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# | Location | File | Last Modified |
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1 | CPEE_v1_Build_7.zip\CPEE_v1_Build_7\Build 7 - Sprint 15\CPE001-122 - CMAC payment methodology for Other than Assistant-At-Surgery | Unit Test CPE001-122.docx | Tue Apr 24 15:18:38 2018 UTC |
2 | CPEE_v1_Build_7.zip\CPEE_v1_Build_7\Build 7 - Sprint 15\CPE001-122 - CMAC payment methodology for Other than Assistant-At-Surgery | Unit Test CPE001-122.docx | Tue Apr 24 18:30:17 2018 UTC |
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1 | HAC Payme nt Process ing - Docu ment Ident ification Screen | |
2 | ||
3 | [DOCUME NT IDENTIF ICATION SC REEN] | |
4 | ||
5 | Batc h Number: 0 | |
6 | PD I Number: 2018071910 00013 | |
7 | Tot al Pages: UNK | |
8 | Pag e Number: 1 of UNK | |
9 | Type of Image: BILL/INVOI CE | |
10 | Image A vailable: No | |
11 | __________ __________ __________ __________ __________ __________ __________ _________ | |
12 | ||
13 | ||
14 | ||
15 | ||
16 | ||
17 | ||
18 | ||
19 | ||
20 | ||
21 | ||
22 | ||
23 | 1) Cont Ed t 2) Next Scr 3) S ort PDI 4 ) Kill PDI 5) Not A val 6) Un rd Img | |
24 | 7) PDI Rev w 8) Paus e 9) C omments 10 ) Btch Cmp 11) PPR 12) PP Rs-PDI | |
25 | ||
26 | ||
27 | ||
28 | PDI: 20180 7191000013 Page #: 1 Img #: 1 Assign ment: | |
29 | Vendor: Ben eficiary: DURHAM,NEL LIE E | |
30 | [BENEFICIA RY ID SCRE EN - BILL/ INVOICE] | |
31 | ||
32 | Benefici ary ID: DU RHAM,NELLI E E Sponsor ID: | |
33 | ||
34 | ||
35 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
36 | ||
37 | Name: DUR HAM,NELLIE E | |
38 | SSN: 458 -28-3090 OHI Cov Co de: 6 - ME DICARE A&B | |
39 | ID #: 458 283090 Start Da te: NOV 1 , 2003 | |
40 | Add 1: 201 MCDERMOTT STREET Stop Da te: | |
41 | Add 2: APT 132 OHI Na me: MED A& B | |
42 | City: DEE R PARK | |
43 | State: TEX AS Commen ts: Yes | |
44 | Zip: 775 366094 | |
45 | Phone: 281 9280395 | |
46 | DOB: FEB 11, 1923 | |
47 | Rel: Spo use | |
48 | ||
49 | ||
50 | 1) Cont Ed t 2) Next Scr 3) P rv Scrn 4 ) Kill 5) Dis D ata 6) Ps d Bene | |
51 | 7) OHI His t 8) OHI Comm 9) O HI Edit 10 ) Ch Ad Fg | |
52 | ||
53 | ||
54 | ||
55 | PDI: 20180 7191000013 Page #: 1 Img #: 1 Assign ment: | |
56 | Vendor: SM ITHFIELD P EDS Ben eficiary: DURHAM,NEL LIE E | |
57 | ||
58 | ||
59 | TAX ID: | TOS: O UTPATIENT | |
60 | NPI: | PAYP: Y es | |
61 | RT NAME: | MCCR: Y es | |
62 | RT ZIP: | PCN: | |
63 | | TOB: | |
64 | | PL ZIP: 7 7536 | |
65 | ||
66 | ---------- ---------- ---------- ------ || Billing/R emit-to In formation |--------- | |
67 | SMITHFIEL D PEDS | |
68 | A/V=Y 043431959 - - | |
69 | FAC TYPE=P HYSICIANS 6 BLACKST ONE VALLEY PL STE 70 6 | |
70 | DRG= LINCOLN | |
71 | CMAC=1 RHODE ISL AND | |
72 | EDI= 028651170 | |
73 | ||
74 | ||
75 | ||
76 | ||
77 | 1) Cont Ed t 2) Next Scr 3) P rev Scr 4 ) Kill 5) Dis D ata 6) Ps d Ven | |
78 | 7) Med Ven | |
79 | ||
80 | ||
81 | ||
82 | PDI: 20180 7191000013 Page #: 1 Img #: 1 Assign ment: | |
83 | Vendor: SM ITHFIELD P EDS Ben eficiary: DURHAM,NEL LIE E | |
84 | [OUTPATIEN T E/E SCRE EN - BILL/ INVOICE] | |
85 | OHI TOC: 6 - MEDICARE A &B OHI Edit TOC: | |
86 | DOS POS I CD REV SVCS/ND C MODS UNT/QTY AMOUNT P/R BAL | |
87 | 1 03/06/ 18 DO R50.9 | |
88 | 2 03/06/ 18 DO 9 9204 AN 1 1000.00 | |
89 | 3 03/06/ 18 DO 9 9204 PA 1 1000.00 | |
90 | 4 03/06/ 18 DO 9 9204 AS 1 1000.00 | |
91 | 5 03/06/ 18 DO 9 9204 NP 1 1000.00 | |
92 | 6 03/06/ 18 DO 1 | |
93 | ||
94 | ||
95 | TOTALS 4,000.00 | |
96 | ||
97 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
98 | ||
99 | ||
100 | ||
101 | ||
102 | ||
103 | ||
104 | 1) Cont Ed t 2) Next Scr 3) P rev Scr 4 ) Kill 5) Payme nts 6) Be n Pymt | |
105 | 7) TPL Pym t 8) Del Data 9) O HI Edit 10 ) Restore | |
106 | ||
107 | ||
108 | ||
109 | ||
110 | PDI: 20180 7191000013 Page #: 1 Img #: 1 Assign ment: | |
111 | Vendor: SM ITHFIELD P EDS Ben eficiary: DURHAM,NEL LIE E | |
112 | [OH I PAYMENTS E/E SCREE N] | |
113 | OHI TOC: 6 - MEDICARE A &B OHI Edit TOC: | |
114 | - -- Primary OHI --- Add'l OHIs | |
115 | DOS SVCS/ NDC Bil led Amt Paid P/R Paid P/R Bal | |
116 | 2 03/06/ 18 99 204-AN 1000.00 900.00 900.00 | |
117 | 3 03/06/ 18 99 204-PA 1000.00 900.00 900.00 | |
118 | 4 03/06/ 18 99 204-AS 1000.00 900.00 900.00 | |
119 | 5 03/06/ 18 99 204-NP 1000.00 900.00 900.00 | |
120 | ||
121 | ||
122 | ||
123 | ||
124 | TOTAL S 4 ,000.00 0.00 3,600.00 0.00 3,600.00 | |
125 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
126 | ||
127 | ||
128 | ||
129 | ||
130 | ||
131 | * * WARNING - OHI was not entere d on Benef iciary ID screen. ** | |
132 | 1) Cont Ed t 2) Next Scr 3) E nt Ttls 4 ) OHI Edit 5) OHI H ist 6) ET DOS | |
133 | ||
134 | ||
135 | ||
136 | ||
137 | PDI: 20180 7191000013 Page #: 1 Img #: 1 Assign ment: | |
138 | Vendor: SM ITHFIELD P EDS Ben eficiary: DURHAM,NEL LIE E | |
139 | [OUTPATIEN T E/E SCRE EN - BILL/ INVOICE] | |
140 | OHI TOC: 6 - MEDICARE A &B OHI Edit TOC: | |
141 | DOS POS I CD REV SVCS/ND C MODS UNT/QTY AMOUNT P/R BAL | |
142 | 1 03/06/ 18 DO R50.9 | |
143 | 2 03/06/ 18 DO 9 9204 AN 1 1000.00 900.00 | |
144 | 3 03/06/ 18 DO 9 9204 PA 1 1000.00 900.00 | |
145 | 4 03/06/ 18 DO 9 9204 AS 1 1000.00 900.00 | |
146 | 5 03/06/ 18 DO 9 9204 NP 1 1000.00 900.00 | |
147 | 6 03/06/ 18 DO 1 | |
148 | ||
149 | ||
150 | TOTALS 4,000.00 3,600.00 | |
151 | ||
152 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
153 | ||
154 | ||
155 | ||
156 | ||
157 | ||
158 | ||
159 | 1) Cont Ed t 2) Next Scr 3) P rev Scr 4 ) Kill 5) Payme nts 6) Be n Pymt | |
160 | 7) TPL Pym t 8) Del Data 9) O HI Edit 10 ) Restore | |
161 | ||
162 | PDI: 20180 7191000013 Page #: 1 Img #: 1 Assign ment: | |
163 | Vendor: SM ITHFIELD P EDS Ben eficiary: DURHAM,NEL LIE E | |
164 | [DOCUME NT IDENTIF ICATION SC REEN] | |
165 | ||
166 | Batc h Number: 0 | |
167 | PD I Number: 2018071910 00013 | |
168 | Tot al Pages: UNK | |
169 | Pag e Number: 1 of UNK | |
170 | Type of Image: BILL/INVOI CE | |
171 | Image A vailable: No | |
172 | __________ __________ __________ __________ __________ __________ __________ _________ | |
173 | ||
174 | ||
175 | ||
176 | ||
177 | ||
178 | ||
179 | ||
180 | ||
181 | ||
182 | ||
183 | ||
184 | 1) Cont Ed t 2) Next Scr 3) S ort PDI 4 ) Kill PDI 5) Not A val 6) Un rd Img | |
185 | 7) PDI Rev w 8) Paus e 9) C omments 10 ) Btch Cmp 11) PPR 12) PP Rs-PDI | |
186 | ||
187 | ||
188 | ||
189 | ||
190 | [ Edit Claim Data Scre en] | |
191 | ||
192 | ||
193 | PDI# 20180 7191000013 Related C laims: | |
194 | ||
195 | No. Claim # RO Cl # Bene Typ Vendor D.O.S D/C | |
196 | --- ----- -- ----- -- ---- ---------- - --- ---------- ------- --- --- | |
197 | ||
198 | 1) RLT81 97 DURH AM,NELLIE E OUT SMITHFIELD 3/6/201 8 | |
199 | ||
200 | ||
201 | ||
202 | ||
203 | ||
204 | ||
205 | ||
206 | ||
207 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
208 | Select: 1 ) Edit | |
209 | 2 ) Continue | |
210 | 3 ) Process New Page | |
211 | ||
212 | Choose: | |
213 | ||
214 | ||
215 | V>IEW OR < P>RINT? V | |
216 | ||
217 | ||
218 | ||
219 | ||
220 | ||
221 | ||
222 | ||
223 | DUZ: 83038 8 Health A dministrat ion Center Page: 1 | |
224 | Date: MAR 16, 2018 Post-Pro cessing Cl aim Report | |
225 | Time: 1412 | |
226 | ||
227 | PDI: 201807191 000013- BATCH: Cl aim #: RLT 8197 | |
228 | EIN: 043431959 - - S tatus: In- Progress | |
229 | Program: CHAMPVA | |
230 | Vendor: SMITHFIEL D PEDS Type: Out patient | |
231 | Pay Prov?: Yes Ser/Admis Date: MAR 6,2018 | |
232 | Sponsor: DURHAM,JA MES O Comp. Date: | |
233 | Bene: DURHAM,NE LLIE E POS: DOC TOR'S OFFI C | |
234 | Bene Sex: F Bene DOB: 02/11/23 P L ZIP: 775 36 | |
235 | ||
236 | Press <RET URN> to co ntinue, <^ > to exit. | |
237 | ||
238 | DX's/Px's/ NDC's P/L Unt/Qty Total Chg TotalAA Mcai d O HI #1 PD OHI #1 P R Deduc t Pa yments AI Reas | |
239 | AlwUnt Chg/Unt AA/Unt A ddl OHI OHI PR B al Cst S hare | |
240 | ---------- --------- ------- ---------- - ------- ---- ---- ------- - ---------- -------- --- ----- ------ -- --------- -- ---- | |
241 | R50.9 1 AC | |
242 | ||
243 | 99204-AN 1 1,000.0 0 16 9.51 100.00 900 .00 AC | |
244 | 1 1,000.0 0 16 9.51 | |
245 | ||
246 | 99204-PA 1 1,000.0 0 16 9.51 100.00 900 .00 AC | |
247 | 1 1,000.0 0 16 9.51 | |
248 | ||
249 | 99204-AS 1 1,000.0 0 1 7.63 100.00 900 .00 AC | |
250 | 1 1,000.0 0 1 7.63 | |
251 | ||
252 | 99204-NP 1 1,000.0 0 1 7.63 100.00 900 .00 AC | |
253 | 1 1,000.0 0 1 7.63 | |
254 | ||
255 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ----- | |
256 | Totals: 4,000.0 0 37 4.28 400.00 3,600 .00 0.00 | |
257 | ||
258 | Press <RET URN> to Co ntinue, <^ > to exit. | |
259 | ||
260 | Tot al Charges Billed: 4,00 0.00 CITI Maximum Re imbursemen t Rate: N/ A | |
261 | Calculated Allowable Amount: 37 4.28 MEDICAID Amount: N/ A | |
262 | A mount Appl ied to Ded uctible: N/A Am ount Paid by TPL: N/ A | |
263 | Cos t Share Cr edited to Cat Cap: N/A Amoun t Reversed from Dedu ctible: N/ A | |
264 | Amount Paid by O ther Insur ance(s): 40 0.00 Am ount Rever sed from C at Cap: N/ A | |
265 | Pa tient Resp onsibility Amount: 3,60 0.00 Amount Red uced from Previous P ayment: N/ A | |
266 | Amount Pa id by Bene ficiary to Vendor: 0.00 L ast PDI Pa yment Diff erence: 0.0 0 | |
267 | Total Amount to be PAID o n claim: N/A Total Paym ent for Cu rrent PDI# 201807191 000013: 0.0 0 | |
268 | Amou nt PAID to Vendor: N/A | |
269 | Amount PA ID to Bene ficiary: N/A | |
270 | ||
271 | Press <RET URN> to Co ntinue, <^ > to exit. | |
272 | ||
273 | Actions fo r Claim: | |
274 | ||
275 | 1) Qual ity Assura nce - CPD (In Prog) | |
276 | ||
277 | Claim Reas ons: 356 - REMI NDER - MAI L CLAIMS T O: CHAMPVA , PO Box 4 69064, DEN VER, CO 80 246-9064 | |
278 | 371 - WHEN RESUBMITT ING CLAIMS YOU MUST ATTACH THE CHAMPVA E OB FOR PRO PER PROCES SING. | |
279 | ||
280 | Press <RET URN> to co ntinue. | |
281 | ||
282 | ||
283 | ||
284 | VIEWING OF PPR | |
285 | ||
286 | ||
287 | ||
288 | Select The Desired A ctive Clai m: EXIT// RLT8197 | |
289 | ||
290 | ||
291 | ||
292 | ||
293 | ||
294 | ||
295 | ||
296 | ||
297 | ||
298 | ||
299 | ||
300 | ||
301 | ||
302 | ||
303 | ||
304 | ||
305 | ||
306 | ||
307 | 1) Quit 2) Selec t 3) Fas t Rev 4) R ej Clm 5) Acc Clm 6) Scroll 7) Adm S usp 8) Com ment 9) M en Hlth M) ore.. | |
308 | Select: Se lect// 5 | |
309 | ||
310 | ||
311 | <V>IEW OR <P>RINT? V | |
312 | ||
313 | ||
314 | ||
315 | ||
316 | ||
317 | ||
318 | ||
319 | DUZ: 58820 2 Health A dministrat ion Center Page: 1 | |
320 | Date: MAR 16, 2018 Post-Pro cessing Cl aim Report | |
321 | Time: 1505 | |
322 | ||
323 | PDI: 201807191 000013- BATCH: Cl aim #: RLT 8197 | |
324 | EIN: 043431959 - - S tatus: Pay ment Req. | |
325 | Program: CHAMPVA | |
326 | Vendor: SMITHFIEL D PEDS Type: Out patient | |
327 | Pay Prov?: Yes Ser/Admis Date: MAR 6,2018 | |
328 | Sponsor: DURHAM,JA MES O Comp. Date: | |
329 | Bene: DURHAM,NE LLIE E POS: DOC TOR'S OFFI C | |
330 | Bene Sex: F Bene DOB: 02/11/23 P L ZIP: 775 36 | |
331 | ||
332 | Press <RET URN> to co ntinue, <^ > to exit. | |
333 | ||
334 | DX's/Px's/ NDC's P/L Unt/Qty Total Chg TotalAA Mcai d O HI #1 PD OHI #1 P R Deduc t Pa yments AI Reas | |
335 | AlwUnt Chg/Unt AA/Unt A ddl OHI OHI PR B al Cst S hare | |
336 | ---------- --------- ------- ---------- - ------- ---- ---- ------- - ---------- -------- --- ----- ------ -- --------- -- ---- | |
337 | R50.9 1 AC | |
338 | ||
339 | 99204-AN 1 1,000.0 0 16 9.51 100.00 900 .00 0.00 169.51 AC | |
340 | 1 1,000.0 0 16 9.51 0.00 | |
341 | ||
342 | 99204-PA 1 1,000.0 0 16 9.51 100.00 900 .00 0.00 169.51 AC | |
343 | 1 1,000.0 0 16 9.51 0.00 | |
344 | ||
345 | 99204-AS 1 1,000.0 0 1 7.63 100.00 900 .00 0.00 17.63 AC | |
346 | 1 1,000.0 0 1 7.63 0.00 | |
347 | ||
348 | 99204-NP 1 1,000.0 0 1 7.63 100.00 900 .00 0.00 17.63 AC | |
349 | 1 1,000.0 0 1 7.63 0.00 | |
350 | ||
351 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ----- | |
352 | Totals: 4,000.0 0 37 4.28 400.00 3,600 .00 0.00 374.28 | |
353 | 0.00 | |
354 | ||
355 | Press <RET URN> to Co ntinue, <^ > to exit. | |
356 | ||
357 | Tot al Charges Billed: 4,00 0.00 CITI Maximum Re imbursemen t Rate: N/ A | |
358 | Calculated Allowable Amount: 37 4.28 MEDICAID Amount: N/ A | |
359 | A mount Appl ied to Ded uctible: 0.00 Am ount Paid by TPL: N/ A | |
360 | Cos t Share Cr edited to Cat Cap: 0.00 Amoun t Reversed from Dedu ctible: N/ A | |
361 | Amount Paid by O ther Insur ance(s): 40 0.00 Am ount Rever sed from C at Cap: N/ A | |
362 | Pa tient Resp onsibility Amount: 3,60 0.00 Amount Red uced from Previous P ayment: N/ A | |
363 | Amount Pa id by Bene ficiary to Vendor: 0.00 L ast PDI Pa yment Diff erence: 0.0 0 | |
364 | Total Amount to be PAID o n claim: 37 4.28 Total Paym ent for Cu rrent PDI# 201807191 000013: +374.2 8 | |
365 | Amou nt PAID to Vendor: 37 4.28 | |
366 | Amount PA ID to Bene ficiary: 0.00 | |
367 | ||
368 | Press <RET URN> to Co ntinue, <^ > to exit. | |
369 | ||
370 | CHAM PVA Benefi ciary Dedu ctible 201 8: 0.00 | |
371 | CHAMPVA F amily Dedu ctible 201 8: 0.00 | |
372 | CHAMP VA Family Catastroph ic Cap 201 8: 0.00 | |
373 | ||
374 | Press <RET URN> to Co ntinue, <^ > to exit. | |
375 | ||
376 | Actions fo r Claim: | |
377 | ||
378 | 1) Qual ity Assura nce (Comp) 2) SNA CAPPS (Pen ding Batch Process) | |
379 | ||
380 | Claim Reas ons: 319 - CFR 17.272(B)( 3) REQUIRE S PROVIDER TO ACCEPT CHAMPVA A LLOWABLE A S FULL PAY MENT. | |
381 | 322 - COST SHARE FOR CLAIM MAY NOT ALWAY S BE PATIE NT LIABILI TY; OHI / CAT CAP MA Y IMPACT. | |
382 | 356 - REMI NDER - MAI L CLAIMS T O: CHAMPVA , PO Box 4 69064, DEN VER, CO 80 246-9064 | |
383 | 371 - WHEN RESUBMITT ING CLAIMS YOU MUST ATTACH THE CHAMPVA E OB FOR PRO PER PROCES SING. | |
384 | ||
385 | Press <RET URN> to co ntinue. | |
386 | ||
387 | ||
388 | ||
389 | VIEWING OF PPR | |
390 | ||
391 | ||
392 | Select OPT ION NAME: CHMLCMA5 Zip c ode/CPT4 c ode displa y | |
393 | Zip code/C PT4 code d isplay | |
394 | ||
395 | ||
396 | ||
397 | C MAC Data | |
398 | ||
399 | ||
400 | Z ip Code: 77536 | |
401 | CHA MPUS Local ity No.: 379 | |
402 | C PT Code: 99204 | |
403 | CMAC Da ta Year: 18 | |
404 | ||
405 | F acility Non-Facili ty Profe ssional Technical | |
406 | - Physicia n $ 133.44 $ 169.51 | |
407 | - Non-Phys ician $ 113.42 $ 144.08 | |
408 | ||
409 | <RETURN> t o continue : | |
410 | ||
411 | ||
412 | ||
413 | ||
414 | ||
415 | DUZ: 55202 Health A dministrat ion Center Page: 1 | |
416 | Date: MAR 20, 2018 Post-Pro cessing Cl aim Report | |
417 | Time: 1518 | |
418 | ||
419 | PDI: 201807291 000022- BATCH: Cl aim #: RLT 8212 | |
420 | EIN: 026362741 - - S tatus: Pay ment Req. | |
421 | Program: CHAMPVA | |
422 | Vendor: JOHNSON T HEODORE S Type: Out patient | |
423 | Pay Prov?: Yes Ser/Admis Date: MAR 3,2018 | |
424 | Sponsor: CHAMPVA,P ATIENT1 Comp. Date: | |
425 | Bene: CHAMPVA,C HILD1 POS: DOC TOR'S OFFI C | |
426 | Bene Sex: M Bene DOB: 08/30/17 P L ZIP: 234 56 | |
427 | ||
428 | Press <RET URN> to co ntinue, <^ > to exit. | |
429 | ||
430 | DX's/Px's/ NDC's P/L Unt/Qty Total Chg TotalAA Mcai d O HI #1 PD OHI #1 P R Deduc t Pa yments AI Reas | |
431 | AlwUnt Chg/Unt AA/Unt A ddl OHI OHI PR B al Cst S hare | |
432 | ---------- --------- ------- ---------- - ------- ---- ---- ------- - ---------- -------- --- ----- ------ -- --------- -- ---- | |
433 | R50.9 1 AC | |
434 | ||
435 | 99204-AN 1 200.0 0 16 4.96 0.00 123.72 AC | |
436 | 1 200.0 0 16 4.96 41.24 | |
437 | ||
438 | 99204-PA 1 200.0 0 16 4.96 0.00 123.72 AC | |
439 | 1 200.0 0 16 4.96 41.24 | |
440 | ||
441 | 99204-AS 1 200.0 0 1 7.16 0.00 12.87 AC | |
442 | 1 200.0 0 1 7.16 4.29 | |
443 | ||
444 | 99204-NP 1 200.0 0 1 7.16 0.00 12.87 AC | |
445 | 1 200.0 0 1 7.16 4.29 | |
446 | ||
447 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ----- | |
448 | Totals: 800.0 0 36 4.23 0.00 273.18 | |
449 | 91.06 | |
450 | ||
451 | Press <RET URN> to Co ntinue, <^ > to exit. | |
452 | ||
453 | Tot al Charges Billed: 80 0.00 CITI Maximum Re imbursemen t Rate: N/ A | |
454 | Calculated Allowable Amount: 36 4.23 MEDICAID Amount: N/ A | |
455 | A mount Appl ied to Ded uctible: 0.00 Am ount Paid by TPL: N/ A | |
456 | Cos t Share Cr edited to Cat Cap: 9 1.06 Amoun t Reversed from Dedu ctible: N/ A | |
457 | Amount Paid by O ther Insur ance(s): N/A Am ount Rever sed from C at Cap: N/ A | |
458 | Pa tient Resp onsibility Amount: N/A Amount Red uced from Previous P ayment: N/ A | |
459 | Amount Pa id by Bene ficiary to Vendor: 0.00 L ast PDI Pa yment Diff erence: 0.0 0 | |
460 | Total Amount to be PAID o n claim: 27 3.18 Total Paym ent for Cu rrent PDI# 201807291 000022: +273.1 8 | |
461 | Amou nt PAID to Vendor: 27 3.18 | |
462 | Amount PA ID to Bene ficiary: 0.00 | |
463 | ||
464 | Press <RET URN> to Co ntinue, <^ > to exit. | |
465 | ||
466 | CHAM PVA Benefi ciary Dedu ctible 201 8: 50.00 (satisfied ) | |
467 | CHAMPVA F amily Dedu ctible 201 8: 50.00 | |
468 | CHAMP VA Family Catastroph ic Cap 201 8: 591.95 | |
469 | ||
470 | Press <RET URN> to Co ntinue, <^ > to exit. | |
471 | ||
472 | Actions fo r Claim: | |
473 | ||
474 | 1) ASQ (Complete) 2) Qual ity Assura nce (Comp) | |
475 | 3) SNA CAPPS (Pen ding Batch Process) | |
476 | ||
477 | Claim Reas ons: 319 - CFR 17.272(B)( 3) REQUIRE S PROVIDER TO ACCEPT CHAMPVA A LLOWABLE A S FULL PAY MENT. | |
478 | 322 - COST SHARE FOR CLAIM MAY NOT ALWAY S BE PATIE NT LIABILI TY; OHI / CAT CAP MA Y IMPACT. | |
479 | 356 - REMI NDER - MAI L CLAIMS T O: CHAMPVA , PO Box 4 69064, DEN VER, CO 80 246-9064 | |
480 | 371 - WHEN RESUBMITT ING CLAIMS YOU MUST ATTACH THE CHAMPVA E OB FOR PRO PER PROCES SING. | |
481 | ||
482 | Press <RET URN> to co ntinue. | |
483 | ||
484 | ||
485 | C MAC Data | |
486 | ||
487 | ||
488 | Z ip Code: 23456 | |
489 | CHA MPUS Local ity No.: 384 | |
490 | C PT Code: 99204 | |
491 | CMAC Da ta Year: 18 | |
492 | ||
493 | F acility Non-Facili ty Profe ssional Technical | |
494 | - Physicia n $ 129.82 $ 164.96 | |
495 | - Non-Phys ician $ 110.35 $ 140.22 | |
496 | ||
497 | <RETURN> t o continue : | |
498 | ||
499 | CMAC Data | |
500 | ||
501 | ||
502 | Z ip Code: 80909 | |
503 | CHA MPUS Local ity No.: 314 | |
504 | C PT Code: 99204 | |
505 | CMAC Da ta Year: 18 | |
506 | ||
507 | F acility Non-Facili ty Profe ssional Technical | |
508 | - Physicia n $ 132.40 $ 168.68 | |
509 | - Non-Phys ician $ 112.54 $ 143.38 | |
510 | ||
511 | <RETURN> t o continue : | |
512 | ||
513 | ||
514 | ||
515 | DUZ: 83038 8 Health A dministrat ion Center Page: 1 | |
516 | Date: MAR 21, 2018 Post-Pro cessing Cl aim Report | |
517 | Time: 919 | |
518 | ||
519 | PDI: 201807391 000004- BATCH: Cl aim #: RLT 8225 | |
520 | EIN: 043431959 - - S tatus: Pay ment Req. | |
521 | Program: CHAMPVA | |
522 | Vendor: SMITHFIEL D PEDS Type: Out patient | |
523 | Pay Prov?: Yes Ser/Admis Date: MAR 4,2018 | |
524 | Sponsor: HAYNES JR ,MICHAEL H Comp. Date: | |
525 | Bene: HAYNES,DE BORAH POS: DOC TOR'S OFFI C | |
526 | Bene Sex: F Bene DOB: 09/01/63 P L ZIP: 891 11 | |
527 | ||
528 | Press <RET URN> to co ntinue, <^ > to exit. | |
529 | ||
530 | DX's/Px's/ NDC's P/L Unt/Qty Total Chg TotalAA Mcai d O HI #1 PD OHI #1 P R Deduc t Pa yments AI Reas | |
531 | AlwUnt Chg/Unt AA/Unt A ddl OHI OHI PR B al Cst S hare | |
532 | ---------- --------- ------- ---------- - ------- ---- ---- ------- - ---------- -------- --- ----- ------ -- --------- -- ---- | |
533 | R50.9 1 AC | |
534 | ||
535 | 99204-SA 1 1,000.0 0 16 8.08 0.00 126.06 AC | |
536 | 1 1,000.0 0 16 8.08 42.02 | |
537 | ||
538 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ----- | |
539 | Totals: 1,000.0 0 16 8.08 0.00 126.06 | |
540 | 42.02 | |
541 | ||
542 | Press <RET URN> to Co ntinue, <^ > to exit. | |
543 | ||
544 | Tot al Charges Billed: 1,00 0.00 CITI Maximum Re imbursemen t Rate: N/ A | |
545 | Calculated Allowable Amount: 16 8.08 MEDICAID Amount: N/ A | |
546 | A mount Appl ied to Ded uctible: 0.00 Am ount Paid by TPL: N/ A | |
547 | Cos t Share Cr edited to Cat Cap: 4 2.02 Amoun t Reversed from Dedu ctible: N/ A | |
548 | Amount Paid by O ther Insur ance(s): N/A Am ount Rever sed from C at Cap: N/ A | |
549 | Pa tient Resp onsibility Amount: N/A Amount Red uced from Previous P ayment: N/ A | |
550 | Amount Pa id by Bene ficiary to Vendor: 0.00 L ast PDI Pa yment Diff erence: 0.0 0 | |
551 | Total Amount to be PAID o n claim: 12 6.06 Total Paym ent for Cu rrent PDI# 201807391 000004: +126.0 6 | |
552 | Amou nt PAID to Vendor: 12 6.06 | |
553 | Amount PA ID to Bene ficiary: 0.00 | |
554 | ||
555 | Press <RET URN> to Co ntinue, <^ > to exit. | |
556 | ||
557 | ||
558 | CHAM PVA Benefi ciary Dedu ctible 201 8: 50.00 (satisfied ) | |
559 | CHAMPVA F amily Dedu ctible 201 8: 50.00 | |
560 | CHAMP VA Family Catastroph ic Cap 201 8: 147.70 | |
561 | ||
562 | Press <RET URN> to Co ntinue, <^ > to exit. | |
563 | ||
564 | ||
565 | ||
566 | Actions fo r Claim: | |
567 | ||
568 | 1) SNA CAPPS (Pen ding Batch Process) 2) Clai mCheck (Co mplete) | |
569 | ||
570 | ||
571 | Claim Reas ons: 319 - CFR 17.272(B)( 3) REQUIRE S PROVIDER TO ACCEPT CHAMPVA A LLOWABLE A S FULL PAY MENT. | |
572 | 322 - COST SHARE FOR CLAIM MAY NOT ALWAY S BE PATIE NT LIABILI TY; OHI / CAT CAP MA Y IMPACT. | |
573 | 356 - REMI NDER - MAI L CLAIMS T O: CHAMPVA , PO Box 4 69064, DEN VER, CO 80 246-9064 | |
574 | 371 - WHEN RESUBMITT ING CLAIMS YOU MUST ATTACH THE CHAMPVA E OB FOR PRO PER PROCES SING. | |
575 | ||
576 | ||
577 | Press <RET URN> to co ntinue. | |
578 | ||
579 | CM AC Data | |
580 | ||
581 | ||
582 | Z ip Code: 89111 | |
583 | CHA MPUS Local ity No.: 350 | |
584 | C PT Code: 99204 | |
585 | CMAC Da ta Year: 18 | |
586 | ||
587 | F acility Non-Facili ty Profe ssional Technical | |
588 | - Physicia n $ 131.83 $ 168.08 | |
589 | - Non-Phys ician $ 112.06 $ 142.87 | |
590 | ||
591 | <RETURN> t o continue : |
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