Overview
Cash collected, claims submitted, and payer balances.
Paid
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Denial rate
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Blue Cross Blue Shield · Service date Jul 25, 2026 · Dr. Samuel Ortiz
MRN MRN-PAT-GEN-126 · 44 yrs
No secondary insurance on file for this patient.
No non-insurance payers (foundations, grants, cash pay) are linked to this claim.
Credentialing status unavailable for this provider.
No referring or supervising providers are attached to this encounter.
No additional submission details (referral numbers, authorization numbers, accident information) on this claim.
Encounter-level place of service is the code on Box 24B of the CMS-1500. Per-line overrides appear in the Service lines table below.
| Date of service | CPT code | Modifiers | Diagnoses | Place of service | Qty | Billed | Details |
|---|---|---|---|---|---|---|---|
| Jul 25, 2026 | 99204 | — | J45.909 | 11 - Office | 1 | $300.00 | |
Allowed— Pri ins paym$0.00 Pri ins adj— Pat resp$0.00 Pat bal$0.00 Bal$300.00 | |||||||
| Date of service | Facility | Status | Billed |
|---|---|---|---|
| Aug 23, 2026 | Northstar Family Health - Main | Paid | $55.00 |
| Aug 12, 2026 | Northstar Family Health - Main | Submitted | $320.00 |
| Jul 25, 2026 | Northstar Family Health - Main | Coded | $4,800.00 |
| Aug 22, 2026 | Northstar Family Health - Main | In intake | $45.00 |
| Jun 8, 2026 | Northstar Family Health - Main | Paid | $1,400.00 |
| Jul 29, 2026 | Northstar Family Health - Main | Paid | $1,400.00 |
| Aug 8, 2026 | Northstar Family Health - Main | Paid | $1,400.00 |
| Jun 12, 2026 | Northstar Family Health - Main | On hold | $320.00 |