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PAGE: 1 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

CAREFIRST BLUE CHOICE PROVIDER REMITTANCE DATA REPORT DATE: 09/11/2021

10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 09/11/2021
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 09/10/2021 PROVIDER: 1740729482815149807 PRINT TIME: 15:08:39

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 09/10/2021

3914 HICKORY AVENUE CHECK/EFT #: 731873349

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME HELSABECK, CHARLES HIC B5R836831240 ACNT 2193497A ICN 26212397369200580

1730744475 0811 081121 1 20553 130.56 51.78 0.00 0.00 CO-45 78.78 51.78
0811 081121 1 J3490 2.50 0.10 0.00 0.00 PR-3 0.10 0.00
CO-45 2.40

PT RESP 0.10 CLM STATUS 1 CLAIM TOTALS 133.06 51.88 0.00 0.00 81.28 51.78
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 51.78

___________________________________________________________________________________________________________________________________
NAME HELSABECK, CHARLES HIC B5R836831240 ACNT 2193678A ICN 26212397421800580

1730744475 0812 081221 1 20553 130.56 51.78 0.00 0.00 CO-45 78.78 51.78
0812 081221 1 J3490 2.50 0.10 0.00 0.00 PR-3 0.10 0.00
CO-45 2.40

PT RESP 0.10 CLM STATUS 1 CLAIM TOTALS 133.06 51.88 0.00 0.00 81.28 51.78
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 51.78

___________________________________________________________________________________________________________________________________
NAME HELSABECK, CHARLES HIC B5R836831240 ACNT 2195410A ICN 26212448686100580

1730744475 0824 082421 3 95851 59 142.50 29.46 0.00 0.00 CO-45 113.04 29.46
0824 082421 1 20553 130.56 51.78 0.00 0.00 CO-45 78.78 51.78
0824 082421 1 J3490 2.50 0.10 0.00 0.00 PR-3 0.10 0.00
CO-45 2.40

PT RESP 0.10 CLM STATUS 1 CLAIM TOTALS 275.56 81.34 0.00 0.00 194.32 81.24
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 81.24

___________________________________________________________________________________________________________________________________
TOTALS: # OF BILLED ALLOWED DEDUCT COINS TOTAL PROV PD PROV CHECK

CLAIMS AMT AMT AMT AMT RC-AMT AMT ADJ AMT AMT

3 541.68 185.10 .00 .00 356.88 184.80 .00 .00

___________________________________________________________________________________________________________________________________
PROVIDER ADJ DETAILS: PLB REASON CODE PLB ADJUSTMENT IDENTIFIER AMOUNT

WO 1246006510 26211604054601580 2076142B 81.31

WO 1246006520 26211604219901580 2076953B 81.31

WO 1246006530 26211623154601580 2066801B 22.18

GLOSSARY: CLAIM ADJUSTMENT REASON CODES

___________________________________________________________________________________________________________________________________
45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement

3 Co-payment Amount

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