provider name/information patient name · services performed amount charged good example: bad...
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Services Performed
Amount Charged
Good Example: Bad Example:
What services were provided?The documentation should list the description of services performed, not just payment on the account.
What is the final patient responsibility for the services?Be sure the documentation includes any adjustments or insurance payments (if applicable) when listing the patient responsibility.
Date of ServiceWhen were services provided?The date of service may be different than the date of payment. Only dates of service which happen during the plan year are eligible for reimbursement.
Provider Name/Information Patient NameWho provided the service?The documentation can include the practice name, the store or merchant name, or the provider name.
Who received the service?Be sure the person who received the service is listed on the documentation. A register receipt is acceptable for prescriptions.
TIP:Do you have the Explanation of Benefits (EOB) from the insurance company? This can be submitted instead of an itemized statement from the provider. EOBs include all the information listed above.
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