An Independent Licensee of the BlueCross BlueShield Association. John Doe, MD Chattanooga, 37402 PRFSSIAL LI F BUSISS BC01 RMIAC ADVIC RMIAC DA 10/8/2003 PRVIDR UMBR 1234567 AX IDIFICAI UMBR 123456789 CHCK UMBR 6181057 CHCK DA 10/8/2003 RMIAC UMBR 2003100810000000 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 X123450010 0901-090103 HALL052601 44444444401 10/01/2003 0901-090103 000099213 45.00 0.00 9.00 PSS 10.00 0.00 0.00 26.00 10.00 1234567 CLAIM AL 45.00 0.00 9.00 10.00 0.00.00 26.00 10.00 SMIH JH Q. X345568000 0801-080103 003F1101CM 40000000401 10/01/2003 0801-080103 009351026 500.00 0.00 33.88 PSS 0.00 0.00 0.00 466.12 1234567 0801-080103 000093543 100.00 0.00 6.77 PSS 0.00 0.00 0.00 93.23 0801-080103 000093545 300.00 0.00 20.33 PSS 0.00 0.00 0.00 279.67 0801-080103 009355526 75.00 75.00 RU 0.00 0.00 0.00 0.00 0.00 0801-080103 009355526 100.00 0.00 6.79 PSS 0.00 0.00 0.00 93.21 0801-080103 000099214 75.00 5.08 PSS 15.00 0.00 0.00 54.92 CLAIM AL 1,150.00 75.00 72.85 15.00 0.00 0.00 987.15 90.00 JS SAM U. X687484000 0801-080103 JS444444444 50000000001 10/01/2003 0801-080103 000099213 45.00 0.00 9.00 PSS 0.00 7.20 0.00 28.80 7.20 7654321 CLAIM AL 45.00 0.00 9.00 0.00 7.20 0.00 28.80 7.20 IRS 0.29 ALS 1,240.00 75.00 90.85 25.00 7.20 0.00 1,041.95 107.20 IRS: 0.29 RMIAC AL 1,042.24 PLAS RAI FR YUR RCRDS Visit BlueAccess at www.bcbst.com to view this information and more. For your service questions or issues call 1-800-924-7141
An Independent Licensee of the BlueCross BlueShield Association. John Doe, MD Chattanooga, LI F BUSISS BC01 RMIAC DA 10/08/03 PRVIDR UMBR 1234567 AX IDIFICAI UMBR 123456789 CHCK UMBR 6181057 CHCK DA 10/08/03 RMIAC UMBR 2003100810000000 PAG UMBR 3 F 3 ADJUSM SUMMARY RMIAC ADJUSMS ***Balance Due BCBS: $12,441.57- RMIAC AL: APPLID AMU: CHCK/F AMU: Amount $1,042.24 $12,441.57-.00 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 204537495 409138947 XFBXQ30200 0608-060902 10012003 1,838.00-0.00 1,838.00-0.00 XXXXX XXXXXXX PUBLIC JH Q 204444816 410726336 XDYZH37200 0508-051602 10012003 5,514.00-0.00 5,514.00-0.00 MIS CRYSAL 203768241 562066972 XDFZ15500 1024-102401 10012003 239.35-0.00 239.35-0.00 HALL CHRIS B 203624754 222480483 XDBKC51901 0910-091001 10012003 247.04-0.00 247.04-0.00 JS SAM U 204347315 408686533 XDVXB84600 0408-040802 10012003 1,838.00-0.00 1,838.00-0.00 BURR AAR D 204747567 396420736 XFJS11800 0919-081902 10012003 1,470.40-0.00 1,470.40-0.00 GD JHY B 205275274 412865495 WXGHPC76700 0220-022003 10012003 96,349.00 95,054.40-1,294.78-0.00 AL 12,441.57-0.00 CURR BALAC DU BCBS 0.00 PLAS RAI FR YUR RCRDS Visit e-health Services at www.bcbst.com to view this information and more.
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.
An Independent Licensee of the BlueCross BlueShield Association. Mercy Hospital Chattanooga, 37402 FACILIY RMIAC ADVIC LI F BUSISS BC01 RMIAC DA 10/8/2003 AX IDIFICAI UMBR 62600000000 CHCK UMBR 555555522 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 X123450010 0828-082803 63446789HALL 41234567801 10/02/2003 0828-082804 3101 99213 011 45.00 0.00 9.00 PDI 10.00 0.00 0.00 26.00 0.00 0828-082805 2250 85.00 65.00 PDI 30.00 0.00 0.00 0.00 0.00 CLAIM AL 130.00 0.00 74.00 40.00 0.00 0.00 26.00 64.00 SMIH JH Q. X345568000 0801-080103 48484848SMIH 40000000401 10/01/2003 0801-080103 0710 00935102011 860.55 0.00 341.20 PSS 0.00 0.00 0.00 519.35 0.00 CLAIM AL 860.55 0.00 341.20 0.00 0.00 0.00 519.35 0.00 I IRS 10.27 WRK P MARI 017999097MARI LIDA G. X687484000 40633623000 10/01/2003 0801-080103 0801-080103 110 006 45.00 0.00 9.00 PGR 802-080103 250 82 2,946.00 15.00 XPI 421.00 803-080103 997 100 851.50 12.00 XPI 0.00 CLAIM AL 296 3,842.50 27.00 430.00 0.00 0.00 0.00 3,721.00 121.50 ALS 4,833.05 27.00 845.20 40.00 0.00 0.00 4,276.26 185.50 IRS 10.27 RMIAC AL 4,286.53 PLAS RAI FR YUR RCRDS Visit BlueAccess at www.bcbst.com to view this information and more. For your service questions or issues call 1-800-924-7141
An Independent Licensee of the BlueCross BlueShield Association. Mercy Hospital Chattanooga, RMIAC ADVIC LI F BUSISS BC01 RMIAC DA 10/08/03 PRVIDR UMBR 1234567 AX IDIFICAI UMBR 123456789 CHCK UMBR 6181057 CHCK DA 10/08/03 RMIAC UMBR 2003100810000000 PAG UMBR 3 F 3 ADJUSM SUMMARY RMIAC ADJUSMS ***Balance Due BCBS: $32,441.57- RMIAC AL: APPLID AMU: CHCK/F AMU: Amount $32,441.57 $32,441.57-.00 IFRMAI CLAIM IFRMAI PAYM IFRMAI AM LAS FIRS UMBR SUBSCRIBR UMBR CLAIM UMBR IQUIRY. DA F SRVIC RIGIAL AMU DUCK D Q 204537495 409138947 XFBXQ30200 0608-060902 12312003 1,838.00-0.00 1,838.00-0.00 XXXXX XXXXXXX PUBLIC JH Q 204444816 410726336 XDYZH37200 0508-051602 12312003 5,514.00-0.00 5,514.00-0.00 MIS CRYSAL 203768241 562066972 XDFZ15500 1024-102401 12312003 239.35-0.00 239.35-0.00 HALL CHRIS B 203624754 222480483 XDBKC51901 0910-091001 12312003 247.04-0.00 247.04-0.00 JS SAM U 204347315 408686533 XDVXB84600 0408-040802 12312003 1,838.00-0.00 1,838.00-0.00 BURR AAR D 204747567 396420736 XFJS11800 0919-081902 12312003 1,470.40-0.00 1,470.40-0.00 GD JHY B 205275274 412865495 WXGHPC76700 0220-022003 12312003 96,349.00 95,054.40-1,294.78-0.00 ADJUS. DA PRVIUSLY APPLID CURRLY APPLID BALAC USADIG AL 32,441.57-0.00 XPLAAI CURR BALAC DU BCBS 0.00 PLAS RAI FR YUR RCRDS Visit e-health Services at www.bcbst.com to view this information and more.
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.