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EXPLANATION OF BENEFITS
JULY 15, 2023
DEPOSIT NOTICE ONLY

PROVIDER SUMMARY

Provider: WEST CAYUGA MEDICAL CENTER

Provider Number: 1811449697

DIRECT DEPOSIT SUMMARY

FUNDS AVAILABLE DATE 07/19/2023 EFT PAYMENT NUMBER 992622031

ACCOUNT TYPE CHECKING

TOTAL EFT PROVIDER DEPOSIT ................... $732.25

TOTAL INTEREST CALCULATED .................... $0.00

TOTAL MEMBER PAYMENTS ........................ $0.00

1901 Market Street

Philadelphia, PA 19103-1480

WEST CAYUGA MEDICAL CENTER

257 WEST CAYUGA STREET
PHILADELPHIA, PA 19140-2439

IP011088
"VISIT US AT OUR WEBSITE: www.ibx.com"
Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance
Company, and with Highmark Blue Shield. Independent Licensees of the Blue Cross and Blue Shield Association
 Provider Number: 1811449697 Page 2of 4
Provider Name: WEST CAYUGA MEDICAL CENTER JULY 15, 2023
DATE(S) NUM REVENUE/ PAY- NON- NON- MEMBER MEM AMOUNT(S)
PROVIDER OUR OTHER MESSAGE
OF OF PROCEDURE MENT CHARGEABLE CHG LIABILITY LIAB PAID
CHARGE ALLOWANCE AMOUNT CODES
SVC SVCS CODE CODE AMOUNT CODE AMOUNT CODE (* = MEMBER)

PATIENT ACCT #: 1096293873 PATIENT: JENNIFER K BERNSTEIN CLAIM NUMBER:

MEMBER ID: 134278236001 MEMBER: JENNIFER K BERNSTEIN 22212416435
06/07/23 1 99214-00-GT 030 115.24 100.24 94.87 20.37 J8121,J0053
CLAIM TOTALS 94.87 20.37

PATIENT ACCT #: 1099775597 PATIENT: JACOB YOCUM CLAIM NUMBER:

MEMBER ID: 120608352001 MEMBER: CLAIRE W YOCUM 22030757546
06/21/23 1 99214-00-95 026 115.24 114.25 .99 25 15.00 D1 99.25 J0053
CLAIM TOTALS .99 15.00 99.25

PATIENT ACCT #: 1101104736 PATIENT: COLLEEN A GIBSON CLAIM NUMBER:

MEMBER ID: 131458981001 MEMBER: COLLEEN A GIBSON 22412278839
06/21/23 1 99214-00 026 115.24 115.24 20.00 D1 95.24 J0053
06/21/23 1 90833-WD 026 80.00 71.14 8.86 25 20.00 D1 51.14 J0053
CLAIM TOTALS 8.86 40.00 146.38

PATIENT ACCT #: 1101104737 PATIENT: VICTORIA PITRE CLAIM NUMBER:

MEMBER ID: 136037083001 MEMBER: VICTORIA PITRE 22412278840
06/22/23 1 99214-00-95 026 115.24 114.25 .99 25 15.00 D1 99.25 J0053
CLAIM TOTALS .99 15.00 99.25

PATIENT ACCT #: 1101672724 PATIENT: SHANNON RAGAZZONE CLAIM NUMBER:

MEMBER ID: 132442101001 MEMBER: SHANNON RAGAZZONE 22031028715
06/27/23 1 99214-00-95 026 115.24 114.25 .99 25 20.00 D1 94.25 J0053
CLAIM TOTALS .99 20.00 94.25

PATIENT ACCT #: 1101672725 PATIENT: BRIDGET C MATTOX CLAIM NUMBER:

MEMBER ID: 132940277001 MEMBER: BRIDGET C MATTOX 22812379391
06/23/23 1 99214-00-95 026 115.24 114.25 .99 25 35.00 D1 79.25 J0053
CLAIM TOTALS .99 35.00 79.25

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 Provider Number: 1811449697 Page 3of 4
Provider Name: WEST CAYUGA MEDICAL CENTER JULY 15, 2023
DATE(S) NUM REVENUE/ PAY- NON- NON- MEMBER MEM AMOUNT(S)
PROVIDER OUR OTHER MESSAGE
OF OF PROCEDURE MENT CHARGEABLE CHG LIABILITY LIAB PAID
CHARGE ALLOWANCE AMOUNT CODES
SVC SVCS CODE CODE AMOUNT CODE AMOUNT CODE (* = MEMBER)

PATIENT ACCT #: 1101672726 PATIENT: TERRYN LEE CLAIM NUMBER:

MEMBER ID: 131274539001 MEMBER: TERRYN LEE 22812379392
06/26/23 1 99214-00-95 026 115.24 114.25 .99 25 15.00 D1 99.25 J0053
CLAIM TOTALS .99 15.00 99.25

PATIENT ACCT #: 1102156529 PATIENT: SPENCER SMITH CLAIM NUMBER:

MEMBER ID: OPE586M98179 MEMBER: SPENCER SMITH 22712475113
06/26/23 1 99204-00-GT 026 176.38 160.14 16.24 25 160.14 A1 X5019,J0053
06/26/23 1 90833-WD-GT 026 80.00 71.14 8.86 25 71.14 A1 X5019,J0053
CLAIM TOTALS 25.10 231.28

PATIENT ACCT #: 1102156530 PATIENT: ETHAN J HALLERMEIER CLAIM NUMBER:

MEMBER ID: 123107794001 MEMBER: JOANNE CHRISTOPHER 22712475114
06/28/23 1 99215-00 175.00 175.00 07 E8038,J0053
CLAIM TOTALS 175.00

PATIENT ACCT #: 1104097153 PATIENT: ETHAN MONCADA CLAIM NUMBER:

MEMBER ID: Z6D540W15219 MEMBER: ETHAN MONCADA 22812890657
07/03/23 1 99214-00-95 026 115.24 114.25 .99 25 20.00 D1 94.25 J0053
CLAIM TOTALS .99 20.00 94.25

MESSAGE(S):
_________
E8038 Invalid diagnosis code used as principal diagnosis code. Please correct and resubmit. Electronically
enabled providers should resubmit electronically.
J0053 If you have any questions, call 1-800-ASK-BLUE.
J8121 Our payment was reduced by the OTHER AMOUNT due to a payment made by another insurance company.
X5019 The allowance for this service has been applied to the dollar deductible amount required under the
patient's coverage.

______________
PAYMENT CODES: ____________________________
NON-CHARGEABLE AMOUNT CODES: _______________________
MEMBER LIABILITY CODES:
026 = CONTRACTED ALLOWANCE 07 = Rejected Non-Billable A1 = Deductible

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Provider Number: 1811449697 Page 4of 4
Provider Name: WEST CAYUGA MEDICAL CENTER JULY 15, 2023

______________
PAYMENT CODES: ____________________________
NON-CHARGEABLE AMOUNT CODES: _______________________
MEMBER LIABILITY CODES:
030 = MEDICARE SUPPLMTL ALLOWANCE Services D1 = Copay
25 = Differential

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