1281s ~ NoKTH DAKUZA DEPARTMENT OF HUNAN SiRvsvES ‘MEDICAL ASSISTANCE ' REMETTANCE ADVICE PAGE «1 aeck NUMBER 00000000 R/A NUMBER 2030 CEXCEPT FOR QSP, TRANSPORTATION, AND BASIC CARE PROVIDERS.) ND NEDICATD HILL noT ACCE®T LEGACY MHIS PAPER CLAIMS RECEIVED AFTER 9/16/15. ORIGINAL PAPER CLAINS AFTER THIS DATE CAN BE SUBNITTED ON OR AFTER 10/5/25. FOR MORE 7NFO: rTP: //wi .ND .GOV/DHS/SERVICES/MEDICAL SERV/MEDICALD/PROVIDER- UPDATES. HTML - CASE NUMBER PAT. CONTROL NUM. PRE.ID/HPE HER eruLeD| RL/OT PAYMENT MSE CONTROL NO, _ TD _NUNBER | RECIPIENT NAME, SONS “°Seevice DATES RX.NO. SERVICE CODE/MOD 1 4015205001877, 900-11-2740, 52-09057-084, C12044 of Son0ssa2s 122914122914, i 87 °° a55.00° 94.7 018 a eeee Robe: 0550 NAMEC UNITED HEALTHCARE INS CO -00 TOTAL CHARGE/PAYMENT AMOUNTS: 1 255.00 EXPLANATION OF MESSAGE CODES USED ABOVE: 3s DUPLICATE CLAIM/SERVICE.