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Fields

Definitions

Claim Number

A system assigned number used to identify a claim.

The first three digits refer to the year (218 = 2018). The next six digits identify the claim. The last two digits may have multiple meanings:

Dates of Service From-Through

The first and last dates that services were performed for this claim.

Group

All patients are associated with a group - this is typically an employer, but can also be a division or sub-division within the employer. Each group is identified by a unique code which is what you see here.

Network

Identifies the network through which the service was provided and applicable benefits were assessed.

Member ID

The system-assigned code used to identify the patient in lieu of a social security code, per HIPAA requirements.

Status and Date

The current status of the claim, and the date this status went into effect. Status options are:

Service Date

The date the service was performed.

Service Code

Three-character code for a specific service.

Charge

The amount charged / billed for the specific service or procedure.

Not Paid

The total amount of the charge that is not covered under the benefit plan.

Reason

This two-character code represents the reason that the claimed service or procedure charge was adjusted or denied.

Covered Amount

The total covered amount for the claim. This is the amount of the claim that your insurance will pay.

Deductible

Lists the base, dollar-denominated amount that a patient is required to payout-of-pocket toward the charges incurred.

Co Ins %

The percentage of the service charge that your insurance covers.

Co Ins Dollars

The dollar amount that your insurance covers for the listed service.

Discount

Lists the dollar-denominated amount that the provider has agreed to waive for the claimed service(s).

Payment

The amount paid to the patient or provider before adjustments.  

Totals

Lists the total charges, total not-paid amounts, total covered amounts, total deductible amounts, total coinsurance dollars and total payments, in that order, for the preceding service lines of the claim.

Adjustments Made To Claim Payments

The total amount of calculated adjustments.

Patient Responsibility

The amount that the patient is responsible for paying.

Employee/Patient - Provider

Lists the patients and/or providers attached to this claim. Underlined provider names appearing in blue are hyperlinks. Left-click on the name to view provider address and contact information.

Withhold

PPO providers can have withholds done when claims are processed and paid. A portion of the payment amount, per service line, can be withheld according to the option that the provider has selected, either a percentage per line or a flat amount per line. These amounts are not paid to the provider at the time of the claim payment, but can be recouped at the end of the year.

Encountered

Encountered is when there is a “capitated” dollar amount taken during the pricing of the claim. This is a negotiated amount for one or more services covered by a capitation agreement and is deducted from the provider’s claim payment.

Payment

If a payment has been paid towards this claim, the amount paid will be shown. If this field is blank, a payment has not been made.

Check Number

If a payment has been paid towards this claim, the check number used will be shown. If the claim number field is blank, no payment has been made.

Service Code Description

A short description of the service code(s) used in the Service Code column, above. For more information, contact your Benefit Administrator.

Reason Code Description

A short description of the reason codes used in the Reason Code column.