|
|
Bill To |
Name |
State |
Subscriber No. |
Rel |
Insured |
Group No. |
|
|---|---|---|---|---|---|---|---|
| P | BH COLORADO ACCESS | CO | J000000 | 1 | Sample, Pat, Q | ||
Id |
Date |
From |
Allowed |
Deduct |
Coins |
Copay |
Paid |
Adjust |
Withheld |
E |
|---|---|---|---|---|---|---|---|---|---|---|
| 2000001 | 06/29/2026 | Patient | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | |
| # | Code | Name | ||
|---|---|---|---|---|
| 1 | 10 | Illness, unspecified | ||
| * |
| Condition Codes | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 |
| 42 RV CC | 43 Description | 44 HCPCS/Rates | 45 Srvc Date | 46 Srvc Unit | 47 Total Charges | 48 Non Convered | 49 | |
|---|---|---|---|---|---|---|---|---|
| 1 | 0900 | Psychological Services | H0023 GT | 06/29/2026 | 1 | 74.00 | ||
| Total Charges | 74.00 |
|---|
| # | Code | POS | TOS | SDOS | EDOS | M1 | M2 | M3 | M4 | ICD1 | ICD2 | ICD3 | ICD4 | Units | Billed Fee | Pro Id | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | |||||||||||||||||
| 2 | |||||||||||||||||
| * |
| Charges | 0.00 |
| Payments ... | 0.00 |
| Balance | 0.00 |
| Charges | 224.00 |
| Payments ... | 0.00 |
| Balance | 224.00 |
| Sl No | Claim/Batch # | Error | Actions |
|---|