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Invoice
Date
Invoice
Number
Due
Date
Bill
Grp
Total Invoice
Amount
Amount Paid
Reason Code
05/31/13
0002600234
06/15/13
1
$4,781.68
-- none --
Payment by other Payment Type
Pending product dispute
Pay based on payroll cycle
Split accountability for payment
Dispute proration
Prepayment of future invoice
Pending eligibility changes
Pending rate changes
Other
Please select a Reason Code for each line where the amount paid is not equal to the amount due.
Please ensure that this payment will be received in accordance with the terms specified in your contract
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MM/DD/YY
* Please Note: Payments submitted after 2PM Eastern Time will be processed on the next business day.
JUNE 2013
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