Dear: Jane Doe Your Claims have been adjudicated by the Payer. Electronic Payment / Advise information has been received by Comapny and summarized as follows. ================================================== ------- HEALTH CARE CLAIM PAYMENT/ADVICE ------- ================================================== ======================================================================================================================================================== Adjustment Date Provider ID Reference ID Adjustment Amt Reason ======================================================================================================================================================== 12/30/2018 1111111111 BBBBBBVP31M0 -42.81 Overpayment Recover 12/31/2018 1111111112 20170514 1710101112 06 -33.44 Overpayment Recover 12/30/2018 1111111113 BBBBBBVP31M2 33.45 Overpayment Recover ======================================================================================================================================================== ======================================================================================================================================================== Check# Amount # Claims NPI or Tax ID Payee Date ======================================================================================================================================================== 201812215555555555 48.80 1 1212121212 ABC COMPANY LLC 12/21/2018 201812215555555556 51.20 2 1212121213 ABC COMPANY 12/22/2018 201812215555555557 5.00 2 1212121212 ABC COMPANY LLC 12/21/2018 -------------------------------------------------------------------------------------------------------------------------------------------------------- Check# Patient ID Last,First Charge Amt Payment Amt Accnt# Status Payer 201812215555555555 M11111110 DOE JR,DAVIS 65.00 48.80 1112 PROCESSED AS PRIMARY ABC HEALTHCARE EAST SERVICE CENTER PO BOX 12234 SOMEWHERE,GA 11111 Tax ID: 11-1111110 Payer Claim Control Number: 111111111000 Line Item: Svc Date CPT Charge Amt Payment Amt Total Adj Amt Remarks 10/25/2018 92507 65.00 48.80 16.20 NO REMARKS Adjustment Group Adj Amt Translated Reason Code CONTRACTUAL OBLIGATIONS 16.20 CHARGES EXCEED YOUR CONTRACTED/LEGISLATED FEE ARRANGEMENT. -------------------------------------------------------------------------------------------------------------------------------------------------------- Check# Patient ID Last,First Charge Amt Payment Amt Accnt# Status Payer 201812215555555556 ZECM11111111 DOE,JANE -65.00 -48.80 L111 OTHER ABC HEALTHCARE WEST 50 EAST RD ANYWHERE,TN 00002-1111 Tax ID: 11-1111111 Payer Claim Control Number: BTBBB1111100 Line Item: Svc Date CPT Charge Amt Payment Amt Total Adj Amt Remarks 10/27/2017 92507 -65.00 -48.80 -16.20 NO REMARKS Adjustment Group Adj Amt Translated Reason Code OTHER ADJUSTMENTS -16.20 CHARGES EXCEED YOUR CONTRACTED/LEGISLATED FEE ARRANGEMENT. Line Item: Svc Date CPT Charge Amt Payment Amt Total Adj Amt Remarks 11/09/2017 92507 -5.00 0.00 -5.00 NO REMARKS Adjustment Group Adj Amt Translated Reason Code OTHER ADJUSTMENTS -5.00 PAYMENT ADJUSTED BECAUSE CHARGES HAVE BEEN PAID BY ANOTHER PAYER. -------------------------------------------------------------------------------------------------------------------------------------------------------- Check# Patient ID Last,First Charge Amt Payment Amt Accnt# Status Payer 201812215555555556 ZECM11111112 SMITH,JOSEPH 100.00 100.00 M111 PROCESSED AS SECONDARY ABC HEALTHCARE WEST 50 EAST RD ANYWHERE,TN 00002 Tax ID: 11-1111111 Payer Claim Control Number: BT1111111141 Line Item: Svc Date CPT Charge Amt Payment Amt Total Adj Amt Remarks 10/25/2017 92507 100.00 100.00 0.00 NO REMARKS -------------------------------------------------------------------------------------------------------------------------------------------------------- Check# Patient ID Last,First Charge Amt Payment Amt Accnt# Status Payer 201812215555555557 ZECM11111112 LASTNAME,FIRST 45.00 0.00 M111 DENIED ABC HEALTHCARE EAST ONE CIRCLE RD SOMEWHERE,GA 11111 Tax ID: 11-1111110 Payer Claim Control Number: BT1111111131 Claim Statement Period: 01/30/2019 - 01/30/2019 Line Item: Svc Date CPT Charge Amt Payment Amt Total Adj Amt Remarks 10/28/2017 92507 45.00 0.00 45.00 NO REMARKS Adjustment Group Adj Amt Translated Reason Code CONTRACTUAL OBLIGATIONS 45.00 CHARGES EXCEED YOUR CONTRACTED/LEGISLATED FEE ARRANGEMENT. -------------------------------------------------------------------------------------------------------------------------------------------------------- Check# Patient ID Last,First Charge Amt Payment Amt Accnt# Status Payer 201812215555555557 ZECM11111112 WORLD,HELLO 65.00 5.00 M111 PROCESSED AS PRIMARY, FWDED ABC HEALTHCARE EAST ONE CIRCLE RD SOMEWHERE,GA 11111 Tax ID: 11-1111110 Payer Claim Control Number: BT1111111121 Line Item: Svc Date CPT Charge Amt Payment Amt Total Adj Amt Remarks 10/30/2017 92507 65.00 5.00 60.00 NO REMARKS Adjustment Group Adj Amt Translated Reason Code CONTRACTUAL OBLIGATIONS 16.20 CHARGES EXCEED YOUR CONTRACTED/LEGISLATED FEE ARRANGEMENT. OTHER ADJUSTMENTS 43.80 PAYMENT ADJUSTED BECAUSE CHARGES HAVE BEEN PAID BY ANOTHER PAYER.