KAISER HEALTH PLAN OF WASHINGTON - MEDICARE PART C PLAN PREPORY SERV DATE POS NOS PROC MODS BILLED ALLOWED DLOUCE NAME: WHITE, DAVID HIC ACCT:653457 IN 1015 101519 11 99214 155.00 D.CO 0.00 GRPARCAMT PROV PD ASGY MOA MAOI MAIS CO-157 185.00 0.00 DO 000 ODO 000 God 195.00 PT RESP: 165.00 0.00 CLAIM TOTALS HIC NAME: JOHNSON. MARY 2014 101419 ACCT: 452678 18500 NON 12700 0.00 MET 0.00 ASG Y MOA MADT MAIS PR-3 50.00 770 CO-45 5720 00-45 19.12 120 11 9921425 11 1014 101419 0.00 0.00 16000 120 58 1130099 0.00 000 50.00 69 94 00-45 120 00 5006 1014 101419 11 17000 1053 305.82 0.00 0.00 24.18 17003 00-45 150.00 2014 101425 11 354 se 40456 24044 59500 0.00 000 CLAIM TOTALS 50.00 PT RESP: NET PROV PD AMT 35456 35456 CHECK AMT 3545 TOTALS: CLAIMS BILLED ALLOWED DEDUCT COPAY CONS AMT AMT AMT AMT 700.00 40456 0.00 50.00 GLOSSARY: GROUP, REASON, MOA, REMARK AND REASON CODES 3 Co-payment amount 22 This care may be covered by another payer per coordination of benefits 23 The impact of prior payer payment 45 Charges exceed fee schedule/maximum allowable of contracted/legislated fet arrangement 197 Precertification/authoritionotification absent 253 Sequestration reduction in a federal payment CO Contractual Obligation provider responsibility MAR Secondary payment cannot be considered without the identityot, or payment information from the OA Other adjustments PR Patient Responsibility QUESTIONS: (Please number your answers) CLAIM FOR DAVID WHITE: 1. Why was this claim denied? 2. What steps should the insurance specialist take in this situation? CLAIM FOR MARY JOHNSON: 3. What is the total provider adjustment for this claim? 4. Does the patient owe anything, if so how much? ENTIRE REMITTANCE ADVICE QUESTION: 5. Why are there no sequestration deductions on this remittance advice? Edit View Insert Format Tools Table KAISER HEALTH PLAN OF WASHINGTON - MEDICARE PART C PLAN PREPORY SERV DATE POS NOS PROC MODS BILLED ALLOWED DLOUCE NAME: WHITE, DAVID HIC ACCT:653457 IN 1015 101519 11 99214 155.00 D.CO 0.00 GRPARCAMT PROV PD ASGY MOA MAOI MAIS CO-157 185.00 0.00 DO 000 ODO 000 God 195.00 PT RESP: 165.00 0.00 CLAIM TOTALS HIC NAME: JOHNSON. MARY 2014 101419 ACCT: 452678 18500 NON 12700 0.00 MET 0.00 ASG Y MOA MADT MAIS PR-3 50.00 770 CO-45 5720 00-45 19.12 120 11 9921425 11 1014 101419 0.00 0.00 16000 120 58 1130099 0.00 000 50.00 69 94 00-45 120 00 5006 1014 101419 11 17000 1053 305.82 0.00 0.00 24.18 17003 00-45 150.00 2014 101425 11 354 se 40456 24044 59500 0.00 000 CLAIM TOTALS 50.00 PT RESP: NET PROV PD AMT 35456 35456 CHECK AMT 3545 TOTALS: CLAIMS BILLED ALLOWED DEDUCT COPAY CONS AMT AMT AMT AMT 700.00 40456 0.00 50.00 GLOSSARY: GROUP, REASON, MOA, REMARK AND REASON CODES 3 Co-payment amount 22 This care may be covered by another payer per coordination of benefits 23 The impact of prior payer payment 45 Charges exceed fee schedule/maximum allowable of contracted/legislated fet arrangement 197 Precertification/authoritionotification absent 253 Sequestration reduction in a federal payment CO Contractual Obligation provider responsibility MAR Secondary payment cannot be considered without the identityot, or payment information from the OA Other adjustments PR Patient Responsibility QUESTIONS: (Please number your answers) CLAIM FOR DAVID WHITE: 1. Why was this claim denied? 2. What steps should the insurance specialist take in this situation? CLAIM FOR MARY JOHNSON: 3. What is the total provider adjustment for this claim? 4. Does the patient owe anything, if so how much? ENTIRE REMITTANCE ADVICE QUESTION: 5. Why are there no sequestration deductions on this remittance advice? Edit View Insert Format Tools Table
