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STATE OF HAWAII DEPARTMENT OF HUMAN SERVICES REQUEST DIVISION Companion Document and Transaction Specifications for the HIPAA 835 Claims Remittance Advice Transaction VERSION 1.4 MARCH 2004DRAFTDRAFTRevision
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How to fill out hi 835 ra companion

01
To fill out the HI 835 RA Companion form, follow these steps:
02
Gather the necessary information, which includes the remittance advice (RA) received, patient information, claim information, and payment details.
03
Fill out the top section of the form with the provider information, such as the provider name, address, and phone number.
04
Enter the RA date and number in the designated fields.
05
Fill in the patient information section, including the patient's name, ID, and account number.
06
Enter the claim information, including the claim number, date(s) of service, and amount billed.
07
Specify the applicable adjustment reason codes and associated amounts in the adjustment section.
08
Provide the payment details, such as the check or EFT number, payment date, and amount received.
09
Review the filled-out form for accuracy and completeness.
10
Submit the completed HI 835 RA Companion form as per the guidelines provided by the relevant healthcare authority or payer.

Who needs hi 835 ra companion?

01
The HI 835 RA Companion form is needed by healthcare providers or medical billing professionals who receive a remittance advice (RA) from payers or insurance companies.
02
It is used to report and reconcile payment information for healthcare services rendered and provides a detailed breakdown of payments, adjustments, and denials.
03
By filling out the HI 835 RA Companion form accurately, providers can ensure proper reimbursement and maintain accurate financial records.
04
This form is particularly relevant for providers who submit electronic claims and receive electronic remittance advice.
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Hi 835 ra companion is a form used for reporting information related to certain taxes or benefits.
Employers or entities responsible for certain tax withholdings or benefit distributions are required to file hi 835 ra companion.
To fill out hi 835 ra companion, one must provide accurate information regarding the taxes or benefits being reported, following the instructions provided on the form.
The purpose of hi 835 ra companion is to ensure accurate reporting and compliance with tax or benefit regulations.
Information such as tax withholdings, benefit distributions, and other related financial data must be reported on hi 835 ra companion.
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