Thread: CLAIM OUTBOUND DETAIL from AFFINITYPLAN.org
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  #1 Old 10-06-2016, 03:46 AM
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Default CLAIM OUTBOUND DETAIL from AFFINITYPLAN.org
Code:
PROV_NPI: 1720199961
EXTERNAL_CLAIM_ID: 072516750072975
CLAIM_ID: 160726213724
BILL_PAYTO_TAX_QUAL: 
BILL_PAYTO_TAXONOMY: 
BILL_PROVIDER_QUAL: 2 
BILL_PROVIDER_LNAME: HORIZON MEDICAL GROUP PC
BILL_PROVIDER_MNAME: 
BILL_PROVIDER_FNAME: 
BILL_PROVIDER_SUFFIX: 
BILL_PROVIDER_ID_QUAL: XX
BILL_PROVIDER_ID: 1063488179
BILL_PROVIDER_ADD1: 2 COATES DRIVE
BILL_PROVIDER_ADD2: 
BILL_PROVIDER_CITY: GOSHEN
BILL_PROVIDER_STATE: NY
BILL_PROVIDER_ZIP: 109246759
BILL_PROVIDER_REF: EI:061494923,
PAY_TO_PROVIDER_QUAL: 2 
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PAY_TO_PROVIDER_ADD1: P O BOX 36363
PAY_TO_PROVIDER_ADD2: 
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PAY_TO_PROVIDER_STATE: NJ
PAY_TO_PROVIDER_ZIP: 071886363
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REN_PROVIDER_ID: 1720199961
REN_PROVIDER_REF: :,
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AREF_PROVIDER_ID: 1780708735
AREF_PROVIDER_REF: :,
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SERVICE_PROV_ENTITY_QUAL: 77 
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SERVICE_PROV_NAME: ST LUKES NEWBURGH INPT
SERVICE_PROV_ID_QUAL: XX
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SERVICE_PROV_ADD1: 70 DUBOIS ST
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SERVICE_PROV_STATE: NY
SERVICE_PROV_ZIP: 125504851
SERVICE_PROV_REF: :,
PRIMARY_SEQ_NUMBER: P 
PRIMARY_RELATION_CODE: 18
PRIMARY_GROUP_NAME: 
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PRIMARY_CLAIM_IND: CI
PRIMARY_PAYER_REF: :,
INSURED_GROUP_ID: 
INSURED_GROUP_NAME: ESSENTIALSQHP
INSURED_PAYER_ID: 23334
INSURED_ID: H0010431501
INSURED_LAST_NAME: ELARDO
INSURED_FIRST_NAME: MICHAEL
INSURED_MIDDLE_NAME: 
INSURED_GENDER: M
INSURED_BIRTH_DATE: 11/16/1973 12:00:00 AM
INSURED_ADD1: 1180 STATE RT 94
INSURED_ADD2: 
INSURED_CITY: NEW WINDSOR
INSURED_STATE: NY
INSURED_ZIP: 12553
INSURED_DEATH: 
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PATIENT_ID: 
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BILL_PROVIDER_PER02: DANA
BILL_PROVIDER_PER03: TE
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BILL_PROVIDER_PER05: 
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EDI_BATCH_NO: 201609306621
PAYER_ESTAMT: 
PAYER_ESTAMT_QUAL: 
SEC_INSURED_ID_QUAL: 
TRI_INSURED_ID_QUAL: 
-----------------------------------
PROV_NPI: 1053305987
EXTERNAL_CLAIM_ID: 072116740607557
CLAIM_ID: 160722212639
BILL_PAYTO_TAX_QUAL: 
BILL_PAYTO_TAXONOMY: 
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BILL_PROVIDER_LNAME: MID HUDSON ANESTHESIOLOGISTS P
BILL_PROVIDER_MNAME: 
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BILL_PROVIDER_ID_QUAL: XX
BILL_PROVIDER_ID: 1144211434
BILL_PROVIDER_ADD1: 2 CATHARINE ST
BILL_PROVIDER_ADD2: 
BILL_PROVIDER_CITY: POUGHKEEPSIE
BILL_PROVIDER_STATE: NY
BILL_PROVIDER_ZIP: 126019998
BILL_PROVIDER_REF: EI:141577313,
PAY_TO_PROVIDER_QUAL: 2 
PAY_TO_PROVIDER_LNAME: 
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PAY_TO_PROVIDER_ADD1: PO BOX 550
PAY_TO_PROVIDER_ADD2: 
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PAY_TO_PROVIDER_STATE: NY
PAY_TO_PROVIDER_ZIP: 126029998
PAY_TO_PROVIDER_REF: 
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REN_PROVIDER_LNAME: SANDESH
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REN_PROVIDER_ID: 1053305987
REN_PROVIDER_REF: :,
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AREF_PROVIDER_LNAME: MUSLIM
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AREF_PROVIDER_SUFFIX: 
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AREF_PROVIDER_ID: 1053534578
AREF_PROVIDER_REF: :,
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SERVICE_PROV_ID_QUAL: XX
SERVICE_PROV_ID: 1003923434
SERVICE_PROV_ADD1: 70 DUBOIS ST
SERVICE_PROV_ADD2: 
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SERVICE_PROV_STATE: NY
SERVICE_PROV_ZIP: 125509998
SERVICE_PROV_REF: :,
PRIMARY_SEQ_NUMBER: P 
PRIMARY_RELATION_CODE: 18
PRIMARY_GROUP_NAME: AFFINITY ESSENTIAL EXCHANGE
PRIMARY_INS_TYPE_CODE: 
PRIMARY_CLAIM_IND: CI
PRIMARY_PAYER_REF: :,
INSURED_GROUP_ID: 
INSURED_GROUP_NAME: ESSENTIALSQHP
INSURED_PAYER_ID: 23334
INSURED_ID: H00104315
INSURED_LAST_NAME: ELARDO
INSURED_FIRST_NAME: MICHAEL
INSURED_MIDDLE_NAME: 
INSURED_GENDER: M
INSURED_BIRTH_DATE: 11/16/1973 12:00:00 AM
INSURED_ADD1: 1180 STATE ROUTE 94
INSURED_ADD2: 
INSURED_CITY: NEW WINDSOR
INSURED_STATE: NY
INSURED_ZIP: 12553
INSURED_DEATH: 
INSURED_UOM: 
INSURED_WEIGHT: 
INSURED_PRG_IND: 
PATIENT_ID: 
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SEC_SEQ_NUMBER: 
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-----------------------------------
PROV_NPI: 1447217617
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