EDI Web Viewer / Claim Number

EDI Web Viewer | Claim Number

Submission Type:	{{data.patientHeaderInfo.format}}	Patient Name:	{{data.patientHeaderInfo.patientName}}	Member:	{{data.patientHeaderInfo.memberID}}	PDI:	{{data.patientHeaderInfo.pdi}}
Medicare Crossover:	{{data.patientHeaderInfo.medicareCrossOver}}	Billing NPI:	{{data.patientHeaderInfo.billingNPI}}	TIN:	{{data.patientHeaderInfo.tin}}	PCN:	{{data.patientHeaderInfo.pcn}}

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Patient Information

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Patient ID:	{{data.patientInfo.patientIdNumber}}
Last Name:	RODGERS-CROMARTIE
First Name:	DOMINIQUE
Date of Birth:	{{data.patientInfo.dateOfBirth}}
Gender:	{{data.patientInfo.gender}}
Date of Death:	{{data.patientInfo.dateOfDeath}}

Address 1:	{{data.patientInfo.addressLineOne}}
Address 2:	{{data.patientInfo.addressLineTwo}}
City:	{{data.patientInfo.city}}
State:	{{data.patientInfo.state}}
ZIP Code:	{{data.patientInfo.postalCode}}
Country:	{{data.patientInfo.country}}

Vendor Information

Service Location Information

Tax ID:	{{data.serviceLocationInfo.taxIdNumber}}
Vendor:	{{data.serviceLocationInfo.name}}
Address 1:	{{data.serviceLocationInfo.addressLineOne}}
Address 2:	{{data.serviceLocationInfo.addressLineTwo}}
City:	{{data.serviceLocationInfo.city}}
State:	{{data.serviceLocationInfo.state}}
ZIP Code:	{{data.serviceLocationInfo.postalCode}}
Country:	{{data.serviceLocationInfo.country}}
NPI:	{{data.serviceLocationInfo.npi}}

Billing Provider Information

Tax ID:	{{data.serviceLocationInfo.taxIdNumber}}
Vendor:	{{data.serviceLocationInfo.name}}
Address 1:	{{data.serviceLocationInfo.addressLineOne}}
Address 2:	{{data.serviceLocationInfo.addressLineTwo}}
City:	{{data.serviceLocationInfo.city}}
State:	{{data.serviceLocationInfo.state}}
ZIP Code:	{{data.serviceLocationInfo.postalCode}}
Country:	{{data.serviceLocationInfo.country}}
NPI:	{{data.serviceLocationInfo.npi}}

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