Required Quarterly Report Format
Community Health Alliance

Required Quarterly Report Format

Listed Below is the Required Quarterly Report Format for all CHA Members:

  • Employer Group Name
  • Employer Group number
  • Provider Tax ID
  • Provider Name
  • Patient SSN
  • Patient Name
  • Date of Service- this should be the date the service began, you can include when the service ended but please put in a separate column
  • CPT Code
  • Billed Charges- this is the original amount of the charge before any discounts or insurance adjustments were made
  • Discount- this is the discount that was applied to the charge.  If this was an Out Of Network Charge then the discount would be $0
  • Amount Paid- should be equal to billed charges- discount
  • Date Paid- this is the date the check was cut for the claim, pull by this date for each group
  • Claim Number
  • ICD-9 (Revenue Code)
  • Place of Service
  • Units

Disclaimer: This information is for informational purposes only and is not intended to constitute professional advice as circumstances may vary. CHA is not liable for information contained on this site. Fee schedule information applies only to M.D.s and D.O.s, not to any other Allied or Behavioral Health providers. CPT code allowables are global and do not represent modifiers. Information contained on this website is subject to change.