how health insurance works assignment sheet

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How Health Insurance Works

Why America Relies on a Private Health Insurance Model

Why You Need Health Insurance

How to choose health insurance, why america relies on health insurance to pay for medical care, alternatives to health insurance, frequently asked questions (faqs).

The Balance / Britney Willson

Health insurance protects your assets from the high cost of medical care. But how it works can be complicated if you don't understand health insurance basics like what a deductible is, when copays apply, and how coinsurance works. Below we tackle these considerations and why health insurance is essential no matter how complicated it might seem.

Key Takeaways

• Health insurance is a necessity for most Americans who cannot afford to pay medical bills out of pocket.
• The cost of your health insurance premium is based on a combination of your copay, coinsurance, deductible, and maximum out-of-pocket costs.
• The current health insurance system doesn't allow equal access to healthcare for all Americans.
• Other countries use universal healthcare, but the Affordable Care Act only incorporates some aspects of that kind of system.

Health insurance is necessary for Americans to pay for the  high cost of healthcare . You generally need it unless you can afford to pay for healthcare on your own or receive government assistance. The very wealthy can afford the cost of even extraordinary emergency or chronic medical care. Those over age 65 usually qualify for Medicare. Lower-income individuals and families may qualify for Medicaid.

Everyone else must either purchase health insurance or risk medical bankruptcy . Since it is so common, many people have lost sight of its underlying purpose. It's just like insurance for your car, home, or apartment. It's supposed to protect your life savings from the devastating costs of a major accident, medical emergency, or chronic disease.

Unlike other insurance, health insurance makes it possible for you to get healthcare when you need it. If you don't have car insurance, you can take the bus until you can afford to get your car fixed. If you break your leg, you can’t splint it yourself until you save up enough to go to the doctor.

Health insurance companies provide lots of choices, options, but before you select a plan, you've got to wade through various combinations of deductibles, copays, coinsurance, and premiums. 

• Monthly premiums. Like auto or homeowners insurance, you pay this even if you never make a claim. That provides the cash flow so insurance companies can pay their day-to-day expenses.
• The  deductible . That's what you pay before the insurance company contributes a dime. It is an annual amount, which means you start over on Jan. 1 of each year if your plan has a calendar-year policy. Plans that renew at other times of the year might not follow the calendar year for resetting the deductible period.
• A copay for each visit. A typical copay might be $20 for a doctor visit, $50 for a hospital visit, and $10 to $40 for each prescription. You pay 100% for the visit until the deductible is met.
• Coinsurance. That’s a percent you pay for procedures, like surgeries, or hospital stays. If your doctor visits you in the hospital, you might pay a copayment for the visit and coinsurance for the hospitalization. 

Why do insurance companies charge deductibles, copays, and coinsurance? They want to keep you from running to the doctor for every sniffle. If healthcare were 100% free, their costs would skyrocket. The Affordable Care Act provided that these out-of-pocket costs for Marketplace plans can't exceed a maximum amount that is adjusted each year. For 2021, it was $8,550 for individuals and $17,100 for a family. For 2022, it is $8,700 for individuals and $17,400 for a family. After that, the insurance company pays 100%.  

All of these details make  picking health insurance  very complicated. You’ve got to be an odds-maker on your own health. For example, you might be willing to pay a higher monthly premium for a lower coinsurance percentage and/or deductible. That would make sense if you have a chronic disease, like diabetes, and know you’ll be in to see the doctor frequently.

On the other hand, people who are healthy might want the lowest premium possible and a  higher deductible . They are willing to take the chance of paying more for healthcare because they believe their risk is small. The lower the deductible, the higher the premium, copay, or coinsurance. As healthcare costs have grown, more people have opted for higher-deductible plans just to keep their monthly premiums affordable. Obamacare has not been able to correct this underlying flaw of the health insurance system.

Before World War II, most Americans had no health insurance. The policies that existed only covered the cost of the hospital room and board. After the war, the federal government instituted a wage freeze to curb inflation, but that meant companies couldn’t give raises to get the best employees. Instead, they offered benefits, including health insurance.

In 1954, the Internal Revenue Service made health insurance premiums non-taxable. That made an additional dollar of health insurance more valuable than a dollar of taxable salary. The Tax Policy Center estimates that this tax break alone increased the federal deficit by $273 billion in 2019, but politicians aren’t likely to get re-elected if they suggest removing it.

This tax break is like providing a government insurance subsidy for the upper-middle classes and the wealthy. The Tax Policy Center found that the average benefit of the health insurance tax break was about $254 for a hypothetical worker in the 12% tax bracket but $347 for those in the 22% tax bracket.  

Many countries have adopted universal healthcare . That's where the government pays for healthcare, just like it pays for education and defense. It's like expanding Medicare or Medicaid to everyone. When Canadians go to the doctor or the hospital, the government picks up most or all of the bill. The downside is that it may take a long time to see a specialist or receive a non-emergency operation. On the other hand, no one has to worry about dying from a disease because they can't afford treatment.

When Hillarycare tried to implement universal healthcare in America, the medical profession and health insurance companies defeated it. Obamacare was initially presented as universal healthcare, but different interest groups and politicians led to that goal being changed. 

Access to healthcare has become part of today's American Dream. Research has found that the higher your income, the better your health, on average. As a result, income inequality has led to healthcare inequality .

How much does health insurance cost?

The median annual health care cost for a single employee in 2020 was $1,440. For family coverage, an employee's median contribution was $5,700.

What is open enrollment for health insurance?

Unlike other products, health insurance can't be bought or exchanged whenever you feel like changing your coverage. For most people, the only chance you have to change your insurance coverage is during the "open enrollment period." If you don't take advantage of open enrollment, you'll only be able to change health insurance coverage with a qualifying life event .

Department of Health and Human Services. " Who Is Eligible for Medicare? "

Medicaid.gov. " Eligibility ."

Healthcare.gov. " Copayment ."

Healthcare.gov. " Out-of-Pocket Maximum/Limit ."

Health Affairs. " High-Deductible Health Plans ."

Congressional Research Service. " Health-Related Tax Expenditures: Overview and Analysis ," Pages 5-6.

Tax Policy Center. " How Does the Tax Exclusion for Employer-Sponsored Health Insurance Work? "

Urban Institute. " How Are Income and Wealth Linked to Health and Longevity? "

Bureau of Labor Statistics. " Medical Care Premiums in the United States, March 2020 ."

• Skip to main content
• How does health insurance work?
• Types of health insurance
• Open enrollment
• Medicaid renewal and redetermination

Understanding health insurance costs

• Common terms

Understanding health insurance

What is health insurance.

What is health insurance exactly? It’s talked about a lot — but how does it really work and why do we need it? Here’s a simple way to look at it: Health insurance is a plan, or policy, that covers a percentage of doctors’ visits and hospital bills. It exists to help offset the costs of medical events, whether they’re planned or happen unexpectedly. Health insurance may also protect us when we’re feeling good — and may help keep us feeling that way — through wellness programs and preventive care.

Even if you’re the picture of good health right now, you never know when you’re going to need health insurance. A car accident, an injury, a cancer diagnosis — those don’t come with warnings. Not having health insurance is a risk, not only for the preservation of your health, but also your financial security. 1

Health insurance is a contract between you and your insurance company/insurer. When you purchase a plan, you become a member of that plan, whether that’s a Medicare plan , Medicaid plan , a plan through your employer or an individual policy , like an Affordable Care Act (ACA) plan .

There are many reasons to have health insurance. One reason is that it may give you peace of mind that you’re covered in case unexpected medical expenses happen. Knowing the details of how health insurance works can be an advantage when you’re deciding which plan is right for you.

• What are the different types of health insurance?

There are different types of health insurance plans to fit different needs. Some types of health insurance include government plans like Affordable Care Act (ACA) plans — which can also be called Marketplace or Exchange plans — Medicare plans and Medicaid plans. Before you choose a plan during open enrollment , it may help to review the various types of plans to get a better understanding of which type of health insurance may work best for you.

Health insurance open enrollment

Open enrollment is a special period of time when you get to start, stop or change your health insurance plan. This period most often happens once a year (unless you undergo a qualifying life event ). There are different enrollment periods depending on if you have insurance through your employer, Medicare or an ACA plan.

Medicaid eligibility renewal — and how to stay covered

If you've been asked to renew your Medicaid eligibility, you may be asking, what should I do next? We're here to help. Learn about Medicaid redetermination — also called Medicaid renewal or recertification — and find out how to stay covered if your Medicaid coverage is changing.

Having insurance doesn’t mean your health care will be free. You’ll still pay a monthly rate, or premium. Members may also pay copayments — or other out-of-pocket fees — or have to meet deductibles every year before insurance coverage kicks in.

Different factors can affect your health insurance costs. It’s important to understand what these costs are before selecting a plan.

Common health insurance terms

Deductibles, premiums, network, claims, benefits — what do all these words actually mean? Health insurance practically seems to have a language of its own. To make it easier, you can check out our list of common terms and get quick definitions that help explain what they mean — in everyday language.

More like this:

• What's a deductible?

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Insurance Unit

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INTERACTIVE: Shady Sam

Unit 8: Unit Plan & Assessments

Unit assessment, insurance 101.

Students will be able to

• Illustrate how everyone risks financial loss and how insurance shares that risk
• Identify factors that impact insurance premiums and the relationship between premiums, deductibles, and coverage limits
• Explain how the insurance industry uses risk pooling and math to provide insurance coverage and make a profit

Auto and Renters Insurance

• List factors that determine auto insurance premiums
• Understand the different types of coverage within a car insurance policy 
• Explain a deductible, out-of-pocket expenses, and what insurance will pay for in different situations
• Identify the value of their possessions and explain how renters insurance can help protect them in the case of emergency or loss

How Health Insurance Works

Students will be able to: 

• Understand the importance of having health insurance 
• Identify the various costs affiliated with having health insurance 
• Explain how health insurance works and the different types of plans available to them 
• Explore steps they can take to lower their medical costs

How to Access Health Insurance

Students will be able to:

• Explain the pros and cons of enrolling in employer-sponsored health plans vs individual plans from the Marketplace
• Explore the specific coverage areas and benefits of healthcare.gov Marketplace plans
• Understand how government healthcare programs like Medicaid, CHIP, and Medicare work and who qualifies for them 
• Investigate health insurance policies and eligibility in their states

Intro to Insurance

Auto insurance.

• Describe the main types of auto insurance policies and compare state requirements 
• Choose an appropriate level of car insurance coverage

Renters & Homeowners Insurance

• Distinguish the similarities and differences between renters and homeowners insurance
• Read the fine print of a rental insurance agreement 
• Assess whether they will need renters insurance after high school
• Appreciate why it is valuable to have insurance, regardless of whether you own or rent a home
• Enumerate what types of perils are and are not covered by standard renters and homeowners insurance policies

Other Types of Insurance

• Explain how pet insurance works and how it compares to human health insurance
• Differentiate between short- and long-term disability insurance
• Decide when a life insurance policy is appropriate and how to select the best type for their needs
• COMPARE: Car Insurance Comparison Shopping
• COMPARE: Select an Insurance Plan
• COMPARE: Types of Health Insurance Plans
• DEBATE: Should the Government Be Allowed to Require Insurance?
• FINE PRINT: Auto Insurance Declaration Page
• FINE PRINT: Health Benefits Form
• FINE PRINT: Renters Insurance Agreement
• INTERACTIVE: Bummer!
• MOVE: What Determines Your Insurance Premium?
• PLAY: Types of Car Insurance
• PLAY: Will Their Auto Insurance Premium Change?
• PROJECT: Introducing Insurance - You Be The Teacher
• RESEARCH: Insurance in Your State

CASE STUDIES

• CASE STUDY: Fender Bender Frenzy!
• CASE STUDY: Like a Good Neighbor, Noelle Is There

FINCAP FRIDAYS

• Puzzling Prescription Prices
• Protect Your Pay
• When Water Does Damage
• Unsure of Insurance
• Healthcare Haste
• Drive Well, Pay Less
• Campfire Tales

QUESTIONS OF THE DAY

• How long will most driving violations affect your car insurance rates?
• How much does a speeding ticket increase the annual cost of car insurance?
• How much does a texting while driving ticket increase auto insurance premiums?
• How much does an average overnight hospital stay cost?
• Until what age can a child stay on their parents' health insurance?
• What GPA is required to earn a Good Student Discount on an auto insurance policy?
• What percent of American adults are carrying medical debt?

DATA CRUNCH + MATH

• DATA CRUNCH: How Do Americans Get Health Insurance?
• DATA CRUNCH: How Do Renters and Homeowners Insurance Compare?
• DATA CRUNCH: How Does the Cost of Health Insurance Premiums Vary by Age?
• DATA CRUNCH: How Many Adults Lack Health Insurance?
• DATA CRUNCH: How Much Do Auto Insurance Rates Vary by Age?

Assessments and Answer Keys

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ANSWER KEY ACCESS

• Getting Started Tutorials
• My Unified Practice Account
• My Unified Practice Subscription
• System Requirements
• Imports & Patient Data
• University Account
• Essential Knowledge
• Receive, Void, & Edit Payments
• Managing a Patient's Credit
• Card Capture for Policy Enforcement & UnifiedPay
• Insurance Billing Workflow
• Claim Forms
• Office Ally Integration
• Billing Reports & Statements
• Manage Your Forms
• The Onboarding Process - Patient Perspective
• Health Screening Forms
• Scheduling Appointments
• Online Booking
• Calendar FAQs
• Flex Scheduling
• Desktop Charting
• iPad App Features
• iPad Charting
• Email Notifications
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• Billing & Payments

CMS-1500 Claim Form Cheat Sheet

Here is a breakdown of each box on the cms-1500 and where they populate from within your unified practice account..

Jump to: 

• Boxes #1 through #13
• Boxes #14 through #23
• Box #24a-#24j
• Boxes #25 through #33b

Box Number: 1 - Insurance Name Where this populates from: Billing Info > Billing Preferences > Insurance Type Description: Where the type of health insurance coverage applicable to this claim is selected. There are seven plan types to select from, by checking the appropriate box. Only one plan type is allowed to be selected.

Box Number: 1a - Insured’s ID Number Where this populates from: Patient File > Insurance tab > Card Info, ID on Card (patient can fill this out during onboarding if you are accepting insurance info). Description: Where the insured's ID number is entered as shown on their ID card for the payer to which the claim is being submitted. 

Box Number: 2 - Patient’s Name Where this populates from: Personal tab of Patient File Description: Where the patient's full name is entered as Last Name, First Name, Middle Initial , separated by commas.

Box Number: 3 - Patient’s Birthdate and Sex Where this populates from: Personal tab of Patient File Description: Where the patient's 8-digit birth date is entered in the format MMDDYYYY. As well, the appropriate box should be marked indicating the sex (gender) of the patient. Only one box can be marked.

Box Number: 4 - Insured’s Name Where this populates from: Personal tab of Patient File OR if covered under someone else, Patient File > Insurance Tab > Card Info > ID on Card (patient can fill this out during onboarding if you are accepting insurance info). Description: Where the insured's full name is entered as Last Name, First Name, Middle Initial , separated by commas.

Box Number: 5 - Patient’s Address Where this populates from: Personal tab of Patient File Description: Where the patient's address information is entered. This is the patient's permanent residence. The first line is for the street address. The second line is for the city and state. The third line is for the zip code and phone number.

Box Number: 6 - Patients relationship to Insured Where this populates from: Insurance tab of the Patient File (If "Covered under someone else's insurance plan?" is switched to Yes OR patient can fill out during onboarding). Description: Where the patient's relationship to the insured is entered. Only one box can be marked.

Box Number: 7 - Insured Address Where this populates from: Personal tab of Patient File OR Patient File >   Insurance Tab > Insured under someone else fields. Description: Where the patient's address information is entered. This is the patient's permanent residence. The first line is for the street address. The second line is for the city and state. The third line is for the zip code and phone number.

Box Number: 8 - Reserved for NUCC Use Where this populates from: can not be modified within Unified Practice Description: Reserved field. It was previously used to report Patient Status. Patient Status no longer exists, so this field has been eliminated.

Box Number: 9 - Other Insured’s Name Where this populates from: Insurance tab must have Primary/Secondary/other insurance info filled out. Then in Billing Info > Billing Preferences , select Primary and Secondary insurances from the drop-down boxes. Description: Indicates that there is a holder of another policy that may cover the patient. The insured's name is entered as Last Name, First Name, Middle Initial, separated by commas. If Box 11d is marked, complete boxes 9, 9a, and 9d, otherwise leave blank.

Box Number: 9a - Other Insured's Policy or Group Number Where this populates from: Insurance tab must have Primary/Secondary/other insurance info filled out. Then in Billing Info > Billing Preferences , select Primary and Secondary insurances from the drop-down boxes. Description: The other insured's policy or group number as it appears on the insured's health care identification card for secondary insurance. If Box 11d is marked, complete boxes 9, 9a, and 9d, otherwise leave blank. 

Box Number: 9b - Reserved for NUCC Use Where this populates from: can not be modified within Unified Practice Description: Box 9b is now a reserved field. It was previously used to report Other Insured's Date of Birth, Sex . Other Insured's Date of Birth, Sex no longer exists, so this field has been eliminated.

Box Number: 9c - Reserved for NUCC Use Where this populates from: can not be modified within Unified Practice Description: Box 9c is now a reserved field. It was previously used to report Employer’s Name or School Name . Employer’s Name or School Name no longer exists, so this field has been eliminated.

Box Number: 9d - Insurance Plan Name or Program Name Where this populates from: can not be modified within Unified Practice Description: Box 9d is the name of the insurance plan or program of the other insured as indicated in Box 9. If Box 11d is marked, complete boxes 9, 9a, and 9d, otherwise leave blank.

Box Number: 10 - Is Patient's Condition Related To Where this populates from: Billing Info > Billing Preferences > Is Patient's condition related to (this carries over from treatment to treatment). Description: Indicate whether the patient’s illness or injury is related to employment, auto accident, or other accident. Only one box on each line can be marked.  Any item marked “YES” indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Box 11.

Box Number: 10a - Employment Where this populates from: Employment (current or previous) would indicate that the condition is related to the patient’s job or workplace. Description: Indicate whether the patient’s illness or injury is related to employment, auto accident, or other accident. Only one box on each line can be marked.  Any item marked YES  indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Box 11.

Box Number: 10b - Auto Accident Where this populates from: Auto accident would indicate that the condition is the result of an automobile accident. The state postal code where the accident occurred must be reported if YES  is marked in 10b for “Auto Accident.” Description: Indicate whether the patient’s illness or injury is related to employment, auto accident, or other accident. Only one box on each line can be marked.  Any item marked YES  indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Box 11.

Box Number: 10c - Other Accident Where this populates from: Other accident would indicate that the condition is the result of any other type of accident. Description: Indicate whether the patient’s illness or injury is related to employment, auto accident, or other accident. Only one box on each line can be marked.  Any item marked YES  indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Box 11.

Box Number:  10d - Reserved for Local Use Where this populates from: can not be modified within Unified Practice Description: Used to identify additional information about the patient’s condition or the claim. When required by payers to provide the sub-set of Condition Codes approved by the NUCC, enter the Condition Code in this field.

Box Number: 11 - Insured Policy Group or FECA Number Where this populates from: Billing Info > Billing Preferences > select which company is being used as Primary for this visit. Description: The insured's policy or group number as it appears on the insured's health care identification card.

Box Number: 11a - Insured Date of Birth and Sex Where this populates from: Personal tab of Patient File Description: Where the insured's 8-digit date of birth in the format MMDDYYYY is entered and a box indicating the insured's gender is marked.

Box Number: 11b - Other Claim ID (Designated by NUCC) Where this populates from: can not be modified within Unified Practice Description: The other claim ID. Claim identifiers are designated by the NUCC.

Box Number: 11c - Insurance Plan Name Or Program Name Where this populates from: Insurance tab of Patient File by selecting the Insurance Plan (goes for all types). Description: The name of the insurance plan or program of the insured. Some payers require an identification number of the primary insurer rather than the name in this field.

Box Number: 11d - Is there another Health Benefit Plan Where this populates from: Billing Info > Billing Preferences > Secondary Insurance Description: If Box 11d is marked, complete boxes 9, 9a, and 9d, otherwise leave blank. This specifies if there is another health benefit plan attached to this claim. Mark the appropriate box ( Yes or No ). Only one box can be marked.

Box Number: 12 - Patients or Authorized Person’s Signature Where this populates from: Billing Info > Billing Preferences >  Signature Date . If switched to Yes, you can enter the date. Otherwise, this is left blank. Description: Where the signature and date indicating authorization to release any medical information needed to process and/or adjudicate the claim. This can be done by entering Signature on File , SOF or the actual signature.

Box Number: 13 - Insured’s or Authorized Person’s Signature Where this populates from: This is automatically populated by Unified Practice with Signature on File. Description: Where the signature indicating authorization of payment for medical benefits to the provider of service. This can be done by entering Signature on File , SOF  or the actual signature.

Box Number: 14 - Date of Current Illness, Injury, or Pregnancy Where this populates from: Billing Info > Billing Preferences > Onset Date Description: Identifies the first date of onset of illness, the actual date of injury, or the LMP for pregnancy. Enter the 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) date of the first date of the present illness, injury, or pregnancy. For pregnancy, use the date of the last menstrual period (LMP) as the first date. Enter the applicable qualifier to identify which date is being reported.

Box Number: 15 - Other Date Where this populates from: Billing Info > Billing Preferences > Other Date Description: Where another date related to the patient’s condition or treatment is entered. Enter the applicable qualifier to identify which date is being reported. 454 Initial Treatment, 304 Latest Visit or Consultation, 453 Acute Manifestation of a Chronic Condition, 439 Accident, 455 Last X-ray, 471 Prescription, 090 Report Start (Assumed Care Date), 091 Report End (Relinquished Care Date), 444 First Visit or Consultation.

Box Number: 16 - Dates patient unable to work in current occupation Where this populates from: can not be modified within Unified Practice Description: Where the time span the patient is, or was, unable to work is entered if the patient is employed and is unable to work in their current occupation. A 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) date must be shown for the “from–to” dates that the patient is unable to work. An entry in this field may indicate employment-related insurance coverage.

Box Number: 17 - Name of Referring Provider or other Source Where this populates from: [1.] Patient File > Personal Tab >   Edit > Referring Provider [2.] Billing Info > Billing Preferences > Fill in referring providers details  toggle switched to Yes Description: Where the name of the referring provider, ordering provider, or supervising provider who referred, ordered or supervised the service(s) or supply(ies) on the claim. The qualifier indicates the role of the provider being reported. Enter the name (First Name, Middle Initial, Last Name) followed by the credentials of the professional who referred or ordered the service(s) or supply(ies) on the claim. Enter the applicable qualifier to the left of the vertical dotted line to identify which provider is being reported. DN Referring Provider, DK Ordering Provider

Box Number: 17a Where this populates from: This field can not be populated from Unified Practice

Box Number: 17b - NPI Where this populates from: Patient File > Personal Tab > Edit > Referring Provider > Add new provider > NPI Description: Where the NPI number of the referring, ordering, or supervising provider is entered. The NPI number refers to the HIPAA National Provider Identifier number.

Box Number: 18 - Hospitalization dates related to current services Where this populates from: can not be modified within Unified Practice Description: Where you would refer to an inpatient stay and indicates the admission and discharge dates associated with the service(s) on the claim. Enter the inpatient 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) hospital admission date followed by the discharge date (if discharge has occurred). If not discharged, leave discharge date blank. This date is when a medical service is furnished as a result of, or subsequent to, a related hospitalization.

Box Number: 19 -  Additional Claim Information Where this populates from: Billing Info > Billing Preferences , Additional Claim Information Description: Used to identify additional information about the patient’s condition or the claim. Please refer to the most current instructions from the public or private payer regarding the use of this field. Some payers ask for certain identifiers in this field. If identifiers are reported in this field, enter the appropriate qualifiers describing the identifier.

Box Number: 20 - Outside Lab, $ charges Where this populates from: Billing Info > Billing Preferences > Outside Lab Description: Used to indicate that services have been rendered by an independent provider.

Box Number: 21- Diagnostic or Nature of Illness or Injury (ICD Ind) Where this populates from: Billing Info > ICD codes Description: Used to identify the applicable ICD indicator to specify which version of ICD codes are being reported. 9 ICD-9 0 ICD-10 Box 21, Lines A through L, are used to indicate the sign, symptom, complaint, or condition of the patient relating to the service(s) on the claim. Up to 12 ICD-9-CM or ICD-10-CM diagnosis codes can be entered.

Box Number: 22 - Resubmission Code, Original Ref No. Where this populates from: Billing Info > Billing Preferences > Resubmission code (left), Original reference number (right) Description: Used to list the original reference number for resubmitted/corrected claims. When resubmitting a claim, enter the appropriate bill frequency code left justified in the left-hand side of the field. 6 Corrected Claim 7 Replacement of prior claim 8 Void/cancel of prior claim

Box Number: 23 - Prior Authorization number Where this populates from: Patient File > Insurance tab > Prior authorization turned on > Authorization # Description: Used to show the payer assigned number authorizing the service(s).

Box Number: 24 Description: Used to list the completed services for the claim. The six service lines in section 24 have been divided horizontally to accommodate submission of both the NPI and another/proprietary identifier and to accommodate the submission of supplemental information to support the billed service. The top area of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 lines of service. The supplemental information is to be placed in the shaded section of 24A through 24G as defined in each Item Number. Providers must verify requirements for this supplemental information with the payer.

Box Number: 24a - Dates of Service Where this populates from: Appointment Date Description: Indicates the actual month, day, and year the service(s) was provided.

Box Number: 24b - Place of service Where this populates from: Locations & Rooms > Edit Location > Facility Code Description: Used to identify the location where the service was rendered. Enter the appropriate two-digit code from the Place of Service Code list for each item used or service performed.

Box Number: 24c - EMG Where this populates from: can not be modified within Unified Practice Description: Identifies if the service was an emergency. Check with payer to determine if this information (emergency indicator) is necessary. If required, enter Y for “YES” or leave blank if “NO” in the bottom, unshaded area of the field. The definition of emergency would be either defined by federal or state regulations or programs, payer contracts, or as defined in 5010A1.

Box Number: 24d - Procedures, services, or supplies Where this populates from: Appointment bill, CPT codes -or- CPT Fee Schedule [on iPad] Description: Used to identify the medical services and procedures provided to the patient. Enter the CPT code(s) and modifier(s) (if applicable) from the appropriate code set in effect on the date of service. This field accommodates the entry of up to four two-digit modifiers. The specific procedure code(s) must be shown without a narrative description.

Box Number: 24e - Diagnostic pointer Where this populates from: Appointment bill, CPT codes, ICD pointer -or- Chief Complaint & ICD [on iPad] Description: Used to indicate the line letter from Box 21 that relates to the reason the service(s) was performed. Enter the diagnosis code reference letter (pointer) as shown in Box 21 to relate the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow. The reference letter(s) should be A – L or multiple letters as applicable. ICD-9-CM (or ICD-10-CM, once mandated) diagnosis codes must be entered in Box 21 only. Do not enter them in 24e.

Box Number: 24f - Charges Where this populates from: Fee Schedule (or if changed, charge in billing info screen) Description: The total billed amount for each service line. Enter the charge for each listed service, right justified in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in cents area if the amount is a whole number.

Box Number: 24g - Days or Units Where this populates from: Appointment Billing Info Description: Used to indicate the number of days corresponding to the dates entered in 24A or units as defined in CPT coding manual(s). Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia units or minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered. Enter numbers left justified in the field. No leading zeros are required. If reporting a fraction of a unit, use the decimal point.

Box Number: 24h - EPSDT Family Plan Where this populates from: cannot be modified within Unified Practice Description: Box 24h is used to identify certain services that may be covered under some state plans.

Box Number: 24i - ID Qualifier Where this populates from: cannot be modified within Unified Practice Description: Indicate the appropriate qualifier and identifying number in the shaded area.

Box Number: 24j - Rendering Provider ID# Where this populates from:  

Description: Indicates the individual performing/rendering the service.

Box Number: 25 - Federal TAX ID number

Where this populates from:   Account > My Account > Personal Tax ID > switch U se this ID as the Tax ID for my Superbills and Claim forms for billing toggle to Yes . 

• If Practitioner Tax ID is empty or Use this Tax ID… .. is turned off then it takes the Tax ID configured in Billing Information
• If both are empty, the field remains empty

Description: Indicates the unique identifier assigned by a federal or state agency. Enter the Federal Tax ID Number (employer ID number or SSN) of the Billing Provider identified in Box 33. This is the tax ID number intended to be used for 1099 reporting purposes. Enter an X in the appropriate box to indicate which number is being reported. Only one box can be marked.

Box Number: 26 - Patient Account Number Where this populates from: cannot be modified within Unified Practice Description: Indicates the identifier assigned by the provider.

Box Number: 27 - Accept Assignment? Where this populates from: Billing Info > Billing Preferences > Accept Assignment Description: Indicates that the provider agrees to accept assignment under the terms of the payer’s program. Enter an X in the correct box. Only one box can be marked. Report Accept Assignment? for all payers.

Box Number: 28 - Total Charge Where this populates from: Service balance due in Billing Info Description: Indicates the total billed amount for all services entered in Box 24f (lines 1–6). Enter total charges for the services (i.e., total of all charges in 24F). Enter the number right justified in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in cents area if the amount is a whole number.

Box Number: 29 - Amount Paid Where this populates from: Billing Info > Billing Preferences > switch Amount Paid - fill-in amount paid by patient for services to Yes and fill in the amount. This will auto-fill from payment received/applied. Description: Indicates the payment received from the patient or other payers. Enter total amount the patient and/or other payers paid on the covered services only. Enter the number right justified in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in cents area if the amount is a whole number.

Box Number: 30 - Balance Due Where this populates from: Total charge minus balance due that is listed on the CMS-1500 form.

Box Number: 31 - Signature of Physician or Supplier Where this populates from: Name in My Account & the Date of Service - or - Clinic Settings then Clinic Staff and click Details to the right to the Practitioner's name.

• The signature will reflect the name of the Practitioner assigned to the appointment - or - the last Practitioner to sign and lock the SOAP note.

Box Number: 32 - Service Facility Location Information Where this populates from: Clinic Settings > Locations & Rooms > Edit Location Description: Indicates the name and address of facility where services were rendered identifies the site where service(s) were provided. Enter the name, address, city, state, and ZIP code of the location where the services were rendered.

Box Number: 32a Where this populates from: Clinic Settings > Locations & Rooms > Edit Location > Service Facility NPI

• If this is not entered, 32a remains empty.  

Box Number: 32b Where this populates from: cannot be modified within Unified Practice Description: Indicates the non-NPI ID number of the service facility as assigned by the payer for the facility. Enter the 2-digit qualifier identifying the non-NPI number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number.

Box Number: 33 - Billing Provider Info & Phone Number Where this populates from: Defaults from Business Information -or- If alternate pay to info is selected in My Account/Billing Information , will pull from there. Description: Box 33 is used to indicate the billing provider’s or supplier’s billing name, address, ZIP code, and phone number and is the billing office location and telephone number of the provider or supplier. Enter the provider’s or supplier’s billing name, address, ZIP code, and phone number. The phone number is to be entered in the area to the right of the field title. Enter the name and address information in the following format: 1st Line – Name 2nd Line – Address 3rd Line – City, State and ZIP Code Item 33 identifies the provider that is requesting to be paid for the services rendered and should always be completed. Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Enter a space between town name and state code; do not include a comma. Report a 9-digit ZIP code, including the hyphen. Do not use a hyphen or space as a separator within the telephone number.

Box Number: 33a - Billing Information > Billing NPI Where this populates from: Clinic Settings > Clinic Staff > Details   -or- My Account if Use this NPI... is turned on .

• If this is turned off for the practitioner account page, this populates from Clinic Settings > Billing information . 
• If both are empty, 33a remains empty. 

Description: Indicates the HIPAA National Provider Identifier number. Enter the NPI number of the billing provider in 33a.

Where this populates from: Billing Info > Billing Preferences > G roup ID Description: Indicates the payer-assigned unique identifier of the professional.