Submission Details

PDI or Claim ID RFAI Status RFAI Submission Date Response Due Date
{{model.claimId || dummy}} {{model.rfaiStatus || dummy }} {{model.rfaiSubmissionDate || dummy}} {{model.responseDate}}
Payer Name Payer ID Payer Claim Control Number Contact Information
{{model.payerName || dummy}} {{model.payerId || dummy}} {{model.payerClaimControlNumber || dummy}} {{model.contactInfo || dummy}}
Billing Provider Billing Provider NPI Billing Provider TIN Submitted By
{{model.billingProvider || dummy}} {{model.providerNpi || dummy}} {{model.providerTin || dummy}} {{model.submittedBy || dummy}}
Patient Last Name Patient First Name Patient Identifier Patient Control Number
{{model.patientLastname || dummy}} {{model.patientFirstName || dummy}} {{model.patientIdentifier || dummy}} {{model.patientcontrolNumber || dummy}}
Information Receiver Bill Type Clearinghouse ID Medical Record Number
{{model.informationReceiver || dummy}} {{model.billType || dummy}} {{model.clearingHouseId || dummy}} {{model.medicalRecordNumber || dummy}}
Service From Service To
{{model.serviceFromDate || dummy }} {{model.serviceToDate || dummy}}

Attachments Requested

HCCS Category Code LOINC Code LOINC Modifier1 LOINC Modifier2 Level Service Line Attachment(s)
{{attachment.statusCode || dummy}} {{attachment.loincCodes || dummy}} {{attachment.loincModCodes1 || dummy}} {{attachment.loincModCodes2 || dummy}} {{attachment.claimLevel || dummy}} {{attachment.serviceLine || dummy}} {{attachment.attachments || dummy}}

Affected Service Lines

Service Line Service From Service To Revenue Code Procedure Code Modifiers Charge Amount
{{line.serviceLineId || dummy}} {{line.serviceFrom || dummy}} {{line.serviceTo || dummy}} {{line.revenueCode || dummy}} {{line.procedureCode || dummy}} {{line.modifiers || dummy}} {{line.chargeAmount? (line.chargeAmount| currency:'USD':true:'1.2-2'):dummy}}

Related 277 RFAIs

Update Comments