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}} |