PaymentAdvice - NOVOHUB Provider

Payment Advice

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Period	Claims Count	Total Submitted Amount	Total Processed Amount	Amount Deducted	Amount Paid	Payment Status	Payment Date	Action

Enrollee Name	Policy Number	Company Name	Encounter Date	Diagnosis	Treatment	Amount Submitted	Amount Processed	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 Submitted	Amount Submitted	Duration Processed	Amount Processed	Comment

Total Captured Amount

Total Processed Amount

Drug Details:

Drug	Description	Dosage Submitted	Amount Submitted	Dosage Processed	Amount Processed	Comment

Total Amount

Total Processed Amount

Total Claims Details:

Total Amount

Total Processed Claims Details:

Total Processed Amount

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