| Patient Name | MRN | Assessment | Payer | SOC Date | Current Billing Period |
Start Date | Billing Period End Date |
Discharge Date |
Month End | Bill PD Days in CM |
Total Period |
HIPPS | LUPA Threshold |
Completed Visits |
Estimated Episode Payment |
CM Gross Revenue |
CM Sequester |
Adjusted Daily Rate |
CM Net Revenue |
Invoice ID | Invoice Date |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| #Pt_Last#, #Pt_First# | #Pt_Agy_ID# | #F26# | #Pay_Name# | #DateFormat(SOC_Date,"mm/dd/yyyy")# | #First_or_second_Period# | #DateFormat(Start_Date,"mm/dd/yyyy")# | #DateFormat(End_Date,"mm/dd/yyyy")# | #DateFormat(endofmonthday,"mm/dd/yyyy")# | #Num_days# | #Total_Periods# | #HHRG# | #LUPA# | style="color:red;" --->>#completed_visits# | #Payment# | #CM_Gross# | #CM_Sequester# | #Total_CM# | #CM_Net# | #Invoice_ID# | #DateFormat(DateSent,"mm/dd/yyyy")# |