Attachment G: Sample Provider claim summary (pdf)
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
