ProcurePM - Add Adjustment

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Patient	Bill	ICN #	CPT	Current Balance (Including PRs)	Charged	Collected / Expected	Office	Provider	Date Of Service

Visit	CPT	Outstanding	Amount	Adjust/Remark	Next Action	Remaining
Warning: Filters exclude $1,388.16 across 7 bills
Bill 258-8797 DOS: Jun-5-2021 Carrey, Zev Facility: Monsey Payer: Empire BC/BC Commercial Plans	99212	$189.44 PR-2 20.00 PR-100 169.44		Add item
	J7341	$34.88 PR-2 5.00 PR-100 29.88		Add item
	- UNASSIGNED PAYMENT -			Add item
Bill 255-7894 May-27-2021 Zhivago, Victor Ahava Five Towns	99213	$360.00		Add item
Bill 255-7894 May-27-2021 Zhivago, Victor Ahava Five Towns	- UNASSIGNED PAYMENT -			Add item

	Provider	Date	Amount	Adjust Code - Meaning	Reference #
Provider Adjustments
	1891798104	12/31/2020	$20.25	FB - Forwarding Balance	9924860989-2020030900140089
	352249024	3/21/2020	-$4.89	L6 - Interest Owed
	1184878274	12/31/2020	$41.08	WO - Overpayment Recovery	2103110AG

From

To

Payer

ID - Txn ID / Check #

Amount

Date	Payer	Method	ID	Amount	Balance	Disbursements		Reversals		Edit	Delete
7/3/2022 9:04a	Empire Blue Cross Blue Shield	Check	2022061712500114	13,69692	000	302	14,53402	4	(83710)	Edit	Delete
7/2/2022 4:47p	Ball, Lucille	Credit Card	246006	9811	300	1	9511	0	-	Edit	Delete

Lucille Ball · F · 5/16/55 DOS: Jun-5-2021 Carrey, Zev Facility: 5Towns Payer: Empire BC/BC Commercial Plans

ICN (insurance only)

Balance Action

Claim Status

Claim Adjustments (used when EOB contains adjustments not allocated to any specific service line) hide this panel
	Adjustments/Remarks
	Add item

CPT 1: 99212-25 · Units Sent: 1 · Charge Sent: $500.00 · Collected (all payers): $194.50 · Current Balance: $189.44 Toggle Mismatch Panel
MISMATCH: This panel is used when the payer responded with a value different from what was submitted Response Charge: Response Units Substituted CPT: Substituted Modifiers:
Current Balance Expand	Amount (Paid/Allowed)	Adjustments/Remarks	Patient Responsible
Mar-19-2022 9:14a Blue Cross Blue Shield ICN B92982122 Charge: $500.00 Paid: $194.50 Discount: $116.06 Patient Balance: $189.44 PR-2: $20.00 PR-100: $169.44 Medicare Charge: $189.44 Patient Balance: $189.44 PR-2: $20.00 PR-100: $169.44	Expecting $109.33 Credit Jul-2-22 (max $3.00)	Add item	Patient Reponsible

CPT 2: J7341-U6 · Units Sent: 3 · Charge Sent: $225.00 · Collected (all payers): $0.00 · Current Balance: $225.00 Toggle Mismatch Panel
MISMATCH: This panel is used when the payer responded with a value different from what was submitted Response Charge: Response Units Substituted CPT:
Current Balance Expand	Paid	Adjustments/Remarks	Ending Balance
Medicare Charge: $225.00 Initial Charge: $225.00	Expecting $45.38 Credit Jul-2-22 (max $3.00)	Add item	Balance

UNSENT SERVICE LINE: To be used when response contains a service line that was not part of the sent claim hide this panel
New CPT: Modifiers: Charge: Units
	Paid	Adjustments/Remarks	Balance
	Expecting $45.38 Credit Jul-2-22 (max $3.00)	Add item	Balance