SubmittedBills - NOVOHUB Provider

Submitted Bills

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Year	Month	Claim Count	Total Amount	Date Submitted	Is Paid	Action

Enrollee Name	Policy Number	Company Name	Encounter Date	Diagnosis	Class	Enrollee Verification Code	Treatment	Date Submitted	Amount Submitted	Actions

Enrollee Details:

Full Name

Company

Subsidiary

Enrollee Age

Gender

Provider Details:

Encounter Type

Doctor Details:

Name of Doctor

ID Number

Area of Specialization

Date Signed

Specialist Details (if any):

Name of Specialist

Specialist Phone No.

Area of Specialization

Date Signed

Treatment Details:

Verification Code

Authorization Code (if any)

Date of Service

Duration of Treatment

Date of Admission

Date of Discharge

Referral Code

Treatment Given

Diagnosis

First Diagnosis

First Differential Diagnosis

Second Diagnosis

Second Differential Diagnosis

Service Details:

Services	Description	Duration	Price	Date Submitted	Date Vetted	Status	Vetted Amount	Comment

Total Captured Amount

Total Vetted Amount

Drug Details:

Drug	Description	Dosage	Amount	Date Submitted	Date Vetted	Status	Vetted Amount	Comment

Total Amount

Total Vetted Amount

Total Claims Details:

Total Amount

Total Vetted Claims Details:

Total Vetted Amount

Comment