Contents
- Index
Account Tracker Report
ACCOUNT TRACKER
INVOICE#: 18295 DATE OF INVOICE: 03/12/97
DATE OF SERVICE: 03/12/97
AS RUN ON: 03/14/97
GUARANTOR: 6749 PATIENT: DOB: 03/17/55 PRIMARY INSURANCE: 0677 SECONDARY INSURANCE: 0845
JOHN MASON SAME GOOD SAM INS CENTER ATRIUM HEALTH PLAN, INC
562 MAPLE PO BOX 21807 PO BOX 64179
SANTA BARBARA, CA 93121-1807 ST PAUL, MN 55164-0179
MONTICELLO, IN 47960
219-583-8657 111-22-3333
LOCATION : 1 MAIN OFFICE ID#: 213412341243 ID#: 12431243
SALESPERSON : DX1: BRAIN TUMOR
PRACTITIONER: JA JOHN ALTMAN DX2: ACCEPT ASSIGNMENT: N
PHYSICIAN : 0358 ROBERT GULLEY MD DX3: INVOICE STATUS : OPEN
BILLED TOTAL AMOUNT NON-
L CODE DESCRIPTION QTY PRICE BILLED PAID ALLOWED BALANCE
-------- ----------------------------------------------- ----- --------- --------- --------- --------- ----------
L0910 TORSO SUPPORT, PTOSIS SUPPORT, CUSTOM FABRICATE 2.00 542.00 1084.00 1084.00 0.00 0.00
L5000 PARTIAL FOOT, SHOE INSERT WITH LONGITUDINAL ARC 2.00 427.00 854.00 854.00 0.00 0.00
L6000 PARTIAL HAND, ROBIN-AIDS WITH THUMB REMAINING ( 2.00 1605.00 3210.00 2804.00 0.00 406.00
L8465 PROSTHETIC SHRINKER, UPPER LIMB, EACH 2.00 0.00 0.00 0.00 0.00 0.00
L8465 PROSTHETIC SHRINKER, UPPER LIMB, EACH 1.00 757.00 757.00 0.00 757.00 0.00
--------- --------- --------- ----------
5905.00 4742.00 757.00 406.00
BILLS PRINTED/SUBMITTED:
Date Carrier Electronically Billed?
----------------------------------------------------------------------
03/14/1997 0677 GOOD SAM INS CENTER NO
PAYMENTS RECEIVED: AMOUNT NON- OVERPAY
DATE PROVIDER CHECK# PAID ALLOWED INV#
-------- --------------------------------- ---------- --------- --------- --------
03/12/97 (PATIENT/GUARANTOR) 2341234 200.00
03/24/97 0677 GOOD SAM INS CENTER 189283 2001.00 757.00
PO BOX 21807
SANTA BARBARA, CA 93121-1807
04/25/97 0845 ATRIUM HEALTH PLAN, INC. 4433234 2541.00
PO BOX 64179
ST PAUL, MN 55164-0179
------------ ----------
4742.00 757.00
ACTIVITY MEMOS:
DATE TYPE USER
-------- --- ----
02/13/97 AR JTM
Ltr. for 30 days after claim filed w/ no payment
03/22/97 CB JTM
follow up to 30 day letter