CLM*A0014189156*332***11^B^1*Y*A*Y*Y~PWK*10*FT***AC*PLAN 80~REF*F8*03231L10001~REF*D9*CF-TCNSL-201118-E-P~REF*EA*0103BB91F6DB451681D5397B848BB632~HI*ABK^L570*ABF^L853*ABF^D225*ABF^L578~NM1*82*1*GLASSMAN MD*BRUCE****XX*1730151119~REF*G2*CR090001~NM1*77*2*ALEXANDRIA VA 376~N3*4660 KENMORE AVE*STE 1100~N4*ALEXANDRIA*VA*223041300~SBR*P*18*******MB~AMT*D*171.06~OI***Y***Y~MOA***MA01~NM1*IL*1*SANDUSKY*MICHAEL*C***MI*3MN9C42MW16~N3*3405 CLAYBORNE AVENUE~N4*ALEXANDRIA*VA*22306~NM1*PR*2*MEDICARE DC VA MD 12202*****PI*12202~LX*1~SV1*HC^17000*135*UN*1***1~DTP*472*D8*20201026~REF*6R*CPDYLOV8FGKD~SVD*12202*63.17*HC^17000**1~CAS*PR*2*15.57~CAS*CO*144*-0.88**45*57.14~DTP*573*D8*20201110~LX*2~SV1*HC^17003*19*UN*1***1~DTP*472*D8*20201026~REF*6R*CPDYJYHEIH2W~SVD*12202*5.87*HC^17003**1~CAS*PR*2*1.45~CAS*CO*144*-0.08**45*11.76~DTP*573*D8*20201110~LX*3~SV1*HC^99214^25*178*UN*1***1^2^3^4~DTP*472*D8*20201026~REF*6R*CPDYLJFUCSGQ~SVD*12202*102.02*HC^99214^25**1~CAS*PR*2*25.15~CAS*CO*144*-1.42**45*52.25~DTP*573*D8*20201110~ { "claimOverview": { "miscInfo": { "origClmNum": "03211F6613P", "claimType": "Professional", "clmNum": "03231L10001", "planCode": "580", "appTransId": "20323CFSIT00001", "dtClmRec": "11/16/2020", "planRepId": "CF-TCNSL-201118-E-P", "comments": "" }, "planInfo": { "patCode": "C", "patientMatch": "A", "claimSource": null } }, "submitterReceiver": { "submitter": { "submitterName": "EMDEON", "submitterId": "133052274", "submitterDetails": [ { "submitterContactName": "EMDEON CUSTOMER SOLUTIONS", "submitterContactNumbers": { "TE": "8008456592" } } ] }, "receiver": { "receiverName": "CAREFIRST", "receiverId": "00580" } }, "member": { "subscriber": { "groupId": "106", "clmFindingInd": "BL", "subsriberLastName": "SANDUSKY", "subscirberFirstName": "MICHAEL", "subscriberMiddleName": "C", "primaryId": "R13125059", "dob": "01/06/1939", "genderCode": "M", "address1": "3405 CLAYBORNE AVENUE", "address2": null, "city": "ALEXANDRIA", "state": "VA", "zipcode": "22306" }, "dependent": null }, "provider": { "billingProivder": { "billingProvTaxonomy": null, "billingProvLastName": "ZZZ ADVANCED DERMATOLOGY OF VIRGINIA INC", "billingProvFirstName": null, "billingProvMiddleName": null, "billingProvNPI": "1801342639", "billingProvTaxId": "811345719", "billingProvId": "CR090001", "billingProvSSN": null, "address1": "4660 KENMORE AVE STE 500", "address2": null, "city": "ALEXANDRIA", "state": "VA", "zipcode": "223041300", "countryCode": null, "billingProvContactName": "GIA CONCANNON", "communicationNumberQualifier1": "TE", "communicationNumber1": "4078752080", "communicationNumberQualifier2": null, "communicationNumber2": null, "communicationNumberQualifier3": null, "communicationNumber3": null }, "payToAddress": { "address1": "PO BOX 862823", "address2": null, "city": "ORLANDO", "state": "FL", "zipcode": "328862823", "countryCode": null }, "payToPlan": null, "pcpReferringProvider": null, "renderingProvider": { "renderingProvLastName": "GLASSMAN MD", "renderingProvFirstName": "BRUCE", "renderingProvMiddleName": null, "renderingProvNPI": "1730151119", "renderingProvTaxonomy": null, "renderingProvId": "CR090001" }, "serviceFacility": { "serviceFacilityName": "ALEXANDRIA VA 376", "serviceFacilityNPI": null, "address1": "4660 KENMORE AVE", "address2": "STE 1100", "city": "ALEXANDRIA", "state": "VA", "zipcode": "223041300", "countryCode": null, "serviceFacilityId": null }, "supervicingProvider": null, "ambulancePickupDropoff": null }, "claimLevel": { "healthClaim": { "patientAcc": "A0014189156", "totalClaimCharges": 332, "pos": "11", "claimFrequency": "1", "providerSignatureOnFile": "Y", "planParticipationCode": "A", "benefitAssignmentIndicator": "Y", "relaseOfInformationCode": "Y", "patientSignatureSoruceCode": null, "relatedCauseCode1": null, "relatedCauseCode2": null }, "dates": { "currentIllness": null, "initialTreatmentDate": null, "lastSeenDate": null, "acuteManifestationDate": null, "accidentDate": null, "lastMenstrualDate": null, "lastXRayDate": null, "participationDate": null, "disabilityStartDate": null, "disabilityEndDate": null, "lastWorkedDate": null, "workReturnDate": null, "admissionDate": null, "dischargeDate": null, "assumedCareDate": null, "relinquishedCareDate": null, "firstVisitDate": null, "repricerReceivedDate": null }, "reference": { "serviceAuthExCode": null, "medicalSec4081Indicator": null, "mammographyCertificationNumber": null, "referenceNumber": null, "priorAuthNumber": null, "claimNumber": "03231L10001", "clinicalLabImprAmendmentNumber": null, "repricedClaimNumber": null, "adjustedRepricedClaimNumber": null, "investigationalDeviceExId": null, "claringTraceNumber": "CF-TCNSL-201118-E-P", "medicalRecordNumber": "0103BB91F6DB451681D5397B848BB632", "demonstrationProjectId": null, "carePlanOversightNumber": null }, "claimNote": null, "ambulanceTransport": null, "ambulanceCertification": null, "claimSupplementalInfos": [ { "reportTypeCode": "10", "transmissionCode": "FT", "controlNumber": "PLAN 80" } ], "diagnosisCodes": [ { "diagnosisType": "Principal Diagnosis Code", "diagnosisQualifier": "ABK", "diagnosisCode": "L570" }, { "diagnosisType": "Other Diagnosis Code", "diagnosisQualifier": "ABF", "diagnosisCode": "L853" }, { "diagnosisType": "Other Diagnosis Code", "diagnosisQualifier": "ABF", "diagnosisCode": "D225" }, { "diagnosisType": "Other Diagnosis Code", "diagnosisQualifier": "ABF", "diagnosisCode": "L578" } ], "procedures": null, "conditions": null }, "otherPayerDetails": [ { "payerName": "MEDICARE DC VA MD 12202", "payerRespSeqCode": "P", "totalClaimCharges": 332, "payerPaidAmount": 171.06, "otherInsurance": { "payerResponsibilitySeqCode": "P", "individualRelationshipCode": "18", "insuredGroupId": null, "insuredGroupName": null, "insuranceType": null, "claimFilingIndicator": "MB", "payerPaidAmount": 171.06, "remainingPatientLiability": null, "nonCoveredAmount": null, "otherInsuranceBenefitsAssignmentIndicator": "Y", "otherInsuranceReleaseInfoCode": "Y" }, "otherAjudication": { "reimbursementRate": null, "hcpcsPayableAmount": null, "claimPaymentRemarkCode1": "MA01", "claimPaymentRemarkCode2": null, "claimPaymentRemarkCode3": null, "claimPaymentRemarkCode4": null, "claimPaymentRemarkCode5": null }, "otherSubscriber": { "otherInsuredId": "3MN9C42MW16", "clmFindingInd": null, "otherInsuredLastName": "SANDUSKY", "otherInsuredFirstName": "MICHAEL", "otherInsuredMiddleName": "C", "otherInsuredAdditionalId": null, "address1": null, "address2": null, "city": null, "state": null, "zipcode": null }, "otherPayer": { "otherPayerName": "MEDICARE DC VA MD 12202", "otherPayerPrimaryId": "12202", "paymentDate": null, "otherPayerSecondaryId": null, "otherPayerPriorAuthorizationNumber": null, "otherPayerReferrlNumber": null, "otehrPayerAdjustmentIndicator": null, "otherPayerClaimControlNumber": null, "address1": "3405 CLAYBORNE AVENUE", "address2": null, "city": null, "state": null, "zipcode": null }, "claimAdjustments": null } ], "serviceLines": [ { "fromDOS": "10/26/2020", "toDOS": "10/26/2020", "pos": "11", "procedureCode": "17000", "procedureModifier1": null, "measurementQantity": 1, "measurementBasis": "UN", "charges": 135, "otherPayerPaidAmount": 63.17, "serviceLineLoop": { "lineNumber": 1, "procedureModifier2": null, "procedureModifier3": null, "procedureModifier4": null, "lineDescription": null, "diagnosisCodePointer1": 1, "diagnosisCodePointer2": null, "diagnosisCodePointer3": null, "diagnosisCodePointer4": null, "emergencyIndicator": null, "epsdtIndicator": null }, "serviceLineDates": { "prescriptionDate": null, "certificationRevisionDatte": null, "beginTherapyDate": null, "lastCertificationDate": null, "lastSeenDate": null, "testPerformedDate": null, "shippedDate": null, "lastXRayDate": null, "initialTreatmentDate": null }, "servieceLineReference": { "repricedLineItemReferenceNumber": null, "adjustedRepricedLineItemReferenceNumber": null, "priorAuthorizationNumber": null, "immunizationBatchNumber": null, "lineItemControlNumber": "CPDYLOV8FGKD", "mammographyCertificationNumber": null, "clinicalLabImprovementAmendmentNumber": null, "referringCliaNumber": null, "referralNumber": null }, "quantityAmountPS1": { "ambulancePatientCount": null, "obstetricAdditionalUnits": null, "salesTaxAmount": null, "postageClaimedAmount": null, "purchasedServiceProviderIdentifier": null, "purchasedServiceChargeAmount": null }, "serviceLineDME": null, "serviceLineSupplementalInfos": null, "serviceLineNotes": null, "serviceLineAmbulanceTransport": null, "serviceLineAmbulanceCertification": null, "serviceLineDrug": null, "serviceLineRenderingProvider": null, "serviceLineServiceFacility": null, "serviceLineSupervisingProvider": null, "serviceLinePCPReferringProvider": null, "serviceLineAmbulancePickupDropoff": null, "serviceLineOrderingProvider": null, "serviceLineAjudications": [ { "otherPayerPrimerId": "12202", "linePaidAmount": 63.17, "procedureCodeIdentifier": "HC", "lineAjudicationDate": "11/10/2020", "remainingPatientLiability": null, "procedureCodeDescription": null, "paidServiceUnitCount": 1, "procedureCode": "17000", "procedureModifier1": null, "procedureModifier2": null, "procedureModifier3": null, "procedureModifier4": null, "serviceLineAdjustment": [ { "groupCode": "PR", "reasonCode": "2", "adjustmentAmount": 15.57, "adjustmentQuantity": null }, { "groupCode": "CO", "reasonCode": "144", "adjustmentAmount": -0.88, "adjustmentQuantity": null }, { "groupCode": "CO", "reasonCode": "45", "adjustmentAmount": 57.14, "adjustmentQuantity": null } ] } ] }, { "fromDOS": "10/26/2020", "toDOS": "10/26/2020", "pos": "11", "procedureCode": "17003", "procedureModifier1": null, "measurementQantity": 1, "measurementBasis": "UN", "charges": 19, "otherPayerPaidAmount": 5.87, "serviceLineLoop": { "lineNumber": 2, "procedureModifier2": null, "procedureModifier3": null, "procedureModifier4": null, "lineDescription": null, "diagnosisCodePointer1": 1, "diagnosisCodePointer2": null, "diagnosisCodePointer3": null, "diagnosisCodePointer4": null, "emergencyIndicator": null, "epsdtIndicator": null }, "serviceLineDates": { "prescriptionDate": null, "certificationRevisionDatte": null, "beginTherapyDate": null, "lastCertificationDate": null, "lastSeenDate": null, "testPerformedDate": null, "shippedDate": null, "lastXRayDate": null, "initialTreatmentDate": null }, "servieceLineReference": { "repricedLineItemReferenceNumber": null, "adjustedRepricedLineItemReferenceNumber": null, "priorAuthorizationNumber": null, "immunizationBatchNumber": null, "lineItemControlNumber": "CPDYJYHEIH2W", "mammographyCertificationNumber": null, "clinicalLabImprovementAmendmentNumber": null, "referringCliaNumber": null, "referralNumber": null }, "quantityAmountPS1": { "ambulancePatientCount": null, "obstetricAdditionalUnits": null, "salesTaxAmount": null, "postageClaimedAmount": null, "purchasedServiceProviderIdentifier": null, "purchasedServiceChargeAmount": null }, "serviceLineDME": null, "serviceLineSupplementalInfos": null, "serviceLineNotes": null, "serviceLineAmbulanceTransport": null, "serviceLineAmbulanceCertification": null, "serviceLineDrug": null, "serviceLineRenderingProvider": null, "serviceLineServiceFacility": null, "serviceLineSupervisingProvider": null, "serviceLinePCPReferringProvider": null, "serviceLineAmbulancePickupDropoff": null, "serviceLineOrderingProvider": null, "serviceLineAjudications": [ { "otherPayerPrimerId": "12202", "linePaidAmount": 5.87, "procedureCodeIdentifier": "HC", "lineAjudicationDate": "11/10/2020", "remainingPatientLiability": null, "procedureCodeDescription": null, "paidServiceUnitCount": 1, "procedureCode": "17003", "procedureModifier1": null, "procedureModifier2": null, "procedureModifier3": null, "procedureModifier4": null, "serviceLineAdjustment": [ { "groupCode": "PR", "reasonCode": "2", "adjustmentAmount": 1.45, "adjustmentQuantity": null }, { "groupCode": "CO", "reasonCode": "144", "adjustmentAmount": -0.08, "adjustmentQuantity": null }, { "groupCode": "CO", "reasonCode": "45", "adjustmentAmount": 11.76, "adjustmentQuantity": null } ] } ] }, { "fromDOS": "10/26/2020", "toDOS": "10/26/2020", "pos": "11", "procedureCode": "99214", "procedureModifier1": "25", "measurementQantity": 1, "measurementBasis": "UN", "charges": 178, "otherPayerPaidAmount": 102.02, "serviceLineLoop": { "lineNumber": 3, "procedureModifier2": null, "procedureModifier3": null, "procedureModifier4": null, "lineDescription": null, "diagnosisCodePointer1": 1, "diagnosisCodePointer2": 2, "diagnosisCodePointer3": 3, "diagnosisCodePointer4": 4, "emergencyIndicator": null, "epsdtIndicator": null }, "serviceLineDates": { "prescriptionDate": null, "certificationRevisionDatte": null, "beginTherapyDate": null, "lastCertificationDate": null, "lastSeenDate": null, "testPerformedDate": null, "shippedDate": null, "lastXRayDate": null, "initialTreatmentDate": null }, "servieceLineReference": { "repricedLineItemReferenceNumber": null, "adjustedRepricedLineItemReferenceNumber": null, "priorAuthorizationNumber": null, "immunizationBatchNumber": null, "lineItemControlNumber": "CPDYLJFUCSGQ", "mammographyCertificationNumber": null, "clinicalLabImprovementAmendmentNumber": null, "referringCliaNumber": null, "referralNumber": null }, "quantityAmountPS1": { "ambulancePatientCount": null, "obstetricAdditionalUnits": null, "salesTaxAmount": null, "postageClaimedAmount": null, "purchasedServiceProviderIdentifier": null, "purchasedServiceChargeAmount": null }, "serviceLineDME": null, "serviceLineSupplementalInfos": null, "serviceLineNotes": null, "serviceLineAmbulanceTransport": null, "serviceLineAmbulanceCertification": null, "serviceLineDrug": null, "serviceLineRenderingProvider": null, "serviceLineServiceFacility": null, "serviceLineSupervisingProvider": null, "serviceLinePCPReferringProvider": null, "serviceLineAmbulancePickupDropoff": null, "serviceLineOrderingProvider": null, "serviceLineAjudications": [ { "otherPayerPrimerId": "12202", "linePaidAmount": 102.02, "procedureCodeIdentifier": "HC", "lineAjudicationDate": "11/10/2020", "remainingPatientLiability": null, "procedureCodeDescription": null, "paidServiceUnitCount": 1, "procedureCode": "99214", "procedureModifier1": "25", "procedureModifier2": null, "procedureModifier3": null, "procedureModifier4": null, "serviceLineAdjustment": [ { "groupCode": "PR", "reasonCode": "2", "adjustmentAmount": 25.15, "adjustmentQuantity": null }, { "groupCode": "CO", "reasonCode": "144", "adjustmentAmount": -1.42, "adjustmentQuantity": null }, { "groupCode": "CO", "reasonCode": "45", "adjustmentAmount": 52.25, "adjustmentQuantity": null } ] } ] } ] }