Examples of Date of Service in a sentence
Cover Page Box # 3 Official Name of Operator Cover Page Box # 4 Date Signed by Operator Recitals Box #5 Contract Title for Service Agreement Recitals Box #6 Date of Service Agreement Article 7 Boxes #7-10 Operator’s designated representative Signature Page Boxes #15-19 Authorized Operator’s representative signature Exhibit A Box #25 Description of services provided Exhibit B All Applicable Boxes • Operator notates if data is collected to provide the described services.
Cover Page Box # 3 Official Name of Operator Cover Page Box # 4 Date Signed by Operator Recitals Box #5 Contract Title for Service Agreement Recitals Box #6 Date of Service Agreement Article 7 Boxes #7-10 Operator’s designated representative Signature Page Boxes #15-19 Authorized Operator’s representative signature Exhibit A Box #25 Description of services provided Exhibit B All Applicable Boxes Operator notates if data is collected to provide the described services.
Cover Page Box # 3 Official Name of Operator Cover Page Box # 4 Date Signed by Operator Recitals Box #5 Contract Title for Service Agreement Recitals Box #6 Date of Service Agreement Article 7 Boxes #7-10 Operator’s designated representative Signature Page Boxes #15-19 Authorized Operator’s representative signature Exhibit A Box #25 Description of services provided Exhibit B All Applicable Boxes Operator notates if data is collected to provide the described services.
BIN Number Version/Release Number Transaction Code (B2) Service Provider IDService Provider ID Qualifier Date of Service Prescription/Service Reference #Prescription/Service Reference # QualifierProcessor Control Number (if a paid claim is being reversed) The following information is returned if the cancel is accepted.Transaction Response Status (A)MEVS Response Code (021) The following information is returned if the cancel was denied.
The primary matching values used to determine which claim is being canceled are the Service Provider ID (201-B1), Prescription/Service Reference # (402-D2), and Date of Service (401-D1), which were submitted on the original claim.