The Zanda claim form is designed to capture the claim information that will be used for printing the CMS-1500 form. This is also in preparation for generating an electronic claim submission via our clearing house integration which is under development.
Learn how to prepare your Zanda account for claiming here.
Tip 💡
The blue number next to a field label on a claim form indicates information that show both on the claim form and the matching block on the CMS-1500 form.
For example:
1. Information blocks on the claim form:
2. Information blocks on the CMS-1500 form with the same information:
How we are populating the Claim information
Insurance Section
- Payer
The claim Payer is populated from the insurer linked to the related client invoice.
The Name (0), Payer ID (1), Type of Health Coverage and Address are populated from the related Payer under Settings > Payments > Insurers.
- Insured
The Insured information is populated from the insurance linked to the invoice. The insurance information is filled in under the client profile (Client > Billing > Insurance).
The Insured's ID Number (1a), Policy Group or FECA Number (11) and Insurance Plan or Program Name (11c) are populated from the insurance linked to the invoice.
If the Primary Policy Holder is ‘Self’, the Name (4), Address, Date of Birth and Sex are populated from the client's profile. If the Primary Policy Holder is a contact, the Name (4), Address, Date of Birth and Sex are populated from the contact’s profile.
- Prior Authorisation
Prior Authorization Number is not pre-populated. This will be added in a future release.
Patient Information Section
- Patient Information Section
The Name (2),Date of Birth (3), Sex and Address (5) fields are populated from the client's profile. The Relationship to the Insured (6) is populated from the insurance linked to the invoice. This information is added under the client profile (Client > Billing > Insurance).
- Patient Condition Section
Important:
The Patient Condition fields are not pre-populated.
- Patient Authorisation Section
The values (12)(13) for this section are populated from the insurance linked to the invoice. The insurance details can be edited in Client > Billing > Insurance.When Client authorized release of information (12) is Yes, the Authorization Date is set to the date the claim is created.
Referring Provider Section
The Referring Provider Information is determined by the referral linked to the invoice.
The Referrer Qualifier is defaulted to “DN - Referring Provider”.The Name fields (17) and NPI Number (17b) are populated from the referral linked to the invoice.
The Other ID and Qualifier are not pre-populated.Diagnosis and Service Section
Diagnoses
The Diagnosis Codes (21) are pre-populated from any diagnosis codes linked to the invoice service items.
Diagnosis codes are populated in the order they appear on the invoice items. When a code is linked to more than one invoice service, only the first instance of the code is populated.
Services
Each invoice item will be listed as a service on the claim form:
- The From Date (24a) is populated from the invoice date.
- The To Date is not pre-populated.
- The Place of Service (24b) code is populated from the place of service code entered for the location linked to the invoice. The location code can be updated under Setting > Configuration > Locations.
- The CPT Code (24d) is populated from invoice item code. The service code can be updated under Settings > Billing > Services.
- The Description (24d) is populated from the name for invoice item service. The service name can be updated under Settings > Billing > Services.
- The Diagnosis Pointers (24e) are based on diagnosis codes linked to invoice item and numbered in relation to the codes pre-populated in the diagnosis codes section.
- The Charges (24f) are populated from the total amount for the line item.
- The Days/Units (24g) are populated from the QTY for the line item.
- The Rendering Provider Taxonomy and NPI (24j) are populated from data populated for the practitioner linked to the Invoice. If no taxonomy and NPI are provided for the practitioner (Settings > Team > Practitioners), the numbers will be populated from the Business Information (Settings > Practice > Business Info).
- The Total Charged (28) is calculated from the sum total of Charges (24f).
- The Total Paid (29) is calculated from the total of payments entered for the Invoice.
Biller Information Section
- General
The Federal Tax I.D. Number and Type (25) are populated from the practitioner linked to the invoice. If no Tax ID Numbers are provided for the practitioner (Settings > Team > Practitioners), the Tax ID will be populated from the Business Information (Settings > Practice > Business Info).
The Accepted Assignment value is populated from the client insurance linked to the invoice.
- Service Facility
The Service Provider or Facility Name (32), Address and Facility NPI (32a) are populated from the location linked to the invoice (Settings > Practice > Locations).
Billing Provider
- The billing provider Name (33) is populated from the Real Name field for the practitioner linked to the Invoice (Settings > Team > Practitioners).
- The billing provider Address (33) is populated from the address of the location linked to the invoice (Settings > Practice > Locations).
- The NPI, Taxonomy and SSN numbers (33a) and populated from the Business Information (Settings > Practice > Business Info). If no tax numbers are provided under the Business Information, the SSN number will be populated from the practitioner linked to the invoice.