Attachment G: Sample Provider claim summary (pdf)

Example Provider Claim Summary with boxes for textual description.

Section names per image

Box A (upper left section of page)

IMPORTANT:  This document contains information intended for the exclusive use of the individual or entity to whom it is addressed and may contain information that is proprietary, privileged, confidential an/or exempt form disclosure under applicable law.

If you are not the intended recipient (or an employee or agent responsible for delivering this to the intended recipient), you are hereby notified that any disclosure, dissemination, distribution or copying of this inforamtion is strictly prohibited and may be subject to legal restriction or sanction.  Please notify the sender by telephone (toll-free 1-800-634-8540) to arrange the return or destruction of the information and all copies.

Jane Marie Doe
1234 East Street
AnytownUSA, IL 60055

Box B (Top of page next to Logo)

EARLY INTERVENTION
CENTRAL BILLING OFFICE
P.O. BOX 19485
Springfield, IL 62794-9485
1-800-634-8540

Box C (Below Box B)

Invoice: 20010200

Date: 07/06/2005

Page: 1

Provider: 12-3456789

Jane Marie Doe

Box D (Below boxes A & C)

The following is to notify you of the action taken on yoru claim(s).  Checks are sent under separate cover by the state Comptroller's Office.

Please reference the Invoice Number above with the Invoice Number shown on the state check.

Attempted recreation of table on attachment G (line breaks will not match)
Provider Service Information Service Dates Minutes / Miles Billed Not Allowed Remarks Benefit Allowed
Child Doe
Ref: 0078
Claim: 05180T8285
Speech Ther Ind Offsite 04/05/2005 60 min 130.00 59.56 16 70.44
Speech Ther Ind Offsite 04/12/2005 60 min 130.00 59.56 16 70.44
Speech Ther Ind Offsite 04/19/2005 60 min 130.00 59.56 16 70.44
Speech Ther Ind Offsite 04/26/2005 60 min 130.00 59.56 16 70.44
SUBTOTAL 520.00 238.24 281.76
** Paid by Insurance: -281.76

16 Charges exceed the EI program allowable rate.

Box E (below box D - uses same header row)

Attempted recreation of table on attachment G (line breaks will not match) - this table does not actually have the header row repeated
Provider Service Information Service Dates Minutes / Miles Billed Not Allowed Remarks Benefit Allowed
Child Doe
Claim: 05167ST208
Speech Ther Ind Offsite 04/06/2005 60 min 130.00 59.56 16 70.44
Speech Ther Ind Offsite 04/13/2005 60 min 130.00 59.56 16 70.44
Speech Ther Ind Offsite 04/27/2005 60 min 130.00 59.56 16 70.44
Speech Ther Ind Offsite 05/06/2005 60 min 130.00 59.56 16 70.44
Speech Ther Ind Offsite 05/11/2005 60 min 130.00 59.56 16 70.44
650.00 297.80 352.20

16 Charges exceed the EI program allowable rate.

Box F (below Box E)

A waiver from the Early Intervention insurance billing requirement has been approved for the above child.  Billing the child's primary and/or secondary insurance carrier is not required for dates of service within the waiver period.  Claims will be honored by the Central Billing Office in accordance with all Early Intervention program requirements. If you have any questions regarding this billing information, please contact the Central Billing Office Help Desk at 1-800-634-8540

Reason: Waived - Service not covered

Status: Approved

Period: 06/01/05 - 12/31/05

Service: Speech Therapy

Box G (Lower Right Corner)

Total benefit payable: 352.20