| Patient ID: | 1234567890 | Address 1: | 1122 Maple Street |
|---|---|---|---|
| Last Name: | RODGERS-CROMARTIE | Address 2: | Apt. B |
| First Name: | DOMINIQUE | City: | New York |
| Date of Birth: | 01/01/1935 | State: | NY |
| Gender: | M | ZIP Code: | 123456 |
| Date of Death: | 01/01/2018 | Country: | USA |
| Tax ID: | 1234567890 | Tax ID: | 1234567890 |
|---|---|---|---|
| Last Name: | RODGERS-CROMARTIE | Address 2: | Apt. B |
| Vendor: | GENERAL DIAGNOSTIC IMA... | Vendor: | GENERAL MEMORIAL HOSPITAL |
| Address 1: | 2000 SOUTH U.S. HIGHWAY 1 | Address 1: | 1212 SOUTH U.S. HIGHWAY 1 |
| Address 2: | - | Address 2: | - |
| City: | New York | City: | New York |
| State: | NY | State: | NY |
| ZIP Code: | 123456 | ZIP Code: | 123456 |
| Country: | USA | Country: | USA |
| NPI: | 1234567890 | NPI: | 1234567890 |
POS: 22
Frequency: 1
| DX: | 1: | A12.64 | 2: | B56.78 | 3: | C56.78 | 4: | D56.78 | 5: | E56.78 | 6: | F56.78 | 7: | G56.78 | 8: | H56.78 | 9: | I56.78 | 10: | J56.78 | 11: | K56.78 |
|---|
Service Lines
| Line # | Service From | Service To | POS | DX Pointer | PROC/NDC | Modifiers | Qty. / Type | Amount |
|---|---|---|---|---|---|---|---|---|
| 1 | 01/01/2017 | 01/01/2017 | 22 | 1, 2, 3 | 12345 | AB99 | 99 ------ UN | $999.99 |
| 1 | 01/01/2017 | 01/01/2017 | 22 | 1, 2, 3 | 12345 | AB99 | 99 ------ UN | $999.99 |
| 1 | 01/01/2017 | 01/01/2017 | 22 | 1, 2, 3 | 12345 | AB99 | 99 ------ UN | $999.99 |
| Total Changes: $9999.99 |
Primary: Healthco Amaigated(12345678)
Secondary: Health Industries Incorporated (34567890)
Tertiary: Y
| Claim Level Adjustments: | Primary Paid | Adj. | Adj. Amount | Secondary Paid | Adj. | Adj. Amount | Tertiary Paid | Adj. | Adj. Amount | |
|---|---|---|---|---|---|---|---|---|---|---|
| $999.99 | AB99 | $99.99 | $999.99 | AB99 | $99.99 | $999.99 | AB99 | $99.99 |
| Line # | Svc. From | Amount | PROC | Primary Paid | Adj. | Adj. Amount | Secondary Paid | Adj. | Adj. Amount | Tertiary Paid | Adj. | Adj. Amount |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 01/01/2017 | $999.99 | 123456 | $999.99 | AB99 | $99.99 | $999.99 | AB99 | $99.99 | $999.99 | AB99 | $99.99 |
| 1 | 01/01/2017 | $999.99 | 123456 | $999.99 | AB99 | $99.99 | $999.99 | AB99 | $99.99 | $999.99 | AB99 | $99.99 |
| 1 | 01/01/2017 | $999.99 | 123456 | $999.99 | AB99 | $99.99 | $999.99 | AB99 | $99.99 | $999.99 | AB99 | $99.99 |
| Remittance Remark Codes: | A12, B34, C56, D78, E99 | A12, B34, C56, D78, E99 | A12, B34, C56, D78, E99 | |||||||||
| Miscellaneous | Provider Accepted Assignment: A | Patient Paid: $99.99 |