PCOVERFORM

PCOVERFORM

Constitution Physician Alliance LLC

PO Box 20002 202312278802

Nashville, TN 37202

1 OF 3 F
Forwarding Service Requested

4511 0.0372
FFATAFTADTDDATFDTAADDATATTFDTFFDADDADTFADTAAATTADDTADAADAAFTATFAD

ENV 4511
WEST CAYUGA MEDICAL CENTER
257 W CAYUGA ST
PHILADELPHIA, PA 19140-2439
 202312278802

L879002800Y
Contact Provider Services with any questions
1 (800) 230-6138
Constitution Physician Alliance LLC
Monday - Friday 7:00 AM - 9:00 PM EST
PO Box 20002
Nashville, TN 37202
Cigna
Claims Department
PO Box 981706
El Paso, TX 79998-1706

Page: 2 of 4

9 9 Date: 12/27/2023
WEST CAYUGA MEDICAL CENT Provider: WEST CAYUGA MEDICAL
257 W CAYUGA ST Provider NPI: 1811449697
Check Number: 1256722
PHILADELPHIA, PA 19140-2439 Voucher Number: 1256722
Negative Balance ID:

Explanation of Initial Claims Payments

Member ID: 31593317 Provider Name: VENGOECHEA, FABIAN A
Member Name: RAMIRO ORELLANO Date(s) of Service: 12/13/2023 - 12/13/2023
Network: VFIPA Paid DRG:
Claim Number: 23355E029487 DRG Weight: 0.00000
Provider Acct No/ Patient Control No: 1158379135 Interest: $0.00
Date(s) of Service Service Billed Allowed Copay Coinsurance Deductible Withhold MIPS Adjustment Payment Reason Code
Code Amount Amount
12/13/2023 - 12/13/2023 99213 78.47 78.47 20.00 0.00 0.00 1.17 0.00 0.00 57.30 1229

Claim Totals: 78.47 78.47 20.00 0.00 0.00 1.17 0.00 0.00 57.30

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name, logos, and other Cigna marks are owned
by Cigna Intellectual Property, Inc.,

INT_20_86290_C © 2020 Cigna

ENV 4511 2 OF 3 F
 202312278802

L879002800Y
Total Check Amount/Total Offsets/Total Refund Requests

Initial Claims Payments 57.30

Claims Adjustments 0.00

Negative Balance recouped

from this check 0.00

Total Check Amount 57.30

Total Refund Requests 0.00

Additional Information
Total Interest on EOP 0.00

Remark Code Explanation

1229 Sequestration - Reduction in Federal Spending. Reduction in payment applies according to Medicare guidelines.
903 $0.00 Check(s) received from provider for this check period
904 $0.00 Amount Written Off
*** Your payment may be reduced by 2% in accordance with the Budget Control Act and Sequestration for dates of service April 1, 2013 and after. Note the reduction will appear in the Withhold field.
*** Effective July 1, 2014, all Home Health Agency (HHA) and Skilled Nursing Facilities (SNF) are required to submit Health Insurance Prospective Payment System (HIPPS) codes on all claims and use
only the 837-Institutional claims format. Cigna will begin to reject or deny HHA and SNF claims that do not contain a HIPPS code or that have been submitted in the 837-Professional claims format
effective dates of service September 1, 2014.
*** CMS requires annual Special Needs Plans (SNP) Model of Care (MOC) training for network providers, and non-network providers who routinely see SNP customers. If you’ve not participated in SNP
MOC training this year, please access the SNP MOC training on Cigna’s Health Care Professionals website:
https://medicareproviders.cigna.com/static/medicareproviders-cigna-com/docs/snp-moc-training.pdf

*** Attention Out-of-Network providers: For provider manuals and Medicare information and tools, please go to https://medicareproviders.cigna.com/. Select the Out-of-Network Provider Manual in
the drop down box for details.
Notes The "R" after a claim number represents a reversal for that claim
The "A" after a claim number represents an adjustment for that claim
The number after an "R" or an "A" on a claim represents the number of times that claim has been reversed or adjusted
Negative Balance/Offset are amounts automatically recouped from total payment(s)
Refund Requests are adjustments that have not been automatically recouped from total payment(s) and will require further action from you to resolve

ENV 4511 2 OF 3 B
 P879002801G
202312278802 P879002801G

Constitution Physician Alliance LLC

PO Box 20002
Nashville, TN 37202

3 OF 3 F
Forwarding Service Requested

FFATAFTADTDDATFDTAADDATATTFDTFFDADDADTFADTAAATTADDTADAADAAFTATFAD

ENV 4511
WEST CAYUGA MEDICAL CENTER
257 W CAYUGA ST
PHILADELPHIA, PA 19140-2439

61-1 CHECK NO.: 01256722

Constitution Physician Alliance LLC 620
PO Box 20002 CHECK DATE: 12/27/2023
Nashville, TN 37202
AMOUNT
$ ******* 57.30
PAY Fifty Seven & 30/100 Dollars
TO THE WEST CAYUGA MEDICAL CENTER
ORDER OF 257 W Cayuga St
Philadelphia, PA 191402439