Contractor

DMERC C

MEDICARE

RUN DATE

11/12/99

Program

DMEEC230

EDIT

RUN TIME

22:08:08

Reprot ID

REPORT

PAGE NO.

1

Originating DMERC

RUN TYPE

PROD

 

 

 

 

 

 

 

 

Supplier

HICN

CCN

BENE NAME

PAT ACCT NBR

TOTAL SUBMITTED

SERV DATE

BILL SLIP

STATUS

ALLEN MARGARET

00133

6442.56

19991109

A

 

YOUR SUPPLIER NUMBER, PATIENT MEDICARE NUMBER AND THE CLAIM CONTROL NUMBER APPEAR IN THESE COLUMNS

ALLEN MARGARET

00133

270.91

19991109

A

ALLEN MARGARET

00133

347.68

19991109

A

BARNEY IRA

00132

3019.07

19991108

A

BARNEY IRA

00132

329.28

19991108

A

BARNEY IRA

00132

587.24

19991108

A

HENINGBURG DANIEL

00115

928.83

19991109

A

LOWERY WINONA

00134

5841.13

19991109

A

LOWERY WINONA

00134

753.48

19991109

A

LOWERY WINONA

00134

347.68

19991109

A

PAIGE WILLIE

00109

5441.70

19991004

A

PAIGE WILLIE

00137

1002.40

19991109

A

SAUNDERS EVELYN

00135

5943.45

19991110

A

SAUNDERS EVELYN

00135

475.26

19991110

A

TAYLOR ROBERT

00136

5575.48

19991110

A

TAYLOR ROBERT

00136

495.66

19991110

A

TAYLOR ROBERT

00136

406.05

19991110

A

ASSIGNED

17

NONASSIGNED

0

TOTAL NUMBER OF CLAIMS RECEIVED

17

ASSIGNED

50

NONASSIGNED

0

TOTAL NUMBER OF LINES RECEIVED

50

ASSIGNED

41207.86

NONASSIGNED

00

TOTAL DOLLAR VALUE OF CLAIMS RECEIVED

41207.86

STATUSES

A=ACCEPTED

R=REJECTED

TX= TRANSFERRED TO DMERC X

RX=REJECTED FOR NSF ERRORS AND SENT TO WRONG REGION


THIS REPORT IS FAXED TO YOU EVERY MORNING (KNOWN AS THE "EDIT REPORT") AND SHOWS CLAIMS THAT WERE SUBMITTED THE PREVIOUS DAY. THE REPORT SHOWS THE NUMBER OF ASSIGNED AND NON-ASSIGNED CLAIMS TRANSMITTED, THE DOLLAR AMOUNT OF EACH CLAIM, AND THE NUMBER OF CLAIMS REJECTED (IF ANY).