TEXTFORMX) C:\Lytec20051500claim.txta -if "MSP" = "NEEDED" then "MSP"`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 "" endift+if [Primary Insurance Custom Field 1] <> "" then [Primary Insurance Custom Field 1] else "F" 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 "" endifD9if "TYPE OF BILL" = "TYPE OF BILL" then "861" 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 Custom Field 1] = "D" then [Secondary Insurance Medigap ID] elseif [Secondary Insurance Custom Field 1] <> "" then [Secondary Insurance Custom Field 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_6_9_<_?_A}   |   ~- [Referring Physician Legacy 1]6%02m %02D %YW?if [Hospital Admission Date] <> "" then [Billing Custom Field 6] endifWAif [Hospital Admission Date] <> "" then [Billing Custom Field 7] endifD%02m %02D %YM if [Referring Physician Custom Field 1] = "2" then "2" endifj if [Referring Physician Custom Field 1] = "2" then [Referring Physician Full Title] 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] endifa&if "NEEDED" = "OCCURENCE CODE 31A" then [Billing Custom Field 99] else "" endifk&if "NEEDED" = "OCCURENCE DATE 31A" then [Billing Custom Field 99] else "" endif%02m%02D%Ya&if "NEEDED" = "OCCURENCE CODE 32A" then [Billing Custom Field 99] else "" endifk&if "NEEDED" = "OCCURENCE DATE 32A" then [Billing Custom Field 99] else "" endif%02m%02D%Ya&if "NEEDED" = "OCCURENCE CODE 33A" then [Billing Custom Field 99] else "" endifk&if "NEEDED" = "OCCURENCE DATE 33A" then [Billing Custom Field 99] else "" endif%02m%02D%Ya(&if "NEEDED" = "OCCURENCE CODE 34A" then [Billing Custom Field 99] else "" endifk,&if "NEEDED" = "OCCURENCE DATE 34A" then [Billing Custom Field 99] else "" endif%02m%02D%Y[7&if "NEEDED" = "VALUE CODE 1" then [Billing Custom Field 99] else "" endifg;&if "NEEDED" = "VALUE AMOUNT 1" then [Billing Custom Field 99] else "" endif%02m%02D%Y[D&if "NEEDED" = "VALUE CODE 3" then [Billing Custom Field 99] else "" endifgH&if "NEEDED" = "VALUE AMOUNT 3" then [Billing Custom Field 99] else "" endif%02m%02D%Ya'if "NEEDED" = "OCCURENCE CODE 31B" then [Billing Custom Field 99] else "" endifk'if "NEEDED" = "OCCURENCE DATE 31B" then [Billing Custom Field 99] else "" endif%02m%02D%Ya'if "NEEDED" = "OCCURENCE CODE 32B" then [Billing Custom Field 99] else "" endifk'if "NEEDED" = "OCCURENCE DATE 32B" then [Billing Custom Field 99] else "" endif%02m%02D%Ya'if "NEEDED" = "OCCURENCE CODE 33B" then [Billing Custom Field 99] else "" endifk'if "NEEDED" = "OCCURENCE DATE 33B" then [Billing Custom Field 99] else "" endif%02m%02D%Ya('if "NEEDED" = "OCCURENCE CODE 34B" then [Billing Custom Field 99] else "" endifk,'if "NEEDED" = "OCCURENCE DATE 34B" then [Billing Custom Field 99] else "" endif%02m%02D%Y[7'if "NEEDED" = "VALUE CODE 2" then [Billing Custom Field 99] else "" endifg;'if "NEEDED" = "VALUE AMOUNT 2" then [Billing Custom Field 99] else "" endif%02m%02D%Y[D'if "NEEDED" = "VALUE CODE 4" then [Billing Custom Field 99] else "" endifgH'if "NEEDED" = "VALUE AMOUNT 4" then [Billing Custom Field 99] else "" endif%02m%02D%YO(if "CONDITION CODE BOX 18" = "NEEDED" then "XX" else "" endifO(if "CONDITION CODE BOX 19" = "NEEDED" then "XX" else "" endifO(if "CONDITION CODE BOX 20" = "NEEDED" then "XX" else "" endifO (if "CONDITION CODE BOX 21" = "NEEDED" then "XX" else "" endifO (if "CONDITION CODE BOX 22" = "NEEDED" then "XX" else "" endifO(if "CONDITION CODE BOX 23" = "NEEDED" then "XX" else "" endifO(if "CONDITION CODE BOX 24" = "NEEDED" then "XX" else "" endifO(if "CONDITION CODE BOX 25" = "NEEDED" then "XX" else "" endifO(if "CONDITION CODE BOX 26" = "NEEDED" then "XX" else "" endifO(if "CONDITION CODE BOX 27" = "NEEDED" then "XX" else "" endifO(if "CONDITION CODE BOX 28" = "NEEDED" then "XX" else "" endif%02m%02D%Y %02m%02D%YZ![#&+ 6if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endif>"G [Provider Legacy 1]i'((  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"?[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 ; Lif "CORRECTED" = "NEEDED" then "DESCRIPTION"