Claim information

In the Claim Snapshot, you can select a particular claim line and the information to view for that line. Below those two options (Line Selection and Line View) is information that applies to the claim, for example, the billing provider, who the claim is paid to, and the date the claim was received.

Claim Snapshot field descriptions

Field	Description
Billing Provider	The individual or organization that issued the bill for the services listed on the claim. Point to the field to show the billing provider's Tax ID. To view billing provider information, click to the right of Billing Provider. The Billing Provider Information tab displays in a Provider Session.
Pay To	Indicates who the payment will be made to: Member. Provider.
Received Date	The date the fund office received the claim. If you're releasing a held claim based on newly received information or copying data from a duplicate claim, you must change the received date. Depending on your setup , the received date defaults to the current date if no entry is made, or the received date is an editable field. If so, enter a period (.) to default to the received date of the last claim, or enter a new date. Important: If a claim's pends were resolved or if a duplicate claim's data was copied, the Received Date might not be the original received date. Depending on your software version, you might see a next to the Received Date field. Hover over this icon to view the claim's original received date.
Place of Service	The code and description identifying the location where service was rendered.
Bill Type	Bill type is a 4-digit code that applies to institutional claims, where each digit identifies specific information: 1st digit is a leading zero and isn't used in ServiceXG. 2nd digit is the facility type. 3rd is the bill classification. 4th is the submission frequency.
Prepaid fields	Prepaid fields display when you click to the left of the Billing Provider. These are prepaid claim amounts that apply to the whole claim and are distributed evenly between all claim lines. Account—The account ID that the provider assigned to the patient. Member—The claim amount prepaid by the member. Medicare—The claim amount prepaid by Medicare. Other Ins—The amount of the claim prepaid by some other insurance.

• Click to the left of the Billing Provider field to display any prepaid claim amounts. These prepaid amounts apply to the whole claim and are distributed evenly between all claim lines.
• Click to the right of the Billing Provider field to open the billing provider's information (Billing Provider Information tab) in a provider session.

Switch viewports by selecting an option from the Line View list. The viewports show different claim line information.

Use the Line Selection or click a claim line in the viewport to view a different claim line. The row you select, is high-lighted. You can always use this to indicate which claim line you're viewing when you switch viewports.

• Beneath the viewport area is a "splitter" that you can drag up or down to adjust the size of the viewport area.

The viewports are:

• Detail—Shows basic information for a claim line. For example, the from and through dates, procedure code, primary diagnosis code, and billed, ineligible, and prepaid amounts. The total billed, ineligible, and prepaid amounts for the claim show at the bottom of the table.

  Claim Detail viewport field descriptions

  Column	Description
  #	The claim line number. If the entire claim is in Held or Audit status, then this field is blank.
  Rev Cd	HIPAA HIPAA (Health Insurance Portability and Accountability Act of 1996) is the United States legislation that provides data privacy and security provisions for safeguarding medical information.-compliant, three-digit code consistent with the National Uniform Billing Committee. Revenue Codes are descriptions and dollar amounts charged for hospital services provided to a patient. The revenue code tells an insurance company whether the procedure was performed in the emergency room, operating room or another department. The claim schedule determines if revenue accounting is necessary for the claim line. Note: 837I claims, may require Revenue codes.
  HCPS	The Healthcare Common Procedure Coding System (HCPCS) is a set of codes that standardize identification of medical services, supplies, and equipment. There are two sets of codes. The first, or Level I, code set is a five-digit numeric code that contains the Physicians Current Procedural Terminology (CPT) maintained by the American Medical Association. The second code set, or Level II is a code set for medical services not included in Level I, such as durable medical equipment, prosthetics, orthotics and supplies. These codes are alpha-numeric and begin with a single letter followed by four numbers.
  Modifiers	Procedure code modifiers—office or medical organization-defined codes that provide additional information concerning a particular service and can be used in the service price calculation.
  From Dt	The start date for the service provided.
  Thru Dt	The end date for the service provided.
  PoS	Place Of Service. Numeric code describing the location where service was rendered. The codes are defined by the plan administrators but also include basys defaults.
  Proc	A code that identifies a specific service performed by a service provider.
  Billed Amt	The amount billed for the line item.
  Qty	The number of times the service was provided.
  BCode	The benefit code representing a benefit or service covered in the Summary Plan Description document (e.g. eye exam, emergency outpatient care, or an office medical visit).
  Inelig Amt	The amount that isn't eligible for payment.
  Considered Amt	The amount considered for payment. It is calculated as follows: Billed Amount - Ineligible Amount.

• Liability—Shows the patient, provider, and FSA Accounts offered and administered by employers that provide a way for employees to set aside, out of their paycheck, pretax dollars to pay for the employee’s share of insurance premiums or medical expenses not covered by the employer’s health plan. liability calculated amounts and indicates if an operator overrode one of the liability calculations.

  Liability viewport field descriptions

  Column	Description
  #	The claim line number. If the entire claim is in Held or Audit status, then this field is blank.
  Patient Liability	Amount the patient owes. Note: The amount is calculated automatically, but you can override it on the Claim Entry or Processing Overrides workspace.
  Provider Liability	Amount that is the provider's responsibility. For example, a provider belongs to a network and bills $90 for a procedure. The network only allows $50. If the claim is paid at 100% (no patient responsibility), then the provider is liable for the remaining $40. Note: The amount is calculated automatically, but you can override it on the Claim Entry or Processing Overrides workspace.
  PPO Discount	The Preferred Provider Organization (PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount.) discount is the amount the member saves using a network provider. The PPO discount is the difference between the provider's billed amount and the PPO's allowed amount. If the plan doesn't use a PPO network, it will be zero. Note: The amount is calculated automatically, but you can override it on the Claim Entry or Processing Overrides workspace.
  Potential FSA Liability	Amount that could be FSA Accounts offered and administered by employers that provide a way for employees to set aside, out of their paycheck, pretax dollars to pay for the employee’s share of insurance premiums or medical expenses not covered by the employer’s health plan. eligible. Patient Liability—Non-reimbursable Ineligible Amounts. Note: The amount is calculated automatically, but you can override it on the Claim Entry or Processing Overrides workspace.
  Overridden	A Yes indicates an operator overrode a liability calculation (patient, provider, FSA, or PPO discount) from the Override workspace. To see who overrode the liability calculation check the Operator Override viewport.

• Miscellaneous—Shows additional information about the procedure—the laterality or specific digit affected. It also shows the revenue code if revenue accounting is used to calculate the claim line.

  Miscellaneous viewport field descriptions

  Column	Description
  #	The claim line number. If the entire claim is in Held or Audit status, then this field is blank.
  Laterality	The side of the body affected by the procedure. L—Left side of the body R—Right side of the body
  Digit	The toe or finger affected by the procedure. The possible values are 1 through 5, where the number represents a particular digit.
  Revenue Code	HIPAA HIPAA (Health Insurance Portability and Accountability Act of 1996) is the United States legislation that provides data privacy and security provisions for safeguarding medical information.-compliant, three-digit code consistent with the National Uniform Billing Committee. Revenue Codes are descriptions and dollar amounts charged for hospital services provided to a patient. The revenue code tells an insurance company whether the procedure was performed in the emergency room, operating room or another department. The claim schedule determines if revenue accounting is necessary for the claim line. Note: 837I claims, may require Revenue codes.

• Operator Override—Shows the name of the operator that overrode the claim calculation, liability calculation, eligibility or PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount. for a claim line.

  Operator Override viewport field descriptions

  Column	Description
  #	The claim line number. If the entire claim is in Held or Audit status, then this field is blank.
  Claim Calculation	The operator ID of the person who performed the override on the claim calculation.
  Claim Calculation Date	Date the claim calculation was overridden.
  Liability	The operator ID of the person who performed the liability calculation (patient, provider, FSA Accounts offered and administered by employers that provide a way for employees to set aside, out of their paycheck, pretax dollars to pay for the employee’s share of insurance premiums or medical expenses not covered by the employer’s health plan., or PPO discount) override. You can view the liability amounts on the Liability viewport.
  Liability Date	Date the claim liability calculation was overridden.
  Eligibility	The operator ID of the person who performed the override.
  Eligibility date	Date the claim eligibility was overridden.
  PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount.	The operator ID of the person who performed the PPO override.
  PPO Date	Date the PPO was overridden.

• Referrals—Shows the referrals for a claim line. The referral information includes the service covered by the referral, the approved number of visits or dollar amount covered by the referral, and the actual quantity used or applied.

  Referrals viewport field descriptions

  Column	Description
  #	The claim line number. If the entire claim is in Held or Audit status, then this field is blank.
  Referral Number	A user-defined referral number.
  Service Code	The service code for the service covered by the referral. This could be a user-defined service code or a procedure code.
  Service Code Description	A description of the service code.
  Approved Qty	The number of approved visits or the approved dollar amount for this referral.
  Applied Qty	The quantity used.
  Accumulated Qty	The total applied quantity for all claim lines using this referral. There could be more than one claim using this referral.
  Qty Type	Indicates if the quantity is a dollar amount or number of visits. D—Dollars Q—Quantity (number of visits)
  Overapplied	A check mark in this column means that the total used quantity (accumulated quantity) is more than what was approved (approved quantity) for the referral.

• Service Provider—Shows the service provider's name, ID, and NPI A unique identifier issued by the National Plan and Provider Enumeration System (NPPES) to all health care providers who want to send or receive HIPAA transactions. The NPI is required under HIPAA legislation for all HIPAA transactions..

  Service Provider viewport field descriptions

  Column	Description
  #	The claim line number. If the entire claim is in Held or Audit status, then this field is blank.
  Name	The provider who renders the services submitted by the billing provider.
  Service ID	The service provider's ID number.
  NPI	The service provider’s National Provider Identifier (NPI). This is a 10-digit ID assigned to the provider by the National Plan and Provider Enumeration System (NPPES). It is possible for service providers under one billing provider to have the same NPI. For example, groups or organizations with multiple subparts could share the same NPI.

• Summary—Shows calculated amounts for the line item, such as the billed, considered, allowed, and covered amounts, along with any discount information. Total amounts for the claim show at the bottom of the table.

  Summary viewport field descriptions

  Column	Description
  #	The claim line number. If the entire claim is in Held or Audit status, then this field is blank.
  Billed	The amount billed for the line item.
  Considered	The amount considered for payment. It is calculated as follows: Billed Amount - Ineligible Amount.
  Allowed	The allowed amount. The considered amount compared to the UCR The Usual, Customary, and Reasonable amounts allowed for a procedure. UCR compares the charge for a procedure to the amount other doctors have charged for the procedure. UCR data can be external data obtained from HIAA or MDR by geographic area, or can be compiled internally. The allowed determination can be based on a percentile; for example, the 85th percentile would cover the charges of 85% of the doctors who submitted bills. or fee schedule amount and the lesser of the two is the amount allowed for the line item.
  Covered	The amount covered by providers. It is calculated as follows: (Allowed Amount - Deductibles) multiplied by (Co-Insurance %).
  Net Covered	The amount that is covered under the plan rules. It is calculated as follows: Covered Amount - COB adjustments.
  Discount	This discount amount. The discount is either: Net Covered Amount multiplied by Discount Percentage OR a configurable discount amount ( e.g. a provider discount or a claim schedule discount)
  MS Discount	The member share discount. This is calculated as follows: Discount (previous column) - a Discount Amount.
  Disc Code	A code that identifies and defines the discount taken on the net covered amount. Note: Discounts taken on billed or considered amounts are considered as ineligible amounts.
  Paid Amount	The actual benefit amount paid. It is calculated as follows: Net Covered Amount - Discount Amount.

• Adjustment—Displays claim information that was adjusted for various reasons, including claim underpayment or overpayment, prior payments adjustments, or disputed case credits.

  Adjustment viewport field descriptions

  Column	Description
  Adj Seq	Adjustment Sequence. Sequence number for the claim adjustment.
  Claim Ref#	Reference number for the adjusted claim.
  Status	The status of the claim. See the Claim statuses topic for descriptions.
  Adjusted From	Reference number of the original claim that was adjusted to a new claim. For example, if claim A100 is the original claim, the new claim, A102, was adjusted from A100.
  Adjusted To	Reference number of the new claim that was adjusted from the original claim. For example, if claim A102 is the new claim, the original claim, A100, is adjusted to A102.
  Action Date	The last date any adjustment changes were made to the claim.
  Reason Code	A code that identifies the adjustment reason. These codes can be site specific. AD—admission choice error BA—billed amount error BC—benefit code error BP—billing provider choice error BQ—billed quantity error CB—COB/prepaid entry error CD—check damaged CL—claimant choice error D—diagnosis error DC—disputed case choice error DP—duplicate claim DS—dates of service error IL—illness choice error PA—provider address error PO—payment override error PP—PPO choice/pre-priced entry error PR—procedure error RD—received date error RF—referral choice error RS—referral service choice error
  Adj Operator	Adjustment Operator. The operator ID of the person who made the change.
  Prior Pay Adj	The prior payment amount for the associated claim, if applicable.
  Paid Amt	The actual benefit amount paid. It is calculated as follows: Net Covered Amount - Discount Amount.

• Prepaids—Displays the member, Medicare, and other prepaid amounts as well as their totals.

  Note: Prepaid amounts apply at each line, not at the claim level.
  Prepaids viewport field descriptions

  Column	Description
  #	The claim line number. If the entire claim is in Held or Audit status, then this field is blank.
  Member Prepaid	Claim amount the member prepaid.
  Medicare Prepaid	Claim amount that Medicare prepaid.
  Medicare Allowed	Prepaid amount that is allowed Medicare allows.
  Other Prepaid	Claim amount prepaid by other insurance carriers.
  Other Allowed	Prepaid amount that is allowed by another insurance carrier.

• Recall History—Shows information related to a released claim that was recalled including the date and time, the operator that recalled the claim, and the prior release operator.

  Recall History viewport field descriptions

  Column	Description
  Recall Date/Time	The last date and time the released claim was recalled.
  Recall Operator	The operator ID of the person who made the change.
  Prior Released Date/Time	The date and time the claim was released prior to being recalled.
  Prior Release Operator	The operator ID of the person that released the claim prior to it being recalled.

Below the viewports are the workspaces. Each workspace shows different information.

The workspace tabs are:

• Line—Shows more information for the Detail viewport. For example, for the selected claim line, the Line workspace lists descriptions of procedure, diagnosis, type of service, and benefit codes. Also, the workspace shows the ineligible codes associated with the ineligible amount and gives a break down of the line item prepaid amount.

  Line workspace field descriptions

  Field	Description
  From Date	The start date for the service provided.
  Through Date	The end date for the service provided.
  Revenue Code	HIPAA HIPAA (Health Insurance Portability and Accountability Act of 1996) is the United States legislation that provides data privacy and security provisions for safeguarding medical information.-compliant, three-digit code consistent with the National Uniform Billing Committee. Revenue Codes are descriptions and dollar amounts charged for hospital services provided to a patient. The revenue code tells an insurance company whether the procedure was performed in the emergency room, operating room or another department. The claim schedule determines if revenue accounting is necessary for the claim line. Note: 837I claims, may require Revenue codes.
  Quantity	The number of times the service was provided.
  Billed	The amount billed for the line item.
  Procedure Code	A code that identifies a specific service performed by a service provider.
  Ineligible	Charges might not be eligible for payment for many reasons including duplicate charges, services not covered, and coverage not in effect. Code—A code and description that explains why a claim amount was denied. Amount—The claim amount that is ineligible.
  Diagnosis Code(s)	Code—An ICD International Classification of Diseases. A coding system developed by the World Health Organization (WHO) for the classification of diseases, symptoms, abnormal findings, external causes of injury, and cause of death. Includes both ICD-9 and ICD-10 codes. code that identifies the service provider's opinion of the patient's disease or condition based on examination. Description—The ICD code description. Primary—When there are multiple codes, a indicates the primary diagnosis code.
  Line Item Provider	The service provider ID and name.
  Type of Service (ToS)	A code and description for the type of service provided by the service provider. Note: If you change a claim's ToS, you'll be asked if you want to apply the new ToS to all claim lines. Click Yes to update or No to only change the selected claim line.
  Benefit Code	The benefit code representing a benefit or service covered in the Summary Plan Description document (e.g. eye exam, emergency outpatient care, or an office medical visit).
  Prepaid	If there is a prepaid amount at the claim level (on the Detail viewport), it is automatically distributed to each claim line. Type—Identifies the source of the prepaid amount, allowed amount, and PPO affiliation: Member, Medicare, Other insurance. Prepaid—The claim amount that was paid previously. Allowed—Applies to Medicare and other insurance. The amount that is allowed for the claim. PPO Flag—Applies to Medicare and other insurance. A Y indicates the plan is affiliated with a PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount..

• Dental—On a dental claim the tooth and service information, such as the tooth number shows for the selected claim line.

  Dental workspace field descriptions

  Column	Description
  Tooth	The tooth number or group of teeth (can include a quadrant of the mouth), the dentist indicated the procedure was performed. Universal/USA System 1-32—Permanent Teeth A-T—Primary Teeth UR—Upper Right Quadrant (1-8) UL—Upper Left Quadrant (9-16) LL—Lower Left Quadrant (17-24) LR—Lower Right Quadrant (25-32) A + following the tooth number, e.g. A+, means the tooth is supernumerary (an additional tooth beyond the regular number of teeth).
  The following tooth surfaces show a in the associated column if affected.
  Mesial (M)	The forward side of the tooth. The mesial of the tooth is found on the "in between surface" of the tooth next to it.
  Distal (D)	The back side of the tooth.
  Occlusal (O)	The chewing surface of the tooth.
  Buccal (B)	The cheek-side of the tooth. This surface is also referred to as the facial surface when referring to the front teeth.
  Lingual (L)	The part of the tooth that is closest to the tongue. This part of the tooth is also called the labial surface.
  Labial (LA)	The side of an anterior tooth that faces towards the lips.
  Facial (F)	The side of a tooth that is adjacent to (or the direction towards) the inside of the lips.
  Incisal (I)	The direction towards the biting edge of anterior teeth or something relating to this edge, incisal guidance or incisal edge.
  Grooves (G)	A groove on the occlusal surface of a posterior tooth. Posterior teeth in general have three types of grooves: dissectional or primary grooves, secondary grooves, and auxiliary grooves.

• Calc Detail—Shows how the amount covered by the fund was calculated for the selected claim line. On this workspace you'll see the amounts applied to deductibles, the coinsurance percentage used, and any COB adjustments taken over time. See the How claims are calculated topic for more information.

  Calc detail workspace field descriptions

  Column	Description
  Pay	A code that indicates the payment type. A—Alternative Payment AR#—Alternative Reverted B—Basic BR#—Basic Reverted M—Major Medical Usually means that benefits are paid subject to deductibles and co-insurance, leaving the claimant with an out-of-pocket balance. MR#—Major Medical Reverted S—Split Payment
  Allowed	The allowed amount. The considered amount compared to the UCR The Usual, Customary, and Reasonable amounts allowed for a procedure. UCR compares the charge for a procedure to the amount other doctors have charged for the procedure. UCR data can be external data obtained from HIAA or MDR by geographic area, or can be compiled internally. The allowed determination can be based on a percentile; for example, the 85th percentile would cover the charges of 85% of the doctors who submitted bills. or fee schedule amount and the lesser of the two is the amount allowed for the line item.
  Annual	The amount applied to an annual deductible.
  Lifetime	The amount applied to a lifetime deductible.
  Copay	The amount applied to a copay deductible.
  Illness	The amount applied to an illness deductible.
  Day	The amount applied to a daily deductible.
  Month	The amount applied to a monthly deductible.
  Other	A deductible amount that doesn't fall into one of the other deductible categories.
  Pat Cov	The patient covered amount under the No Surprises Act (NSA). The amount covered by providers. It is calculated as follows: (Allowed Amount - Deductibles) multiplied by (Co-Insurance %).
  Cov Adj	The coverage adjustment amount under the No Surprises Act (NSA). It's the NSA covered amount based on the out-of-network QPA amount less than the member liability.
  Co-Insurance %	The percentage of the benefit that is the claimant's responsibility after the claimant has met deductible amounts.
  Covered	The patient covered amount minus the covered adjustment amount.
  COB A provision for determining benefits when a member has more than one benefit plan.	The Coordination of Benefit (COB) adjustment amount. This is any amount that has been paid by other insurance or is being drawn from coverage savings.
  NET	The amount that is covered under the plan rules. It is calculated as follows: Covered Amount - COB adjustments.

• Cap Detail—Shows how the pricing for the claim line was determined and the allowed amount was calculated. See How claims are calculated for additional information.

  Hint: This workspace can be very helpful in troubleshooting schedule and payment issues.
  Cap detail workspace field descriptions

  Field	Description
  Fund	A code that identifies the fund A plan's asset pool held in trust for the benefit of union members and their families. The fund is the foundation of the basys system. Fund type examples include, welfare, pension, annuity and political action. associated with the claim.
  Group	The group A set of members with similar characteristics, (i.e., same type of work, such as plumbers or electricians, or geographic location). associated with the claim.
  Subgroup	The subgroup A way to categorize group members into a certain set for benefit plans (e.g. active and retired employees). Subgroup distinctions are only used in Claims, COBRA and Eligibility. associated with the claim.
  Benefit Plan	The benefit plan under which the claim was processed.
  PPO	The PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount. code associated with the claim, if applicable.
  Coverage	The coverage code identifies who is covered by a benefit plan type, for example, individual or family.
  Schedule	A code that identifies the claim schedule used to process the claim line.
  Schedule Detail	A reference number that identifies the parameters used to process the claim line.
  Considered	The amount considered for payment. It is calculated as follows: Billed Amount - Ineligible Amount.
  Pay Type	A code that indicates the payment type. A—Alternative Payment AR#—Alternative Reverted B—Basic BR#—Basic Reverted M—Major Medical Usually means that benefits are paid subject to deductibles and co-insurance, leaving the claimant with an out-of-pocket balance. MR#—Major Medical Reverted S—Split Payment
  Cap Code	The Cap Code A code setup within the schedule to identify the source of the pricing information. used to determine how the allowed amount is calculated. See Cap Codes and descriptions for details.
  Path	The path The pricing methods used and the order, established in the schedule. code used to determine the UCR The Usual, Customary, and Reasonable amounts allowed for a procedure. UCR compares the charge for a procedure to the amount other doctors have charged for the procedure. UCR data can be external data obtained from HIAA or MDR by geographic area, or can be compiled internally. The allowed determination can be based on a percentile; for example, the 85th percentile would cover the charges of 85% of the doctors who submitted bills. pricing information. See for details.
  Cap Amount	The amount based on the path followed.
  Percentage	The percentage of the cap amount that was allowed.
  Adjustment	An amount that adjusted the cap amount.
  Adj Code	A code that identifies the adjustment reason. A—Already Allowed (under a prior pay type) C—Over Considered M—Maximum O—Operator Override R—Reversion
  Dev Type	The deviation type applied to the UCR. A—Threshold Amount. Increases the UCR by a dollar amount if the considered amount exceeds the UCR. F—Flat Fee. Allows the UCR The Usual, Customary, and Reasonable amounts allowed for a procedure. UCR compares the charge for a procedure to the amount other doctors have charged for the procedure. UCR data can be external data obtained from HIAA or MDR by geographic area, or can be compiled internally. The allowed determination can be based on a percentile; for example, the 85th percentile would cover the charges of 85% of the doctors who submitted bills. if it is within a dollar amount of the considered amount. S—Threshold Percent. Increases the UCR by a percentage amount if the considered amount exceeds the UCR. P—Percentage. Allows the UCR if it is within a specified percentage of the considered amount.
  Dev Amount	The amount or percentage used based on the deviation type.
  Allowed	The allowed amount. The considered amount compared to the UCR The Usual, Customary, and Reasonable amounts allowed for a procedure. UCR compares the charge for a procedure to the amount other doctors have charged for the procedure. UCR data can be external data obtained from HIAA or MDR by geographic area, or can be compiled internally. The allowed determination can be based on a percentile; for example, the 85th percentile would cover the charges of 85% of the doctors who submitted bills. or fee schedule amount and the lesser of the two is the amount allowed for the line item.
  Original Quantity	The original billed quantity when a quantity maximum has been hit.
  Zip	The service provider's Zip code used in determining pricing for a geographic area.
  GEO Used	The geographical code (or Zip prefix) used in determining pricing for a geographical area.
  Region Used	Region code associated with the procedure source to further define pricing.
  QPA Amount	The qualifying payment amount. Generally, the median of contracted rates for a specific service in the same geographic region within the same insurance market as of January 31st, 2019.
  OON Amount	The out-of-network allowed amount.

• Messages—Shows the claim and line comments that will display as internal messages, or on the member or provider Explanation of Benefits (EOB EOBs are sent to members and payees to inform them of the disposition of claims. Typically an EOB identifies the date and type of service, the billed amount, deductibles, co-insurance, and an explanation of any ineligible charges. An EOB can also be a helpful tool in identifying fraudulent claims, as the member receives notification even when payment is made to the provider. An EOB isn't a bill.).

  Claim messages workspace field descriptions

  Column	Description
  Level	Claim message level Claim—Indicates the message applies at the claim level. Line—Indicates the message applies to a particular claim line.
  Line	Line number The claim line number associated to messages at the line level.
  Template	A pre-formatted user-defined message. The format is <Template Code>—<Type Code>—<Type Description>.
  Recipient	Message receiver M—Member P—Provider (default) MP—Member and Provider Blank—Internal comment
  Message	The internal or other message that will display for the recipient.

• Pends/Audits—Shows all the pends and audits that have been applied to the claim. This workspace includes when the claim was held for pend or audit, the operator ID, and who resolved them.

  By default, the table lists only unresolved pends and audits. Select the check box to include resolved pends and audits.

  

  Pends/Audits workspace field descriptions

  Column	Description
  Type	The type of item—Pend or Audit.
  Code-Description	The pend or audit code and description.
  Line	The claim line number to which the pend or audit applies. If the pend or audit applies to the whole claim instead of a specific claim line, you'll see a dash in this column. A claim line can have multiple pends and/or audits associated with it. Each pend or audit will list as a separate row in this workspace.
  Held When	The date the operator (or system) assigned the pend or audit code to the claim or line item.
  Held By	The operator (or system) that assigned the pend or audit code to the claim or line item.
  Resolved When	The date the operator resolved the pend or audit.
  Resolved By	The operator that resolved the pend or audit.

• CACC—Shows all claim specific accumulator records for paid claims or claims released for payment. This record shows how the claim impacted the accumulators at a particular date.

  CACC workspace field descriptions

  Column	Description
  Accumulator	User-defined accumulator code followed by the description. This can be a Deductible, Maximum, Reversion, Day, or COB Accumulator. Accumulator types
  Applied Amt	The amount applied to the defined accumulator.
  Schedule Amt	The accumulator amount defined in the schedule.
  Remaining Amt	The remaining accumulator amount.
  Schedule	The schedule code. Note: The schedule code is only used to reference an accumulator amount.