EXPLANATION OF BENEFITS

000221 J280DUAP 020802 E00741181532

/

Please Retain for Future Reference

Provider ID: / 0002776331
Issue Date: / 12/13/2011
Provider: / Page 1 of 2
David Walker Medical Services

12399 Smith Street

Laurel, MD20210
Notes: The benefits listed below reflect your portion of this payment. For Participating Physicians and Facilities Only – If your practice has a chance of address and/or telephone number, please contact (company) online at:
Patient ID:990076322166 / Patient Name:CYRUS JORDAN / Group Number: 955478-10-001 NY VB
Patient Acct:5893322211 / Group Name:BASKETBALL ASSOC / Product: Choice HMO
Claim ID: ETKTX77654
SERVICE
DATES / SERVICE CODE / SUBMITTED
CHARGES / ALLOWED AMOUNT / NOT
PAYABLE / DEDUCTIBLE / CO INS. / COPAY
AMOUNT / PAYABLE
AMOUNT / RC
11/25/11 / 99225 / 200.00 / 150.00 / 100.00 / 50.00 / PP
12/16/11 / 65225 / 90.00 / 70.00 / 70.00
12/16/11 / 99213 / 230.00 / 130.00 / 30.00 / 100.00

TOTALS

/ 520.00 / 350.00 / 100.00 / 30.00 / 220.00
ISSUED AMT: / 220.00
Total Patient Responsibility: / 130.00
Patient ID:987776539873 / Patient Name:JEREMY DOE / Group Number: 894432-10-001 PA AA
Patient Acct: 8273772654 / Group Name: DOE ASSOCIATES / Product: Choice HMO
Claim ID: ETKTY76643
SERVICE
DATES / SERVICE CODE / SUBMITTED
CHARGES / ALLOWED AMOUNT / NOT
PAYABLE / DEDUCTIBLE / CO INS. / COPAY
AMOUNT / PAYABLE
AMOUNT / RC
10/16/11 / 00313 / 230.00 / 200.00 / 100.00 / 50.00 / 50.00
10/16/11 / 98558 / 320.00 / 320.00 / PN
10/16/11 / 32871 / 60.00 / 60.00 / 50.00 / 10.00
10/18/11 / 99786 / 350.00 / 350.00 / 100.00 / 250.00

TOTALS

/ 960.00 / 610.00 / 320.00 / 100.00 / 150.00 / 50.00 / 310.00
ISSUED AMT: / 310.00
Total Patient Responsibility: / 620.00

EOB TOTALS

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1480.00

/

960.00

/

320.00

/

200.00

/

150.00

/

80.00

/

530.00

REMARKS:

PP: Expense incurred prior to coverage.

PN: Services denied at the time authorization/pre-certification was requested.

For Questions Regarding This Claim

CALL (123) 456-7890 For Assistance

Note: All inquires should reference the ID number above for prompt response.

Sun Insurance – Detail W/RC 31 of 2