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    20 views38 pages

    Eft-1657073 20230418

    Uploaded by

    Ro Daniela

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 38

    D BEST TRANSPORTATION LLC EFT-1657073

    68594 CALLE PRADO


    CATHEDRAL CITY, CA 92234

    UNION BANK 90-4150


    Inland Empire Health Plan 1222
    400 California Street
    Claims Payments
    San Francisco, CA 94101
    P.O. Box 1800 EFT-1657073
    Rancho Cucamonga, CA 91729-1800
    909-890-2000
    DATE: 04/18/2023
    VOID SIX MONTHS AFTER CHECK DATE
    $*******74,828.56

    PAY: Seventy-Four Thousand Eight Hundred Twenty-Eight And 56 / 100 Dollars

    TO THE D BEST TRANSPORTATION LLC PAID VIA ACH, please give 1 to 2


    ORDER
    68594 CALLE PRADO days for deposits to post after
    OF
    CATHEDRAL CITY, CA 92234 check date.

    FILE COPY NON NEGOTIABLE


    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 1

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    20110700658900 Medi-Cal ACKERMAN, SHANNON D BEST TRANSPORTATION LLC


    0059409025 001003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059409025 002003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059409025 003003 04/10/2023 04/06/2023 04/06/2023 A0380 7.00 19.25 19.25 0.00 0.00 0.00 0.00 19.25 P A1

    Patient Acct. # 1114 Claim Totals : 179.25 179.25 0.00 0.00 0.00 0.00 179.25

    Member Totals : 179.25 179.25 0.00 0.00 0.00 0.00 179.25

    20080700005400 Medi-Cal ADELIZZI, DANIEL D BEST TRANSPORTATION LLC


    0059403442 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403442 002003 04/10/2023 04/06/2023 04/06/2023 A0425 169.00 419.12 419.12 0.00 0.00 0.00 0.00 419.12 P A1
    0059403442 003003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403442 004003 04/10/2023 04/06/2023 04/06/2023 A0425 169.00 419.12 419.12 0.00 0.00 0.00 0.00 419.12 P A1

    Patient Acct. # 946 Claim Totals : 852.24 852.24 0.00 0.00 0.00 0.00 852.24

    0059408080 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408080 002003 04/10/2023 04/07/2023 04/07/2023 A0425 169.00 419.12 419.12 0.00 0.00 0.00 0.00 419.12 P A1
    0059408080 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408080 004003 04/10/2023 04/07/2023 04/07/2023 A0425 169.00 419.12 419.12 0.00 0.00 0.00 0.00 419.12 P A1

    Patient Acct. # 946 Claim Totals : 852.24 852.24 0.00 0.00 0.00 0.00 852.24

    0059489865 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489865 002003 04/11/2023 04/08/2023 04/08/2023 A0425 169.00 419.12 419.12 0.00 0.00 0.00 0.00 419.12 P A1
    0059489865 003003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489865 004003 04/11/2023 04/08/2023 04/08/2023 A0425 169.00 419.12 419.12 0.00 0.00 0.00 0.00 419.12 P A1

    Patient Acct. # 946 Claim Totals : 852.24 852.24 0.00 0.00 0.00 0.00 852.24

    0059553332 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553332 002003 04/12/2023 04/10/2023 04/10/2023 A0425 169.00 419.12 419.12 0.00 0.00 0.00 0.00 419.12 P A1
    0059553332 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553332 004003 04/12/2023 04/10/2023 04/10/2023 A0425 169.00 419.12 419.12 0.00 0.00 0.00 0.00 419.12 P A1

    Patient Acct. # 946 Claim Totals : 852.24 852.24 0.00 0.00 0.00 0.00 852.24

    Member Totals : 3,408.96 3,408.96 0.00 0.00 0.00 0.00 3,408.96

    20170401011600 Medi-Cal ALEJOS, RENE D BEST TRANSPORTATION LLC


    0059408002 001003 04/10/2023 04/07/2023 04/07/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059408002 002003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408002 003003 04/10/2023 04/07/2023 04/07/2023 A0425 150.00 372.00 372.00 0.00 0.00 0.00 0.00 372.00 P A1
    0059408002 004003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408002 005003 04/10/2023 04/07/2023 04/07/2023 A0425 150.00 372.00 372.00 0.00 0.00 0.00 0.00 372.00 P A1

    Patient Acct. # 739 Claim Totals : 768.00 768.00 0.00 0.00 0.00 0.00 768.00

    0059489696 001003 04/11/2023 04/08/2023 04/08/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059489696 002003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 2

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059489696 003003 04/11/2023 04/08/2023 04/08/2023 A0425 150.00 372.00 372.00 0.00 0.00 0.00 0.00 372.00 P A1
    0059489696 004003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489696 005003 04/11/2023 04/08/2023 04/08/2023 A0425 150.00 372.00 372.00 0.00 0.00 0.00 0.00 372.00 P A1

    Patient Acct. # 739 Claim Totals : 768.00 768.00 0.00 0.00 0.00 0.00 768.00

    0059490229 001003 04/11/2023 04/09/2023 04/09/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059490229 002003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490229 003003 04/11/2023 04/09/2023 04/09/2023 A0425 150.00 372.00 372.00 0.00 0.00 0.00 0.00 372.00 P A1
    0059490229 004003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490229 005003 04/11/2023 04/09/2023 04/09/2023 A0425 150.00 372.00 372.00 0.00 0.00 0.00 0.00 372.00 P A1

    Patient Acct. # 739 Claim Totals : 768.00 768.00 0.00 0.00 0.00 0.00 768.00

    0059553271 001003 04/12/2023 04/10/2023 04/10/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059553271 002003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553271 003003 04/12/2023 04/10/2023 04/10/2023 A0425 150.00 372.00 372.00 0.00 0.00 0.00 0.00 372.00 P A1
    0059553271 004003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553271 005003 04/12/2023 04/10/2023 04/10/2023 A0425 150.00 372.00 372.00 0.00 0.00 0.00 0.00 372.00 P A1

    Patient Acct. # 739 Claim Totals : 768.00 768.00 0.00 0.00 0.00 0.00 768.00

    Member Totals : 3,072.00 3,072.00 0.00 0.00 0.00 0.00 3,072.00

    20030300013000 Medi-Cal ALVAREZ, SUSANA D BEST TRANSPORTATION LLC


    0059403526 001003 04/10/2023 04/06/2023 04/06/2023 A0420 2.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403526 002003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403526 003003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403526 004003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403526 005003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403526 006003 04/10/2023 04/06/2023 04/06/2023 A0380 4.00 11.00 11.00 0.00 0.00 0.00 0.00 11.00 P A1
    0059403526 007003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403526 008003 04/10/2023 04/06/2023 04/06/2023 A0380 4.00 11.00 11.00 0.00 0.00 0.00 0.00 11.00 P A1

    Patient Acct. # 1115 Claim Totals : 372.00 372.00 0.00 0.00 0.00 0.00 372.00

    Member Totals : 372.00 372.00 0.00 0.00 0.00 0.00 372.00

    40000047577600 Medi-Cal AMBRIZ CARRASCO, KAILANI D BEST TRANSPORTATION LLC


    0059408129 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408129 002003 04/10/2023 04/07/2023 04/07/2023 A0425 7.00 17.36 17.36 0.00 0.00 0.00 0.00 17.36 P A1
    0059408129 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408129 004003 04/10/2023 04/07/2023 04/07/2023 A0425 7.00 17.36 17.36 0.00 0.00 0.00 0.00 17.36 P A1

    Patient Acct. # 1084 Claim Totals : 48.72 48.72 0.00 0.00 0.00 0.00 48.72

    Member Totals : 48.72 48.72 0.00 0.00 0.00 0.00 48.72

    20011100029200 Medi-Cal AVILA, MARCELINA D BEST TRANSPORTATION LLC


    0059403332 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 3

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059403332 002003 04/10/2023 04/06/2023 04/06/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059403332 003003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403332 004003 04/10/2023 04/06/2023 04/06/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 628 Claim Totals : 172.72 172.72 0.00 0.00 0.00 0.00 172.72

    0059407985 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407985 002003 04/10/2023 04/07/2023 04/07/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059407985 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407985 004003 04/10/2023 04/07/2023 04/07/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 628 Claim Totals : 172.72 172.72 0.00 0.00 0.00 0.00 172.72

    0059489649 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489649 002003 04/11/2023 04/08/2023 04/08/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059489649 003003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489649 004003 04/11/2023 04/08/2023 04/08/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 628 Claim Totals : 172.72 172.72 0.00 0.00 0.00 0.00 172.72

    0059490197 001003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490197 002003 04/11/2023 04/09/2023 04/09/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059490197 003003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490197 004003 04/11/2023 04/09/2023 04/09/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 628 Claim Totals : 172.72 172.72 0.00 0.00 0.00 0.00 172.72

    0059553251 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553251 002003 04/12/2023 04/10/2023 04/10/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059553251 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553251 004003 04/12/2023 04/10/2023 04/10/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 628 Claim Totals : 172.72 172.72 0.00 0.00 0.00 0.00 172.72

    Member Totals : 863.60 863.60 0.00 0.00 0.00 0.00 863.60

    20170700909000 Medi-Cal AVINA, DAVID D BEST TRANSPORTATION LLC


    0059403348 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403348 002003 04/10/2023 04/06/2023 04/06/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059403348 003003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403348 004003 04/10/2023 04/06/2023 04/06/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 685 Claim Totals : 172.72 172.72 0.00 0.00 0.00 0.00 172.72

    0059407993 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407993 002003 04/10/2023 04/07/2023 04/07/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059407993 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407993 004003 04/10/2023 04/07/2023 04/07/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 685 Claim Totals : 172.72 172.72 0.00 0.00 0.00 0.00 172.72

    0059489665 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 4

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059489665 002003 04/11/2023 04/08/2023 04/08/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059489665 003003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489665 004003 04/11/2023 04/08/2023 04/08/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 685 Claim Totals : 172.72 172.72 0.00 0.00 0.00 0.00 172.72

    0059490212 001003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490212 002003 04/11/2023 04/09/2023 04/09/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059490212 003003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490212 004003 04/11/2023 04/09/2023 04/09/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 685 Claim Totals : 172.72 172.72 0.00 0.00 0.00 0.00 172.72

    0059553261 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553261 002003 04/12/2023 04/10/2023 04/10/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059553261 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553261 004003 04/12/2023 04/10/2023 04/10/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 685 Claim Totals : 172.72 172.72 0.00 0.00 0.00 0.00 172.72

    Member Totals : 863.60 863.60 0.00 0.00 0.00 0.00 863.60

    40000013097400 Medi-Cal BAYES, OATOMISHA D BEST TRANSPORTATION LLC


    0059489392 001003 04/11/2023 04/08/2023 04/08/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059489392 002003 04/11/2023 04/08/2023 04/08/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059489392 003003 04/11/2023 04/08/2023 04/08/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059489392 004003 04/11/2023 04/08/2023 04/08/2023 A0380 5.00 13.75 13.75 0.00 0.00 0.00 0.00 13.75 P A1
    0059489392 005003 04/11/2023 04/08/2023 04/08/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059489392 006003 04/11/2023 04/08/2023 04/08/2023 A0380 5.00 13.75 13.75 0.00 0.00 0.00 0.00 13.75 P A1

    Patient Acct. # 117 Claim Totals : 347.50 347.50 0.00 0.00 0.00 0.00 347.50

    0059553116 001003 04/12/2023 04/10/2023 04/10/2023 A0420 2.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553116 002003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553116 003003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553116 004003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553116 005003 04/12/2023 04/10/2023 04/10/2023 A0380 3.00 8.25 8.25 0.00 0.00 0.00 0.00 8.25 P A1
    0059553116 006003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553116 007003 04/12/2023 04/10/2023 04/10/2023 A0380 3.00 8.25 8.25 0.00 0.00 0.00 0.00 8.25 P A1

    Patient Acct. # 117 Claim Totals : 356.50 356.50 0.00 0.00 0.00 0.00 356.50

    Member Totals : 704.00 704.00 0.00 0.00 0.00 0.00 704.00

    40000040794200 Medi-Cal CAMPANA, JOHN D BEST TRANSPORTATION LLC


    0059403389 001003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403389 002003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403389 003003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403389 004003 04/10/2023 04/06/2023 04/06/2023 A0380 6.00 16.50 16.50 0.00 0.00 0.00 0.00 16.50 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 5

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059403389 005003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403389 006003 04/10/2023 04/06/2023 04/06/2023 A0380 6.00 16.50 16.50 0.00 0.00 0.00 0.00 16.50 P A1

    Patient Acct. # 813 Claim Totals : 353.00 353.00 0.00 0.00 0.00 0.00 353.00

    0059408020 001003 04/10/2023 04/07/2023 04/07/2023 A0420 2.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059408020 002003 04/10/2023 04/07/2023 04/07/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059408020 003003 04/10/2023 04/07/2023 04/07/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059408020 004003 04/10/2023 04/07/2023 04/07/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059408020 005003 04/10/2023 04/07/2023 04/07/2023 A0380 2.00 5.50 5.50 0.00 0.00 0.00 0.00 5.50 P A1
    0059408020 006003 04/10/2023 04/07/2023 04/07/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059408020 007003 04/10/2023 04/07/2023 04/07/2023 A0380 2.00 5.50 5.50 0.00 0.00 0.00 0.00 5.50 P A1

    Patient Acct. # 813 Claim Totals : 351.00 351.00 0.00 0.00 0.00 0.00 351.00

    0059489744 001003 04/11/2023 04/08/2023 04/08/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059489744 002003 04/11/2023 04/08/2023 04/08/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059489744 003003 04/11/2023 04/08/2023 04/08/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059489744 004003 04/11/2023 04/08/2023 04/08/2023 A0380 6.00 16.50 16.50 0.00 0.00 0.00 0.00 16.50 P A1
    0059489744 005003 04/11/2023 04/08/2023 04/08/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059489744 006003 04/11/2023 04/08/2023 04/08/2023 A0380 6.00 16.50 16.50 0.00 0.00 0.00 0.00 16.50 P A1

    Patient Acct. # 813 Claim Totals : 353.00 353.00 0.00 0.00 0.00 0.00 353.00

    Member Totals : 1,057.00 1,057.00 0.00 0.00 0.00 0.00 1,057.00

    40000022056200 Medi-Cal CAPORUSSO, DOLORES D BEST TRANSPORTATION LLC


    0059403491 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403491 002003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403491 003003 04/10/2023 04/06/2023 04/06/2023 A0425 2.00 4.96 4.96 0.00 0.00 0.00 0.00 4.96 P A1
    0059403491 004003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403491 005003 04/10/2023 04/06/2023 04/06/2023 A0425 2.00 4.96 4.96 0.00 0.00 0.00 0.00 4.96 P A1

    Patient Acct. # 1061 Claim Totals : 33.92 33.92 0.00 0.00 0.00 0.00 33.92

    0059489905 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489905 002003 04/11/2023 04/08/2023 04/08/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059489905 003003 04/11/2023 04/08/2023 04/08/2023 A0425 2.00 4.96 4.96 0.00 0.00 0.00 0.00 4.96 P A1
    0059489905 004003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489905 005003 04/11/2023 04/08/2023 04/08/2023 A0425 2.00 4.96 4.96 0.00 0.00 0.00 0.00 4.96 P A1

    Patient Acct. # 1061 Claim Totals : 33.92 33.92 0.00 0.00 0.00 0.00 33.92

    Member Totals : 67.84 67.84 0.00 0.00 0.00 0.00 67.84

    20160100295300 Medi-Cal CAREY, LOGAN D BEST TRANSPORTATION LLC


    0059403460 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403460 002003 04/10/2023 04/06/2023 04/06/2023 A0425 238.00 590.24 590.24 0.00 0.00 0.00 0.00 590.24 P A1
    0059403460 003003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 6

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059403460 004003 04/10/2023 04/06/2023 04/06/2023 A0425 238.00 590.24 590.24 0.00 0.00 0.00 0.00 590.24 P A1

    Patient Acct. # 952 Claim Totals : 1,194.48 1,194.48 0.00 0.00 0.00 0.00 1,194.48

    0059408084 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408084 002003 04/10/2023 04/07/2023 04/07/2023 A0425 238.00 590.24 590.24 0.00 0.00 0.00 0.00 590.24 P A1
    0059408084 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408084 004003 04/10/2023 04/07/2023 04/07/2023 A0425 238.00 590.24 590.24 0.00 0.00 0.00 0.00 590.24 P A1

    Patient Acct. # 952 Claim Totals : 1,194.48 1,194.48 0.00 0.00 0.00 0.00 1,194.48

    0059489880 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489880 002003 04/11/2023 04/08/2023 04/08/2023 A0425 238.00 590.24 590.24 0.00 0.00 0.00 0.00 590.24 P A1
    0059489880 003003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489880 004003 04/11/2023 04/08/2023 04/08/2023 A0425 238.00 590.24 590.24 0.00 0.00 0.00 0.00 590.24 P A1

    Patient Acct. # 952 Claim Totals : 1,194.48 1,194.48 0.00 0.00 0.00 0.00 1,194.48

    0059553337 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553337 002003 04/12/2023 04/10/2023 04/10/2023 A0425 238.00 590.24 590.24 0.00 0.00 0.00 0.00 590.24 P A1
    0059553337 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553337 004003 04/12/2023 04/10/2023 04/10/2023 A0425 238.00 590.24 590.24 0.00 0.00 0.00 0.00 590.24 P A1

    Patient Acct. # 952 Claim Totals : 1,194.48 1,194.48 0.00 0.00 0.00 0.00 1,194.48

    Member Totals : 4,777.92 4,777.92 0.00 0.00 0.00 0.00 4,777.92

    20141003131500 Medi-Cal CORRAL, LUCY D BEST TRANSPORTATION LLC


    0059489440 001003 04/11/2023 04/08/2023 04/08/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059489440 002003 04/11/2023 04/08/2023 04/08/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059489440 003003 04/11/2023 04/08/2023 04/08/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059489440 004003 04/11/2023 04/08/2023 04/08/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059489440 005003 04/11/2023 04/08/2023 04/08/2023 A0380 3.00 8.25 8.25 0.00 0.00 0.00 0.00 8.25 P A1
    0059489440 006003 04/11/2023 04/08/2023 04/08/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059489440 007003 04/11/2023 04/08/2023 04/08/2023 A0380 3.00 8.25 8.25 0.00 0.00 0.00 0.00 8.25 P A1

    Patient Acct. # 239 Claim Totals : 346.50 346.50 0.00 0.00 0.00 0.00 346.50

    Member Totals : 346.50 346.50 0.00 0.00 0.00 0.00 346.50

    40000083966900 Medi-Cal DILLON, NANCY D BEST TRANSPORTATION LLC


    0059403175 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403175 002003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403175 003003 04/10/2023 04/06/2023 04/06/2023 A0425 56.00 138.88 138.88 0.00 0.00 0.00 0.00 138.88 P A1
    0059403175 004003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403175 005003 04/10/2023 04/06/2023 04/06/2023 A0425 56.00 138.88 138.88 0.00 0.00 0.00 0.00 138.88 P A1

    Patient Acct. # 175 Claim Totals : 301.76 301.76 0.00 0.00 0.00 0.00 301.76

    0059407851 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407851 002003 04/10/2023 04/07/2023 04/07/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 7

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059407851 003003 04/10/2023 04/07/2023 04/07/2023 A0425 56.00 138.88 138.88 0.00 0.00 0.00 0.00 138.88 P A1
    0059407851 004003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407851 005003 04/10/2023 04/07/2023 04/07/2023 A0425 56.00 138.88 138.88 0.00 0.00 0.00 0.00 138.88 P A1

    Patient Acct. # 175 Claim Totals : 301.76 301.76 0.00 0.00 0.00 0.00 301.76

    0059489416 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489416 002003 04/11/2023 04/08/2023 04/08/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059489416 003003 04/11/2023 04/08/2023 04/08/2023 A0425 56.00 138.88 138.88 0.00 0.00 0.00 0.00 138.88 P A1
    0059489416 004003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489416 005003 04/11/2023 04/08/2023 04/08/2023 A0425 56.00 138.88 138.88 0.00 0.00 0.00 0.00 138.88 P A1

    Patient Acct. # 175 Claim Totals : 301.76 301.76 0.00 0.00 0.00 0.00 301.76

    0059553133 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553133 002003 04/12/2023 04/10/2023 04/10/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059553133 003003 04/12/2023 04/10/2023 04/10/2023 A0425 56.00 138.88 138.88 0.00 0.00 0.00 0.00 138.88 P A1
    0059553133 004003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553133 005003 04/12/2023 04/10/2023 04/10/2023 A0425 56.00 138.88 138.88 0.00 0.00 0.00 0.00 138.88 P A1

    Patient Acct. # 175 Claim Totals : 301.76 301.76 0.00 0.00 0.00 0.00 301.76

    Member Totals : 1,207.04 1,207.04 0.00 0.00 0.00 0.00 1,207.04

    20141000284800 Medi-Cal DONOVAN, SHERRY D BEST TRANSPORTATION LLC


    0059553377 001003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553377 002003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553377 003003 04/12/2023 04/10/2023 04/10/2023 A0380 8.00 22.00 22.00 0.00 0.00 0.00 0.00 22.00 P A1

    Patient Acct. # 1095 Claim Totals : 182.00 182.00 0.00 0.00 0.00 0.00 182.00

    Member Totals : 182.00 182.00 0.00 0.00 0.00 0.00 182.00

    20050100162200 Medi-Cal DUDLEY, CHARLOTTE D BEST TRANSPORTATION LLC


    0059553199 001003 04/12/2023 04/10/2023 04/10/2023 A0420 2.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553199 002003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553199 003003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553199 004003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553199 005003 04/12/2023 04/10/2023 04/10/2023 A0380 56.00 154.00 154.00 0.00 0.00 0.00 0.00 154.00 P A1
    0059553199 006003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553199 007003 04/12/2023 04/10/2023 04/10/2023 A0380 56.00 154.00 154.00 0.00 0.00 0.00 0.00 154.00 P A1

    Patient Acct. # 461 Claim Totals : 648.00 648.00 0.00 0.00 0.00 0.00 648.00

    Member Totals : 648.00 648.00 0.00 0.00 0.00 0.00 648.00

    20140101062500 Medi-Cal EDMONDS SCARCIA, DAWN D BEST TRANSPORTATION LLC


    0059553382 001003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553382 002003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553382 003003 04/12/2023 04/10/2023 04/10/2023 A0380 35.00 96.25 96.25 0.00 0.00 0.00 0.00 96.25 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 8

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    Patient Acct. # 1127 Claim Totals : 256.25 256.25 0.00 0.00 0.00 0.00 256.25

    Member Totals : 256.25 256.25 0.00 0.00 0.00 0.00 256.25

    19970400386600 Medi-Cal ENTLER, MARTIN D BEST TRANSPORTATION LLC


    0059403378 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403378 002003 04/10/2023 04/06/2023 04/06/2023 A0425 35.00 86.80 86.80 0.00 0.00 0.00 0.00 86.80 P A1
    0059403378 003003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403378 004003 04/10/2023 04/06/2023 04/06/2023 A0425 35.00 86.80 86.80 0.00 0.00 0.00 0.00 86.80 P A1

    Patient Acct. # 774 Claim Totals : 187.60 187.60 0.00 0.00 0.00 0.00 187.60

    0059408011 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408011 002003 04/10/2023 04/07/2023 04/07/2023 A0425 35.00 86.80 86.80 0.00 0.00 0.00 0.00 86.80 P A1
    0059408011 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408011 004003 04/10/2023 04/07/2023 04/07/2023 A0425 35.00 86.80 86.80 0.00 0.00 0.00 0.00 86.80 P A1

    Patient Acct. # 774 Claim Totals : 187.60 187.60 0.00 0.00 0.00 0.00 187.60

    0059489712 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489712 002003 04/11/2023 04/08/2023 04/08/2023 A0425 35.00 86.80 86.80 0.00 0.00 0.00 0.00 86.80 P A1
    0059489712 003003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489712 004003 04/11/2023 04/08/2023 04/08/2023 A0425 35.00 86.80 86.80 0.00 0.00 0.00 0.00 86.80 P A1

    Patient Acct. # 774 Claim Totals : 187.60 187.60 0.00 0.00 0.00 0.00 187.60

    0059553287 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553287 002003 04/12/2023 04/10/2023 04/10/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059553287 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553287 004003 04/12/2023 04/10/2023 04/10/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 774 Claim Totals : 172.72 172.72 0.00 0.00 0.00 0.00 172.72

    Member Totals : 735.52 735.52 0.00 0.00 0.00 0.00 735.52

    40000057881900 Medi-Cal ESCOBEDO, MARK D BEST TRANSPORTATION LLC


    0059403204 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403204 002003 04/10/2023 04/06/2023 04/06/2023 A0425 216.00 535.68 535.68 0.00 0.00 0.00 0.00 535.68 P A1
    0059403204 003003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403204 004003 04/10/2023 04/06/2023 04/06/2023 A0425 216.00 535.68 535.68 0.00 0.00 0.00 0.00 535.68 P A1

    Patient Acct. # 294 Claim Totals : 1,085.36 1,085.36 0.00 0.00 0.00 0.00 1,085.36

    0059407895 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407895 002003 04/10/2023 04/07/2023 04/07/2023 A0425 216.00 535.68 535.68 0.00 0.00 0.00 0.00 535.68 P A1
    0059407895 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407895 004003 04/10/2023 04/07/2023 04/07/2023 A0425 216.00 535.68 535.68 0.00 0.00 0.00 0.00 535.68 P A1

    Patient Acct. # 294 Claim Totals : 1,085.36 1,085.36 0.00 0.00 0.00 0.00 1,085.36

    0059489449 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489449 002003 04/11/2023 04/08/2023 04/08/2023 A0425 216.00 535.68 535.68 0.00 0.00 0.00 0.00 535.68 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 9

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059489449 003003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489449 004003 04/11/2023 04/08/2023 04/08/2023 A0425 216.00 535.68 535.68 0.00 0.00 0.00 0.00 535.68 P A1

    Patient Acct. # 294 Claim Totals : 1,085.36 1,085.36 0.00 0.00 0.00 0.00 1,085.36

    0059553158 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553158 002003 04/12/2023 04/10/2023 04/10/2023 A0425 216.00 535.68 535.68 0.00 0.00 0.00 0.00 535.68 P A1
    0059553158 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553158 004003 04/12/2023 04/10/2023 04/10/2023 A0425 216.00 535.68 535.68 0.00 0.00 0.00 0.00 535.68 P A1

    Patient Acct. # 294 Claim Totals : 1,085.36 1,085.36 0.00 0.00 0.00 0.00 1,085.36

    Member Totals : 4,341.44 4,341.44 0.00 0.00 0.00 0.00 4,341.44

    20110600297900 Medi-Cal FEWER, JAMES D BEST TRANSPORTATION LLC


    0059403296 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403296 002003 04/10/2023 04/06/2023 04/06/2023 A0425 22.00 54.56 54.56 0.00 0.00 0.00 0.00 54.56 P A1
    0059403296 003003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403296 004003 04/10/2023 04/06/2023 04/06/2023 A0425 22.00 54.56 54.56 0.00 0.00 0.00 0.00 54.56 P A1

    Patient Acct. # 520 Claim Totals : 123.12 123.12 0.00 0.00 0.00 0.00 123.12

    0059407947 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407947 002003 04/10/2023 04/07/2023 04/07/2023 A0425 22.00 54.56 54.56 0.00 0.00 0.00 0.00 54.56 P A1
    0059407947 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407947 004003 04/10/2023 04/07/2023 04/07/2023 A0425 22.00 54.56 54.56 0.00 0.00 0.00 0.00 54.56 P A1

    Patient Acct. # 520 Claim Totals : 123.12 123.12 0.00 0.00 0.00 0.00 123.12

    0059489570 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489570 002003 04/11/2023 04/08/2023 04/08/2023 A0425 22.00 54.56 54.56 0.00 0.00 0.00 0.00 54.56 P A1
    0059489570 003003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489570 004003 04/11/2023 04/08/2023 04/08/2023 A0425 22.00 54.56 54.56 0.00 0.00 0.00 0.00 54.56 P A1

    Patient Acct. # 520 Claim Totals : 123.12 123.12 0.00 0.00 0.00 0.00 123.12

    0059553221 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553221 002003 04/12/2023 04/10/2023 04/10/2023 A0425 22.00 54.56 54.56 0.00 0.00 0.00 0.00 54.56 P A1
    0059553221 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553221 004003 04/12/2023 04/10/2023 04/10/2023 A0425 22.00 54.56 54.56 0.00 0.00 0.00 0.00 54.56 P A1

    Patient Acct. # 520 Claim Totals : 123.12 123.12 0.00 0.00 0.00 0.00 123.12

    Member Totals : 492.48 492.48 0.00 0.00 0.00 0.00 492.48

    20120600242900 Medicare FLEISCHER, ENEDINA D BEST TRANSPORTATION LLC


    0059403414 001003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 20.00 0.00 0.00 0.00 0.00 D
    0059403414 002003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 20.00 0.00 0.00 0.00 0.00 D
    0059403414 003003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 140.00 0.00 0.00 0.00 0.00 D
    0059403414 004003 04/10/2023 04/06/2023 04/06/2023 A0380 27.00 74.25 74.25 74.25 0.00 0.00 0.00 0.00 D
    0059403414 005003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 140.00 0.00 0.00 0.00 0.00 D
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 10

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059403414 006003 04/10/2023 04/06/2023 04/06/2023 A0380 27.00 74.25 74.25 74.25 0.00 0.00 0.00 0.00 D

    Patient Acct. # 882 Claim Totals : 468.50 468.50 468.50 0.00 0.00 0.00 0.00

    0059412238 001002 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059412238 002002 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059412238 003002 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059412238 004002 04/10/2023 04/06/2023 04/06/2023 A0380 27.00 74.25 74.25 0.00 0.00 0.00 0.00 74.25 P A1
    0059412238 005002 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059412238 006002 04/10/2023 04/06/2023 04/06/2023 A0380 27.00 74.25 74.25 0.00 0.00 0.00 0.00 74.25 P A1

    Patient Acct. # 882 Claim Totals : 468.50 468.50 0.00 0.00 0.00 0.00 468.50

    0059489808 001003 04/11/2023 04/08/2023 04/08/2023 A0424 1.00 20.00 20.00 20.00 0.00 0.00 0.00 0.00 D
    0059489808 002003 04/11/2023 04/08/2023 04/08/2023 A0424 1.00 20.00 20.00 20.00 0.00 0.00 0.00 0.00 D
    0059489808 003003 04/11/2023 04/08/2023 04/08/2023 T2005 1.00 140.00 140.00 140.00 0.00 0.00 0.00 0.00 D
    0059489808 004003 04/11/2023 04/08/2023 04/08/2023 A0380 27.00 74.25 74.25 74.25 0.00 0.00 0.00 0.00 D
    0059489808 005003 04/11/2023 04/08/2023 04/08/2023 T2005 1.00 140.00 140.00 140.00 0.00 0.00 0.00 0.00 D
    0059489808 006003 04/11/2023 04/08/2023 04/08/2023 A0380 27.00 74.25 74.25 74.25 0.00 0.00 0.00 0.00 D

    Patient Acct. # 882 Claim Totals : 468.50 468.50 468.50 0.00 0.00 0.00 0.00

    0059503599 001002 04/11/2023 04/08/2023 04/08/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059503599 002002 04/11/2023 04/08/2023 04/08/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059503599 003002 04/11/2023 04/08/2023 04/08/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059503599 004002 04/11/2023 04/08/2023 04/08/2023 A0380 27.00 74.25 74.25 0.00 0.00 0.00 0.00 74.25 P A1
    0059503599 005002 04/11/2023 04/08/2023 04/08/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059503599 006002 04/11/2023 04/08/2023 04/08/2023 A0380 27.00 74.25 74.25 0.00 0.00 0.00 0.00 74.25 P A1

    Patient Acct. # 882 Claim Totals : 468.50 468.50 0.00 0.00 0.00 0.00 468.50

    Member Totals : 1,874.00 1,874.00 937.00 0.00 0.00 0.00 937.00

    20150400728700 Medi-Cal FLORES, CHRISTINA D BEST TRANSPORTATION LLC


    0059403254 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403254 002003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403254 003003 04/10/2023 04/06/2023 04/06/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1
    0059403254 004003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403254 005003 04/10/2023 04/06/2023 04/06/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1

    Patient Acct. # 458 Claim Totals : 143.04 143.04 0.00 0.00 0.00 0.00 143.04

    0059407927 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407927 002003 04/10/2023 04/07/2023 04/07/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059407927 003003 04/10/2023 04/07/2023 04/07/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1
    0059407927 004003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407927 005003 04/10/2023 04/07/2023 04/07/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1

    Patient Acct. # 458 Claim Totals : 143.04 143.04 0.00 0.00 0.00 0.00 143.04
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 11

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059489522 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489522 002003 04/11/2023 04/08/2023 04/08/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059489522 003003 04/11/2023 04/08/2023 04/08/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1
    0059489522 004003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489522 005003 04/11/2023 04/08/2023 04/08/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1

    Patient Acct. # 458 Claim Totals : 143.04 143.04 0.00 0.00 0.00 0.00 143.04

    0059553195 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553195 002003 04/12/2023 04/10/2023 04/10/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059553195 003003 04/12/2023 04/10/2023 04/10/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1
    0059553195 004003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553195 005003 04/12/2023 04/10/2023 04/10/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1

    Patient Acct. # 458 Claim Totals : 143.04 143.04 0.00 0.00 0.00 0.00 143.04

    Member Totals : 572.16 572.16 0.00 0.00 0.00 0.00 572.16

    40000103624400 Medi-Cal FORGEA, HAROLD D BEST TRANSPORTATION LLC


    0059553388 001003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553388 002003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553388 003003 04/12/2023 04/10/2023 04/10/2023 A0380 51.00 140.25 140.25 0.00 0.00 0.00 0.00 140.25 P A1

    Patient Acct. # 1128 Claim Totals : 300.25 300.25 0.00 0.00 0.00 0.00 300.25

    Member Totals : 300.25 300.25 0.00 0.00 0.00 0.00 300.25

    40000037232600 Medi-Cal GERVAIS, ALYSSA D BEST TRANSPORTATION LLC


    0059403431 001003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403431 002003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403431 003003 04/10/2023 04/06/2023 04/06/2023 A0425 70.00 173.60 173.60 0.00 0.00 0.00 0.00 173.60 P A1
    0059403431 004003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403431 005003 04/10/2023 04/06/2023 04/06/2023 A0425 70.00 173.60 173.60 0.00 0.00 0.00 0.00 173.60 P A1

    Patient Acct. # 942 Claim Totals : 371.20 371.20 0.00 0.00 0.00 0.00 371.20

    0059408067 001003 04/10/2023 04/07/2023 04/07/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059408067 002003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408067 003003 04/10/2023 04/07/2023 04/07/2023 A0425 70.00 173.60 173.60 0.00 0.00 0.00 0.00 173.60 P A1
    0059408067 004003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408067 005003 04/10/2023 04/07/2023 04/07/2023 A0425 70.00 173.60 173.60 0.00 0.00 0.00 0.00 173.60 P A1

    Patient Acct. # 942 Claim Totals : 371.20 371.20 0.00 0.00 0.00 0.00 371.20

    0059489855 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489855 002003 04/11/2023 04/08/2023 04/08/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059489855 003003 04/11/2023 04/08/2023 04/08/2023 A0425 70.00 173.60 173.60 0.00 0.00 0.00 0.00 173.60 P A1
    0059489855 004003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489855 005003 04/11/2023 04/08/2023 04/08/2023 A0425 70.00 173.60 173.60 0.00 0.00 0.00 0.00 173.60 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 12

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    Patient Acct. # 942 Claim Totals : 371.20 371.20 0.00 0.00 0.00 0.00 371.20

    0059553323 001003 04/12/2023 04/10/2023 04/10/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059553323 002003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553323 003003 04/12/2023 04/10/2023 04/10/2023 A0425 70.00 173.60 173.60 0.00 0.00 0.00 0.00 173.60 P A1
    0059553323 004003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553323 005003 04/12/2023 04/10/2023 04/10/2023 A0425 70.00 173.60 173.60 0.00 0.00 0.00 0.00 173.60 P A1

    Patient Acct. # 942 Claim Totals : 371.20 371.20 0.00 0.00 0.00 0.00 371.20

    Member Totals : 1,484.80 1,484.80 0.00 0.00 0.00 0.00 1,484.80

    20150200001500 Medicare HARRINGTON, KRISTEY D BEST TRANSPORTATION LLC


    0059553120 001003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 20.00 0.00 0.00 0.00 0.00 D
    0059553120 002003 04/12/2023 04/10/2023 04/10/2023 T2005 TP 1.00 102.50 102.50 102.50 0.00 0.00 0.00 0.00 D

    Patient Acct. # 131 Claim Totals : 122.50 122.50 122.50 0.00 0.00 0.00 0.00

    0059590094 001002 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059590094 002002 04/12/2023 04/10/2023 04/10/2023 T2005 TP 1.00 102.50 102.50 0.00 0.00 0.00 0.00 102.50 P A1

    Patient Acct. # 131 Claim Totals : 122.50 122.50 0.00 0.00 0.00 0.00 122.50

    Member Totals : 245.00 245.00 122.50 0.00 0.00 0.00 122.50

    20050200210000 Medicare HAYDUK, JOSEPHINE D BEST TRANSPORTATION LLC


    0059403517 001003 04/10/2023 04/06/2023 04/06/2023 A0420 2.00 20.00 20.00 20.00 0.00 0.00 0.00 0.00 D
    0059403517 002003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 20.00 0.00 0.00 0.00 0.00 D
    0059403517 003003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 20.00 0.00 0.00 0.00 0.00 D
    0059403517 004003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 140.00 0.00 0.00 0.00 0.00 D
    0059403517 005003 04/10/2023 04/06/2023 04/06/2023 A0380 30.00 82.50 82.50 82.50 0.00 0.00 0.00 0.00 D
    0059403517 006003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 140.00 0.00 0.00 0.00 0.00 D
    0059403517 007003 04/10/2023 04/06/2023 04/06/2023 A0380 30.00 82.50 82.50 82.50 0.00 0.00 0.00 0.00 D

    Patient Acct. # 1092 Claim Totals : 505.00 505.00 505.00 0.00 0.00 0.00 0.00

    0059412357 001002 04/10/2023 04/06/2023 04/06/2023 A0420 2.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059412357 002002 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059412357 003002 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059412357 004002 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059412357 005002 04/10/2023 04/06/2023 04/06/2023 A0380 30.00 82.50 82.50 0.00 0.00 0.00 0.00 82.50 P A1
    0059412357 006002 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059412357 007002 04/10/2023 04/06/2023 04/06/2023 A0380 30.00 82.50 82.50 0.00 0.00 0.00 0.00 82.50 P A1

    Patient Acct. # 1092 Claim Totals : 505.00 505.00 0.00 0.00 0.00 0.00 505.00

    Member Totals : 1,010.00 1,010.00 505.00 0.00 0.00 0.00 505.00

    20080700245600 Medicare HEARD, MICHAEL D BEST TRANSPORTATION LLC


    0059403533 001003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 20.00 0.00 0.00 0.00 0.00 D
    0059403533 002003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 140.00 0.00 0.00 0.00 0.00 D
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 13

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059403533 003003 04/10/2023 04/06/2023 04/06/2023 A0380 5.00 13.75 13.75 13.75 0.00 0.00 0.00 0.00 D

    Patient Acct. # 1116 Claim Totals : 173.75 173.75 173.75 0.00 0.00 0.00 0.00

    0059412388 001002 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059412388 002002 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059412388 003002 04/10/2023 04/06/2023 04/06/2023 A0380 5.00 13.75 13.75 0.00 0.00 0.00 0.00 13.75 P A1

    Patient Acct. # 1116 Claim Totals : 173.75 173.75 0.00 0.00 0.00 0.00 173.75

    Member Totals : 347.50 347.50 173.75 0.00 0.00 0.00 173.75

    40000080232500 Medi-Cal JACOBS, KEVIN D BEST TRANSPORTATION LLC


    0059403553 001003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403553 002003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403553 003003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403553 004003 04/10/2023 04/06/2023 04/06/2023 A0380 63.00 173.25 173.25 0.00 0.00 0.00 0.00 173.25 P A1

    Patient Acct. # 1117 Claim Totals : 343.25 343.25 0.00 0.00 0.00 0.00 343.25

    Member Totals : 343.25 343.25 0.00 0.00 0.00 0.00 343.25

    40000029901300 Medicare KATZ, MARK D BEST TRANSPORTATION LLC


    0059403559 001003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 20.00 0.00 0.00 0.00 0.00 D
    0059403559 002003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 140.00 0.00 0.00 0.00 0.00 D
    0059403559 003003 04/10/2023 04/06/2023 04/06/2023 A0380 6.00 16.50 16.50 16.50 0.00 0.00 0.00 0.00 D

    Patient Acct. # 1118 Claim Totals : 176.50 176.50 176.50 0.00 0.00 0.00 0.00

    0059412413 001002 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059412413 002002 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059412413 003002 04/10/2023 04/06/2023 04/06/2023 A0380 6.00 16.50 16.50 0.00 0.00 0.00 0.00 16.50 P A1

    Patient Acct. # 1118 Claim Totals : 176.50 176.50 0.00 0.00 0.00 0.00 176.50

    Member Totals : 353.00 353.00 176.50 0.00 0.00 0.00 176.50

    20171000152400 Medi-Cal KING, JOHN D BEST TRANSPORTATION LLC


    0059403289 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403289 002003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403289 003003 04/10/2023 04/06/2023 04/06/2023 A0425 23.00 57.04 57.04 0.00 0.00 0.00 0.00 57.04 P A1
    0059403289 004003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403289 005003 04/10/2023 04/06/2023 04/06/2023 A0425 23.00 57.04 57.04 0.00 0.00 0.00 0.00 57.04 P A1

    Patient Acct. # 513 Claim Totals : 138.08 138.08 0.00 0.00 0.00 0.00 138.08

    0059407938 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407938 002003 04/10/2023 04/07/2023 04/07/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059407938 003003 04/10/2023 04/07/2023 04/07/2023 A0425 23.00 57.04 57.04 0.00 0.00 0.00 0.00 57.04 P A1
    0059407938 004003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407938 005003 04/10/2023 04/07/2023 04/07/2023 A0425 23.00 57.04 57.04 0.00 0.00 0.00 0.00 57.04 P A1

    Patient Acct. # 513 Claim Totals : 138.08 138.08 0.00 0.00 0.00 0.00 138.08
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 14

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059489554 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489554 002003 04/11/2023 04/08/2023 04/08/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1
    0059489554 003003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489554 004003 04/11/2023 04/08/2023 04/08/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1

    Patient Acct. # 513 Claim Totals : 133.04 133.04 0.00 0.00 0.00 0.00 133.04

    0059553216 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553216 002003 04/12/2023 04/10/2023 04/10/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1
    0059553216 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553216 004003 04/12/2023 04/10/2023 04/10/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1

    Patient Acct. # 513 Claim Totals : 133.04 133.04 0.00 0.00 0.00 0.00 133.04

    Member Totals : 542.24 542.24 0.00 0.00 0.00 0.00 542.24

    40000093189600 Medi-Cal KLEIN, JAMES D BEST TRANSPORTATION LLC


    0059403182 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403182 002003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403182 003003 04/10/2023 04/06/2023 04/06/2023 A0425 41.00 101.68 101.68 0.00 0.00 0.00 0.00 101.68 P A1
    0059403182 004003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403182 005003 04/10/2023 04/06/2023 04/06/2023 A0425 41.00 101.68 101.68 0.00 0.00 0.00 0.00 101.68 P A1

    Patient Acct. # 236 Claim Totals : 227.36 227.36 0.00 0.00 0.00 0.00 227.36

    0059407877 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407877 002003 04/10/2023 04/07/2023 04/07/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059407877 003003 04/10/2023 04/07/2023 04/07/2023 A0425 41.00 101.68 101.68 0.00 0.00 0.00 0.00 101.68 P A1
    0059407877 004003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407877 005003 04/10/2023 04/07/2023 04/07/2023 A0425 41.00 101.68 101.68 0.00 0.00 0.00 0.00 101.68 P A1

    Patient Acct. # 236 Claim Totals : 227.36 227.36 0.00 0.00 0.00 0.00 227.36

    0059489427 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489427 002003 04/11/2023 04/08/2023 04/08/2023 A0425 41.00 101.68 101.68 0.00 0.00 0.00 0.00 101.68 P A1
    0059489427 003003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489427 004003 04/11/2023 04/08/2023 04/08/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059489427 005003 04/11/2023 04/08/2023 04/08/2023 A0425 41.00 101.68 101.68 0.00 0.00 0.00 0.00 101.68 P A1

    Patient Acct. # 236 Claim Totals : 227.36 227.36 0.00 0.00 0.00 0.00 227.36

    0059490099 001003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490099 002003 04/11/2023 04/09/2023 04/09/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059490099 003003 04/11/2023 04/09/2023 04/09/2023 A0425 41.00 101.68 101.68 0.00 0.00 0.00 0.00 101.68 P A1
    0059490099 004003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490099 005003 04/11/2023 04/09/2023 04/09/2023 A0425 41.00 101.68 101.68 0.00 0.00 0.00 0.00 101.68 P A1

    Patient Acct. # 236 Claim Totals : 227.36 227.36 0.00 0.00 0.00 0.00 227.36

    0059553139 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 15

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059553139 002003 04/12/2023 04/10/2023 04/10/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059553139 003003 04/12/2023 04/10/2023 04/10/2023 A0425 41.00 101.68 101.68 0.00 0.00 0.00 0.00 101.68 P A1
    0059553139 004003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553139 005003 04/12/2023 04/10/2023 04/10/2023 A0425 41.00 101.68 101.68 0.00 0.00 0.00 0.00 101.68 P A1

    Patient Acct. # 236 Claim Totals : 227.36 227.36 0.00 0.00 0.00 0.00 227.36

    Member Totals : 1,136.80 1,136.80 0.00 0.00 0.00 0.00 1,136.80

    40000097599800 Medi-Cal KNIGHT, TERESA D BEST TRANSPORTATION LLC


    0059403354 001003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403354 002003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403354 003003 04/10/2023 04/06/2023 04/06/2023 T2005 TP 1.00 102.50 102.50 0.00 0.00 0.00 0.00 102.50 P A1
    0059403354 004003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403354 005003 04/10/2023 04/06/2023 04/06/2023 T2005 TP 1.00 102.50 102.50 0.00 0.00 0.00 0.00 102.50 P A1

    Patient Acct. # 719 Claim Totals : 255.00 255.00 0.00 0.00 0.00 0.00 255.00

    0059553266 001003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553266 002003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553266 003003 04/12/2023 04/10/2023 04/10/2023 T2005 TP 1.00 102.50 102.50 0.00 0.00 0.00 0.00 102.50 P A1
    0059553266 004003 04/12/2023 04/10/2023 04/10/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059553266 005003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553266 006003 04/12/2023 04/10/2023 04/10/2023 A0380 2.00 5.50 5.50 0.00 0.00 0.00 0.00 5.50 P A1

    Patient Acct. # 719 Claim Totals : 298.00 298.00 0.00 0.00 0.00 0.00 298.00

    Member Totals : 553.00 553.00 0.00 0.00 0.00 0.00 553.00

    20120200478700 Medi-Cal LAKE, RANDALL D BEST TRANSPORTATION LLC


    0059553145 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553145 002003 04/12/2023 04/10/2023 04/10/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059553145 003003 04/12/2023 04/10/2023 04/10/2023 A0425 29.00 71.92 71.92 0.00 0.00 0.00 0.00 71.92 P A1
    0059553145 004003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553145 005003 04/12/2023 04/10/2023 04/10/2023 A0425 29.00 71.92 71.92 0.00 0.00 0.00 0.00 71.92 P A1

    Patient Acct. # 283 Claim Totals : 167.84 167.84 0.00 0.00 0.00 0.00 167.84

    Member Totals : 167.84 167.84 0.00 0.00 0.00 0.00 167.84

    40000098485100 Medicare LARA, ALEXANDRO D BEST TRANSPORTATION LLC


    0059403369 001003 04/10/2023 04/06/2023 04/06/2023 A0130 1.00 15.00 15.00 15.00 0.00 0.00 0.00 0.00 D
    0059403369 002003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 10.00 0.00 0.00 0.00 0.00 D
    0059403369 003003 04/10/2023 04/06/2023 04/06/2023 A0380 3.00 8.25 8.25 8.25 0.00 0.00 0.00 0.00 D
    0059403369 004003 04/10/2023 04/06/2023 04/06/2023 A0130 1.00 15.00 15.00 15.00 0.00 0.00 0.00 0.00 D
    0059403369 005003 04/10/2023 04/06/2023 04/06/2023 A0380 3.00 8.25 8.25 8.25 0.00 0.00 0.00 0.00 D

    Patient Acct. # 720 Claim Totals : 56.50 56.50 56.50 0.00 0.00 0.00 0.00

    0059412150 001002 04/10/2023 04/06/2023 04/06/2023 A0130 1.00 15.00 15.00 0.00 0.00 0.00 0.00 15.00 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 16

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059412150 002002 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059412150 003002 04/10/2023 04/06/2023 04/06/2023 A0380 3.00 8.25 8.25 0.00 0.00 0.00 0.00 8.25 P A1
    0059412150 004002 04/10/2023 04/06/2023 04/06/2023 A0130 1.00 15.00 15.00 0.00 0.00 0.00 0.00 15.00 P A1
    0059412150 005002 04/10/2023 04/06/2023 04/06/2023 A0380 3.00 8.25 8.25 0.00 0.00 0.00 0.00 8.25 P A1

    Patient Acct. # 720 Claim Totals : 56.50 56.50 0.00 0.00 0.00 0.00 56.50

    0059489681 001003 04/11/2023 04/08/2023 04/08/2023 A0130 1.00 15.00 15.00 15.00 0.00 0.00 0.00 0.00 D
    0059489681 002003 04/11/2023 04/08/2023 04/08/2023 A0428 UJ 1.00 10.00 10.00 10.00 0.00 0.00 0.00 0.00 D
    0059489681 003003 04/11/2023 04/08/2023 04/08/2023 A0380 3.00 8.25 8.25 8.25 0.00 0.00 0.00 0.00 D
    0059489681 004003 04/11/2023 04/08/2023 04/08/2023 A0130 1.00 15.00 15.00 15.00 0.00 0.00 0.00 0.00 D
    0059489681 005003 04/11/2023 04/08/2023 04/08/2023 A0380 3.00 8.25 8.25 8.25 0.00 0.00 0.00 0.00 D

    Patient Acct. # 720 Claim Totals : 56.50 56.50 56.50 0.00 0.00 0.00 0.00

    0059503594 001002 04/11/2023 04/08/2023 04/08/2023 A0130 1.00 15.00 15.00 0.00 0.00 0.00 0.00 15.00 P A1
    0059503594 002002 04/11/2023 04/08/2023 04/08/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059503594 003002 04/11/2023 04/08/2023 04/08/2023 A0380 3.00 8.25 8.25 0.00 0.00 0.00 0.00 8.25 P A1
    0059503594 004002 04/11/2023 04/08/2023 04/08/2023 A0130 1.00 15.00 15.00 0.00 0.00 0.00 0.00 15.00 P A1
    0059503594 005002 04/11/2023 04/08/2023 04/08/2023 A0380 3.00 8.25 8.25 0.00 0.00 0.00 0.00 8.25 P A1

    Patient Acct. # 720 Claim Totals : 56.50 56.50 0.00 0.00 0.00 0.00 56.50

    Member Totals : 226.00 226.00 113.00 0.00 0.00 0.00 113.00

    20060001594800 Medi-Cal LARA, JOEL D BEST TRANSPORTATION LLC


    0059403266 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403266 002003 04/10/2023 04/06/2023 04/06/2023 A0425 53.00 131.44 131.44 0.00 0.00 0.00 0.00 131.44 P A1
    0059403266 003003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403266 004003 04/10/2023 04/06/2023 04/06/2023 A0425 53.00 131.44 131.44 0.00 0.00 0.00 0.00 131.44 P A1

    Patient Acct. # 502 Claim Totals : 276.88 276.88 0.00 0.00 0.00 0.00 276.88

    0059407932 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407932 002003 04/10/2023 04/07/2023 04/07/2023 A0425 53.00 131.44 131.44 0.00 0.00 0.00 0.00 131.44 P A1
    0059407932 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407932 004003 04/10/2023 04/07/2023 04/07/2023 A0425 53.00 131.44 131.44 0.00 0.00 0.00 0.00 131.44 P A1

    Patient Acct. # 502 Claim Totals : 276.88 276.88 0.00 0.00 0.00 0.00 276.88

    0059489538 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489538 002003 04/11/2023 04/08/2023 04/08/2023 A0425 47.00 116.56 116.56 0.00 0.00 0.00 0.00 116.56 P A1
    0059489538 003003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489538 004003 04/11/2023 04/08/2023 04/08/2023 A0425 47.00 116.56 116.56 0.00 0.00 0.00 0.00 116.56 P A1

    Patient Acct. # 502 Claim Totals : 247.12 247.12 0.00 0.00 0.00 0.00 247.12

    0059553205 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553205 002003 04/12/2023 04/10/2023 04/10/2023 A0425 47.00 116.56 116.56 0.00 0.00 0.00 0.00 116.56 P A1
    0059553205 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 17

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059553205 004003 04/12/2023 04/10/2023 04/10/2023 A0425 47.00 116.56 116.56 0.00 0.00 0.00 0.00 116.56 P A1

    Patient Acct. # 502 Claim Totals : 247.12 247.12 0.00 0.00 0.00 0.00 247.12

    Member Totals : 1,048.00 1,048.00 0.00 0.00 0.00 0.00 1,048.00

    20140300613500 Medi-Cal LARA, MICHAEL D BEST TRANSPORTATION LLC


    0059403258 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403258 002003 04/10/2023 04/06/2023 04/06/2023 A0425 26.00 64.48 64.48 0.00 0.00 0.00 0.00 64.48 P A1
    0059403258 003003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403258 004003 04/10/2023 04/06/2023 04/06/2023 A0425 26.00 64.48 64.48 0.00 0.00 0.00 0.00 64.48 P A1

    Patient Acct. # 463 Claim Totals : 142.96 142.96 0.00 0.00 0.00 0.00 142.96

    Member Totals : 142.96 142.96 0.00 0.00 0.00 0.00 142.96

    19971001120000 Medi-Cal LAWRENCE, HEATHER D BEST TRANSPORTATION LLC


    0059403501 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403501 002003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403501 003003 04/10/2023 04/06/2023 04/06/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059403501 004003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403501 005003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403501 006003 04/10/2023 04/06/2023 04/06/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 1072 Claim Totals : 192.72 192.72 0.00 0.00 0.00 0.00 192.72

    0059408107 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408107 002003 04/10/2023 04/07/2023 04/07/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059408107 003003 04/10/2023 04/07/2023 04/07/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059408107 004003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408107 005003 04/10/2023 04/07/2023 04/07/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 1072 Claim Totals : 182.72 182.72 0.00 0.00 0.00 0.00 182.72

    0059489922 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489922 002003 04/11/2023 04/08/2023 04/08/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059489922 003003 04/11/2023 04/08/2023 04/08/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059489922 004003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489922 005003 04/11/2023 04/08/2023 04/08/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 1072 Claim Totals : 182.72 182.72 0.00 0.00 0.00 0.00 182.72

    0059553358 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553358 002003 04/12/2023 04/10/2023 04/10/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059553358 003003 04/12/2023 04/10/2023 04/10/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059553358 004003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553358 005003 04/12/2023 04/10/2023 04/10/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 1072 Claim Totals : 182.72 182.72 0.00 0.00 0.00 0.00 182.72

    Member Totals : 740.88 740.88 0.00 0.00 0.00 0.00 740.88


    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 18

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    40000091565000 Medi-Cal LEONARD, PATRICK D BEST TRANSPORTATION LLC


    0059403303 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403303 002003 04/10/2023 04/06/2023 04/06/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1
    0059403303 003003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403303 004003 04/10/2023 04/06/2023 04/06/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1

    Patient Acct. # 591 Claim Totals : 1,006.00 1,006.00 0.00 0.00 0.00 0.00 1,006.00

    0059407957 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407957 002003 04/10/2023 04/07/2023 04/07/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1
    0059407957 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407957 004003 04/10/2023 04/07/2023 04/07/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1

    Patient Acct. # 591 Claim Totals : 1,006.00 1,006.00 0.00 0.00 0.00 0.00 1,006.00

    0059489585 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489585 002003 04/11/2023 04/08/2023 04/08/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1
    0059489585 003003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489585 004003 04/11/2023 04/08/2023 04/08/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1

    Patient Acct. # 591 Claim Totals : 1,006.00 1,006.00 0.00 0.00 0.00 0.00 1,006.00

    0059490163 001003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490163 002003 04/11/2023 04/09/2023 04/09/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1
    0059490163 003003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490163 004003 04/11/2023 04/09/2023 04/09/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1

    Patient Acct. # 591 Claim Totals : 1,006.00 1,006.00 0.00 0.00 0.00 0.00 1,006.00

    0059553236 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553236 002003 04/12/2023 04/10/2023 04/10/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1
    0059553236 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553236 004003 04/12/2023 04/10/2023 04/10/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1

    Patient Acct. # 591 Claim Totals : 1,006.00 1,006.00 0.00 0.00 0.00 0.00 1,006.00

    Member Totals : 5,030.00 5,030.00 0.00 0.00 0.00 0.00 5,030.00

    20151201067200 Medi-Cal LEONARD, RICK D BEST TRANSPORTATION LLC


    0059403312 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403312 002003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403312 003003 04/10/2023 04/06/2023 04/06/2023 A0425 21.00 52.08 52.08 0.00 0.00 0.00 0.00 52.08 P A1
    0059403312 004003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403312 005003 04/10/2023 04/06/2023 04/06/2023 A0425 21.00 52.08 52.08 0.00 0.00 0.00 0.00 52.08 P A1

    Patient Acct. # 592 Claim Totals : 128.16 128.16 0.00 0.00 0.00 0.00 128.16

    0059407963 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407963 002003 04/10/2023 04/07/2023 04/07/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059407963 003003 04/10/2023 04/07/2023 04/07/2023 A0425 21.00 52.08 52.08 0.00 0.00 0.00 0.00 52.08 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 19

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059407963 004003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407963 005003 04/10/2023 04/07/2023 04/07/2023 A0425 21.00 52.08 52.08 0.00 0.00 0.00 0.00 52.08 P A1

    Patient Acct. # 592 Claim Totals : 128.16 128.16 0.00 0.00 0.00 0.00 128.16

    0059489601 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489601 002003 04/11/2023 04/08/2023 04/08/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059489601 003003 04/11/2023 04/08/2023 04/08/2023 A0425 21.00 52.08 52.08 0.00 0.00 0.00 0.00 52.08 P A1
    0059489601 004003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489601 005003 04/11/2023 04/08/2023 04/08/2023 A0425 21.00 52.08 52.08 0.00 0.00 0.00 0.00 52.08 P A1

    Patient Acct. # 592 Claim Totals : 128.16 128.16 0.00 0.00 0.00 0.00 128.16

    0059553241 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553241 002003 04/12/2023 04/10/2023 04/10/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059553241 003003 04/12/2023 04/10/2023 04/10/2023 A0425 21.00 52.08 52.08 0.00 0.00 0.00 0.00 52.08 P A1
    0059553241 004003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553241 005003 04/12/2023 04/10/2023 04/10/2023 A0425 21.00 52.08 52.08 0.00 0.00 0.00 0.00 52.08 P A1

    Patient Acct. # 592 Claim Totals : 128.16 128.16 0.00 0.00 0.00 0.00 128.16

    Member Totals : 512.64 512.64 0.00 0.00 0.00 0.00 512.64

    20150101207800 Medi-Cal LEZAMA, MARIA D BEST TRANSPORTATION LLC


    0059407840 001003 04/10/2023 04/07/2023 04/07/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059407840 002003 04/10/2023 04/07/2023 04/07/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059407840 003003 04/10/2023 04/07/2023 04/07/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059407840 004003 04/10/2023 04/07/2023 04/07/2023 A0380 6.00 16.50 16.50 0.00 0.00 0.00 0.00 16.50 P A1
    0059407840 005003 04/10/2023 04/07/2023 04/07/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059407840 006003 04/10/2023 04/07/2023 04/07/2023 A0380 6.00 16.50 16.50 0.00 0.00 0.00 0.00 16.50 P A1

    Patient Acct. # 135 Claim Totals : 353.00 353.00 0.00 0.00 0.00 0.00 353.00

    0059553125 001003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553125 002003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553125 003003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553125 004003 04/12/2023 04/10/2023 04/10/2023 A0380 6.00 16.50 16.50 0.00 0.00 0.00 0.00 16.50 P A1
    0059553125 005003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553125 006003 04/12/2023 04/10/2023 04/10/2023 A0380 6.00 16.50 16.50 0.00 0.00 0.00 0.00 16.50 P A1

    Patient Acct. # 135 Claim Totals : 353.00 353.00 0.00 0.00 0.00 0.00 353.00

    Member Totals : 706.00 706.00 0.00 0.00 0.00 0.00 706.00

    20020400145900 Medi-Cal LINCOURT, MATTHEW D BEST TRANSPORTATION LLC


    0059403510 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403510 002003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403510 003003 04/10/2023 04/06/2023 04/06/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059403510 004003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 20

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059403510 005003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403510 006003 04/10/2023 04/06/2023 04/06/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 1073 Claim Totals : 192.72 192.72 0.00 0.00 0.00 0.00 192.72

    0059408114 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408114 002003 04/10/2023 04/07/2023 04/07/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059408114 003003 04/10/2023 04/07/2023 04/07/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059408114 004003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408114 005003 04/10/2023 04/07/2023 04/07/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 1073 Claim Totals : 182.72 182.72 0.00 0.00 0.00 0.00 182.72

    0059489940 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489940 002003 04/11/2023 04/08/2023 04/08/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059489940 003003 04/11/2023 04/08/2023 04/08/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059489940 004003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489940 005003 04/11/2023 04/08/2023 04/08/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 1073 Claim Totals : 182.72 182.72 0.00 0.00 0.00 0.00 182.72

    0059553362 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553362 002003 04/12/2023 04/10/2023 04/10/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059553362 003003 04/12/2023 04/10/2023 04/10/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1
    0059553362 004003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553362 005003 04/12/2023 04/10/2023 04/10/2023 A0425 32.00 79.36 79.36 0.00 0.00 0.00 0.00 79.36 P A1

    Patient Acct. # 1073 Claim Totals : 182.72 182.72 0.00 0.00 0.00 0.00 182.72

    Member Totals : 740.88 740.88 0.00 0.00 0.00 0.00 740.88

    40000052323200 Medi-Cal LOWRY, ASHLEY D BEST TRANSPORTATION LLC


    0059403211 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403211 002003 04/10/2023 04/06/2023 04/06/2023 A0425 150.00 372.00 372.00 0.00 0.00 0.00 0.00 372.00 P A1
    0059403211 003003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403211 004003 04/10/2023 04/06/2023 04/06/2023 A0425 150.00 372.00 372.00 0.00 0.00 0.00 0.00 372.00 P A1

    Patient Acct. # 328 Claim Totals : 758.00 758.00 0.00 0.00 0.00 0.00 758.00

    0059407905 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407905 002003 04/10/2023 04/07/2023 04/07/2023 A0425 149.00 369.52 369.52 0.00 0.00 0.00 0.00 369.52 P A1
    0059407905 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407905 004003 04/10/2023 04/07/2023 04/07/2023 A0425 149.00 369.52 369.52 0.00 0.00 0.00 0.00 369.52 P A1

    Patient Acct. # 328 Claim Totals : 753.04 753.04 0.00 0.00 0.00 0.00 753.04

    0059489479 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489479 002003 04/11/2023 04/08/2023 04/08/2023 A0425 149.00 369.52 369.52 0.00 0.00 0.00 0.00 369.52 P A1
    0059489479 003003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489479 004003 04/11/2023 04/08/2023 04/08/2023 A0425 149.00 369.52 369.52 0.00 0.00 0.00 0.00 369.52 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 21

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    Patient Acct. # 328 Claim Totals : 753.04 753.04 0.00 0.00 0.00 0.00 753.04

    0059490131 001003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490131 002003 04/11/2023 04/09/2023 04/09/2023 A0425 149.00 369.52 369.52 0.00 0.00 0.00 0.00 369.52 P A1
    0059490131 003003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490131 004003 04/11/2023 04/09/2023 04/09/2023 A0425 149.00 369.52 369.52 0.00 0.00 0.00 0.00 369.52 P A1

    Patient Acct. # 328 Claim Totals : 753.04 753.04 0.00 0.00 0.00 0.00 753.04

    0059553164 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553164 002003 04/12/2023 04/10/2023 04/10/2023 A0425 149.00 369.52 369.52 0.00 0.00 0.00 0.00 369.52 P A1
    0059553164 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553164 004003 04/12/2023 04/10/2023 04/10/2023 A0425 149.00 369.52 369.52 0.00 0.00 0.00 0.00 369.52 P A1

    Patient Acct. # 328 Claim Totals : 753.04 753.04 0.00 0.00 0.00 0.00 753.04

    Member Totals : 3,770.16 3,770.16 0.00 0.00 0.00 0.00 3,770.16

    40000089531600 Medi-Cal LUNA-REYNOSO, MARIA D BEST TRANSPORTATION LLC


    0059407844 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407844 002003 04/10/2023 04/07/2023 04/07/2023 A0425 6.00 14.88 14.88 0.00 0.00 0.00 0.00 14.88 P A1
    0059407844 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407844 004003 04/10/2023 04/07/2023 04/07/2023 A0425 6.00 14.88 14.88 0.00 0.00 0.00 0.00 14.88 P A1

    Patient Acct. # 137 Claim Totals : 43.76 43.76 0.00 0.00 0.00 0.00 43.76

    0059553129 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553129 002003 04/12/2023 04/10/2023 04/10/2023 A0425 6.00 14.88 14.88 0.00 0.00 0.00 0.00 14.88 P A1
    0059553129 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553129 004003 04/12/2023 04/10/2023 04/10/2023 A0425 6.00 14.88 14.88 0.00 0.00 0.00 0.00 14.88 P A1

    Patient Acct. # 137 Claim Totals : 43.76 43.76 0.00 0.00 0.00 0.00 43.76

    Member Totals : 87.52 87.52 0.00 0.00 0.00 0.00 87.52

    40000107411900 Medi-Cal LYNCH, STEVEN D BEST TRANSPORTATION LLC


    0059403568 001003 04/10/2023 04/06/2023 04/06/2023 A0424 2.00 40.00 40.00 0.00 0.00 0.00 0.00 40.00 P A1
    0059403568 002003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403568 003003 04/10/2023 04/06/2023 04/06/2023 A0380 80.00 220.00 220.00 0.00 0.00 0.00 0.00 220.00 P A1

    Patient Acct. # 1119 Claim Totals : 400.00 400.00 0.00 0.00 0.00 0.00 400.00

    Member Totals : 400.00 400.00 0.00 0.00 0.00 0.00 400.00

    19971001214300 Medi-Cal MACIAS, ANTOINETTE D BEST TRANSPORTATION LLC


    0059403340 001003 04/10/2023 04/06/2023 04/06/2023 A0130 1.00 15.00 15.00 0.00 0.00 0.00 0.00 15.00 P A1
    0059403340 002003 04/10/2023 04/06/2023 04/06/2023 A0380 21.00 57.75 57.75 0.00 0.00 0.00 0.00 57.75 P A1
    0059403340 003003 04/10/2023 04/06/2023 04/06/2023 A0130 1.00 15.00 15.00 0.00 0.00 0.00 0.00 15.00 P A1
    0059403340 004003 04/10/2023 04/06/2023 04/06/2023 A0380 21.00 57.75 57.75 0.00 0.00 0.00 0.00 57.75 P A1

    Patient Acct. # 655 Claim Totals : 145.50 145.50 0.00 0.00 0.00 0.00 145.50

    0059553256 001003 04/12/2023 04/10/2023 04/10/2023 A0130 1.00 15.00 15.00 0.00 0.00 0.00 0.00 15.00 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 22

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059553256 002003 04/12/2023 04/10/2023 04/10/2023 A0380 21.00 57.75 57.75 0.00 0.00 0.00 0.00 57.75 P A1
    0059553256 003003 04/12/2023 04/10/2023 04/10/2023 A0130 1.00 15.00 15.00 0.00 0.00 0.00 0.00 15.00 P A1
    0059553256 004003 04/12/2023 04/10/2023 04/10/2023 A0380 21.00 57.75 57.75 0.00 0.00 0.00 0.00 57.75 P A1

    Patient Acct. # 655 Claim Totals : 145.50 145.50 0.00 0.00 0.00 0.00 145.50

    Member Totals : 291.00 291.00 0.00 0.00 0.00 0.00 291.00

    20110700621400 Medi-Cal MARTINEZ, ROSA D BEST TRANSPORTATION LLC


    0059403470 001003 04/10/2023 04/06/2023 04/06/2023 A0420 2.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403470 002003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403470 003003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403470 004003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403470 005003 04/10/2023 04/06/2023 04/06/2023 A0380 18.00 49.50 49.50 0.00 0.00 0.00 0.00 49.50 P A1
    0059403470 006003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403470 007003 04/10/2023 04/06/2023 04/06/2023 A0380 18.00 49.50 49.50 0.00 0.00 0.00 0.00 49.50 P A1

    Patient Acct. # 998 Claim Totals : 439.00 439.00 0.00 0.00 0.00 0.00 439.00

    0059408093 001003 04/10/2023 04/07/2023 04/07/2023 A0420 2.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059408093 002003 04/10/2023 04/07/2023 04/07/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059408093 003003 04/10/2023 04/07/2023 04/07/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059408093 004003 04/10/2023 04/07/2023 04/07/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059408093 005003 04/10/2023 04/07/2023 04/07/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059408093 006003 04/10/2023 04/07/2023 04/07/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059408093 007003 04/10/2023 04/07/2023 04/07/2023 A0380 13.00 35.75 35.75 0.00 0.00 0.00 0.00 35.75 P A1
    0059408093 008003 04/10/2023 04/07/2023 04/07/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059408093 009003 04/10/2023 04/07/2023 04/07/2023 A0380 13.00 35.75 35.75 0.00 0.00 0.00 0.00 35.75 P A1
    0059408093 010003 04/10/2023 04/07/2023 04/07/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059408093 011003 04/10/2023 04/07/2023 04/07/2023 A0380 13.00 35.75 35.75 0.00 0.00 0.00 0.00 35.75 P A1
    0059408093 012003 04/10/2023 04/07/2023 04/07/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1

    Patient Acct. # 998 Claim Totals : 767.25 767.25 0.00 0.00 0.00 0.00 767.25

    0059408099 001003 04/10/2023 04/07/2023 04/07/2023 A0380 13.00 35.75 35.75 35.75 0.00 0.00 0.00 0.00 D DCS

    Patient Acct. # 998 Claim Totals : 35.75 35.75 35.75 0.00 0.00 0.00 0.00

    0059489888 001003 04/11/2023 04/08/2023 04/08/2023 A0420 2.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059489888 002003 04/11/2023 04/08/2023 04/08/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059489888 003003 04/11/2023 04/08/2023 04/08/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059489888 004003 04/11/2023 04/08/2023 04/08/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059489888 005003 04/11/2023 04/08/2023 04/08/2023 A0380 18.00 49.50 49.50 0.00 0.00 0.00 0.00 49.50 P A1
    0059489888 006003 04/11/2023 04/08/2023 04/08/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059489888 007003 04/11/2023 04/08/2023 04/08/2023 A0380 18.00 49.50 49.50 0.00 0.00 0.00 0.00 49.50 P A1

    Patient Acct. # 998 Claim Totals : 439.00 439.00 0.00 0.00 0.00 0.00 439.00
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 23

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059490275 001003 04/11/2023 04/09/2023 04/09/2023 A0420 2.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059490275 002003 04/11/2023 04/09/2023 04/09/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059490275 003003 04/11/2023 04/09/2023 04/09/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059490275 004003 04/11/2023 04/09/2023 04/09/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059490275 005003 04/11/2023 04/09/2023 04/09/2023 A0380 18.00 49.50 49.50 0.00 0.00 0.00 0.00 49.50 P A1
    0059490275 006003 04/11/2023 04/09/2023 04/09/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059490275 007003 04/11/2023 04/09/2023 04/09/2023 A0380 18.00 49.50 49.50 0.00 0.00 0.00 0.00 49.50 P A1

    Patient Acct. # 998 Claim Totals : 439.00 439.00 0.00 0.00 0.00 0.00 439.00

    0059553348 001003 04/12/2023 04/10/2023 04/10/2023 A0420 2.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553348 002003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553348 003003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553348 004003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553348 005003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553348 006003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553348 007003 04/12/2023 04/10/2023 04/10/2023 A0380 13.00 35.75 35.75 0.00 0.00 0.00 0.00 35.75 P A1
    0059553348 008003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553348 009003 04/12/2023 04/10/2023 04/10/2023 A0380 13.00 35.75 35.75 0.00 0.00 0.00 0.00 35.75 P A1
    0059553348 010003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553348 011003 04/12/2023 04/10/2023 04/10/2023 A0380 8.00 22.00 22.00 0.00 0.00 0.00 0.00 22.00 P A1
    0059553348 012003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1

    Patient Acct. # 998 Claim Totals : 753.50 753.50 0.00 0.00 0.00 0.00 753.50

    0059553353 001003 04/12/2023 04/10/2023 04/10/2023 A0380 8.00 22.00 22.00 22.00 0.00 0.00 0.00 0.00 D DCS

    Patient Acct. # 998 Claim Totals : 22.00 22.00 22.00 0.00 0.00 0.00 0.00

    Member Totals : 2,895.50 2,895.50 57.75 0.00 0.00 0.00 2,837.75

    20140101312200 Medi-Cal MARTINEZ, VICTOR D BEST TRANSPORTATION LLC


    0059403403 001003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403403 002003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403403 003003 04/10/2023 04/06/2023 04/06/2023 A0425 67.00 166.16 166.16 0.00 0.00 0.00 0.00 166.16 P A1
    0059403403 004003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403403 005003 04/10/2023 04/06/2023 04/06/2023 A0425 67.00 166.16 166.16 0.00 0.00 0.00 0.00 166.16 P A1

    Patient Acct. # 849 Claim Totals : 356.32 356.32 0.00 0.00 0.00 0.00 356.32

    0059408037 001003 04/10/2023 04/07/2023 04/07/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059408037 002003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408037 003003 04/10/2023 04/07/2023 04/07/2023 A0425 67.00 166.16 166.16 0.00 0.00 0.00 0.00 166.16 P A1
    0059408037 004003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408037 005003 04/10/2023 04/07/2023 04/07/2023 A0425 67.00 166.16 166.16 0.00 0.00 0.00 0.00 166.16 P A1

    Patient Acct. # 849 Claim Totals : 356.32 356.32 0.00 0.00 0.00 0.00 356.32
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 24

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059489776 001003 04/11/2023 04/08/2023 04/08/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059489776 002003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489776 003003 04/11/2023 04/08/2023 04/08/2023 A0425 67.00 166.16 166.16 0.00 0.00 0.00 0.00 166.16 P A1
    0059489776 004003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489776 005003 04/11/2023 04/08/2023 04/08/2023 A0425 67.00 166.16 166.16 0.00 0.00 0.00 0.00 166.16 P A1

    Patient Acct. # 849 Claim Totals : 356.32 356.32 0.00 0.00 0.00 0.00 356.32

    0059490244 001003 04/11/2023 04/09/2023 04/09/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059490244 002003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490244 003003 04/11/2023 04/09/2023 04/09/2023 A0425 67.00 166.16 166.16 0.00 0.00 0.00 0.00 166.16 P A1
    0059490244 004003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490244 005003 04/11/2023 04/09/2023 04/09/2023 A0425 67.00 166.16 166.16 0.00 0.00 0.00 0.00 166.16 P A1

    Patient Acct. # 849 Claim Totals : 356.32 356.32 0.00 0.00 0.00 0.00 356.32

    0059553303 001003 04/12/2023 04/10/2023 04/10/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059553303 002003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553303 003003 04/12/2023 04/10/2023 04/10/2023 A0425 68.00 168.64 168.64 0.00 0.00 0.00 0.00 168.64 P A1
    0059553303 004003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553303 005003 04/12/2023 04/10/2023 04/10/2023 A0425 68.00 168.64 168.64 0.00 0.00 0.00 0.00 168.64 P A1

    Patient Acct. # 849 Claim Totals : 361.28 361.28 0.00 0.00 0.00 0.00 361.28

    Member Totals : 1,786.56 1,786.56 0.00 0.00 0.00 0.00 1,786.56

    20160600601200 Medi-Cal MEDINA, DANIEL D BEST TRANSPORTATION LLC


    0059403229 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403229 002003 04/10/2023 04/06/2023 04/06/2023 A0425 6.00 14.88 14.88 0.00 0.00 0.00 0.00 14.88 P A1
    0059403229 003003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403229 004003 04/10/2023 04/06/2023 04/06/2023 A0425 6.00 14.88 14.88 0.00 0.00 0.00 0.00 14.88 P A1

    Patient Acct. # 359 Claim Totals : 43.76 43.76 0.00 0.00 0.00 0.00 43.76

    0059553186 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553186 002003 04/12/2023 04/10/2023 04/10/2023 A0425 6.00 14.88 14.88 0.00 0.00 0.00 0.00 14.88 P A1
    0059553186 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553186 004003 04/12/2023 04/10/2023 04/10/2023 A0425 6.00 14.88 14.88 0.00 0.00 0.00 0.00 14.88 P A1

    Patient Acct. # 359 Claim Totals : 43.76 43.76 0.00 0.00 0.00 0.00 43.76

    Member Totals : 87.52 87.52 0.00 0.00 0.00 0.00 87.52

    20141102292100 Medi-Cal MEDINA, MIKE D BEST TRANSPORTATION LLC


    0059403275 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403275 002003 04/10/2023 04/06/2023 04/06/2023 A0425 6.00 14.88 14.88 0.00 0.00 0.00 0.00 14.88 P A1
    0059403275 003003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403275 004003 04/10/2023 04/06/2023 04/06/2023 A0425 6.00 14.88 14.88 0.00 0.00 0.00 0.00 14.88 P A1

    Patient Acct. # 508 Claim Totals : 43.76 43.76 0.00 0.00 0.00 0.00 43.76
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 25

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059553210 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553210 002003 04/12/2023 04/10/2023 04/10/2023 A0425 6.00 14.88 14.88 0.00 0.00 0.00 0.00 14.88 P A1
    0059553210 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553210 004003 04/12/2023 04/10/2023 04/10/2023 A0425 6.00 14.88 14.88 0.00 0.00 0.00 0.00 14.88 P A1

    Patient Acct. # 508 Claim Totals : 43.76 43.76 0.00 0.00 0.00 0.00 43.76

    Member Totals : 87.52 87.52 0.00 0.00 0.00 0.00 87.52

    40000041269000 Medi-Cal MEDINA, RICHARD D BEST TRANSPORTATION LLC


    0059403222 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403222 002003 04/10/2023 04/06/2023 04/06/2023 A0425 6.00 14.88 14.88 0.00 0.00 0.00 0.00 14.88 P A1
    0059403222 003003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403222 004003 04/10/2023 04/06/2023 04/06/2023 A0425 6.00 14.88 14.88 0.00 0.00 0.00 0.00 14.88 P A1

    Patient Acct. # 357 Claim Totals : 43.76 43.76 0.00 0.00 0.00 0.00 43.76

    0059553181 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553181 002003 04/12/2023 04/10/2023 04/10/2023 A0425 6.00 14.88 14.88 0.00 0.00 0.00 0.00 14.88 P A1
    0059553181 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553181 004003 04/12/2023 04/10/2023 04/10/2023 A0425 6.00 14.88 14.88 0.00 0.00 0.00 0.00 14.88 P A1

    Patient Acct. # 357 Claim Totals : 43.76 43.76 0.00 0.00 0.00 0.00 43.76

    Member Totals : 87.52 87.52 0.00 0.00 0.00 0.00 87.52

    19990900573000 Medi-Cal MOONEY, MARIA D BEST TRANSPORTATION LLC


    0059408120 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408120 002003 04/10/2023 04/07/2023 04/07/2023 A0425 4.00 9.92 9.92 0.00 0.00 0.00 0.00 9.92 P A1
    0059408120 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408120 004003 04/10/2023 04/07/2023 04/07/2023 A0425 4.00 9.92 9.92 0.00 0.00 0.00 0.00 9.92 P A1

    Patient Acct. # 1080 Claim Totals : 33.84 33.84 0.00 0.00 0.00 0.00 33.84

    0059553367 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553367 002003 04/12/2023 04/10/2023 04/10/2023 A0425 4.00 9.92 9.92 0.00 0.00 0.00 0.00 9.92 P A1
    0059553367 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553367 004003 04/12/2023 04/10/2023 04/10/2023 A0425 4.00 9.92 9.92 0.00 0.00 0.00 0.00 9.92 P A1

    Patient Acct. # 1080 Claim Totals : 33.84 33.84 0.00 0.00 0.00 0.00 33.84

    Member Totals : 67.68 67.68 0.00 0.00 0.00 0.00 67.68

    40000103836100 Medi-Cal NORRIS, ANGELINE D BEST TRANSPORTATION LLC


    0059553394 001003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553394 002003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553394 003003 04/12/2023 04/10/2023 04/10/2023 A0380 25.00 68.75 68.75 0.00 0.00 0.00 0.00 68.75 P A1

    Patient Acct. # 1129 Claim Totals : 228.75 228.75 0.00 0.00 0.00 0.00 228.75

    Member Totals : 228.75 228.75 0.00 0.00 0.00 0.00 228.75


    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 26

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    40000088832800 Medi-Cal O' HAVER, STEVEN D BEST TRANSPORTATION LLC


    0059403239 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403239 002003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403239 003003 04/10/2023 04/06/2023 04/06/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1
    0059403239 004003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403239 005003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403239 006003 04/10/2023 04/06/2023 04/06/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1

    Patient Acct. # 429 Claim Totals : 153.04 153.04 0.00 0.00 0.00 0.00 153.04

    0059407920 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407920 002003 04/10/2023 04/07/2023 04/07/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059407920 003003 04/10/2023 04/07/2023 04/07/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1
    0059407920 004003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407920 005003 04/10/2023 04/07/2023 04/07/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059407920 006003 04/10/2023 04/07/2023 04/07/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1

    Patient Acct. # 429 Claim Totals : 153.04 153.04 0.00 0.00 0.00 0.00 153.04

    0059489506 001003 04/11/2023 04/08/2023 04/08/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059489506 002003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489506 003003 04/11/2023 04/08/2023 04/08/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059489506 004003 04/11/2023 04/08/2023 04/08/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1
    0059489506 005003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489506 006003 04/11/2023 04/08/2023 04/08/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1

    Patient Acct. # 429 Claim Totals : 153.04 153.04 0.00 0.00 0.00 0.00 153.04

    0059553190 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553190 002003 04/12/2023 04/10/2023 04/10/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059553190 003003 04/12/2023 04/10/2023 04/10/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1
    0059553190 004003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553190 005003 04/12/2023 04/10/2023 04/10/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059553190 006003 04/12/2023 04/10/2023 04/10/2023 A0425 24.00 59.52 59.52 0.00 0.00 0.00 0.00 59.52 P A1

    Patient Acct. # 429 Claim Totals : 153.04 153.04 0.00 0.00 0.00 0.00 153.04

    Member Totals : 612.16 612.16 0.00 0.00 0.00 0.00 612.16

    20170900561600 Medi-Cal PADRON, ISRAEL D BEST TRANSPORTATION LLC


    0059408075 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408075 002003 04/10/2023 04/07/2023 04/07/2023 A0425 157.00 389.36 389.36 0.00 0.00 0.00 0.00 389.36 P A1
    0059408075 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408075 004003 04/10/2023 04/07/2023 04/07/2023 A0425 157.00 389.36 389.36 0.00 0.00 0.00 0.00 389.36 P A1

    Patient Acct. # 943 Claim Totals : 792.72 792.72 0.00 0.00 0.00 0.00 792.72

    0059553327 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 27

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059553327 002003 04/12/2023 04/10/2023 04/10/2023 A0425 157.00 389.36 389.36 0.00 0.00 0.00 0.00 389.36 P A1
    0059553327 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553327 004003 04/12/2023 04/10/2023 04/10/2023 A0425 157.00 389.36 389.36 0.00 0.00 0.00 0.00 389.36 P A1

    Patient Acct. # 943 Claim Totals : 792.72 792.72 0.00 0.00 0.00 0.00 792.72

    Member Totals : 1,585.44 1,585.44 0.00 0.00 0.00 0.00 1,585.44

    40000100028400 Medi-Cal PENA, JOSE D BEST TRANSPORTATION LLC


    0059553293 001003 04/12/2023 04/10/2023 04/10/2023 A0420 2.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553293 002003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553293 003003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553293 004003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553293 005003 04/12/2023 04/10/2023 04/10/2023 A0380 8.00 22.00 22.00 0.00 0.00 0.00 0.00 22.00 P A1
    0059553293 006003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553293 007003 04/12/2023 04/10/2023 04/10/2023 A0380 8.00 22.00 22.00 0.00 0.00 0.00 0.00 22.00 P A1

    Patient Acct. # 787 Claim Totals : 384.00 384.00 0.00 0.00 0.00 0.00 384.00

    Member Totals : 384.00 384.00 0.00 0.00 0.00 0.00 384.00

    19980601078100 Medi-Cal PHILLIPS, ASHLEY D BEST TRANSPORTATION LLC


    0059403409 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403409 002003 04/10/2023 04/06/2023 04/06/2023 A0425 33.00 81.84 81.84 0.00 0.00 0.00 0.00 81.84 P A1
    0059403409 003003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403409 004003 04/10/2023 04/06/2023 04/06/2023 A0425 33.00 81.84 81.84 0.00 0.00 0.00 0.00 81.84 P A1

    Patient Acct. # 876 Claim Totals : 177.68 177.68 0.00 0.00 0.00 0.00 177.68

    0059408043 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408043 002003 04/10/2023 04/07/2023 04/07/2023 A0425 33.00 81.84 81.84 0.00 0.00 0.00 0.00 81.84 P A1
    0059408043 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408043 004003 04/10/2023 04/07/2023 04/07/2023 A0425 33.00 81.84 81.84 0.00 0.00 0.00 0.00 81.84 P A1

    Patient Acct. # 876 Claim Totals : 177.68 177.68 0.00 0.00 0.00 0.00 177.68

    0059489792 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489792 002003 04/11/2023 04/08/2023 04/08/2023 A0425 33.00 81.84 81.84 0.00 0.00 0.00 0.00 81.84 P A1
    0059489792 003003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489792 004003 04/11/2023 04/08/2023 04/08/2023 A0425 33.00 81.84 81.84 0.00 0.00 0.00 0.00 81.84 P A1

    Patient Acct. # 876 Claim Totals : 177.68 177.68 0.00 0.00 0.00 0.00 177.68

    0059553309 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553309 002003 04/12/2023 04/10/2023 04/10/2023 A0425 33.00 81.84 81.84 0.00 0.00 0.00 0.00 81.84 P A1
    0059553309 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553309 004003 04/12/2023 04/10/2023 04/10/2023 A0425 33.00 81.84 81.84 0.00 0.00 0.00 0.00 81.84 P A1

    Patient Acct. # 876 Claim Totals : 177.68 177.68 0.00 0.00 0.00 0.00 177.68

    Member Totals : 710.72 710.72 0.00 0.00 0.00 0.00 710.72


    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 28

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    20120300674100 Medicare PURVIS, ROBERT D BEST TRANSPORTATION LLC


    0059407861 001003 04/10/2023 04/07/2023 04/07/2023 A0420 2.00 20.00 20.00 20.00 0.00 0.00 0.00 0.00 D
    0059407861 002003 04/10/2023 04/07/2023 04/07/2023 A0424 1.00 20.00 20.00 20.00 0.00 0.00 0.00 0.00 D
    0059407861 003003 04/10/2023 04/07/2023 04/07/2023 A0424 1.00 20.00 20.00 20.00 0.00 0.00 0.00 0.00 D
    0059407861 004003 04/10/2023 04/07/2023 04/07/2023 T2005 1.00 140.00 140.00 140.00 0.00 0.00 0.00 0.00 D
    0059407861 005003 04/10/2023 04/07/2023 04/07/2023 A0380 9.00 24.75 24.75 24.75 0.00 0.00 0.00 0.00 D
    0059407861 006003 04/10/2023 04/07/2023 04/07/2023 T2005 1.00 140.00 140.00 140.00 0.00 0.00 0.00 0.00 D
    0059407861 007003 04/10/2023 04/07/2023 04/07/2023 A0380 9.00 24.75 24.75 24.75 0.00 0.00 0.00 0.00 D

    Patient Acct. # 183 Claim Totals : 389.50 389.50 389.50 0.00 0.00 0.00 0.00

    0059415974 001002 04/10/2023 04/07/2023 04/07/2023 A0420 2.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059415974 002002 04/10/2023 04/07/2023 04/07/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059415974 003002 04/10/2023 04/07/2023 04/07/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059415974 004002 04/10/2023 04/07/2023 04/07/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059415974 005002 04/10/2023 04/07/2023 04/07/2023 A0380 9.00 24.75 24.75 0.00 0.00 0.00 0.00 24.75 P A1
    0059415974 006002 04/10/2023 04/07/2023 04/07/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059415974 007002 04/10/2023 04/07/2023 04/07/2023 A0380 9.00 24.75 24.75 0.00 0.00 0.00 0.00 24.75 P A1

    Patient Acct. # 183 Claim Totals : 389.50 389.50 0.00 0.00 0.00 0.00 389.50

    Member Totals : 779.00 779.00 389.50 0.00 0.00 0.00 389.50

    19970503161300 Medi-Cal REGALADO, SONIA D BEST TRANSPORTATION LLC


    0059553232 001003 04/12/2023 04/10/2023 04/10/2023 A0424 2.00 40.00 40.00 0.00 0.00 0.00 0.00 40.00 P A1
    0059553232 002003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553232 003003 04/12/2023 04/10/2023 04/10/2023 A0380 4.00 11.00 11.00 0.00 0.00 0.00 0.00 11.00 P A1

    Patient Acct. # 546 Claim Totals : 191.00 191.00 0.00 0.00 0.00 0.00 191.00

    Member Totals : 191.00 191.00 0.00 0.00 0.00 0.00 191.00

    20060003717300 Medi-Cal RENTERIA, ANGELINA D BEST TRANSPORTATION LLC


    0059407868 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407868 002003 04/10/2023 04/07/2023 04/07/2023 A0425 86.00 213.28 213.28 0.00 0.00 0.00 0.00 213.28 P A1
    0059407868 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407868 004003 04/10/2023 04/07/2023 04/07/2023 A0425 86.00 213.28 213.28 0.00 0.00 0.00 0.00 213.28 P A1

    Patient Acct. # 223 Claim Totals : 440.56 440.56 0.00 0.00 0.00 0.00 440.56

    Member Totals : 440.56 440.56 0.00 0.00 0.00 0.00 440.56

    19970700520300 Medi-Cal REYES, ALEJANDRO D BEST TRANSPORTATION LLC


    0059403422 001003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403422 002003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403422 003003 04/10/2023 04/06/2023 04/06/2023 A0425 147.00 364.56 364.56 0.00 0.00 0.00 0.00 364.56 P A1
    0059403422 004003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403422 005003 04/10/2023 04/06/2023 04/06/2023 A0425 147.00 364.56 364.56 0.00 0.00 0.00 0.00 364.56 P A1

    Patient Acct. # 921 Claim Totals : 753.12 753.12 0.00 0.00 0.00 0.00 753.12
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 29

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059408051 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408051 002003 04/10/2023 04/07/2023 04/07/2023 A0425 145.00 359.60 359.60 0.00 0.00 0.00 0.00 359.60 P A1
    0059408051 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408051 004003 04/10/2023 04/07/2023 04/07/2023 A0425 145.00 359.60 359.60 0.00 0.00 0.00 0.00 359.60 P A1

    Patient Acct. # 921 Claim Totals : 733.20 733.20 0.00 0.00 0.00 0.00 733.20

    0059489840 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489840 002003 04/11/2023 04/08/2023 04/08/2023 A0425 145.00 359.60 359.60 0.00 0.00 0.00 0.00 359.60 P A1
    0059489840 003003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489840 004003 04/11/2023 04/08/2023 04/08/2023 A0425 145.00 359.60 359.60 0.00 0.00 0.00 0.00 359.60 P A1

    Patient Acct. # 921 Claim Totals : 733.20 733.20 0.00 0.00 0.00 0.00 733.20

    0059490260 001003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490260 002003 04/11/2023 04/09/2023 04/09/2023 A0425 145.00 359.60 359.60 0.00 0.00 0.00 0.00 359.60 P A1
    0059490260 003003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490260 004003 04/11/2023 04/09/2023 04/09/2023 A0425 145.00 359.60 359.60 0.00 0.00 0.00 0.00 359.60 P A1

    Patient Acct. # 921 Claim Totals : 733.20 733.20 0.00 0.00 0.00 0.00 733.20

    0059553316 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553316 002003 04/12/2023 04/10/2023 04/10/2023 A0425 145.00 359.60 359.60 0.00 0.00 0.00 0.00 359.60 P A1
    0059553316 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553316 004003 04/12/2023 04/10/2023 04/10/2023 A0425 145.00 359.60 359.60 0.00 0.00 0.00 0.00 359.60 P A1

    Patient Acct. # 921 Claim Totals : 733.20 733.20 0.00 0.00 0.00 0.00 733.20

    Member Totals : 3,685.92 3,685.92 0.00 0.00 0.00 0.00 3,685.92

    20010200435200 Medi-Cal SANCHEZ, JOANNE D BEST TRANSPORTATION LLC


    0059403159 001003 04/10/2023 04/06/2023 04/06/2023 A0420 2.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403159 002003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403159 003003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403159 004003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403159 005003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403159 006003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403159 007003 04/10/2023 04/06/2023 04/06/2023 A0380 27.00 74.25 74.25 0.00 0.00 0.00 0.00 74.25 P A1
    0059403159 008003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403159 009003 04/10/2023 04/06/2023 04/06/2023 A0380 27.00 74.25 74.25 0.00 0.00 0.00 0.00 74.25 P A1
    0059403159 010003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403159 011003 04/10/2023 04/06/2023 04/06/2023 A0380 30.00 82.50 82.50 0.00 0.00 0.00 0.00 82.50 P A1
    0059403159 012003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1

    Patient Acct. # 145 Claim Totals : 891.00 891.00 0.00 0.00 0.00 0.00 891.00

    0059403166 001003 04/10/2023 04/06/2023 04/06/2023 A0380 30.00 82.50 82.50 82.50 0.00 0.00 0.00 0.00 D DCS

    Patient Acct. # 145 Claim Totals : 82.50 82.50 82.50 0.00 0.00 0.00 0.00
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 30

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059489407 001003 04/11/2023 04/08/2023 04/08/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059489407 002003 04/11/2023 04/08/2023 04/08/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059489407 003003 04/11/2023 04/08/2023 04/08/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059489407 004003 04/11/2023 04/08/2023 04/08/2023 A0380 30.00 82.50 82.50 0.00 0.00 0.00 0.00 82.50 P A1
    0059489407 005003 04/11/2023 04/08/2023 04/08/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059489407 006003 04/11/2023 04/08/2023 04/08/2023 A0380 30.00 82.50 82.50 0.00 0.00 0.00 0.00 82.50 P A1

    Patient Acct. # 145 Claim Totals : 485.00 485.00 0.00 0.00 0.00 0.00 485.00

    Member Totals : 1,458.50 1,458.50 82.50 0.00 0.00 0.00 1,376.00

    19970300909300 Medi-Cal SASABE, DARLENE D BEST TRANSPORTATION LLC


    0059403393 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403393 002003 04/10/2023 04/06/2023 04/06/2023 A0425 28.00 69.44 69.44 0.00 0.00 0.00 0.00 69.44 P A1
    0059403393 003003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403393 004003 04/10/2023 04/06/2023 04/06/2023 A0425 28.00 69.44 69.44 0.00 0.00 0.00 0.00 69.44 P A1

    Patient Acct. # 848 Claim Totals : 152.88 152.88 0.00 0.00 0.00 0.00 152.88

    0059408027 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408027 002003 04/10/2023 04/07/2023 04/07/2023 A0425 28.00 69.44 69.44 0.00 0.00 0.00 0.00 69.44 P A1
    0059408027 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059408027 004003 04/10/2023 04/07/2023 04/07/2023 A0425 28.00 69.44 69.44 0.00 0.00 0.00 0.00 69.44 P A1

    Patient Acct. # 848 Claim Totals : 152.88 152.88 0.00 0.00 0.00 0.00 152.88

    0059489760 001003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489760 002003 04/11/2023 04/08/2023 04/08/2023 A0425 28.00 69.44 69.44 0.00 0.00 0.00 0.00 69.44 P A1
    0059489760 003003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489760 004003 04/11/2023 04/08/2023 04/08/2023 A0425 28.00 69.44 69.44 0.00 0.00 0.00 0.00 69.44 P A1

    Patient Acct. # 848 Claim Totals : 152.88 152.88 0.00 0.00 0.00 0.00 152.88

    0059553298 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553298 002003 04/12/2023 04/10/2023 04/10/2023 A0425 28.00 69.44 69.44 0.00 0.00 0.00 0.00 69.44 P A1
    0059553298 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553298 004003 04/12/2023 04/10/2023 04/10/2023 A0425 28.00 69.44 69.44 0.00 0.00 0.00 0.00 69.44 P A1

    Patient Acct. # 848 Claim Totals : 152.88 152.88 0.00 0.00 0.00 0.00 152.88

    Member Totals : 611.52 611.52 0.00 0.00 0.00 0.00 611.52

    40000080981900 Medi-Cal SIRES, JOEL D BEST TRANSPORTATION LLC


    0059553399 001003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553399 002003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553399 003003 04/12/2023 04/10/2023 04/10/2023 A0380 242.00 665.50 665.50 0.00 0.00 0.00 0.00 665.50 P A1

    Patient Acct. # 1130 Claim Totals : 825.50 825.50 0.00 0.00 0.00 0.00 825.50

    Member Totals : 825.50 825.50 0.00 0.00 0.00 0.00 825.50


    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 31

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    40000076058500 Medi-Cal SMITH, MARLON D BEST TRANSPORTATION LLC


    0059553151 001003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553151 002003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553151 003003 04/12/2023 04/10/2023 04/10/2023 A0380 26.00 71.50 71.50 0.00 0.00 0.00 0.00 71.50 P A1

    Patient Acct. # 285 Claim Totals : 231.50 231.50 0.00 0.00 0.00 0.00 231.50

    Member Totals : 231.50 231.50 0.00 0.00 0.00 0.00 231.50

    20170800498400 Medi-Cal STARLING, FLOYD D BEST TRANSPORTATION LLC


    0059403576 001003 04/10/2023 04/06/2023 04/06/2023 A0130 1.00 15.00 15.00 0.00 0.00 0.00 0.00 15.00 P A1
    0059403576 002003 04/10/2023 04/06/2023 04/06/2023 A0380 26.00 71.50 71.50 0.00 0.00 0.00 0.00 71.50 P A1
    0059403576 003003 04/10/2023 04/06/2023 04/06/2023 A0130 1.00 15.00 15.00 0.00 0.00 0.00 0.00 15.00 P A1
    0059403576 004003 04/10/2023 04/06/2023 04/06/2023 A0380 26.00 71.50 71.50 0.00 0.00 0.00 0.00 71.50 P A1

    Patient Acct. # 1120 Claim Totals : 173.00 173.00 0.00 0.00 0.00 0.00 173.00

    Member Totals : 173.00 173.00 0.00 0.00 0.00 0.00 173.00

    40000100343900 Medi-Cal SUAREZ LUNA, RAMON D BEST TRANSPORTATION LLC


    0059403477 001003 04/10/2023 04/06/2023 04/06/2023 A0420 6.00 60.00 60.00 0.00 0.00 0.00 0.00 60.00 P A1
    0059403477 002003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403477 003003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403477 004003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403477 005003 04/10/2023 04/06/2023 04/06/2023 A0380 1.00 2.75 2.75 0.00 0.00 0.00 0.00 2.75 P A1
    0059403477 006003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403477 007003 04/10/2023 04/06/2023 04/06/2023 A0380 1.00 2.75 2.75 0.00 0.00 0.00 0.00 2.75 P A1

    Patient Acct. # 1013 Claim Totals : 385.50 385.50 0.00 0.00 0.00 0.00 385.50

    Member Totals : 385.50 385.50 0.00 0.00 0.00 0.00 385.50

    20140704740600 Medi-Cal TURNER, RICHARD D BEST TRANSPORTATION LLC


    0059403483 001003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403483 002003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403483 003003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403483 004003 04/10/2023 04/06/2023 04/06/2023 A0380 16.00 44.00 44.00 0.00 0.00 0.00 0.00 44.00 P A1
    0059403483 005003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403483 006003 04/10/2023 04/06/2023 04/06/2023 A0380 16.00 44.00 44.00 0.00 0.00 0.00 0.00 44.00 P A1

    Patient Acct. # 1032 Claim Totals : 408.00 408.00 0.00 0.00 0.00 0.00 408.00

    0059489897 001003 04/11/2023 04/08/2023 04/08/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059489897 002003 04/11/2023 04/08/2023 04/08/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059489897 003003 04/11/2023 04/08/2023 04/08/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059489897 004003 04/11/2023 04/08/2023 04/08/2023 A0380 16.00 44.00 44.00 0.00 0.00 0.00 0.00 44.00 P A1
    0059489897 005003 04/11/2023 04/08/2023 04/08/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059489897 006003 04/11/2023 04/08/2023 04/08/2023 A0380 16.00 44.00 44.00 0.00 0.00 0.00 0.00 44.00 P A1

    Patient Acct. # 1032 Claim Totals : 408.00 408.00 0.00 0.00 0.00 0.00 408.00
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 32

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    Member Totals : 816.00 816.00 0.00 0.00 0.00 0.00 816.00

    20140704768500 Medi-Cal VALLESPIR, ANAMARIE D BEST TRANSPORTATION LLC


    0059403317 001003 04/10/2023 04/06/2023 04/06/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059403317 002003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403317 003003 04/10/2023 04/06/2023 04/06/2023 A0425 228.00 565.44 565.44 0.00 0.00 0.00 0.00 565.44 P A1
    0059403317 004003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403317 005003 04/10/2023 04/06/2023 04/06/2023 A0425 228.00 565.44 565.44 0.00 0.00 0.00 0.00 565.44 P A1

    Patient Acct. # 601 Claim Totals : 1,154.88 1,154.88 0.00 0.00 0.00 0.00 1,154.88

    0059407976 001003 04/10/2023 04/07/2023 04/07/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059407976 002003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407976 003003 04/10/2023 04/07/2023 04/07/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1
    0059407976 004003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407976 005003 04/10/2023 04/07/2023 04/07/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1

    Patient Acct. # 601 Claim Totals : 1,016.00 1,016.00 0.00 0.00 0.00 0.00 1,016.00

    0059489617 001003 04/11/2023 04/08/2023 04/08/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059489617 002003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489617 003003 04/11/2023 04/08/2023 04/08/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1
    0059489617 004003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489617 005003 04/11/2023 04/08/2023 04/08/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1

    Patient Acct. # 601 Claim Totals : 1,016.00 1,016.00 0.00 0.00 0.00 0.00 1,016.00

    0059490180 001003 04/11/2023 04/09/2023 04/09/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059490180 002003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490180 003003 04/11/2023 04/09/2023 04/09/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1
    0059490180 004003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490180 005003 04/11/2023 04/09/2023 04/09/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1

    Patient Acct. # 601 Claim Totals : 1,016.00 1,016.00 0.00 0.00 0.00 0.00 1,016.00

    0059553246 001003 04/12/2023 04/10/2023 04/10/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059553246 002003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553246 003003 04/12/2023 04/10/2023 04/10/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1
    0059553246 004003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553246 005003 04/12/2023 04/10/2023 04/10/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1

    Patient Acct. # 601 Claim Totals : 1,016.00 1,016.00 0.00 0.00 0.00 0.00 1,016.00

    Member Totals : 5,218.88 5,218.88 0.00 0.00 0.00 0.00 5,218.88

    40000056338500 Medi-Cal VAN BIBBER, ANNABELLE D BEST TRANSPORTATION LLC


    0059403325 001003 04/10/2023 04/06/2023 04/06/2023 A0420 2.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403325 002003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403325 003003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 33

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059403325 004003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403325 005003 04/10/2023 04/06/2023 04/06/2023 A0380 6.00 16.50 16.50 0.00 0.00 0.00 0.00 16.50 P A1
    0059403325 006003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403325 007003 04/10/2023 04/06/2023 04/06/2023 A0380 6.00 16.50 16.50 0.00 0.00 0.00 0.00 16.50 P A1

    Patient Acct. # 614 Claim Totals : 373.00 373.00 0.00 0.00 0.00 0.00 373.00

    Member Totals : 373.00 373.00 0.00 0.00 0.00 0.00 373.00

    20141200697700 Medi-Cal WAGNER, TIMOTHY D BEST TRANSPORTATION LLC


    0059553276 001003 04/12/2023 04/10/2023 04/10/2023 A0420 2.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553276 002003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553276 003003 04/12/2023 04/10/2023 04/10/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059553276 004003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553276 005003 04/12/2023 04/10/2023 04/10/2023 A0380 1.00 2.75 2.75 0.00 0.00 0.00 0.00 2.75 P A1
    0059553276 006003 04/12/2023 04/10/2023 04/10/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059553276 007003 04/12/2023 04/10/2023 04/10/2023 A0380 1.00 2.75 2.75 0.00 0.00 0.00 0.00 2.75 P A1

    Patient Acct. # 743 Claim Totals : 345.50 345.50 0.00 0.00 0.00 0.00 345.50

    Member Totals : 345.50 345.50 0.00 0.00 0.00 0.00 345.50

    40000030689200 Medi-Cal WERNER, DOUGLAS D BEST TRANSPORTATION LLC


    0059403590 001003 04/10/2023 04/06/2023 04/06/2023 T2001 TP 1.00 4.15 4.15 0.00 0.00 0.00 0.00 4.15 P A1

    Patient Acct. # 1121 Claim Totals : 4.15 4.15 0.00 0.00 0.00 0.00 4.15

    Member Totals : 4.15 4.15 0.00 0.00 0.00 0.00 4.15

    20150600513900 Medi-Cal WOODY, BO D BEST TRANSPORTATION LLC


    0059403218 001003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403218 002003 04/10/2023 04/06/2023 04/06/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1
    0059403218 003003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403218 004003 04/10/2023 04/06/2023 04/06/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1
    0059403218 005003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403218 006003 04/10/2023 04/06/2023 04/06/2023 A0425 246.00 610.08 610.08 0.00 0.00 0.00 0.00 610.08 P A1
    0059403218 007003 04/10/2023 04/06/2023 04/06/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059403218 008003 04/10/2023 04/06/2023 04/06/2023 A0425 246.00 610.08 610.08 0.00 0.00 0.00 0.00 610.08 P A1

    Patient Acct. # 331 Claim Totals : 2,240.16 2,240.16 0.00 0.00 0.00 0.00 2,240.16

    0059407912 001003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407912 002003 04/10/2023 04/07/2023 04/07/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1
    0059407912 003003 04/10/2023 04/07/2023 04/07/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059407912 004003 04/10/2023 04/07/2023 04/07/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1

    Patient Acct. # 331 Claim Totals : 1,006.00 1,006.00 0.00 0.00 0.00 0.00 1,006.00

    0059489491 001003 04/11/2023 04/08/2023 04/08/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059489491 002003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 34

    Member # Line of Business Patient Name Provider Name


    Line/ Received Service Date Amount Amount Not Copay/ Deduct Withhold Net S
    Claim# Ver# Date From To Proc Mod Qty Billed Allowed Covered Coins Amount Amount Paid T Reason Interest Adjust

    0059489491 003003 04/11/2023 04/08/2023 04/08/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1
    0059489491 004003 04/11/2023 04/08/2023 04/08/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059489491 005003 04/11/2023 04/08/2023 04/08/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1

    Patient Acct. # 331 Claim Totals : 1,016.00 1,016.00 0.00 0.00 0.00 0.00 1,016.00

    0059490147 001003 04/11/2023 04/09/2023 04/09/2023 A0428 UJ 1.00 10.00 10.00 0.00 0.00 0.00 0.00 10.00 P A1
    0059490147 002003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490147 003003 04/11/2023 04/09/2023 04/09/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1
    0059490147 004003 04/11/2023 04/09/2023 04/09/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059490147 005003 04/11/2023 04/09/2023 04/09/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1

    Patient Acct. # 331 Claim Totals : 1,016.00 1,016.00 0.00 0.00 0.00 0.00 1,016.00

    0059553175 001003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553175 002003 04/12/2023 04/10/2023 04/10/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1
    0059553175 003003 04/12/2023 04/10/2023 04/10/2023 T2001 1.00 7.00 7.00 0.00 0.00 0.00 0.00 7.00 P A1
    0059553175 004003 04/12/2023 04/10/2023 04/10/2023 A0425 200.00 496.00 496.00 0.00 0.00 0.00 0.00 496.00 P A1

    Patient Acct. # 331 Claim Totals : 1,006.00 1,006.00 0.00 0.00 0.00 0.00 1,006.00

    Member Totals : 6,284.16 6,284.16 0.00 0.00 0.00 0.00 6,284.16

    40000104497900 Medi-Cal YANEZ FETIS, DIEGO D BEST TRANSPORTATION LLC


    0059403595 001003 04/10/2023 04/06/2023 04/06/2023 A0420 2.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403595 002003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403595 003003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403595 004003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403595 005003 04/10/2023 04/06/2023 04/06/2023 A0380 3.00 8.25 8.25 0.00 0.00 0.00 0.00 8.25 P A1
    0059403595 006003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403595 007003 04/10/2023 04/06/2023 04/06/2023 A0380 3.00 8.25 8.25 0.00 0.00 0.00 0.00 8.25 P A1

    Patient Acct. # 1122 Claim Totals : 356.50 356.50 0.00 0.00 0.00 0.00 356.50

    Member Totals : 356.50 356.50 0.00 0.00 0.00 0.00 356.50

    40000081254100 Medi-Cal ZAVALETA ROMERO, MALAEL D BEST TRANSPORTATION LLC


    0059403605 001003 04/10/2023 04/06/2023 04/06/2023 A0420 2.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403605 002003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403605 003003 04/10/2023 04/06/2023 04/06/2023 A0424 1.00 20.00 20.00 0.00 0.00 0.00 0.00 20.00 P A1
    0059403605 004003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403605 005003 04/10/2023 04/06/2023 04/06/2023 A0380 15.00 41.25 41.25 0.00 0.00 0.00 0.00 41.25 P A1
    0059403605 006003 04/10/2023 04/06/2023 04/06/2023 T2005 1.00 140.00 140.00 0.00 0.00 0.00 0.00 140.00 P A1
    0059403605 007003 04/10/2023 04/06/2023 04/06/2023 A0380 15.00 41.25 41.25 0.00 0.00 0.00 0.00 41.25 P A1

    Patient Acct. # 1123 Claim Totals : 422.50 422.50 0.00 0.00 0.00 0.00 422.50

    Member Totals : 422.50 422.50 0.00 0.00 0.00 0.00 422.50


    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 35

    Provider Totals : 77,386.06 77,386.06 2,557.50 0.00 0.00 0.00 74,828.56

    Vendor Totals : 77,386.06 77,386.06 2,557.50 0.00 0.00 0.00 74,828.56


    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 36

    ** Summary Page **
    Total Number of Claims: 193
    Total Number of Claims Lines: 918
    Total Payment Amount: 74,828.56

    Explanation Code Legend

    A1 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.


    DCS Exact duplicate claim/service.
    ST Code Legend: P Payable, D Denied, E Encounter

    PLEASE NOTE

    Medi-Cal

    * Under the Knox-Keene Act, Health and Safety Code 1379 of the State of California and Title 22 of the California Code of Regulations, the patient to whom services were provided is not liable for any portion of the bill, except non-benefit
    items or non-covered services.

    * Acknowledgement of claim receipt - Contracted Providers can confirm receipt of submitted claim(s) by logging into the Provider Portal at www.iehp.org. To obtain website instructions, please call IEHP Provider Relations Team at (909)
    890-2054.

    * Acknowledgement of claim receipt - Non-Contracted Providers can confirm receipt of submitted claim(s) by calling IEHP’s Provider Relations Team at (909) 890-2054.

    * In Compliance with AB1455, if you disagree with your payment, you may contact the IEHP Provider Relations Team at (909)890-2054 or (866) 223-4347 Monday - Friday 8:00am to 5:00pm PST. You may also file a Provider Dispute within
    365-days from the claim determination date. Disputes should be submitted to IEHP Claims Appeals Resolution Unit P.O. Box 4319, Rancho Cucamonga, CA 91729. Please visit www.iehp.org to obtain a Provider Dispute Resolution form
    online.

    * In accordance with our agreement, negative balances will be offset against future claims to be paid to you.

    Withhold Amount

    *By statute enacted in March 2009, effective September 22, 2012, Med-Cal has reduced payments to specific provider types by one percent (1%) with a corresponding reduction to Medi-Cal Managed Care Plans. Due to this legislative
    mandate, IEHP has reduced payments to impacted providers referenced in the statue as follows:
    *Services rendered for dates of service on or after March 1, 2009 are reduced by 1%.

    IEHP DualChoice (HMO D-SNP)/ IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan)

    Withhold Amount - all providers * In accordance with Medicare mandated guidelines, your payment for dates of services on or after 04/01/13, may reflect a 2% sequestration reduction
    Inland Empire Health Plan
    Remittance Advice
    D BEST TRANSPORTATION LLC Check Date: 04/18/2023
    68594 CALLE PRADO Check Amount: $74,828.56
    CATHEDRAL CITY, CA 92234 Check No.: EFT-1657073
    874218562 Page No.: 37

    Contracted Providers

    * Acknowledgement of claim receipt - Contracted Providers can confirm receipt of submitted claim(s) by logging into the Provider Portal at www.iehp.org. To obtain website instructions, please call IEHP Provider Relations Team at (909)
    890-2054.

    * In accordance with our agreement, negative balances will be offset against future claims to be paid to you.

    * Appeals and Payment Dispute Requests - can be submitted within the timeframe indicated in your contract to: IEHP DualChoice Cal MediConnect Claims Appeals and Resolution Unit P.O. Box 40, Rancho Cucamonga, CA 91729. Please
    visit www.iehp.org to obtain a Provider Dispute Resolution form online. For more information, please contact IEHP Provider Relations Team at (909)890-2054 or (866) 223-4347.

    * Other Health Coverage Information - If your claim was denied requesting an explanation of benefits from the primary insurance carrier, details of our members other health coverage can be obtained as follows:
    - Logon to IEHP’s provider portal at www.iehp.org
    - Logon to DHCS’s Automated Eligibility Verification System (AEVS) at https://www.medi-cal.ca.gov/MCWeb/Login.aspx
    - Call IEHP’s Provider Relations Team at (909) 890-2054

    Non- Contracted Providers

    Payment Appeals and Disputes for IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) members should be submitted to IEHP at P.O. Box 40, Rancho Cucamonga, CA 91729

    * Appeals - If you disagree with the outcome of a claim, you may submit an appeal attached with a Waiver of Liability and any supporting documentation within 60-days from the denial date. The Waiver of Liability Form can be found on the
    CMS website - www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Manuals reference Appendix 7.

    *Payment Dispute Resolution (PDR) - If you disagree with the payment of a claim, you can submit a PDR with any supporting documentation within 120-days from the initial determination date.

    * Acknowledgement of claim receipt - Non-Contracted Providers can confirm receipt of submitted claim(s) by calling IEHP’s Provider Relations Team at (909) 890-2054.

    * Other Health Coverage Information - If your claim was denied requesting an explanation of benefits from the primary insurance carrier, details of our members other health coverage can be obtained as follows:
    - Logon to IEHP’s provider portal at www.iehp.org
    - Logon to DHCS’s Automated Eligibility Verification System (AEVS) at https://www.medi-cal.ca.gov/MCWeb/Login.aspx
    - Call IEHP’s Provider Relations Team at (909) 890-2054

    Legal Notice

    * Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly present false information in an application for insurance may be guilty of a crime and may be subject to civil and criminal penalties
    in accordance with the State and Federal False Claims Acts.

    * Please assist IEHP in preventing possible benefit abuse. Request another form of identification from the Member in addition to the IEHP card.

    V09.04.2020

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