Page Title

Section Header

Claim ID Claim Status Patient Control # Pre-authorization #
999999999999 INPROCESS ABC123456 1234567890

Veteran Information
ID: 0123456789012345678901234567889
First Name: DOMINIQUE
Last Name: RODGERS-CROMARTIE
Middle Name: EMMANUEL
Address 1: 1122 CONSTITUTION ST
Address 2: APT 1234
City: INDIAN HARBOUR BCH
State: FL
Zip: 012345

Card Header
ID: 0123456789012345678901234567889
First Name: DOMINIQUE
Last Name: RODGERS-CROMARTIE
Middle Name: EMMANUEL
Address 1: 1122 CONSTITUTION ST
Address 2: APT 1234
City: INDIAN HARBOUR BCH
State: FL
Zip: 012345

Card Header
ID: 0123456789012345678901234567889
First Name: DOMINIQUE
Last Name: RODGERS-CROMARTIE
Middle Name: EMMANUEL
Address 1: 1122 CONSTITUTION ST
Address 2: APT 1234
City: INDIAN HARBOUR BCH
State: FL
Zip: 012345

Card Header
ID: 0123456789012345678901234567889
First Name: DOMINIQUE
Last Name: RODGERS-CROMARTIE
Middle Name: EMMANUEL
Address 1: 1122 CONSTITUTION ST
Address 2: APT 1234
City: INDIAN HARBOUR BCH
State: FL
Zip: 012345
Label
Content
Label
Content

Table Section

Number of Results: 1,234,567

Alphabetical Heading Numerical Heading Heading Alphabetical Heading Numerical Heading History Button
Whoosiewhatzits Things 1,456 Stuff Thingamabobs Junk Dohickies 637 Accoutrements
Whachamacallits Materials 1,001,857 Doomaflidgies Goods Whachamacallits Materials 1,001,857 Doomaflidgies
Elements Gobbledigook 12,234,326 Impedimenta Paraphanelia Junk Dohickies 637 Accoutrements
Junk Dohickies 637 Accoutrements Items Junk Dohickies 637 Accoutrements

Simple Table Header

Alphabetical Heading Numerical Heading Heading
Whoosiewhatzits Things 1,456 Stuff Thingamabobs
Whachamacallits Materials 1,001,857 Doomaflidgies Goods
Elements Gobbledigook 12,234,326 Impedimenta Paraphanelia
Junk Dohickies 637 Accoutrements Items

Claim Line Items

Alphabetical Heading Numerical Heading Heading
Whoosiewhatzits Things 1,456 Stuff Thingamabobs
Whachamacallits Materials 1,001,857 Doomaflidgies Goods
Elements Gobbledigook 12,234,326 Impedimenta Paraphanelia
Junk Dohickies 637 Accoutrements Items

Payment Line Items

Alphabetical Heading Numerical Heading
Whoosiewhatzits Things 1,456 Stuff
Whachamacallits Materials 1,001,857 Doomaflidgies
Elements Gobbledigook 12,234,326 Impedimenta
Junk Dohickies 637 Accoutrements

Form Elements

Modal Testing

Status Messages

The following claims cannot be disapproved because they are completed, partially reconciled or rejected:
1181514, 2158691, 1141414
Congratulations! The following claims are completed, partially reconciled or rejected:
1181514, 2158691, 1141414
The following claims cannot be disapproved because they are completed, partially reconciled or rejected: 1181514, 2158691, 1141414, 1181514, 2158691, 1141414, 1181514, 2158691, 1141414
Congratulations! The following claims are completed, partially reconciled or rejected: 1181514, 2158691, 1141414
The following claims cannot be disapproved because they are completed, partially reconciled or rejected: 1181514, 2158691, 1141414, 1181514, 2158691, 1141414, 1181514, 2158691, 1141414
Congratulations! The following claims are completed, partially reconciled or rejected: 1181514, 2158691, 1141414
Congratulations! The following claims are completed, partially reconciled or rejected: 1181514, 2158691, 1141414
Congratulations! The following claims are completed, partially reconciled or rejected:
1181514, 2158691, 1141414

Tab Testing

Other Insurance # (Secondary Payer): 0123456789012345678901234567889
Other Insurance Plan (Secondary Payer): INSURANCE CORPORATION
Other Insurance # (Tertiary Payer): 0123456789012345678901234567889
Other Insurance Plan (Tertiary Payer): INSURANCE COMPANY
Admission Date: 01/01/2017
Discharge Date: 01/01/2017
Covered Days: 365
Provider DRG: FL
Attending Physician: A. GONZALES
Treasury Payment Date (PD): 01/01/2017
Total Paid Amount per PD: $9,999.00
Check / EFT / TRN: 012345
CARC: 012345
Total Amount per CARC: $9,999.00
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No line items found.
Alphabetical Heading Numerical Heading Heading Alphabetical Heading Numerical Heading Heading Button
Whoosiewhatzits Things 1,456 Stuff Thingamabobs Junk Dohickies 637 Accoutrements Items
Whachamacallits Materials 1,001,857 Doomaflidgies Goods Whachamacallits Materials 1,001,857 Doomaflidgies Goods
Elements Gobbledigook 12,234,326 Impedimenta Paraphanelia Junk Dohickies 637 Accoutrements Items
Junk Dohickies 637 Accoutrements Items Junk Dohickies 637 Accoutrements Items
No rejection history found.
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Primary OHI Payer ID: 012334567890
OHI Payer Name: AAA Insurance Company Other Subscriber Info: Subscriber Name
Payment Seq. Indicator: P ID Code: 000123456
OHI Group Name: AAA Insurance Group Secondary ID: 0001234567890
Filing Indicator: MA Remittance Date: 01/01/2017
Insurance Type: N/A Payer Prior Authorization #: 01234567890
Claim Adj. Date: 01/01/2017 Payer Prior Reference #: 34567891230
RARC Codes: ZZ123, ZZ124, ZZ125, ZZ126, ZZ127, ZZ128, ZZ129, ZZ130, ZZ131, ZZ132, ZZ133
OHI Paid Amount Total Non-Covered Quantity Adjustment Code Adjustment Amount
$9999.99 $999.99 1
1
2		 ZZ123
ZZ124
ZZ125		 $799.99
$100.00
$100.00

Secondary OHI Payer ID: 012334567890
OHI Payer Name: BBB Insurance Company Other Subscriber Info: Subscriber Name
Payment Seq. Indicator: S ID Code: 000123456
OHI Group Name: BBB Insurance Group Secondary ID: 0001234567890
Filing Indicator: MA Remittance Date: 01/01/2017
Insurance Type: N/A Payer Prior Authorization #: 01234567890
Claim Adj. Date: 01/01/2017 Payer Prior Reference #: 34567891230
RARC Codes: ZZ123, ZZ124, ZZ125, ZZ126, ZZ127, ZZ128, ZZ129, ZZ130, ZZ131, ZZ132, ZZ133
OHI Paid Amount Total Non-Covered Quantity Adjustment Code Adjustment Amount
$9999.99 $999.99 1
1
2		 ZZ123
ZZ124
ZZ125		 $799.99
$100.00
$100.00

Tertiary OHI Payer ID: 012334567890
OHI Payer Name: CCC Insurance Company Other Subscriber Info: Subscriber Name
Payment Seq. Indicator: T ID Code: 000123456
OHI Group Name: CCC Insurance Group Secondary ID: 0001234567890
Filing Indicator: MA Remittance Date: 01/01/2017
Insurance Type: N/A Payer Prior Authorization #: 01234567890
Claim Adj. Date: 01/01/2017 Payer Prior Reference #: 34567891230
RARC Codes: ZZ123, ZZ124, ZZ125, ZZ126, ZZ127, ZZ128, ZZ129, ZZ130, ZZ131, ZZ132, ZZ133
OHI Paid Amount Total Non-Covered Quantity Adjustment Code Adjustment Amount
$9999.99 $999.99 1
1
2		 ZZ123
ZZ124
ZZ125		 $799.99
$100.00
$100.00
OHI Paid TOTAL Non-Covered TOTAL     Adjustment TOTAL
$9999.99 $999.99     $99999.99

OHI Line Adjustments

Line ID OHI ID PST Service Date Adj. Date Revenue Code PROC Billed Amt. OHI Paid Amt. Non-Covered Amt. CAGC Adj. Reason Code Adj. Amount
1 O123456789 P 01/01/2017 01/01/2017 1234 ZZ123 $9999.99 $9999.99 $9999.99 1 ABC123 $9999.99
1 O123456789 P 01/01/2017 01/01/2017 1234 ZZ123 $9999.99 $9999.99 $9999.99 1 ABC123 $9999.99
1 O123456789 P 01/01/2017 01/01/2017 1234 ZZ123 $9999.99 $9999.99 $9999.99 1 ABC123 $9999.99
1 O123456789 P 01/01/2017 01/01/2017 1234 ZZ123 $9999.99 $9999.99 $9999.99 1 ABC123 $9999.99
1 O123456789 P 01/01/2017 01/01/2017 1234 ZZ123 $9999.99 $9999.99 $9999.99 1 ABC123 $9999.99
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Wildcards

For text fields, search parameters will match exact value (but case insensitive) by default. For example, an entry of “John” will return only “John,” or “JOHN,” or “john,” but not “Johnson.”

Partial entries can be searched by use of wildcard character(s) at any place in the text field. the wildcard characters are the percent (%) sign and the underscore (_) character. For example, to match both “12345” and “12367,” the entry of “123%” or “123__” can be given. The percent sign can be used to match any number of characters, while the underscore can be used to match any single character.

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