deviation, explain. If unable or unwilling to provide all requested financial detail, elaborate on problematic data elements, estimating the number and percentage of affected claims and encounters. No for details provided. Financial Response If No or Detail to be Yes with Provided deviation, explain. Submitted Single, 50 words. Charges Nothing required list. 1: Yes, 2: No Discount Single, 50 words. Amount Nothing required list. 1: Yes, 2: No Allowable Single, 50 words. Charges Nothing required list. 1: Yes, 2: No Copayment Single, 50 words. Nothing required list. 1: Yes, 2: No Coinsurance Single, 50 words. Nothing required list. 1: Yes, 2: No Deductibles Single, 50 words. Nothing required list. 1: Yes, 2: No Coordination Single, 50 words. of Benefits Nothing required
deviation, explain. If unable or unwilling to provide all requested financial detail, elaborate on problematic data elements, estimating the number and percentage of affected claims and encounters. No for details provided. Financial Detail to be Provided Response If No or Yes with deviation, explain. Submitted Charges Single, list. 1: Yes, 2: No 50 words. Nothing required Discount Amount Single, list. 1: Yes, 2: No 50 words. Nothing required Allowable Charges Single, list. 1: Yes, 2: No 50 words. Nothing required Copayment Single, list. 1: Yes, 2: No 50 words. Nothing required Coinsurance Single, list. 1: Yes, 2: No 50 words. Nothing required Deductibles Single, list. 1: Yes, 2: No 50 words. Nothing required Coordination of Benefits Single, 50 words. Nothing required