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