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VERESE LAMBERT EOB

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Ramesh C R Ramesh
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43 views

VERESE LAMBERT EOB

Ok

Uploaded by

Ramesh C R Ramesh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Humana

500 West Main Street


Louisville, KY 40202-4268
Billing Provider
MORNINGSTAR DIAGNOSTICS INC
8150 W 111TH ST STE 5
PALOS HILLS, IL 604652591

Provider Name: MORNINGSTAR DIAGNOSTICS INC Check/Remit #: 003878136


Insured Name: VERESE LAMBERT Check Amount: 160.12
Patient Name: VERESE LAMBERT Check Date: 11/25/2024
Member ID: H78244326 Federal Tax ID: 931861923
Claim #: 820243250016331 Payee ID 1316623986
Claim Receive Date: 11/19/2024 Service Provider ID 1316623986
Patient Acct #: 19362 Priority Payer Name:
Group: 02A72201 Priority Payer Id:
Priority Payer Group:

Dates of Service Service Billed Provider Allowed Other Sequestration Paid HIPAA
Deductible Copay Coins
Service Codes Units Amount Discount Amount Insurance Amount Amount Codes
45 / N781 /
09/06/2024 88325 1.00 308.24 148.12 0.00 0.00 0.00 0.00 0.00 0.00 160.12
N782
Totals 308.24 148.12 0.00 0.00 0.00 0.00 0.00 0.00 160.12

Estimated Member Responsibility $0.00 Total Paid $160.12


Humana
500 West Main Street
Louisville, KY 40202-4268
Claim Adjustment Reason Codes Description
45: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
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)
Remark Codes Description
N781: Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected
deductible. This amount may be billed to a subsequent payer.
N782: Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected
coinsurance. This amount may be billed to a subsequent payer.

Reconsideration/Appeal Rights

http://apps.humana.com/marketing/documents.asp?file=2859948

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