TEXTFORMX) C:\Lytec20051500claim.txta =if "MSP" = "NEEDED" then "MSP" else "" endif`if "DELAY REASON CODE" = "NEEDED" then [Billing Custom Field 99] else "" endif/+ 5if "A" = "B" then "OZ" else "" endif5if "A" = "B" then "EL" else "" endif5 if "A" = "B" then "AC" else "" endifTif "PWK" = "NEEDED" then "Attachment Control Number" else "" endif+ I)if "A" = "B" then "SPECIAL AMBULANCE NOTE" else "" endif2+  5 36  @ 4B Hif "A" = "B" then "PATIENT WEIGHT ex 999" else "" endifUif "A" = "B" then "AMBULANCE TRANSPORT CODE - I R T X" else "" endif\if "A" = "B" then "Ambulance Transportation Code - A B C D E" else "" endifA if "A" = "B" then "Mileage - 9999" else "" endif5if "A" = "B" then "07" else "" endifSif "A" = "B" then "Condition or Response Code - Y N" else "" endif_if "A" = "B" then "Condition Indicator 1 - 01 through 09 and 60" else "" endif_if "A" = "B" then "Condition Indicator 2 - 01 through 09 and 60" else "" endif_if "A" = "B" then "Condition Indicator 3 - 01 through 09 and 60" else "" endif_if "A" = "B" then "Condition Indicator 4 - 01 through 09 and 60" else "" endif_if "A" = "B" then "Condition Indicator 5 - 01 through 09 and 60" else "" endifr+if [Primary Insurance Custom Field 1] = "" then "F" else [Primary Insurance Custom Field 1] endif<, 9 if "CORRECTED" = "NEEDED" then "CORRECTED"I if "CORRECTED" = "NEEDED" then "CLM-05-03" else "" endif: if "CORRECTED" = "NEEDED" then "ICN or REF"a+ if "Claim Office Number 2010BB" = "Needed" then "FY space NUMBER" else "" endiffgh imj'k-@3       %02m %02D %YE*F/ 1  <  G Z[Patient Last Name] " " [Patient First Name] " " [Patient Middle Initial]q2[Primary Insured Last Name] " "[Primary Insured First Name] " " [Primary Insured Middle Initial] n! o& p* q/ 2 \! if [Secondary Insurance Relation to Insured] = "18" then "X" else "" endif\& if [Secondary Insurance Relation to Insured] = "01" then "X" else "" endif\* if [Secondary Insurance Relation to Insured] = "19" then "X" else "" endif\/ if [Secondary Insurance Relation to Insured] = "G8" then "X" else "" endif  R# if [Patient Marital Status] = "S" then "X" else " " endifR) if [Patient Marital Status] = "M" then "X" else " " endif. if [Patient Marital Status] = "X" or [Patient Marital Status] = "D" or [Patient Marital Status] = "W" then " X" else " " endifL2 MJ   %CU# if [Patient Employment Status] = "F" then "X" else " " endifR) if [Patient Student Status] = "F" then "X" else " " endifR/ if [Patient Student Status] = "P" then "X" else " " endif 3  N4 O@ %C        ?3 G#H) P6%02m %02D %YODif [Primary Insured Sex] = "M" then "X" else " " endifOJif [Primary Insured Sex] = "F" then "X" else " " endif%02m %02D %YQif [Secondary Insured Sex] = "M" then "X" else " " endifQif [Secondary Insured Sex] = "F" then "X" else " " endif " U#if [Box - Auto Accident] = "X" then "X" else " X" endif.S3  V#if [Box - Other Accident] = "X" then "X" else " X" endifi3if [Primary Insurance Custom Field 1] = "C" then "" else [Primary Insurance Name] endifo pif [Secondary Insurance Custom Field 1] = "C" then [Medicare Secondary Reason] else " " endifU"if [Secondary Insurance Custom Field 1] = "G" then "BL" elseif [Secondary Insurance Custom Field 1]= "D" then "MC" elseif [Secondary Insurance Custom Field 1]= "C" then "MB" elseif [Secondary Insurance Custom Field 1]= "H" then "CH" elseif [Secondary Insurance Custom Field 1]= "E" then "OF" else "CI" endif%if [Secondary Insurance Type] = "D" then [Secondary Insurance Medigap ID] elseif [Secondary Insurance Payer ID 1] <> "" then [Secondary Insurance Payer ID 1] else "99999" endif^4if [Secondary Insurance Indicator] = "Y" then "X" else " X" endif# Signature on filet%%02m %02D %Y#8 Signature on filedif [Accident Date] <> "" then [Accident Date] else [Symptom Date] endif%02m %02D %Y$ 6%02m %02D %YD%02m %02D %Y}   |   ~- [Referring Physician Legacy 1]6%02m %02D %YD%02m %02D %YU if [Referring Physician Custom Field 1] = "2" then "2" else "" endifs if [Referring Physician Custom Field 1] = "2" then [Referring Physician Full Title] else "" endifC v! 0G4!if [Lab Charges] = "Y" then "X" else " " endifG9!if [Lab Charges] = "Y" then " " else "X" endif?!I#if [Insurance Code Set] = "0" then "10" else "09" endif-#[Claim Diagnosis 1 - ICD Code]-#[Claim Diagnosis 2 - ICD Code]-#[Claim Diagnosis 3 - ICD Code]-!#[Claim Diagnosis 4 - ICD Code]\.#if [Primary Insurance Type] = "E" then [Medicaid Resubmission Number] endifb=#if [Primary Insurance Type] = "E" then [Medicaid Original Reference Number] endif-$[Claim Diagnosis 5 - ICD Code]-$[Claim Diagnosis 6 - ICD Code]-$[Claim Diagnosis 7 - ICD Code]-!$[Claim Diagnosis 8 - ICD Code]-%[Claim Diagnosis 9 - ICD Code].%[Claim Diagnosis 10 - ICD Code].%[Claim Diagnosis 11 - ICD Code].!%[Claim Diagnosis 12 - ICD Code]$3% if [CLIA Number] = "" and [Provider Mammography Certification] = "" then [Primary Insurance Prior Authorization] elseif [CLIA Number] <> "" then "CLIA " [CLIA Number] elseif [Provider Mammography Certification] <> "" then "MM " [Provider Mammography Certification] endif&Nif "AMBULANCE PICKUP" = "NEEDED" and "PLACE OF SERVICE" = "41" then "PW 12345 STREET ADDRESS CITY ST ZIP+EXT" else "" endif'Nif "AMBULANCE DROPOFF" = "NEEDED" and "PLACE OF SERVICE" = "41" then "45 DROPOFFNAME 12345 STREET ADDRESS CITY ST ZIP+EXT" else "" endif%02m%02D%Y %02m%02D%YZ![#& 3 >if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endifF"O [Provider Legacy 1]i'if [Claim Detail - NDC Code] <> "" and [Claim Detail - NDC Unit Measurement] <> "" then "NDC N4 " [Claim Detail - NDC Unit Measurement] " "[Claim Detail - NDC Code] elseif [Claim Detail - NDC Code] <> "" and [Claim Detail - NDC Unit Measurement] = "" then "NDC N4 UN " [Claim Detail - NDC Code] else [Claim Detail - Custom Field 1] endif )  U&V+ c4 d>eH[         =  @  H ^  " _#  - .if [Facility Zip Code Plus 4] <> "" then [Facility Zip Code][Facility Zip Code Plus 4] else [Facility Zip Code] endift%02m %02D %y%02m %02D %y"?[Practice Legacy 1] B%        if [Supervising Physician Code] <> "" and [Supervising Physician Legacy 1] = "" then "UPIN" else [Supervising Physician Legacy 1] endifD*  if "Version" = "4010" and "EPSDT" = "Needed" then "Populate CLM-12 with 01, 02, 03, 05, 07, 08, or 09" else "" endifZ if "EPSDT" = "Y or N" then "Populate CRC-02" else [EPSDT Findings] endif if "EPSDT" = "Needed" then "Populate CRC-03" elseif [EPSDT Findings] = "N" then "NU" elseif [EPSDT Findings] = "Y" then [EPSDT Referral Code1] else "" endif if "EPSDT" = "Needed" then "Populate CRC-04" elseif [EPSDT Findings] = "N" then "" elseif [EPSDT Findings] = "Y" then [EPSDT Referral Code2] else "" endif if "EPSDT" = "Needed" then "Populate CRC-05" elseif [EPSDT Findings] = "N" then "" elseif [EPSDT Findings] = "Y" then [EPSDT Referral Code3] else "" endif ! E2 E _ Lc