P6082028001

P6082028001

P.O. Box 21545

Eagan, MN 55121-0545
202312268800

1 OF 2
Electronic Service Requested

6766 0.0248

ENV 6766
ADAFADTDDTDDTTFATAATTFTAAAFATDFDFTDAADFFFDTADTDATDFAAAFDAAFTDTDDD
WEST CAYUGA MEDCN PC
257 W CAYUGA ST
PHILADELPHIA, PA 19140-2439

PNC BANK, NATIONAL ASSOCIATION 60-162 CHECK NO.: 1353846

JEANNETTE, PA 433
CHECK DATE: 12/14/23

PO Box 21545, Eagan, MN 55121-0545 AMOUNT

*****$74.25
PAY Seventy Four & 25/100 Dollars
VOID AFTER 6 MONTHS
TO THE
ORDER OF WEST CAYUGA MEDCN PC
257 W Cayuga St
Philadelphia PA 19140

Authorized Signature
 202312268800

L6082028000
Index_2023345038489_81-3661898_2148432000_017377_Page001
202312268800

c/o Processing Center

P.O. Box 21974 Independence Administrators is an Independent Licensee of the
Eagan, MN 55121 Blue Cross and Blue Shield Association.

To reach a Customer Experience

Advocate, please call: 844-864-4352
WEST CAYUGA MEDCN PC
257 W CAYUGA ST
PHILADELPHIA, PA 19140

Date: 12/14/2023
Provider Number: S1953807

Explanation of Payment:
Paid to: WEST CAYUGA MEDCN PC Check Date: 12/14/2023
Check No: 1353846 Amount: $74.25

Interested in secure direct deposits using electronic funds transfer (EFT) and electronic remittance advice (ERA) to replace paper check and EOPs?
To learn more, visit: www.ibxtpa.com/providers

Proc Rev Allowed Non-Covered Patient

Date(s) of Service Code Code # Svcs Billed Amount Amount Amount Code Deductible Coinsurance Paid Amount Responsibility
Patient Name: DAVID MAYO Claim Number: 2023345038489
Patient Number: 1149777336 Member ID: XHQ2148432000 Network Description: Independence Administrators
11/15/23 - 11/15/23 99214 1 115.24 114.25 0.00 26, 16 0.00 0.00 74.25 40.00
Totals: 115.24 114.25 0.00 0.00 0.00 74.25 40.00
Incentive Pool Accrual 0.00

Allowed Non-Covered Patient

Billed Amount Amount Amount Code Deductible Coinsurance Paid Amount Responsibility
Statement Totals: 115.24 114.25 0.00 0.00 0.00 74.25 40.00

Incentive Pool Accrual Totals: 0.00

Explanation of Message Codes / Network

26 Co-payment Amount
16 Participating Network Provider

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