Billing Version 0.0089897

87875644456

  • Case Name : Case Name Here
    Total Visits : 04
  • Referring Physician : Mark B William
    Phone : (676) 909-8989
    Fax : (676) 909-8989
    Doctor's Orders Expires : 08/20/2018
    Total Visits : 07
    Visit Used : 04
    Visits Left : 03
  • * Authorization Expires : 08/20/2018
    Total Visits : 07
    Visit Used : 04
    Visits Left : 03
    Auth# : 0679967867
  • Insurance Eligible Through : 08/20/2018
    Eligibilty Comments : Comments Here...
Date of Birth: 12/02/1978 (38)
Ins Class: Medicare
Ins Name: Max Bupa

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Charge ID
Date of Service
Procedure Code
Units
Charge
Total Charge
Payment
Adjustment
Balance
Ins Balance
Patient Balance
234568017 01/01/2020 97113 2 $23.00 $23.00 $23.00 $0.00 $0.00 $0.00 $0.00
384280176 01/01/2020 97114 2 $23.00 $23.00 $23.00 $0.00 $0.00 $0.00 $0.00
897580176 01/01/2020 97115 2 $23.00 $23.00 $23.00 $0.00 $0.00 $0.00 $0.00
  Deposit Date Transaction Payment Adjustment Transfer Detail Amt From Ins Code Check Number Transfer
Ins Code
  04/14/2020 PCON - INSURANCE PAYMENT CONTRAC $23.00 $0.00 $0.00 Medicare(1001) 98543202 Patient
  07/27/2020 AIWO - INSURANCE ADJUSTMENT $23.00 $0.00 $0.00 Medicare(1001) 32143201 Patient
134878788 01/01/2020 97116 2 $23.00 $23.00 $23.00 $0.00 $0.00 $0.00 $0.00
675348788 01/01/2020 97119 2 $23.00 $23.00 $23.00 $0.00 $0.00 $0.00 $0.00