NATIONAL HERITAGE INSURANCE COMPANY PO BOX 272857 CHICO CA 95927-2857 (866) 502-9054 SOME DOCTOR PRODUCTION DATE : 01/21/2005 PO BOX 123456 PAYMENT ISSUE DATE : 01/21/2005 SOMEWHERE CA 91722 PAYMENT AMOUNT : 240.39 PAYMENT TRACE NO : 1234567890 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMS CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/20/2005 PAT ID NUMBER : 123456789D CLAIM START DATE : 01/19/2005 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 MA18 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 01/19/05 11721 01 50.00 43.12 0.00 43.12 1 6.88 42 ---------------------------------------------------------------------------------------------------- TOTALS 50.00 43.12 0.00 43.12 1 6.88 42 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMMC CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/20/2005 PAT ID NUMBER : 123456789A CLAIM START DATE : 01/19/2005 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 01/19/05 11721 50.00 0.00 50.00 49 N115 ---------------------------------------------------------------------------------------------------- TOTALS 50.00 0.00 0.00 50.00 49 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMMC CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/10/2005 PAT ID NUMBER : 123456789A CLAIM START DATE : 12/30/2004 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 MA07 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 12/30/04 11721 01 50.00 41.36 33.09 8.27 2 8.64 42 ---------------------------------------------------------------------------------------------------- TOTALS 50.00 41.36 33.09 8.27 2 8.64 42 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMMC CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/20/2005 PAT ID NUMBER : 123456789D CLAIM START DATE : 01/19/2005 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 MA18 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 01/19/05 11721 01 50.00 43.12 0.00 43.12 1 6.88 42 ---------------------------------------------------------------------------------------------------- TOTALS 50.00 43.12 0.00 43.12 1 6.88 42 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMMC CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/19/2005 PAT ID NUMBER : 123456789D CLAIM START DATE : 01/18/2005 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 MA07 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 01/18/05 99213 01 63.00 57.71 0.00 57.71 1 5.29 42 ---------------------------------------------------------------------------------------------------- TOTALS 63.00 57.71 0.00 57.71 1 5.29 42 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMMC CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/20/2005 PAT ID NUMBER : 123456789D CLAIM START DATE : 01/18/2005 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 MA07 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 01/18/05 11721 01 50.00 43.12 0.00 43.12 1 6.88 42 ---------------------------------------------------------------------------------------------------- TOTALS 50.00 43.12 0.00 43.12 1 6.88 42 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMS CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/10/2005 PAT ID NUMBER : 123456789D CLAIM START DATE : 01/07/2005 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 01/07/05 99213 01 63.00 57.71 46.17 11.54 2 5.29 42 ---------------------------------------------------------------------------------------------------- TOTALS 63.00 57.71 46.17 11.54 2 5.29 42 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMMC CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/20/2005 PAT ID NUMBER : 123456789D CLAIM START DATE : 01/19/2005 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 MA07 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 01/19/05 11721 01 50.00 43.12 0.00 43.12 1 6.88 42 ---------------------------------------------------------------------------------------------------- TOTALS 50.00 43.12 0.00 43.12 1 6.88 42 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMMC CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/20/2005 PAT ID NUMBER : 123456789D CLAIM START DATE : 01/19/2005 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 MA07 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 01/19/05 11721 01 50.00 43.12 0.00 43.12 1 6.88 42 ---------------------------------------------------------------------------------------------------- TOTALS 50.00 43.12 0.00 43.12 1 6.88 42 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMMC CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/20/2005 PAT ID NUMBER : 123456789D CLAIM START DATE : 01/19/2005 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 MA07 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 01/19/05 99203 01 120.00 105.64 0.00 105.64 1 14.36 42 ---------------------------------------------------------------------------------------------------- TOTALS 120.00 105.64 0.00 105.64 1 14.36 42 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMMC CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/10/2005 PAT ID NUMBER : 123456789D CLAIM START DATE : 12/30/2004 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 MA07 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 12/30/04 99311 01 100.00 44.36 35.49 8.87 2 55.64 42 ---------------------------------------------------------------------------------------------------- TOTALS 100.00 44.36 35.49 8.87 2 55.64 42 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMMC CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/04/2005 PAT ID NUMBER : 123456789D CLAIM START DATE : 09/28/2004 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 09/28/04 11721 50.00 0.00 50.00 151 M27 ---------------------------------------------------------------------------------------------------- TOTALS 50.00 0.00 0.00 50.00 151 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMS CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/19/2005 PAT ID NUMBER : 123456789D CLAIM START DATE : 01/18/2005 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 01/18/05 99213 01 63.00 57.71 0.00 57.71 1 5.29 42 ---------------------------------------------------------------------------------------------------- TOTALS 63.00 57.71 0.00 57.71 1 5.29 42 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMMC CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/10/2005 PAT ID NUMBER : 123456789D CLAIM START DATE : 12/28/2004 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 MA07 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 12/28/04 11040 01 44.00 43.54 34.83 8.71 2 0.46 42 12/30/04 11720 01 50.00 27.79 22.23 5.56 2 22.21 42 ---------------------------------------------------------------------------------------------------- TOTALS 94.00 71.33 57.06 14.27 2 22.67 42 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMS CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/20/2005 PAT ID NUMBER : 123456789D CLAIM START DATE : 01/19/2005 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 MA18 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 01/19/05 99213 01 63.00 57.71 0.00 57.71 1 5.29 42 ---------------------------------------------------------------------------------------------------- TOTALS 63.00 57.71 0.00 57.71 1 5.29 42 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMS CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/20/2005 PAT ID NUMBER : 123456789D CLAIM START DATE : 01/19/2005 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 01/19/05 11721 01 50.00 43.12 0.00 43.12 1 6.88 42 ---------------------------------------------------------------------------------------------------- TOTALS 50.00 43.12 0.00 43.12 1 6.88 42 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMMC CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/10/2005 PAT ID NUMBER : 123456789D CLAIM START DATE : 12/30/2004 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 MA07 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 12/30/04 99311 01 100.00 44.36 35.49 8.87 2 55.64 42 ---------------------------------------------------------------------------------------------------- TOTALS 100.00 44.36 35.49 8.87 2 55.64 42 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMMC CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/10/2005 PAT ID NUMBER : 123456789D CLAIM START DATE : 12/30/2004 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 MA07 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 12/30/04 11721 01 50.00 41.36 33.09 8.27 2 8.64 42 ---------------------------------------------------------------------------------------------------- TOTALS 50.00 41.36 33.09 8.27 2 8.64 42 ____________________________________________________________________________________________________ PAT ACCOUNT NO : 9999 MMS CLAIM ID : 9999999999999 PAT NAME : SOME PATIENT RECEIVED DATE : 01/20/2005 PAT ID NUMBER : 123456789D CLAIM START DATE : 01/18/2005 SERVICE PROVIDER: CLAIM REMARK CODES : MA01 MA07 ---------------------------------------------------------------------------------------------------- SERVICE PROC UNITS BILLED ALLOWED PAID ADJ ADJ LINE REMARK DATE CODE AMT AMT AMT AMT CODES CODE ---------------------------------------------------------------------------------------------------- 01/18/05 99213 01 63.00 57.71 0.00 57.71 1 5.29 42 ---------------------------------------------------------------------------------------------------- TOTALS 63.00 57.71 0.00 57.71 1 5.29 42 ____________________________________________________________________________________________________ GLOSSARY ==================================================================================================== 1 Deductible Amount 2 Coinsurance Amount 42 Charges exceed our fee schedule or maximum allowable amount. 49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. 151 Payment adjusted because the payer deems the information submitted does not support this many services. M27 The patient has been relieved of liability of payment of these items and services under the limitation of liability provision of the law. You, the provider, are ultimately liable for the patient's waived charges, including any charges for coinsurance, since the items or services were not reasonable and necessary or constituted custodial care, and you knew or could reasonably have been expected to know, that they were not covered.You may appeal this determination provided that the patient does not exercise his/her appeal rights. If the beneficiary appeals the initial determination, you are automatically made a party to the appeals determination. If, however, the patient or his/her representative has stated in writing that he/she does not intend to request a reconsideration, or the patient's liability was entirely waived in the initial determination, you may initiate an appeal.You may ask for a reconsideration for hospital insurance (or a review for medical insurance) regarding both the coverage determination and the issue of whether you exercised due care. The request for reconsideration must be filed within 120 days of the date of this notice (or, for a medical insurance review, within 120 days of the date of this notice). You may make the request through any Social Security office or through this office. MA01 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 review. However, in order to be eligible for a review, you must write to us within 120 days of the date of this notice, unless you have a good reason for being late.An institutional provider, e.g., hospital, Skilled Nursing Facility (SNF), Home Health Agency (HHA) or hospice may appeal only if the claim involves a reasonable and necessary denial, a SNF recertified bed denial, or a home health denial because the patient was not homebound or was not in need of intermittent skilled nursing services, or a hospice care denial because the patient was not terminally ill, and either the patient or the provider is liable under Section 1879 of the Social Security Act, and the patient chooses not to appeal.If your carrier issues telephone review decisions, a professional provider should phone the carrier’s office for a telephone review if the criteria for a telephone review are met. MA07 The claim information has also been forwarded to Medicaid for review. MA18 The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them. N115 This decision was based on a local medical review policy (LMRP). An LMRP provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LMRP. ==================================================================================================== THANK YOU FOR USING ECLAIMS FOR YOUR ELECTRONIC CLAIMS TRANSMISSION THIS REPORT CONTAINS HEALTH CARE INFORMATION. HANDLE ONLY ACCORDING TO THE APPROPRIATE SECURITY AND PRIVACY PROCEDURES. EClaims X12 835 DLL Version 1.1.9 (c) 2004 EClaims Inc.