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| # | Location | File | Last Modified |
|---|---|---|---|
| 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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