UnitedHealthcare

UnitedHealthcare Community & State

P.O. Box 5290
Kingston NY 12402
Florida
PHONE: 1-866-842-4968

PAYMENT DATE: 02/10/21

PAYEE TAX NUMBER: 833538514
PAYEE NPI: 1811522618
PAYEE ID: 007374639002
MV528 CORP
PAYEE NAME: MV528 CORP
4100 SW 57TH AVE
PAYMENT NUMBER: 2021021016001473
MIAMI FL 33155-5319
PAYMENT AMOUNT: $200.76
GRP ID: FLMW
RA REFERENCE ID: 2021021016001473

PROVIDER REMITTANCE ADVICE

PROVIDER REMITTANCE AT A GLANCE

NET PAYABLE $200.76

OVERPAYMENT AMOUNT
RECOVERED AMOUNT
NET PAID AMOUNT $200.76

PLEASE SEE NEXT PAGE FOR MORE INFORMATION

STD-PRA-833538514-5200000000087120823 Page 1 of 8
 UnitedHealthcare
UnitedHealthcare Community & State
STD-PRA
P.O. Box 5290
Kingston NY 12402
PHONE: 1-866-842-4968
PROVIDER
REMITTANCE ADVICE
Florida

PAYMENT DATE: 02/10/21

PAYEE TAX NUMBER: 833538514
PAYEE ID: 007374639002
PAYEE NAME: MV528 CORP
MV528 CORP
PAYMENT NUMBER: 2021021016001473
4100 SW 57TH AVE
PAYMENT AMOUNT: $200.76
MIAMI FL 33155-5319
GRP ID: FLMW
RA REFERENCE ID: 2021021016001473

PATIENT: MARIA E ACOSTA

SUBSCRIBER ID: 115644269 SUBSCRIBER NAME: MARIA E ACOSTA PROMPT PAY DISC: $0.00 CLAIM NUMBER: 21B183538600 PATIENT ACCOUNT: 9-1-122770
MEMBER ID: 8903545737 INTEREST AMOUNT: $0.00 COVERAGE DATE: 01/01/18 REMIT DETAIL: Professional Claim PRODUCT DESC.: FL UnitedHealthcare Dual
SERVICING PROV NPI: 1770873317 SERVICING PROV NM: MARCOS G VALERIO Complete SNP QMB Medicaid
COB PRIMARY INS: FLORIDA MEDICARE Wrap
BILLING NPI: 1811522618
CARRIER ID:
DATE(S) OF DESCRIPTION OF SERVICE UNITS BILLED AMT DISALLOW ALLOWED AMT DEDUCT AMT COPAY/COINS COB PMT AMT WITHHOLD PAID TO PATIENT RESP AUTH# RMK CD GRP CD/
SERVICE AMT AMT AMT PROVIDER AMT RSN CD
AMT
01/25/21 - billing code 99214 POS/ Bill Type 1 $189.00 $144.85 $44.15 $0.00 $0.00 $44.15 $0.00 OA23,
01/25/21 11 CO45
CLAIM NUMBER: 21B183538600 $189.00 $144.85 $44.15 $0.00 $0.00 $44.15 $0.00 OA23
SUBTOTAL:

SUBSCRIBER ID: 115644269 SUBSCRIBER NAME: MARIA E ACOSTA PROMPT PAY DISC: $0.00 CLAIM NUMBER: 21B183542400 PATIENT ACCOUNT: 9-1-122751
MEMBER ID: 8903545737 INTEREST AMOUNT: $0.00 COVERAGE DATE: 01/01/18 REMIT DETAIL: Professional Claim PRODUCT DESC.: FL UnitedHealthcare Dual
SERVICING PROV NPI: 1770873317 SERVICING PROV NM: MARCOS G VALERIO Complete SNP QMB Medicaid
COB PRIMARY INS: FLORIDA MEDICARE Wrap
BILLING NPI: 1811522618
CARRIER ID:
DATE(S) OF DESCRIPTION OF SERVICE UNITS BILLED AMT DISALLOW ALLOWED AMT DEDUCT AMT COPAY/COINS COB PMT AMT WITHHOLD PAID TO PATIENT RESP AUTH# RMK CD GRP CD/
SERVICE AMT AMT AMT PROVIDER AMT RSN CD
AMT
01/25/21 - billing code 93000 POS/ Bill Type 1 $30.00 $19.14 $10.86 $0.00 $0.00 $10.86 $0.00 OA23,
01/25/21 11 CO45
CLAIM NUMBER: 21B183542400 $30.00 $19.14 $10.86 $0.00 $0.00 $10.86 $0.00 OA23
SUBTOTAL:

STD-PRA-833538514-5200000000087120823 Page 2 of 8
 STD-PRA

PROVIDER
REMITTANCE ADVICE
Florida

PAYMENT DATE: 02/10/21

PAYEE TAX NUMBER: 833538514
PAYEE ID: 007374639002
PAYEE NAME: MV528 CORP
PAYMENT NUMBER: 2021021016001473
PAYMENT AMOUNT: $200.76
GRP ID: FLMW
RA REFERENCE ID: 2021021016001473

PATIENT: DARRELL P ANDERSON

SUBSCRIBER ID: 119073767 SUBSCRIBER NAME: DARRELL P ANDERSON PROMPT PAY DISC: $0.00 CLAIM NUMBER: 21B058702100 PATIENT ACCOUNT: 9-1-122170
MEMBER ID: 8888394010 INTEREST AMOUNT: $0.00 COVERAGE DATE: 01/01/18 REMIT DETAIL: Professional Claim PRODUCT DESC.: FL UnitedHealthcare Dual
SERVICING PROV NPI: 1770873317 SERVICING PROV NM: MARCOS G VALERIO Complete SNP Full Medicaid
COB PRIMARY INS: FLORIDA MEDICARE Wrap
BILLING NPI: 1811522618
CARRIER ID:
DATE(S) OF DESCRIPTION OF SERVICE UNITS BILLED AMT DISALLOW ALLOWED AMT DEDUCT AMT COPAY/COINS COB PMT AMT WITHHOLD PAID TO PATIENT RESP AUTH# RMK CD GRP CD/
SERVICE AMT AMT AMT PROVIDER AMT RSN CD
AMT
01/11/21 - billing code 93970 POS/ Bill Type 1 $333.00 $208.30 $124.70 $121.36 $0.00 $3.34 $0.00 OA23,
01/11/21 11 CO45
CLAIM NUMBER: 21B058702100 $333.00 $208.30 $124.70 $121.36 $0.00 $3.34 $0.00 OA23
SUBTOTAL:

SUBSCRIBER ID: 119073767 SUBSCRIBER NAME: DARRELL P ANDERSON PROMPT PAY DISC: $0.00 CLAIM NUMBER: 21B058699900 PATIENT ACCOUNT: 9-1-122171
MEMBER ID: 8888394010 INTEREST AMOUNT: $0.00 COVERAGE DATE: 01/01/18 REMIT DETAIL: Professional Claim PRODUCT DESC.: FL UnitedHealthcare Dual
SERVICING PROV NPI: 1770873317 SERVICING PROV NM: MARCOS G VALERIO Complete SNP Full Medicaid
COB PRIMARY INS: FLORIDA MEDICARE Wrap
BILLING NPI: 1811522618
CARRIER ID:
DATE(S) OF DESCRIPTION OF SERVICE UNITS BILLED AMT DISALLOW ALLOWED AMT DEDUCT AMT COPAY/COINS COB PMT AMT WITHHOLD PAID TO PATIENT RESP AUTH# RMK CD GRP CD/
SERVICE AMT AMT AMT PROVIDER AMT RSN CD
AMT
01/12/21 - billing code 93925 POS/ Bill Type 1 $431.00 $268.73 $162.27 $19.86 $0.00 $142.41 $0.00 OA23,
01/12/21 11 CO45
CLAIM NUMBER: 21B058699900 $431.00 $268.73 $162.27 $19.86 $0.00 $142.41 $0.00 OA23
SUBTOTAL:
TOTAL PAYABLE TO PROVIDER $200.76

PROVIDER TOTALS
SERVICE PROVIDER ID BILLED DISALLOW CONSIDERED ALLOWED AMT DEDUCT AMT COPAY/COINS COB PMT AMT WITHHOLD PAID TO PATIENT RESP INTEREST PROMPT PAY
AMOUNT AMT AMT AMT AMT PROVIDER AMT AMOUNT DISCOUNT
AMT
005124349008 $983.00 $641.02 $0.00 $341.98 $0.00 $0.00 $141.22 $0.00 $200.76 $0.00 $0.00 $0.00

STD-PRA-833538514-5200000000087120823 Page 3 of 8
 STD-PRA

PROVIDER
REMITTANCE ADVICE
Florida

PAYMENT DATE: 02/10/21

PAYEE TAX NUMBER: 833538514
PAYEE ID: 007374639002
PAYEE NAME: MV528 CORP
PAYMENT NUMBER: 2021021016001473
PAYMENT AMOUNT: $200.76
GRP ID: FLMW
RA REFERENCE ID: 2021021016001473

PAYEE TOTALS
PAYEE ID BILLED DISALLOW DISCOUNT ALLOWED AMT DEDUCT AMT COPAY/COINS COB PMT AMT WITHHOLD PAID TO PATIENT RESP INTEREST PROMPT PAY
AMOUNT AMT AMT AMT AMT PROVIDER AMT AMOUNT DISCOUNT
AMT
007374639002 $983.00 $641.02 $0.00 $341.98 $0.00 $0.00 $141.22 $0.00 $200.76 $0.00 $0.00 $0.00

REMARKS
CO45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
OA23 The impact of prior payer(s) adjudication including payments and/or adjustments.

STD-PRA-833538514-5200000000087120823 Page 4 of 8
 STD-PRA

PROVIDER
REMITTANCE ADVICE
Florida

PAYMENT DATE: 02/10/21

PAYEE TAX NUMBER: 833538514
PAYEE ID: 007374639002
PAYEE NAME: MV528 CORP
PAYMENT NUMBER: 2021021016001473
PAYMENT AMOUNT: $200.76
GRP ID: FLMW
RA REFERENCE ID: 2021021016001473

Billing Alerts

Section 1905(n) of the Social Security Act prohibits a provider from billing an individual with coverage as a Medicaid Full Dual, or Qualified Medicare Beneficiary (QMB) for the Medicare deductible or coinsurance.

Provider Communications

To contact Provider Services, please call 866-842-4968 or you may reach out to your Physician Advocate.

Doing Business With Us

Would you rather view this document online?

Link users can access UnitedHealthcare Community Plan provider remittance advice in Document Vault as soon as they’re generated – no more waiting for the mail. You can use Document Vault to download PDF files

or print your documents. You can even turn off mailed delivery of these documents. Learn more at UHCprovider.com/documentvault. Not yet a Link user? Visit UHCprovider.com/link to learn about all our self-service

tools.

Online Service for UnitedHealthcare Community Plan

Please visit UHCprovider.com for valuable resources such as Care Provider Manuals, reimbursement policies, newsletters, forms and clinical practice guidelines. UHCprovider.com is also your gateway to our

self-service tools on Link. You can use Link to get eligibility information, check claim status, submit claim reconsideration requests and much more.

Connect With Us Electronically

Electronic data interchange (EDI), electronic funds transfer and electronic remittance advice may help reduce the time spent checking eligibility, submitting claims and posting payments. Visit UHCprovider.com/edi or

contact EDI Support at ac_edi_ops@uhc.com or 800-210-8315.

National Provider Identifier Information

The National Provider Identifier (NPI) number is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care

providers. When covered health care providers, health plans and health care clearinghouses submit claims/encounter data, they will use the NPI in the administrative and financial transactions adopted under HIPAA.

The NPI number is required on all claims submissions and subsequent encounters. Claims may be denied if the rendering provider’s NPI number is missing or invalid (if required for the Provider Type). Failure to do so

may result in a denied claim.

NPI information can be updated using the following methods :

Phone: 877-842-3210
Online: UHCprovider.com/demoupdate

STD-PRA-833538514-5200000000087120823 Page 5 of 8
 STD-PRA

PROVIDER
REMITTANCE ADVICE
Florida

PAYMENT DATE: 02/10/21

PAYEE TAX NUMBER: 833538514
PAYEE ID: 007374639002
PAYEE NAME: MV528 CORP
PAYMENT NUMBER: 2021021016001473
PAYMENT AMOUNT: $200.76
GRP ID: FLMW
RA REFERENCE ID: 2021021016001473

COB Primary Carrier Information

When UnitedHealthcare is the secondary payer, additional COB primary carrier information can be obtained by accessing the claim detail in the claimsLink application found at UHCprovider.com.

Corrected Claims
If the claim rejection results in the need to submit a corrected claim, the provider may do so within ninety (90) days of the date of this notice, or in accordance with your provider contract, whichever is stricter. For proper

adjudication, please ensure the following information is listed on the claim form:

∙ CMS 1500

∙ Enter the appropriate claim frequency code in Box 22 left justified in the left-hand side of the field

∙ 7 – Replacement of prior claim

∙ 8 – Void/cancel of prior claim

∙ Enter original claim number under Original Ref No. Box 22

∙ UB04

∙ Enter the appropriate claim frequency code in the 3rd position of the Type of Bill in Box 4

∙ 7 – Replacement of prior claim

∙ 8 – Void/cancel of prior claim

∙ Enter original Claim number in Document Control Number Box 64

∙ Electronic Submissions

∙ Submit original claim number in Loop 2300, REF segment, REF02 element where REF01=F8

∙ Submit the frequency code in Loop 2300, CLM segment, CLM05-3 element

Make sure to resubmit the entire claim as originally submitted (even line items that were previously paid correctly). Following the National Uniform Billing Committee (NUBC) claim frequency guidelines, when sending a

replacement or void claim, the entire original or previous submission must be replaced or voided.

Appeals Procedures

Contracted Providers
All providers may file an appeal within 30 days of any adverse action by UnitedHealthcare Dual Complete. However, UnitedHealthcare urges providers to file claims correctly the first time, or, if time allows, resubmit the

claim for reconsideration to resolve the issue (timely filing requirement is 180 days from the date of service).

Appeals are required to be submitted in writing to:

STD-PRA-833538514-5200000000087120823 Page 6 of 8
 STD-PRA

PROVIDER
REMITTANCE ADVICE
Florida

PAYMENT DATE: 02/10/21

PAYEE TAX NUMBER: 833538514
PAYEE ID: 007374639002
PAYEE NAME: MV528 CORP
PAYMENT NUMBER: 2021021016001473
PAYMENT AMOUNT: $200.76
GRP ID: FLMW
RA REFERENCE ID: 2021021016001473

UnitedHealthcare

Attn: Complaint and Appeals Department

P.O. Box 6106, MS CA124-0157

Cypress, CA 90630

Expedited Fax: 866-373-1081

Standard Fax: 888-517-7113

Attention Non-contracted Medicare Providers

Appeals Process for Non-contracted Medicare Providers

Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may request reconsideration (appeal) of a Medicare Advantage plan payment denial determination. To appeal a

claim denial, submit a written request within 60 calendar days of the remittance notification date and include at a minimum:

∙ A statement indicating factual or legal basis for appeal

∙ A signed Waiver of Liability form (you may obtain a copy on UHCprovider.com)

∙ A copy of the original claim

∙ A copy of the remittance notice showing the claim denial

∙ Any additional information, clinical records or documentation

Mail the appeal request to:

UnitedHealthcare Dual Complete Claims Appeal Request

P.O. Box 31364

Salt Lake City, UT 84131-0364

Payment Dispute Process for Non-contracted Medicare Providers

Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may file a payment dispute for a Medicare Advantage plan payment determination. A payment dispute may be filed

when the provider disagrees with the amount paid, including issues related to bundling of services. To dispute a claim denial, submit a written request within 120 calendar days of the remittance notification date and

include at a minimum:

∙ A statement indicating factual or legal basis for the dispute

∙ A copy of the original claim

∙ A copy of the remittance notice showing the claim payment

STD-PRA-833538514-5200000000087120823 Page 7 of 8
 STD-PRA

PROVIDER
REMITTANCE ADVICE
Florida

PAYMENT DATE: 02/10/21

PAYEE TAX NUMBER: 833538514
PAYEE ID: 007374639002
PAYEE NAME: MV528 CORP
PAYMENT NUMBER: 2021021016001473
PAYMENT AMOUNT: $200.76
GRP ID: FLMW
RA REFERENCE ID: 2021021016001473

∙ Any additional information, clinical records or documentation to support the dispute

Mail the payment dispute to:

UnitedHealthcare Dual Complete Claims Dispute

P.O. Box 31364

Salt Lake City, UT 84131-0364

Alternative Methods for Demographic Changes

If you have an office demographic change to any of the information below, please send an email to hpdemo@uhc.com or contact Provider Services at 866-842-4968.

∙ Office addresses, hours and locations

∙ Languages spoken

∙ Phone, fax and website information

∙ Ages and genders served

∙ Panel status

If your payee name, billing address and/or payee tax payer identification number (TIN) are not correctly displayed on this Provider Remittance Advice, please contact Provider Services at 866-842-4968.

STD-PRA-833538514-5200000000087120823 Page 8 of 8