West City Medical Response - Provider Summary

Provider Information
$ 2.2 k $2,133.51
Provider Name West City Medical Response

Provider Billing Address 130 North Summit Street, Suite 105, Akron, OH 44308
$ 2.1 k
Service Location Address Roosevelt Regional Medical Center - 400 Ontario Boulevard, Corona, CA 92882

Provider Phone Number 800-312-4947

$ 2.1 k
Start Date 11/20/2018

End Date 11/20/2018

$ 2.0 k

Summary Statistics $ 2.0 k

$1,929.04 $1,929.04

Total Amount Billed $2,133.51

$ 1.9 k
Total Reasonable Value $1,929.04

Total Amount Paid by Third Party $0.00

$ 1.9 k
Total Amount Adjusted $0.00

Total Amount Paid by Patient $0.00

$ 1.8 k
$0.00 Total Amount Billed Total Reasonable Value Total Lesser of Billed/Reasonable
Total Balance Due Value
Total Lesser of Billed/Reasonable Value $1,929.04

Conclusions

1 This provider billed $2,133.51 for ambulance services on November 20,2018

2 Ambulance services arrived at the scene on November 19, 2018, at 11:43 pm. Mr Farrell was transported to Roosevelt Regional Medical Center emergency department on November 20, 2018, arriving at 1:18 am.

3 All category code set rules were validated and confirmed. The charges were reviewed and audited, resultsing in a resonable value of $1,929.04

4 The reasonable value is based on the billed charges in comparison to average charges for the geographical area for the location where the services were provided.

5 Review of the billing record found $0.00 was adjusted.No payments were found to have been made by a third party of Mr Farrell. Based on the statements submitted for review, the entire billing record reflectrs no outstanding balance.

Lesser of
PMIC Amount Amount
Applied Amount Find-A- National Amount Balance Billed/Reas
Date Provider Diagnosis Code Description Units Wasserman Medical Geographic Reasonable Paid by Paid by
Code Billed Code U&C Adjusted Due onable
PFR Fees Modifier Value Third Party Patient
Value

11/20/18 West City Medical Not Provided ALS Emerg 1 $ 1,797.88 $ 1,797.88 1.000 $ 1,797.88 $ - $ - $ - $ - $ 1,797.88
Response Mandated
Comment: The reasonable value for ALS (advanced life support) is based on billed charges in comparison to average charges for the geographic area.

11/20/18 West City Medical Not Provided Mileage 3 $ 131.16 $ 131.16 1.000 $ 131.16 $ - $ - $ - $ - $ 131.16
Response
Comment: The reasonable value for mileage is based on billed charges in comparison to average charges for the geographic area.

11/20/18 West City Medical Not Provided Night Charge 1 $ 204.47 $ 204.47 1.000 $ - $ - $ - $ - $ - $ -
Response
Comment: This ancillary service is included in the base rate.