Specific Reimbursement Audit Worksheet

Select the desired sorting option by checking the corresponding box. The sample shows the report sorted by service dates.

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

When the third-party administrator paid.

Seq

Sequence. Used for tracking purposes.

CPT

Current Procedural Terminology code.

Claim #

Claim number.

Sub #

Submission number.

Billed Charges

How much the claim billed.

PPO Discount

PPO network discount.

Excluded Charges

Charges excluded according to policy terms.

Negotiated Discount

Discount, if any, negotiated with the provider.

Admin Paid

Amount paid to the plan administrator.

Adjustments

Any adjustments to the claim.

Allowable

Amount allowed on the claim.

Reimb %

Percent of allowed that is reimbursable.

Reimbursable

Dollar amount to be reimbursed.

Adjustment

Any reimbursement adjustments.

Date

Adjustment date.

Reason

Adjustment reason.