| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | facility | 0;1 | POINTER | 4 | B | Enter a Pay-to Provider. Usually, a Pay-to Provider is a medical center (Example VAMC, M&ROC, etc.). If you enter only one Pay-to Provider, it will be the default Pay-to Provider for all claims and you do not need to associate divisions with the default. Multiple Pay-to Providers must be associated with the divisions to which they apply. |
| .02 | name(+) | 0;2 | FREE TEXT | You may modify the Pay-to Provider Name for use on electronic or printed claims. | ||
| .03 | federal tax number | 0;3 | FREE TEXT | Enter the Federal Tax ID for the Pay-to Provider. Make sure you enter the Tax ID Number for the Pay-to Provider which may be different from your site's Tax ID. Enter 10 digits in the format NN-NNNNNNN. | ||
| .04 | telephone number | 0;4 | FREE TEXT | Enter the phone number to be used on electronic or printed claims. This is the number you would want a payer to use to contact the site about a claim. | ||
| .05 | parent pay-to provider | 0;5 | NUMERIC | This field determines if this entry in the sub-file is a Pay-to provider institution or if it is a Division being linked to the parent Pay-to Provider institution - another sub-file entry. If this field is defined, then it holds the IEN in this sub-file which is the parent Pay-to Provider institution for this specific division. If this field is nil, then this means that this sub-file entry is the parent Pay-to Provider Institution. This field should not be set via FileMan. The application in the IB site parameter edit option will set this field appropriately based on user input. | ||
| 1.01 | street address 1 | 1;1 | FREE TEXT | You may modify the Pay-to Provider Address for use on electronic or printed claims. You may enter a P.O. Box. | ||
| 1.02 | street address 2 | 1;2 | FREE TEXT | Enter additional Address information if needed. | ||
| 1.03 | city | 1;3 | FREE TEXT | You may modify the Pay-to Provider Address for use on electronic or printed claims. | ||
| 1.04 | state | 1;4 | POINTER | 5 | You may modify the Pay-to Provider Address for use on electronic or printed claims. | |
| 1.05 | zip | 1;5 | FREE TEXT | You may modify the Pay-to Provider Address for use on electronic or printed claims. |
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