This Tab displays the details of the payments and payment advice information that has been received in response to a claim submission.
Associated EOPs
Patient Name: DAVELL, RICHARD
Patient Code:
Claim Number: 61693A
Settlement Date: 03/05/2007
Provider: John J Smith, MD
Payer:
Payment Type: NON
Check/ACH Number: 123
HCFA Claim Payment Status Code: 1 - Processed as Primary
RTN/Account Number: /
CONCERT Remittance Status: Remittance processed
Total Check Amount: 0.00
Service Date
CPT Code
ADJ Code
Description
Qty
Billed Amount
Adjust Amount
Payment Amount
01/24/2007
76770
US EXAM ABDO BACK WALL, COMP
0
261.00
85.49
Total:
Total Claim Payment:
*** End of Report ***