| Invoice ID | Dispatch ID | Service Date | Patient Name | Service Code | Origin Name | Origin Address | Destination Name | Destination Address | Mileage | Price Invoiced | Amount Received | Amount Due | Billing Notes | Beebe Comments | AEC Comments | Epic Comments |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4696 | 1296 | Nov 28, 2023 | Cahoe, Charles | A0427 | Beebe Hospital |
Beebe Hospital, 377 B, 424 Savannah Road, Lewes, DE 19958
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Thomas Jefferson University Hospital |
Thomas Jefferson University Hospital, 5226 GIBBON BUILDING, 111 S. 11th St, Philadelphia, PA 19107
|
119.8 | $1,651.25 | $73.07 | $1,578.18 |
2024/12/27_Humana take back for in facility global fee. NR 12/27/24
Claim denied The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. No inpatient info founf on PGBA. LDZ 03/08/2024
Denied for mileage. NR 1/30/24
Facesheet attached is for a different patient, please attach correct facesheet for insurance LDZ 11/29/2023
Facesheet attached - WJO
!Primary payer take back due to global fee
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| 4696 | 359 | Aug 13, 2023 | Bonner, Carmen | A0427 | Beebe Hospital |
Beebe Hospital, ED 14, 424 Savannah Road, Lewes, DE 19958
|
Children's Hospital of Philadelphia |
Children's Hospital of Philadelphia, 3E RM 26, 34th Street And Civic Center Blvd, Philadelphia, PA 19104
|
115 | $1,609.01 | $73.07 | $1,535.94 |
2024/12/16_Claim submitted on 9/11/24 , s/w Kathy stated that the Home plan upheld the appeal and for more information , you can message to payer on portal or on Availity (by clicking on Message this payer) . Claim# 22729075994. Callref# Kathy 12/16/24. 12/16/24/MK
#359- 08/20/2023 MB
!Primary insurance not covered
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