P683502800K

P683502800K

Health Partners Plans

901 Market Street, Suite 500
Philadelphia, PA 19107
202312188800

Forwarding Service Requested

1 OF 6
Questions? Please contact Provider Service at (215)
7276 0.0744 991-4350 or Toll free (888)991-9023.

ENV 7276
FFATAFTADTDDATFDTAADDATATTFDTFFDADDADTFADTAAATTADDTADAADAAFTATFAD
WEST CAYUGA MEDICINE PC
257 W CAYUGA ST Payor ID: 80142
PHILADELPHIA, PA 19140-2439

Your name WEST CAYUGA MEDICINE PC and tax id have been

verified by the IRS

Tax ID: 813661898 EPC Draft #: 317733732 Payment Week: 50 Payment Date: 12/15/2023
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: HERMINIO RAMOS Insured: 890248287HERMINIO RAMOS Payer Claim #: 2023120600205
Pat. Acct #: 1153280549 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/02/23-12/02/23 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: CRYSTAL CABAN Insured: 630175570CRYSTAL CABAN Payer Claim #: 2023120600206

Pat. Acct #: 1153576510 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: SHANAE BRADLEY Insured: 950137888SHANAE BRADLEY Payer Claim #: 2023120600207

Pat. Acct #: 1153576316 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: DAVID SHIPTON Insured: 230502072DAVID SHIPTON Payer Claim #: 2023120600433

Pat. Acct #: 1153280160 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/01/23-12/01/23 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: JAMES CHAMBERS Insured: 690111641JAMES CHAMBERS Payer Claim #: 2023120600437

Pat. Acct #: 1153280220 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/01/23-12/01/23 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: IVAN ORTIZ Insured: 050478812IVAN ORTIZ Payer Claim #: 2023120600439

Pat. Acct #: 1153280254 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/01/23-12/01/23 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: JOSELYN TORRES Insured: 110008798JOSELYN TORRES Payer Claim #: 2023120600441

Pat. Acct #: 1153280403 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/01/23-12/01/23 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: JENNY FOX Insured: 430103653JENNY FOX Payer Claim #: 2023120600443

Pat. Acct #: 1153280306 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
 P683502800K
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Tax ID: 813661898 EPC Draft #: 317733732 Payment Week: 50 Payment Date: 12/15/2023
Service Date Procedures No. of Amount Allowed Payment Patient Other Not Covered Sequest- Adjustment
From To (Modifier) Units Billed Responsibility Ins. Paid ration Reason
12/01/23-12/01/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45

ENV 7276
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

Patient: CHRISTINE BORRELLI Insured: 001205052CHRISTINE BORRELLI Payer Claim #: 2023120600451

Pat. Acct #: 1153280450 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/02/23-12/02/23 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: BEATRIZ CRUZ Insured: 001347388BEATRIZ CRUZ Payer Claim #: 2023120600453

Pat. Acct #: 1153280461 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
10/27/23-10/27/23 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: DAVID ENELOW Insured: 600225028DAVID ENELOW Payer Claim #: 2023120600455

Pat. Acct #: 1153280522 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/02/23-12/02/23 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: ALEXANDER HERNANDEZ Insured: 540107942ALEXANDER Payer Claim #: 2023120600460

Pat. Acct #: 1153279970 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/01/23-12/01/23 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: HELEN ANDERSON Insured: 001045449HELEN ANDERSON Payer Claim #: 2023120600462

Pat. Acct #: 1153279989 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
10/30/23-10/30/23 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: ELIZABETH CUEVAS Insured: 100000523ELIZABETH CUEVAS Payer Claim #: 2023120600464

Pat. Acct #: 1153279997 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/01/23-12/01/23 99213 1 78.47 0.00 0.00 0.00 0.00 78.47 0.00 CO23 CO45
Total for Claim: 78.47 0.00 0.00 0.00 0.00 78.47 0.00

Patient: MICHAEL NOLEN Insured: 780208228MICHAEL NOLEN Payer Claim #: 2023120600468

Pat. Acct #: 1153280053 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/02/23-12/02/23 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: LUIS A TORRES Insured: 010011358LUIS A TORRES Payer Claim #: 2023120600470

Pat. Acct #: 1153280061 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/01/23-12/01/23 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 #: 2023120600474

Pat. Acct #: 1153576358 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: ANGEL GONZALEZ Insured: 001616676ANGEL GONZALEZ Payer Claim #: 2023120600478

Pat. Acct #: 1153576454 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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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Tax ID: 813661898 EPC Draft #: 317733732 Payment Week: 50 Payment Date: 12/15/2023
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: ELIZABETH ROMERO HECHAVA Insured: 440667216ELIZABETH ROMERO Payer Claim #: 2023120600479

ENV 7276
Pat. Acct #: 1153576532 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 99204 1 176.38 141.57 141.57 0.00 0.00 34.81 0.00 CO45
Total for Claim: 176.38 141.57 141.57 0.00 0.00 34.81 0.00

Patient: ROBERT PISANO Insured: 410193227ROBERT PISANO Payer Claim #: 2023120600481

Pat. Acct #: 1153576581 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: SHAWN BOYLE Insured: 870160670SHAWN BOYLE Payer Claim #: 2023120600483

Pat. Acct #: 1153576807 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: WILLIAM JR NAZWORTH Insured: 130166692WILLIAM JR NAZWORTH Payer Claim #: 2023120600485

Pat. Acct #: 1153576835 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
11/01/23-11/01/23 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: KAYLA DAVIS Insured: 370334480KAYLA DAVIS Payer Claim #: 2023120600487

Pat. Acct #: 1153576856 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: ELLEN COLON Insured: 110115057ELLEN COLON Payer Claim #: 2023120600489

Pat. Acct #: 1153576928 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: ROBERTO LOPEZ Insured: 160184807ROBERTO LOPEZ Payer Claim #: 2023120600491

Pat. Acct #: 1153576262 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/01/23-12/01/23 99213 GT 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: JOSEFINA CINTRON Insured: 001328014JOSEFINA CINTRON Payer Claim #: 2023120600492

Pat. Acct #: 1153576275 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: FELIX GONZALEZ Insured: 120005340FELIX GONZALEZ Payer Claim #: 2023120600496

Pat. Acct #: 1153576247 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 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: SHEILA NEAL Insured: 001687012SHEILA NEAL Payer Claim #: 2023120700342

Pat. Acct #: 1154023200 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/05/23-12/05/23 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: DAJUAN JONES Insured: 001832565DAJUAN JONES Payer Claim #: 2023120714351

Pat. Acct #: 1154022713 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/05/23-12/05/23 99213 1 78.47 64.62 64.62 0.00 0.00 13.85 0.00 CO45
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Tax ID: 813661898 EPC Draft #: 317733732 Payment Week: 50 Payment Date: 12/15/2023
Service Date Procedures No. of Amount Allowed Payment Patient Other Not Covered Sequest- Adjustment
From To (Modifier) Units Billed Responsibility Ins. Paid ration Reason
Total for Claim: 78.47 64.62 64.62 0.00 0.00 13.85 0.00

ENV 7276
Patient: AIXA PACHECO Insured: 199952533AIXA PACHECO Payer Claim #: 2023120714352
Pat. Acct #: 1154022726 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/05/23-12/05/23 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: AMBER NEVEDOMSKY Insured: 040115621AMBER NEVEDOMSKY Payer Claim #: 2023120714353

Pat. Acct #: 1154022747 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/04/23-12/04/23 99213 GT 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: LUIS RIOS Insured: 670164544LUIS RIOS Payer Claim #: 2023120714354

Pat. Acct #: 1154022867 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/05/23-12/05/23 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: JERSON RODRIGUEZVARGA Insured: 991181580JERSON Payer Claim #: 2023120714357

Pat. Acct #: 1154022992 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/05/23-12/05/23 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: ISRAEL LOPEZ Insured: 780176591ISRAEL LOPEZ Payer Claim #: 2023120714358

Pat. Acct #: 1154023014 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/05/23-12/05/23 99204 1 176.38 141.57 141.57 0.00 0.00 34.81 0.00 CO45
Total for Claim: 176.38 141.57 141.57 0.00 0.00 34.81 0.00

Patient: LAUREN RAMOS Insured: 200176285LAUREN RAMOS Payer Claim #: 2023120714359

Pat. Acct #: 1154023052 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/05/23-12/05/23 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: CARRIE FELTMAN Insured: 160347201CARRIE FELTMAN Payer Claim #: 2023120714360

Pat. Acct #: 1154023142 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/05/23-12/05/23 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: JOHANNA LOPEZ Insured: 001958851JOHANNA LOPEZ Payer Claim #: 2023120803035

Pat. Acct #: 1154503732 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/06/23-12/06/23 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: ROBERT WALKER Insured: 040375211ROBERT WALKER Payer Claim #: 2023120803036

Pat. Acct #: 1154496787 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/06/23-12/06/23 99213 GT 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: ROBERTO LOPEZ Insured: 160184807ROBERTO LOPEZ Payer Claim #: 2023120803038

Pat. Acct #: 1154504028 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/06/23-12/06/23 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
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Tax ID: 813661898 EPC Draft #: 317733732 Payment Week: 50 Payment Date: 12/15/2023
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: PATRICK MARKEE Insured: 002188470PATRICK MARKEE Payer Claim #: 2023120803040

ENV 7276
Pat. Acct #: 1154504175 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/06/23-12/06/23 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: GERARDA DROZ-PABON Insured: 001464220GERARDA DROZ-PABON Payer Claim #: 2023120803041

Pat. Acct #: 1154504328 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/06/23-12/06/23 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: EVANGELINE THOMPKINS Insured: 002716008EVANGELINE Payer Claim #: 2023120803042

Pat. Acct #: 1154504433 Provider: West Cayuga Medicine Pc Group/Check Number: 01/922990
12/06/23-12/06/23 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

Statement Summary Amount Billed Payment Patient Other Ins. Not Covered
Responsibility Paid
3,601.87 2,890.05 0.00 0.00 711.82

Explanations
Administered By Code Description
HEALTH PARTNERS OF CO45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
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
depending upon liability)
CO23 The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only
with Group Code OA)

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 P683502804W
202312188800 P683502804W

Health Partners Plans

901 Market Street, Suite 500
Philadelphia, PA 19107

Forwarding Service Requested

6 OF 6
ENV 7276
FFATAFTADTDDATFDTAADDATATTFDTFFDADDADTFADTAAATTADDTADAADAAFTATFAD
WEST CAYUGA MEDICINE PC
257 W CAYUGA ST
PHILADELPHIA, PA 19140-2439

Electronic Payment Clearinghouse

PNC - ECHO
Pittsburgh PA 15219
60-162 DRAFT NO. 317733732
433
901 Market Street, Suite 500
Philadelphia, PA 19107
ELECTRONIC COMMERCE BENEFIT TRUST
DRAFT DATE: 12/15/2023
VOID AFTER 180 DAYS

PAYABLE THROUGH Two Thousand Eight Hundred Ninety & 05/100 Dollars
AMOUNT
DRAFT *****$2,890.05
TO THE WEST CAYUGA MEDICINE PC
ORDER OF 257 W CAYUGA ST

PHILADELPHIA PA 19140