P683502804W

P683502804W

P6835028COV
Health Partners Plans
901 Market Street, Suite 500
Philadelphia, PA 19107
202307240116

Forwarding Service Requested Check Number

1 OF 1
301686412
ALL FOR AADC 190
7484 0.3820 AB 0.534

ENV 7484
ADDTTFDDDFTFDFTTFAFADAFDFTFFFTTTTTAFAFADFADDFTAFATAFDFTTTAAFFTADA
WEST CAYUGA MEDICINE PC 128
257 W CAYUGA ST
PHILADELPHIA, PA 19140-2439

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W V P E L R Z T U H - U T U T R K

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$3,648.84
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view your EOP offline

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Electronic Payment Clearinghouse

PNC - ECHO
Pittsburgh PA 15219
60-162 DRAFT NO. 301686412
433
901 Market Street, Suite 500
Philadelphia, PA 19107
ELECTRONIC COMMERCE BENEFIT TRUST
DRAFT DATE: 07/21/2023
VOID AFTER 180 DAYS

PAYABLE THROUGH Three Thousand Six Hundred Forty Eight & 84/100 Dollars
AMOUNT
DRAFT *****$3,648.84
TO THE WEST CAYUGA MEDICINE PC
ORDER OF 257 W CAYUGA ST

PHILADELPHIA PA 19140

C301686412C A043301627A 1069954659C

 P683502800K
P683502800K

Health Partners Plans

901 Market Street, Suite 500
Philadelphia, PA 19107
202307248800

Forwarding Service Requested

1 OF 7
Questions? Please contact Provider Service at (215)
8714 0.0868 991-4350 or Toll free (888)991-9023.

ENV 8714
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 #: 301686412 Payment Week: 29 Payment Date: 07/21/2023
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: ANA DELGADO ALVERI Insured: 140251505ANA DELGADO ALVERI Payer Claim #: 2023062303120
Pat. Acct #: 1098471490 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
06/17/23-06/17/23 J3420 1 -50.00 -1.61 -1.61 0.00 0.00 -48.39 0.00 CO45
Total for Claim: -50.00 -1.61 -1.61 0.00 0.00 -48.39 0.00

Patient: ANA DELGADO ALVERI Insured: 140251505ANA DELGADO ALVERI Payer Claim #: 2023062303120
Pat. Acct #: 1098471490 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
06/17/23-06/17/23 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: JORGE OYOLA Insured: 002270882JORGE OYOLA Payer Claim #: 2023071217455

Pat. Acct #: 1104507657 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/05/23-07/05/23 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: RACHEL HERLING Insured: 300154479RACHEL HERLING Payer Claim #: 2023071217456

Pat. Acct #: 1104507650 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/06/23-07/06/23 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: CARRIE FELTMAN Insured: 160347201CARRIE FELTMAN Payer Claim #: 2023071217457

Pat. Acct #: 1104507656 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/05/23-07/05/23 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: MICHELLE HOLCOMB Insured: 190117193MICHELLE HOLCOMB Payer Claim #: 2023071217458

Pat. Acct #: 1104507659 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
06/21/23-06/21/23 99205 1 350.00 178.72 178.72 0.00 0.00 171.28 0.00 CO45
Total for Claim: 350.00 178.72 178.72 0.00 0.00 171.28 0.00

Patient: EMERALD MARTEZ Insured: 360140181EMERALD MARTEZ Payer Claim #: 2023071217459

Pat. Acct #: 1104507655 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/05/23-07/05/23 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: CARLOS RAMOS Insured: 770142215CARLOS RAMOS Payer Claim #: 2023071217461

Pat. Acct #: 1104507649 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
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Tax ID: 813661898 EPC Draft #: 301686412 Payment Week: 29 Payment Date: 07/21/2023
Service Date Procedures No. of Amount Allowed Payment Patient Other Not Covered Sequest- Adjustment
From To (Modifier) Units Billed Responsibility Ins. Paid ration Reason
07/06/23-07/06/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45

ENV 8714
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: FELIX GONZALEZ Insured: 120005340FELIX GONZALEZ Payer Claim #: 2023071217462

Pat. Acct #: 1104507658 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/05/23-07/05/23 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: JOCELYN LANAUSSE Insured: 650108627JOCELYN LANAUSSE Payer Claim #: 2023071217464

Pat. Acct #: 1104507652 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/06/23-07/06/23 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: ANDRE LOZADA Insured: 240130092ANDRE LOZADA Payer Claim #: 2023071217465

Pat. Acct #: 1104507646 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/06/23-07/06/23 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: SABRINA MENENDEZ Insured: 750103310SABRINA MENENDEZ Payer Claim #: 2023071217466

Pat. Acct #: 1104507651 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/06/23-07/06/23 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 DIAZ Insured: 001402649ANA DIAZ Payer Claim #: 2023071217467

Pat. Acct #: 1104507648 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/06/23-07/06/23 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: RUBIN DIAZ Insured: 001404711RUBIN DIAZ Payer Claim #: 2023071217468

Pat. Acct #: 1104507654 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/05/23-07/05/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
07/05/23-07/05/23 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: ALSHARIEF YOUNG Insured: 310143245ALSHARIEF YOUNG Payer Claim #: 2023071217469

Pat. Acct #: 1104507653 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/06/23-07/06/23 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: KRISTINE MALLOY Insured: 187700170KRISTINE MALLOY Payer Claim #: 2023071313606

Pat. Acct #: 1105113538 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/08/23-07/08/23 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: BILLY RODRIGUEZ Insured: 240109350BILLY RODRIGUEZ Payer Claim #: 2023071313607

Pat. Acct #: 1105113531 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/07/23-07/07/23 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: GRISELL RODRIGUEZ Insured: 002459307GRISELL RODRIGUEZ Payer Claim #: 2023071313610

Pat. Acct #: 1105113537 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/08/23-07/08/23 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
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Tax ID: 813661898 EPC Draft #: 301686412 Payment Week: 29 Payment Date: 07/21/2023
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: ALEXANDER HERNANDEZ Insured: 540107942ALEXANDER Payer Claim #: 2023071313611

ENV 8714
Pat. Acct #: 1105113547 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/05/23-07/05/23 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: ALBERT COX Insured: 980000325ALBERT COX Payer Claim #: 2023071313612

Pat. Acct #: 1105113534 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/07/23-07/07/23 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: PAUL LANDES Insured: 410274907PAUL LANDES Payer Claim #: 2023071313613

Pat. Acct #: 1105113528 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/07/23-07/07/23 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: MICHELLE GALLAGHER Insured: 600008758MICHELLE GALLAGHER Payer Claim #: 2023071313615

Pat. Acct #: 1105113542 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/05/23-07/05/23 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: JEREMY CRUZ Insured: 200010358JEREMY CRUZ Payer Claim #: 2023071313616

Pat. Acct #: 1105113539 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/05/23-07/05/23 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: IRMA ACEVEDO Insured: 160104084IRMA ACEVEDO Payer Claim #: 2023071313617

Pat. Acct #: 1105113527 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/07/23-07/07/23 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: ALYSSA BANGERT Insured: 190173509ALYSSA BANGERT Payer Claim #: 2023071313618

Pat. Acct #: 1105113526 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
06/23/23-06/23/23 99213 1 78.47 11.15 11.15 0.00 53.47 13.85 0.00 OA23 CO23
CO45
Total for Claim: A COB payment of 53.47 78.47 11.15 11.15 0.00 53.47 13.85 0.00
is included in the Adjustment Amount
Patient: PRINCESS RODRIGUEZ Insured: 360106849PRINCESS RODRIGUEZ Payer Claim #: 2023071313619
Pat. Acct #: 1105113536 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/08/23-07/08/23 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: GRISSELLE PLASENCIA GUTI Insured: 580196789GRISSELLE PLASENCIA Payer Claim #: 2023071313620
Pat. Acct #: 1105113530 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/07/23-07/07/23 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: KEILA ALVAREZ NIEVES Insured: 530654198KEILA ALVAREZ NIEVES Payer Claim #: 2023071313621
Pat. Acct #: 1105113532 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/07/23-07/07/23 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: TAMARA SANTOS Insured: 480105094TAMARA SANTOS Payer Claim #: 2023071313622

Pat. Acct #: 1105113533 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
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Tax ID: 813661898 EPC Draft #: 301686412 Payment Week: 29 Payment Date: 07/21/2023
Service Date Procedures No. of Amount Allowed Payment Patient Other Not Covered Sequest- Adjustment
From To (Modifier) Units Billed Responsibility Ins. Paid ration Reason
07/07/23-07/07/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45

ENV 8714
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: JUAN LUCIANO Insured: 680199377JUAN LUCIANO Payer Claim #: 2023071313623

Pat. Acct #: 1105113535 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/08/23-07/08/23 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: DIANE DUFFIN Insured: 170102564DIANE DUFFIN Payer Claim #: 2023071313624

Pat. Acct #: 1105113544 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/05/23-07/05/23 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: ROBERT WALKER Insured: 040375211ROBERT WALKER Payer Claim #: 2023071313626

Pat. Acct #: 1105113548 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/05/23-07/05/23 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: MICHELE MCGINLEY Insured: 187682651MICHELE MCGINLEY Payer Claim #: 2023071313627

Pat. Acct #: 1105113541 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/05/23-07/05/23 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: DAMON DAVIS Insured: 001384956DAMON DAVIS Payer Claim #: 2023071313628

Pat. Acct #: 1105113546 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/05/23-07/05/23 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: JOSELINA QUEZADA Insured: 440133006JOSELINA QUEZADA Payer Claim #: 2023071313629

Pat. Acct #: 1105113543 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/05/23-07/05/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
07/05/23-07/05/23 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: BRANDI LAWRENCE Insured: 860105379BRANDI LAWRENCE Payer Claim #: 2023071412279

Pat. Acct #: 1105588823 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/05/23-07/05/23 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: SHALEE PACHECO Insured: 140422948SHALEE PACHECO Payer Claim #: 2023071412280

Pat. Acct #: 1105588824 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/07/23-07/07/23 99205 GT 1 350.00 178.72 178.72 0.00 0.00 171.28 0.00 CO45
Total for Claim: 350.00 178.72 178.72 0.00 0.00 171.28 0.00

Patient: BRANDI LAWRENCE Insured: 860105379BRANDI LAWRENCE Payer Claim #: 2023071412281

Pat. Acct #: 1105588822 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
06/21/23-06/21/23 99205 1 350.00 178.72 178.72 0.00 0.00 171.28 0.00 CO45
Total for Claim: 350.00 178.72 178.72 0.00 0.00 171.28 0.00

Patient: MALVIN MARTINEZ Insured: 400147483MALVIN MARTINEZ Payer Claim #: 2023071714148

Pat. Acct #: 1106057404 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/10/23-07/10/23 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
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Tax ID: 813661898 EPC Draft #: 301686412 Payment Week: 29 Payment Date: 07/21/2023
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: CLARA DEL RIO Insured: 630121720CLARA DEL RIO Payer Claim #: 2023071714149

ENV 8714
Pat. Acct #: 1106057405 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/10/23-07/10/23 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: WILMARY MILETT SANTIAG Insured: 840341491WILMARY MILETT Payer Claim #: 2023071714151
Pat. Acct #: 1106438363 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/12/23-07/12/23 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: EDWARD KOPP Insured: 450150132EDWARD KOPP Payer Claim #: 2023071714155

Pat. Acct #: 1106438362 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/12/23-07/12/23 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: ADAM RICHARDSON Insured: 189681468ADAM RICHARDSON Payer Claim #: 2023071714156

Pat. Acct #: 1106438355 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/12/23-07/12/23 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: ERIC SANTIAGO Insured: 940008773ERIC SANTIAGO Payer Claim #: 2023071714157

Pat. Acct #: 1106438358 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/12/23-07/12/23 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: MANUEL REYES Insured: 391092172MANUEL REYES Payer Claim #: 2023071714158

Pat. Acct #: 1106438356 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/12/23-07/12/23 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: DANIEL ALLOWSING Insured: 710001876DANIEL ALLOWSING Payer Claim #: 2023071714159

Pat. Acct #: 1106438360 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/12/23-07/12/23 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: BRYAN PERSSON Insured: 120142527BRYAN PERSSON Payer Claim #: 2023071714160

Pat. Acct #: 1106438359 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/12/23-07/12/23 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: NICOLE AQUINO Insured: 600205334NICOLE AQUINO Payer Claim #: 2023071714161

Pat. Acct #: 1106438357 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
07/12/23-07/12/23 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

Statement Summary Amount Billed Payment Patient Other Ins. Not Covered
Responsibility Paid
4,891.91 3,648.84 0.00 53.47 1,243.07

Explanations
Administered By Code Description
HEALTH PARTNERS OF CO45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
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PHILADELPHI
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

ENV 8714
depending upon liability)
OA23 The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only
with Group Code OA)
CO23 The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only
with Group Code OA)
PI16 Claim/service lacks information or has submission/billing error(s). Usage: Do not use this
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.
M119 Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC).

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https://enrollments.echohealthinc.com/efteradirect/HealthPartnersPlans

Please call the following number for appeals 888-991-9023.

 P683502804W
202307248800 P683502804W

Health Partners Plans

901 Market Street, Suite 500
Philadelphia, PA 19107

Forwarding Service Requested

7 OF 7
ENV 8714
FFATAFTADTDDATFDTAADDATATTFDTFFDADDADTFADTAAATTADDTADAADAAFTATFAD
WEST CAYUGA MEDICINE PC
257 W CAYUGA ST
PHILADELPHIA, PA 19140-2439

Electronic Payment Clearinghouse

PNC - ECHO
Pittsburgh PA 15219
60-162 DRAFT NO. 301686412
433
901 Market Street, Suite 500
Philadelphia, PA 19107
ELECTRONIC COMMERCE BENEFIT TRUST
DRAFT DATE: 07/21/2023
VOID AFTER 180 DAYS

PAYABLE THROUGH Three Thousand Six Hundred Forty Eight & 84/100 Dollars
AMOUNT
DRAFT *****$3,648.84
TO THE WEST CAYUGA MEDICINE PC
ORDER OF 257 W CAYUGA ST

PHILADELPHIA PA 19140