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htm

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

AETNA PROVIDER REMITTANCE DATA REPORT DATE: 09/16/2021

151 FARMINGTON AVENUE AETNA 6400 PRINT DATE: 09/16/2021
HARTFORD, CT 06156 CARRIER RUN DATE: 09/15/2021 PROVIDER: 1740729482815149807 PRINT TIME: 06:07:09

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 09/15/2021

3914 HICKORY AVE CHECK/EFT #: FC9212590003288

BALTIMORE, MD 212111834

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

___________________________________________________________________________________________________________________________________
NAME LITTLE, PEARLIE HIC MEBMML5Q ACNT 2100569A ICN 210813C546860000

1730744475 0525 052521 1 20553 -130.56 0.00 0.00 CO-55 -130.56 0.00
REM: N623

0525 052521 1 J3490 -2.50 0.00 0.00 CO-45 -1.00 -1.50

PT RESP CLM STATUS 22 CLAIM TOTALS -133.06 0.00 0.00 0.00 -131.56 -1.50
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -1.50

___________________________________________________________________________________________________________________________________
NAME LITTLE, PEARLIE HIC MEBMML5Q ACNT 2100569A ICN 210913C546860000

1730744475 0525 052521 1 20553 130.56 0.00 0.00 CO-55 130.56 0.00
REM: N623

0525 052521 1 J3490 2.50 1.50 0.00 0.00 CO-45 1.00 1.50
PT RESP CLM STATUS 1 CLAIM TOTALS 133.06 1.50 0.00 0.00 131.56 1.50
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 1.50

___________________________________________________________________________________________________________________________________
TOTALS: # OF BILLED ALLOWED DEDUCT COINS TOTAL PROV PD PROV CHECK

CLAIMS AMT AMT AMT AMT RC-AMT AMT ADJ AMT AMT

2 .00 1.50 .00 .00 .00 .00 .00 .00

GLOSSARY: CLAIM ADJUSTMENT REASON CODES

___________________________________________________________________________________________________________________________________
55 Procedure/treatment/drug is deemed experimental/investigational by the payer

45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement

GLOSSARY: REMITTANCE ADVICE REMARK CODES

___________________________________________________________________________________________________________________________________
N623 Not covered when deemed unscientific/unproven/outmoded/experimental/excessive/inappropriate.

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

AETNA PROVIDER REMITTANCE DATA REPORT DATE: 09/16/2021
151 FARMINGTON AVENUE AETNA 6400 PRINT DATE: 09/16/2021
HARTFORD, CT 06156 CARRIER RUN DATE: 09/16/2021 PROVIDER: 1740729482815149807 PRINT TIME: 06:07:09

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 09/16/2021

3914 HICKORY AVE CHECK/EFT #: 921259000098066

BALTIMORE, MD 212111834

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

___________________________________________________________________________________________________________________________________
NAME FREDERICK, RONELL HIC 1C63VX8EQ17 ACNT 2195268A ICN EWY1SD42F0000

1740729482 0823 082321 1 95851 59 142.50 63.60 0.00 0.00 OA-23 78.90 0.00
REM: N19 PR-97 63.60

0823 082321 1 95851 GY76 190.00 190.00 0.00 -190.00 OA-23 190.00 0.00
REM: N19

PR-97 190.00

PT RESP 63.60 CLM STATUS 2 CLAIM TOTALS 332.50 253.60 0.00 -190.00 522.50 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME OLAH, DALLAS HIC W264914483 ACNT 1891318B ICN E536QJ91W0000

1740729482 0405 040521 1 99213 25 -189.64 0.00 0.00 CO-45 -130.80 -18.84
PR-3 -40.00

0405 040521 1 20611 LT -208.22 0.00 0.00 CO-55 -208.22 0.00

REM: N623

0405 040521 1 J7325 -21.34 0.00 0.00 CO-153 -21.34 0.00

PT RESP -40.00 CLM STATUS 22 CLAIM TOTALS -419.20 0.00 0.00 0.00 -400.36 -18.84
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET -18.84

___________________________________________________________________________________________________________________________________
NAME OLAH, DALLAS HIC W264914483 ACNT 1891318B ICN E536QJ91W0001

1740729482 0405 040521 1 99213 25 189.64 58.84 0.00 0.00 CO-45 130.80 18.84
PR-3 40.00

0405 040521 1 20611 LT 208.22 90.33 0.00 0.00 CO-55 208.22 0.00
REM: N623

0405 040521 1 J7325 21.34 21.34 0.00 0.00 PR-119 21.34 0.00
REM: N130

PT RESP 61.34 CLM STATUS 1 CLAIM TOTALS 419.20 170.51 0.00 0.00 400.36 18.84
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 18.84

___________________________________________________________________________________________________________________________________
NAME FREDERICK, RONELL HIC 1C63VX8EQ17 ACNT 2195425A ICN EX36SCHBY0000

1740729482 0819 081921 1 29530 50 127.48 49.69 0.00 -49.69 OA-23 127.48 0.00
PR-3 49.69

PT RESP 0.00 CLM STATUS 2 CLAIM TOTALS 127.48 49.69 0.00 -49.69 177.17 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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TOTALS: # OF BILLED ALLOWED DEDUCT COINS TOTAL PROV PD PROV CHECK

CLAIMS AMT AMT AMT AMT RC-AMT AMT ADJ AMT AMT

4 459.98 473.80 .00 -239.69 699.67 .00 .00 .00

___________________________________________________________________________________________________________________________________
PROVIDER ADJ DETAILS: PLB REASON CODE PLB ADJUSTMENT IDENTIFIER AMOUNT

FB 921252000125173 57.23

FB 921259000098066 -57.23

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

AETNA PROVIDER REMITTANCE DATA REPORT DATE: 09/16/2021
151 FARMINGTON AVENUE AETNA 6400 PRINT DATE: 09/16/2021
HARTFORD, CT 06156 CARRIER RUN DATE: 09/16/2021 PROVIDER: 1740729482815149807 PRINT TIME: 06:07:09

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 09/16/2021

3914 HICKORY AVE CHECK/EFT #: 921259000098066

BALTIMORE, MD 212111834

GLOSSARY: CLAIM ADJUSTMENT REASON CODES

___________________________________________________________________________________________________________________________________
23 The impact of prior payer(s) adjudication including payments and/or adjustments

97 The benefit for this service is included in the payment/allowance for another

service/procedure that has already been adjudicated

2 Coinsurance Amount

45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement

3 Co-payment Amount

55 Procedure/treatment/drug is deemed experimental/investigational by the payer

153 Payer deems the information submitted does not support this dosage.

119 Benefit maximum for this time period or occurrence has been reached.

GLOSSARY: REMITTANCE ADVICE REMARK CODES

___________________________________________________________________________________________________________________________________
N19 Procedure code incidental to primary procedure.

N623 Not covered when deemed unscientific/unproven/outmoded/experimental/excessive/inappropriate.

N130 Consult plan benefit documents/guidelines for information about restrictions for this service.

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

AETNA PROVIDER REMITTANCE DATA REPORT DATE: 09/16/2021
151 FARMINGTON AVENUE AETNA 6400 PRINT DATE: 09/16/2021
HARTFORD, CT 06156 CARRIER RUN DATE: 09/16/2021 PROVIDER: 1740729482815149807 PRINT TIME: 06:07:09

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 09/16/2021

3914 HICKORY AVE CHECK/EFT #: 921259000098080

BALTIMORE, MD 212111834

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

___________________________________________________________________________________________________________________________________
NAME MARONICK, THOMAS HIC W248735410 ACNT 2193883A ICN EFPCTJ2FB0000

1740729482 0818 081821 1 97110 76GP 62.20 22.80 0.00 0.00 CO-45 39.40 21.68
REM: N123 PR-3 1.12

0818 081821 1 97110 76GP 62.20 17.56 0.00 0.00 CO-59 44.64 17.56
REM: N123

0818 081821 1 98943 32.28 17.71 0.00 0.00 CO-45 14.57 0.00
PR-3 17.71

0818 081821 1 98941 AT 82.68 26.17 0.00 0.00 CO-45 56.51 0.00
PR-3 26.17

PT RESP 45.00 CLM STATUS 1 CLAIM TOTALS 239.36 84.24 0.00 0.00 200.12 39.24
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 39.24

___________________________________________________________________________________________________________________________________
NAME MARONICK, THOMAS HIC W248735410 ACNT 1879216C ICN E2PCSB61H0000

1740729482 0406 040621 1 98943 32.28 32.28 0.00 0.00 CO-151 32.28 0.00
REM: N362

0406 040621 1 98941 82.68 82.68 0.00 0.00 CO-151 82.68 0.00
REM: N362

0406 040621 1 97110 76 248.80 70.23 0.00 0.00 CO-151 248.80 0.00
0406 040621 1 73560 LT 72.12 72.12 0.00 0.00 CO-151 72.12 0.00
REM: N362

PT RESP CLM STATUS 1 CLAIM TOTALS 435.88 257.31 0.00 0.00 435.88 0.00
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME ROSS, LASHAWNDA HIC W263511528 ACNT 1879640C ICN EQJMTSTVZ0000

1740729482 0326 032621 1 95851 59 142.50 142.50 0.00 0.00 CO-97 142.50 0.00
REM: N19

0326 032621 1 95851 76 190.00 190.00 0.00 0.00 CO-97 190.00 0.00
REM: N19

0326 032621 1 20553 130.56 25.27 0.00 0.00 CO-18 130.56 0.00
REM: N702

0326 032621 1 J3490 2.50 1.25 0.00 0.00 CO-18 2.50 0.00
REM: N702

PT RESP CLM STATUS 1 CLAIM TOTALS 465.56 359.02 0.00 0.00 465.56 0.00
BILL TYPE 117 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
NAME MARONICK, THOMAS HIC W248735410 ACNT 2197125A ICN ERWZTSHL50000

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1740729482 0907 090721 1 20553 130.56 50.53 0.000.00 CO-45 80.03 5.53
PR-3 45.00

0907 090721 1 J3490 2.50 1.25 0.00 0.00 CO-45 1.25 1.25
PT RESP 45.00 CLM STATUS 1 CLAIM TOTALS 133.06 51.78 0.00 0.00 126.28 6.78
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 6.78

___________________________________________________________________________________________________________________________________

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

AETNA PROVIDER REMITTANCE DATA REPORT DATE: 09/16/2021
151 FARMINGTON AVENUE AETNA 6400 PRINT DATE: 09/16/2021
HARTFORD, CT 06156 CARRIER RUN DATE: 09/16/2021 PROVIDER: 1740729482815149807 PRINT TIME: 06:07:09

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 09/16/2021

3914 HICKORY AVE CHECK/EFT #: 921259000098080

BALTIMORE, MD 212111834

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

___________________________________________________________________________________________________________________________________
NAME BRISON, LONDON HIC W264936501 ACNT 1891877C ICN E1ACSD5BV0000

1740729482 0406 040621 1 E0855 BP 115.08 20.65 0.00 0.00 CO-45 94.43 20.65
PT RESP CLM STATUS 1 CLAIM TOTALS 115.08 20.65 0.00 0.00 94.43 20.65
BILL TYPE 127 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 20.65

___________________________________________________________________________________________________________________________________
NAME ROSS, LASHAWNDA HIC W263511528 ACNT 1871230C ICN E136SBJZD0000

1740729482 0323 032321 1 E0855 BP 115.08 20.65 0.00 4.13 CO-45 94.43 16.52
PT RESP 4.13 CLM STATUS 1 CLAIM TOTALS 115.08 20.65 0.00 4.13 94.43 16.52
BILL TYPE 127 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 16.52

___________________________________________________________________________________________________________________________________
NAME BROWN, MICHAEL C HIC W245167797 ACNT 1879543A ICN PWY1R85D60000

1740729482 0405 040521 1 99213 25 1,896.40 1,896.40 0.00 0.00 OA-193 1,896.40 0.00
REM: N1

0405 040521 1 20553 1,305.60 1,305.60 0.00 0.00 OA-193 1,305.60 0.00
REM: N1

0405 040521 1 J3490 25.00 25.00 0.00 0.00 OA-193 25.00 0.00
REM: N1

PT RESP CLM STATUS 1 CLAIM TOTALS 3,227.00 3,227.00 0.00 0.00 3,227.00 0.00
BILL TYPE 111 DRG CD ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00

___________________________________________________________________________________________________________________________________
TOTALS: # OF BILLED ALLOWED DEDUCT COINS TOTAL PROV PD PROV CHECK

CLAIMS AMT AMT AMT AMT RC-AMT AMT ADJ AMT AMT

7 4,731.02 4,020.65 .00 4.13 4,643.70 83.19 .00 .00

___________________________________________________________________________________________________________________________________
PROVIDER ADJ DETAILS: PLB REASON CODE PLB ADJUSTMENT IDENTIFIER AMOUNT

FB 921253000025092 328.44

WO ERFCQ8HPT0000-1872434A-2021-03-26 83.19

CS ERFCQ8HPT0000-1872434A-2021-03-26 -83.19

FB 921259000098080 -245.25

GLOSSARY: CLAIM ADJUSTMENT REASON CODES

___________________________________________________________________________________________________________________________________
45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement

3 Co-payment Amount

59 Processed based on multiple or concurrent procedure rules

151 Payment adjusted because the payer deems the information submitted does not support this

many/frequency of services.

97 The benefit for this service is included in the payment/allowance for another

service/procedure that has already been adjudicated

18 Exact duplicate claim/service (Use only with Group Code OA except where state workers'

compensation regulations requires CO)

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

AETNA PROVIDER REMITTANCE DATA REPORT DATE: 09/16/2021
151 FARMINGTON AVENUE AETNA 6400 PRINT DATE: 09/16/2021
HARTFORD, CT 06156 CARRIER RUN DATE: 09/16/2021 PROVIDER: 1740729482815149807 PRINT TIME: 06:07:09

REMITTANCE NOTICE

WHOLE BODY HEALTHCARE LLC DATE: 09/16/2021

3914 HICKORY AVE CHECK/EFT #: 921259000098080

BALTIMORE, MD 212111834

GLOSSARY: CLAIM ADJUSTMENT REASON CODES

___________________________________________________________________________________________________________________________________
2 Coinsurance Amount

193 Original payment decision is being maintained

GLOSSARY: REMITTANCE ADVICE REMARK CODES

___________________________________________________________________________________________________________________________________
N123 Alert: This is a split service and represents a portion of the units from the originally submitted service.

N362 The number of Days or Units of Service exceeds our acceptable maximum.

N19 Procedure code incidental to primary procedure.

N702 Decision based on review of previously adjudicated claims or for claims in process for the same/similar type of services.

N1 Alert: You may appeal this decision in writing within the required time limits following receipt of this notice by following
the instructions included in your contract, plan benefit documents or jurisdiction statutes.

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