PLEASE RETAIN FOR YOUR RECORDS

Transcription

1 An Independent Licensee of the BlueCross BlueShield Association. John Doe, MD Chattanooga, PRFSSIAL LI F BUSISS BC01 RMIAC ADVIC RMIAC DA 10/8/2003 PRVIDR UMBR AX IDIFICAI UMBR CHCK UMBR CHCK DA 10/8/2003 RMIAC UMBR PAG UMBR 1 F 3 IFRMAI CLAIM IFRMAI PAYM IFRMAI LAS AM ACCU # BLU PRFRRD FIRS AM MMBR ID CLAIM UMBR RCVD D SRV PRV DA F SRVIC FRM/HRU PRCDUR / MDIFIR AL CHARGS - CVRD CRAC WRI FF DD/ CPAY CIS HR ISURAC/ MDICAR CLAIM PAID IRS PAID WS HALL CHRIS B X HALL /01/ PSS CLAIM AL SMIH JH Q. X F1101CM /01/ PSS PSS PSS RU PSS PSS CLAIM AL 1, JS SAM U. X JS /01/ PSS CLAIM AL IRS 0.29 ALS 1, , IRS: 0.29 RMIAC AL 1, PLAS RAI FR YUR RCRDS Visit BlueAccess at to view this information and more. For your service questions or issues call

2 An Independent Licensee of the BlueCross BlueShield Association. John Doe, MD Chattanooga, LI F BUSISS BC01 RMIAC DA 10/08/03 PRVIDR UMBR AX IDIFICAI UMBR CHCK UMBR CHCK DA 10/08/03 RMIAC UMBR PAG UMBR 3 F 3 ADJUSM SUMMARY RMIAC ADJUSMS ***Balance Due BCBS: $12, RMIAC AL: APPLID AMU: CHCK/F AMU: Amount $1, $12, IFRMAI CLAIM IFRMAI PAYM IFRMAI AM SUBSCRIBR CLAIM UMBR DA F ADJUS. RIGIAL PRVIUSLY CURRLY BALAC LAS FIRS UMBR UMBR IQUIRY. SRVIC DA AMU APPLID APPLID USADIG XPLAAI DUCK D Q XFBXQ , , XXXXX XXXXXXX PUBLIC JH Q XDYZH , , MIS CRYSAL XDFZ HALL CHRIS B XDBKC JS SAM U XDVXB , , BURR AAR D XFJS , , GD JHY B WXGHPC , , , AL 12, CURR BALAC DU BCBS 0.00 PLAS RAI FR YUR RCRDS Visit e-health Services at to view this information and more.

3 What ach Column on Your Commercial Professional Remittance Advice Means to You: Column xplanation umber 1 Patient s last name and patient s account number. 2 Patient s first name and member ID number. 3 he claim number (assigned by BlueCross BlueShield of ennessee), the date the Claim was RIGIALLY received by BlueCross BlueShield of ennessee and the servicing provider ID number. 4 he date of the service (beginning and ending date). 5 he code that describes the procedure that was performed and applicable modifiers. 6 he total charge for the specified service. 7 he amount of the total charge that is not covered by the patient s health plan. 8 he explanation code which explains any charge that is not covered by the patient s health plan. (See Remittance xplanations list for code description). 9 he amount of the total charge that the provider is responsible for based on contractual agreements. 10 he explanation code which explains any amount that the provider is responsible for based on contractual agreements. (See Remittance xplanations list for code description). 11 he amount of the deductible or copay that is the patient responsibility. 12 he amount of the total charge that the patient is responsible for. 13 he amount of the charge paid by another insurance company (or Medicare). 14 he amount of the total charge that will be reimbursed by BlueCross BlueShield of ennessee. Also, any applicable interest that may apply to the claim payment will be indicated here. 15 he amount of the billed charge that is the patient responsibility.

4 An Independent Licensee of the BlueCross BlueShield Association. Mercy Hospital Chattanooga, FACILIY RMIAC ADVIC LI F BUSISS BC01 RMIAC DA 10/8/2003 AX IDIFICAI UMBR CHCK UMBR CHCK DA 10/8/2003 RMIAC UMBR ########### PAG UMBR 1 F 3 IFRMAI CLAIM IFRMAI PAYM IFRMAI LAS AM HSP CHAR # FIRS AM MMBR ID CLAIM UMBR RCVD D DA F SRVIC FRM/HRU RV CD PRC CD DRG U I AL CHARGS - CVRD CRAC WRI FF DD/ CPAY CIS HR ISURAC/ MDICAR CLAIM PAID IRS PAID WS U WRK P HALL CHRIS B X HALL /02/ PDI PDI CLAIM AL SMIH JH Q. X SMIH /01/ PSS CLAIM AL I IRS WRK P MARI MARI LIDA G. X /01/ PGR , XPI XPI 0.00 CLAIM AL 296 3, , ALS 4, , IRS RMIAC AL 4, PLAS RAI FR YUR RCRDS Visit BlueAccess at to view this information and more. For your service questions or issues call

5 An Independent Licensee of the BlueCross BlueShield Association. Mercy Hospital Chattanooga, RMIAC ADVIC LI F BUSISS BC01 RMIAC DA 10/08/03 PRVIDR UMBR AX IDIFICAI UMBR CHCK UMBR CHCK DA 10/08/03 RMIAC UMBR PAG UMBR 3 F 3 ADJUSM SUMMARY RMIAC ADJUSMS ***Balance Due BCBS: $32, RMIAC AL: APPLID AMU: CHCK/F AMU: Amount $32, $32, IFRMAI CLAIM IFRMAI PAYM IFRMAI AM LAS FIRS UMBR SUBSCRIBR UMBR CLAIM UMBR IQUIRY. DA F SRVIC RIGIAL AMU DUCK D Q XFBXQ , , XXXXX XXXXXXX PUBLIC JH Q XDYZH , , MIS CRYSAL XDFZ HALL CHRIS B XDBKC JS SAM U XDVXB , , BURR AAR D XFJS , , GD JHY B WXGHPC , , , ADJUS. DA PRVIUSLY APPLID CURRLY APPLID BALAC USADIG AL 32, XPLAAI CURR BALAC DU BCBS 0.00 PLAS RAI FR YUR RCRDS Visit e-health Services at to view this information and more.

6 What ach Column on Your Commercial Facility Remittance Advice Means to You: Column xplanation umber 1 Patient s last name and hospital chart number. 2 Patient s first name and member ID number. 3 he claim number (assigned by BlueCross BlueShield of ennessee) and the date the claim was RIGIALLY received by BlueCross BlueShield of ennessee. 4 he date of the service (beginning and ending date). 5 he revenue code for the specified procedure. 6 he code that describes the service that was performed and the DRG number (if applicable). 7 he number of units for the service. 8 he total charge for the service. 9 he amount of the total charge that that is not covered by the patient s health plan. 10 he explanation code which explains any amount that is not covered by the patient s health plan (See Remittance xplanations list for code description). 11 he amount of the total charge that the provider is responsible for based on contractual agreements. 12 he explanation code which explains any amount that the provider is responsible for based on contractual agreements (See Remittance xplanations list for code description). 13 he amount of the deductible or copay that is the patient responsibility. 14 he amount of the total charge that the patient is responsible for. 15 he amount of the charge paid by another insurance company (or Medicare). 16 he amount of the total charge that will be reimbursed by BlueCross BlueShield of ennessee. Also, any applicable interest that may apply to the claim payment will be indicated here. 17 he amount of the billed charge that is the patient responsibility.