Aetna

151 FARMINGTON AVENUE

HARTFORD, CT 06156

ERA, Provider and Payer Information

ERA and Payer Information

Payer: AETNA EFT Trace / Check #: 922033000301107

EFT Payment / Check Date 02/02/2022 EFT Payment Amount $0.00
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: ERNESTO MORALES Morales, Ernesto Member ID: W23333071701 Claim ID: E6PCVWD370000
Patient Account #: C198860694

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

01/20/2022 - 01/20/2022 81002 0.00 $10.00 $10.00 CO-B11 $0.00 $0.00 $ 0.00 $0.00 $0.00 N418
01/20/2022 - 01/20/2022 99204 0.00 $360.00 $360.00 CO-B11 $0.00 $0.00 $ 0.00 $0.00 $0.00 N418

TOTALS $370.00 $360.00 $0.00 $0.00 $ 0.00 $0.00 $0.00

Interest $0.00

Discount: $ 0.00

$0.00
PAYMENT AMOUNT
Procedure Code Date Adjustment Level Code Translation Amount

81002 01/20/2022 Service CO-B11 The claim/service has been transferred to the proper payer/processor $10.00
for processing. Claim/service not covered by this payer/processor.
99204 01/20/2022 Service CO-B11 The claim/service has been transferred to the proper payer/processor $360.00
for processing. Claim/service not covered by this payer/processor.

N418 Misrouted claim. See the payers claim submission instructions.

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