Check Summary Transaction Date: January 16, 2024

BLUECROSS BLUESHIELD OF ILLINOIS Payee Tax ID: 371456298 Payee Name: UNIVERSAL HEALTHCLINICS S
C
300 E RANDOLPH Payee ID: 1699806497 Payee Address:
P O BOX 958363
CHICAGO, IL 606015099 Check/EFT Trace Number: C24016957146140
HOFFMAN ESTATES, IL
Payment Amount: 1,743.21
601958363
Check/EFT Date: 01/16/2024
Production End Cycle Date: 01/16/2024

Patient Name: AGUILAR, ERIK Claim Number: 0202336350655B80X00 Claim Date: 12/04/2023-12/04/2023 Claim Status Code: 1
Patient ID: LAR896431282 Group / Policy: 000P154120000 Facility Type: 11 Claim Charge: $405.00
Patient Ctrl Nmbr: 36407 Contract Hdr: PREFERRED PROVIDER Claim Frequency: 1 Claim Payment: $193.90
Rendering Prvd: APPIAGYEI, MICHAEL ORGANIZATION Claim Received Date: 12/29/2023 Patient Resp: $0.00
Original Ref Nmbr: Rendering Prv ID:

Line Details Results: 3

Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
81964 12/04/2023 - HC:99214 / 25 / 1 $141.84 (B6) $300.00 CO-45 $158.16 $141.84
12/04/2023
81965 12/04/2023 - HC:90686 / / 1 $23.06 (B6) $65.00 CO-45 $41.94 $23.06
12/04/2023
81966 12/04/2023 - HC:90460 / / 1 $29.00 (B6) $40.00 CO-45 $11.00 $29.00
12/04/2023

Supplemental Information - AMT/Payer Codes: $193.90 (AU)

Patient Name: BONSU, JOSEPH A Claim Number: 0202400250496Z10X00 Claim Date: 11/15/2023-11/15/2023 Claim Status Code: 1
Patient ID: FUN998043822 Group / Policy: 000P606070000 Facility Type: 11 Claim Charge: $225.00
Patient Ctrl Nmbr: 9277 Contract Hdr: PREFERRED PROVIDER Claim Frequency: 1 Claim Payment: $141.84
Rendering Prvd: APPIAGYEI, MICHAEL ORGANIZATION Claim Received Date: 01/02/2024 Patient Resp: $0.00
Original Ref Nmbr: Rendering Prv ID:

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Payer: BLUECROSS BLUESHIELD OF ILLINOIS Check/EFT Trace Number: C24016957146140 Check/EFT Date: 01/16/2024 Total Paid: $1,743.21

Line Details Results: 1

Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
92771 11/15/2023 - HC:99214 / / 1 $141.84 (B6) $225.00 CO-45 $83.16 $141.84
11/15/2023

Supplemental Information - AMT/Payer Codes: $141.84 (AU)

Patient Name: ESPINOSA, MIGUEL Claim Number: 0202401650095Y40X00 Claim Date: 01/04/2024-01/04/2024 Claim Status Code: 1
Patient ID: FHL835328895 Group / Policy: 000P573200100 Facility Type: 11 Claim Charge: $774.00
Patient Ctrl Nmbr: 36624 Contract Hdr: PREFERRED PROVIDER Claim Frequency: 1 Claim Payment: $476.49
Rendering Prvd: APPIAGYEI, MICHAEL ORGANIZATION Claim Received Date: 01/16/2024 Patient Resp: $30.00
Original Ref Nmbr: Rendering Prv ID:

Line Details Results: 5

Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
82559 01/04/2024 - HC:99213 / 25 / 1 $100.38 (B6) $230.00 PR-3 $30.00 $70.38
01/04/2024 CO-45 $129.62
82560 01/04/2024 - HC:90686 / / 1 $23.06 (B6) $65.00 CO-45 $41.94 $23.06
01/04/2024
82561 01/04/2024 - HC:90651 / / 1 $332.05 (B6) $369.00 CO-45 $36.95 $332.05
01/04/2024
82562 01/04/2024 - HC:90460 / / 2 $35.00 (B6) $80.00 CO-45 $45.00 $35.00
01/04/2024
82679 01/04/2024 - HC:90461 / / 1 $16.00 (B6) $30.00 CO-45 $14.00 $16.00
01/04/2024

Supplemental Information - AMT/Payer Codes: $506.49 (AU)

Patient Name: ESPINOZA, SANTIAGO Claim Number: 0202401650320Y80X00 Claim Date: 01/04/2024-01/04/2024 Claim Status Code: 1
Patient ID: FHL835328895 Group / Policy: 000P573200100 Facility Type: 11 Claim Charge: $774.00
Patient Ctrl Nmbr: 36623 Contract Hdr: PREFERRED PROVIDER Claim Frequency: 1 Claim Payment: $476.49
Rendering Prvd: APPIAGYEI, MICHAEL ORGANIZATION Claim Received Date: 01/16/2024 Patient Resp: $30.00
Original Ref Nmbr: Rendering Prv ID:

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Payer: BLUECROSS BLUESHIELD OF ILLINOIS Check/EFT Trace Number: C24016957146140 Check/EFT Date: 01/16/2024 Total Paid: $1,743.21

Line Details Results: 5

Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
82555 01/04/2024 - HC:99213 / 25 / 1 $100.38 (B6) $230.00 PR-3 $30.00 $70.38
01/04/2024 CO-45 $129.62
82556 01/04/2024 - HC:90651 / / 1 $332.05 (B6) $369.00 CO-45 $36.95 $332.05
01/04/2024
82557 01/04/2024 - HC:90686 / / 1 $23.06 (B6) $65.00 CO-45 $41.94 $23.06
01/04/2024
82558 01/04/2024 - HC:90460 / / 2 $35.00 (B6) $80.00 CO-45 $45.00 $35.00
01/04/2024
82678 01/04/2024 - HC:90461 / / 1 $16.00 (B6) $30.00 CO-45 $14.00 $16.00
01/04/2024

Supplemental Information - AMT/Payer Codes: $506.49 (AU)

Patient Name: MITCHELL, VIVIAN Claim Number: 02024015504V5590X00 Claim Date: 11/27/2023-11/27/2023 Claim Status Code: 1
Patient ID: MCD832201621 Group / Policy: 0000532001100 Facility Type: 11 Claim Charge: $365.00
Patient Ctrl Nmbr: 9392 Contract Hdr: PREFERRED PROVIDER Claim Frequency: 1 Claim Payment: $160.00
Rendering Prvd: APPIAGYEI, MICHAEL ORGANIZATION Claim Received Date: 01/15/2024 Patient Resp: $126.22
Original Ref Nmbr: Rendering Prv ID:

Line Details Results: 2

Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
93921 11/27/2023 - HC:99396 / / 1 $160.00 (B6) $160.00 $160.00
11/27/2023
93922 11/27/2023 - HC:99203 / 25 / 1 $126.22 (B6) $205.00 PR-1 $126.22 $0.00
11/27/2023 CO-45 $78.78

Supplemental Information - AMT/Payer Codes: $286.22 (AU)

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Payer: BLUECROSS BLUESHIELD OF ILLINOIS Check/EFT Trace Number: C24016957146140 Check/EFT Date: 01/16/2024 Total Paid: $1,743.21

Patient Name: MITCHELL, VIVIAN Claim Number: 02024015506V9270X00 Claim Date: 01/11/2024-01/11/2024 Claim Status Code: 1
Patient ID: MCD832201621 Group / Policy: 0003079560004 Facility Type: 11 Claim Charge: $225.00
Patient Ctrl Nmbr: 9832 Contract Hdr: PREFERRED PROVIDER Claim Frequency: 1 Claim Payment: $0.00
Rendering Prvd: APPIAGYEI, MICHAEL ORGANIZATION Claim Received Date: 01/15/2024 Patient Resp: $141.84
Original Ref Nmbr: Rendering Prv ID:

Line Details Results: 1

Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
98321 01/11/2024 - HC:99214 / / 1 $141.84 (B6) $225.00 PR-1 $141.84 $0.00
01/11/2024 CO-45 $83.16

Supplemental Information - AMT/Payer Codes: $141.84 (AU)

Patient Name: MONEGAIN, SAMORIA Claim Number: 02024015506V9380X00 Claim Date: 11/29/2023-11/29/2023 Claim Status Code: 1
Patient ID: WJW847613111 Group / Policy: 0002928931000 Facility Type: 11 Claim Charge: $269.00
Patient Ctrl Nmbr: 9410 Contract Hdr: PREFERRED PROVIDER Claim Frequency: 1 Claim Payment: $0.00
Rendering Prvd: APPIAGYEI, MICHAEL ORGANIZATION Claim Received Date: 01/15/2024 Patient Resp: $177.41
Original Ref Nmbr: Rendering Prv ID:

Line Details Results: 3

Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
94101 11/29/2023 - HC:96372 / / 1 $30.69 (B6) $34.00 PR-1 $30.69 $0.00
11/29/2023 CO-45 $3.31
94102 11/29/2023 - HC:J3420 / / 1 $4.88 (B6) $10.00 PR-1 $4.88 $0.00
11/29/2023 CO-45 $5.12
94103 11/29/2023 - HC:99214 / 25 / 1 $141.84 (B6) $225.00 PR-1 $141.84 $0.00
11/29/2023 CO-45 $83.16

Supplemental Information - AMT/Payer Codes: $177.41 (AU)

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Payer: BLUECROSS BLUESHIELD OF ILLINOIS Check/EFT Trace Number: C24016957146140 Check/EFT Date: 01/16/2024 Total Paid: $1,743.21

Patient Name: OSEIOWUSU, EVELYN Claim Number: 02024004502512P0X00 Claim Date: 11/20/2023-11/20/2023 Claim Status Code: 1
Patient ID: EIU000977629 Group / Policy: Facility Type: 11 Claim Charge: $327.00
Patient Ctrl Nmbr: 9329 Contract Hdr: Claim Frequency: 1 Claim Payment: $194.11
Rendering Prvd: APPIAGYEI, MICHAEL Rendering Prv ID: Claim Received Date: 01/04/2024 Patient Resp: $0.00
Original Ref Nmbr:

Line Details Results: 4

Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
93291 11/20/2023 - HC:99214 / 25 / 1 $142.66 (B6) $225.00 CO-45 $82.34 $142.66
11/20/2023
93292 11/20/2023 - HC:80061 / / 1 $13.39 (B6) $30.00 CO-45 $16.61 $13.39
11/20/2023
93293 11/20/2023 - HC:90471 / / 1 $15.00 (B6) $32.00 CO-45 $17.00 $15.00
11/20/2023
93294 11/20/2023 - HC:90686 / / 1 $23.06 (B6) $40.00 CO-45 $16.94 $23.06
11/20/2023

Supplemental Information - AMT/Payer Codes: $194.11 (AU)

Patient Name: PEREZ, GUADALUPE Claim Number: 020233215082X070X01 Claim Date: 10/27/2023-10/27/2023 Claim Status Code: 22
Patient ID: HFA803623998 Group / Policy: 000P138850000 Facility Type: 11 Claim Charge: $-335.00
Patient Ctrl Nmbr: 35692 Contract Hdr: PREFERRED PROVIDER Claim Frequency: Claim Payment: $-52.06
Rendering Prvd: APPIAGYEI, MICHAEL ORGANIZATION Claim Received Date: 12/21/2023 Patient Resp: $0.00
Original Ref Nmbr: 020233215082X070X00 Rendering Prv ID:

Line Details Results: 3

Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
10/27/2023 - HC:99213 / 25 / 1 $-230.00 PR-45 $-230.00 $0.00
10/27/2023
10/27/2023 - HC:90686 / / 1 $-65.00 CO-45 $-41.94 $-23.06
10/27/2023

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Payer: BLUECROSS BLUESHIELD OF ILLINOIS Check/EFT Trace Number: C24016957146140 Check/EFT Date: 01/16/2024 Total Paid: $1,743.21

Line Details Results: 3

Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
10/27/2023 - HC:90460 / / 1 $-40.00 CO-45 $-11.00 $-29.00
10/27/2023

Patient Name: PEREZ, GUADALUPE Claim Number: 020233215082X070X02 Claim Date: 10/27/2023-10/27/2023 Claim Status Code: 1
Patient ID: HFA803623998 Group / Policy: 000P138850000 Facility Type: 11 Claim Charge: $335.00
Patient Ctrl Nmbr: 35692 Contract Hdr: PREFERRED PROVIDER Claim Frequency: Claim Payment: $152.44
Rendering Prvd: APPIAGYEI, MICHAEL ORGANIZATION Claim Received Date: 01/03/2024 Patient Resp: $0.00
Original Ref Nmbr: 020233215082X070X01 Rendering Prv ID:

Line Details Results: 3

Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
10/27/2023 - HC:99213 / 25 / 1 $100.38 (B6) $230.00 CO-45 $129.62 $100.38
10/27/2023
10/27/2023 - HC:90686 / / 1 $23.06 (B6) $65.00 CO-45 $41.94 $23.06
10/27/2023
10/27/2023 - HC:90460 / / 1 $29.00 (B6) $40.00 CO-45 $11.00 $29.00
10/27/2023

Supplemental Information - AMT/Payer Codes: $152.44 (AU)

Patient Name: VILLARREAL, TINA Claim Number: 020233215087X120X00 Claim Date: 10/26/2023-10/26/2023 Claim Status Code: 22
Patient ID: MGAT50557141 Group / Policy: 000XOPPOX0000 Facility Type: 11 Claim Charge: $-650.00
Patient Ctrl Nmbr: 35335 Contract Hdr: PREFERRED PROVIDER Claim Frequency: 1 Claim Payment: $-194.69
Rendering Prvd: APPIAGYEI, MICHAEL ORGANIZATION Claim Received Date: 11/17/2023 Patient Resp: $0.00
Original Ref Nmbr: Rendering Prv ID:

Line Details Results: 5

Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units

Page 6
Payer: BLUECROSS BLUESHIELD OF ILLINOIS Check/EFT Trace Number: C24016957146140 Check/EFT Date: 01/16/2024 Total Paid: $1,743.21

Line Details Results: 5

Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
78191 10/26/2023 - HC:99214 / 25 / 1 $-300.00 PR-1 $-141.84 $0.00
10/26/2023 CO-45 $-158.16
78192 10/26/2023 - HC:0241U / QW / 1 $-195.00 CO-45 $-52.37 $-142.63
10/26/2023
78193 10/26/2023 - HC:87651 / 59 / 1 $-50.00 PR-1 $-35.09 $0.00
10/26/2023 CO-45 $-14.91
78194 10/26/2023 - HC:90686 / / 1 $-65.00 CO-45 $-41.94 $-23.06
10/26/2023
78288 10/26/2023 - HC:90460 / / 1 $-40.00 CO-45 $-11.00 $-29.00
10/26/2023

Patient Name: VILLARREAL, TINA Claim Number: 020233215087X120X01 Claim Date: 10/26/2023-10/26/2023 Claim Status Code: 1
Patient ID: MGAT50557141 Group / Policy: 000XOPPOX0000 Facility Type: 11 Claim Charge: $650.00
Patient Ctrl Nmbr: 35335 Contract Hdr: PREFERRED PROVIDER Claim Frequency: Claim Payment: $194.69
Rendering Prvd: APPIAGYEI, MICHAEL ORGANIZATION Claim Received Date: 01/09/2024 Patient Resp: $176.93
Original Ref Nmbr: 020233215087X120X00 Rendering Prv ID:

Line Details Results: 5

Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
10/26/2023 - HC:99214 / 25 / 1 $141.84 (B6) $300.00 PR-1 $141.84 $0.00
10/26/2023 CO-45 $158.16
10/26/2023 - HC:0241U / QW / 1 $142.63 (B6) $195.00 CO-45 $52.37 $142.63
10/26/2023
10/26/2023 - HC:87651 / 59 / 1 $35.09 (B6) $50.00 PR-1 $35.09 $0.00
10/26/2023 CO-45 $14.91
10/26/2023 - HC:90686 / / 1 $23.06 (B6) $65.00 CO-45 $41.94 $23.06
10/26/2023
10/26/2023 - HC:90460 / / 1 $29.00 (B6) $40.00 CO-45 $11.00 $29.00
10/26/2023

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Payer: BLUECROSS BLUESHIELD OF ILLINOIS Check/EFT Trace Number: C24016957146140 Check/EFT Date: 01/16/2024 Total Paid: $1,743.21

Supplemental Information - AMT/Payer Codes: $371.62 (AU)

Code Descriptions

AMT CODE(S):
B6=Allowed - Actual
AU=Coverage Amount

GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility

CLAIM ADJUSTMENT REASON CODE(S):

45=Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. 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 depending upon liability)
3=Co-payment Amount
1=Deductible Amount

CLAIM STATUS CODE(S):

1=Processed as Primary
22=Reversal of Previous Payment

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