Primary Payer ID: |
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Payment Seq. Indicator: | P |
Filing Indicator: |
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Claim Adjustment Date: |
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Other Payer Name: |
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OHI Group Name: |
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Insurance Type: |
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Covered Days: |
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Lifetime Reserve Days: |
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Lifetime Psych. Days: |
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Claim DRG Amount: |
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Claim Disproportionate Share: |
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MSP Pass-Thru Amt: |
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Claim PPS Capital Amt: |
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PPS Claim Capital FSP DRG: |
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PPS Claim Capital HSP DRG: |
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PPS Claim Capital DSH DRG: |
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PPS Oper. Fed. Spec. DRG Amt: |
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Old Capital Amount: |
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PPS Capital IME Amount: |
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PPS Oper. Hosp. Spec. DRG Amt: |
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PPS Capital Outlier Amount: |
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Claim Indirect Teaching Amt: |
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Non-Payable Prof. Component: |
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PPS Capital Exception Amt: |
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Cost Report Day Count: |
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Reimbursement Rate: |
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Claim HCPCS Pay Amt: |
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ESRD Paid Amount: |
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Non-Payable Prof: |
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Secondary Payer ID: |
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Payment Seq. Indicator: | S |
Filing Indicator: |
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Claim Adjustment Date: |
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Other Payer Name: |
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OHI Group Name: |
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Insurance Type: |
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Covered Days: |
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Lifetime Reserve Days: |
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Lifetime Psych. Days: |
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Claim DRG Amount: |
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Claim Disproportionate Share: |
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MSP Pass-Thru Amt: |
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Claim PPS Capital Amt: |
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PPS Claim Capital FSP DRG: |
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PPS Claim Capital HSP DRG: |
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PPS Claim Capital DSH DRG: |
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PPS Oper. Fed. Spec. DRG Amt: |
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Old Capital Amount: |
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PPS Capital IME Amount: |
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PPS Oper. Hosp. Spec. DRG Amt: |
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PPS Capital Outlier Amount: |
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Claim Indirect Teaching Amt: |
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Non-Payable Prof. Component: |
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PPS Capital Exception Amt: |
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Cost Report Day Count: |
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Reimbursement Rate: |
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Claim HCPCS Pay Amt: |
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ESRD Paid Amount: |
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Non-Payable Prof: |
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Tertiary Payer ID: |
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Payment Seq. Indicator: | T |
Filing Indicator: |
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Claim Adjustment Date: |
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Other Payer Name: |
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OHI Group Name: |
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Insurance Type: |
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Covered Days: |
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Lifetime Reserve Days: |
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Lifetime Psych. Days: |
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Claim DRG Amount: |
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Claim Disproportionate Share: |
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MSP Pass-Thru Amt: |
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Claim PPS Capital Amt: |
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PPS Claim Capital FSP DRG: |
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PPS Claim Capital HSP DRG: |
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PPS Claim Capital DSH DRG: |
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PPS Oper. Fed. Spec. DRG Amt: |
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Old Capital Amount: |
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PPS Capital IME Amount: |
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PPS Oper. Hosp. Spec. DRG Amt: |
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PPS Capital Outlier Amount: |
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Claim Indirect Teaching Amt: |
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Non-Payable Prof. Component: |
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PPS Capital Exception Amt: |
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Cost Report Day Count: |
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Reimbursement Rate: |
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---|---|
Claim HCPCS Pay Amt: |
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ESRD Paid Amount: |
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Non-Payable Prof: |
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