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1-5 of 5 Claims Retrieved
Claim ID
Provider
Member
Claim Type
Begin
Charges
Status
RVXCMED00100
MSD Hospital M 09/12/2019 $200 Pended
1 - 1 of 1 items items per page
Error Messages
Code
Description
Batch Date
51303 Member Not Found 09/30/20
51304 Provider Not Found 09/30/20
51302 Claim Not Found 09/30/20
Received:
Input:
Input Method: Electronic (batch)
Last Action:
Next Review:
Paid:
HRA Indicator:
Input:
Payee: Provider
Batch ID:
Processing Application:
ICD Version   Input: ICD-10
Create From Claim ID:
Memo:
Assignment of Benefits:
Explanation of Benefits Ind:
Othr Carrier EOB: No
X-Rays: No
Opt out:
External Entity Received Date:
ER Autopay:
Claim Subtype: Hospital
Status: Pended with Errors
User:
Adjusted Claim ID:
Original Claim ID:
Related FSA Claim ID:
Misc/Image ID:
Network Status:
Payment Drag Date:
Processed: ICD-10
Supp Accident Benefit: 0.00
Input Standard Unique Health ID:
External Refferal: No
External Reauthorization Number:
Date of Current Illness:
Date of Current Illness:
1st Date of Same Illness:
Accepts Assignments: No
Do Notes Exists? No
Letters Exists? No
Authorization #
Date #
Patient Account:
Condition Related To:
Transaction ID:
Electronic External Encounter ID:
Medical Records: No
Anasthesia Related Procedure Codes:
Calculated:
Line
From Date
To Date
POS
TOS
Procedure
Diagnosis
Charges
Units
1 02/16/2018 02/16/2018 11 VO 99215 V33 $250.00 1
2 02/05/2018 02/05/2018 11 LO 01990 A27 $100.00 1
3 02/16/2018 02/16/2018 11 VO 99215 V33 $250.00 1
4 02/05/2018 02/05/2018 11 LO 01990 A27 $100.00 1
5 02/16/2018 02/16/2018 11 VO 99215 V33 $250.00 1
Claim Level
Carrier Type: Commercial
Carrier Paid: $1,000.00
Allowed: $1,000.00
RARC: No
Disallowed: $0.00
Sanction: $0.00
Coinsurance: $0.00
Copay: $0.00
Deductible: $0.00
CARC: No
Line Level
Pro Rated: Yes
Carrier Paid: $500.00
Allowed: $500.00
Adjusted: No
Disallowed: $0.00
Sanction: $0.00
Coinsurance: $0.00
Copay: $0.00
Deductible: $0.00
CARC: No
Line
From Date
To Date
POS
TOS
Procedure
Diagnosis
Charges
Units
1 02/16/2018 02/16/2018 11 VO 99215 V33 $250.00 1
2 02/05/2018 02/05/2018 11 LO 01990 A27 $100.00 1
3 02/16/2018 02/16/2018 11 VO 99215 V33 $250.00 1
4 02/05/2018 02/05/2018 11 LO 01990 A27 $100.00 1
5 02/16/2018 02/16/2018 11 VO 99215 V33 $250.00 1
Benefit Details
Considered Charge: $12,000.00
Allowed: $11,990.00
Disallow $10.00
Deductible $4,500.00
Copay: $0.00
Coinsurance $4,491.00
COB Adjustments $0.00
Benefit: $2,999.00
Considered Allowed: $11,990.00
Considered Benefit $2,999.00
Allowed Units 1
Withhold $0.00
Patient Liability Disallow $0.00
Total Patient Liability $8,991.00
HRA Paid: $0.00
FSA Paid: $0.00
Primary Disallow Explanation: PDC - Provider Agreement Discount.
Capitation Indicator: Noncapitated
Overrides: Yes
Procedure, Diagnosis, Type of Service
Type of Service: SRO
Service Rule: C2O
Procedure: 31000
Additional Modifiers: --
Diagnosis: 431
National Drug Code: --
National Drug Code Units: --
UM
Referral ID: 15IHM0025
Referral: Required
Preauth ID: 23ABCD1234
Preauth: Required
Preauth Charge: $0.00
Neg Amount: $0.00
Additional Line Information
Provider Program: No
Value Based Benefit Rule: 0
Pay Percent: --
Essential Health Benefit ID: --
Miscellaneous Data: --
Surcharge Amount: $0.00
Surcharge Percentage: 0.00
Surcharge Reason: --
Surcharge Explanation: --
Medical Utilization Edit: --
Service Location Zip Input: --