• Provider/Pharmacy
Name.
• Provider/Pharmacy Address.
• Provider/Pharmacy Taxpayer
Identification Number (TIN).
• Check Number.
• Voucher Date.
• Patient Name.
• Sponsor Name.
• Last four digits of Sponsor
SSN.
• Date(s) of Service/Date(s)
Prescription(s) Filled.
• Pharmacy EOB - Prescription
Number.
• Pharmacy EOB - Prescription
Name.
• Billed Amount.
• Reason Codes.
• Allowed Covered Charges.
• Deductible.
• Cost-Share/Copayment Amount.
• Total Paid by Other Health
Insurance (OHI).
• Catastrophic Cap.
• Remarks.
• Description(s) of Reason Code(s).
• Interest paid.
• Federal tax Withheld.
• Accumulated Toward Catastrophic
Cap.
• Accumulated Toward Individual
Deductible.
• Accumulated Toward Family Deductible.
• Offset (In the event payment
is offset or partially offset and applied toward a debt)
• Amount Paid (If payment was
not issued but money was withheld and applied towards another debt,
information regarding where the funds were applied).