eRemittance - PALMETTO GBA
eRemittance - PALMETTO GBA Payee :Best Surgeon Ever
Date: 09/01/2022 NPI: TIN: Reference ID: 806137437 Amount: $3613.33
Payor : PALMETTO GBA (1621724116 ) , (10312) , () PO BOX 100306 COLUMBIA SC 292023306
Explanation of Payment ---------------------------------------------------------------------------------------------------------Claims:
1
(1) Patient Name Subscriber Name Provider Name Claim Statement Dates
Patient ID Claim Status 19 Payer Claim ID Claim Amount $9300.00 Provider Claim ID Paid Amount $1453.83 --Received Date Pt Responsibility $370.88 Outpatient Adjudication Claim Status Description : Processed as Primary, Forwarded to Additional Payer(s). Forwarded to : BCBS OF TENNESSEEOTHER : 80026 Serv Date
08/10/2022 08/10/2022 08/10/2022 08/10/2022 08/10/2022 08/10/2022 08/10/2022 08/10/2022 08/10/2022 08/10/2022
Units
Serv Code
Billed
Paid
1
HC:19357:RT
$2960.00
$843.46
1
HC:19342:LT:51
$2300.00
$277.33
HC:19370:51:LT
$1825.00
$0.00
1 HC:19380:51:XU:LT
$1821.00
$294.09
$394.00
$38.95
1
HC:15860:51
Allowed Adjustments
$1075.84 CO-45: $1884.16 , CO-253: $17.21 PR-2: $215.17 $353.74 CO-45: $1592.52 , CO-253: $5.66 , CO-59: $353.74 PR-2: $70.75 - CO-236: $1825.00 $375.11 CO-45: $1070.79 , CO-253: $6.00 , CO-59: $375.10 PR-2: $75.02 $49.69 CO-45: $294.63 , CO-253: $0.80 , CO-59: $49.68 PR-2: $9.94
---------------------------------------------------------------------------------------------------------Adjustment Group Codes CO : Contractual Obligations PR : Patient Responsibility Adjustment Reason Codes 2 : Coinsurance Amount 45 : 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) 50 : These are non-covered services because this is not deemed a 'medical necessity' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 59 : Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 144 : Incentive adjustment, e.g. preferred product/service. 236 : This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements. 253 : Sequestration - reduction in federal payment Remark Codes MA01 : Alert: If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you have a good reason for being late. MA18 : Alert: The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them. M25 : The information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request an appeal, we will, upon application from the patient, reimburse him/her