SELECT DISTINCT a.Agency_Name,a.Agency_Address1,a.Agency_City,a.Agency_State,a.Agency_ZIP,a.Agency_Contact_Phone,a.Agent_FEIN, a.Natl_Provider_ID, p.Agency_Assigned_ID, p.Last_Name_M0040,p.First_Name_M0040, p.HI_Claim_Number, p.Middle_Initial_M0040,p.Street_Address,p.City,p.State_M0050,p.Zip_M0060,p.MSA_Code,p.DOB_M0066,p.Gender_M0069 ,p.Telephone, p.Employee_ID, an.Certification_Start,an.Certification_End, an.Start_of_Care_M0030,an.Source_of_Admission , an.Assessment_Reason_M0100, an.Claim_Key,an.HHRG_175_Score, an.HHRG_230_Score, an.HHRG_250_Score, an.HHRG_390_Score, an.HHRG_420_Score, an.HHRG_440_Score, pr.PayName, i.Invoice_ID, i.InvoiceTotal, i.PayerBalance,i.assessment_tracker_id , i.patient_id,pr.payer_id FROM #Request.prefix_db_agency#.Invoices i, #Request.prefix_db_agency#.ScheduleItems si, #Request.prefix_db_agency#.patient p, #Request.prefix_db_agency#.Payer pr,#Request.prefix_db_lookup#.Agency a, #Request.prefix_db_agency#.Assessment_New an WHERE i.invoice_id = '#url.inv#' AND i.Agency_ID = '#Session.AgencyId#' AND a.Agency_ID = i.Agency_ID and an.assessment_tracker_id = i.assessment_tracker_id AND p.patient_id = i.patient_id AND pr.payer_id = i.patientpayer_id GROUP BY i.invoice_id SELECT DISTINCT si.Rev_Code,si.Visit_Type,si.HCPCS,si.Visit_Date,si.Total_Units,si.Total_Eclaim , i.Invoice_ID, i.InvoiceTotal, i.PayerBalance FROM #Request.prefix_db_agency#.Invoices i, #Request.prefix_db_agency#.ScheduleItems si WHERE i.invoice_id = '#url.inv#' AND i.Agency_ID = '#session.agencyid#' AND si.invoice_id = i.invoice_id AND si.Assessment_Tracker_ID =i.Assessment_Tracker_ID AND si.Total_Eclaim !=0 AND si.deleted = 0 select Last_Name,First_Name from #Request.prefix_db_lookup#.Employee where Employee_ID = #Session.EmployeeId#
ERROR DESCRIPTION 3a PAT.CNTL NO 4 TYPE OF BILL
b. MED.REC NO
5 FED.TAX NO 6.STATEMENT COVERS PERIOD
FROM THROUGH
9.PATIENT ADDRESS                 a
b
8 PATIENT NAME                      a c
b d
10.BIRTH DATE 11.SEX 12.ADMISSION DATE 14.ADMISSION TYPE 15.ADMISSION SRC
checked >  Male  checked >  Female
42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV.DATE 46 SERV.UNITS 47 TOTAL CHARGES 48 NON COVERD CHARGES
50 PAYER NAME 51 HEALTH PLAN ID 52 REL.INFO 53 ASG.BEN. 54 PRIOR PAYMENTS 55 EST.AMOUNT DUE 56 NPI 57 OTHER PRE ID
58 INSURED NAME 59 P.REL 60 INSURED'S UNIQUE ID 61 GROUP NAME 62 INSURNCE GROUP N0 63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYEE NAME
18  self
66
69 ADMIT DX 70 PATIENT REASON BX 71 PPS CODE 72 ECI
74 PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE 75 76 ATTENDING QUAL
CODE DATE CODE DATE CODE DATE
c.OTHER PROCEDURE d.OTHER PROCEDURE e.OTHER PROCEDURE 77 OPERATING QUAL
CODE DATE CODE DATE CODE DATE