From 31089440 8352656 1.216.920.6220 Mon Mar 13 23:! 243 2023 MDT Page 1 of 4 ‘STANDARD INSURANCE. COMPANY Explanation of Payment DENTAL & CLAIMS DEPARTMENT Page 1 of 4 0, 80x 82622 LINCOLN. NE ts 2622 {800-547-9515 (Toll-Free Number) Fax for new Chai 102-467-7336, Date: 03/13/2023, GOFS MCDONOUGH LLC 1880 WEST OAK PKWY SUITE 111 MARIETTA GA 30062 Any reconsideration request concerning these claims should be sent to: QUALITY CONTROL, PO BOX 82629, LINCOLN NE 68501-2629 or call ol-fee at 888-418-6811 Questions Regarding This Method of ‘Your nae, GOES MCDONOLIGH LLC and Tax 1D have been verified by the Bey Payment? Visit echoveards.com Tax Ds 463740068 EPC Deut te 287538213 Pavment eek: Payment Dates 03/1/2028 th Puc Pay aeot serie eset Sbitisd Ele Covered ch Minus Remain Ne Code Cole Service Desergion Type, Charms Charges Ammoat_ Code Delt Charges opr 0221723 -CBLEXTRACT 17 one 020125 CHLEXTRACT 28 (022123. GEN ANESTHES. asic sq 9400400 aus_Basic 234100 151400 _ 151000 5000144000 _s0% 16800 “Gai Processed sng Aen Contract ‘Sup-rorat Ties00| uN Anup AMOUNT Ta PATIENT: 12700 OTAL eM 1168.00 ‘ini Froese sing Aetna Contac SUB-TOTAL, 00 ILL AREF AMOUNT TO PATENT: 00 TOrML PAID 0 AMouNTeD 168.00 Payment technology ieanse under U.S. Patent RE43004 and U.S. Patent RE4A7EFrom 31089440 8352656 1.216.920.6220 Mon Mar 13 23:! 243 2023 MDT Page 2 of 4 Explanation of Payment Page 2 of 4 REMARK CODE DEFINITIONS TINS PROCEDURE HAS PREVIOUSLY BEEN REPORTED, TO APPEAL THE PREVIOUS BENEFIT DETERMINATION, SUBMIT A REQUEST FOR REVIEW WITH EXPLANATION ANDIOR ADDITIONAL INFORMATION TO: QUALITY ASSURANCE, P.O, BOX 82629, LINCOLN, NE 68501-2629 OR FAX TO, 802-308-258, Curent Dental Terminology copyrighted American Dental Association. Signup for online EOP statements ate standard com/dena and EFT at htpsenolimens,ECHOhesthine com/EFTERADinesgnop. In addon to whats shown on tis Benefit Statement your sate may offer specific appeal righ Adonal infomation ean be found on our website: wr standard com; sgh on unde your account, ‘ew this claim and select Appeal Process. You may also contact our office by phone or mal or view the ceniticae of coverage Payment technology ieanse under U.S. Patent RE43004 and U.S. Patent RE4A7EFrom 31089440 8352656 1.216.920.6220 Mon Mar 13 23:59:43 2023 MDT Page 3 of 4 Explanation of Payment Page 3 of 4 Keep this stub for your records anand QuicRemit” Tran Nbr: 287559213 cw2 Ma ard Vale: S1.16800 4288 8910 0554 3779 Date 037132025 GoFs MeponouGH LL 1880 WEST OAK PKWY SUITE 11 MARIETTA Ga 30062 ye 06/23 ECHO Health, Inc. Payment technology ieanse under U.S. Patent RE43004 and U.S. Patent RE4A7EFrom 31089440 8352656 1.216.920.6220 Mon Mar 13 23:! 243 2023 MDT Page 4 of 4 QuicRemit Payment Notification QuicRemit® cw2 123 1234 1234 1234 1234 yg 01/25, ECHO Health, Inc. Dear Provider: The attached remittance includes a QuicRemit virtual card payment. This electronic payment is being provided to you courtesy of ECHO Health Inc. For your convenience, we have consolidated multiple claims into a single payment when possible. This electronic payment is a voluntary option and does not require enrollment or any bank routing information, For assistance in processing a QuicRemit Payment see below: +The payment has been issued on a Commercial Visa Card ‘+ To begin, simply input the 16 digit number into your merchant terminal + Ifa security code is required, the CVV2 code is included on the card ‘+ if your merchant terminal requires an address, please use the following 810 Sharon Dr Westlake OH 44145 ‘+ The Payment can be processed one time or itemized. ‘+ Transaction Fees are based on normal Visa Card rates ‘+ Todeciine this accelerated payment, please contact QuicRemit at the number below. ‘+ Declining QuicRemit will prevent this accelerated payment from being offered again. For assistance process payment, please contact QuicRemit at (888) 457-4216. ‘Customer service hours Monday - Friday 8AM - 6PM Eastern Time. you sat o accept payment by vital card, processing fees wi occur as defined in your merchant agiesment wih your acquong bank you prefer aaifecent fom of payment, please cal the custome sevice phare numba above o ently your payment prelerence IMPORTANT NOTICE REGAROING TRANSMISSIONS OF PROTECTED HEALTH INFORMATION Proc Het omen Pi invita heh Infomation wine rang ore Hens eras Para & fez At of 1885 the epibne ported eur Ay Pl cranednoe mended ony othe rand rcpt a deraie sue oteuncetardeg ha equrenets f PAA abr apa fr ha one Pave teen met 28 communesboncomans PH. Yous eesng ie oan see ne colgtlon rena ina seve ana content mare Re-ecose wet acta cate or serie yew rtd Urano ane creo arin covet ou est yout pai deca ‘teeter law Hy at ntthe andar oust ne ha an ees sopyngosetuzon oth mon ety anotes Hou Payment technology ieanse under U.S. Patent RE43004 and U.S. Patent RE4A7E