Claim Number A system assigned number used to identify a claim.
Dates of Service From-Through The first and last dates that services were performed for this claim.
Group The Underwriter and Group Code of the group the patient belongs to.
Social Security Number The patient's social security number.
Status and Date The current status of the claim, and the date this status went into
effect.
Service Date The date the service was performed.
Service Code Three-digit code which represents the place of service.
Charge The dollar amount charged to the patient for the procedure.
Covered Amount The total covered amount for the claim.
Not Paid An accumulation of all not-covered amounts.
Reason Code Claim adjustment reason codes indicate the reason a claim has been adjusted.
Co Ins % Displays the coinsurance percentage at which the claim was paid.
Payment The amount
paid to the patient or provider before
adjustments.
Totals Lists the totals for charges, covered amounts, not paid amounts, and
payments prior to adjustments.
Adjustments The total amount of calculated adjustments.
Employee/Patient - Provider Lists the patients and/or providers attached to this claim.
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 description of service codes used within the claim. Service codes
are HIPAA-defined.
Reason Code Description A description of reason codes used within the claim. Reason codes are
HIPAA-defined.