Intellect (Windows OS) 277CA Report Examples
(12/2011)
Example of printout when 277CA file is picked up with an error:
Claim Status Report
Client Name
Client Address
Client City, State, Zip
Page: (Use this date to bring up file in Access Claim Report>>) Date Printed & by who
========================================================================================================================================
ACN Name Subscriber Date CPT Modifier CNN/Doctor Charge Payment Description
0 *** Palmetto 0.00 0.00
0 **Practice Status (Your practice name) ###.## 0.00 A1 - Acknowledgement/Receipt – The claim/encounter has been received. This
0 *Doctor Status (Your provider name) A8 – Acknowledgement / Rejected for Relational field in error. Pending
Example of printout when 277CA file is picked up without erroneous error:
Claim Status Report
Client Name
Client Address
Client City, State, Zip
Page: (Use this date to bring up file in Access Claim Report>>) Date Printed & by who
========================================================================================================================================
ACN Name Subscriber Date CPT Modifier CNN/Doctor Charge Payment Description
4843 SMITH, JOE 102938474A 12/22/2011 JONES, MD 100.00 0.00 A-7 Acknowledgement/Rejected for Invalid Information – The claim/encounte
3938 HILL, MARY 928374654A 12/22/2011 JONES, MD 125.00 0.00 A8 Rejected for Relational field in ERROR 496 Submitter not approved for elec
8374 COBB, TOM 938475461A 12/22/2011 JONES, MD 230.00 0.00 A2 Acknowledgement/Acceptance into adjudication system-The claim/encount
2234 MARKS, IDA 874266523A 12/22/2011 JONES, MD 125.00 0.00 A2 Acknowledgement/Acceptance into adjudication system-The claim/encount
8362 TODD, GREG 374654324A 12/22/2011 JONES, MD 375.00 0.00 A2 Acknowledgement/Acceptance into adjudication system-The claim/encount
8762 GRAY, BILL 495765475A 12/22/2011 JONES, MD 180.00 0.00 A8 Rejected for Relational field in ERROR 496 Submitter not approved for elec