Eop (4

P683502804W
P683502804W
P6835028COV
Health Partners Plans
901 Market Street, Suite 500
Philadelphia, PA 19107
202307240116
Forwarding Service Requested Check Number
1 OF 1
301686412
ALL FOR AADC 190
7484 0.3820 AB 0.534
ENV 7484
ADDTTFDDDFTFDFTTFAFADAFDFTFFFTTTTTAFAFADFADDFTAFATAFDFTTTAAFFTADA
WEST CAYUGA MEDICINE PC 128
257 W CAYUGA ST
PHILADELPHIA, PA 19140-2439
Your Explanation of Payment (EOP) has been converted to a digital file. To securely
access your EOP online for this payment, please follow the steps listed below:
1. Visit: https://remit.changehealthcare.com
2. Enter your unique Remit ID:

W V P E L R Z T U H - U T U T R K
3. Enter check amount:

$3,648.84
4. Upon downloading your EOP file, check your "Downloads Folder" on your local computer to
view your EOP offline
Please be sure to save the Remit ID code mentioned above for future reference.
If you would like to see all your EOPs in one secure portal and receive payments electronically instead of via paper
check, follow the enrollment instructions in the link above.
Contact us at : 866-943-9579 Monday-Friday 8:00am-4:30pm CST for assistance to access your EOP for this payment,
enroll for electronic EOPs and payments or to opt for paper EOPs.
Electronic Payment Clearinghouse

PNC - ECHO
Pittsburgh PA 15219
60-162 DRAFT NO. 301686412
433
ELECTRONIC COMMERCE BENEFIT TRUST
DRAFT DATE: 07/21/2023
VOID AFTER 180 DAYS
PAYABLE THROUGH Three Thousand Six Hundred Forty Eight & 84/100 Dollars
AMOUNT
DRAFT *****$3,648.84
TO THE WEST CAYUGA MEDICINE PC
ORDER OF 257 W CAYUGA ST
PHILADELPHIA PA 19140
C301686412C A043301627A 1069954659C

P683502800K
P683502800K

202307248800
Forwarding Service Requested
1 OF 7
Questions? Please contact Provider Service at (215)
8714 0.0868 991-4350 or Toll free (888)991-9023.
ENV 8714
FFATAFTADTDDATFDTAADDATATTFDTFFDADDADTFADTAAATTADDTADAADAAFTATFAD
WEST CAYUGA MEDICINE PC
257 W CAYUGA ST Payor ID: 80142
Your name WEST CAYUGA MEDICINE PC and tax id have been

verified by the IRS
Tax ID: 813661898 EPC Draft #: 301686412 Payment Week: 29 Payment Date: 07/21/2023
Service Date Procedures No. of Amount Allowed Payment Patient Other Not Covered Sequest- Adjustment
From To (Modifier) Units Billed Responsibility Ins. Paid ration Reason
Patient: ANA DELGADO ALVERI Insured: 140251505ANA DELGADO ALVERI Payer Claim #: 2023062303120
Pat. Acct #: 1098471490 Provider: West Cayuga Medicine Pc Group/Check Number: 01/2078662
06/17/23-06/17/23 J3420 1 -50.00 -1.61 -1.61 0.00 0.00 -48.39 0.00 CO45
Total for Claim: -50.00 -1.61 -1.61 0.00 0.00 -48.39 0.00
Patient: ANA DELGADO ALVERI Insured: 140251505ANA DELGADO ALVERI Payer Claim #: 2023062303120
06/17/23-06/17/23 J3420 1 50.00 0.00 0.00 0.00 0.00 50.00 0.00 PI16 M119
Total for Claim: 50.00 0.00 0.00 0.00 0.00 50.00 0.00
Patient: JORGE OYOLA Insured: 002270882JORGE OYOLA Payer Claim #: 2023071217455

07/05/23-07/05/23 99214 1 115.24 93.53 93.53 0.00 0.00 21.71 0.00 CO45
Total for Claim: 115.24 93.53 93.53 0.00 0.00 21.71 0.00
Patient: RACHEL HERLING Insured: 300154479RACHEL HERLING Payer Claim #: 2023071217456

07/06/23-07/06/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: CARRIE FELTMAN Insured: 160347201CARRIE FELTMAN Payer Claim #: 2023071217457

07/05/23-07/05/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: MICHELLE HOLCOMB Insured: 190117193MICHELLE HOLCOMB Payer Claim #: 2023071217458

06/21/23-06/21/23 99205 1 350.00 178.72 178.72 0.00 0.00 171.28 0.00 CO45
Total for Claim: 350.00 178.72 178.72 0.00 0.00 171.28 0.00
Patient: EMERALD MARTEZ Insured: 360140181EMERALD MARTEZ Payer Claim #: 2023071217459

07/05/23-07/05/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: CARLOS RAMOS Insured: 770142215CARLOS RAMOS Payer Claim #: 2023071217461

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07/06/23-07/06/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
ENV 8714
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: FELIX GONZALEZ Insured: 120005340FELIX GONZALEZ Payer Claim #: 2023071217462

07/05/23-07/05/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: JOCELYN LANAUSSE Insured: 650108627JOCELYN LANAUSSE Payer Claim #: 2023071217464

07/06/23-07/06/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: ANDRE LOZADA Insured: 240130092ANDRE LOZADA Payer Claim #: 2023071217465

07/06/23-07/06/23 99214 1 115.24 93.53 93.53 0.00 0.00 21.71 0.00 CO45
Total for Claim: 115.24 93.53 93.53 0.00 0.00 21.71 0.00
Patient: SABRINA MENENDEZ Insured: 750103310SABRINA MENENDEZ Payer Claim #: 2023071217466

07/06/23-07/06/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: ANA DIAZ Insured: 001402649ANA DIAZ Payer Claim #: 2023071217467

07/06/23-07/06/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: RUBIN DIAZ Insured: 001404711RUBIN DIAZ Payer Claim #: 2023071217468

07/05/23-07/05/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
07/05/23-07/05/23 Q9992 1 50.00 50.00 50.00 0.00 0.00 0.00 0.00
Total for Claim: 128.47 114.62 114.62 0.00 0.00 13.85 0.00
Patient: ALSHARIEF YOUNG Insured: 310143245ALSHARIEF YOUNG Payer Claim #: 2023071217469

07/06/23-07/06/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: KRISTINE MALLOY Insured: 187700170KRISTINE MALLOY Payer Claim #: 2023071313606

07/08/23-07/08/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: BILLY RODRIGUEZ Insured: 240109350BILLY RODRIGUEZ Payer Claim #: 2023071313607

07/07/23-07/07/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: GRISELL RODRIGUEZ Insured: 002459307GRISELL RODRIGUEZ Payer Claim #: 2023071313610

07/08/23-07/08/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
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Patient: ALEXANDER HERNANDEZ Insured: 540107942ALEXANDER Payer Claim #: 2023071313611
ENV 8714
07/05/23-07/05/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: ALBERT COX Insured: 980000325ALBERT COX Payer Claim #: 2023071313612

07/07/23-07/07/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: PAUL LANDES Insured: 410274907PAUL LANDES Payer Claim #: 2023071313613

07/07/23-07/07/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: MICHELLE GALLAGHER Insured: 600008758MICHELLE GALLAGHER Payer Claim #: 2023071313615

07/05/23-07/05/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: JEREMY CRUZ Insured: 200010358JEREMY CRUZ Payer Claim #: 2023071313616

07/05/23-07/05/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: IRMA ACEVEDO Insured: 160104084IRMA ACEVEDO Payer Claim #: 2023071313617

07/07/23-07/07/23 99214 1 115.24 93.53 93.53 0.00 0.00 21.71 0.00 CO45
Total for Claim: 115.24 93.53 93.53 0.00 0.00 21.71 0.00
Patient: ALYSSA BANGERT Insured: 190173509ALYSSA BANGERT Payer Claim #: 2023071313618

06/23/23-06/23/23 99213 1 78.47 11.15 11.15 0.00 53.47 13.85 0.00 OA23 CO23
CO45
Total for Claim: A COB payment of 53.47 78.47 11.15 11.15 0.00 53.47 13.85 0.00
is included in the Adjustment Amount
Patient: PRINCESS RODRIGUEZ Insured: 360106849PRINCESS RODRIGUEZ Payer Claim #: 2023071313619
07/08/23-07/08/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: GRISSELLE PLASENCIA GUTI Insured: 580196789GRISSELLE PLASENCIA Payer Claim #: 2023071313620
07/07/23-07/07/23 99214 1 115.24 93.53 93.53 0.00 0.00 21.71 0.00 CO45
Total for Claim: 115.24 93.53 93.53 0.00 0.00 21.71 0.00
Patient: KEILA ALVAREZ NIEVES Insured: 530654198KEILA ALVAREZ NIEVES Payer Claim #: 2023071313621
07/07/23-07/07/23 99214 1 115.24 93.53 93.53 0.00 0.00 21.71 0.00 CO45
Total for Claim: 115.24 93.53 93.53 0.00 0.00 21.71 0.00
Patient: TAMARA SANTOS Insured: 480105094TAMARA SANTOS Payer Claim #: 2023071313622

P683502800K
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07/07/23-07/07/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
ENV 8714
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: JUAN LUCIANO Insured: 680199377JUAN LUCIANO Payer Claim #: 2023071313623

07/08/23-07/08/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: DIANE DUFFIN Insured: 170102564DIANE DUFFIN Payer Claim #: 2023071313624

07/05/23-07/05/23 99214 1 115.24 93.53 93.53 0.00 0.00 21.71 0.00 CO45
Total for Claim: 115.24 93.53 93.53 0.00 0.00 21.71 0.00
Patient: ROBERT WALKER Insured: 040375211ROBERT WALKER Payer Claim #: 2023071313626

07/05/23-07/05/23 99214 GT 1 115.24 93.53 93.53 0.00 0.00 21.71 0.00 CO45
Total for Claim: 115.24 93.53 93.53 0.00 0.00 21.71 0.00
Patient: MICHELE MCGINLEY Insured: 187682651MICHELE MCGINLEY Payer Claim #: 2023071313627

07/05/23-07/05/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: DAMON DAVIS Insured: 001384956DAMON DAVIS Payer Claim #: 2023071313628

07/05/23-07/05/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: JOSELINA QUEZADA Insured: 440133006JOSELINA QUEZADA Payer Claim #: 2023071313629

07/05/23-07/05/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
07/05/23-07/05/23 Q9992 1 50.00 50.00 50.00 0.00 0.00 0.00 0.00
Total for Claim: 128.47 114.62 114.62 0.00 0.00 13.85 0.00
Patient: BRANDI LAWRENCE Insured: 860105379BRANDI LAWRENCE Payer Claim #: 2023071412279

07/05/23-07/05/23 99214 GT 1 115.24 93.53 93.53 0.00 0.00 21.71 0.00 CO45
Total for Claim: 115.24 93.53 93.53 0.00 0.00 21.71 0.00
Patient: SHALEE PACHECO Insured: 140422948SHALEE PACHECO Payer Claim #: 2023071412280

07/07/23-07/07/23 99205 GT 1 350.00 178.72 178.72 0.00 0.00 171.28 0.00 CO45
Total for Claim: 350.00 178.72 178.72 0.00 0.00 171.28 0.00
Patient: BRANDI LAWRENCE Insured: 860105379BRANDI LAWRENCE Payer Claim #: 2023071412281

06/21/23-06/21/23 99205 1 350.00 178.72 178.72 0.00 0.00 171.28 0.00 CO45
Total for Claim: 350.00 178.72 178.72 0.00 0.00 171.28 0.00
Patient: MALVIN MARTINEZ Insured: 400147483MALVIN MARTINEZ Payer Claim #: 2023071714148

07/10/23-07/10/23 99214 1 115.24 93.53 93.53 0.00 0.00 21.71 0.00 CO45
Total for Claim: 115.24 93.53 93.53 0.00 0.00 21.71 0.00
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Patient: CLARA DEL RIO Insured: 630121720CLARA DEL RIO Payer Claim #: 2023071714149
ENV 8714
07/10/23-07/10/23 99214 1 115.24 93.53 93.53 0.00 0.00 21.71 0.00 CO45
Total for Claim: 115.24 93.53 93.53 0.00 0.00 21.71 0.00
Patient: WILMARY MILETT SANTIAG Insured: 840341491WILMARY MILETT Payer Claim #: 2023071714151
07/12/23-07/12/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: EDWARD KOPP Insured: 450150132EDWARD KOPP Payer Claim #: 2023071714155

07/12/23-07/12/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: ADAM RICHARDSON Insured: 189681468ADAM RICHARDSON Payer Claim #: 2023071714156

07/12/23-07/12/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: ERIC SANTIAGO Insured: 940008773ERIC SANTIAGO Payer Claim #: 2023071714157

07/12/23-07/12/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: MANUEL REYES Insured: 391092172MANUEL REYES Payer Claim #: 2023071714158

07/12/23-07/12/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: DANIEL ALLOWSING Insured: 710001876DANIEL ALLOWSING Payer Claim #: 2023071714159

07/12/23-07/12/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: BRYAN PERSSON Insured: 120142527BRYAN PERSSON Payer Claim #: 2023071714160

07/12/23-07/12/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Patient: NICOLE AQUINO Insured: 600205334NICOLE AQUINO Payer Claim #: 2023071714161

07/12/23-07/12/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00
Statement Summary Amount Billed Payment Patient Other Ins. Not Covered
Responsibility Paid
4,891.91 3,648.84 0.00 53.47 1,243.07
Explanations
Administered By Code Description
HEALTH PARTNERS OF CO45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
P683502800K
202307248800 P683502800K
6 OF 7
PHILADELPHI
Usage: This adjustment amount cannot equal the total service or claim charge amount; and
must not duplicate provider adjustment amounts (payments and contractual reductions) that
have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO
ENV 8714
depending upon liability)
OA23 The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only
with Group Code OA)
CO23 The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only
with Group Code OA)
PI16 Claim/service lacks information or has submission/billing error(s). Usage: Do not use this
code for claims attachment(s)/other documentation. At least one Remark Code must be
provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice
Remark Code that is not an ALERT.) Refer to the 835 Healthcare Policy Identification
Segment (loop 2110 Service Payment Information REF), if present.
M119 Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC).
Eliminate paper checks and EOP's while saving time and money. Sign up for our FREE electronic funds
transfer and electronic remittance solution at
https://enrollments.echohealthinc.com/efteradirect/HealthPartnersPlans
Please call the following number for appeals 888-991-9023.

P683502804W
202307248800 P683502804W

Forwarding Service Requested
7 OF 7
ENV 8714
FFATAFTADTDDATFDTAADDATATTFDTFFDADDADTFADTAAATTADDTADAADAAFTATFAD
WEST CAYUGA MEDICINE PC
257 W CAYUGA ST
Electronic Payment Clearinghouse

PNC - ECHO
Pittsburgh PA 15219
60-162 DRAFT NO. 301686412
433
ELECTRONIC COMMERCE BENEFIT TRUST
DRAFT DATE: 07/21/2023
VOID AFTER 180 DAYS
PAYABLE THROUGH Three Thousand Six Hundred Forty Eight & 84/100 Dollars
AMOUNT
DRAFT *****$3,648.84
TO THE WEST CAYUGA MEDICINE PC
ORDER OF 257 W CAYUGA ST
PHILADELPHIA PA 19140

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P683502804W

Forwarding Service Requested Check Number

2. Enter your unique Remit ID:

3. Enter check amount:

Electronic Payment Clearinghouse

C301686412C A043301627A 1069954659C

Health Partners Plans

Forwarding Service Requested

Your name WEST CAYUGA MEDICINE PC and tax id have been

Patient: JORGE OYOLA Insured: 002270882JORGE OYOLA Payer Claim #: 2023071217455

Patient: RACHEL HERLING Insured: 300154479RACHEL HERLING Payer Claim #: 2023071217456

Patient: CARRIE FELTMAN Insured: 160347201CARRIE FELTMAN Payer Claim #: 2023071217457

Patient: MICHELLE HOLCOMB Insured: 190117193MICHELLE HOLCOMB Payer Claim #: 2023071217458

Patient: EMERALD MARTEZ Insured: 360140181EMERALD MARTEZ Payer Claim #: 2023071217459

Patient: CARLOS RAMOS Insured: 770142215CARLOS RAMOS Payer Claim #: 2023071217461

Patient: FELIX GONZALEZ Insured: 120005340FELIX GONZALEZ Payer Claim #: 2023071217462

Patient: JOCELYN LANAUSSE Insured: 650108627JOCELYN LANAUSSE Payer Claim #: 2023071217464

Patient: ANDRE LOZADA Insured: 240130092ANDRE LOZADA Payer Claim #: 2023071217465

Patient: SABRINA MENENDEZ Insured: 750103310SABRINA MENENDEZ Payer Claim #: 2023071217466

Patient: ANA DIAZ Insured: 001402649ANA DIAZ Payer Claim #: 2023071217467

Patient: RUBIN DIAZ Insured: 001404711RUBIN DIAZ Payer Claim #: 2023071217468

Patient: ALSHARIEF YOUNG Insured: 310143245ALSHARIEF YOUNG Payer Claim #: 2023071217469

Patient: KRISTINE MALLOY Insured: 187700170KRISTINE MALLOY Payer Claim #: 2023071313606

Patient: BILLY RODRIGUEZ Insured: 240109350BILLY RODRIGUEZ Payer Claim #: 2023071313607

Patient: GRISELL RODRIGUEZ Insured: 002459307GRISELL RODRIGUEZ Payer Claim #: 2023071313610

Patient: ALBERT COX Insured: 980000325ALBERT COX Payer Claim #: 2023071313612

Patient: PAUL LANDES Insured: 410274907PAUL LANDES Payer Claim #: 2023071313613

Patient: MICHELLE GALLAGHER Insured: 600008758MICHELLE GALLAGHER Payer Claim #: 2023071313615

Patient: JEREMY CRUZ Insured: 200010358JEREMY CRUZ Payer Claim #: 2023071313616

Patient: IRMA ACEVEDO Insured: 160104084IRMA ACEVEDO Payer Claim #: 2023071313617

Patient: ALYSSA BANGERT Insured: 190173509ALYSSA BANGERT Payer Claim #: 2023071313618

Patient: TAMARA SANTOS Insured: 480105094TAMARA SANTOS Payer Claim #: 2023071313622

Patient: JUAN LUCIANO Insured: 680199377JUAN LUCIANO Payer Claim #: 2023071313623

Patient: DIANE DUFFIN Insured: 170102564DIANE DUFFIN Payer Claim #: 2023071313624

Patient: ROBERT WALKER Insured: 040375211ROBERT WALKER Payer Claim #: 2023071313626

Patient: MICHELE MCGINLEY Insured: 187682651MICHELE MCGINLEY Payer Claim #: 2023071313627

Patient: DAMON DAVIS Insured: 001384956DAMON DAVIS Payer Claim #: 2023071313628

Patient: JOSELINA QUEZADA Insured: 440133006JOSELINA QUEZADA Payer Claim #: 2023071313629

Patient: BRANDI LAWRENCE Insured: 860105379BRANDI LAWRENCE Payer Claim #: 2023071412279

Patient: SHALEE PACHECO Insured: 140422948SHALEE PACHECO Payer Claim #: 2023071412280

Patient: BRANDI LAWRENCE Insured: 860105379BRANDI LAWRENCE Payer Claim #: 2023071412281

Patient: MALVIN MARTINEZ Insured: 400147483MALVIN MARTINEZ Payer Claim #: 2023071714148

Patient: EDWARD KOPP Insured: 450150132EDWARD KOPP Payer Claim #: 2023071714155

Patient: ADAM RICHARDSON Insured: 189681468ADAM RICHARDSON Payer Claim #: 2023071714156

Patient: ERIC SANTIAGO Insured: 940008773ERIC SANTIAGO Payer Claim #: 2023071714157

Patient: MANUEL REYES Insured: 391092172MANUEL REYES Payer Claim #: 2023071714158

Patient: DANIEL ALLOWSING Insured: 710001876DANIEL ALLOWSING Payer Claim #: 2023071714159

Patient: BRYAN PERSSON Insured: 120142527BRYAN PERSSON Payer Claim #: 2023071714160

Patient: NICOLE AQUINO Insured: 600205334NICOLE AQUINO Payer Claim #: 2023071714161

Please call the following number for appeals 888-991-9023.

Health Partners Plans

Forwarding Service Requested

Electronic Payment Clearinghouse

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