Credit payment & adjustments off of Member s Account

Transcription

1 PAGE: 1 10/29/2014 PROVIDER REIMBURSEMENT VOUCHER PROVIDER S NAME PROVIDER NO: _ TAX ID: _ CLAIMS PAID *** SECURE CARE *** CHECK NUMBER: PER PROVIDER LETTER CLAIM IS PAID IN DUPLICATE. 03/24/ /24/ /24/2014 J /24/2014 J TOTAL Add payment & adjustments back on to Member s Account 09/29/ L SQ TOTAL

2 PAGE: 2 PROVIDER S NAME PROVIDER NO: TAX ID: _ Provider s Name Provider s Street Address City, State & Zip NUMBER OF CLAIMS 3 TOTAL BILLED $ BALANCE CARRIED FORWARD $186.37CR COPAYMENTS $4.43CR WITHHOLD $3.80CR And you will still have this outstanding credit ACCOUNT STATUS BILLED CHARGES # CLAIMS CLAIMS PAID / DENIED $ CLAIMS IN PROCESS $ TOTAL ALL CLAIMS $ PROVIDER HAS THE RIGHT TO APPEAL DECISION. REFER TO THE APPEAL PROCESS IN THE PROVIDER BILLING MANUAL. HOLD UNTIL YOU RECEIVE A VOUCHER THAT IS ACCOMPANIED WITH A CHECK OR ELECTRONIC DEPOSIT

3 PAGE: 1 11/05/2014 PROVIDER REIMBURSEMENT VOUCHER PROVIDER S NAME PROVIDER NO: _ TAX ID: _ CLAIMS PAID *** SECURE CARE *** CHECK NUMBER: /07/ L SQ 3 TOTAL

4 PAGE: 2 PROVIDER S NAME PROVIDER NO: TAX ID: _ Provider s Name Provider s Street Address City, State & Zip NUMBER OF CLAIMS 1 TOTAL BILLED $ TOTAL TO BE PAID $34.90 CREDIT BALANCE $186.37CR BALANCE CARRIED FORWARD $151.47CR COPAYMENTS $35.00 WITHHOLD $.71 And you will still have this outstanding credit ACCOUNT STATUS BILLED CHARGES # CLAIMS CLAIMS PAID / DENIED $ CLAIMS IN PROCESS $ TOTAL ALL CLAIMS $ PROVIDER HAS THE RIGHT TO APPEAL DECISION. REFER TO THE APPEAL PROCESS IN THE PROVIDER BILLING MANUAL. *** FOR CUSTOMER SERVICE CALL *** COMMERCIAL: or (740) PEIA: or (740) SECURE CARE: or (740) MOUNTAIN HEALTH TRUST: or (740) ALL THESE CLAIMS WERE DENIED FOR A CORRECTED NPI NUMBER. You do not have to hold this voucher. These claims should be corrected and re-submitted to The Health Plan as soon as possible so they don t deny for Timely Filing.

5 PAGE: 1 11/12/2014 PROVIDER REIMBURSEMENT VOUCHER PROVIDER S NAME PROVIDER NO: _ TAX ID: _ CLAIMS DENIED *** SECURE CARE *** RENDERING NPI MISSING 10/22/ /22/ TOTAL NPI CLAIM CODES: 206 RENDERING NPI MISSING 10/22/ AS /22/ AS TOTAL NPI CLAIM CODES: 206 RENDERING NPI MISSING 10/29/ TOTAL NPI CLAIM CODES: 206

6 PAGE: 2 PROVIDER S NAME PROVIDER NO: TAX ID: _ Provider s Name Provider s Street Address City, State & Zip NUMBER OF CLAIMS 3 TOTAL BILLED $7, CREDIT BALANCE $151.47CR BALANCE CARRIED FORWARD $151.47CR ACCOUNT STATUS BILLED CHARGES # CLAIMS Outstanding credit carried over and not reduced because nothing paid this time. CLAIMS PAID / DENIED $7, CLAIMS IN PROCESS $ TOTAL ALL CLAIMS $7, PROVIDER HAS THE RIGHT TO APPEAL DECISION. REFER TO THE APPEAL PROCESS IN THE PROVIDER BILLING MANUAL. *** FOR CUSTOMER SERVICE CALL *** COMMERCIAL: or (740) PEIA: or (740) SECURE CARE: or (740) MOUNTAIN HEALTH TRUST: or (740) HOLD UNTIL YOU RECEIVE A VOUCHER THAT IS ACCOMPANIED WITH A CHECK OR ELECTRONIC DEPOSIT

7 PAGE: 1 11/19/2014 PROVIDER REIMBURSEMENT VOUCHER PROVIDER S NAME PROVIDER NO: _ TAX ID: _ CLAIMS PAID *** SECURE CARE *** CHECK NUMBER: /15/ L SQ 3 TOTAL

8 PAGE: 2 PROVIDER S NAME PROVIDER NO: TAX ID: _ Provider s Name Provider s Street Address City, State & Zip NUMBER OF CLAIMS 2 TOTAL BILLED $1, TOTAL TO BE PAID $67.97 CREDIT BALANCE $151.47CR BALANCE CARRIED FORWARD $83.50CR COPAYMENTS $35.00 WITHHOLD $1.39 And you will still have this outstanding credit ACCOUNT STATUS BILLED CHARGES # CLAIMS CLAIMS PAID / DENIED $1, CLAIMS IN PROCESS $ TOTAL ALL CLAIMS $1, PROVIDER HAS THE RIGHT TO APPEAL DECISION. REFER TO THE APPEAL PROCESS IN THE PROVIDER BILLING MANUAL. *** FOR CUSTOMER SERVICE CALL *** COMMERCIAL: or (740) PEIA: or (740) SECURE CARE: or (740) MOUNTAIN HEALTH TRUST: or (740)

9 PAGE: 1 12/17/2014 PROVIDER REIMBURSEMENT VOUCHER PROVIDER S NAME PROVIDER NO: _ TAX ID: _ NOW IF YOU POST ALL THE DEBITS AND CREDITS, YOU WILL BALANCE OUT TO THE CHECK OR ELECTRONIC DEPOSIT AMOUNT. CLAIMS PAID *** SECURE CARE *** CHECK NUMBER: /13/ L SQ TOTAL /03/ L SQ CLAIM CODES: TOTAL /29/ L SQ TOTAL /13/ L SQ 3 TOTAL CLAIMS DENIED *** SECURE CARE *** 10/22/ /22/ TOTAL R1 CLAIM CODES: 16 10/22/ AS /22/ AS TOTAL R1 CLAIM CODES: 16

10 PAGE: 4 PROVIDER S NAME PROVIDER NO: TAX ID: _ Provider s Name Provider s Street Address City, State & Zip NUMBER OF CLAIMS 6 TOTAL BILLED $8, TOTAL TO BE PAID $ LESS ADVANCE $83.50CR NET PAID $ COPAYMENTS $35.00 WITHHOLD $8.99 Outstanding credit has now cleared and you receive a check in this amount. ACCOUNT STATUS BILLED CHARGES # CLAIMS CLAIMS PAID / DENIED $8, CLAIMS IN PROCESS $16, TOTAL ALL CLAIMS $25, PROVIDER HAS THE RIGHT TO APPEAL DECISION. REFER TO THE APPEAL PROCESS IN THE PROVIDER BILLING MANUAL. *** FOR CUSTOMER SERVICE CALL *** COMMERCIAL: or (740) PEIA: or (740) SECURE CARE: or (740) MOUNTAIN HEALTH TRUST: or (740)