QuickView Info: A     QuickView Info: B

Patient Account #: 1234567
Place of Service: 22
Frequency: 1
Statement From/To: 01/01/2018 to 01/01/2018
Previous PDI/Claim ID: 123456789
Admission Type: UNK
Admission Source: UNK
Admission Date/Time: 01/01/2018     13:00
Accident Date: 01/01/2018
Patient Paid Amt: $999.99
Patient Signature: B
Patient Status: UNK
Prior Authorization: 123456789
Referral Number: 123456789
Provider Accept Asmt: A
Assignment of Benefits: Y
Discharge Date/Time: 01/01/2018     15:00
Accident Ind: 12 34 56

POS: 22     Frequency: 1

DX:     1:   A12.34 2:   B56.78 3:   C56.78 4:   D56.78 5:   E56.78 6:   F56.78 7:  G56.78
Total Charges:    $99999.99
Primary OHI Payer ID: 1234567
Payment Seq. Indicator: P
Filing Indicator: CI
Claim Adjustment Date: 01/01/2018
OHI Payer Name: Healthcare Amalgamated Incorporated
OHI Group Name: Healthco Health Group
Insurance Type: X

Medicare Outpatient Adjudication

Reimbursement Rate: 99%
Claim HCPCS Pay Amt: $999.99
Remit. Remark Codes: A123
B345
C567
D789
ESRD Paid Amount: $999.99
Non-Payable Prof.: $99.99

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Secondary OHI Payer ID: 1234567
Payment Seq. Indicator: P
Filing Indicator: CI
Claim Adjustment Date: 01/01/2018
OHI Payer Name: Healthcare Amalgamated Incorporated
OHI Group Name: Healthco Health Group
Insurance Type: X

Medicare Outpatient Adjudication

Reimbursement Rate: 99%
Claim HCPCS Pay Amt: $999.99
Remit. Remark Codes: A123
B345
C567
D789
ESRD Paid Amount: $999.99
Non-Payable Prof.: $99.99

Lorem ipsum dolor sit amet consectetur adipisicing elit. Voluptas praesentium autem velit error illo a dolores sit? Porro exercitationem, ab sit tempora sint maiores. Perferendis neque at odit corporis libero. Dolores quos exercitationem, vitae perspiciatis cumque, impedit iure reprehenderit mollitia vel delectus, quas quasi qui in quo recusandae ipsam neque! Quas, qui!

OHI Service Line Adjustments

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
$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 01/01/2017 123456 $999.99 AB99 $99.99 $999.99 AB99 $99.99 $999.99 AB99 $99.99
1 01/01/2017 01/01/2017 123456 $999.99 AB99 $99.99 $999.99 AB99 $99.99 $999.99 AB99 $99.99
1 01/01/2017 01/01/2017 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