Professional Documents
Culture Documents
RECOVERED AMOUNT
MEMBER ID: 4501507828 INTEREST AMOUNT: $0.00 PCP NUMBER: 003224073002 REMIT DETAIL: Professional Claim PRODUCT DESC.: PA Medicaid Healthy Plus
SERVICING PROV NPI: 1477671345 SERVICING PROV NM: NORTHSHORE CLINICAL LAB PCP NAME: PARGOLA, EILEEN F. w/Copay and Limits
CARRIER ID:
DATE(S) OF DESCRIPTION OF SERVICE UNITS BILLED AMT DISALLOW ALLOWED AMT DEDUCT AMT COPAY/COINS COB PMT AMT WITHHOLD PAID TO PATIENT RESP AUTH# RMK CD GRP CD/
SERVICE AMT AMT AMT PROVIDER AMT RSN CD
AMT
12/20/21 - billing code G2023 POS/ Bill Type 1 $35.00 $25.00 $10.00 $0.00 $0.00 $10.00 $0.00 CO45
12/20/21 81
12/20/21 - billing code U0003 POS/ Bill Type 1 $135.00 $55.00 $80.00 $0.00 $0.00 $80.00 $0.00 CO45
12/20/21 81
12/20/21 - billing code U0005 POS/ Bill Type 1 $35.00 $35.00 $0.00 $0.00 $0.00 $0.00 N425 CO96,
12/20/21 81 CO45
CLAIM NUMBER: 22E364968500 $205.00 $115.00 $90.00 $0.00 $0.00 $90.00 $0.00 N425
SUBTOTAL:
SUBSCRIBER ID: 118973917 SUBSCRIBER NAME: DESTINY L WASHINGTON PROMPT PAY DISC: $0.00 CLAIM NUMBER: 22E385636000 PATIENT ACCOUNT: WASDE038-7405037
MEMBER ID: 4501507828 INTEREST AMOUNT: $0.00 PCP NUMBER: 003224073002 REMIT DETAIL: Professional Claim PRODUCT DESC.: PA Medicaid Healthy Plus
SERVICING PROV NPI: 1477671345 SERVICING PROV NM: NORTHSHORE CLINICAL LAB PCP NAME: PARGOLA, EILEEN F. w/Copay and Limits
CARRIER ID:
DATE(S) OF DESCRIPTION OF SERVICE UNITS BILLED AMT DISALLOW ALLOWED AMT DEDUCT AMT COPAY/COINS COB PMT AMT WITHHOLD PAID TO PATIENT RESP AUTH# RMK CD GRP CD/
AMT
12/20/21 - billing code 87811 POS/ Bill Type 1 $60.00 $48.49 $11.51 $0.00 $0.00 $11.51 $0.00 CO45
12/20/21 81
CLAIM NUMBER: 22E385636000 $60.00 $48.49 $11.51 $0.00 $0.00 $11.51 $0.00
SUBTOTAL:
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STD-PRA
PROVIDER
REMITTANCE ADVICE
Pennsylvania
PROVIDER TOTALS
SERVICE PROVIDER ID BILLED DISALLOW CONSIDERED ALLOWED AMT DEDUCT AMT COPAY/COINS COB PMT AMT WITHHOLD PAID TO PATIENT RESP INTEREST PROMPT PAY
AMT
001329064002 $265.00 $163.49 $0.00 $101.51 $0.00 $0.00 $0.00 $0.00 $101.51 $0.00 $0.00 $0.00
PAYEE TOTALS
PAYEE ID BILLED DISALLOW DISCOUNT ALLOWED AMT DEDUCT AMT COPAY/COINS COB PMT AMT WITHHOLD PAID TO PATIENT RESP INTEREST PROMPT PAY
AMT
001329064502 $265.00 $163.49 $0.00 $101.51 $0.00 $0.00 $0.00 $0.00 $101.51 $0.00 $0.00 $0.00
REMARKS
CO45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
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STD-PRA
PROVIDER
REMITTANCE ADVICE
Pennsylvania
Provider Communications
To contact Provider Services, please call 1-800-600-9007 or you may reach out to your Physician Advocate.
Balance Billing
Billing or balance billing UnitedHealthcare Community Plan Medicaid members is prohibited and may violate federal and state medical assistance rules and regulations.
Link users can access UnitedHealthcare Community Plan provider remittance advice in Document Vault as soon as they’re generated – no more waiting for the mail. You can use Document Vault to download PDF files
or print your documents. You can even turn off mailed delivery of these documents. Learn more at UHCprovider.com/documentvault. Not yet a Link user? Visit UHCprovider.com/link to learn about all our self-service
tools.
Please visit UHCprovider.com for valuable resources such as Care Provider Manuals, reimbursement policies, newsletters, forms and clinical practice guidelines. UHCprovider.com is also your gateway to our
self-service tools on Link. You can use Link to get eligibility information, check claim status, submit claim reconsideration requests and much more.
Electronic data interchange (EDI), electronic funds transfer and electronic remittance advice may help reduce the time spent checking eligibility, submitting claims and posting payments. Visit UHCprovider.com/edi or
The National Provider Identifier (NPI) number is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care
providers. When covered health care providers, health plans and health care clearinghouses submit claims/encounter data, they will use the NPI in the administrative and financial transactions adopted under HIPAA.
The NPI number is required on all claims submissions and subsequent encounters. Claims may be denied if the rendering provider’s NPI number is missing or invalid (if required for the Provider Type). Failure to do so
Phone: 877-842-3210
Online: UHCprovider.com/demoupdate
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STD-PRA
PROVIDER
REMITTANCE ADVICE
Pennsylvania
When UnitedHealthcare is the secondary payer, additional COB primary carrier information can be obtained by accessing the claim detail in the claimsLink application found at UHCprovider.com.
Corrected Claims
If the outcome of a claim results in the need to submit a corrected claim, the provider may do so in accordance with your provider contract. For proper adjudication, please ensure the following information is listed on the
claim form:
∙ CMS 1500
∙ Enter the appropriate claim frequency code in Box 22 left justified in the left-hand side of the field
∙ UB04
∙ Enter the appropriate claim frequency code in the 3rd position of the Type of Bill in Box 4
∙ Electronic Submissions
∙ Submit original claim number in Loop 2300, REF segment, REF02 element where REF01=F8
∙ Submit the frequency code in Loop 2300, CLM segment, CLM05-3 element
Make sure to resubmit the entire claim as originally submitted (even line items that were previously paid correctly). Following the National Uniform Billing Committee (NUBC) claim frequency guidelines, when sending a
replacement or void claim, the entire original or previous submission must be replaced or voided.
Appeals Procedures
Network providers may dispute a denial of payment herein by UnitedHealthcare Community Plan.
Disputes from participating providers must be made in writing within forty-five (45) days of the date of the UnitedHealthcare Community Plan Remittance Advice and must be sent to:
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STD-PRA
PROVIDER
REMITTANCE ADVICE
Pennsylvania
The appeal must include a letter detailing the dispute, a copy of the Remittance Advice, and related medical records and/or other supporting information. Non-participating providers may appeal within one hundred
eighty (180) days in the format described above and to the same address. Payments by UnitedHealthcare Community Plan for services rendered to members enrolled though the Medicare, Medicaid or
Medicaid-expansion programs are subject to applicable law addressing fraud and abuse in such programs. By accepting such payment, the provider acknowledges that such law applies and agrees to comply
therewith.
Billing Alerts
UnitedHealthcare enrolls members through the Medicare, Medicaid or Medicaid-expansion programs and payment for the services our members receive is payment in full - balance billing, other than co-pays and
deductibles, is prohibited. By accepting payment from UnitedHealthcare, the provider agrees to abide by the laws, regulations and agency policies that govern such programs, including the prohibitions on fraud,
waste and abuse. You can report possible fraud, waste or abuse anonymously by calling 1-877-766-3844. If you have any questions, contact UnitedHealthcare at 1-800-600-9007.
OptumInsight Denials (R10 or R11) for Medical Records fax directly to (877) 285-9063 or (877) 285-9098, or forward by mail to: OptumInsight, Attn: Medical Records, PO Box 105067, Atlanta, GA 30348
*Please note that if the Medical Records are not submitted to OptumInsight, there could be delays in the processing of your claims* Confirmation of a member’s eligibility is accurate as of the time of your call. It
does not guarantee payment of your claim. Eligibility status may change at any time, including retroactive enrollment or termination.
Provider Information
IF YOUR PAYEE NAME, BILLING ADDRESS AND/OR PAYEE TAXPAYER IDENTIFICATION NUMBER (TIN) ARE NOT CORRECTLY DISPLAYED ON THIS EXPLANATION OF BENEFITS, PLEASE CORRECT THE
INFORMATION IN THE SPACE BELOW AND RETURN THIS SECTION TO UnitedHealthcare Community Plan DBM Claims, P.O. Box 16900, Phoenix, AZ 85020.
____________________________________
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