File INSURANCE_VERIFICATION_PROCESSOR(355.33) Data List
| DATE ENTERED |
ENTERED BY |
SOURCE OF INFORMATION |
STATUS |
DATE PROCESSED |
PROCESSED BY |
NEW COMPANY |
NEW GROUP/PLAN |
NEW POLICY |
DATE VERIFIED |
VERIFIED BY |
IIV STATUS |
OVERRIDE FRESHNESS FLAG |
REMOTE LOCATION |
IIV PROCESSED DATE |
REAL TIME VERIFICATION |
BPS RESPONSE |
SERVICE DATE |
INSURANCE COMPANY NAME |
PHONE NUMBER |
BILLING PHONE NUMBER |
PRECERTIFICATION PHONE NUMBER |
REIMBURSE? |
STREET ADDRESS [LINE 1] |
STREET ADDRESS [LINE 2] |
STREET ADDRESS [LINE 3] |
CITY |
STATE |
ZIP CODE |
IS THIS A GROUP POLICY? |
*GROUP NAME |
*GROUP NUMBER |
UTILITZATION REVIEW REQUIRED |
PRECERTIFICATION REQUIRED |
AMBULATORY CARE CERTIFICATION |
EXCLUDE PREEXISTING CONDITION |
BENEFITS ASSIGNABLE |
TYPE OF PLAN |
BANKING IDENTIFICATION NUMBER |
PROCESSOR CONTROL NUMBER (PCN) |
PATIENT NAME |
EFFECTIVE DATE |
EXPIRATION DATE |
*SUBSCRIBER ID |
WHOSE INSURANCE |
PT. RELATIONSHIP TO INSURED |
*NAME OF INSURED |
INSURED'S DOB |
INSURED'S SSN |
PRIMARY CARE PROVIDER |
PRIMARY PROVIDER PHONE |
COORDINATION OF BENEFITS |
INSURED'S SEX |
PT. RELATIONSHIP - HIPAA |
PHARMACY RELATIONSHIP CODE |
PHARMACY PERSON CODE |
ESGHP? |
SPONSORING EMPLOYER NAME |
EMPLOYMENT STATUS |
RETIREMENT DATE |
SEND BILL TO EMPLOYER |
EMPLOYER CLAIMS STREET LINE 1 |
EMPLOYER CLAIMS STREET LINE 2 |
EMPLOYER CLAIMS STREET LINE 3 |
EMPLOYER CLAIMS CITY |
EMPLOYER CLAIMS STATE |
EMPLOYER CLAIMS ZIP CODE |
EMPLOYER CLAIMS PHONE NUMBER |
PATIENT ID |
SUBSCRIBER ADDRESS LINE 1 |
SUBSCRIBER ADDRESS LINE 2 |
SUBSCRIBER ADDRESS CITY |
SUBSCRIBER ADDRESS STATE |
SUBSCRIBER ADDRESS ZIP |
SUBSCRIBER ADDRESS COUNTRY |
SUBSCRIBER ADDRESS SUBDIVISION |
SUBSCRIBER PHONE |
INQ SERVICE TYPE CODE 1 |
INQ SERVICE TYPE CODE 2 |
INQ SERVICE TYPE CODE 3 |
INQ SERVICE TYPE CODE 4 |
INQ SERVICE TYPE CODE 5 |
INQ SERVICE TYPE CODE 6 |
INQ SERVICE TYPE CODE 7 |
INQ SERVICE TYPE CODE 8 |
INQ SERVICE TYPE CODE 9 |
INQ SERVICE TYPE CODE 10 |
INQ SERVICE TYPE CODE 11 |
INQ SERVICE TYPE CODE 12 |
INQ SERVICE TYPE CODE 13 |
INQ SERVICE TYPE CODE 14 |
INQ SERVICE TYPE CODE 15 |
INQ SERVICE TYPE CODE 16 |
INQ SERVICE TYPE CODE 17 |
INQ SERVICE TYPE CODE 18 |
INQ SERVICE TYPE CODE 19 |
INQ SERVICE TYPE CODE 20 |
GROUP NAME |
GROUP NUMBER |
SUBSCRIBER ID |
NAME OF INSURED |