Hi All,
Below is a sample report on payments made.
Ideally on another sheet I would list all unique "Payer Claim # / Medicare ICN #".
Then I would need to extract the associated "Patient Control Number" and patient names.
This report is copied from a PDF document into Excel.
There is no consistency in the number of rows or where the patient control number or names appear.
Thank you in advance.
Sample below:
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [1 OF 10]
Service Dates: 02/01/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17040C123177 CH Claim Trace Id: 039034999659656 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 176.61 Paid: $ 0.00 Patient Responsibility: $ 176.61 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 1 Patient Id: 00000 Patient Control Number: 186613
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 2/1/2017 H2014 - 7 176.61 0
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 1 of 10 Page 1 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [2 OF 10]
Service Dates: 01/31/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17040C123273 CH Claim Trace Id: 039034999660656 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 14.03 Paid: $ 0.00 Patient Responsibility: $ 14.03 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 2 Patient Id: 00000 Patient Control Number: 186614
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/31/2017 T1016 - 1 14.03 0
HN
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 2 of 10 Page 2 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [3 OF 10]
Service Dates: 01/27/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17035C099954 CH Claim Trace Id: 034032702671656 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 80.48 Paid: $ 0.00 Patient Responsibility: $ 80.48 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 3 Patient Id: 00000 Patient Control Number: 186458
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/27/2017 H0004 - 4 80.48 0
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 3 of 10 Page 3 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [4 OF 10]
Service Dates: 01/26/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17035C100098 CH Claim Trace Id: 034032699421659 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 92.75 Paid: $ 0.00 Patient Responsibility: $ 92.75 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 4 Patient Id: 00000 Patient Control Number: 186459
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/26/2017 T1016 - 5 92.75 0
HO
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 4 of 10 Page 4 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [5 OF 10]
Service Dates: 01/24/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17034C128311 CH Claim Trace Id: 033031633801657 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 30.40 Paid: $ 0.00 Patient Responsibility: $ 30.40 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 5 Patient Id: 00000 Patient Control Number: 186314
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/24/2017 T1016 - 1 30.4 0
HO
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 5 of 10 Page 5 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [6 OF 10]
Service Dates: 02/06/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17040C123281 CH Claim Trace Id: 039034999273657 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 307.20 Paid: $ 0.00 Patient Responsibility: $ 307.20 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 6 Patient Id: 00000 Patient Control Number: 186788
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 2/6/2017 H0004 - 8 307.2 0
HR
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 6 of 10 Page 6 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [7 OF 10]
Service Dates: 02/01/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17040C123311 CH Claim Trace Id: 039034999591656 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 14.03 Paid: $ 0.00 Patient Responsibility: $ 14.03 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 7 Patient Id: 00000 Patient Control Number: 186713
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 2/1/2017 T1016 - 1 14.03 0
HN
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 7 of 10 Page 7 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [8 OF 10]
Service Dates: 01/19/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17035C100089 CH Claim Trace Id: 034032703019657 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 112.24 Paid: $ 0.00 Patient Responsibility: $ 112.24 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 8 Patient Id: 00000 Patient Control Number: 186407
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/19/2017 T1016 - 8 112.24 0
HN
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 8 of 10 Page 8 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [9 OF 10]
Service Dates: 02/01/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17040C123245 CH Claim Trace Id: 039034999592656 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 14.03 Paid: $ 0.00 Patient Responsibility: $ 14.03 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 9 Patient Id: 00000 Patient Control Number: 186720
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 2/1/2017 T1016 - 1 14.03 0
HN
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 9 of 10 Page 9 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [10 OF 10]
Service Dates: 02/01/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17040C123223 CH Claim Trace Id: 039034999228657 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 70.15 Paid: $ 0.00 Patient Responsibility: $ 70.15 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 10 Patient Id: 00000 Patient Control Number: 186709
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 2/1/2017 T1016 - 5 70.15 0
HN
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 10 of 10 Page 10 of 15
Change Healthcare EFT/Check #: 170410000005725 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 2 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [1 OF 5]
Service Dates: 01/27/2017 Processing Status: 1 - Processed as Primary
Payer Claim # / Medicare ICN #: 17034C128322 CH Claim Trace Id: 033031633798657 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 131.04 Paid: $ 0.00 Patient Responsibility: $ - Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 11 Patient Id: A00162406 Patient Control Number: 186310
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/27/2017 H0004 - 4 131.04 131.04
SUPPLEMENTAL INFORMATION/ADJUSTMENT - ADJUDICATION INFORMATION - CLAIM
Supp/Adj Group Code Description Supp/Adj Reason Code Description Amount $
AMT Supplemental Information AU Coverage Amount 131.04
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 24 Charges are covered under a capitation agreement/managed care plan. Start: 01/01/1995 | Last Modified: 09/30/2007
AMT Supplemental Info B6 Allowed - Actual
Claim 1 of 5 Page 11 of 15
Change Healthcare EFT/Check #: 170410000005725 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 2 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [2 OF 5]
Service Dates: 01/27/2017 Processing Status: 1 - Processed as Primary
Payer Claim # / Medicare ICN #: 17034C128330 CH Claim Trace Id: 033031633797657 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 30.40 Paid: $ 0.00 Patient Responsibility: $ - Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 12 Patient Id: A00162406 Patient Control Number: 186309
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/27/2017 T1016 - 1 30.4 30.4
HO
SUPPLEMENTAL INFORMATION/ADJUSTMENT - ADJUDICATION INFORMATION - CLAIM
Supp/Adj Group Code Description Supp/Adj Reason Code Description Amount $
AMT Supplemental Information AU Coverage Amount 30.4
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 24 Charges are covered under a capitation agreement/managed care plan. Start: 01/01/1995 | Last Modified: 09/30/2007
AMT Supplemental Info B6 Allowed - Actual
Claim 2 of 5 Page 12 of 15
Change Healthcare EFT/Check #: 170410000005725 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 2 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [3 OF 5]
Service Dates: 01/30/2017 Processing Status: 1 - Processed as Primary
Payer Claim # / Medicare ICN #: 17035C100044 CH Claim Trace Id: 034032699458659 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 12.53 Paid: $ 0.00 Patient Responsibility: $ - Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 13 Patient Id: A00162406 Patient Control Number: 186537
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/30/2017 T1016 - 1 12.53 12.53
HN
SUPPLEMENTAL INFORMATION/ADJUSTMENT - ADJUDICATION INFORMATION - CLAIM
Supp/Adj Group Code Description Supp/Adj Reason Code Description Amount $
AMT Supplemental Information AU Coverage Amount 12.53
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 24 Charges are covered under a capitation agreement/managed care plan. Start: 01/01/1995 | Last Modified: 09/30/2007
AMT Supplemental Info B6 Allowed - Actual
Claim 3 of 5 Page 13 of 15
Change Healthcare EFT/Check #: 170410000005725 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 2 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [4 OF 5]
Service Dates: 01/31/2017 Processing Status: 1 - Processed as Primary
Payer Claim # / Medicare ICN #: 17035C100047 CH Claim Trace Id: 034032699466659 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 25.06 Paid: $ 0.00 Patient Responsibility: $ - Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 14 Patient Id: A00162406 Patient Control Number: 186545
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/31/2017 T1016 - 2 25.06 25.06
HN
SUPPLEMENTAL INFORMATION/ADJUSTMENT - ADJUDICATION INFORMATION - CLAIM
Supp/Adj Group Code Description Supp/Adj Reason Code Description Amount $
AMT Supplemental Information AU Coverage Amount 25.06
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 24 Charges are covered under a capitation agreement/managed care plan. Start: 01/01/1995 | Last Modified: 09/30/2007
AMT Supplemental Info B6 Allowed - Actual
Claim 4 of 5 Page 14 of 15
Change Healthcare EFT/Check #: 170410000005725 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 2 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [5 OF 5]
Service Dates: 01/30/2017 Processing Status: 1 - Processed as Primary
Payer Claim # / Medicare ICN #: 17035C100084 CH Claim Trace Id: 034032699366659 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 30.40 Paid: $ 0.00 Patient Responsibility: $ - Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 15 Patient Id: A00162406 Patient Control Number: 186396
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/30/2017 T1016 - 1 30.4 30.4
HO
SUPPLEMENTAL INFORMATION/ADJUSTMENT - ADJUDICATION INFORMATION - CLAIM
Supp/Adj Group Code Description Supp/Adj Reason Code Description Amount $
AMT Supplemental Information AU Coverage Amount 30.4
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 24 Charges are covered under a capitation agreement/managed care plan. Start: 01/01/1995 | Last Modified: 09/30/2007
AMT Supplemental Info B6 Allowed - Actual
Below is a sample report on payments made.
Ideally on another sheet I would list all unique "Payer Claim # / Medicare ICN #".
Then I would need to extract the associated "Patient Control Number" and patient names.
This report is copied from a PDF document into Excel.
There is no consistency in the number of rows or where the patient control number or names appear.
Thank you in advance.
Sample below:
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [1 OF 10]
Service Dates: 02/01/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17040C123177 CH Claim Trace Id: 039034999659656 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 176.61 Paid: $ 0.00 Patient Responsibility: $ 176.61 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 1 Patient Id: 00000 Patient Control Number: 186613
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 2/1/2017 H2014 - 7 176.61 0
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 1 of 10 Page 1 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [2 OF 10]
Service Dates: 01/31/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17040C123273 CH Claim Trace Id: 039034999660656 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 14.03 Paid: $ 0.00 Patient Responsibility: $ 14.03 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 2 Patient Id: 00000 Patient Control Number: 186614
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/31/2017 T1016 - 1 14.03 0
HN
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 2 of 10 Page 2 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [3 OF 10]
Service Dates: 01/27/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17035C099954 CH Claim Trace Id: 034032702671656 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 80.48 Paid: $ 0.00 Patient Responsibility: $ 80.48 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 3 Patient Id: 00000 Patient Control Number: 186458
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/27/2017 H0004 - 4 80.48 0
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 3 of 10 Page 3 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [4 OF 10]
Service Dates: 01/26/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17035C100098 CH Claim Trace Id: 034032699421659 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 92.75 Paid: $ 0.00 Patient Responsibility: $ 92.75 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 4 Patient Id: 00000 Patient Control Number: 186459
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/26/2017 T1016 - 5 92.75 0
HO
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 4 of 10 Page 4 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [5 OF 10]
Service Dates: 01/24/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17034C128311 CH Claim Trace Id: 033031633801657 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 30.40 Paid: $ 0.00 Patient Responsibility: $ 30.40 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 5 Patient Id: 00000 Patient Control Number: 186314
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/24/2017 T1016 - 1 30.4 0
HO
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 5 of 10 Page 5 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [6 OF 10]
Service Dates: 02/06/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17040C123281 CH Claim Trace Id: 039034999273657 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 307.20 Paid: $ 0.00 Patient Responsibility: $ 307.20 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 6 Patient Id: 00000 Patient Control Number: 186788
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 2/6/2017 H0004 - 8 307.2 0
HR
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 6 of 10 Page 6 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [7 OF 10]
Service Dates: 02/01/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17040C123311 CH Claim Trace Id: 039034999591656 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 14.03 Paid: $ 0.00 Patient Responsibility: $ 14.03 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 7 Patient Id: 00000 Patient Control Number: 186713
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 2/1/2017 T1016 - 1 14.03 0
HN
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 7 of 10 Page 7 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [8 OF 10]
Service Dates: 01/19/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17035C100089 CH Claim Trace Id: 034032703019657 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 112.24 Paid: $ 0.00 Patient Responsibility: $ 112.24 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 8 Patient Id: 00000 Patient Control Number: 186407
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/19/2017 T1016 - 8 112.24 0
HN
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 8 of 10 Page 8 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [9 OF 10]
Service Dates: 02/01/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17040C123245 CH Claim Trace Id: 039034999592656 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 14.03 Paid: $ 0.00 Patient Responsibility: $ 14.03 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 9 Patient Id: 00000 Patient Control Number: 186720
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 2/1/2017 T1016 - 1 14.03 0
HN
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 9 of 10 Page 9 of 15
Change Healthcare EFT/Check #: 170410000001501 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 1 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [10 OF 10]
Service Dates: 02/01/2017 Processing Status: 4 - Denied
Payer Claim # / Medicare ICN #: 17040C123223 CH Claim Trace Id: 039034999228657 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 70.15 Paid: $ 0.00 Patient Responsibility: $ 70.15 Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
Remark Codes: N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000
N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 10 Patient Id: 00000 Patient Control Number: 186709
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 2/1/2017 T1016 - 5 70.15 0
HN
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 26 Expenses incurred prior to coverage. Start: 01/01/1995
Claim 10 of 10 Page 10 of 15
Change Healthcare EFT/Check #: 170410000005725 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 2 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [1 OF 5]
Service Dates: 01/27/2017 Processing Status: 1 - Processed as Primary
Payer Claim # / Medicare ICN #: 17034C128322 CH Claim Trace Id: 033031633798657 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 131.04 Paid: $ 0.00 Patient Responsibility: $ - Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 11 Patient Id: A00162406 Patient Control Number: 186310
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/27/2017 H0004 - 4 131.04 131.04
SUPPLEMENTAL INFORMATION/ADJUSTMENT - ADJUDICATION INFORMATION - CLAIM
Supp/Adj Group Code Description Supp/Adj Reason Code Description Amount $
AMT Supplemental Information AU Coverage Amount 131.04
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 24 Charges are covered under a capitation agreement/managed care plan. Start: 01/01/1995 | Last Modified: 09/30/2007
AMT Supplemental Info B6 Allowed - Actual
Claim 1 of 5 Page 11 of 15
Change Healthcare EFT/Check #: 170410000005725 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 2 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [2 OF 5]
Service Dates: 01/27/2017 Processing Status: 1 - Processed as Primary
Payer Claim # / Medicare ICN #: 17034C128330 CH Claim Trace Id: 033031633797657 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 30.40 Paid: $ 0.00 Patient Responsibility: $ - Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 12 Patient Id: A00162406 Patient Control Number: 186309
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/27/2017 T1016 - 1 30.4 30.4
HO
SUPPLEMENTAL INFORMATION/ADJUSTMENT - ADJUDICATION INFORMATION - CLAIM
Supp/Adj Group Code Description Supp/Adj Reason Code Description Amount $
AMT Supplemental Information AU Coverage Amount 30.4
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 24 Charges are covered under a capitation agreement/managed care plan. Start: 01/01/1995 | Last Modified: 09/30/2007
AMT Supplemental Info B6 Allowed - Actual
Claim 2 of 5 Page 12 of 15
Change Healthcare EFT/Check #: 170410000005725 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 2 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [3 OF 5]
Service Dates: 01/30/2017 Processing Status: 1 - Processed as Primary
Payer Claim # / Medicare ICN #: 17035C100044 CH Claim Trace Id: 034032699458659 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 12.53 Paid: $ 0.00 Patient Responsibility: $ - Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 13 Patient Id: A00162406 Patient Control Number: 186537
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/30/2017 T1016 - 1 12.53 12.53
HN
SUPPLEMENTAL INFORMATION/ADJUSTMENT - ADJUDICATION INFORMATION - CLAIM
Supp/Adj Group Code Description Supp/Adj Reason Code Description Amount $
AMT Supplemental Information AU Coverage Amount 12.53
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 24 Charges are covered under a capitation agreement/managed care plan. Start: 01/01/1995 | Last Modified: 09/30/2007
AMT Supplemental Info B6 Allowed - Actual
Claim 3 of 5 Page 13 of 15
Change Healthcare EFT/Check #: 170410000005725 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 2 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [4 OF 5]
Service Dates: 01/31/2017 Processing Status: 1 - Processed as Primary
Payer Claim # / Medicare ICN #: 17035C100047 CH Claim Trace Id: 034032699466659 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 25.06 Paid: $ 0.00 Patient Responsibility: $ - Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 14 Patient Id: A00162406 Patient Control Number: 186545
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/31/2017 T1016 - 2 25.06 25.06
HN
SUPPLEMENTAL INFORMATION/ADJUSTMENT - ADJUDICATION INFORMATION - CLAIM
Supp/Adj Group Code Description Supp/Adj Reason Code Description Amount $
AMT Supplemental Information AU Coverage Amount 25.06
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 24 Charges are covered under a capitation agreement/managed care plan. Start: 01/01/1995 | Last Modified: 09/30/2007
AMT Supplemental Info B6 Allowed - Actual
Claim 4 of 5 Page 14 of 15
Change Healthcare EFT/Check #: 170410000005725 EFT/Check Date: 02/13/2017 EFT/Check Amount: $ 0.00 Payment Type: NON
ERA Check 2 of 2 RBHA 1 CH Payer Id: 33628 CH Process Date: 02/15/2017
Provider Name: Tax Id: 860480412 NPI: 1053362368 Other Payee Id:
Address: 123 Street Addl. Payee Id: 1053362368 POS:
CLAIM PROCESSING INFORMATION - CLAIM [5 OF 5]
Service Dates: 01/30/2017 Processing Status: 1 - Processed as Primary
Payer Claim # / Medicare ICN #: 17035C100084 CH Claim Trace Id: 034032699366659 Place Of Service: Total Adjustment Amount: $ 0.00
Charge: $ 30.40 Paid: $ 0.00 Patient Responsibility: $ - Deductible: $ -
Co-Insurance: $ - Co-Pay: $ - Other/Crossover Insurance:
PATIENT - SUBSCRIBER INFORMATION
Patient Name: Patient 15 Patient Id: A00162406 Patient Control Number: 186396
Corrected Patient/Subscriber Name:
Subscriber Name: Subscriber Id: Group/Policy Id:
Other Subscr. Name: Other Subscriber Id: Group/Policy Id:
REMITTANCE PROCESSING INFORMATION - SERVICE LINE DETAIL
Svc Line # Service Date Proc Code - Units Charge $ Allowed $
Modifiers
1 1/30/2017 T1016 - 1 30.4 30.4
HO
SUPPLEMENTAL INFORMATION/ADJUSTMENT - ADJUDICATION INFORMATION - CLAIM
Supp/Adj Group Code Description Supp/Adj Reason Code Description Amount $
AMT Supplemental Information AU Coverage Amount 30.4
SUPPLEMENTAL INFORMATION/ADJUSTMENT INFORMATION - SERVICE LINES
Svc Line # Supp/Adj Group Code Description Supp/Adj Reason Code Description
1 CO Contractual Obligations 24 Charges are covered under a capitation agreement/managed care plan. Start: 01/01/1995 | Last Modified: 09/30/2007
AMT Supplemental Info B6 Allowed - Actual
