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Check Information
UHC
9900 BREN ROAD MINNETONKA, MN 553439664
BEST DOC EVER
Provider#: Provider Tax ID#: NPI / Group Provider Number: Created Date: 8/23/2022
Non-payment#: Check Date: 8/24/2022 Check Amount: $0.00 Provider Adj Amt: $0.00
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Claim Information
Patient Name:
Member Identification#:
Insured Name:
Member Identification#:
Claim ID:
Patient Account Number:
Claim Status: Processed as
Rendering Provider:
Primary Claim Payment Amount:
Rendering NPI:
$0.00 Claim Adj Amt:
Payer Claim Control# / ICN#:
Claim Adj Codes:
Patient Responsibility:
Claim Remark Codes:
Patient Responsibility Reason Code:
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Patient Group#: Service Line Information Proc/Rev Paid Billed Allowed Units Code, Mods Amount Amount 19380,RT $6,849.78 $0.00 1 13101,RT $2,232.59 $0.00 1 $2,145.91 $0.00 1982861860 1 11406
Begin End Service Rendering Service Date Date NPI 6/24/2022 6/24/2022 1982861860 6/24/2022 6/24/2022 1982861860 6/24/2022
6/24/2022
SERVICE LINE TOTALS:
$11,228.28 $0.00
Deduct Coins CoPay Late Filing Other Adjust Provider Remark Amount Amount Amount Red. Adjusts Codes Paid Codes $6,849.78 CO-226 $0.00 N706 $0.00 $0.00 $0.00 $0.00 N20 $2,232.59 CO-272 $0.00 $0.00 $0.00 $0.00 $0.00 N706 $0.00 $0.00 $0.00 $0.00 $2,145.91 CO-226 $0.00 ·········· ········· $0.00 $11,228.28 $0.oo $0.oo $0.00 $0.00
Check Totals Claim Adjustments TOTALS: $0.00
Billed Amount
Allowed Amount
Deduct Amount
Coins Amount
CoPay Amount
$11,228.28
$0.00
$0.00
$0.00
$0.00
Late Filing Red. Other Adjustments ··························· $0.oo $11,228.28
Total Paid ·· s;o.oo
Adjustment Codes Glossary CO : Contractual Obligations: Use this code when a joint payer/payee contractual agreement or a regulatory requirement resulted in an adjustment.
C0-226: Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficienVincomplete. 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.) Start: 09/21/20081 Last Modified: 07/01/201 3
C0-27 2: Coverage/program guidelines were not met. Start: 1 1/01/2015
N20: Service not payable with other service rendered on the same date. Start: 01/01/2000
N706: Missing documentation. Start: 03/01/2014