Page 1 of 2

EXPLANATION OF BENEFITS
JULY 28, 2023

PROVIDER SUMMARY

Provider: WEST CAYUGA MEDCN PC

Provider Number: 1811449697

PAYMENT SUMMARY

TOTAL PROVIDER PAYMENTS ...................... $0.00

TOTAL INTEREST CALCULATED .................... $0.00

TOTAL MEMBER PAYMENTS ........................ $0.00

1901 Market Street

Philadelphia, PA 19103-1480

WEST CAYUGA MEDCN PC

257 W CAYUGA ST
PHILADELPHIA, PA 19140-2439

IP010775
"VISIT US AT OUR WEBSITE: www.ibx.com"
Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance
Company, and with Highmark Blue Shield. Independent Licensees of the Blue Cross and Blue Shield Association
 Provider Number: 1811449697 Page 2of 2
Provider Name: WEST CAYUGA MEDCN PC JULY 28, 2023
DATE(S) NUM REVENUE/ PAY- NON- NON- MEMBER MEM AMOUNT(S)
PROVIDER OUR OTHER MESSAGE
OF OF PROCEDURE MENT CHARGEABLE CHG LIABILITY LIAB PAID
CHARGE ALLOWANCE AMOUNT CODES
SVC SVCS CODE CODE AMOUNT CODE AMOUNT CODE (* = MEMBER)

PATIENT ACCT #: 1107815466 PATIENT: STEVEN SEAFORD CLAIM NUMBER:

MEMBER ID: MSJ601990332 MEMBER: STEVEN SEAFORD 22613693638
07/14/23 1 99214-00-95 026 115.24 114.25 .99 25 114.25 A1 X5019,J0053
CLAIM TOTALS .99 114.25

PATIENT ACCT #: 1109936795 PATIENT: JOSEPH CALLAHAN CLAIM NUMBER:

MEMBER ID: 134378148001 MEMBER: JOSEPH CALLAHAN 22314108128
07/21/23 1 99214-WD-95 026 115.24 75.93 25 39.31 D1 X5085,J0053
CLAIM TOTALS 75.93 39.31

MESSAGE(S):
_________
J0053 If you have any questions, call 1-800-ASK-BLUE.
X5019 The allowance for this service has been applied to the dollar deductible amount required under the
patient's coverage.
X5085 The allowance for this service has been applied to the co-payment amount required under the patient's
coverage.

______________
PAYMENT CODES: ____________________________
NON-CHARGEABLE AMOUNT CODES: _______________________
MEMBER LIABILITY CODES:
026 = CONTRACTED ALLOWANCE 25 = Differential A1 = Deductible
D1 = Copay

IP010775