Specific Cumulative Paid Claims Worksheet

Provider

Who provided the care.

Svc From

First date of service on the claim.

Svc To

Last date of service on the claim.

TPA Paid Date

When the third-party administrator made payment.

Submission #

Submission number.

Billed Charges

How much the claim was for.

PPO Discount

Any discount applicable to the PPO providing the care.

Excluded Charges

Any amount excluded by the policy terms.

Negotiated Discount

Any discount to charges negotiated with the provider.

Admin Paid

Amount paid to the administrator.

Cumulative Paid

Cumulative amount paid on the claim.