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EXPLANATION OF BENEFITS
JULY 21, 2023
DEPOSIT NOTICE ONLY

PROVIDER SUMMARY

Provider: WEST CAYUGA MEDICAL CENTER

Provider Number: 1811449697

DIRECT DEPOSIT SUMMARY

FUNDS AVAILABLE DATE 07/26/2023 EFT PAYMENT NUMBER 992627616

ACCOUNT TYPE CHECKING

TOTAL EFT PROVIDER DEPOSIT ................... $276.97

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

IP010707
"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 2
Provider Name: WEST CAYUGA MEDICAL CENTER JULY 21, 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 #: 1102540088 PATIENT: SHANNON G EARLEY CLAIM NUMBER:

MEMBER ID: 120592716001 MEMBER: SEAN V EARLEY 22612632538
06/29/23 1 99213-00-95 78.47 78.47 H1 L5018,J0053
CLAIM TOTALS 78.47

PATIENT ACCT #: 1103253815 PATIENT: JOSEPH CALLAHAN CLAIM NUMBER:

MEMBER ID: 134378148001 MEMBER: JOSEPH CALLAHAN 22312672960
06/30/23 1 99204-00-95 026 176.38 160.14 16.24 25 20.00 D1 140.14 J0053
06/30/23 1 90833-WD-95 026 80.00 71.14 8.86 25 20.00 D1 51.14 J0053
CLAIM TOTALS 25.10 40.00 191.28

PATIENT ACCT #: 1105113517 PATIENT: CLAIRE O'CONNOR CLAIM NUMBER:

MEMBER ID: FLY414W08224 MEMBER: CLAIRE O CONNOR 22613125883
07/07/23 1 99214-00-95 026 115.24 114.25 .99 25 28.56 C1 85.69 J0053
CLAIM TOTALS .99 28.56 85.69

MESSAGE(S):
_________
J0053 If you have any questions, call 1-800-ASK-BLUE.
L5018 The Subscriber did not respond to our recent inquiry asking if the Member is covered by other insurance.
Therefore, this claim and all future claims will be denied until the Subscriber notifies the Plan if
other insurance exists.

______________
PAYMENT CODES: ____________________________
NON-CHARGEABLE AMOUNT CODES: _______________________
MEMBER LIABILITY CODES:
026 = CONTRACTED ALLOWANCE 25 = Differential C1 = Coinsurance
D1 = Copay
H1 = Rejected Billable Non-Covered
Service

IP010707