WVRPUMADUS 8fofeUl? S:0Gi 16 PM PAGE = i/0Ue 8 =—Fax bOrver aetna Fax Message To: david Fax: 8882359876 From: Date: Friday, May 05, 2017 4:05:18 PM. Pages (including this page): 02 Subject: This message is intended only for the use of the individual or entity to which i addressed and may contain confidential and/or proprietary information. If you are not the intended recipient or the employee or agent responsible for delivering the message to the intended recipient, you are hereby nolified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you received this communication in error, please notify the sender at the phone number above. NOTICE TO RECIPIENT(S) OF INFORMATION: Information disclosed to you pertaining to alcohol or drug abuse treatment is protected by federal confidentiality rules (42 CFR Part 2), which prohibit any further disclosure of this information by you without the express written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.™ VAPUMAP US efofeUl!s S001 1S Hag OP Merey Care Pan 44350 E, Colton Center Bivd, Bldg D Phoenix, A7, 83040 ‘Pu PAGE = é/UUe = Fax borver Aryou have any questions, please contact the Claims Department at (602) 263-3000 oF (800) 624-3879 a Remit Date: 63/042017 3 A7-TE.CH RADION OGY & OPEN MRE on a ai inesaaetd jenefit Plan: S Acute TIN: so0910845 Tan OROCE DARCELD Tata AT eT Taso PRI Meer Ms 00125155 Autorrton Ts ‘al. HIGRCICASD Date ot Biths "187/19 Provider: ZELL. STEVEN Retind Anwiae 0.8, ial DRG: Severity tne IG, | Dates orsenie] Sew Mal] Rev [FAN tar] Wille) [ovaloned] wale [Patan Repos | COR] Procasedoacon] Net Litrom= tira) | Cave Coie Cade] CaP “| amv ‘Snwunt |CorPay[ Ow. [Contns|_Paid_| “Amouat|Peely | Amn T [| wom? rmohre) [es 1 | M0 eam] 2089] 000_o0n] om om] 0s] ow] 2083 Chim Yeas |_—aa00] 9.1] aoa and a0] oo] —o.no| 2049] oo] a0 Coadetbsricon ‘Thllonod = Charged ev achonayimam alas or coinicegiuad sangre Fae ORTON MATT Tar TTF Tia Say TFNTFD Member Ds 47420123 Antoine ‘aime: 17HC19905 Dateot et; 02071979 Troi: SHALLPATEL USA R Reto At B00 na DR: Seventy af ns: [Uj | Dates of Service| Serv Mod Rey | FEN’ Vinit | Billed [Disallowed) Allowable | Patient Responsibility Processed | Groan-Tare | Code_Cave| Cone [CaP | Ansan Suet (Coa | Dad | Cots ‘Anau T | mats anon Ts 7 | 31860) Sion 008} —a)_a0)] — 0 a TS 2] oawis —_Ts2 sis_1 | sooo] se 0%] oo] non] so] oc] om “nan Tom ——3460] 36600] ——oaal — ono —a00 —0 9) — amo] — ued Coeeergon Tine 0 THESP ARF NON-COVERED STRVICTS BECAUSETHIS S NOT DEEMED A MUICAT NFCTSSTTV RY THF PAYER Lime? M7 = 1M RELATED OR QUALIFYING CLAIMSERVICE WAS NOT IDENIIED ON TS CLAIBL Fatt TNT TANT Tava ETE Ts ata DENTE Member ID: AE0238 Antointon 1s ‘aime: 17SICouOSe Death: UIST Treider: SHABLEAZEL, LISA R < OW Fa DRC: Severity af Ma 1], | DasofScnke] Sev Mou] Ro [NT Gen Bild [Dualoned Alpwanc Tat RIN |-COR | ProcacdDucoaal] Ne | ron Tire) | Cole_Cale| Cale [CAP Arve Amoont_CorPay | Ded. Coins|_taid_| ‘mua | Pray | Amount 1 Wael ono a a rT 2 Was mst FS 1 sto se00] 0c] 007] nop ooo oul oan] __ von) on “Clan Tots 366,00] 366.00] oon] cof 0.00 a 0.09] 0.00) 0.09] “0 coe Beripion Une] s0-THESE ARE NON-COVERED SERVICES BECAISE HIS NOT DEEMED A'MEDICAL NECESSTIW BV THE PAYER ime? IS-THIS SFRVICEROCTDURE RFQURTS THAT A QUALIFYING SFRVICEIPROCFDURE RF RECEIVED AND COVERED, THE QUALIFYING OVER SF RVICE!PROCEDUREAS NOT REEN RECEIVEDIADIDICATED 122-ADO-ON CODE CANNOT BE ULED BY NSELE Faia TATDRR SACRE Tatar Ae OTT Tama FIT Members ARTIS Aurttion is ‘hin. 7020088055 Dateot th: 7180 ‘reir: ELL STEVEN Refied Anaunte 00 Final DRG: Seery tne aes oF erie rom. Th TAS Unit flow 2800) 2ST [sation romans Paien Responsiiy Amount CvPay 7343] 000] a0) 00o 000 [PReomr] net eval aso] 31457) 343] owl 0.00 ood} p00] ool 33.5]