89/88/23 12:04:48 Horizon Blue Cross B -> Horizon Blue Cross B Page 881 Horizon abaonate, Claim Status Details Patient Information Patent Name DELANEY M AKMENTINS. Patient ID # (CCID): SHZNBBA37030 Patient Account 1111209730 Date of Bit 10/25/1995 Provider Information Biling Prowiser# 13661898 Bling Provider NE: TeT1449697 Claim Information Ciaim 28282223987300 Claim Status: FINALIZED ‘Service Date Range Frome o77i2023 To: 071712023 Total Claim Amount: 95000 Fayee (Suoscriber of Provider) Paymert Amount 9.00 Coinsuiance: 0.00 CoPay: 2.00 Decuitbie! 341.19 NotCovered 000 Claim Message Claim Received Date: evo7/2023 Payment Metros: Paymert Number: Payment Date: ‘Other Insurance Amount Paid; 0.00 Mecicate Amount Paid: 0.00 Sr eee rr Sito “ice” — Sec ga temim—Arele man, ‘Message Description usz2 ‘Pease rater to your Explaraon Ot Payments for deta pertainng to ths service ane. If you have questions about this information, please call Physician Services at 1-800-624-1110. Representatives are available Monday through Friday, botween 8 a.m. and 5 p.m. Eastern Time. The information contained in this fax message is confidential information only forthe use of the individuals or entity named above. If you have received this in error, please destroy the fax and notify us immediately. The Provider understands that the receipt or use of this information does not guarantee payment of any health care claim by Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNU) and such information is subject to change, even retroactively, at any time. ‘Sevees and proces trough Hoon Bue Coes Shoe Sid Naw rey of Horizon Haatnare ot Now Jers, ne, Indaperde tensaes oho Sle Cross Sie Shiels Asscion, eh Reged mar fw Bho Gros Siw Sie Associ, ‘Garvie matka! Harzan Bho Goss le Sa ot New dese. © 2029 Hein Shin rors Sh Sind of Now srsny Tree Pann Pizza Est, New, New Joreay C7105 220, sasquniony