Primary: Healthco Amalgamated (12345678) Seconday: Health Industries Incorporated 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 | ||||
| $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 | |||||||||
| Miscellaneous | Provider Accepted Assignment: A Patient Paid: $99.99 | |||||||||||