Box 1 pulls from the Insurance Program in the Payor's Database for the payor on the patient's insurance policy. 

Box 1a pulls from the Member ID Number listed on the patient's insurance policy. 

Box 2 pulls from the Patient Name listed on the patient's record. 

Note: The patient name is pulled at the time a claim is generated. If a name was previously misspelled, the corrected name will appear on the claim, even if the purchase still shows the old spelling.

Box 3 pulls from the patient's Date of Birth and Sex listed on their record under the General tab. 

Box 4 is fueled by the name of the insured on the insurance policy. 

If the patient is the primary insured, the patient's name as it appears on the patient record will populate. 

If someone other than the patient is the primary insured, that person's name will populate as it appears in the patient's insurance policy. 

Box 5 pulls from the Street Address, City, State, and Zip Code entered in the General tab of the patient's record. 

Box 6 pulls from the Primary Insured field on the insurance policy. 

Box 7 pulls from the primary insured's address. 

If the patient is the primary insured, the patient's address as it appears in the General tab of patient record will populate. 

If someone other than the patient is the primary insured, that person's address will populate as it appears in the patient's insurance policy. 

ChiroUp will not populate Box 8.

Box 9 will only populate when Box 11d is marked Yes. 

Box 9 will pull from the Primary Insured's name on the additional policy listed on the purchase. 

If the patient is the primary insured, the patient's name as it appears on patient record will populate. 

If someone other than the patient is the primary insured, that person's name will populate as it appears in the patient's insurance policy. 

Box 9a will pull from the Plan ID or Group ID field on the other insurance policy on the purchase. 

ChiroUp will not populate Box 9b and 9c

 Box 9d is pulled from the Insurance Plan/Program Name on the other policy on the purchase. 

Box 10a, 10b, and 10c pulls Condition Related To: field in Claim Info, found within the Pointing section of the related encounter.

ChiroUp will not populate Box 10d.

Box 11 pulls from the Plan ID or Group ID on the patient's insurance policy.

Box 11a pulls from the primary insured's date of birth and sex. 

If the patient is the primary insured, the patient's Date of birth and Sex as it appears in the General tab of patient record will populate. 

If someone other than the patient is the primary insured, that person's Date of birth and Sex will populate as it appears in the patient's insurance policy. 

Box 11b is pulled from the Claim Number under Property & Casualty Claim Information in the patient's insurance policy. If a Claim Number is present, then the qualifier Y4 will also populate. 

Box 11c pulls from the Insurance Plan/Program Name on the insurance policy.

If there is more than one insurance policy on the purchase, then Yes will be checked. If there is only one insurance policy on the purchase, then No will be checked. 

Box 12 pulls from the Release of Patient Information setting on the patient's insurance policy. If this field is checked, then Signature on File will populate. 

Tip: You can set a default for this field in your Global billing settings. When you check Release of Patient information in your Global billing settings, all newly created insurance policies will default this field to be checked. 

Box 13 pulls from the Signature on File setting on the patient's insurance policy. If this field is checked, then Signature on File will populate. 

Tip: You can set a default for this field in your Global billing settings. When you check Signature on File in your Global billing settings, all newly created insurance policies will default this field to be checked. 

Box 14 pulls from the Onset of Current Symptoms or Illness field in Claim Info, found within the Pointing section of the related encounter.

Box 15 pulls from a variety of date fields in Claim Info, found within the Pointing section of the related encounter.

Below are the list of dates that may populate into Box 15, as well as their associated qualifier. 

• Initial Treatment - Qualifier 454 
• Latest Visit or Consultation - Qualifier 304
• Acute Manifestation of a Chronic Condition - Qualifier 453
• Accident - Qualifier 439 
• Last X-ray- Qualifier 455 
• Prescription - Qualifier 471
• Report Start (Assumed Care Date) - Qualifier 090 
• Report End (Relinquished Care Date) - Qualifier 091
• First Visit or Consultation - Qualifier 444 

Box 16 pulls from the Dates patient unable to work field in Claim Info, found within the Pointing section of the related encounter.

Box 17 pulls from the Referring Provider, Supervising Provider, or Ordering Provider field in Claim Info, found within the Pointing section of the related encounter.

• If Referring Provider, then Qualifier DN will populate.
• If Supervising Provider, then Qualifier DQ will populate.
• If Ordering Provider, then Qualifier DK will populate. 

Box 17a pulls from the ID number field under Provider Details in Claim Info (either Provider Commercial Number, UPIN Number, or State License Number). 

• If Provider Commercial Number, then Qualifier G2 will populate. 
• If UPIN Number, then Qualifier 1G will populate. 
• If State License Number, then Qualifier 0B will populate. 

Box 17b pulls from the Provider NPI field under Provider Details in Claim Info. 

Box 18 pulls from Hospital dates related to current services field in Claim Info, found within the Pointing section of the related encounter.

ChiroUp will not populate Box 19

Box 20 will always populate No. No charges will be recorded. 

Box 21 pulls from the Diagnosis codes listed on the purchase. The Qualifier 0 will always populate. 

Box 22 pulls from the Generation type. 

• If you are generating the claim for the first time, this field will be left blank. 
• If Generation type is Original, this field will be left blank.  
• If Generation type is Replacement, the Qualifier 7 will populate. 
• If Generation type is Void, then Qualifier 8 will populate. 

The Payor Claim Control # field will populate as the Original Ref. No. in Box 22. 

Box 23 pulls from either the Prior Authorization Number or Referral Number entered on the patient's insurance policy under their corresponding discipline benefit. 

Box 24a pulls from the Date of Service for each service code (only one DOS per claim form, listed for each service code). 

Box 24a pulls from the Place of Service for each service code (only one Place of Service per claim form, listed for each service code). Place of Service code is entered in Clinic Settings > Location. 

ChiroUp will not populate Box 24c.

Box 24d pulls from the service codes and their associated modifiers on the purchase. 

Box 24e pulls from the Diagnosis Pointing in the purchase. Each diagnosis code is assigned a letter in Box 21. Box 24e will display the assigned letter for each DX code in the order in which it has been pointed for each service code.

Box 24f pulls from the Billed Amount on each listed service code, multiplied by number of Units indicated.

Box 24g pulls from the Units indicated on each listed service code. 

Box 24h pulls from the EPSDT referral field in Claim Info, found within the Pointing section of the related encounter.

• If Yes, then the Qualifier Y will populate. 
• If No, then the Qualifier N will populate.
• If Available - Not Used, then the Qualifier AV will populate.
• If Under Treatment, then the Qualifier S2 will populate. 
• If New Service Requested, then the Qualifier ST will populate. 
• If Not Used, then the Qualifier NU will populate.
• If Not Applicable, then no Qualifier will populate. 

Box 24i will populate the Qualifier ZZ if there is a taxonomy code saved for the rendering provider. 

Box 24j pulls from the rendering provider's Taxonomy code and NPI number. This is entered in ChiroUp under Clinic Settings > Users > Billing for the rendering provider. 

Box 25 pulls from the Tax ID and Tax ID Type in the associated Billing Profile. Access this information in ChiroUp under Clinic Settings > Billing > Profiles. 

Box 26 pulls from the Account Number listed under the General tab of the patient's record. 

Box 27 pulls from the Accept Assignment setting on the patient's insurance policy. If this field is checked, then Yes will populate as checked. If the Accept Assignment field is not checked on the insurance policy, then Box 27 will check the No field. 

Tip: You can set a default for this field in your Global billing settings. When you check Accept Assignment in your Global billing settings, all newly created insurance policies will default this field to be checked. 

Box 28 pulls from the total Billed Amount for all of the service codes on the purchase (Billed amount multiplied by units). 

Box 29 pulls from any existing patient and payor payments on the purchase. 

ChiroUp will not populate Box 30.

Box 31 will populate with Signature on File and the date in which the claim was generate will populate. 

Box 32 pulls from the Clinic Location Address which can be accessed in Clinic Settings > Locations within ChiroUp. The Street Address, City, State, and Postal Code will only populate in Box 32 if it is different than the address entered in Box 33. 

Box 32a pulls from the NPI Number entered for the clinic location, accessible in Clinic Settings > Locations. 

ChiroUp will not populate Box 32b.

Box 33 pulls from the associated Billing Profile details - Name, Street Address, City, State, Postal Code, and Phone Number. 

See the associated billing profile on the purchase: 

See billing profile details in Clinic Settings > Billing > Profiles. 

Box 32a pulls from the NPI Number entered for the associated Billing Profile, accessible in Clinic Settings > Billing > Profiles. 

ChiroUp will not populate Box 33b.