Claim Number
Claim Status
Claim Type
Employee SSN
Employee Last Name
Employee First Name
Employee Middle Initial
Employee Date Of Birth
Employee Address
Employee City
Employee State
Employee Zip
Patient SSN
Patient Last Name
Patient First Name
Patient Middle Initial
Patient Suffix
Relationship to Employee
Patient DOB
Student
Disabled
Unit
Location
Group
Plan
Option
Network
Mail Rec
DOS First
DOS Last
Admission Date
Data Entry Date
Pend Date
Proc Date
Paid Date
Adjust Date
Total Charges
Pay to Provider
Prov Check #
Pay To Employee
Employee Check #
Other Ins Pay
3rd Party Pay
Diag1
Diag2
Diag3
Diag4
CPT1
CPT2
CPT3
CPT4
CPT5
CPT6
V31
V32
V33
V34
Pend Acc
Pend Stud
Pend Disab
Pend Prex
Pend OI
Pend TPL
Pend Detail
Pend Internal
Provider Tax ID
Prov Suffix
Provider Name
Doctor Name
Suppress Check