Manual Reconciliation | Out of System Payment

Success

The following error occurred: {{message}}

Claim ID	Veteran Name
{{claimDetail.claimId}}	{{claimDetail.veteranInfo.firstName + ' ' + claimDetail.veteranInfo.lastName}}
Claim Type	Billing Provider Name
{{claimDetail.claimType}}	{{claimDetail.billingProviderInfo.lastName}}
Claim Status	Service Provider Name
{{claimDetail.claimStatus}}	{{claimDetail.serviceProviderInfo.lastName}}

Amount Billed	Description of Service	Check Number
Line Number {{lineItem.line_number}}
{{lineItem.billed_amount}}	{{lineItem.remittance_remark_code}}	{{lineItem.check_eft_trn}}
Service Date From	Service Date To	Check Date
{{lineItem.service_from_date}}	{{lineItem.service_to_date}}	{{lineItem.treasury_payment_date}}
Payment Amount
{{lineItem.paid_amount}}

Payment Information

Payment Type Required

Authorization or Check # Required Alphanumeric Only

Payment Date mm/dd/yyyy Required

Amount VA Will Pay $$.¢¢ Required

Adjustment 1

Amount $$.¢¢ Required

Group Code

Claim Adjustment Reason Code (CARC)

Remittance Advice Remark Code (RARC) Maximum 2 Selections

Clear RARC for Adjustment 1

Adjustment 2

Amount $$.¢¢ Required

Group Code

Claim Adjustment Reason Code (CARC)

Remittance Advice Remark Code (RARC) Maximum 2 Selections

Clear RARC for Adjustment 2

Adjustment 3

Amount $$.¢¢ Required

Group Code

Claim Adjustment Reason Code (CARC)

Remittance Advice Remark Code (RARC) Maximum 2 Selections

Clear RARC for Adjustment 3

Adjustment 4

Amount $$.¢¢ Required

Group Code

Claim Adjustment Reason Code (CARC)

Remittance Advice Remark Code (RARC) Maximum 2 Selections

Clear RARC for Adjustment 4

Adjustment 5

Amount $$.¢¢ Required

Group Code

Claim Adjustment Reason Code (CARC)

Remittance Advice Remark Code (RARC) Maximum 2 Selections

Clear RARC for Adjustment 5

CAGC / CARC / RARC Selection Summary

Adjustment {{i+1}}
Amount:	${{adjustment.amount}}
Business Rule:
Group Code:	{{adjustment.groupCode}}
CARC:	{{adjustment.CARC}}
RARC 1	{{adjustment.RARCs[0]}}
RARC 2	{{adjustment.RARCs[1]}}