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

Ledger Full

 
11/11/2018   11:22:10 AM
Date of
Service
Location
Location
Identifier
Provider
CPT Code
Mod
1
Mod
2
Mod
3
Insurance PreAuth Dx1  Units
Charge
Amount
Patient
Payments
Balance
Patient
Balance
Insurance
Payments
Insurance
Adjustments
Insurance
Balance
Primary
Payments
Secondary
Payments
Tertiary
Payments
Charge ID Case ID Status
4/11/2008 Indian School PT - James Miller 97110 LT RT MT ORTHONET HEALTHNET - 72610 1 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2678628 139222 Active
4/11/2008 Indian School PT - Mark Peterson 97110 CL RT MT ORTHONET HEALTHNET - 72610 1 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2678628 139222 Active
Total 280 $360.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ($0.00) $0.00 $0.00