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htm

PAGE: 1 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022

10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME CRAFT, JACOB HIC MKM836054546 ACNT 2214552A ICN 26220320637100580

1467460394 0117 011722 1 98943 32.28 15.55 0.00 0.00 PR-3 1.80 13.75
CO-45 16.73

0117 011722 1 98941 AT 82.68 23.20 0.00 0.00 PR-3 23.20 0.00
CO-45 59.48

0117 011722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 19.66
REM: N123

0117 011722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 47.06 15.14
REM: N123

0117 011722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 47.06 15.14
REM: N123

0117 011722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 47.06 15.14
REM: N123

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 0.00 284.93 78.83
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 78.83

___________________________________________________________________________________________________________________________________
NAME SHAW, VONZELLA HIC PJN811154548 ACNT 2220212A ICN 26220320320000580

1114551561 0117 011722 1 98941 AT 82.68 23.20 0.00 4.64 PR-2 4.64 18.56
CO-45 59.48

0117 011722 1 97110 76GP 62.20 19.66 0.00 3.93 PR-2 3.93 15.73
REM: N123 CO-45 42.54

0117 011722 1 97110 76GP 62.20 19.66 0.00 3.03 PR-2 3.03 12.11
REM: N123 CO-45 42.54

PI-97 -38.02

OA-70 42.54

0117 011722 1 97110 76GP 62.20 19.66 0.00 3.03 PR-2 3.03 12.11
REM: N123 CO-45 42.54

PI-97 -38.02

OA-70 42.54

0117 011722 1 97110 76GP 62.20 19.66 0.00 3.03 PR-2 3.03 12.11
REM: N123 CO-45 42.54

PI-97 -38.02

OA-70 42.54

PT RESP 17.66 CLM STATUS 1 CLAIM TOTALS 331.48 101.84 0.00 17.66 243.20 70.62
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 70.62

___________________________________________________________________________________________________________________________________
NAME VON NORDECK, MARIANNHIC PJN818014860 ACNT 2220127A ICN 26220320382600580

1578569786 0111 011122 1 20553 130.56 60.92 0.00 12.18 PR-2 12.18 48.74
CO-45 69.64

0111 011122 1 J3490 2.50 0.10 0.00 0.02 PR-2 0.02 0.08
CO-45 2.40

PT RESP 12.20 CLM STATUS 1 CLAIM TOTALS 133.06 61.02 0.00 12.20 72.04 48.82

PAGE: 2 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 48.82

___________________________________________________________________________________________________________________________________
NAME BEACH, MARCIA HIC LHS810951076 ACNT 2230918A ICN 26220617675900580

1578569786 0217 021722 1 99203 233.36 81.79 0.00 0.00 PR-3 15.00 66.79
CO-45 151.57

PT RESP 15.00 CLM STATUS 1 CLAIM TOTALS 233.36 81.79 0.00 0.00 166.57 66.79
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 66.79

___________________________________________________________________________________________________________________________________
NAME DAVIS, VERNON S HIC BPZ810884829 ACNT 2230875A ICN 26220617463900580

1114551561 0218 021822 1 98943 32.28 15.55 0.00 0.00 CO-45 16.73 15.55
0218 021822 1 98941 AT 82.68 23.20 0.00 0.00 CO-45 59.48 23.20
0218 021822 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 19.66
REM: N123

0218 021822 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0218 021822 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

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OA-70 42.54

0218 021822 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 0.00 259.93 103.83
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 103.83

___________________________________________________________________________________________________________________________________
NAME DAVIS, VERNON S HIC BPZ810884829 ACNT 2230658A ICN 26220617956200580

1467460394 0216 021622 1 98943 32.28 15.55 0.00 0.00 CO-45 16.73 15.55
0216 021622 1 98941 AT 82.68 23.20 0.00 0.00 CO-45 59.48 23.20
0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 19.66
REM: N123

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 0.00 259.93 103.83
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 103.83

___________________________________________________________________________________________________________________________________

PAGE: 3 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME JOHNSON, GLORIA HIC BPZ810910704 ACNT 2226315A ICN 26220558555700580

1467460394 0209 020922 1 98943 32.28 15.55 0.00 0.00 CO-45 16.73 15.55
0209 020922 1 98941 AT 82.68 23.20 0.00 0.00 CO-45 59.48 23.20
0209 020922 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 19.66
REM: N123

0209 020922 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0209 020922 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0209 020922 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 0.00 259.93 103.83
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 103.83

___________________________________________________________________________________________________________________________________
NAME JOHNSON, GLORIA HIC BPZ810910704 ACNT 2230958A ICN 26220617478900580

1578569786 0216 021622 1 99213 189.64 56.39 0.00 0.00 PR-3 5.00 51.39
CO-45 133.25

PT RESP 5.00 CLM STATUS 1 CLAIM TOTALS 189.64 56.39 0.00 0.00 138.25 51.39
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 51.39

___________________________________________________________________________________________________________________________________
NAME JOHNSON, GLORIA HIC BPZ810910704 ACNT 2230676A ICN 26220617553800580

1467460394 0217 021722 1 98943 32.28 15.55 0.00 0.00 CO-45 16.73 15.55
0217 021722 1 98941 AT 82.68 23.20 0.00 0.00 CO-45 59.48 23.20
0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 19.66
REM: N123

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 0.00 259.93 103.83
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 103.83

___________________________________________________________________________________________________________________________________
NAME JOHNSON, GLORIA HIC BPZ810910704 ACNT 2230857A ICN 26220617663300580

1467460394 0216 021622 1 98943 32.28 15.55 0.00 0.00 CO-45 16.73 15.55

PAGE: 4 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

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REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

0216 021622 1 98941 AT 82.68 23.20 0.00 0.00 CO-45 59.48 23.20
0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 19.66
REM: N123

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 0.00 259.93 103.83
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 103.83

___________________________________________________________________________________________________________________________________
NAME WATERS, MITCHELL HIC BPZ811131844 ACNT 2230913A ICN 26220617487500580

1467460394 0216 021622 1 98943 32.28 15.55 0.00 0.00 CO-45 16.73 15.55
0216 021622 1 98941 AT 82.68 23.20 0.00 0.00 CO-45 59.48 23.20
0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 19.66
REM: N123

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 0.00 259.93 103.83
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 103.83

___________________________________________________________________________________________________________________________________
NAME WATERS, MITCHELL HIC BPZ811131844 ACNT 2230897A ICN 26220617490000580

1467460394 0218 021822 1 98943 32.28 15.55 0.00 0.00 CO-45 16.73 15.55
0218 021822 1 98941 AT 82.68 23.20 0.00 0.00 CO-45 59.48 23.20
0218 021822 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 19.66
REM: N123

0218 021822 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0218 021822 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

PAGE: 5 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

OA-70 42.54

0218 021822 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 0.00 259.93 103.83
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 103.83

___________________________________________________________________________________________________________________________________
NAME WATERS, MITCHELL HIC BPZ811131844 ACNT 2230995A ICN 26220617925900580

1578569786 0216 021622 1 99213 189.64 56.39 0.00 0.00 PR-3 5.00 51.39
CO-45 133.25

PT RESP 5.00 CLM STATUS 1 CLAIM TOTALS 189.64 56.39 0.00 0.00 138.25 51.39
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 51.39

___________________________________________________________________________________________________________________________________
NAME WATERS, MITCHELL HIC BPZ811131844 ACNT 2230996A ICN 26220617965300580

1578569786 0217 021722 3 95851 142.50 34.66 0.00 0.00 CO-45 107.84 34.66
PT RESP CLM STATUS 1 CLAIM TOTALS 142.50 34.66 0.00 0.00 107.84 34.66
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 34.66

___________________________________________________________________________________________________________________________________
NAME WATERS, MITCHELL HIC BPZ811131844 ACNT 2230689A ICN 26220618105000580

1467460394 0217 021722 1 98943 32.28 15.55 0.00 0.00 CO-45 16.73 15.55
0217 021722 1 98941 AT 82.68 23.20 0.00 0.00 CO-45 59.48 23.20
0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 19.66

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REM: N123

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 0.00 259.93 103.83
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 103.83

___________________________________________________________________________________________________________________________________
NAME DAVIS, CURTIS HIC EDL810983293 ACNT 2230887A ICN 26220617534000580

1467460394 0218 021822 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 19.66
REM: N123

0218 021822 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0218 021822 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14

PAGE: 6 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

REM: N123 PI-97 -38.02

OA-70 42.54

0218 021822 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0218 021822 1 97140 76GP 57.16 18.35 0.00 0.00 CO-45 38.81 14.33
PI-97 -34.79

OA-70 38.81

PT RESP CLM STATUS 1 CLAIM TOTALS 305.96 96.99 0.00 0.00 226.55 79.41
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 79.41

___________________________________________________________________________________________________________________________________
NAME DAVIS, CURTIS HIC EDL810983293 ACNT 2230929A ICN 26220618003800580

1578569786 0218 021822 3 95851 142.50 34.66 0.00 0.00 CO-45 107.84 34.66
PT RESP CLM STATUS 1 CLAIM TOTALS 142.50 34.66 0.00 0.00 107.84 34.66
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 34.66

___________________________________________________________________________________________________________________________________
NAME JOHNSON DAVIS, TANESHIC EDL810983293 ACNT 2231010A ICN 26220617613200580

1467460394 0218 021822 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 19.66
REM: N123

0218 021822 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0218 021822 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0218 021822 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0218 021822 1 97140 76GP 57.16 18.35 0.00 0.00 CO-45 38.81 14.33
PI-97 -34.79

OA-70 38.81

PT RESP CLM STATUS 1 CLAIM TOTALS 305.96 96.99 0.00 0.00 226.55 79.41
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 79.41

___________________________________________________________________________________________________________________________________
NAME COLEY, WILLIAM E HIC MYY810744830 ACNT 2230640A ICN 26220618142000580

1467460394 0217 021722 1 99213 25 189.64 59.36 0.00 0.00 PR-3 25.00 34.36
CO-45 130.28

0217 021722 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0217 021722 1 98941 AT 82.68 25.23 0.00 0.00 CO-45 57.45 25.23
0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46

PAGE: 7 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

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REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

REM: N123 PI-97 -35.90

OA-70 40.82

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 553.40 187.02 0.00 0.00 406.14 147.26
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 147.26

___________________________________________________________________________________________________________________________________
NAME JOHNSON, LYNN Y HIC MYY810760351 ACNT 2230959A ICN 26220617793400580

1578569786 0216 021622 1 99203 233.36 86.09 0.00 0.00 PR-3 15.00 71.09
CO-45 147.27

PT RESP 15.00 CLM STATUS 1 CLAIM TOTALS 233.36 86.09 0.00 0.00 162.27 71.09
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 71.09

___________________________________________________________________________________________________________________________________
NAME JONES, KENYONA HIC MYY810747334 ACNT 2226267A ICN 26220558240500580

1114551561 0210 021022 1 72050 111.00 52.32 0.00 0.00 CO-45 58.68 52.32
0210 021022 1 72070 68.44 33.02 0.00 0.00 CO-45 35.42 33.02
0210 021022 1 72100 83.60 35.36 0.00 0.00 CO-45 48.24 35.36
0210 021022 2 73560 RTLT 144.24 62.30 0.00 0.00 CO-45 81.94 62.30
0210 021022 1 98941 AT 82.68 0.00 0.00 PR-197 82.68 0.00
REM: M62

PT RESP 82.68 CLM STATUS 1 CLAIM TOTALS 489.96 183.00 0.00 0.00 306.96 183.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 183.00

___________________________________________________________________________________________________________________________________
NAME JONES, KENYONA HIC MYY810747334 ACNT 2230960A ICN 26220617916200580

1578569786 0216 021622 1 20611 LT 208.22 110.29 0.00 0.00 PR-3 15.00 95.29
CO-45 97.93

0216 021622 1 J7324 257.08 147.75 0.00 0.00 CO-45 109.33 147.75
PT RESP 15.00 CLM STATUS 1 CLAIM TOTALS 465.30 258.04 0.00 0.00 222.26 243.04
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 243.04

___________________________________________________________________________________________________________________________________
NAME MORSE, JOEL N HIC MYY810742139 ACNT 2219699A ICN 26220320002900580

1467460394 0114 011422 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0114 011422 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0114 011422 1 97110 GY76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0114 011422 1 97110 GY76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

PAGE: 8 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

OA-70 40.82

0114 011422 1 97110 GY76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0114 011422 1 97110 GY76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 275.86 87.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 87.90

___________________________________________________________________________________________________________________________________
NAME MORSE, JOEL N HIC MYY810742139 ACNT 2218355A ICN 26220320116600580

1114551561 0106 010622 1 99213 25 189.64 59.36 0.00 0.00 PR-3 25.00 34.36
CO-45 130.28

0106 010622 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0106 010622 1 98941 AT 82.68 25.23 0.00 0.00 CO-45 57.45 25.23
0106 010622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0106 010622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0106 010622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0106 010622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

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PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 553.40 187.02 0.00 0.00 406.14 147.26
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 147.26

___________________________________________________________________________________________________________________________________
NAME MORSE, JOEL N HIC MYY810742139 ACNT 2219024A ICN 26220320286400580

1114551561 0110 011022 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0110 011022 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0110 011022 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0110 011022 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0110 011022 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0110 011022 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46

PAGE: 9 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 275.86 87.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 87.90

___________________________________________________________________________________________________________________________________
NAME MORSE, JOEL N HIC MYY810742139 ACNT 2220134A ICN 26220320368500580

1114551561 0112 011222 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0112 011222 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0112 011222 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0112 011222 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0112 011222 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0112 011222 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 275.86 87.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 87.90

___________________________________________________________________________________________________________________________________
NAME MORSE, JOEL N HIC MYY810742139 ACNT 2220186A ICN 26220320866900580

1114551561 0117 011722 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0117 011722 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0117 011722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0117 011722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0117 011722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0117 011722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 275.86 87.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 87.90

___________________________________________________________________________________________________________________________________
NAME MORSE, JOEL N HIC MYY810742139 ACNT 2222586A ICN 26220458959000580

PAGE: 10 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

1467460394 0119 011922 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91

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0119 011922 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0119 011922 1 97110 GY76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0119 011922 1 97110 GY76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0119 011922 1 97110 GY76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0119 011922 1 97110 GY76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 275.86 87.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 87.90

___________________________________________________________________________________________________________________________________
NAME MORSE, JOEL N HIC MYY810742139 ACNT 2223625A ICN 26220459041100580

1467460394 0131 013122 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0131 013122 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0131 013122 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0131 013122 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0131 013122 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0131 013122 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 275.86 87.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 87.90

___________________________________________________________________________________________________________________________________
NAME MORSE, JOEL N HIC MYY810742139 ACNT 2223054A ICN 26220459115100580

1467460394 0121 012122 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0121 012122 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0121 012122 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0121 012122 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46

PAGE: 11 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

REM: N123 PI-97 -35.90

OA-70 40.82

0121 012122 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0121 012122 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 275.86 87.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 87.90

___________________________________________________________________________________________________________________________________
NAME MORSE, JOEL N HIC MYY810742139 ACNT 2222559A ICN 26220459130400580

1114551561 0124 012422 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0124 012422 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0124 012422 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0124 012422 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0124 012422 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0124 012422 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 275.86 87.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 87.90

___________________________________________________________________________________________________________________________________
NAME MORSE, JOEL N HIC MYY810742139 ACNT 2223003A ICN 26220459249400580

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1114551561 0126 012622 1 99213 25 189.64 59.36 0.00 0.00 PR-3 25.00 34.36
CO-45 130.28

0126 012622 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0126 012622 1 98941 AT 82.68 25.23 0.00 0.00 CO-45 57.45 25.23
0126 012622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0126 012622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0126 012622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PAGE: 12 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

0126 012622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 553.40 187.02 0.00 0.00 406.14 147.26
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 147.26

___________________________________________________________________________________________________________________________________
NAME MORSE, JOEL N HIC MYY810742139 ACNT 2223056A ICN 26220459269400580

1467460394 0128 012822 1 99213 25 189.64 59.36 0.00 0.00 PR-3 25.00 34.36
CO-45 130.28

0128 012822 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0128 012822 1 98941 AT 82.68 25.23 0.00 0.00 CO-45 57.45 25.23
0128 012822 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0128 012822 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0128 012822 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0128 012822 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 553.40 187.02 0.00 0.00 406.14 147.26
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 147.26

___________________________________________________________________________________________________________________________________
NAME MORSE, JOEL N HIC MYY810742139 ACNT 2226273A ICN 26220558633800580

1467460394 0209 020922 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0209 020922 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0209 020922 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0209 020922 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0209 020922 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0209 020922 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 275.86 87.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 87.90

PAGE: 13 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME MORSE, JOEL N HIC MYY810742139 ACNT 2228579A ICN 26220558669800580

1467460394 0214 021422 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0214 021422 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0214 021422 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38

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REM: N123

0214 021422 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0214 021422 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0214 021422 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 275.86 87.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 87.90

___________________________________________________________________________________________________________________________________
NAME MORSE, JOEL N HIC MYY810742139 ACNT 2230372A ICN 26220617770300580

1467460394 0217 021722 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0217 021722 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 275.86 87.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 87.90

___________________________________________________________________________________________________________________________________
NAME STERN, CHRISTOPHER RHIC MYY815263615 ACNT 2230989A ICN 26220617485900580

1578569786 0216 021622 1 20611 RT 208.22 110.29 0.00 0.00 PR-3 15.00 95.29
CO-45 97.93

PT RESP 15.00 CLM STATUS 1 CLAIM TOTALS 208.22 110.29 0.00 0.00 112.93 95.29
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 95.29

___________________________________________________________________________________________________________________________________

PAGE: 14 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME WILSON, YVETTE G HIC MYY817622789 ACNT 2218576A ICN 26220320350000580

1578569786 0106 010622 1 20553 130.56 66.25 0.00 0.00 PR-3 15.00 51.25
CO-45 64.31

0106 010622 1 J3490 2.50 0.10 0.00 0.00 CO-45 2.40 0.10
PT RESP 15.00 CLM STATUS 1 CLAIM TOTALS 133.06 66.35 0.00 0.00 81.71 51.35
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 51.35

___________________________________________________________________________________________________________________________________
NAME WILSON, YVETTE G HIC MYY817622789 ACNT 2228758A ICN 26220558072300580

1467460394 0215 021522 1 99213 25 189.64 59.36 0.00 0.00 PR-3 25.00 34.36
CO-45 130.28

0215 021522 1 98943 32.28 0.00 0.00 PR-197 32.28 0.00

REM: M62

0215 021522 1 98941 AT 82.68 0.00 0.00 PR-197 82.68 0.00

REM: M62

0215 021522 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0215 021522 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0215 021522 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0215 021522 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

PT RESP 388.76 CLM STATUS 1 CLAIM TOTALS 553.40 59.36 0.00 0.00 519.04 34.36
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 34.36

___________________________________________________________________________________________________________________________________
NAME MORRISSEY, ELENA I HIC MHT811388103 ACNT 2230884A ICN 26220617956600580

1467460394 0216 021622 1 98943 32.28 16.91 0.00 0.00 PR-3 14.77 2.14
CO-45 15.37

0216 021622 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.23 0.00
CO-45 57.45

0216 021622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0216 021622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

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OA-70 40.82

0216 021622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0216 021622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP 40.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 290.86 72.90

PAGE: 15 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 72.90

___________________________________________________________________________________________________________________________________
NAME MORRISSEY, ELENA I HIC MHT811388103 ACNT 2230683A ICN 26220618027800580

1467460394 0217 021722 1 98943 32.28 16.91 0.00 0.00 PR-3 14.77 2.14
CO-45 15.37

0217 021722 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.23 0.00
CO-45 57.45

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP 40.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 290.86 72.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 72.90

___________________________________________________________________________________________________________________________________
NAME ANYANWU, WHITNEY HIC BYG814819215 ACNT 2230629A ICN 26220617752700580

1114551561 0216 021622 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0216 021622 1 98941 AT 82.68 25.23 0.00 0.00 CO-45 57.45 25.23
0216 021622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0216 021622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0216 021622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0216 021622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 250.86 112.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 112.90

___________________________________________________________________________________________________________________________________
NAME ANYANWU, WHITNEY HIC BYG814819215 ACNT 2230915A ICN 26220617767500580

1578569786 0216 021622 3 95851 142.50 37.67 0.00 0.00 CO-45 104.83 37.67
PT RESP CLM STATUS 1 CLAIM TOTALS 142.50 37.67 0.00 0.00 104.83 37.67
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 37.67

PAGE: 16 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME BRUCE, THERESA HIC AHN811139781 ACNT 2226219A ICN 26220558475300580

1467460394 0210 021022 1 98943 32.28 15.55 0.00 1.56 PR-2 1.56 13.99
CO-45 16.73

0210 021022 1 98941 AT 82.68 23.20 0.00 2.32 PR-2 2.32 20.88
CO-45 59.48

0210 021022 1 97110 76GP 62.20 19.66 0.00 0.00 PR-3 19.66 0.00
REM: N123 CO-45 42.54

0210 021022 1 97110 76GP 62.20 19.66 0.00 0.00 PR-3 0.34 14.80
REM: N123 CO-45 42.54

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PI-97 -38.02

OA-70 42.54

0210 021022 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0210 021022 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP 23.88 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 3.88 279.93 79.95
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 79.95

___________________________________________________________________________________________________________________________________
NAME BURGESS, TATIANA A HIC AHN814833614 ACNT 2230641A ICN 26220617783300580

1467460394 0216 021622 1 98943 32.28 15.55 0.00 1.56 PR-2 1.56 13.99
CO-45 16.73

0216 021622 1 98941 AT 82.68 23.20 0.00 2.32 PR-2 2.32 20.88
CO-45 59.48

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 PR-3 19.66 0.00
REM: N123 CO-45 42.54

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 PR-3 0.34 14.80
REM: N123 CO-45 42.54

PI-97 -38.02

OA-70 42.54

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP 23.88 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 3.88 279.93 79.95
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 79.95

___________________________________________________________________________________________________________________________________
NAME BURGESS, TATIANA A HIC AHN814833614 ACNT 2230637A ICN 26220617968000580

1467460394 0217 021722 1 98943 32.28 15.55 0.00 1.56 PR-2 1.56 13.99

PAGE: 17 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

CO-45 16.73

0217 021722 1 98941 AT 82.68 23.20 0.00 2.32 PR-2 2.32 20.88
CO-45 59.48

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 PR-3 19.66 0.00
REM: N123 CO-45 42.54

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 PR-3 0.34 14.80
REM: N123 CO-45 42.54

PI-97 -38.02

OA-70 42.54

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP 23.88 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 3.88 279.93 79.95
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 79.95

___________________________________________________________________________________________________________________________________
NAME COLE, TRUDY HIC BYG811187488 ACNT 2223420A ICN 26220458850700580

1578569786 0127 012722 1 20611 RT 208.22 110.29 0.00 0.00 PR-3 10.00 100.29
CO-45 97.93

0127 012722 1 J7324 EJ 257.08 148.74 0.00 0.00 CO-45 108.34 148.74
PT RESP 10.00 CLM STATUS 1 CLAIM TOTALS 465.30 259.03 0.00 0.00 216.27 249.03
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 249.03

___________________________________________________________________________________________________________________________________
NAME COLE, TRUDY HIC BYG811187488 ACNT 2230644A ICN 26220617563400580

1467460394 0216 021622 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0216 021622 1 98941 AT 82.68 25.23 0.00 0.00 CO-45 57.45 25.23
0216 021622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0216 021622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0216 021622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0216 021622 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

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OA-70 40.82

PT RESP CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 250.86 112.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 112.90

___________________________________________________________________________________________________________________________________

PAGE: 18 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME HEILBRON, SARAH A HIC BYG810839066 ACNT 2230956A ICN 26220617727500580

1578569786 0217 021722 3 95851 142.50 37.67 0.00 0.00 CO-45 104.83 37.67
PT RESP CLM STATUS 1 CLAIM TOTALS 142.50 37.67 0.00 0.00 104.83 37.67
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 37.67

___________________________________________________________________________________________________________________________________
NAME HEILBRON, SARAH A HIC BYG810839066 ACNT 2230654A ICN 26220617804500580

1467460394 0217 021722 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP CLM STATUS 1 CLAIM TOTALS 281.08 102.43 0.00 0.00 193.41 87.67
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 87.67

___________________________________________________________________________________________________________________________________
NAME HELLMAN, MADELAINE RHIC BYG814769496 ACNT 2230892A ICN 26220617547300580

1467460394 0218 021822 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0218 021822 1 98941 AT 82.68 25.23 0.00 0.00 CO-45 57.45 25.23
0218 021822 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0218 021822 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0218 021822 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0218 021822 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

PT RESP CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 250.86 112.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 112.90

___________________________________________________________________________________________________________________________________
NAME KELLEY, LESLEY HIC BYG810723455 ACNT 2218546A ICN 26220320547800580

1578569786 0106 010622 1 20553 130.56 66.25 0.00 0.00 CO-45 64.31 66.25
0106 010622 1 J3490 2.50 0.10 0.00 0.00 CO-45 2.40 0.10
PT RESP CLM STATUS 1 CLAIM TOTALS 133.06 66.35 0.00 0.00 66.71 66.35

PAGE: 19 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 66.35

___________________________________________________________________________________________________________________________________
NAME KELLEY, LESLEY HIC BYG810723455 ACNT 2230679A ICN 26220617516200580

1467460394 0217 021722 1 98941 AT 82.68 25.23 0.00 0.00 CO-45 57.45 25.23
0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 PI-97 -35.90

OA-70 40.82

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46

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REM: N123 PI-97-35.90

OA-70 40.82

PT RESP CLM STATUS 1 CLAIM TOTALS 331.48 110.75 0.00 0.00 235.49 95.99
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 95.99

___________________________________________________________________________________________________________________________________
NAME MATHWICH, HANNAH HIC AHN818561179 ACNT 2230871A ICN 26220617491000580

1467460394 0216 021622 1 99213 25 189.64 56.39 0.00 0.00 PR-3 20.00 36.39
CO-45 133.25

0216 021622 1 98943 32.28 15.55 0.00 1.56 PR-2 1.56 13.99
CO-45 16.73

0216 021622 1 98941 AT 82.68 23.20 0.00 2.32 PR-2 2.32 20.88
CO-45 59.48

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 19.66
REM: N123

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP 23.88 CLM STATUS 1 CLAIM TOTALS 553.40 173.78 0.00 3.88 413.18 136.34
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 136.34

___________________________________________________________________________________________________________________________________
NAME MERCADO, RAFAEL A HIC AHN815349092 ACNT 2218552A ICN 26220320109300580

1578569786 0106 010622 1 20553 130.56 60.92 0.00 0.00 CO-45 69.64 60.92
0106 010622 1 J3490 2.50 0.10 0.00 0.01 PR-2 0.01 0.09

PAGE: 20 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

CO-45 2.40

PT RESP 0.01 CLM STATUS 1 CLAIM TOTALS 133.06 61.02 0.00 0.01 72.04 61.01
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 61.01

___________________________________________________________________________________________________________________________________
NAME MERCADO, RAFAEL A HIC AHN815349092 ACNT 2218911A ICN 26220320214600580

1578569786 0105 010522 1 20553 130.56 60.92 0.00 0.00 CO-45 69.64 60.92
0105 010522 1 J3490 2.50 0.10 0.00 0.01 PR-2 0.01 0.09
CO-45 2.40

PT RESP 0.01 CLM STATUS 1 CLAIM TOTALS 133.06 61.02 0.00 0.01 72.04 61.01
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 61.01

___________________________________________________________________________________________________________________________________
NAME MERCADO, RAFAEL A HIC AHN815349092 ACNT 2230377A ICN 26220617596900580

1114551561 0217 021722 1 99213 25 189.64 56.39 0.00 0.00 PR-3 20.00 36.39
CO-45 133.25

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 19.66
REM: N123

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0217 021722 1 97140 76GP 57.16 18.35 0.00 0.00 CO-45 38.81 14.33
PI-97 -34.79

OA-70 38.81

PT RESP 20.00 CLM STATUS 1 CLAIM TOTALS 495.60 153.38 0.00 0.00 379.80 115.80
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 115.80

___________________________________________________________________________________________________________________________________
NAME MERCADO, RAFAEL A HIC AHN815349092 ACNT 2230881A ICN 26220617603400580

1467460394 0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 PR-3 5.67 13.99
REM: N123 CO-45 42.54

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

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PAGE: 21 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

OA-70 42.54

0216 021622 1 97140 76GP 57.16 18.35 0.00 0.00 PR-3 14.33 0.00
CO-45 38.81

PI-97 -34.79

OA-70 38.81

PT RESP 20.00 CLM STATUS 1 CLAIM TOTALS 305.96 96.99 0.00 0.00 246.55 59.41
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 59.41

___________________________________________________________________________________________________________________________________
NAME MERCADO, RAFAEL A HIC AHN815349092 ACNT 2230980A ICN 26220617710400580

1578569786 0216 021622 3 95851 142.50 34.66 0.00 0.00 CO-45 107.84 34.66
PT RESP CLM STATUS 1 CLAIM TOTALS 142.50 34.66 0.00 0.00 107.84 34.66
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 34.66

___________________________________________________________________________________________________________________________________
NAME PITTS, MUSTAFA HIC AHN811139580 ACNT 2230684A ICN 26220617513700580

1467460394 0217 021722 1 99213 25 189.64 56.39 0.00 4.00 PR-2 4.00 52.39
CO-45 133.25

0217 021722 1 98943 32.28 15.55 0.00 0.31 PR-2 0.31 15.24
CO-45 16.73

0217 021722 1 98941 AT 82.68 23.20 0.00 0.46 PR-2 0.46 22.74
CO-45 59.48

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 19.66
REM: N123

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0217 021722 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP 4.77 CLM STATUS 1 CLAIM TOTALS 553.40 173.78 0.00 4.77 393.18 155.45
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 155.45

___________________________________________________________________________________________________________________________________
NAME PITTS, MUSTAFA HIC AHN811139580 ACNT 2230891A ICN 26220617936800580

1467460394 0216 021622 1 98943 32.28 15.55 0.00 0.31 PR-2 0.31 15.24
CO-45 16.73

0216 021622 1 98941 AT 82.68 23.20 0.00 0.46 PR-2 0.46 22.74
CO-45 59.48

0216 021622 1 97110 76GP 62.20 19.66 0.00 3.93 PR-2 3.93 15.73
REM: N123 CO-45 42.54

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.07 PR-2 0.07 15.07

PAGE: 22 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

REM: N123 CO-45 42.54

PI-97 -38.02

OA-70 42.54

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0216 021622 1 97110 76GP 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP 4.77 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 4.77 259.93 99.06
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 99.06

___________________________________________________________________________________________________________________________________
NAME TAUB, SHEINA HIC AHN811171504 ACNT 2219189A ICN 26220321082300580

1578569786 0110 011022 1 20553 130.56 60.92 0.00 0.00 CO-45 69.64 60.92
0110 011022 1 J3490 2.50 0.10 0.00 0.01 PR-2 0.01 0.09
CO-45 2.40

PT RESP 0.01 CLM STATUS 1 CLAIM TOTALS 133.06 61.02 0.00 0.01 72.04 61.01

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BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 61.01

___________________________________________________________________________________________________________________________________
NAME BRYANT BAKER, JANICEHIC MYY810755854 ACNT 2228558A ICN 26220633998600580

1467460394 0215 021522 1 99213 25 189.64 59.36 0.00 0.00 CO-45 130.28 59.36
0215 021522 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0215 021522 1 98941 AT 82.68 42.40 0.00 0.00 CO-45 40.28 42.40
0215 021522 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 553.40 204.19 0.00 0.00 349.21 204.19
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 204.19

___________________________________________________________________________________________________________________________________
NAME BYER, MAUREEN HIC MYY810753236 ACNT 2223019A ICN 26220613839800580

1578569786 0131 013122 3 95851 142.50 68.49 0.00 0.00 OA-23 18.87 49.62
CO-45 74.01

PT RESP CLM STATUS 2 CLAIM TOTALS 142.50 68.49 0.00 0.00 92.88 49.62
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 49.62

___________________________________________________________________________________________________________________________________
NAME CARTER, SONIA E HIC MYY810788500 ACNT 2160434E ICN 26220344342300580

1114551561 0610 061021 1 99213 25 189.64 0.00 0.00 OA-18 189.64 0.00
0610 061021 1 98941 AT 82.68 42.75 0.00 0.00 OA-23 34.20 8.55
CO-45 39.93

0610 061021 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0610 061021 4 97110 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 553.40 145.18 0.00 0.00 442.42 110.98
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.98

___________________________________________________________________________________________________________________________________

PAGE: 23 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME CARTER, SONIA E HIC MYY810788500 ACNT 2219680A ICN 26220613805900580

1467460394 0113 011322 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0113 011322 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0113 011322 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME COLEMAN, DOROTHY M HIC MYY811116045 ACNT 2223028A ICN 26220613696000580

1467460394 0128 012822 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0128 012822 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0128 012822 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME COLEMAN, DOROTHY M HIC MYY811116045 ACNT 2223710A ICN 26220613716700580

1467460394 0202 020222 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0202 020222 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0202 020222 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME COLEMAN, DOROTHY M HIC MYY811116045 ACNT 2222506A ICN 26220613771000580

1467460394 0119 011922 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0119 011922 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0119 011922 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME COLEMAN, DOROTHY M HIC MYY811116045 ACNT 2223023A ICN 26220613786400580

1467460394 0121 012122 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0121 012122 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0121 012122 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME COLEMAN, DOROTHY M HIC MYY811116045 ACNT 2222653A ICN 26220613789200580

1467460394 0126 012622 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91

PAGE: 24 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022

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OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

0126 012622 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0126 012622 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME COLEMAN, DOROTHY M HIC MYY811116045 ACNT 2223398A ICN 26220613801900580

1114551561 0131 013122 1 99213 25 189.64 59.36 0.00 0.00 CO-45 130.28 59.36
0131 013122 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0131 013122 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0131 013122 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 553.40 204.19 0.00 0.00 383.13 170.27
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 170.27

___________________________________________________________________________________________________________________________________
NAME COLEMAN, DOROTHY M HIC MYY811116045 ACNT 2223031A ICN 26220613807300580

1578569786 0128 012822 1 99213 189.64 98.58 0.00 0.00 OA-23 78.86 19.72
CO-45 91.06

PT RESP CLM STATUS 2 CLAIM TOTALS 189.64 98.58 0.00 0.00 169.92 19.72
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 19.72

___________________________________________________________________________________________________________________________________
NAME COLEMAN, DOROTHY M HIC MYY811116045 ACNT 2222523A ICN 26220613896600580

1467460394 0124 012422 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0124 012422 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0124 012422 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME COLEMAN, DOROTHY M HIC MYY811116045 ACNT 2224580A ICN 26220625143200580

1467460394 0207 020722 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0207 020722 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0207 020722 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME COLEMAN, DOROTHY M HIC MYY811116045 ACNT 2224273A ICN 26220625219900580

1467460394 0204 020422 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0204 020422 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0204 020422 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52

PAGE: 25 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME MACKEY, SARAH E HIC MYY815086345 ACNT 2224171A ICN 26220613701700580

1467460394 0203 020322 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0203 020322 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0203 020322 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME MACKEY, SARAH E HIC MYY815086345 ACNT 2222556A ICN 26220613738800580

1467460394 0124 012422 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0124 012422 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0124 012422 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME MACKEY, SARAH E HIC MYY815086345 ACNT 2223686A ICN 26220613770400580

1578569786 0201 020122 1 20553 130.56 0.00 0.00 CO-45 130.56 0.00

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0201 020122 4 J1885 100.00 2.18 0.00 0.00 OA-23 1.74 0.44
CO-45 97.82

PT RESP CLM STATUS 2 CLAIM TOTALS 230.56 2.18 0.00 0.00 230.12 0.44
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.44

___________________________________________________________________________________________________________________________________
NAME MACKEY, SARAH E HIC MYY815086345 ACNT 2222494A ICN 26220613801300580

1467460394 0125 012522 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0125 012522 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0125 012522 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME MACKEY, SARAH E HIC MYY815086345 ACNT 2223456A ICN 26220614189100580

1114551561 0201 020122 1 99213 25 189.64 59.36 0.00 0.00 CO-45 130.28 59.36
0201 020122 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0201 020122 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0201 020122 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 553.40 204.19 0.00 0.00 383.13 170.27
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 170.27

PAGE: 26 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME MACKEY, SARAH E HIC MYY815086345 ACNT 2224271A ICN 26220625040900580

1578569786 0203 020322 3 95851 59 142.50 68.49 0.00 1.37 PR-2 1.37 12.33
OA-23 54.79

CO-45 74.01

0203 020322 1 20553 130.56 0.00 0.00 CO-45 130.56 0.00

PT RESP 1.37 CLM STATUS 2 CLAIM TOTALS 273.06 68.49 0.00 1.37 259.36 12.33
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 12.33

___________________________________________________________________________________________________________________________________
NAME MACKEY, SARAH E HIC MYY815086345 ACNT 2224652A ICN 26220625121700580

1467460394 0208 020822 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0208 020822 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0208 020822 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME SCRUGGS, NANCY A HIC MYY810764611 ACNT 2223066A ICN 26220613670200580

1467460394 0121 012122 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0121 012122 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0121 012122 2 97110 GY76GP 124.40 42.76 0.00 0.00 CO-45 81.64 42.76
PT RESP CLM STATUS 2 CLAIM TOTALS 239.36 102.07 0.00 0.00 171.21 68.15
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 68.15

___________________________________________________________________________________________________________________________________
NAME SCRUGGS, NANCY A HIC MYY810764611 ACNT 2222589A ICN 26220613675700580

1467460394 0119 011922 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0119 011922 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0119 011922 2 97110 GY76GP 124.40 42.76 0.00 0.00 CO-45 81.64 42.76
PT RESP CLM STATUS 2 CLAIM TOTALS 239.36 102.07 0.00 0.00 171.21 68.15
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 68.15

___________________________________________________________________________________________________________________________________
NAME SCRUGGS, NANCY A HIC MYY810764611 ACNT 2223067A ICN 26220613715700580

1578569786 0121 012122 1 20611 LT 208.22 110.35 0.00 0.00 OA-23 88.28 22.07
CO-45 97.87

0121 012122 1 J7324 257.08 147.75 0.00 0.00 OA-23 118.20 29.55
CO-45 109.33

PT RESP CLM STATUS 2 CLAIM TOTALS 465.30 258.10 0.00 0.00 413.68 51.62
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 51.62

___________________________________________________________________________________________________________________________________
NAME SCRUGGS, NANCY A HIC MYY810764611 ACNT 2222496A ICN 26220613781300580

1467460394 0125 012522 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91

PAGE: 27 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

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BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

0125 012522 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0125 012522 2 97110 GY76GP 124.40 42.76 0.00 0.00 CO-45 81.64 42.76
PT RESP CLM STATUS 2 CLAIM TOTALS 239.36 102.07 0.00 0.00 171.21 68.15
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 68.15

___________________________________________________________________________________________________________________________________
NAME SCRUGGS, NANCY A HIC MYY810764611 ACNT 2223020A ICN 26220613795200580

1467460394 0126 012622 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0126 012622 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0126 012622 2 97110 GY76GP 124.40 42.76 0.00 0.00 CO-45 81.64 42.76
PT RESP CLM STATUS 2 CLAIM TOTALS 239.36 102.07 0.00 0.00 171.21 68.15
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 68.15

___________________________________________________________________________________________________________________________________
NAME SCRUGGS, NANCY A HIC MYY810764611 ACNT 2223629A ICN 26220613833100580

1467460394 0131 013122 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0131 013122 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0131 013122 2 97110 GY76GP 124.40 42.76 0.00 0.00 CO-45 81.64 42.76
PT RESP CLM STATUS 2 CLAIM TOTALS 239.36 102.07 0.00 0.00 171.21 68.15
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 68.15

___________________________________________________________________________________________________________________________________
NAME SCRUGGS, NANCY A HIC MYY810764611 ACNT 2223755A ICN 26220613836000580

1578569786 0202 020222 1 99213 189.64 98.58 0.00 0.00 OA-23 78.86 19.72
CO-45 91.06

PT RESP CLM STATUS 2 CLAIM TOTALS 189.64 98.58 0.00 0.00 169.92 19.72
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 19.72

___________________________________________________________________________________________________________________________________
NAME SCRUGGS, NANCY A HIC MYY810764611 ACNT 2222892A ICN 26220613851600580

1578569786 0119 011922 1 20611 RT 208.22 110.35 0.00 0.00 OA-23 88.28 22.07
CO-45 97.87

0119 011922 1 J7324 257.08 147.75 0.00 0.00 OA-23 118.20 29.55
CO-45 109.33

PT RESP CLM STATUS 2 CLAIM TOTALS 465.30 258.10 0.00 0.00 413.68 51.62
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 51.62

___________________________________________________________________________________________________________________________________
NAME SCRUGGS, NANCY A HIC MYY810764611 ACNT 2223724A ICN 26220614188200580

1467460394 0202 020222 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0202 020222 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0202 020222 2 97110 GY76GP 124.40 42.76 0.00 0.00 CO-45 81.64 42.76
PT RESP CLM STATUS 2 CLAIM TOTALS 239.36 102.07 0.00 0.00 171.21 68.15

PAGE: 28 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 68.15

___________________________________________________________________________________________________________________________________
NAME SCRUGGS, NANCY A HIC MYY810764611 ACNT 2223070A ICN 26220614237500580

1578569786 0131 013122 1 20611 LT 208.22 110.35 0.00 0.00 OA-23 88.28 22.07
CO-45 97.87

0131 013122 1 J7324 EJ 257.08 147.75 0.00 0.00 OA-23 118.20 29.55
CO-45 109.33

PT RESP CLM STATUS 2 CLAIM TOTALS 465.30 258.10 0.00 0.00 413.68 51.62
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 51.62

___________________________________________________________________________________________________________________________________
NAME SCRUGGS, NANCY A HIC MYY810764611 ACNT 2224312A ICN 26220625026100580

1467460394 0204 020422 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0204 020422 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0204 020422 2 97110 GY76GP 124.40 42.76 0.00 0.00 CO-45 81.64 42.76
PT RESP CLM STATUS 2 CLAIM TOTALS 239.36 102.07 0.00 0.00 171.21 68.15
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 68.15

___________________________________________________________________________________________________________________________________
NAME SCRUGGS, NANCY A HIC MYY810764611 ACNT 2224586A ICN 26220625264100580

1467460394 0207 020722 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0207 020722 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0207 020722 2 97110 GY76GP 124.40 42.76 0.00 0.00 CO-45 81.64 42.76
PT RESP CLM STATUS 2 CLAIM TOTALS 239.36 102.07 0.00 0.00 171.21 68.15
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 68.15

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___________________________________________________________________________________________________________________________________
NAME SCRUGGS, NANCY A HIC MYY810764611 ACNT 2224976A ICN 26220634038300580

1578569786 0207 020722 1 20611 LT 208.22 110.35 0.00 0.00 OA-23 88.28 22.07
CO-45 97.87

0207 020722 1 J7324 EJ 257.08 147.75 0.00 0.00 OA-23 118.20 29.55
CO-45 109.33

PT RESP CLM STATUS 2 CLAIM TOTALS 465.30 258.10 0.00 0.00 413.68 51.62
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 51.62

___________________________________________________________________________________________________________________________________
NAME SHAW, ROBERT F HIC MYY810312253 ACNT 2223076A ICN 26220613682200580

1114551561 0128 012822 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0128 012822 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0128 012822 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________

PAGE: 29 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME SHAW, ROBERT F HIC MYY810312253 ACNT 2222497A ICN 26220613693800580

1114551561 0125 012522 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0125 012522 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0125 012522 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME SHAW, ROBERT F HIC MYY810312253 ACNT 2223071A ICN 26220613757300580

1114551561 0121 012122 1 99213 25 189.64 59.36 0.00 0.00 CO-45 130.28 59.36
0121 012122 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0121 012122 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0121 012122 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 553.40 204.19 0.00 0.00 383.13 170.27
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 170.27

___________________________________________________________________________________________________________________________________
NAME SHAW, ROBERT F HIC MYY810312253 ACNT 2223458A ICN 26220613834700580

1114551561 0201 020122 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0201 020122 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0201 020122 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME SHAW, ROBERT F HIC MYY810312253 ACNT 2222596A ICN 26220613917600580

1578569786 0125 012522 3 95851 59 142.50 68.49 0.00 0.00 OA-23 54.79 13.70
CO-45 74.01

0125 012522 1 20553 130.56 0.00 0.00 CO-45 130.56 0.00

0125 012522 4 J1885 100.00 2.18 0.00 0.00 OA-23 1.74 0.44
CO-45 97.82

PT RESP CLM STATUS 2 CLAIM TOTALS 373.06 70.67 0.00 0.00 358.92 14.14
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 14.14

___________________________________________________________________________________________________________________________________
NAME SHAW, ROBERT F HIC MYY810312253 ACNT 2223074A ICN 26220614371200580

1578569786 0121 012122 1 20553 130.56 0.00 0.00 CO-45 130.56 0.00
0121 012122 4 J1885 100.00 2.18 0.00 0.00 OA-23 1.74 0.44
CO-45 97.82

PT RESP CLM STATUS 2 CLAIM TOTALS 230.56 2.18 0.00 0.00 230.12 0.44
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.44

___________________________________________________________________________________________________________________________________
NAME SHAW, ROBERT F HIC MYY810312253 ACNT 2223078A ICN 26220614524600580

PAGE: 30 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

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1578569786 0128 012822 1 20553 130.56 0.00 0.00 CO-45 130.56 0.00
0128 012822 4 J1885 100.00 2.18 0.00 0.00 OA-23 1.74 0.44
CO-45 97.82

PT RESP CLM STATUS 2 CLAIM TOTALS 230.56 2.18 0.00 0.00 230.12 0.44
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.44

___________________________________________________________________________________________________________________________________
NAME SHAW, ROBERT F HIC MYY810312253 ACNT 2224587A ICN 26220624978300580

1114551561 0207 020722 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0207 020722 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0207 020722 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME SHAW, ROBERT F HIC MYY810312253 ACNT 2223688A ICN 26220625261700580

1578569786 0201 020122 1 20553 130.56 0.00 0.00 CO-45 130.56 0.00
0201 020122 4 J1885 100.00 2.18 0.00 0.00 OA-23 1.74 0.44
CO-45 97.82

PT RESP CLM STATUS 2 CLAIM TOTALS 230.56 2.18 0.00 0.00 230.12 0.44
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.44

___________________________________________________________________________________________________________________________________
NAME SINGER, MICHAEL D HIC MYY810947475 ACNT 2223725A ICN 26220613851200580

1467460394 0202 020222 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0202 020222 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0202 020222 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME STROW, PATRICK H HIC MYY810311273 ACNT 2223030A ICN 26220613703400580

1467460394 0126 012622 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0126 012622 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0126 012622 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME STROW, PATRICK H HIC MYY810311273 ACNT 2222592A ICN 26220613795100580

1467460394 0119 011922 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0119 011922 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 4.07 38.33
CO-45 40.28

0119 011922 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52

PAGE: 31 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 223.00 140.76
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 140.76

___________________________________________________________________________________________________________________________________
NAME STROW, PATRICK H HIC MYY810311273 ACNT 2223638A ICN 26220613802000580

1467460394 0131 013122 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0131 013122 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0131 013122 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME STROW, PATRICK H HIC MYY810311273 ACNT 2223487A ICN 26220613817200580

1467460394 0201 020122 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0201 020122 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0201 020122 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME STROW, PATRICK H HIC MYY810311273 ACNT 2223034A ICN 26220613859100580

1467460394 0127 012722 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0127 012722 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0127 012722 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME STROW, PATRICK H HIC MYY810311273 ACNT 2223081A ICN 26220613907000580

1578569786 0131 013122 1 99213 189.64 98.58 0.00 0.00 OA-23 78.86 19.72

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CO-45 91.06

PT RESP CLM STATUS 2 CLAIM TOTALS 189.64 98.58 0.00 0.00 169.92 19.72
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 19.72

___________________________________________________________________________________________________________________________________
NAME STROW, PATRICK H HIC MYY810311273 ACNT 2224236A ICN 26220625009800580

1467460394 0203 020322 1 98943 GY 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0203 020322 1 98941 AT 82.68 42.40 0.00 0.00 OA-23 33.92 8.48
CO-45 40.28

0203 020322 4 97110 GY76GP 248.80 85.52 0.00 0.00 CO-45 163.28 85.52
PT RESP CLM STATUS 2 CLAIM TOTALS 363.76 144.83 0.00 0.00 252.85 110.91
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 110.91

___________________________________________________________________________________________________________________________________
NAME BRIZUELA, BEATRIZ HIC ZKR60285019602 ACNT 2220149A ICN 26220320008700580

PAGE: 32 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

1467460394 0112 011222 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0112 011222 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0112 011222 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

0112 011222 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

0112 011222 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

PT RESP 211.60 CLM STATUS 1 CLAIM TOTALS 301.56 42.14 0.00 0.00 284.42 17.14
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.02 LATE FILING CHARGE 0.00 NET 17.16

___________________________________________________________________________________________________________________________________
NAME BRIZUELA, BEATRIZ HIC ZKR60285019602 ACNT 2220193A ICN 26220320048500580

1114551561 0117 011722 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0117 011722 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0117 011722 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

0117 011722 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

0117 011722 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

0117 011722 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

PT RESP 273.80 CLM STATUS 1 CLAIM TOTALS 363.76 42.14 0.00 0.00 346.62 17.14
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.02 LATE FILING CHARGE 0.00 NET 17.16

___________________________________________________________________________________________________________________________________
NAME BRIZUELA, BEATRIZ HIC ZKR60285019602 ACNT 2220023A ICN 26220320129200580

1376969998 0111 011122 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0111 011122 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0111 011122 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

0111 011122 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

0111 011122 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

0111 011122 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

PT RESP 273.80 CLM STATUS 1 CLAIM TOTALS 363.76 42.14 0.00 0.00 346.62 17.14
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.02 LATE FILING CHARGE 0.00 NET 17.16

___________________________________________________________________________________________________________________________________

PAGE: 33 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME BRIZUELA, BEATRIZ HIC ZKR60285019602 ACNT 2218819A ICN 26220320187600580

1114551561 0105 010522 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0105 010522 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

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0105 010522 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

0105 010522 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

0105 010522 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

PT RESP 211.60 CLM STATUS 1 CLAIM TOTALS 301.56 42.14 0.00 0.00 284.42 17.14
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.02 LATE FILING CHARGE 0.00 NET 17.16

___________________________________________________________________________________________________________________________________
NAME BRIZUELA, BEATRIZ HIC ZKR60285019602 ACNT 2219054A ICN 26220320322000580

1376969998 0110 011022 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0110 011022 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0110 011022 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

0110 011022 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

0110 011022 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

0110 011022 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

PT RESP 273.80 CLM STATUS 1 CLAIM TOTALS 363.76 42.14 0.00 0.00 346.62 17.14
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.02 LATE FILING CHARGE 0.00 NET 17.16

___________________________________________________________________________________________________________________________________
NAME BRIZUELA, BEATRIZ HIC ZKR60285019602 ACNT 2220317A ICN 26220329379200580

1467460394 0118 011822 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0118 011822 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0118 011822 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

0118 011822 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

0118 011822 1 97110 76GP 62.20 0.00 0.00 PR-198 62.20 0.00
REM: N54 N123

PT RESP 211.60 CLM STATUS 1 CLAIM TOTALS 301.56 42.14 0.00 0.00 284.42 17.14
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.01 LATE FILING CHARGE 0.00 NET 17.15

___________________________________________________________________________________________________________________________________
NAME FRENCH, NICOLE HIC XDP297W10743 ACNT 2226234A ICN 26220557947400580

PAGE: 34 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

1467460394 0211 021122 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0211 021122 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 20.00 5.23
CO-45 57.45

0211 021122 1 97110 76GP 62.20 21.38 21.38 0.00 PR-1 21.38 0.00
REM: N123 CO-45 40.82

0211 021122 1 97110 76GP 62.20 21.38 16.46 0.00 PR-1 16.46 0.00
REM: N123 CO-45 40.82

CO-B10 -35.90

OA-70 40.82

0211 021122 1 97110 76GP 62.20 21.38 16.46 0.00 PR-1 16.46 0.00
REM: N123 CO-45 40.82

CO-B10 -35.90

OA-70 40.82

0211 021122 1 97110 76GP 62.20 21.38 16.46 0.00 PR-1 16.46 0.00
REM: N123 CO-45 40.82

CO-B10 -35.90

OA-70 40.82

PT RESP 90.76 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 70.76 0.00 270.86 22.14
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 22.14

___________________________________________________________________________________________________________________________________
NAME FRENCH, NICOLE HIC XDP297W10743 ACNT 2228605A ICN 26220558365400580

1467460394 0214 021422 1 99213 25 189.64 59.36 0.00 0.00 PR-3 20.00 39.36
CO-45 130.28

0214 021422 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0214 021422 1 98941 AT 82.68 25.23 0.00 0.00 CO-45 57.45 25.23
0214 021422 1 97110 76GP 62.20 21.38 21.38 0.00 PR-1 21.38 0.00
REM: N123 CO-45 40.82

0214 021422 1 97110 76GP 62.20 21.38 16.46 0.00 PR-1 16.46 0.00
REM: N123 CO-45 40.82

CO-B10 -35.90

OA-70 40.82

0214 021422 1 97110 76GP 62.20 21.38 16.46 0.00 PR-1 16.46 0.00
REM: N123 CO-45 40.82

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CO-B10 -35.90

OA-70 40.82

0214 021422 1 97110 76GP 62.20 21.38 16.46 0.00 PR-1 16.46 0.00
REM: N123 CO-45 40.82

CO-B10 -35.90

OA-70 40.82

PT RESP 90.76 CLM STATUS 1 CLAIM TOTALS 553.40 187.02 70.76 0.00 401.14 81.50
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 81.50

___________________________________________________________________________________________________________________________________

PAGE: 35 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME FRENCH, NICOLE HIC XDP297W10743 ACNT 2230678A ICN 26220617865300580

1467460394 0216 021622 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0216 021622 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 20.00 5.23
CO-45 57.45

0216 021622 1 97110 76GP 62.20 21.38 21.38 0.00 PR-1 21.38 0.00
REM: N123 CO-45 40.82

0216 021622 1 97110 76GP 62.20 21.38 16.46 0.00 PR-1 16.46 0.00
REM: N123 CO-45 40.82

CO-B10 -35.90

OA-70 40.82

0216 021622 1 97110 76GP 62.20 21.38 16.46 0.00 PR-1 16.46 0.00
REM: N123 CO-45 40.82

CO-B10 -35.90

OA-70 40.82

0216 021622 1 97110 76GP 62.20 21.38 16.46 0.00 PR-1 16.46 0.00
REM: N123 CO-45 40.82

CO-B10 -35.90

OA-70 40.82

PT RESP 90.76 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 70.76 0.00 270.86 22.14
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 22.14

___________________________________________________________________________________________________________________________________
NAME GREEN, ALEXIS HIC YSQ960W11532 ACNT 2230692A ICN 26220617595900580

1467460394 0216 021622 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0216 021622 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 20.00 5.23
CO-45 57.45

0216 021622 1 97110 76GP 62.20 21.38 0.00 2.13 PR-2 2.13 19.25
REM: N123 CO-45 40.82

0216 021622 1 97110 76GP 62.20 21.38 0.00 1.64 PR-2 1.64 14.82
REM: N123 CO-45 40.82

CO-B10 -35.90

OA-70 40.82

PT RESP 23.77 CLM STATUS 1 CLAIM TOTALS 239.36 84.90 0.00 3.77 179.38 56.21
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 56.21

___________________________________________________________________________________________________________________________________
NAME MCGINNIS, ROBERT R HIC XQHW01664839 ACNT 2228624A ICN 26220558060200580

1467460394 0214 021422 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0214 021422 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0214 021422 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0214 021422 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

PAGE: 36 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

OA-70 40.82

0214 021422 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

OA-70 40.82

0214 021422 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

OA-70 40.82

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 275.86 87.90

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BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 87.90

___________________________________________________________________________________________________________________________________
NAME MCGINNIS, ROBERT R HIC XQHW01664839 ACNT 2226467A ICN 26220558305000580

1578569786 0210 021022 1 20550 117.54 59.73 0.00 0.00 PR-3 25.00 34.73
CO-45 57.81

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 117.54 59.73 0.00 0.00 82.81 34.73
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 34.73

___________________________________________________________________________________________________________________________________
NAME MCGINNIS, ROBERT R HIC XQHW01664839 ACNT 2226323A ICN 26220558524900580

1467460394 0210 021022 1 98943 32.28 16.91 0.00 0.00 CO-45 15.37 16.91
0210 021022 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.00 0.23
CO-45 57.45

0210 021022 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0210 021022 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

OA-70 40.82

0210 021022 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

OA-70 40.82

0210 021022 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

OA-70 40.82

PT RESP 25.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 275.86 87.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 87.90

___________________________________________________________________________________________________________________________________
NAME PHILLIPS, EMORY L HIC U3S833504154 ACNT 2209577A ICN 26220618036100580

1114551561 1123 112321 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

1123 112321 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

OA-70 40.82

1123 112321 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

PAGE: 37 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

OA-70 40.82

PT RESP CLM STATUS 1 CLAIM TOTALS 186.60 64.14 0.00 0.00 132.30 54.30
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 54.30

___________________________________________________________________________________________________________________________________
NAME TURNER, TAMMY S HIC HUF3HZN47850200 ACNT 2226367A ICN 26220558148100580

1467460394 0210 021022 1 98943 32.28 16.91 0.00 0.00 PR-3 4.77 12.14
CO-45 15.37

0210 021022 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.23 0.00
CO-45 57.45

0210 021022 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0210 021022 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

OA-70 40.82

0210 021022 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

OA-70 40.82

0210 021022 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

OA-70 40.82

PT RESP 30.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 280.86 82.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 82.90

___________________________________________________________________________________________________________________________________
NAME TURNER, TAMMY S HIC HUF3HZN47850200 ACNT 2226287A ICN 26220558654000580

1114551561 0209 020922 1 98943 32.28 16.91 0.00 0.00 PR-3 4.77 12.14
CO-45 15.37

0209 020922 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.23 0.00
CO-45 57.45

0209 020922 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0209 020922 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

OA-70 40.82

0209 020922 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

OA-70 40.82

0209 020922 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46

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REM: N123 CO-B10
-35.90

OA-7040.82

PT RESP 30.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 280.86 82.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 82.90

___________________________________________________________________________________________________________________________________

PAGE: 38 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME TURNER, TAMMY S HIC HUF3HZN47850200 ACNT 2228634A ICN 26220558723600580

1467460394 0214 021422 1 98943 32.28 16.91 0.00 0.00 PR-3 4.77 12.14
CO-45 15.37

0214 021422 1 98941 AT 82.68 25.23 0.00 0.00 PR-3 25.23 0.00
CO-45 57.45

0214 021422 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 21.38
REM: N123

0214 021422 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

OA-70 40.82

0214 021422 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

OA-70 40.82

0214 021422 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

OA-70 40.82

PT RESP 30.00 CLM STATUS 1 CLAIM TOTALS 363.76 127.66 0.00 0.00 280.86 82.90
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 82.90

___________________________________________________________________________________________________________________________________
NAME TURNER, TAMMY S HIC HUF3HZN47850200 ACNT 2230687A ICN 26220618130700580

1467460394 0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 PR-3 21.38 0.00
REM: N123 CO-45 40.82

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 PR-3 8.62 7.84
REM: N123 CO-45 40.82

CO-B10 -35.90

OA-70 40.82

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

OA-70 40.82

0217 021722 1 97110 76GP 62.20 21.38 0.00 0.00 CO-45 40.82 16.46
REM: N123 CO-B10 -35.90

OA-70 40.82

PT RESP 30.00 CLM STATUS 1 CLAIM TOTALS 248.80 85.52 0.00 0.00 208.04 40.76
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 40.76

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 1903571B ICN 26212243318200580

1114551561 0414 041421 1 98943 -32.28 0.00 0.00 PI-97 18.09 0.00
CO-45 -16.73

OA-23 -16.91

OA-70 -16.73

1114551561 0414 041421 1 98941 -82.68 0.00 -0.09 CO-45 -59.48 -2.88
OA-23 -0.23

PAGE: 39 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

PR-3 -20.00

1114551561 0414 041421 1 97110 -62.20 0.00 0.00 OA-23 -18.10 -1.56
REM: N123 CO-45 -42.54

1114551561 0414 041421 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.56
REM: N123 OA-23 -18.10

1114551561 0414 041421 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.56
REM: N123 OA-23 -18.10

PT RESP -20.09 CLM STATUS 22 CLAIM TOTALS -301.56 0.00 0.00 -0.09 -293.91 -7.56
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -7.56

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 1903571B ICN 26212243318202580

1114551561 0414 041421 1 98943 32.28 15.55 0.00 0.00 OA-23 16.91 0.00

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OA-70 16.73

CO-45 16.73

PI-97-18.09

1114551561 0414 041421 1 98941 82.68 23.20 0.00 2.09 PR-2 2.09 20.88
OA-23 0.23

CO-45 59.48

1114551561 0414 041421 1 97110 62.20 19.66 0.00 0.00 OA-23 18.10 1.56
REM: N123 CO-45 42.54

1114551561 0414 041421 1 97110 62.20 19.66 0.00 0.00 OA-23 18.10 1.56
REM: N123 CO-45 42.54

1114551561 0414 041421 1 97110 62.20 19.66 0.00 0.00 OA-23 18.10 1.56
REM: N123 CO-45 42.54

PT RESP 2.09 CLM STATUS 1 CLAIM TOTALS 301.56 97.73 0.00 2.09 273.91 25.56
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 25.56

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 1990995A ICN 26212243318600580

1114551561 0427 042721 1 98943 -322.80 0.00 0.00 PI-97 308.61 0.00
CO-45 -307.25

OA-23 -16.91

OA-70 -307.25

1114551561 0427 042721 1 98941 -826.80 0.00 -0.09 CO-45 -803.60 -2.88
OA-23 -0.23

PR-3 -20.00

1114551561 0427 042721 1 97110 -622.00 0.00 0.00 CO-45 -602.34 -1.97
REM: N123 OA-23 -17.69

1114551561 0427 042721 1 97110 -622.00 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -602.34

1114551561 0427 042721 1 97110 -622.00 0.00 0.00 CO-45 -602.34 -1.97
REM: N123 OA-23 -17.69

1114551561 0427 042721 1 97110 -622.00 0.00 0.00 OA-23 -17.69 -1.97

PAGE: 40 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

REM: N123 CO-45 -602.34

PT RESP -20.09 CLM STATUS 22 CLAIM TOTALS -3,637.60 0.00 0.00 -0.09 -3,626.75 -10.76
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -10.76

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 1990995A ICN 26212243318602580

1114551561 0427 042721 1 98943 322.80 15.55 0.00 0.00 OA-23 16.91 0.00
OA-70 307.25

CO-45 307.25

PI-97 -308.61

1114551561 0427 042721 1 98941 826.80 23.20 0.00 2.09 PR-2 2.09 20.88
OA-23 0.23

CO-45 803.60

1114551561 0427 042721 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.66
REM: N123 OA-70 602.34

CO-45 602.34

CO-97 -602.03

1114551561 0427 042721 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 602.34

1114551561 0427 042721 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 602.34

1114551561 0427 042721 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 602.34

PT RESP 2.09 CLM STATUS 1 CLAIM TOTALS 3,637.60 117.39 0.00 2.09 3,607.06 28.45
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 28.45

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 1927747B ICN 26212243319700580

1114551561 0416 041621 1 98943 -32.28 0.00 0.00 PI-97 18.09 0.00
CO-45 -16.73

OA-23 -16.91

OA-70 -16.73

1114551561 0416 041621 1 98941 -82.68 0.00 -0.09 CO-45 -59.48 -2.88
OA-23 -0.23

PR-3 -20.00

1114551561 0416 041621 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

1114551561 0416 041621 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -42.54

1114551561 0416 041621 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

1114551561 0416 041621 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -42.54

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PT RESP -20.09 CLM STATUS 22 CLAIM TOTALS -363.76 0.00 0.00 -0.09 -352.91 -10.76

PAGE: 41 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -10.76

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 1927747B ICN 26212243319702580

1114551561 0416 041621 1 98943 32.28 15.55 0.00 0.00 OA-23 16.91 0.00
OA-70 16.73

CO-45 16.73

PI-97 -18.09

1114551561 0416 041621 1 98941 82.68 23.20 0.00 2.09 PR-2 2.09 20.88
OA-23 0.23

CO-45 59.48

1114551561 0416 041621 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.66
REM: N123 OA-70 42.54

CO-45 42.54

CO-97 -42.23

1114551561 0416 041621 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

1114551561 0416 041621 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

1114551561 0416 041621 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

PT RESP 2.09 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 2.09 333.22 28.45
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 28.45

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2026158A ICN 26212243320300580

1114551561 0504 050421 1 98943 -322.80 0.00 0.00 PI-97 308.61 0.00
CO-45 -307.25

OA-23 -16.91

OA-70 -307.25

1114551561 0504 050421 1 98941 -826.80 0.00 -0.09 CO-45 -803.60 -2.88
OA-23 -0.23

PR-3 -20.00

1114551561 0504 050421 1 97110 -622.00 0.00 0.00 CO-45 -602.34 -1.97
REM: N123 OA-23 -17.69

1114551561 0504 050421 1 97110 -622.00 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -602.34

1114551561 0504 050421 1 97110 -622.00 0.00 0.00 CO-45 -602.34 -1.97
REM: N123 OA-23 -17.69

1114551561 0504 050421 1 97110 -622.00 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -602.34

PT RESP -20.09 CLM STATUS 22 CLAIM TOTALS -3,637.60 0.00 0.00 -0.09 -3,626.75 -10.76
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -10.76

___________________________________________________________________________________________________________________________________

PAGE: 42 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2026158A ICN 26212243320302580

1114551561 0504 050421 1 98943 322.80 15.55 0.00 0.00 OA-23 16.91 0.00
OA-70 307.25

CO-45 307.25

PI-97 -308.61

1114551561 0504 050421 1 98941 826.80 23.20 0.00 2.09 PR-2 2.09 20.88
OA-23 0.23

CO-45 803.60

1114551561 0504 050421 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.66
REM: N123 OA-70 602.34

CO-45 602.34

CO-97 -602.03

1114551561 0504 050421 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 602.34

1114551561 0504 050421 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 602.34

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1114551561 0504 050421 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 602.34

PT RESP 2.09 CLM STATUS 1 CLAIM TOTALS 3,637.60 117.39 0.00 2.09 3,607.06 28.45
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 28.45

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 1989159A ICN 26212243322400580

1114551561 0428 042821 1 98943 -322.80 0.00 0.00 PI-97 308.61 0.00
CO-45 -307.25

OA-23 -16.91

OA-70 -307.25

1114551561 0428 042821 1 98941 -826.80 0.00 -0.09 CO-45 -803.60 -2.88
OA-23 -0.23

PR-3 -20.00

1114551561 0428 042821 1 97110 -622.00 0.00 0.00 CO-45 -602.34 -1.97
REM: N123 OA-23 -17.69

1114551561 0428 042821 1 97110 -622.00 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -602.34

1114551561 0428 042821 1 97110 -622.00 0.00 0.00 CO-45 -602.34 -1.97
REM: N123 OA-23 -17.69

1114551561 0428 042821 1 97110 -622.00 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -602.34

PT RESP -20.09 CLM STATUS 22 CLAIM TOTALS -3,637.60 0.00 0.00 -0.09 -3,626.75 -10.76
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -10.76

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 1989159A ICN 26212243322402580

1114551561 0428 042821 1 98943 322.80 15.55 0.00 0.00 OA-23 16.91 0.00

PAGE: 43 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

OA-70 307.25

CO-45 307.25

PI-97 -308.61

1114551561 0428 042821 1 98941 826.80 23.20 0.00 2.09 PR-2 2.09 20.88
OA-23 0.23

CO-45 803.60

1114551561 0428 042821 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.66
REM: N123 OA-70 602.34

CO-45 602.34

CO-97 -602.03

1114551561 0428 042821 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 602.34

1114551561 0428 042821 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 602.34

1114551561 0428 042821 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 602.34

PT RESP 2.09 CLM STATUS 1 CLAIM TOTALS 3,637.60 117.39 0.00 2.09 3,607.06 28.45
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 28.45

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 1991277A ICN 26212243324600580

1114551561 0430 043021 1 98943 -322.80 0.00 0.00 PI-97 308.61 0.00
CO-45 -307.25

OA-23 -16.91

OA-70 -307.25

1114551561 0430 043021 1 98941 -826.80 0.00 -0.09 CO-45 -803.60 -2.88
OA-23 -0.23

PR-3 -20.00

1114551561 0430 043021 1 97110 -622.00 0.00 0.00 CO-45 -602.34 -1.97
REM: N123 OA-23 -17.69

1114551561 0430 043021 1 97110 -622.00 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -602.34

1114551561 0430 043021 1 97110 -622.00 0.00 0.00 CO-45 -602.34 -1.97
REM: N123 OA-23 -17.69

1114551561 0430 043021 1 97110 -622.00 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -602.34

PT RESP -20.09 CLM STATUS 22 CLAIM TOTALS -3,637.60 0.00 0.00 -0.09 -3,626.75 -10.76
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -10.76

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 1991277A ICN 26212243324602580

1114551561 0430 043021 1 98943 322.80 15.55 0.00 0.00 OA-23 16.91 0.00
OA-70 307.25

CO-45 307.25

PAGE: 44 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022

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10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

PI-97 -308.61

1114551561 0430 043021 1 98941 826.80 23.20 0.00 2.09 PR-2 2.09 20.88
OA-23 0.23

CO-45 803.60

1114551561 0430 043021 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.66
REM: N123 OA-70 602.34

CO-45 602.34

CO-97 -602.03

1114551561 0430 043021 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 602.34

1114551561 0430 043021 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 602.34

1114551561 0430 043021 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 602.34

PT RESP 2.09 CLM STATUS 1 CLAIM TOTALS 3,637.60 117.39 0.00 2.09 3,607.06 28.45
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 28.45

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2186656A ICN 26212243348400580

1114551561 0628 062821 1 98943 -32.28 0.00 0.00 PI-97 18.09 0.00
CO-45 -16.73

OA-23 -16.91

OA-70 -16.73

1114551561 0628 062821 1 98941 AT -82.68 0.00 -0.09 CO-45 -59.48 -2.88
OA-23 -0.23

PR-3 -20.00

1114551561 0628 062821 1 97110 76GP -62.20 0.00 0.00 OA-23 -18.10 -1.56
REM: N123 CO-45 -42.54

1114551561 0628 062821 1 97110 76GP -62.20 0.00 0.00 CO-45 -42.54 -1.56
REM: N123 OA-23 -18.10

1114551561 0628 062821 1 97110 76GP -62.20 0.00 0.00 CO-45 -42.54 -1.56
REM: N123 OA-23 -18.10

PT RESP -20.09 CLM STATUS 22 CLAIM TOTALS -301.56 0.00 0.00 -0.09 -293.91 -7.56
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -7.56

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2186656A ICN 26212243348402580

1114551561 0628 062821 1 98943 32.28 15.55 0.00 0.00 OA-23 16.91 0.00
OA-70 16.73

CO-45 16.73

PI-97 -18.09

1114551561 0628 062821 1 98941 AT 82.68 23.20 0.00 2.09 PR-2 2.09 20.88
OA-23 0.23

CO-45 59.48

PAGE: 45 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

1114551561 0628 062821 1 97110 76GP 62.20 19.66 0.00 0.00 OA-23 18.10 1.56
REM: N123 CO-45 42.54

1114551561 0628 062821 1 97110 76GP 62.20 19.66 0.00 0.00 OA-23 18.10 1.56
REM: N123 CO-45 42.54

1114551561 0628 062821 1 97110 76GP 62.20 19.66 0.00 0.00 OA-23 18.10 1.56
REM: N123 CO-45 42.54

PT RESP 2.09 CLM STATUS 1 CLAIM TOTALS 301.56 97.73 0.00 2.09 273.91 25.56
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 25.56

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2027831A ICN 26212243350400580

1114551561 0505 050521 1 98943 -322.80 0.00 0.00 PI-97 308.61 0.00
CO-45 -307.25

OA-23 -16.91

OA-70 -307.25

1114551561 0505 050521 1 98941 -826.80 0.00 -0.09 CO-45 -803.60 -2.88
OA-23 -0.23

PR-3 -20.00

1114551561 0505 050521 1 97110 -622.00 0.00 0.00 CO-45 -602.34 -1.97
REM: N123 OA-23 -17.69

1114551561 0505 050521 1 97110 -622.00 0.00 0.00 OA-23 -17.69 -1.97

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REM: N123 CO-45 -602.34

1114551561 0505 050521 1 97110 -622.00 0.00 0.00 CO-45 -602.34 -1.97
REM: N123 OA-23 -17.69

1114551561 0505 050521 1 97110 -622.00 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -602.34

PT RESP -20.09 CLM STATUS 22 CLAIM TOTALS -3,637.60 0.00 0.00 -0.09 -3,626.75 -10.76
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -10.76

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2027831A ICN 26212243350402580

1114551561 0505 050521 1 98943 322.80 15.55 0.00 0.00 OA-23 16.91 0.00
OA-70 307.25

CO-45 307.25

PI-97 -308.61

1114551561 0505 050521 1 98941 826.80 23.20 0.00 2.09 PR-2 2.09 20.88
OA-23 0.23

CO-45 803.60

1114551561 0505 050521 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.66
REM: N123 OA-70 602.34

CO-45 602.34

CO-97 -602.03

1114551561 0505 050521 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 602.34

PAGE: 46 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

1114551561 0505 050521 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 602.34

1114551561 0505 050521 1 97110 622.00 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 602.34

PT RESP 2.09 CLM STATUS 1 CLAIM TOTALS 3,637.60 117.39 0.00 2.09 3,607.06 28.45
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 28.45

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2078005A ICN 26212243352500580

1114551561 0517 051721 1 98943 -32.28 0.00 0.00 PI-97 18.09 0.00
CO-45 -16.73

OA-23 -16.91

OA-70 -16.73

1114551561 0517 051721 1 98941 -82.68 0.00 -0.09 CO-45 -59.48 -2.88
OA-23 -0.23

PR-3 -20.00

1114551561 0517 051721 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

1114551561 0517 051721 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -42.54

1114551561 0517 051721 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

1114551561 0517 051721 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -42.54

PT RESP -20.09 CLM STATUS 22 CLAIM TOTALS -363.76 0.00 0.00 -0.09 -352.91 -10.76
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -10.76

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2078005A ICN 26212243352502580

1114551561 0517 051721 1 98943 32.28 15.55 0.00 0.00 OA-23 16.91 0.00
OA-70 16.73

CO-45 16.73

PI-97 -18.09

1114551561 0517 051721 1 98941 82.68 23.20 0.00 2.09 PR-2 2.09 20.88
OA-23 0.23

CO-45 59.48

1114551561 0517 051721 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.66
REM: N123 OA-70 42.54

CO-45 42.54

CO-97 -42.23

1114551561 0517 051721 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

1114551561 0517 051721 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

PAGE: 47 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

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12/04/2022, 09:30 https://pm-wfe-116.advancedmd.com/practicemanager/claims/clm_printedireport.htm
3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

1114551561 0517 051721 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

PT RESP 2.09 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 2.09 333.22 28.45
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 28.45

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2092142A ICN 26212243353300580

1114551561 0524 052421 1 99213 25 -189.64 0.00 0.00 OA-18 -155.28 0.00
OA-23 -34.36

1114551561 0524 052421 1 98943 -32.28 0.00 0.00 PI-97 18.09 0.00
CO-45 -16.73

OA-23 -16.91

OA-70 -16.73

1114551561 0524 052421 1 98941 -82.68 0.00 0.00 PI-97 61.51 0.00
CO-45 -59.48

OA-23 -25.23

OA-70 -59.48

1114551561 0524 052421 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -42.54

1114551561 0524 052421 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

1114551561 0524 052421 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -42.54

1114551561 0524 052421 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

PT RESP CLM STATUS 22 CLAIM TOTALS -553.40 0.00 0.00 0.00 -545.52 -7.88
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -7.88

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2092142A ICN 26212243353302580

1114551561 0524 052421 1 99213 25 189.64 56.39 0.00 0.00 OA-23 34.36 25.00
OA-70 133.25

CO-45 133.25

PI-97 -136.22

1114551561 0524 052421 1 98943 32.28 15.55 0.00 0.00 OA-23 16.91 0.00
OA-70 16.73

CO-45 16.73

PI-97 -18.09

1114551561 0524 052421 1 98941 82.68 23.20 0.00 0.00 OA-23 25.23 0.00
OA-70 59.48

CO-45 59.48

PI-97 -61.51

1114551561 0524 052421 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

PAGE: 48 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

1114551561 0524 052421 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

1114551561 0524 052421 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

1114551561 0524 052421 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

PT RESP CLM STATUS 1 CLAIM TOTALS 553.40 173.78 0.00 0.00 520.52 32.88
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 32.88

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2122974A ICN 26212244325900580

1114551561 0602 060221 1 98943 -32.28 0.00 0.00 PI-97 18.09 0.00
CO-45 -16.73

OA-23 -16.91

OA-70 -16.73

1114551561 0602 060221 1 98941 -82.68 0.00 -0.09 CO-45 -59.48 -2.88
OA-23 -0.23

PR-3 -20.00

1114551561 0602 060221 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

1114551561 0602 060221 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -42.54

1114551561 0602 060221 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

1114551561 0602 060221 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97

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REM: N123 CO-45 -42.54

PT RESP -20.09 CLM STATUS 22 CLAIM TOTALS -363.76 0.00 0.00 -0.09 -352.91 -10.76
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -10.76

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2122974A ICN 26212244325902580

1114551561 0602 060221 1 98943 32.28 15.55 0.00 0.00 OA-23 16.91 0.00
OA-70 16.73

CO-45 16.73

PI-97 -18.09

1114551561 0602 060221 1 98941 82.68 23.20 0.00 2.09 PR-2 2.09 20.88
OA-23 0.23

CO-45 59.48

1114551561 0602 060221 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.66
REM: N123 OA-70 42.54

CO-45 42.54

CO-97 -42.23

1114551561 0602 060221 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

PAGE: 49 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

1114551561 0602 060221 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

1114551561 0602 060221 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

PT RESP 2.09 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 2.09 333.22 28.45
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 28.45

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2105873A ICN 26212244327600580

1376969998 0526 052621 1 98943 -32.28 0.00 0.00 PI-97 18.09 0.00
CO-45 -16.73

OA-23 -16.91

OA-70 -16.73

1376969998 0526 052621 1 98941 -82.68 0.00 -0.09 CO-45 -59.48 -2.88
OA-23 -0.23

PR-3 -20.00

1376969998 0526 052621 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

1376969998 0526 052621 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -42.54

1376969998 0526 052621 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

1376969998 0526 052621 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -42.54

PT RESP -20.09 CLM STATUS 22 CLAIM TOTALS -363.76 0.00 0.00 -0.09 -352.91 -10.76
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -10.76

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2105873A ICN 26212244327602580

1376969998 0526 052621 1 98943 32.28 15.55 0.00 0.00 OA-23 16.91 0.00
OA-70 16.73

CO-45 16.73

PI-97 -18.09

1376969998 0526 052621 1 98941 82.68 23.20 0.00 2.09 PR-2 2.09 20.88
OA-23 0.23

CO-45 59.48

1376969998 0526 052621 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.66
REM: N123 OA-70 42.54

CO-45 42.54

CO-97 -42.23

1376969998 0526 052621 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

1376969998 0526 052621 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

PAGE: 50 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

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_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________
1376969998 0526 052621 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

PT RESP 2.09 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 2.09 333.22 28.45
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 28.45

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2142385A ICN 26212244328400580

1114551561 0604 060421 1 98941 -82.68 0.00 -0.09 OA-23 -0.23 -2.88
CO-45 -59.48

PR-3 -20.00

1114551561 0604 060421 1 98943 -32.28 0.00 0.00 OA-23 -16.91 0.00
OA-70 -16.73

PI-97 18.09

CO-45 -16.73

1114551561 0604 060421 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -42.54

1114551561 0604 060421 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

1114551561 0604 060421 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -42.54

1114551561 0604 060421 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

PT RESP -20.09 CLM STATUS 22 CLAIM TOTALS -363.76 0.00 0.00 -0.09 -352.91 -10.76
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -10.76

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2142385A ICN 26212244328402580

1114551561 0604 060421 1 98941 82.68 23.20 0.00 2.09 PR-2 2.09 20.88
OA-23 0.23

CO-45 59.48

1114551561 0604 060421 1 98943 32.28 15.55 0.00 0.00 OA-23 16.91 0.00
OA-70 16.73

CO-45 16.73

PI-97 -18.09

1114551561 0604 060421 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.66
REM: N123 OA-70 42.54

CO-45 42.54

CO-97 -42.23

1114551561 0604 060421 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

1114551561 0604 060421 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

1114551561 0604 060421 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

PAGE: 51 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

PT RESP 2.09 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 2.09 333.22 28.45
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 28.45

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2160612A ICN 26212244332800580

1376969998 0611 061121 1 98943 -32.28 0.00 0.00 PI-97 18.09 0.00
CO-45 -16.73

OA-23 -16.91

OA-70 -16.73

1376969998 0611 061121 1 98941 -82.68 0.00 -0.09 CO-45 -59.48 -2.88
OA-23 -0.23

PR-3 -20.00

1376969998 0611 061121 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

1376969998 0611 061121 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -42.54

1376969998 0611 061121 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

1376969998 0611 061121 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -42.54

PT RESP -20.09 CLM STATUS 22 CLAIM TOTALS -363.76 0.00 0.00 -0.09 -352.91 -10.76
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -10.76

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2160612A ICN 26212244332802580

1376969998 0611 061121 1 98943 32.28 15.55 0.00 0.00 OA-23 16.91 0.00
OA-70 16.73

CO-45 16.73

PI-97 -18.09

1376969998 0611 061121 1 98941 82.68 23.20 0.00 2.09 PR-2 2.09 20.88

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OA-23 0.23

CO-45 59.48

1376969998 0611 061121 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.66
REM: N123 OA-70 42.54

CO-45 42.54

CO-97 -42.23

1376969998 0611 061121 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

1376969998 0611 061121 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

1376969998 0611 061121 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

PT RESP 2.09 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 2.09 333.22 28.45
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 28.45

PAGE: 52 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2160117A ICN 26212244333500580

1376969998 0609 060921 1 98941 -82.68 0.00 -0.09 OA-23 -0.23 -2.88
CO-45 -59.48

PR-3 -20.00

1376969998 0609 060921 1 98943 -32.28 0.00 0.00 OA-23 -16.91 0.00
OA-70 -16.73

PI-97 18.09

CO-45 -16.73

1376969998 0609 060921 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -42.54

1376969998 0609 060921 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

1376969998 0609 060921 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -42.54

1376969998 0609 060921 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

PT RESP -20.09 CLM STATUS 22 CLAIM TOTALS -363.76 0.00 0.00 -0.09 -352.91 -10.76
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -10.76

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2160117A ICN 26212244333502580

1376969998 0609 060921 1 98941 82.68 23.20 0.00 2.09 PR-2 2.09 20.88
OA-23 0.23

CO-45 59.48

1376969998 0609 060921 1 98943 32.28 15.55 0.00 0.00 OA-23 16.91 0.00
OA-70 16.73

CO-45 16.73

PI-97 -18.09

1376969998 0609 060921 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.26
REM: N123 OA-70 42.54

CO-45 42.54

CO-97 -41.83

1376969998 0609 060921 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

1376969998 0609 060921 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

1376969998 0609 060921 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

PT RESP 2.09 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 2.09 333.62 28.05
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 28.05

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2181718A ICN 26212244335000580

1114551561 0614 061421 1 98943 -32.28 0.00 0.00 PI-97 18.09 0.00

PAGE: 53 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

CO-45 -16.73

OA-23 -16.91

OA-70 -16.73

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1114551561 0614 061421 1 98941 -82.68 0.00-0.09 CO-45 -59.48 -2.88
OA-23 -0.23

PR-3 -20.00

1114551561 0614 061421 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

1114551561 0614 061421 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -42.54

1114551561 0614 061421 1 97110 -62.20 0.00 0.00 CO-45 -42.54 -1.97
REM: N123 OA-23 -17.69

1114551561 0614 061421 1 97110 -62.20 0.00 0.00 OA-23 -17.69 -1.97
REM: N123 CO-45 -42.54

PT RESP -20.09 CLM STATUS 22 CLAIM TOTALS -363.76 0.00 0.00 -0.09 -352.91 -10.76
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -10.76

___________________________________________________________________________________________________________________________________
NAME WEISS, JAFFA HIC 811200572 ACNT 2181718A ICN 26212244335002580

1114551561 0614 061421 1 98943 32.28 15.55 0.00 0.00 OA-23 16.91 0.00
OA-70 16.73

CO-45 16.73

PI-97 -18.09

1114551561 0614 061421 1 98941 82.68 23.20 0.00 2.09 PR-2 2.09 20.88
OA-23 0.23

CO-45 59.48

1114551561 0614 061421 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 0.00
REM: N123 OA-70 42.54

CO-45 42.54

CO-97 -40.57

1114551561 0614 061421 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

1114551561 0614 061421 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

1114551561 0614 061421 1 97110 62.20 19.66 0.00 0.00 OA-23 17.69 1.97
REM: N123 CO-45 42.54

PT RESP 2.09 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 2.09 334.88 26.79
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 26.79

___________________________________________________________________________________________________________________________________
NAME MACALPINE, MAIYA HIC BOF892762696 ACNT 1872274A ICN 26211127182200580

1114551561 0326 032621 1 98943 -322.80 -16.91 0.00 CO-45 -305.89 0.00
0326 032621 1 98941 -826.80 -25.23 0.00 CO-45 -801.57 0.00
0326 032621 1 97110 -622.00 0.00 0.00 PR-167 -622.00 0.00

PAGE: 54 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

REM: N123

0326 032621 1 97110 -622.00 0.00 0.00 PR-167 -622.00 0.00

REM: N123

PT RESP -1,286.14 CLM STATUS 22 CLAIM TOTALS -2,393.60 0.00 -42.14 0.00 -2,351.46 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME MACALPINE, MAIYA F HIC BOF892762696 ACNT 1872274E ICN 26211127182202580

1114551561 0326 032621 1 98943 32.28 16.91 16.91 0.00 PR-1 16.91 0.00
CO-45 15.37

0326 032621 1 98941 82.68 25.23 25.23 0.00 PR-1 25.23 0.00
CO-45 57.45

0326 032621 1 97110 76GP 62.20 0.00 0.00 PR-167 62.20 0.00
REM: N123

0326 032621 1 97110 76GP 62.20 0.00 0.00 PR-167 62.20 0.00
REM: N123

PT RESP 166.54 CLM STATUS 1 CLAIM TOTALS 239.36 42.14 42.14 0.00 197.22 0.00
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME GOURGOULIATOU, MARIAHIC SOD119065795001 ACNT 2226314A ICN 26220557991100580

1467460394 0209 020922 1 97110 76GP 62.20 0.00 0.00 PR-119 62.20 0.00
REM: N123

0209 020922 1 97110 76GP 62.20 0.00 0.00 PR-119 62.20 0.00
REM: N123

0209 020922 1 97110 76GP 62.20 0.00 0.00 PR-119 62.20 0.00
REM: N123

0209 020922 1 97110 76GP 62.20 0.00 0.00 PR-119 62.20 0.00
REM: N123

0209 020922 1 97140 76GP 57.16 0.00 0.00 PR-119 57.16 0.00
PT RESP 305.96 CLM STATUS 4 CLAIM TOTALS 305.96 0.00 0.00 0.00 305.96 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME GOURGOULIATOU, MARIAHIC SOD119065795001 ACNT 2228610A ICN 26220558122600580

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1467460394 0214 021422 1 97110 76GP 62.20 0.00 0.00 PR-119 62.20 0.00
REM: N123

0214 021422 1 97110 76GP 62.20 0.00 0.00 PR-119 62.20 0.00
REM: N123

0214 021422 1 97110 76GP 62.20 0.00 0.00 PR-119 62.20 0.00
REM: N123

0214 021422 1 97110 76GP 62.20 0.00 0.00 PR-119 62.20 0.00
REM: N123

0214 021422 1 97140 76GP 57.16 0.00 0.00 PR-119 57.16 0.00
PT RESP 305.96 CLM STATUS 4 CLAIM TOTALS 305.96 0.00 0.00 0.00 305.96 0.00

PAGE: 55 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME TURNER, TAMMY S HIC HUF3HZN47850200 ACNT 2230994A ICN 26220617076800580

1578569786 0217 021722 3 95851 142.50 37.67 37.67 0.00 PR-1 37.67 0.00
CO-45 104.83

PT RESP 37.67 CLM STATUS 1 CLAIM TOTALS 142.50 37.67 37.67 0.00 104.83 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME GOURGOULIATOU, MARIAHIC SOD119065795001 ACNT 2230691A ICN 26220617471700580

1467460394 0216 021622 1 97110 76GP 62.20 0.00 0.00 PR-119 62.20 0.00
REM: N123

0216 021622 1 97110 76GP 62.20 0.00 0.00 PR-119 62.20 0.00
REM: N123

0216 021622 1 97110 76GP 62.20 0.00 0.00 PR-119 62.20 0.00
REM: N123

0216 021622 1 97110 76GP 62.20 0.00 0.00 PR-119 62.20 0.00
REM: N123

0216 021622 1 97140 76GP 57.16 0.00 0.00 PR-119 57.16 0.00
PT RESP 305.96 CLM STATUS 4 CLAIM TOTALS 305.96 0.00 0.00 0.00 305.96 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME TORRES, CYNTHIA HIC C9U3HZN76388520 ACNT 2230907A ICN 26220617538700580

1114551561 0216 021622 1 97110 76GP 62.20 21.38 21.38 0.00 PR-1 21.38 0.00
REM: N123 CO-45 40.82

0216 021622 1 97110 76GP 62.20 21.38 16.46 0.00 PR-1 16.46 0.00
REM: N123 CO-45 40.82

CO-B10 -35.90

OA-70 40.82

0216 021622 1 97110 76GP 62.20 21.38 16.46 0.00 PR-1 16.46 0.00
REM: N123 CO-45 40.82

CO-B10 -35.90

OA-70 40.82

0216 021622 1 97110 76GP 62.20 21.38 16.46 0.00 PR-1 16.46 0.00
REM: N123 CO-45 40.82

CO-B10 -35.90

OA-70 40.82

0216 021622 1 97140 76GP 57.16 19.95 15.58 0.00 PR-1 15.58 0.00
CO-45 37.21

CO-B10 -32.84

OA-70 37.21

PT RESP 86.34 CLM STATUS 1 CLAIM TOTALS 305.96 105.47 86.34 0.00 219.62 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

PAGE: 56 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME DONOVAN, DOUGLAS HIC PJN811962900 ACNT 2231005A ICN 26220617572700580

1578569786 0215 021522 1 E0855 NU 115.08 115.08 115.08 0.00 PR-1 115.08 0.00
PT RESP 115.08 CLM STATUS 1 CLAIM TOTALS 115.08 115.08 115.08 0.00 0.00 0.00
BILL TYPE 121 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME DONOVAN, DOUGLAS HIC PJN811962900 ACNT 2230648A ICN 26220617625200580

1467460394 0217 021722 1 98943 32.28 15.55 15.55 0.00 PR-1 15.55 0.00

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CO-45 16.73

0217 021722 1 98941 AT 82.68 23.20 23.20 0.00 PR-1 23.20 0.00
CO-45 59.48

0217 021722 1 97110 76GP 62.20 19.66 19.66 0.00 PR-1 19.66 0.00
REM: N123 CO-45 42.54

0217 021722 1 97110 76GP 62.20 19.66 15.14 0.00 PR-1 15.14 0.00
REM: N123 CO-45 42.54

PI-97 -38.02

OA-70 42.54

0217 021722 1 97110 76GP 62.20 19.66 15.14 0.00 PR-1 15.14 0.00
REM: N123 CO-45 42.54

PI-97 -38.02

OA-70 42.54

0217 021722 1 97110 76GP 62.20 19.66 15.14 0.00 PR-1 15.14 0.00
REM: N123 CO-45 42.54

PI-97 -38.02

OA-70 42.54

PT RESP 103.83 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 103.83 0.00 259.93 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME DONOVAN, DOUGLAS HIC PJN811962900 ACNT 2230659A ICN 26220617809400580

1467460394 0216 021622 1 99213 25 189.64 56.39 56.39 0.00 PR-1 56.39 0.00
CO-45 133.25

0216 021622 1 98943 32.28 15.55 15.55 0.00 PR-1 15.55 0.00
CO-45 16.73

0216 021622 1 98941 AT 82.68 23.20 23.20 0.00 PR-1 23.20 0.00
CO-45 59.48

0216 021622 1 97110 76GP 62.20 19.66 19.66 0.00 PR-1 19.66 0.00
REM: N123 CO-45 42.54

0216 021622 1 97110 76GP 62.20 19.66 15.14 0.00 PR-1 15.14 0.00
REM: N123 CO-45 42.54

PI-97 -38.02

OA-70 42.54

0216 021622 1 97110 76GP 62.20 19.66 15.14 0.00 PR-1 15.14 0.00
REM: N123 CO-45 42.54

PAGE: 57 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

PI-97 -38.02

OA-70 42.54

0216 021622 1 97110 76GP 62.20 19.66 15.14 0.00 PR-1 15.14 0.00
REM: N123 CO-45 42.54

PI-97 -38.02

OA-70 42.54

PT RESP 160.22 CLM STATUS 1 CLAIM TOTALS 553.40 173.78 160.22 0.00 393.18 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME DONOVAN, DOUGLAS HIC PJN811962900 ACNT 2231004A ICN 26220618104000580

1578569786 0208 020822 1 L0637 NU 2,105.08 705.27 705.27 0.00 PR-1 705.27 0.00
CO-45 1,399.81

PT RESP 705.27 CLM STATUS 1 CLAIM TOTALS 2,105.08 705.27 705.27 0.00 1,399.81 0.00
BILL TYPE 121 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME BELL, JOHN HIC VVL810990255 ACNT 2218359A ICN 26220320473700580

1578569786 0106 010622 1 20553 130.56 60.92 60.92 0.00 PR-1 60.92 0.00
CO-45 69.64

0106 010622 1 J3490 2.50 0.10 0.10 0.00 PR-1 0.10 0.00
CO-45 2.40

PT RESP 61.02 CLM STATUS 1 CLAIM TOTALS 133.06 61.02 61.02 0.00 72.04 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME MOGASE, CATHERINE M HIC VVL817961393 ACNT 2219174A ICN 26220320580300580

1578569786 0110 011022 3 95851 59 142.50 34.66 34.66 0.00 PR-1 34.66 0.00
CO-45 107.84

0110 011022 1 20553 130.56 60.92 60.92 0.00 PR-1 60.92 0.00
CO-45 69.64

0110 011022 1 J3490 2.50 0.10 0.10 0.00 PR-1 0.10 0.00
CO-45 2.40

PT RESP 95.68 CLM STATUS 1 CLAIM TOTALS 275.56 95.68 95.68 0.00 179.88 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME BROWN, SHANTELL M HIC MYY810766536 ACNT 2228593A ICN 26220557981700580

1467460394 0214 021422 1 98943 32.28 0.00 0.00 PR-197 32.28 0.00
REM: M62

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0214 021422 1 98941 AT 82.68 0.00 0.00 PR-197 82.68 0.00
REM: M62

0214 021422 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0214 021422 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

PAGE: 58 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

0214 021422 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0214 021422 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

PT RESP 363.76 CLM STATUS 1 CLAIM TOTALS 363.76 0.00 0.00 0.00 363.76 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME STERN, CHRISTOPHER RHIC MYY815263615 ACNT 2228632A ICN 26220558041400580

1467460394 0214 021422 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0214 021422 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0214 021422 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0214 021422 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

PT RESP 248.80 CLM STATUS 1 CLAIM TOTALS 248.80 0.00 0.00 0.00 248.80 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME WILSON, YVETTE G HIC MYY817622789 ACNT 2226373A ICN 26220558111900580

1467460394 0210 021022 1 98943 32.28 0.00 0.00 PR-197 32.28 0.00
REM: M62

0210 021022 1 98941 AT 82.68 0.00 0.00 PR-197 82.68 0.00

REM: M62

0210 021022 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0210 021022 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0210 021022 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0210 021022 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

PT RESP 363.76 CLM STATUS 1 CLAIM TOTALS 363.76 0.00 0.00 0.00 363.76 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME GREENIDGE, CIRRON HIC MYY817773991 ACNT 2228664A ICN 26220558127000580

1467460394 0215 021522 1 98943 32.28 0.00 0.00 PR-197 32.28 0.00
REM: M62

0215 021522 1 98941 AT 82.68 0.00 0.00 PR-197 82.68 0.00

REM: M62

0215 021522 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

PAGE: 59 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

0215 021522 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0215 021522 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0215 021522 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

PT RESP 363.76 CLM STATUS 1 CLAIM TOTALS 363.76 0.00 0.00 0.00 363.76 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME BROWN, SHANTELL M HIC MYY810766536 ACNT 2226212A ICN 26220558405900580

1467460394 0210 021022 1 98943 32.28 0.00 0.00 PR-197 32.28 0.00

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REM: M62

0210 021022 1 98941 AT 82.68 0.00 0.00 PR-197 82.68 0.00

REM: M62

0210 021022 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0210 021022 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0210 021022 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0210 021022 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

PT RESP 363.76 CLM STATUS 1 CLAIM TOTALS 363.76 0.00 0.00 0.00 363.76 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME BROWN, SHANTELL M HIC MYY810766536 ACNT 2226226A ICN 26220558440100580

1467460394 0211 021122 1 98943 32.28 0.00 0.00 PR-197 32.28 0.00
REM: M62

0211 021122 1 98941 AT 82.68 0.00 0.00 PR-197 82.68 0.00

REM: M62

0211 021122 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0211 021122 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0211 021122 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

PT RESP 301.56 CLM STATUS 1 CLAIM TOTALS 301.56 0.00 0.00 0.00 301.56 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME GALLOWAY FRANC, MARGHIC MYY810678116 ACNT 2226312A ICN 26220558492200580

1467460394 0209 020922 1 98943 32.28 0.00 0.00 PR-197 32.28 0.00
REM: M62

PAGE: 60 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

0209 020922 1 98941 AT 82.68 0.00 0.00 PR-197 82.68 0.00
REM: M62

0209 020922 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0209 020922 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0209 020922 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0209 020922 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

PT RESP 363.76 CLM STATUS 1 CLAIM TOTALS 363.76 0.00 0.00 0.00 363.76 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME STERN, CHRISTOPHER RHIC MYY815263615 ACNT 2226342A ICN 26220558623500580

1467460394 0209 020922 1 98943 32.28 0.00 0.00 PR-197 32.28 0.00
REM: M62

0209 020922 1 98941 AT 82.68 0.00 0.00 PR-197 82.68 0.00

REM: M62

0209 020922 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0209 020922 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0209 020922 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0209 020922 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

PT RESP 363.76 CLM STATUS 1 CLAIM TOTALS 363.76 0.00 0.00 0.00 363.76 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME WILSON, YVETTE G HIC MYY817622789 ACNT 2226346A ICN 26220558691700580

1467460394 0209 020922 1 98943 32.28 0.00 0.00 PR-197 32.28 0.00
REM: M62

0209 020922 1 98941 AT 82.68 0.00 0.00 PR-197 82.68 0.00

REM: M62

0209 020922 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0209 020922 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0209 020922 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

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0209 020922 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

PAGE: 61 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

PT RESP 363.76 CLM STATUS 1 CLAIM TOTALS 363.76 0.00 0.00 0.00 363.76 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME WILSON, YVETTE G HIC MYY817622789 ACNT 2228637A ICN 26220558786700580

1467460394 0214 021422 1 98943 32.28 0.00 0.00 PR-197 32.28 0.00
REM: M62

0214 021422 1 98941 AT 82.68 0.00 0.00 PR-197 82.68 0.00

REM: M62

0214 021422 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0214 021422 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0214 021422 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

0214 021422 1 97110 76GP 62.20 0.00 0.00 PR-197 62.20 0.00
REM: M62 N123

PT RESP 363.76 CLM STATUS 1 CLAIM TOTALS 363.76 0.00 0.00 0.00 363.76 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME SCRUGGS, NANCY A HIC MYY810764611 ACNT 2218944B ICN 26220618421400580

1114551561 0107 010722 1 29530 RT 63.74 0.00 0.00 OA-18 63.74 0.00
0107 010722 1 98943 GY 32.28 0.00 0.00 OA-18 32.28 0.00
0107 010722 1 98941 AT 82.68 0.00 0.00 OA-18 48.76 0.00
OA-23 33.92

0107 010722 2 97110 GY76GP 124.40 0.00 0.00 OA-18 124.40 0.00
PT RESP CLM STATUS 2 CLAIM TOTALS 303.10 0.00 0.00 0.00 303.10 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME SCRUGGS, NANCY A HIC MYY810764611 ACNT 2218935B ICN 26220618421700580

1578569786 0105 010522 3 95851 142.50 0.00 0.00 OA-18 129.30 0.00
OA-23 13.20

PT RESP CLM STATUS 2 CLAIM TOTALS 142.50 0.00 0.00 0.00 142.50 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME SCRUGGS, NANCY A HIC MYY810764611 ACNT 2219037B ICN 26220618433800580

1376969998 0110 011022 1 29530 50 127.48 0.00 0.00 OA-18 127.48 0.00
0110 011022 1 98943 GY 32.28 0.00 0.00 OA-18 32.28 0.00
0110 011022 1 98941 AT 82.68 0.00 0.00 OA-18 48.76 0.00
OA-23 33.92

0110 011022 2 97110 GY76GP 124.40 0.00 0.00 OA-18 124.40 0.00
PT RESP CLM STATUS 2 CLAIM TOTALS 366.84 0.00 0.00 0.00 366.84 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

PAGE: 62 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME KENNY, THEODORE HIC MHT810447955 ACNT 2230894A ICN 26220617480100580

1467460394 0218 021822 1 98943 32.28 0.00 0.00 PR-27 32.28 0.00
0218 021822 1 98941 AT 82.68 0.00 0.00 PR-27 82.68 0.00
0218 021822 4 97110 76GP 248.80 0.00 0.00 PR-27 248.80 0.00
PT RESP 363.76 CLM STATUS 1 CLAIM TOTALS 363.76 0.00 0.00 0.00 363.76 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME KENNY, THEODORE HIC MHT810447955 ACNT 2230965A ICN 26220617566700580

1578569786 0218 021822 3 95851 59 142.50 0.00 0.00 PR-27 142.50 0.00
0218 021822 4 95851 59 190.00 0.00 0.00 PR-27 190.00 0.00
0218 021822 1 20553 130.56 0.00 0.00 PR-27 130.56 0.00
0218 021822 1 J3490 2.50 0.00 0.00 PR-27 2.50 0.00
PT RESP 465.56 CLM STATUS 1 CLAIM TOTALS 465.56 0.00 0.00 0.00 465.56 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________

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NAME KENNY, THEODORE HIC MHT810447955 ACNT 2230864A ICN 26220617634100580

1467460394 0216 021622 1 99213 25 189.64 0.00 0.00 PR-27 189.64 0.00
0216 021622 1 98943 32.28 0.00 0.00 PR-27 32.28 0.00
0216 021622 1 98941 AT 82.68 0.00 0.00 PR-27 82.68 0.00
0216 021622 4 97110 76GP 248.80 0.00 0.00 PR-27 248.80 0.00
PT RESP 553.40 CLM STATUS 1 CLAIM TOTALS 553.40 0.00 0.00 0.00 553.40 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME KENNY, THEODORE HIC MHT810447955 ACNT 2230964A ICN 26220618149900580

1578569786 0216 021622 1 20553 130.56 0.00 0.00 PR-27 130.56 0.00
0216 021622 1 J3490 2.50 0.00 0.00 PR-27 2.50 0.00
PT RESP 133.06 CLM STATUS 1 CLAIM TOTALS 133.06 0.00 0.00 0.00 133.06 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME BRUCE, THERESA HIC AHN811139781 ACNT 84948759 ICN 26210603240800580

1114551561 0208 020821 1 97140 59 -55.00 0.00 0.00 PR-3 -14.33 0.00
OA-70 -36.65

PI-97 32.63

CO-45 -36.65

0208 020821 1 97110 76GP -35.00 0.00 0.00 CO-45 -15.34 -19.66
REM: N123

0208 020821 1 97110 76GP -35.00 0.00 0.00 CO-45 -15.34 -15.14
REM: N123 OA-70 -15.34

PI-97 10.82

0208 020821 1 97110 76GP -35.00 0.00 0.00 PI-97 10.82 -15.14
REM: N123 OA-70 -15.34

CO-45 -15.34

PAGE: 63 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

0208 020821 1 97110 76GP -35.00 0.00 0.00 OA-70 -15.34 -15.14
REM: N123 PI-97 10.82

CO-45 -15.34

0208 020821 1 98943 -45.00 0.00 -0.99 CO-45 -29.45 -8.89

PR-3 -5.67

0208 020821 1 99213 25 -90.00 0.00 0.00 CO-96 -90.00 0.00

REM: M86

PT RESP -20.99 CLM STATUS 22 CLAIM TOTALS -330.00 0.00 0.00 -0.99 -255.04 -73.97
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -73.97

___________________________________________________________________________________________________________________________________
NAME BRUCE, THERESA HIC AHN811139781 ACNT 84948759 ICN 26210603240802580

1114551561 0208 020821 1 97140 59 55.00 18.35 0.00 0.00 PR-3 14.33 0.00
CO-45 36.65

PI-97 -32.63

OA-70 36.65

0208 020821 1 97110 76GP 35.00 19.66 0.00 0.00 PR-3 5.10 14.56
REM: N123 CO-45 15.34

0208 020821 1 97110 76GP 35.00 19.66 0.00 0.00 CO-45 15.34 15.14
REM: N123 PI-97 -10.82

OA-70 15.34

0208 020821 1 97110 76GP 35.00 19.66 0.00 0.00 CO-45 15.34 15.14
REM: N123 PI-97 -10.82

OA-70 15.34

0208 020821 1 97110 76GP 35.00 19.66 0.00 0.00 CO-45 15.34 15.14
REM: N123 PI-97 -10.82

OA-70 15.34

0208 020821 1 98943 45.00 15.55 0.00 1.56 PR-2 1.56 13.99
CO-45 29.45

0208 020821 1 99213 25 90.00 0.00 0.00 CO-96 90.00 0.00

REM: M86

PT RESP 20.99 CLM STATUS 1 CLAIM TOTALS 330.00 112.54 0.00 1.56 254.47 73.97
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 73.97

___________________________________________________________________________________________________________________________________
NAME BRUCE, THERESA HIC AHN811139781 ACNT 1869855C ICN 26211136466704580

1376969998 0401 040121 1 98943 -32.28 0.00 -1.56 CO-45 -16.73 -13.99
0401 040121 1 98941 -82.68 0.00 -0.32 CO-45 -59.48 -2.88
PR-3 -20.00

0401 040121 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -19.66

REM: N123

0401 040121 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -15.14

REM: N123 OA-70 -42.54

PI-97 38.02

PAGE: 64 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

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GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

0401 040121 1 97110 76 -62.20 0.00 0.00 PI-97 38.02 -15.14
REM: N123 OA-70 -42.54

CO-45 -42.54

0401 040121 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -15.14

REM: N123 OA-70 -42.54

PI-97 38.02

PT RESP -21.88 CLM STATUS 22 CLAIM TOTALS -363.76 0.00 0.00 -1.88 -279.93 -81.95
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -81.95

___________________________________________________________________________________________________________________________________
NAME BRUCE, THERESA HIC AHN811139781 ACNT 1869855C ICN 26211136466706580

1376969998 0401 040121 1 98943 32.28 15.55 0.00 1.56 PR-2 1.56 13.99
CO-45 16.73

0401 040121 1 98941 82.68 23.20 0.00 2.32 PR-2 2.32 20.88
CO-45 59.48

0401 040121 1 97110 76 62.20 19.66 0.00 0.00 PR-3 18.00 1.66
REM: N123 CO-45 42.54

0401 040121 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0401 040121 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0401 040121 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP 21.88 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 3.88 277.93 81.95
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 81.95

___________________________________________________________________________________________________________________________________
NAME BRUCE, THERESA HIC AHN811139781 ACNT 1877957C ICN 26211137069604580

1730744475 0408 040821 1 98943 -32.28 0.00 -1.29 CO-45 -19.06 -11.65
PR-3 -0.28

0408 040821 1 98941 -82.68 0.00 0.00 CO-45 -62.96 0.00

PR-3 -19.72

0408 040821 1 97110 76 -62.20 0.00 0.00 CO-45 -45.49 -16.71

REM: N123

0408 040821 1 97110 76 -62.20 0.00 0.00 CO-45 -45.49 -12.87

REM: N123 OA-70 -45.49

PI-97 41.65

0408 040821 1 97110 76 -62.20 0.00 0.00 PI-97 41.65 -12.87

REM: N123 OA-70 -45.49

CO-45 -45.49

0408 040821 1 97110 76 -62.20 0.00 0.00 CO-45 -45.49 -12.87

PAGE: 65 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

REM: N123 OA-70 -45.49

PI-97 41.65

PT RESP -21.29 CLM STATUS 22 CLAIM TOTALS -363.76 0.00 0.00 -1.29 -295.50 -66.97
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -66.97

___________________________________________________________________________________________________________________________________
NAME BRUCE, THERESA HIC AHN811139781 ACNT 1877957C ICN 26211137069606580

1730744475 0408 040821 1 98943 32.28 13.22 0.00 1.32 PR-2 1.32 11.90
CO-45 19.06

0408 040821 1 98941 82.68 19.72 0.00 1.97 PR-2 1.97 17.75
CO-45 62.96

0408 040821 1 97110 76 62.20 16.71 0.00 0.00 PR-3 16.71 0.00
REM: N123 CO-45 45.49

0408 040821 1 97110 76 62.20 16.71 0.00 0.00 PR-3 1.29 11.58
REM: N123 CO-45 45.49

PI-97 -41.65

OA-70 45.49

0408 040821 1 97110 76 62.20 16.71 0.00 0.00 CO-45 45.49 12.87
REM: N123 PI-97 -41.65

OA-70 45.49

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0408 040821 1 97110 76 62.20 16.71 0.00 0.00 CO-45 45.49 12.87
REM: N123 PI-97 -41.65

OA-70 45.49

PT RESP 21.29 CLM STATUS 1 CLAIM TOTALS 363.76 99.78 0.00 3.29 293.50 66.97
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 66.97

___________________________________________________________________________________________________________________________________
NAME BRUCE, THERESA HIC AHN811139781 ACNT 1903492C ICN 26211197254104580

1114551561 0414 041421 1 98943 -32.28 0.00 -1.56 CO-45 -16.73 -13.99
0414 041421 1 98941 -82.68 0.00 -0.32 CO-45 -59.48 -2.88
PR-3 -20.00

0414 041421 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -19.66

REM: N123

0414 041421 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -15.14

REM: N123 OA-70 -42.54

PI-97 38.02

0414 041421 1 97110 76 -62.20 0.00 0.00 PI-97 38.02 -15.14

REM: N123 OA-70 -42.54

CO-45 -42.54

0414 041421 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -15.14

REM: N123 OA-70 -42.54

PI-97 38.02

PT RESP -21.88 CLM STATUS 22 CLAIM TOTALS -363.76 0.00 0.00 -1.88 -279.93 -81.95
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -81.95

PAGE: 66 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

___________________________________________________________________________________________________________________________________
NAME BRUCE, THERESA HIC AHN811139781 ACNT 1903492C ICN 26211197254106580

1114551561 0414 041421 1 98943 32.28 15.55 0.00 1.56 PR-2 1.56 13.99
CO-45 16.73

0414 041421 1 98941 82.68 23.20 0.00 2.32 PR-2 2.32 20.88
CO-45 59.48

0414 041421 1 97110 76 62.20 19.66 0.00 0.00 PR-3 18.00 1.66
REM: N123 CO-45 42.54

0414 041421 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0414 041421 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0414 041421 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP 21.88 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 3.88 277.93 81.95
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 81.95

___________________________________________________________________________________________________________________________________
NAME BRUCE, THERESA HIC AHN811139781 ACNT 2021936C ICN 26211347716504580

1114551561 0503 050321 1 98943 -32.28 0.00 -1.56 CO-45 -16.73 -13.99
0503 050321 1 98941 -82.68 0.00 -0.32 CO-45 -59.48 -2.88
PR-3 -20.00

0503 050321 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -19.66

REM: N123

0503 050321 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -15.14

REM: N123 OA-70 -42.54

PI-97 38.02

0503 050321 1 97110 76 -62.20 0.00 0.00 PI-97 38.02 -15.14

REM: N123 OA-70 -42.54

CO-45 -42.54

0503 050321 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -15.14

REM: N123 OA-70 -42.54

PI-97 38.02

PT RESP -21.88 CLM STATUS 22 CLAIM TOTALS -363.76 0.00 0.00 -1.88 -279.93 -81.95
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -81.95

___________________________________________________________________________________________________________________________________
NAME BRUCE, THERESA HIC AHN811139781 ACNT 2021936C ICN 26211347716506580

1114551561 0503 050321 1 98943 32.28 15.55 0.00 1.56 PR-2 1.56 13.99
CO-45 16.73

0503 050321 1 98941 82.68 23.20 0.00 2.32 PR-2 2.32 20.88
CO-45 59.48

PAGE: 67 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

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WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

0503 050321 1 97110 76 62.20 19.66 0.00 0.00 PR-3 18.00 1.66
REM: N123 CO-45 42.54

0503 050321 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0503 050321 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0503 050321 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP 21.88 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 3.88 277.93 81.95
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 81.95

___________________________________________________________________________________________________________________________________
NAME BRUCE, THERESA HIC AHN811139781 ACNT 2022329C ICN 26211348456004580

1114551561 0505 050521 1 98943 -32.28 0.00 -1.56 CO-45 -16.73 -13.99
0505 050521 1 98941 -82.68 0.00 -0.32 CO-45 -59.48 -2.88
PR-3 -20.00

0505 050521 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -19.66

REM: N123

0505 050521 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -15.14

REM: N123 OA-70 -42.54

PI-97 38.02

0505 050521 1 97110 76 -62.20 0.00 0.00 PI-97 38.02 -15.14

REM: N123 OA-70 -42.54

CO-45 -42.54

0505 050521 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -15.14

REM: N123 OA-70 -42.54

PI-97 38.02

PT RESP -21.88 CLM STATUS 22 CLAIM TOTALS -363.76 0.00 0.00 -1.88 -279.93 -81.95
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -81.95

___________________________________________________________________________________________________________________________________
NAME BRUCE, THERESA HIC AHN811139781 ACNT 2022329C ICN 26211348456006580

1114551561 0505 050521 1 98943 32.28 15.55 0.00 1.56 PR-2 1.56 13.99
CO-45 16.73

0505 050521 1 98941 82.68 23.20 0.00 2.32 PR-2 2.32 20.88
CO-45 59.48

0505 050521 1 97110 76 62.20 19.66 0.00 0.00 PR-3 18.00 1.66
REM: N123 CO-45 42.54

0505 050521 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PAGE: 68 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

0505 050521 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0505 050521 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP 21.88 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 3.88 277.93 81.95
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 81.95

___________________________________________________________________________________________________________________________________
NAME JAMESON, ASHLEY HIC AHN818989505 ACNT 1894599C ICN 27211160186704580

1376969998 0408 040821 1 98943 -32.28 0.00 -1.56 CO-45 -16.73 -13.99
0408 040821 1 98941 -82.68 0.00 -0.32 CO-45 -59.48 -2.88
PR-3 -20.00

0408 040821 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -19.66

REM: N123

0408 040821 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -15.14

REM: N123 OA-70 -42.54

PI-97 38.02

0408 040821 1 97110 76 -62.20 0.00 0.00 PI-97 38.02 -15.14

REM: N123 OA-70 -42.54

CO-45 -42.54

0408 040821 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -15.14

REM: N123 OA-70 -42.54

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PI-97 38.02

PT RESP -21.88 CLM STATUS 22 CLAIM TOTALS -363.76 0.00 0.00 -1.88 -279.93 -81.95
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -81.95

___________________________________________________________________________________________________________________________________
NAME JAMESON, ASHLEY HIC AHN818989505 ACNT 1894599C ICN 27211160186706580

1376969998 0408 040821 1 98943 32.28 15.55 0.00 1.56 PR-2 1.56 13.99
CO-45 16.73

0408 040821 1 98941 82.68 23.20 0.00 2.32 PR-2 2.32 20.88
CO-45 59.48

0408 040821 1 97110 76 62.20 19.66 0.00 0.00 PR-3 18.00 1.66
REM: N123 CO-45 42.54

0408 040821 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0408 040821 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0408 040821 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

PAGE: 69 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

_________________________ CLAIM CONTINUED FROM PREVIOUS PAGE ____________________________________________________________________

OA-70 42.54

PT RESP 21.88 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 3.88 277.93 81.95
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 81.95

___________________________________________________________________________________________________________________________________
NAME BRUCE, THERESA HIC AHN811139781 ACNT 1933127C ICN 27211233926304580

1114551561 0421 042121 1 98943 -32.28 0.00 -1.56 CO-45 -16.73 -13.99
0421 042121 1 98941 -82.68 0.00 -0.32 CO-45 -59.48 -2.88
PR-3 -20.00

0421 042121 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -19.66

REM: N123

0421 042121 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -15.14

REM: N123 OA-70 -42.54

PI-97 38.02

0421 042121 1 97110 76 -62.20 0.00 0.00 PI-97 38.02 -15.14

REM: N123 OA-70 -42.54

CO-45 -42.54

0421 042121 1 97110 76 -62.20 0.00 0.00 CO-45 -42.54 -15.14

REM: N123 OA-70 -42.54

PI-97 38.02

PT RESP -21.88 CLM STATUS 22 CLAIM TOTALS -363.76 0.00 0.00 -1.88 -279.93 -81.95
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -81.95

___________________________________________________________________________________________________________________________________
NAME BRUCE, THERESA HIC AHN811139781 ACNT 1933127C ICN 27211233926306580

1114551561 0421 042121 1 98943 32.28 15.55 0.00 1.56 PR-2 1.56 13.99
CO-45 16.73

0421 042121 1 98941 82.68 23.20 0.00 2.32 PR-2 2.32 20.88
CO-45 59.48

0421 042121 1 97110 76 62.20 19.66 0.00 0.00 PR-3 18.00 1.66
REM: N123 CO-45 42.54

0421 042121 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0421 042121 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

0421 042121 1 97110 76 62.20 19.66 0.00 0.00 CO-45 42.54 15.14
REM: N123 PI-97 -38.02

OA-70 42.54

PT RESP 21.88 CLM STATUS 1 CLAIM TOTALS 363.76 117.39 0.00 3.88 277.93 81.95
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 81.95

___________________________________________________________________________________________________________________________________
TOTALS: # OF BILLED ALLOWED DEDUCT COINS TOTAL PROV PD PROV CHECK

PAGE: 70 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

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REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC AMT PROV PD

CLAIMS AMT AMT AMT AMT RC-AMT AMT ADJ AMT AMT

209 52,753.78 19,822.29 1,577.39 104.66 39,794.17 11,277.56 -.11 11,218.01

___________________________________________________________________________________________________________________________________
PROVIDER ADJ DETAILS: PLB REASON CODE PLB ADJUSTMENT IDENTIFIER AMOUNT

WO 2056008160 26210256344101580 104458988 2.00

WO 2056008170 26210281527801580 104458988 2.00

WO 2056008180 26210284813701580 104458988 2.00

WO 2056008190 26210362993001580 104458988 2.00

WO 2056008200 26210364443501580 104458988 2.00

WO 2056008210 26210396233101580 104458988 2.00

WO 2056008220 26210396351901580 104458988 1.66

WO 2056008230 26211468502801580 2066770A 2.00

WO 2056008240 26211468904301580 2077453A 2.00

WO 2056008250 26211525431801580 2092298A 2.00

WO 2056008260 26211549639603580 2100282B 2.00

WO 2056008270 26211557557003580 2105694B 2.00

WO 2056008280 26211617187203580 2121689B 2.00

WO 2056008290 26211659369603580 2134363B 2.00

WO 2056008300 26211667211603580 2134377B 2.00

WO 2056008310 26211687892503580 2160448B 2.00

WO 2056008320 26211687948003580 2159653B 2.00

WO 2056008330 26211817367003580 2183484B 2.00

WO 2056008340 26211828020103580 2183453B 2.00

WO 2056008350 26211897645401580 2184573A 2.00

WO 2056008360 26212577564101580 2192551B 2.00

WO 2056008370 26212878190501580 2202078A 2.00

WO 2056008380 26212878843101580 2202077A 2.00

WO 2056008390 26212998018701580 2203191A 2.00

WO 2056008400 26212998101301580 2203170A 2.00

WO 2056008410 26212998464101580 2203404A 2.00

WO 2056008420 26212998500001580 2203348A 2.00

WO 2056008430 26212998696201580 2203178A 2.00

WO 2056008440 26212998745101580 2203275A 2.00

WO 2056008450 27211650012403580 2134719B 2.00

L6 -0.11

GLOSSARY: CLAIM ADJUSTMENT REASON CODES

___________________________________________________________________________________________________________________________________
3 Co-payment Amount

45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement

2 Coinsurance Amount

97 The benefit for this service is included in the payment/allowance for another

PAGE: 71 CLINIC # 738490 (C980 ) ADVANCED MD REPORT NO: CPX425.01

GHMSI PROVIDER REMITTANCE DATA REPORT DATE: 03/05/2022
10455 MILL RUN CIRCLE MARYLAND BLUE SHIELD 2419 PRINT DATE: 03/05/2022
OWINGS MILLS, MD 211170000 CARRIER RUN DATE: 03/09/2022 PROVIDER: 1740729482815149807 PRINT TIME: 15:07:37

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 03/09/2022

3914 HICKORY AVENUE CHECK/EFT #: 733440308

BALTIMORE, MD 212111834

GLOSSARY: CLAIM ADJUSTMENT REASON CODES

___________________________________________________________________________________________________________________________________
service/procedure that has already been adjudicated

70 Cost outlier - Adjustment to compensate for additional costs.

197 Precertification/authorization/notification absent.

23 The impact of prior payer(s) adjudication including payments and/or adjustments

18 Exact duplicate claim/service (Use only with Group Code OA except where state workers'

compensation regulations requires CO)

198 Precertification/authorization exceeded.

1 Deductible Amount

B10 Allowed amount has been reduced because a component of the basic procedure/test was paid

167 This (these) diagnosis(es) is (are) not covered

119 Benefit maximum for this time period or occurrence has been reached.

27 Expenses incurred after coverage terminated.

96 Non-covered charge(s)

GLOSSARY: REMITTANCE ADVICE REMARK CODES

___________________________________________________________________________________________________________________________________
N123 Alert: This is a split service and represents a portion of the units from the originally submitted service.

M62 Missing/incomplete/invalid treatment authorization code.

N54 Claim information is inconsistent with pre-certified/authorized services.

M86 Service denied because payment already made for same/similar procedure within set time frame.

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