Patient Information
Patient Name:
Doe, John
Account No:
1234567890
Patient Type:
(A50)
Charge Information
Facility:
McKay-Dee Hospital Center (CPA-132)
Admit Date:
3/1/2018
Scramble Fin Class:
SELECT HEALTH
Billing Desc:
Charge #:
987654321
Claim Information
State / Status:
Appeal 1st / Active
Claim ??? Type:
Appeal
Billed Amount:
$37,295
Paid Amount:
$0
Denied Amount:
$37,295
Account Balance:
$37,295
Denial Date:
4/2/2018
Insurance Information
Carrier:
(1970) Select Med
Policy No:
123456789
Phone:
800-538-5038
Address:
PO BOX 30192
SALT LAKE CITY UT 84130-0192
Guarantor:
Doe, John
Group Name:
( )
[Unknown Header]