PCOVERFORM

PCOVERFORM

PO Box 20002
Nashville, TN 37202 202312268801

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Forwarding Service Requested

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ENV 13720
WEST CAYUGA MEDICAL CENTER
257 W CAYUGA ST
PHILADELPHIA, PA 19140-2439
 202312268801

L879002800Y
Contact Provider Services with any questions
1 (800) 230-6138
PO Box 20002
Monday - Friday 7:00 AM - 9:00 PM EST
Nashville, TN 37202
Cigna
Claims Department
PO Box 4433
Baltimore, MD 21223

Page: 2 of 5

9 9 Date: 12/26/2023
WEST CAYUGA MEDICAL CENT Provider: WEST CAYUGA MEDICAL
257 W CAYUGA ST Provider NPI: 1811449697
Check Number: 22947494
PHILADELPHIA, PA 19140-2439 Voucher Number: 22947494
Negative Balance ID:

Explanation of Initial Claims Payments

Member ID: 36747631 Provider Name: VENGOECHEA, FABIAN A
Member Name: BETH DUNYAN Date(s) of Service: 10/17/2023 - 10/17/2023
Network: PAIND Paid DRG:
Claim Number: 23306E036204 DRG Weight: 0.00000
Provider Acct No/ Patient Control No: 1141597979 Interest: $0.00
Date(s) of Service Service Billed Allowed Copay Coinsurance Deductible Withhold MIPS Adjustment Payment Reason Code
Code Amount Amount
10/17/2023 - 10/17/2023 99213 78.47 0.00 0.00 0.00 0.00 0.00 0.00 78.47 0.00 1213

Claim Totals: 78.47 0.00 0.00 0.00 0.00 0.00 0.00 78.47 0.00

Member ID: 35820005 Provider Name: VENGOECHEA, FABIAN A

Member Name: CARLOS RODRIGUEZ Date(s) of Service: 12/07/2023 - 12/07/2023
Network: PAIND Paid DRG:
Claim Number: 23347E035333 DRG Weight: 0.00000
Provider Acct No/ Patient Control No: 1155670234 Interest: $0.00
Date(s) of Service Service Billed Allowed Copay Coinsurance Deductible Withhold MIPS Adjustment Payment Reason Code
Code Amount Amount

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name, logos, and other Cigna marks are
owned by Cigna Intellectual Property, Inc.,

INT_20_86290_C © 2020 Cigna

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Date: 12/26/2023
Provider: WEST CAYUGA MEDICAL
Provider NPI: 1811449697
Check Number: 22947494
Voucher Number: 22947494
Negative Balance ID:

12/07/2023 - 12/07/2023 99213 78.47 78.47 0.00 15.69 0.00 1.26 0.00 0.00 61.52 1229 N782

Claim Totals: 78.47 78.47 0.00 15.69 0.00 1.26 0.00 0.00 61.52

Member ID: 10026088 Provider Name: VENGOECHEA, FABIAN A

Member Name: ANA CARMONA Date(s) of Service: 12/11/2023 - 12/11/2023
Network: PAIND Paid DRG:
Claim Number: 23348E040948 DRG Weight: 0.00000
Provider Acct No/ Patient Control No: 1156518133 Interest: $0.00
Date(s) of Service Service Billed Allowed Copay Coinsurance Deductible Withhold MIPS Adjustment Payment Reason Code
Code Amount Amount
12/11/2023 - 12/11/2023 99213 78.47 78.47 0.00 0.00 0.00 1.57 0.00 0.00 76.90 1229

Claim Totals: 78.47 78.47 0.00 0.00 0.00 1.57 0.00 0.00 76.90

Total Check Amount/Total Offsets/Total Refund Requests

Initial Claims Payments 138.42

Claims Adjustments 0.00

Negative Balance recouped

from this check 0.00

Total Check Amount 138.42

Total Refund Requests 0.00

Additional Information
Total Interest on EOP 0.00

Remark Code Explanation

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L879002800Y
PO Box 20002
Nashville, TN 37202

1213 The Requested Referral or Authorization was not received in the allotted time frame.
1229 Sequestration - Reduction in Federal Spending. Reduction in payment applies according to Medicare guidelines.
903 $0.00 Check(s) received from provider for this check period
904 $0.00 Amount Written Off
N782 Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.
*** If applicable, important information regarding appeal rights is attached.
*** Appeal information and waiver of liability form is accessible via the following link: www.cigna.com/appeal-wol-medicare
*** Select ancillary providers including Home Health, DME, Podiatry and Ambulance must submit all new requests for pre-certification through the Bravo Provider Portal HSConnect effective 08/1/2012.
Faxed request for authorization will not be accepted. For additional information please review hsconnect.bravohealth.com or call Provider Customer Service at 1-866-948-8759. CMS requires annual
Special Needs Plans (SNP) Model of Care (MOC) training for network providers, and non-network providers who routinely see SNP customers. If you’ve not participated in SNP MOC training this year,
please access the SNP MOC training on Cigna’s Health Care Professionals website: https://www.cigna.com/static/docs/medicare-2019/snp-moc-training.pdf
*** Link to provider appeal/waiver rights: www.cigna.com/appeal-wol-medicare

*** Attention Out-of-Network providers: For provider manuals and Medicare information and tools, please go to https://medicareproviders.cigna.com/. Select the Out-of-Network Provider Manual in
the drop down box for details.
Notes The "R" after a claim number represents a reversal for that claim
The "A" after a claim number represents an adjustment for that claim
The number after an "R" or an "A" on a claim represents the number of times that claim has been reversed or adjusted
Negative Balance/Offset are amounts automatically recouped from total payment(s)
Refund Requests are adjustments that have not been automatically recouped from total payment(s) and will require further action from you to resolve

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202312268801 P879002801G

PO Box 20002
Nashville, TN 37202

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Forwarding Service Requested

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ENV 13720
WEST CAYUGA MEDICAL CENTER
257 W CAYUGA ST
PHILADELPHIA, PA 19140-2439

65-7293 CHECK NO.: 022947494

2550
CHECK DATE: 12/26/2023
AMOUNT
$ ******* 138.42
PAY One Hundred Thirty Eight & 42/100 Dollars
TO THE WEST CAYUGA MEDICAL CENTER
ORDER OF 257 W Cayuga St
Philadelphia, PA 191402439
Wachovia Bank, N.A.
Philadelphia, PA 19102