P683502800K

P683502800K

Health Partners Plans

901 Market Street, Suite 500
Philadelphia, PA 19107
202312268800

Forwarding Service Requested

1 OF 7
Questions? Please contact Provider Service at (215)
6768 0.0868 991-4350 or Toll free (888)991-9023.

ENV 6768
FFATAFTADTDDATFDTAADDATATTFDTFFDADDADTFADTAAATTADDTADAADAAFTATFAD
WEST CAYUGA MEDICINE PC
257 W CAYUGA ST Payor ID: 80142
PHILADELPHIA, PA 19140-2439

Your name WEST CAYUGA MEDICINE PC and tax id have been

verified by the IRS

Tax ID: 813661898 EPC Draft #: 318466915 Payment Week: 51 Payment Date: 12/22/2023
Service Date Procedures No. of Amount Allowed Payment Patient Other Not Covered Sequest- Adjustment
From To (Modifier) Units Billed Responsibility Ins. Paid ration Reason
Patient: JUAN OSORIO GUEVARE Insured: 700131389JUAN OSORIO GUEVARE Payer Claim #: 2023090812832
Pat. Acct #: 1123697856 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
09/01/23-09/01/23 99213 1 -78.47 0.00 0.00 0.00 0.00 -78.47 0.00 PI22
Total for Claim: -78.47 0.00 0.00 0.00 0.00 -78.47 0.00

Patient: JUAN OSORIO GUEVARE Insured: 700131389JUAN OSORIO GUEVARE Payer Claim #: 2023090812832
Pat. Acct #: 1123697856 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
09/01/23-09/01/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: JUAN OSORIO GUEVARE Insured: 700131389JUAN OSORIO GUEVARE Payer Claim #: 2023092107571
Pat. Acct #: 1127711585 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
09/08/23-09/08/23 99213 1 -78.47 0.00 0.00 0.00 0.00 -78.47 0.00 PI22
Total for Claim: -78.47 0.00 0.00 0.00 0.00 -78.47 0.00

Patient: JUAN OSORIO GUEVARE Insured: 700131389JUAN OSORIO GUEVARE Payer Claim #: 2023092107571
Pat. Acct #: 1127711585 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
09/08/23-09/08/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: ANA DELGADO ALVERI Insured: 140251505ANA DELGADO ALVERI Payer Claim #: 2023112018543
Pat. Acct #: 1147787122 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
09/06/23-09/06/23 J3420 1 -50.00 -1.31 -1.31 0.00 0.00 -48.69 0.00 CO45
Total for Claim: -50.00 -1.31 -1.31 0.00 0.00 -48.69 0.00

Patient: ANA DELGADO ALVERI Insured: 140251505ANA DELGADO ALVERI Payer Claim #: 2023112018543
Pat. Acct #: 1147787122 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
09/06/23-09/06/23 J3420 1 50.00 0.00 0.00 0.00 0.00 50.00 0.00 PI16 M119
Total for Claim: 50.00 0.00 0.00 0.00 0.00 50.00 0.00

Patient: ADAM RICHARDSON Insured: 189681468ADAM RICHARDSON Payer Claim #: 2023121313033

Pat. Acct #: 1155669898 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/07/23-12/07/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: KELLY CORSON Insured: 530164135KELLY CORSON Payer Claim #: 2023121313034

Pat. Acct #: 1155669910 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
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Tax ID: 813661898 EPC Draft #: 318466915 Payment Week: 51 Payment Date: 12/22/2023
Service Date Procedures No. of Amount Allowed Payment Patient Other Not Covered Sequest- Adjustment
From To (Modifier) Units Billed Responsibility Ins. Paid ration Reason
12/08/23-12/08/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45

ENV 6768
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: TOI WILLIAMS Insured: 002881199TOI WILLIAMS Payer Claim #: 2023121313036

Pat. Acct #: 1155669950 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/08/23-12/08/23 99214 1 115.24 93.53 93.53 0.00 0.00 21.71 0.00 CO45
Total for Claim: 115.24 93.53 93.53 0.00 0.00 21.71 0.00

Patient: CYNTHIA SALAMANCA Insured: 950214046CYNTHIA SALAMANCA Payer Claim #: 2023121313037

Pat. Acct #: 1155670141 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/07/23-12/07/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: RAUL FRANCO Insured: 470204804RAUL FRANCO Payer Claim #: 2023121313038

Pat. Acct #: 1155669982 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/07/23-12/07/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: BRENALIZ RIVERA Insured: 750101711BRENALIZ RIVERA Payer Claim #: 2023121313039

Pat. Acct #: 1155670010 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/08/23-12/08/23 99213 GT 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: RICHARD RIVERA Insured: 820001728RICHARD RIVERA Payer Claim #: 2023121313041

Pat. Acct #: 1155670349 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/07/23-12/07/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: MHIA RIVERA Insured: 340160540MHIA RIVERA Payer Claim #: 2023121313042

Pat. Acct #: 1155670378 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/07/23-12/07/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: MARK FELTMAN Insured: 001532607MARK FELTMAN Payer Claim #: 2023121313044

Pat. Acct #: 1155670131 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/07/23-12/07/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: RUBEN JR CRUZ Insured: 980131539RUBEN JR CRUZ Payer Claim #: 2023121313045

Pat. Acct #: 1155670238 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/08/23-12/08/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: ROY JR BARONE Insured: 780118097ROY JR BARONE Payer Claim #: 2023121313046

Pat. Acct #: 1155670246 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/07/23-12/07/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: ELIDA ROSARIO Insured: 340285799ELIDA ROSARIO Payer Claim #: 2023121313048

Pat. Acct #: 1156082765 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/09/23-12/09/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
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Tax ID: 813661898 EPC Draft #: 318466915 Payment Week: 51 Payment Date: 12/22/2023
Service Date Procedures No. of Amount Allowed Payment Patient Other Not Covered Sequest- Adjustment
From To (Modifier) Units Billed Responsibility Ins. Paid ration Reason
Patient: AMANDA FABRY Insured: 530565833AMANDA FABRY Payer Claim #: 2023121313050

ENV 6768
Pat. Acct #: 1156082610 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/09/23-12/09/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: MANUEL REYES Insured: 391092172MANUEL REYES Payer Claim #: 2023121313052

Pat. Acct #: 1156082935 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/08/23-12/08/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: ROBERTO CRUZ Insured: 780117306ROBERTO CRUZ Payer Claim #: 2023121313053

Pat. Acct #: 1156082851 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/06/23-12/06/23 99214 GT 1 115.24 93.53 93.53 0.00 0.00 21.71 0.00 CO45
Total for Claim: 115.24 93.53 93.53 0.00 0.00 21.71 0.00

Patient: LUIS JIMENEZ Insured: 990120701LUIS JIMENEZ Payer Claim #: 2023121313054

Pat. Acct #: 1156082974 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/09/23-12/09/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: LLEWELLYN DOWD Insured: 350159455LLEWELLYN DOWD Payer Claim #: 2023121313055

Pat. Acct #: 1156083042 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/08/23-12/08/23 99213 GT 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: BRYAN PERSSON Insured: 120142527BRYAN PERSSON Payer Claim #: 2023121313056

Pat. Acct #: 1156083151 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/08/23-12/08/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: JACOB MONTES GONZALE Insured: 130121199JACOB MONTES Payer Claim #: 2023121414393
Pat. Acct #: 1156350887 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
11/02/23-11/02/23 99214 1 115.24 93.53 93.53 0.00 0.00 21.71 0.00 CO45
11/02/23-11/02/23 Q9992 1 50.00 50.00 50.00 0.00 0.00 0.00 0.00
Total for Claim: 165.24 143.53 143.53 0.00 0.00 21.71 0.00

Patient: MALVIN MARTINEZ Insured: 400147483MALVIN MARTINEZ Payer Claim #: 2023121414394

Pat. Acct #: 1156517861 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/11/23-12/11/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: CHRIS RENNER Insured: 630146020CHRIS RENNER Payer Claim #: 2023121414396

Pat. Acct #: 1156517915 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/12/23-12/12/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: JOSEFINA CINTRON Insured: 001328014JOSEFINA CINTRON Payer Claim #: 2023121414397

Pat. Acct #: 1156518116 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/11/23-12/11/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: MALISSA NAPLES Insured: 002231576MALISSA NAPLES Payer Claim #: 2023121414398

Pat. Acct #: 1156518149 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
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Tax ID: 813661898 EPC Draft #: 318466915 Payment Week: 51 Payment Date: 12/22/2023
Service Date Procedures No. of Amount Allowed Payment Patient Other Not Covered Sequest- Adjustment
From To (Modifier) Units Billed Responsibility Ins. Paid ration Reason
12/11/23-12/11/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45

ENV 6768
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: DANIELLE BRUENGER Insured: 070009285DANIELLE BRUENGER Payer Claim #: 2023121414400

Pat. Acct #: 1156518028 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/11/23-12/11/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: JUAN MALDONADO Insured: 470188787JUAN MALDONADO Payer Claim #: 2023121414401

Pat. Acct #: 1156518043 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/12/23-12/12/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: BRIAN FELIBERTY Insured: 790109377BRIAN FELIBERTY Payer Claim #: 2023121414402

Pat. Acct #: 1156518065 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/11/23-12/11/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: CHRISTOPHER ROSS Insured: 400148717CHRISTOPHER ROSS Payer Claim #: 2023121414403

Pat. Acct #: 1156518264 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/11/23-12/11/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: ORLANDO ESQUILIN Insured: 250607894ORLANDO ESQUILIN Payer Claim #: 2023121414404

Pat. Acct #: 1156518353 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/11/23-12/11/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: NICOLETTE ANDERSON Insured: 030306662NICOLETTE ANDERSON Payer Claim #: 2023121414407

Pat. Acct #: 1156518381 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/11/23-12/11/23 99214 1 115.24 93.53 93.53 0.00 0.00 21.71 0.00 CO45
Total for Claim: 115.24 93.53 93.53 0.00 0.00 21.71 0.00

Patient: ENRIQUE LOPEZ Insured: 220100898ENRIQUE LOPEZ Payer Claim #: 2023121414408

Pat. Acct #: 1156518275 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/11/23-12/11/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: THERESA HOPKINS Insured: 001674569THERESA HOPKINS Payer Claim #: 2023121414409

Pat. Acct #: 1156518561 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/11/23-12/11/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: DAQUAN THOMAS Insured: 510143919DAQUAN THOMAS Payer Claim #: 2023121414410

Pat. Acct #: 1156518716 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/12/23-12/12/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: JENNIFER LARKIN Insured: 520115597JENNIFER LARKIN Payer Claim #: 2023121414411

Pat. Acct #: 1156518742 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/11/23-12/11/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
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Tax ID: 813661898 EPC Draft #: 318466915 Payment Week: 51 Payment Date: 12/22/2023
Service Date Procedures No. of Amount Allowed Payment Patient Other Not Covered Sequest- Adjustment
From To (Modifier) Units Billed Responsibility Ins. Paid ration Reason
Patient: TIMOTHY CAMACHO Insured: 440355061TIMOTHY CAMACHO Payer Claim #: 2023121414412

ENV 6768
Pat. Acct #: 1156518786 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/12/23-12/12/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: EDWIN COLON Insured: 710138291EDWIN COLON Payer Claim #: 2023121503654

Pat. Acct #: 1156818530 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/12/23-12/12/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: EDNA MENDEZ Insured: 330149466EDNA MENDEZ Payer Claim #: 2023121503655

Pat. Acct #: 1156818629 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/13/23-12/13/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: JAMIE DONOVAN Insured: 530197613JAMIE DONOVAN Payer Claim #: 2023121503656

Pat. Acct #: 1156818640 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/13/23-12/13/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
12/13/23-12/13/23 Q9992 1 50.00 50.00 50.00 0.00 0.00 0.00 0.00
Total for Claim: 128.47 114.62 114.62 0.00 0.00 13.85 0.00

Patient: CARLOS GONZALEZ Insured: 130100721CARLOS GONZALEZ Payer Claim #: 2023121503658

Pat. Acct #: 1156818728 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/13/23-12/13/23 99214 1 115.24 93.53 93.53 0.00 0.00 21.71 0.00 CO45
Total for Claim: 115.24 93.53 93.53 0.00 0.00 21.71 0.00

Patient: FRANCIS APONTE Insured: 410139302FRANCIS APONTE Payer Claim #: 2023121503659

Pat. Acct #: 1156818758 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/13/23-12/13/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: EMILY CLAY Insured: 510123746EMILY CLAY Payer Claim #: 2023121815281

Pat. Acct #: 1157306142 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/13/23-12/13/23 99213 GT 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: SHANE STERNER Insured: 630175489SHANE STERNER Payer Claim #: 2023121815283

Pat. Acct #: 1157305161 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/14/23-12/14/23 99213 GT 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: BRIDGET BRZYCKI Insured: 001181212BRIDGET BRZYCKI Payer Claim #: 2023121815285

Pat. Acct #: 1157305923 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/14/23-12/14/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: MANUEL ORTIZ Insured: 002280786MANUEL ORTIZ Payer Claim #: 2023121815287

Pat. Acct #: 1157306026 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/14/23-12/14/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: JUAN GERARDO Insured: 770403273JUAN GERARDO Payer Claim #: 2023121815288

Pat. Acct #: 1157306051 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
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Tax ID: 813661898 EPC Draft #: 318466915 Payment Week: 51 Payment Date: 12/22/2023
Service Date Procedures No. of Amount Allowed Payment Patient Other Not Covered Sequest- Adjustment
From To (Modifier) Units Billed Responsibility Ins. Paid ration Reason
12/14/23-12/14/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45

ENV 6768
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: NICOLE PETRIKIS Insured: 700190617NICOLE PETRIKIS Payer Claim #: 2023121815290

Pat. Acct #: 1157306113 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/14/23-12/14/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: DANIEL ALLOWSING Insured: 710001876DANIEL ALLOWSING Payer Claim #: 2023121815291

Pat. Acct #: 1157305907 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
12/14/23-12/14/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: LORI BARCLAY Insured: 130139948LORI BARCLAY Payer Claim #: 2023121815292

Pat. Acct #: 1157378152 Provider: West Cayuga Medicine Pc Group/Check Number: 01/928951
10/24/23-10/24/23 99213 GT 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Statement Summary Amount Billed Payment Patient Other Ins. Not Covered
Responsibility Paid
3,971.94 3,409.62 0.00 0.00 562.32

Explanations
Administered By Code Description
HEALTH PARTNERS OF PI16 Claim/service lacks information or has submission/billing error(s). Usage: Do not use this
PHILADELPHI
code for claims attachment(s)/other documentation. At least one Remark Code must be
provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice
Remark Code that is not an ALERT.) Refer to the 835 Healthcare Policy Identification
Segment (loop 2110 Service Payment Information REF), if present.
CO45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
Usage: This adjustment amount cannot equal the total service or claim charge amount; and
must not duplicate provider adjustment amounts (payments and contractual reductions) that
have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO
depending upon liability)
M119 Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC).
PI22 This care may be covered by another payer per coordination of benefits.

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