claim form basis by adding the total of the charges in Box 24. There is not an option in ChiroTouch that affects this field. Box 29 Back to Top Box 29 calculates the amount paid by the patient. This field will read 0.00 if you are accepting assignment with the insurance company. If you are not accepting assignment, you can determine whether or not you would like the insurance company to see the amount paid by the patient. This setup affects all accounts in the ChiroTouch system and will also affect all accounts with clients for which you do not accept assignment with the insurance company. This setup can be found by going to the Billing/Statements/Reports tab from the Patient Flow screen. Page 41
42 From the Billing/Statements/Setup screen, click [Setup] in the lower right-hand corner of the screen. Page 42
43 Box 30 Back to Top Box 30 totals the amount due to your office from the insurance company. If you accept assignment, this will be the total of all charges from Boxes 24F (1-6). If you do not accept assignment, this amount will be zero. Box 31 Back to Top Box 31 allows for a signature of the physician with degrees and credentials. The name that populates in this form is initially entered in the Maintenance application of ChiroTouch. Enter the Providers section of the Maintenance application. The Line that signifies Full Name is where you will enter in the provider's name and credentials. Page 43
44 If a provider needs to specify the billing name as anything other than their full name in the provider section (e.g. if a provider is performing services under the guidance of another provider), an override can be found in the Maintenance application under Payor Information. Page 44
45 1. Select the payor which requires an override in box Select the Provider Pin column by clicking the [Click Here] button. 3. Enter the number specified by the insurance company into the appropriate box for the appropriate provider. Click [Exit] when complete. Page 45
46 4. Confirm that you would like to save your changes. When entering patient information in patient management, you have the option to choose which provider the patients charges will be billed under. 1. From the Patient Flow screen, click [Patient Mgmt]. 2. Select a patient from the list, and click [Pat. Info]. 3. In the Patient Information screen, select the billing provider from the drop-down menu. 4. Select <use Appointment Provider> to use the provider information of the provider who saw the patient for any date of service. Page 46
47 5. To specify a provider, select the name of the provider you would like to use from the drop down menu. 6. If you select a specific provider from this drop-down menu, that provider's name will appear on every claim form for this account, regardless of who provided services for the date of service on the claim form. ChiroTouch will always enter Box 31 as the provider's name. If you would like to indicate that the provider's signature is on file (by placing a line of text under the provider's name in Box 31 that reads on file ), enter the Billing/Statements/Reports tab from the Patient Flow screen. 7. From the Billing tab, click [Setup]. 8. Select the boxes outlined below to print On File in box 31 of your claim form. Page 47
48 Box 32 Back to Top Box 32 can be found on a per patient basis from the Patient Management screen. 1. From the Patient Flow screen, click [Patient Mgmt]. 2. Select a patient from the list, and click [Pat. Info]. 3. Navigate to the Condition tab. Page 48
49 Information for Box 32 can be entered here. 4. Customize this information for this particular account, click [Copy Billing Address] to input the billing address into this field, or select the Use Provider s Facility Address checkbox. 5. Set up a default to automatically load the address for all of your new patients by clicking [Setup] in the Patient Management screen. Page 49
50 6. Under New Patient Defaults select the address you would like to use. 7. Select Use Provider s Facility Address to automatically load the providers facility address. Page 50
51 To set up this address: 1. Log into the Maintenance application. 2. Enter the address to be used as the Facility Address for that provider. Page 51
52 If you select Copy Billing Address in the Setup screen of Patient Management, ChiroTouch will copy the billing address as it is entered in the section of the Maintenance application. 3. In the Options section, enter the Billing Address into the Billing Address (Box 33) box. Page 52
53 This billing address will also populate in Box 33 of your claim form. Box 32a and b Back to Top Box 32a references the Service Facility NPI Number. Box 32b references the Group Number specific to the insurance company. Both numbers can accessed in the in the Providers section of the Maintenance application. Page 53
54 Box 32a is initially entered in the Facility NPI box of the Provider s Information screen. Box 32b can be entered in the Providers information section; however, Box 32b is a per insurance group number, and it is not recommended to enter the group number into the Providers information screen. Page 54
55 If the number in Box 32a (just as Box 32b) is specific to an insurance company and is not the NPI number, you can find an override field for these boxes in the Payor Information screen in the Maintenance application. Use this section to enter information for Box 32b on a per insurance company basis. Page 55
56 1. Select the payor with specified information for Box 32a and b 2. Select the Provider Pin column by clicking the [Click Here] button. Page 56
57 3. Enter the number specified by the insurance company into the appropriate box for the appropriate provider. 4. When finished, click [Exit]. 5. Confirm saving your changes when prompted. If Box 32a or b needs to be edited on a per account basis for any reason, you can find the override of the Provider NPI box and the Payor Information override in the patient's Insurance screen. 1. From the Patient Management screen in the Front Desk application, select the patient account that requires the specific information. 2. Click [Insurance]. Page 57
58 3. From the Insurance screen, open the Insured s/ Other Insured s Information screen. 4. Click [Billing Info] to bring up the override section. Page 58
59 Box 33 Back to Top Box 33 asks for the billing provider's Info. The address in box 33 is found in the screen of the Maintenance application. Enter the billing address into the Billing Address (Box 33) section. Page 59
60 Box 33a and b Back to Top Box 33a references the billing provider s NPI Number. Box 33b references the physician s ID number specific to the insurance company. Both numbers can accessed in the Providers section of the Maintenance application. Page 60
61 Box 33a is initially entered in the NPI box of the Providers screen. The NPI box also populates box 24J on the claim form. Box 33b can also be entered here; however, Box 33b is a per insurance group number, and it is not recommended to enter the physicians ID number here in the Providers screen. If the number in Box 33a (just as Box 33b) is specific to an insurance company and is not the NPI number, you can find an override field for these boxes in the Payor Information section of the Maintenance application. Use this section to enter information for Box 33b on a per Insurance Company Basis. Page 61
62 1. Select the payor with specified information for Box 33a and b. 2. Select the Provider Pin column by clicking [Click Here]. Page 62
![3. Enter the number specified by the insurance company into the appropriate box for the appropriate provider. Click [Exit] when complete. 4.](/docs-images/78/76843892/images/63-1.jpg "Click [Yes] to confirm that you would like to save your changes.")
63 3. Enter the number specified by the insurance company into the appropriate box for the appropriate provider. Click [Exit] when complete. 4. Click [Yes] to confirm that you would like to save your changes. If Box 33a or b needs to be edited on a per account basis for any reason, you can find the override of the Provider NPI box and the Payor Information override in the patient's Insurance screen. 1. From the Patient Management screen on the Front Desk application, select the patient account that requires the specific information. Page 63
![2. Click [Insurance]. 3.](/docs-images/78/76843892/images/64-1.jpg "From the Insurance Screen, click [Insured s/ Other Insured s Information]. 4.")
64 2. Click [Insurance]. 3. From the Insurance Screen, click [Insured s/ Other Insured s Information]. 4. Click [Billing Info] to bring up the override section. Page 64
65 Back to Top Page 65
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