Debit Balance Report DBR Capital Blue Cross by erin.natividad

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									                                                              Debit Balance Report (DBR)
The Debit Balance Report (DBR) identifies claims that have been overpaid, adjusted and offset.
This report is included with SORs that have an offset amount listed in the Debit Remittance
Balance field. The Debit Remittance Balance field is located on the Payment Totals page of the
SOR. The DBR field descriptions are shown in the table that follows, along with a sample DBR.

                                      Debit Balance Report Headings and Descriptions
           Heading                                                                                         Description
For the Payment Week:                         Beginning date of the week covered by the SOR payment
Provider Group #                             Provider group ID number and name
Patient Account #                            An alpha/numeric medical record number that may be assigned by the Provider and included on
                                             the claim.
Claim Number                                  A unique number assigned by Capital BlueCross to identify one particular claim.
Subscriber ID                                 Member’s Capital BlueCross identification number (alpha prefix not included).
Patient First Name                           First name of the patient (subscriber or dependent) for whom the services were rendered.
Patient Last Name                            Last name of the patient (subscriber or dependent) for whom the services were rendered.
Date of Service                              Month, day, and year of the service.
Amount Recovered                             The dollar amount that is taken back for this claim from this week’s payment.
Remaining Debit Balance                      The outstanding balance still owed by the Provider to Capital BlueCross on this account.
Total                                         Total remaining outstanding balance




        Health care benefit programs issued or administered by Capital BlueCross
        and/or its subsidiaries, Capital Advantage Insurance Company® and
        Keystone Health Plan® Central. Independent licensees of the Blue Cross
        and Blue Shield Association. Communications issued by Capital
        BlueCross in its capacity as administrator of programs and provider
        relations for all companies.

                                                                            Debit Balance Report

                                                                        For the payment week of xx/xx/xxxx


        Provider Group Number:                                   xxxxxxxxxx                ABC Group

        Patient Account #      Claim Number        Subscriber ID      Patient First Name   Patient Last Name Date of Service   Amount Recovered   Remaining Debit Balance
        ######                 #####X######        8########          FirstName            LastName          xx/xx/xxxx                 $##.##                     ##.##

        ######                 #####X######        8########          FirstName            LastName          xx/xx/xxxx                $###.##                     $#.##

        ######                 #####X######        8########          FirstName            LastName          xx/xx/xxxx                $###.##                    $##.##

        ######                 #####X######        8########          FirstName            LastName          xx/xx/xxxx                 $##.##                     $#.##



        Total                                                                                                                          $###.##                    $##.##




                                                                       Debit Balance Report Sample

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance
         ®                          ®
Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association.
Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

								
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