A. Tax and Check Information:
- Check No
- The check number or EFT trace number.
- Check / PRA Date
- Month/day/year the check or Provider Remittance Advice was released.
- Check Amount
- The amount of the check being issued.
- Tax Identification Number
- The Federal tax ID number for the physician/hospital or other practitioner.
- NPI
- The National Provider Identification number for the physician/hospital or other practitioner.
B. Customer/Patient Information:
- Claim #
- Claim ID Number used internally by WPS.
- Group #
- The group (control) number for the plan sponsor.
- Patient Account
- A unique number supplied and used by the physician/hospital or other practitioner.
- Patient Name
- The full first and last name of the patient.
- Patient ID
- WPS’ unique Customer ID for the patient.
- Insured Name
- The full first and last name of the patient.
C. Dates of Service:
Month/day/year service was provided.
D. Service Code:
The procedure code that identifies the service being performed.
E. Submitted Charges:
The amount billed for this service.
F. Negotiated or Allowed Amount:
When the physician/hospital or other practitioner is participating (in network), the rate that has been negotiated for the service. Otherwise, the amount recognized under the customer’s plan.
G. Deductible, Copay, and Coinsurance:
- Deductible
- Patient deductible applied to either section E (Submitted Charges) or F (Negotiated or Allowed Amount), depending on physician/hospital or other practitioner’s network status and the plan.
- Copayment
- The copayment owed by the patient for this service.
- Coinsurance
- The portion of the charge, in addition to any copay or deductible, for which the patient is responsible.
H. Discount:
When the physician/hospital or other practitioner is contracted to withhold an additional amount, specified by the customer’s plan.
I. Less Other Amount:
An adjustment that may impact the amount the plan will pay. Examples: amount paid by other carrier, or amount previously paid on the same claim.
J. See Remarks:
Corresponds to the remark in section M (Remarks).
K. Payable Amount:
Amount the plan pays for this service in absence of any amount identified in section I (Less Other Amount).
L. Issued Amount:
This amount is equal to the Payable Amount identified in section K (Payable Amount) minus any outstanding claim reimbursement requests identified by WPS.
M. Remarks:
Explanation of denied or pended charges or any additional information. Corresponds to expense line above with the same data in section J (See Remarks), or the entire claim if no data is present.
