*** Effective Date: 9/15/2025
*** Master ***
"1500","Standard 1500 (Baseline) 09/15/25","1500        ","N"
*** Option ***
"1","0","1500","LOC_1","1","6"," ","0","6","N","Box  1 - Insurance Type","Select Appropriate Data Source","Y",""
"1","1","1500","LOC_1A","88","1"," ","0",""," ","Box  1a - Insured's ID Number","","Y",""
"2","0","1500","LOC_2","30","1","Y","0","","N","Box  2 - Patient's Name",""," ",""
"3","0","1500","LOC_3","32","1","Y","0",""," ","Box  3 - Patient Birth",""," ",""
"3","1","1500","LOC_3A","33","1","Y","0",""," ","Box  3 - Patient Sex","This box does not allow for user options"," ",""
"3","2","1500","LOC_3B","1024","1","Y","0",""," ","Box 3 - Birth Date Year",""," ",""
"4","0","1500","LOC_4","30","1","F","0","","N","Box  4 - Insured's Name","","F",""
"5","0","1500","LOC_5","55","1"," ","0","","N","Box  5 - Patient's Address","","Y",""
"5","1","1500","LOC_5A","38","4"," ","0",""," ","Box  5a - Patient's Phone",""," ",""
"6","0","1500","LOC_6","86","1"," ","0",""," ","Box  6 - Patient Relation to Insured",""," ",""
"7","0","1500","LOC_7","54","1"," ","0","","N","Box  7 - Insured's Address","","Y",""
"7","1","1500","LOC_7a","39","4","Y","0",""," ","Box  7a - Insured's Phone",""," ",""
"8","0","1500","LOC_8","34","1"," ","0",""," ","Box  8 - Patient Status",""," ",""
"10","0","1500","LOC_10","118","1"," ","0",""," ","Box 10 - Patient Condition",""," ",""
"10","1","1500","LOC_10d","0","2"," ","12",""," ","Box 10d - Claim Codes",""," ",""
"11","0","1500","LOC_11","29","1"," ","0","","N","Box 11 - Insured's Policy Group",""," ",""
"11","1","1500","LOC_11c","66","1"," ","0",""," ","Box 11c - Insurance Plan Name",""," ",""
"11","2","1500","LOC_11d","118","1","N","0",""," ","Box 11d - Other Health Benefit Plan",""," ",""
"11","3","1500","LOC_11a","0","1","N","0",""," ","Box 11a - Insured's Date of Birth and Sex",""," ",""
"12","0","1500","LOC_12","43","1"," ","0",""," ","Box 12 - Patient's Signature",""," ",""
"13","0","1500","LOC_13","43","1"," ","0","","N","Box 13 - Insured's Signature",""," ",""
"14","0","1500","LOC_14","46","2","F","12","","N","Box 14 - Illness Onset Date and Qualifier","","Y",""
"15","0","1500","LOC_15","0","1"," ","0",""," ","Box 15 - Other Date",""," ",""
"17","0","1500","LOC_17","105","2"," ","2","","N","Box 17 - Name of Referring Physician","Enter Constant Value for Qualifier if Needed","Y",""
"17","1","1500","LOC_17a","103","1"," ","0","","N","Box 17b - Referring Physician ID","","Y",""
"17","2","1500","LOC_17b","0","2"," ","2",""," ","Box 17a - Referring Physician Additional ID and Qualifier","Enter Constant Value for Qualifier if Needed"," ",""
"19","0","1500","LOC_19","0","2"," ","60",""," ","Box 19 - Reserved",""," ",""
"20","0","1500","LOC_20","","1"," ","0",""," ","Box 20 - Outside Lab",""," ",""
"21","0","1500","LOC_21","99","1"," ","0","","N","Box 21 - Diagnosis Codes","","Y",""
"21","1","1500","LOC_21A","100","4"," ","0",""," ","Box 21 - Diagnosis Descriptions","","Y",""
"21","2","1500","LOC_21B","1","1","N","0",""," ","Box 21 - Diagnosis Version",""," ",""
"22","0","1500","LOC_22","0","2"," ","12",""," ","Box 22 - Resubmission Code",""," ",""
"22","1","1500","LOC_22A","0","2"," ","25",""," ","Box 22 - Original Ref No",""," ",""
"23","0","1500","LOC_23","13","1"," ","0","","N","Box 23 - Prior Authorization Number",""," ",""
"24","0","1500","LOC_24_ITEMIZATION","501","5"," ","0","  1X XV  2X XV  3X XV  4X XV  5X XV  6X XV  7X XV  8X XS  9X XV 10X XV 11X XV 12X XV 13X XV 14X XV 15X XV 16X XV","N","Box 24 - Itemizations","Select Modalities and Visits or Charges","Y",""
"24","1","1500","LOC_24_SORTING","1004","1","Y","0","","Y","Box 24 - Charge Sorting Options","Select Sort Order"," ",""
"24","2","1500","LOC_24_ITEM_CONSOLIDATION","1011","1","Y","0","","Y","Box 24 - Itemized Consolidation","Select Consolidation Option"," ",""
"24","3","1500","LOC_24_A","1023","1","Y","0",""," ","Box 24A - Dates of Service",""," ",""
"24","5","1500","LOC_24_B","1","2","F","2","12"," ","Box 24B - Place of Service","2 digit code based on institution, entered constant or bypass"," ",""
"24","6","1500","LOC_24_C","1","2"," ","2","1"," ","Box 24C - EMG/Type of Service",""," ",""
"24","7","1500","LOC_24_D","1018","1","F","0","","Y","Box 24D - CPT/HCPCS",""," ",""
"24","8","1500","LOC_24_D2","1020","1"," ","0",""," ","Box 24D - Modifier",""," ",""
"24","9","1500","LOC_24_E","0","2"," ","8",""," ","Box 24E - Diagnosis ",""," ",""
"24","10","1500","LOC_24_F","1031","1","Y","0",""," ","Box 24F - Charges Amount",""," ",""
"24","11","1500","LOC_24_G","0","4"," ","0",""," ","Box 24G - Days or Units",""," ",""
"24","12","1500","LOC_24_J","0","2"," ","20",""," ","Box 24I/J Top Line - Qualifier/ID",""," ",""
"24","13","1500","LOC_24_K","0","2"," ","10",""," ","Box 24J - Provider ID",""," ",""
"24","14","1500","LOC_24_DATA","500","4"," ","0","","N","Box 24 - Data Retireval (not Visible to end user)","","Y",""
"25","0","1500","LOC_25","17","1"," ","0","","N","Box 25 - Federal Tax ID","","Y",""
"26","0","1500","LOC_26","12","2"," ","15","","N","Box 26 - Patient Account No","","Y",""
"27","0","1500","LOC_27","74","1"," ","0",""," ","Box 27 - Accept Assignment",""," ",""
"28","0","1500","LOC_28","1016","1"," ","0",""," ","Box 28 - Total Charge",""," ",""
"29","0","1500","LOC_29","0","1"," ","0",""," ","Box 29 - Amount Paid",""," ",""
"30","0","1500","LOC_30","1033","1"," ","0",""," ","Box 30 - Balance Due",""," ",""
"31","0","1500","LOC_31","120","2"," ","25",""," ","Box 31 - Signature of Supplier",""," ",""
"31","1","1500","LOC_31A","0","1"," ","0",""," ","Box 31a - Signature Date",""," ",""
"32","0","1500","LOC_32","0","1"," ","0",""," ","Box 32 - Facility Information","","Y",""
"32","1","1500","LOC_32A","0","1"," ","0",""," ","Box 32a - NPI#/PIN#",""," ",""
"32","2","1500","LOC_32B","0","2"," ","15",""," ","Box 32b - Other code",""," ",""
"33","0","1500","LOC_33","10","7"," ","250","","N","Box 33 - Provider Name/Address/Phone","","Y",""
"33","1","1500","LOC_33A","0","1"," ","0",""," ","Box 33a - NPI#/PIN#",""," ",""
"33","2","1500","LOC_33B","0","2"," ","15",""," ","Box 33b - GRP#",""," ",""
"90","0","1500","LOC_90","117","1"," ","0","","N","Heading Area","","Y",""
"92","0","1500","LOC_92","0","1"," ","0",""," ","Claim ID Number",""," ",""
"100","0","1500","UNIT_FORMAT","2","4","Y","0","","N","Format - Punctuation (not used yet)",""," ",""
"101","0","1500","MONEY_FORMAT","5","1","Y","0","","N","Format - Money","Select Format for Dollar Values"," ",""
"102","0","1500","ZIP_CODE","0","1","Y","0",""," ","Format - Zip Code (Default 5 Digit)",""," ",""
"150","0","1500","SEL_INS","0","1"," ","250",""," ","Selected Insurances",""," ",""
*** Choice ***
"1","0","1500","11","1","Provider Information From Patient Unit"
"1","0","1500","10","2","Provider Information From Control File"
"1","1","1500","82","1","Claim Number From Current Insurance"
"1","1","1500","88","2","Contract Number From Current Insurance"
"2","0","1500","30","1","Patient Name"
"3","0","1500","32","1","Patient Birthday"
"3","1","1500","33","1","Patient Sex"
"3","2","1500","1024","1","Format date as MM DD YYYY"
"3","2","1500","1026","2","Format date as MM DD YY"
"4","0","1500","84","1","Guarantor Name"
"4","0","1500","30","2","Patient Name"
"5","0","1500","55","1","Patient Address"
"5","1","1500","38","1","Patient Phone Number"
"6","0","1500","86","1","Guarantor Relation to Patient"
"7","0","1500","54","1","Guarantor Address"
"7","1","1500","39","1","Guarantor Phone Number"
"8","0","1500","34","1","Patient Marital Status"
"10","0","1500","74","1","Employ/Auto/Other (No/Yes/No)"
"10","0","1500","118","2","Employ/Auto/Other (No/No/No)"
"10","0","1500","76","3","Employ/Auto/Other (Yes/No/No)"
"10","1","1500","1","1","Constant Value (Entered)"
"11","0","1500","29","1","Insurance Claim Number"
"11","0","1500","44","2","Insurance Group Code"
"11","1","1500","66","1","Current Insurance Name"
"11","1","1500","44","2","Insurance Group Code"
"11","2","1500","118","1","Constant (No)"
"11","2","1500","74","2"," Yes if secondary insurer found, else No"
"11","3","1500","32","1","Insured Birthday and Sex"
"12","0","1500","120","1","System Agency Representative Name"
"12","0","1500","43","2","Constant: SIGNATURE ON FILE"
"12","0","1500","118","3","Constant: SIGNATURE ON FILE (NO DATE)"
"13","0","1500","120","1","Agency Representative Name"
"13","0","1500","43","2","Constant: SIGNATURE ON FILE"
"14","0","1500","46","1","Diagnosis 1 Onset Date"
"14","0","1500","35","2","Patient Admit Date"
"14","0","1500","162","3","Patient Accident Date"
"15","0","1500","35","1","Patient Admit Date"
"17","0","1500","105","1","Physician Name"
"17","0","1500","56","2","Institution (First for this admit)"
"17","1","1500","110","1","Physician UPIN"
"17","1","1500","103","2","Physician Taxonomy"
"17","1","1500","109","3","Physician NPI "
"17","1","1500","104","4","Physician License"
"17","1","1500","56","5","Institution Provider # (First for this admit)"
"17","2","1500","1","1","Only Optional Qualifier "
"17","2","1500","103","2","Physician Taxonomy Plus Optional Qualifier"
"19","0","1500","95","1","Treatment Authorization"
"19","0","1500","1","2","Constant Value (Entered)"
"20","0","1500","74","1","Constant (Y)"
"20","0","1500","118","2","Constant (N)"
"21","0","1500","99","1","Patient Diagnosis Codes"
"21","0","1500","28","2","Patient Diagnosis Code (Primary)"
"21","0","1500","96","3","Treatment Plan Diagnosis Codes"
"21","1","1500","100","1","Patient Diagnosis Descriptions"
"21","1","1500","97","2","Treatment Plan Diagnosis Descriptions"
"21","2","1500","1","1","Print 0 or 9 Based on Diagnosis Version"
"22","0","1500","1","1","Constant Value (Entered)"
"22","1","1500","1","1","Constant Value (Entered)"
"23","0","1500","92","1","Treatment Auth w/Matching ID"
"23","0","1500","89","2","Treatment Auth Notes"
"23","0","1500","93","3","Treatment Auth For Modality in Auth Name"
"23","0","1500","95","4","Treatment Auth Code"
"23","0","1500","12","5","Patient Number"
"23","0","1500","13","6","Patient Medical Record Number"
"23","0","1500","44","7","Insurance Group Code"
"23","0","1500","29","8","Insurance Claim Number"
"24","1","1500","1004","1","Sort by Revenue-Code/Chg-Date/Chg-Code (default)"
"24","1","1500","1005","2","Sort by Chg-Date/Revenue-Code/Chg-Code"
"24","1","1500","1047","3","Sort by Authorization/Revenue-Code/Chg-Date/Chg-Code"
"24","2","1500","1013","1","Print Revenue Code/Date Consolidation (Use Rev-code/Chg-Date Sort)"
"24","2","1500","1011","2","Print Each Charge"
"24","2","1500","1012","3","Print Charge/Sequential Date Consolidation (Use Chg-Date/Rev-Code Sort)"
"24","2","1500","1017","4","Print Charge/Same Day Consolidation  (Use Chg-Date/Rev-Code Sort)"
"24","2","1500","1004","5","Print Revenue Code/Same Day Consolidation (Use Rev-code/Chg-Date Sort)"
"24","3","1500","1023","1","Charge From and To Service Dates"
"24","3","1500","94","2","Treatment Authorization Dates"
"24","5","1500","76","1","Service Location Based on Institution"
"24","5","1500","1","2","Constant Value (Entered)"
"24","6","1500","1","1","Constant Value (Entered)"
"24","6","1500","1036","2","Charge Modality Care Type Code"
"24","7","1500","1018","1","Charge Revenue Code"
"24","7","1500","1027","2","Charge CPT Code Number"
"24","7","1500","1022","3","Charge Revenue Code (Pos 1 - 4 Only)"
"24","8","1500","1021","1","Charge Revenue Description"
"24","8","1500","1020","2","Charge Description"
"24","8","1500","1035","3","Charge Revenue Other Code"
"24","9","1500","27","1","Patient Diagnosis Count"
"24","9","1500","1","2","Constant Value (Entered)"
"24","9","1500","28","3","Patient Diagnosis Code (Primary)"
"24","10","1500","1030","1","Charge Gross Amount (Selected Charges)"
"24","10","1500","1031","2","Charge Net Amount (Selected Charges)"
"24","12","1500","1038","1","Charge Employee Taxonomy With ZZ Qualifier"
"24","12","1500","74","2","Constant Value (Entered) With ZZ Qualifier"
"24","12","1500","1","3","Constant Value (Entered)"
"24","13","1500","1038","1","Charge Employee Taxonomy"
"24","13","1500","1020","2","Charge Description"
"24","13","1500","67","3","System NPI Number"
"24","13","1500","71","4","Insurance Provider Number"
"24","13","1500","1302","5","Unit NPI Number Based on Patient Unit"
"24","13","1500","1","6","Constant Value (Entered)"
"25","0","1500","17","1","Federal Tax ID"
"25","0","1500","19","2","Federal Tax ID From Unit Master"
"25","0","1500","18","3","Federal Tax ID Plus 3 Digit Suffix"
"26","0","1500","12","1","Patient Number"
"26","0","1500","13","2","Patient Medical Record Number"
"26","0","1500","23","3","Bill Date-Patient # as Invoice No"
"26","0","1500","1","4","Constant Value (Entered)"
"26","0","1500","74","5","Invoice Number (Bill Master ID)"
"27","0","1500","74","1","Constant (Y)"
"27","0","1500","118","2","Constant (N)"
"28","0","1500","1016","1","Print Total On Each Multi Page Bill"
"28","0","1500","1014","2","Print Total On Last Page After All Charges"
"29","0","1500","76","1","Constant 0.00"
"29","0","1500","77","2","Insurance Co-Pay Amount (Current Insurance)"
"30","0","1500","1033","1","Balance Due Charges (Page option same as Charge Total)"
"31","0","1500","120","1","System Agency Representative Name"
"31","0","1500","43","2","Constant: SIGNATURE ON FILE"
"31","0","1500","1","3","Constant Value (Entered)"
"31","1","1500","121","1","System Billing Date"
"31","1","1500","122","2","System Todays Date"
"32","0","1500","10","1","Provider Information From Control File"
"32","0","1500","55","2","Patient Name And Address"
"32","0","1500","56","3","Institution (First for admit)"
"32","0","1500","11","4","Unit Provider Information Based on Patient"
"32","1","1500","67","1","System NPI Number"
"32","1","1500","56","2","Institution Provider # (First for this admit)"
"32","1","1500","1302","3","Unit NPI Number Based on Patient Unit"
"32","2","1500","1","1","Constant Value (Entered)"
"33","0","1500","11","1","Provider Information From Patient Unit"
"33","0","1500","10","2","Provider Information From Control File"
"33","0","1500","105","3","Physician Name"
"33","0","1500","117","4","Insurance Name and Address (Cur-Ins)"
"33","0","1500","1","5","Constant Value (Entered)"
"33","1","1500","67","1","System NPI Number"
"33","1","1500","68","2","System Medicare Provider Number"
"33","1","1500","69","3","System Medicaid Provider Number"
"33","1","1500","71","4","Insurance Provider Number"
"33","1","1500","56","5","Institution Provider # (First for this admit)"
"33","1","1500","1302","6","Unit NPI Number Based on Patient Unit"
"33","2","1500","71","1","Insurance Provider Number"
"33","2","1500","1","2","Constant Value (Entered)"
"90","0","1500","117","1","Insurance Name & Address"
"90","0","1500","54","2","Guarantor Name And Address"
"92","0","1500","76","1","Claim ID Number"
"100","0","1500","3","1","Remove commas, dashs, and decimal points"
"100","0","1500","2","2","Allow commas, dashs, and decimal points"
"101","0","1500","4","1","Format Dollars with Decimal Space"
"101","0","1500","5","2","Format Dollars With Decimal Point"
"102","0","1500","1039","2","Format full 9 digit zip codes"
"150","0","1500","74","1","Store and Auto Select Insurances"
