Aetna

151 FARMINGTON AVENUE

HARTFORD, CT 06156

ERA, Provider and Payer Information

ERA and Payer Information

Payer: AETNA EFT Trace / Check #: 822033000301109

EFT Payment / Check Date 02/07/2022 EFT Payment Amount $649.31
Provider Information

Name: GREATER LONG BEACH Address: PO BOX 4067 Payer Assigned ID 1417976705
GENITO-URINARY MEDICAL GROUP, I State, City, Zip SEAL BEACH, CA 90740-8067

Claim, Service / Line Level and Adjustment Information

Claim Information

Patient Name: JAIME ROBLES GARCIA Robles Garcia, Jaime Member ID: W258614767 Claim ID: E6PCVL3BL0000
Patient Account #: C198323730

Service / Line Level and Adjustment Information

Service / Line Level Information
DOS PL Code Units Charges Adjustments Co-Pay Deductible Co-Ins Patient Ins. Paid Remarks

01/05/2022 - 01/05/2022 81002 0.00 $10.00 $6.94 CO-45 $0.00 $0.00 $ 0.00 $0.00 $3.06
01/05/2022 - 01/05/2022 99204 0.00 $360.00 $255.31 CO-45 $40.00 $0.00 $ 0.00 $40.00 $104.69
PR-3

TOTALS $370.00 $255.31 $40.00 $0.00 $ 0.00 $40.00 $107.75

Interest $0.00

Discount: $ 0.00

$107.75
PAYMENT AMOUNT
Procedure Code Date Adjustment Level Code Translation Amount

81002 01/05/2022 Service CO-45 Charges exceed your contracted/ legislated fee arrangement. $6.94

99204 01/05/2022 Service CO-45 Charges exceed your contracted/ legislated fee arrangement. $215.31

99204 01/05/2022 Service PR-3 Co-payment Amount $40.00

N19 Procedure code incidental to primary procedure.

Page 1 of 2
Claim, Service / Line Level and Adjustment Information

Claim Information

Patient Name: JAIME ROBLES GARCIA Robles Garcia, Jaime Member ID: W258614767 Claim ID: EKACWZ4280000
Patient Account #: C198469979

Service / Line Level and Adjustment Information

Service / Line Level Information
DOS PL Code Units Charges Adjustments Co-Pay Deductible Co-Ins Patient Ins. Paid Remarks

01/10/2022 - 01/10/2022 J1580 0.00 $20.00 $18.31 CO-45 $0.00 $0.00 $ 0.00 $0.00 $1.69
01/10/2022 - 01/10/2022 52000 0.00 $400.00 $206.60 CO-45 $40.00 $0.00 $ 0.00 $40.00 $193.40
PR-3
01/10/2022 - 01/10/2022 81002 0.00 $10.00 $6.94 CO-45 $0.00 $0.00 $ 0.00 $0.00 $3.06
01/10/2022 - 01/10/2022 96372 0.00 $50.00 $50.00 CO-97 $0.00 $0.00 $ 0.00 $0.00 $0.00 N19
01/10/2022 - 01/10/2022 99213 0.00 $160.00 $160.00 CO-97 $0.00 $0.00 $ 0.00 $0.00 $0.00 N19

TOTALS $640.00 $160.00 $40.00 $0.00 $ 0.00 $40.00 $198.15

Interest $0.00

Discount: $ 0.00

$198.15
PAYMENT AMOUNT
Procedure Code Date Adjustment Level Code Translation Amount

J1580 01/10/2022 Service CO-45 Charges exceed your contracted/ legislated fee arrangement. $18.31

52000 01/10/2022 Service PR-3 Co-payment Amount $40.00

52000 01/10/2022 Service CO-45 Charges exceed your contracted/ legislated fee arrangement. $166.60

81002 01/10/2022 Service CO-45 Charges exceed your contracted/ legislated fee arrangement. $6.94

96372 01/10/2022 Service CO-97 Payment is included in the allowance for another service/procedure. $50.00

99213 01/10/2022 Service CO-97 Payment is included in the allowance for another service/procedure. $160.00

N19 Procedure code incidental to primary procedure.

Page 2 of 2