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HPP - 317733732 - 12152023

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This document is a payment summary from Health Partners Plans to West Cayuga Medicine PC. It includes details of 10 medical claims, listing patient names and account numbers, dates of service, procedures/codes, amounts billed and paid, and adjustment reasons. For each claim, the allowed amount and payment amount match, while portions of the billed amount are noted as not covered.

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© All Rights Reserved
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HPP - 317733732 - 12152023

Uploaded by

Andres Felipe Chavarrio Suarez
26 views6 pages
This document is a payment summary from Health Partners Plans to West Cayuga Medicine PC. It includes details of 10 medical claims, listing patient names and account numbers, dates of service, procedures/codes, amounts billed and paid, and adjustment reasons. For each claim, the allowed amount and payment amount match, while portions of the billed amount are noted as not covered.

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© © All Rights Reserved

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This document is a payment summary from Health Partners Plans to West Cayuga Medicine PC. It includes details of 10 medical claims, listing patient names and account numbers, dates of service, procedures/codes, amounts billed and paid, and adjustment reasons. For each claim, the allowed amount and payment amount match, while portions of the billed amount are noted as not covered.

Copyright:

© All Rights Reserved
Download as PDF, TXT or read online from Scribd
Download as pdf or txt
26 views6 pages

HPP - 317733732 - 12152023

Uploaded by

Andres Felipe Chavarrio Suarez
This document is a payment summary from Health Partners Plans to West Cayuga Medicine PC. It includes details of 10 medical claims, listing patient names and account numbers, dates of service, procedures/codes, amounts billed and paid, and adjustment reasons. For each claim, the allowed amount and payment amount match, while portions of the billed amount are noted as not covered.

Copyright:

© All Rights Reserved
Download as PDF, TXT or read online from Scribd
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You are on page 1/ 6

P683502800K

P683502800K

Health Partners Plans


901 Market Street, Suite 500
Philadelphia, PA 19107
202312188800

Forwarding Service Requested

1 OF 6
Questions? Please contact Provider Service at (215)
7276 0.0744 991-4350 or Toll free (888)991-9023.

ENV 7276
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 #: 317733732 Payment Week: 50 Payment Date: 12/15/2023
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: HERMINIO RAMOS Insured: 890248287HERMINIO RAMOS Payer Claim #: 2023120600205
Pat. Acct #: 1153280549 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/02/23-12/02/23 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: CRYSTAL CABAN Insured: 630175570CRYSTAL CABAN Payer Claim #: 2023120600206


Pat. Acct #: 1153576510 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: SHANAE BRADLEY Insured: 950137888SHANAE BRADLEY Payer Claim #: 2023120600207


Pat. Acct #: 1153576316 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: DAVID SHIPTON Insured: 230502072DAVID SHIPTON Payer Claim #: 2023120600433


Pat. Acct #: 1153280160 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/01/23-12/01/23 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: JAMES CHAMBERS Insured: 690111641JAMES CHAMBERS Payer Claim #: 2023120600437


Pat. Acct #: 1153280220 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/01/23-12/01/23 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: IVAN ORTIZ Insured: 050478812IVAN ORTIZ Payer Claim #: 2023120600439


Pat. Acct #: 1153280254 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/01/23-12/01/23 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: JOSELYN TORRES Insured: 110008798JOSELYN TORRES Payer Claim #: 2023120600441


Pat. Acct #: 1153280403 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/01/23-12/01/23 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: JENNY FOX Insured: 430103653JENNY FOX Payer Claim #: 2023120600443


Pat. Acct #: 1153280306 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
P683502800K
202312188800 P683502800K

2 OF 6
Tax ID: 813661898 EPC Draft #: 317733732 Payment Week: 50 Payment Date: 12/15/2023
Service Date Procedures No. of Amount Allowed Payment Patient Other Not Covered Sequest- Adjustment
From To (Modifier) Units Billed Responsibility Ins. Paid ration Reason
12/01/23-12/01/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45

ENV 7276
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: CHRISTINE BORRELLI Insured: 001205052CHRISTINE BORRELLI Payer Claim #: 2023120600451


Pat. Acct #: 1153280450 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/02/23-12/02/23 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: BEATRIZ CRUZ Insured: 001347388BEATRIZ CRUZ Payer Claim #: 2023120600453


Pat. Acct #: 1153280461 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
10/27/23-10/27/23 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: DAVID ENELOW Insured: 600225028DAVID ENELOW Payer Claim #: 2023120600455


Pat. Acct #: 1153280522 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/02/23-12/02/23 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: ALEXANDER HERNANDEZ Insured: 540107942ALEXANDER Payer Claim #: 2023120600460


Pat. Acct #: 1153279970 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/01/23-12/01/23 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: HELEN ANDERSON Insured: 001045449HELEN ANDERSON Payer Claim #: 2023120600462


Pat. Acct #: 1153279989 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
10/30/23-10/30/23 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: ELIZABETH CUEVAS Insured: 100000523ELIZABETH CUEVAS Payer Claim #: 2023120600464


Pat. Acct #: 1153279997 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/01/23-12/01/23 99213 1 78.47 0.00 0.00 0.00 0.00 78.47 0.00 CO23 CO45
Total for Claim: 78.47 0.00 0.00 0.00 0.00 78.47 0.00

Patient: MICHAEL NOLEN Insured: 780208228MICHAEL NOLEN Payer Claim #: 2023120600468


Pat. Acct #: 1153280053 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/02/23-12/02/23 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: LUIS A TORRES Insured: 010011358LUIS A TORRES Payer Claim #: 2023120600470


Pat. Acct #: 1153280061 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/01/23-12/01/23 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: BILLY RODRIGUEZ Insured: 240109350BILLY RODRIGUEZ Payer Claim #: 2023120600474


Pat. Acct #: 1153576358 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: ANGEL GONZALEZ Insured: 001616676ANGEL GONZALEZ Payer Claim #: 2023120600478


Pat. Acct #: 1153576454 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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
P683502800K
202312188800 P683502800K

3 OF 6
Tax ID: 813661898 EPC Draft #: 317733732 Payment Week: 50 Payment Date: 12/15/2023
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: ELIZABETH ROMERO HECHAVA Insured: 440667216ELIZABETH ROMERO Payer Claim #: 2023120600479

ENV 7276
Pat. Acct #: 1153576532 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 99204 1 176.38 141.57 141.57 0.00 0.00 34.81 0.00 CO45
Total for Claim: 176.38 141.57 141.57 0.00 0.00 34.81 0.00

Patient: ROBERT PISANO Insured: 410193227ROBERT PISANO Payer Claim #: 2023120600481


Pat. Acct #: 1153576581 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: SHAWN BOYLE Insured: 870160670SHAWN BOYLE Payer Claim #: 2023120600483


Pat. Acct #: 1153576807 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: WILLIAM JR NAZWORTH Insured: 130166692WILLIAM JR NAZWORTH Payer Claim #: 2023120600485


Pat. Acct #: 1153576835 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
11/01/23-11/01/23 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: KAYLA DAVIS Insured: 370334480KAYLA DAVIS Payer Claim #: 2023120600487


Pat. Acct #: 1153576856 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: ELLEN COLON Insured: 110115057ELLEN COLON Payer Claim #: 2023120600489


Pat. Acct #: 1153576928 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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 LOPEZ Insured: 160184807ROBERTO LOPEZ Payer Claim #: 2023120600491


Pat. Acct #: 1153576262 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/01/23-12/01/23 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: JOSEFINA CINTRON Insured: 001328014JOSEFINA CINTRON Payer Claim #: 2023120600492


Pat. Acct #: 1153576275 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: FELIX GONZALEZ Insured: 120005340FELIX GONZALEZ Payer Claim #: 2023120600496


Pat. Acct #: 1153576247 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: SHEILA NEAL Insured: 001687012SHEILA NEAL Payer Claim #: 2023120700342


Pat. Acct #: 1154023200 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/05/23-12/05/23 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: DAJUAN JONES Insured: 001832565DAJUAN JONES Payer Claim #: 2023120714351


Pat. Acct #: 1154022713 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/05/23-12/05/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
P683502800K
202312188800 P683502800K

4 OF 6
Tax ID: 813661898 EPC Draft #: 317733732 Payment Week: 50 Payment Date: 12/15/2023
Service Date Procedures No. of Amount Allowed Payment Patient Other Not Covered Sequest- Adjustment
From To (Modifier) Units Billed Responsibility Ins. Paid ration Reason
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

ENV 7276
Patient: AIXA PACHECO Insured: 199952533AIXA PACHECO Payer Claim #: 2023120714352
Pat. Acct #: 1154022726 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/05/23-12/05/23 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: AMBER NEVEDOMSKY Insured: 040115621AMBER NEVEDOMSKY Payer Claim #: 2023120714353


Pat. Acct #: 1154022747 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: LUIS RIOS Insured: 670164544LUIS RIOS Payer Claim #: 2023120714354


Pat. Acct #: 1154022867 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/05/23-12/05/23 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: JERSON RODRIGUEZVARGA Insured: 991181580JERSON Payer Claim #: 2023120714357


Pat. Acct #: 1154022992 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/05/23-12/05/23 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: ISRAEL LOPEZ Insured: 780176591ISRAEL LOPEZ Payer Claim #: 2023120714358


Pat. Acct #: 1154023014 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/05/23-12/05/23 99204 1 176.38 141.57 141.57 0.00 0.00 34.81 0.00 CO45
Total for Claim: 176.38 141.57 141.57 0.00 0.00 34.81 0.00

Patient: LAUREN RAMOS Insured: 200176285LAUREN RAMOS Payer Claim #: 2023120714359


Pat. Acct #: 1154023052 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/05/23-12/05/23 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: CARRIE FELTMAN Insured: 160347201CARRIE FELTMAN Payer Claim #: 2023120714360


Pat. Acct #: 1154023142 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/05/23-12/05/23 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: JOHANNA LOPEZ Insured: 001958851JOHANNA LOPEZ Payer Claim #: 2023120803035


Pat. Acct #: 1154503732 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/06/23-12/06/23 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: ROBERT WALKER Insured: 040375211ROBERT WALKER Payer Claim #: 2023120803036


Pat. Acct #: 1154496787 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/06/23-12/06/23 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: ROBERTO LOPEZ Insured: 160184807ROBERTO LOPEZ Payer Claim #: 2023120803038


Pat. Acct #: 1154504028 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/06/23-12/06/23 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
P683502800K
202312188800 P683502800K

5 OF 6
Tax ID: 813661898 EPC Draft #: 317733732 Payment Week: 50 Payment Date: 12/15/2023
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: PATRICK MARKEE Insured: 002188470PATRICK MARKEE Payer Claim #: 2023120803040

ENV 7276
Pat. Acct #: 1154504175 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/06/23-12/06/23 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: GERARDA DROZ-PABON Insured: 001464220GERARDA DROZ-PABON Payer Claim #: 2023120803041


Pat. Acct #: 1154504328 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/06/23-12/06/23 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: EVANGELINE THOMPKINS Insured: 002716008EVANGELINE Payer Claim #: 2023120803042


Pat. Acct #: 1154504433 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/06/23-12/06/23 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

Statement Summary Amount Billed Payment Patient Other Ins. Not Covered
Responsibility Paid
3,601.87 2,890.05 0.00 0.00 711.82

Explanations
Administered By Code Description
HEALTH PARTNERS OF CO45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
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
depending upon liability)
CO23 The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only
with Group Code OA)

Eliminate paper checks and EOP's while saving time and money. Sign up for our FREE electronic funds
transfer and electronic remittance solution at
https://enrollments.echohealthinc.com/efteradirect/HealthPartnersPlans

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


P683502804W
202312188800 P683502804W

Health Partners Plans


901 Market Street, Suite 500
Philadelphia, PA 19107

Forwarding Service Requested

6 OF 6
ENV 7276
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. 317733732
433
901 Market Street, Suite 500
Philadelphia, PA 19107
ELECTRONIC COMMERCE BENEFIT TRUST
DRAFT DATE: 12/15/2023
VOID AFTER 180 DAYS

PAYABLE THROUGH Two Thousand Eight Hundred Ninety & 05/100 Dollars
AMOUNT
DRAFT *****$2,890.05
TO THE WEST CAYUGA MEDICINE PC
ORDER OF 257 W CAYUGA ST

PHILADELPHIA PA 19140

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