|
Back to
Sample Screen Page |
|
Verify: |
Patient Address |
Payer Address |
|
NOTICE: This
information is classified as individually
identifiable healthcare information and is
intended strictly for the confidential use of
the authorized requestor. Any unauthorized use
or disclosure of this information is prohibited.
|
|
SEARCH CRITERIA
|
|
Provider ID:
|
987654321
|
|
Member ID:
|
123456789
|
|
Last Name:
|
Smith |
|
First Name:
|
Robert |
|
Date of Birth:
|
04/20/1936
|
|
Gender:
|
Male |
|
Beginning Date of
Service: |
03/03/2003
|
|
Ending Date of
Service: |
03/03/2003
|
|
MEMBER |
|
Member ID:
|
12345678900
|
|
Name: |
SMITH, ROBERT R
|
|
Date of Birth:
|
04/20/1936
|
|
Sex: |
MALE |
|
Status Code:
|
Processed according
to contract/plan provisions. |
|
Status Category:
|
Finalized-The
claim/encounter has completed the adjudication
cycle and no more action will be taken.
|
|
CLAIM LEVEL
INFORMATION
|
|
Claim Number:
|
201234567
|
Adjudication Date:
|
09/05/2003
|
|
Status Effective
Date: |
09/04/2003
|
Billing Type:
|
131 |
|
Service From Date:
|
03/03/2003
|
Payment Method
Code: |
Check |
|
Service To Date:
|
03/03/2003
|
Check Number:
|
009484767
|
|
Entity Identifier:
|
|
Check Issue Date:
|
09/05/2003
|
|
Medical Record
Number: |
7027862
|
Total Claim Charged
Amount: |
$2244.40
|
|
Transaction
Reference: |
120487085
|
Claim Payment
Amount: |
$300.00
|
|
SERVICE LINE
INFORMATION |
|
Line: |
1 |
Service Dates:
|
03/03/2003 -
03/03/2003 |
| Proc/Rev Code |
Mod |
Qty |
Charged |
Paid |
Status Date |
|
99283 , 450
|
|
1 |
$300.00
|
$0.00 |
03/13/2003
|
|
Status Code:
|
Will worker's
compensation cover submitted charges?
|
|
Status Category:
|
Finalized/Denial-The claim/line has been denied.
|
|
Line: |
2 |
Service Dates:
|
03/03/2003 -
03/03/2003 |
|
Proc/Rev Code
|
Mod |
Qty |
Charged
|
Paid |
Status Date
|
|
10120 , 450
|
|
1 |
$243.00
|
$0.00 |
03/13/2003
|
|
Status Code:
|
Will worker's
compensation cover submitted charges?
|
|
Status Category:
|
Finalized/Denial-The claim/line has been denied.
|
|
Line: |
3 |
Service Dates:
|
03/03/2003 -
03/03/2003 |
|
Proc/Rev Code
|
Mod |
Qty |
Charged
|
Paid |
Status Date
|
|
73550 , 320
|
LT |
1 |
$292.00
|
$0.00 |
03/13/2003
|
|
Status Code:
|
Will worker's
compensation cover submitted charges?
|
|
Status Category:
|
Finalized/Denial-The claim/line has been denied.
|
|
Line: |
4 |
Service Dates:
|
03/03/2003 -
03/03/2003 |
|
Proc/Rev Code
|
Mod |
Qty |
Charged
|
Paid |
Status Date
|
|
J0690 , 250
|
|
1 |
$45.10 |
$0.00 |
03/13/2003
|
|
Status Code:
|
Will worker's
compensation cover submitted charges?
|
|
Status Category:
|
Finalized/Denial-The claim/line has been denied.
|
|
Line: |
5 |
Service Dates:
|
03/03/2003 -
03/03/2003 |
|
Proc/Rev Code
|
Mod |
Qty |
Charged
|
Paid |
Status Date
|
|
Q0081 , 260
|
|
1 |
$130.00
|
$0.00 |
03/13/2003
|
|
Status Code:
|
Will worker's
compensation cover submitted charges?
|
|
Status Category:
|
Finalized/Denial-The claim/line has been denied.
|
|
Line: |
6 |
Service Dates:
|
03/03/2003 -
03/03/2003 |
|
Proc/Rev Code
|
Mod |
Qty |
Charged
|
Paid |
Status Date
|
|
90718 , 636
|
|
1 |
$47.10 |
$0.00 |
03/13/2003
|
|
Status Code:
|
Will worker's
compensation cover submitted charges?
|
|
Status Category:
|
Finalized/Denial-The claim/line has been denied.
|
|
Line: |
7 |
Service Dates:
|
03/03/2003 -
03/03/2003 |
|
Proc/Rev Code
|
Mod |
Qty |
Charged
|
Paid |
Status Date
|
|
90782 , 940
|
|
1 |
$65.00 |
$0.00 |
03/13/2003
|
|
Status Code:
|
Will worker's
compensation cover submitted charges?
|
|
Status Category:
|
Finalized/Denial-The claim/line has been denied.
|
|
Line: |
8 |
Service Dates:
|
03/03/2003 -
03/03/2003 |
|
Proc/Rev Code
|
Mod |
Qty |
Charged
|
Paid |
Status Date
|
|
99283 , 450
|
|
1 |
$300.00
|
$250.00
|
09/04/2003
|
|
Status Code:
|
Claim/line has been
paid. |
|
Status Category:
|
Finalized/Payment-The claim/line has been paid.
|
|
Line: |
9 |
Service Dates:
|
03/03/2003 -
03/03/2003 |
|
Proc/Rev Code
|
Mod |
Qty |
Charged
|
Paid |
Status Date
|
|
10120 , 450
|
|
1 |
$243.00
|
$50.00 |
09/04/2003
|
|
Status Code:
|
Claim/line has been
paid. |
|
Status Category:
|
Finalized/Payment-The claim/line has been paid.
|
|
Line: |
10 |
Service Dates:
|
03/03/2003 -
03/03/2003 |
|
Proc/Rev Code
|
Mod |
Qty |
Charged
|
Paid |
Status Date
|
|
73550 , 320
|
LT |
1 |
$292.00
|
$0.00 |
09/04/2003
|
|
Status Code:
|
Claim/line has been
paid. |
|
Status Category:
|
Finalized/Payment-The claim/line has been paid.
|
|
Line: |
11 |
Service Dates:
|
03/03/2003 -
03/03/2003 |
|
Proc/Rev Code
|
Mod |
Qty |
Charged
|
Paid |
Status Date
|
|
J0690 , 250
|
|
1 |
$45.10 |
$0.00 |
09/04/2003
|
|
Status Code:
|
Claim/line has been
paid. |
|
Status Category:
|
Finalized/Payment-The claim/line has been paid.
|
|
Line: |
12 |
Service Dates:
|
03/03/2003 -
03/03/2003 |
|
Proc/Rev Code
|
Mod |
Qty |
Charged
|
Paid |
Status Date
|
|
Q0081 , 260
|
|
1 |
$130.00
|
$0.00 |
09/04/2003
|
|
Status Code:
|
Claim/line has been
paid. |
|
Status Category:
|
Finalized/Payment-The claim/line has been paid.
|
|
Line: |
13 |
Service Dates:
|
03/03/2003 -
03/03/2003 |
|
Proc/Rev Code
|
Mod |
Qty |
Charged
|
Paid |
Status Date
|
|
90718 , 636
|
|
1 |
$47.10 |
$0.00 |
09/04/2003
|
|
Status Code:
|
Claim/line has been
paid. |
|
Status Category:
|
Finalized/Payment-The claim/line has been paid.
|
|
Line: |
14 |
Service Dates:
|
03/03/2003 -
03/03/2003 |
|
Proc/Rev Code
|
Mod |
Qty |
Charged
|
Paid |
Status Date
|
|
90782 , 940
|
|
1 |
$65.00 |
$0.00 |
09/04/2003
|
|
Status Code:
|
Claim/line has been
paid. |
|
Status Category:
|
Finalized/Payment-The claim/line has been paid.
|
|
Passport Reference
Number: |
2003120123456789
|
|
Transaction run on
12/04/2003 at 10:22:17 AM CT by Joe Smith -
Passport Health Communications
|
|
|
