Collection Report Sample

The Collection Report provides a detailed summary of the patient accounts that meet the delinquency criteria that your practice specifies.

Tips:

• To see instructions for running the report shown below, see the Collection Report Instructions.

• To see descriptions of the report fields, click More.

   

  Collection Report Fields Tip:  To see more information about a field, click the hyperlink for the field name.
  GUARANTOR INFORMATION	Guarantor last name, first name and middle initial Mailing address lines City, State and Zip Code Phone Number
  GUARANTOR #	Guarantor's patient account number
  PATIENT #	Patient account number
  EMPLOYER	Employer Information if applicable Employer name Employer mailing address Employer City, State and Zip Code
  REMARKS	Patient remarks
  PATIENT INFORMATION	Patient last name, first name and middle initial Patient mailing address lines Patient City, State and Zip Code Patient Phone Number
  RELATIONSHIP TO THE ABOVE	Patient's relationship to the guarantor
  DATE OF BIRTH	Patient date of birth
  PATIENT'S SEX	Patient gender
  MARITAL STATUS	Patient marital status
  INSURANCE INFORMATION
  CODE	Primary insurance assigned to patient
  NAME	Insurance company name
  POLICY HOLDER	Patient's policy holder's first name, middle initial and last name
  REL P.	Patient's relationship to policy holder
  CERTIFICATE #	Policy holder insurance certificate number
  GROUP #	Patient's policy holder insurance group number
  MBR #	Patient's policy holder member number
  BALANCE INFORMATION
  PATIENT BALANCE	Patient responsible outstanding balance
  INSURANCE BALANCE	Patient insurance responsible outstanding balance
  OTHER BALANCE	Patient Other balance
  UNAPPLIED CREDIT	Dollar amount of patient's unapplied payments
  DATE LAST SERVICE	Date of last service for patient
  DATE LAST STATEMENT	Date of the last statement for the patient
  DATE LAST PAYMENT	Date of the last payment made by the patient
  PATIENT PMTS Y-T-D	Dollar amount of the payments the patient has made year-to-date
  DIAGNOSIS INFORMATION
  CODE	Diagnosis code for most recent patient service
  DESCRIPTION	Diagnosis description
  NOTES	Patient notes
  SERVICE DETAIL INFORMATION
  TICKET #	Ticket number for patient service
  SERV DATE	Date of service associated with ticket
  BILL DATE	Date the ticket is billed
  PD ST	Paid status of ticket
  LOCATION	Location of service
  PROVIDER	Provider associated with patient service
  RE SP	Responsible party for ticket charge
  INSURANCE 1	Insurance assigned to ticket
  INSURANCE 2	Insurance two for patient
  INSURANCE 3	Insurance three for patient
  TOTAL CHARGES	Total dollar amount for ticket services
  TOTAL PAYMENT	Total dollar amount of payments for ticket services
  TOTAL ADJUSTS	Total dollar amount of adjustments for ticket services
  TKT BALANCE	Total dollar amount of ticket balance Calculation:  Balance = Charges - (payments + adjustments)
  DIAG1	Patient diagnosis code associated with the ticket
  DIAG2	Patient diagnosis associated with the ticket
  PROCEDURE	Procedure code for services on ticket
  PROCEDURE DESCRIPTION	Procedure description
  T.O.S.	Procedure's type of service assigned to ticket
  PROC FEE	Dollar amount of fee for procedure
  UTS	Number of units for the procedure
  EXTENSION	Total dollar amount of procedure fee
  CODE	Payment transaction code associated with ticket
  TRANSACTION DESCRIPTION	Payment transaction code description
  DATE	Transaction date
  TYPE	Transaction type
  AMOUNT	Dollar amount of transaction