OnStaff 2000 (Unix OS) 277CA Report Examples
(12/2012)
Example of Acknowledgement Report WITH an error:
Acknowledgement Report
Client Name
Client Address
Client City, State, Zip
Client Phone
Page: 1 Report prepared on: Jan 3 2012 By:(Operator Name)
Description Payer/SSN/DOS Status Qty/Amount .
Palmetto GBA 01102
Received Claims 01/03/2012 Processed Claims 01/03/2012
--------------------------------------------------------------------------------------------------------------------------------------------------
A1 Receipt-The claim/encounter has been received. WQ Accepted ###.##
19 Entity acknowledges receipt of claim/encounter.
AA Total Rejected Quantity #
YY Total Rejected Amount ###.##
--------------------------------------------------------------------------------------------------------------------------------------------------
Practice Name
Rejected for relational field in error. Pending U Rejected ###.##
496 Submitter not approved for electronic claims submissions on behalf of entity.
Entity not primary
AA Total Rejected Quantity #
YY Total Rejected Amount ###.##
Example of Acknowledgement Report WITHOUT erroneous error:
Acknowledgement Report
Client Name
Client Address
Client City, State, Zip
Client Phone
Client Phone
Page: 1 Report prepared on: Jan 3 2012 By:(Operator Name)
Description Payer/SSN/DOS Status Qty/Amount .
Palmetto GBA 01102
Received Claims 01/03/2012 Processed Claims 01/03/2012
--------------------------------------------------------------------------------------------------------------------------------------------------
A1 Receipt-The claim/encounter has been received. WQ Accepted ###.##
19 Entity acknowledges receipt of claim/encounter.
AA Total Rejected Quantity #
YY Total Rejected Amount ###.##
--------------------------------------------------------------------------------------------------------------------------------------------------
Pt Last, First Name Pt Subscriber#
A1 Receipt-The claim/encounter has been received.
AA Total Accepted Quantity #
YY Total Accepted Amount ###.##