PROOF OF CLAIMS FILING AND TIMELINESS August 25, 2018 ATTN: RAILROAD MEDICARE Re: Appeal ot Denial for Timely Filing ‘We cordially request a review and payment ofthe following Claims for sonices rendered to this patient. The following claim informs ‘original elaim submission date was prior to your timely fling deacine. ition was provided by our elgime cloaringhouse chowing that the that was fled on behalf of PATRICIA J RAVNAAS. On 1/16/2015 we submites Piowder formation (ng) 1 iame Ne TH ‘Bing AaareSs Pay To Aaaress 1 = J Fronger Infrmation (Atendioa Penden a me NPL Tao Service Facity Factity Adaress | Paertinomaten me Member. Bate ot Binh “Group Number Group Name Sasser inomaton me ‘Subserber ID Bate ot BiH Group Nomber Group Name (len ntomaton atient Claim Iden (ELMO) ayer Oiaim (ONDON) ‘Submited Fieidentiior 204 215016062390 3408055 [Clearing House1 Format ‘Gon Tabourd Fie [sereasese SS7-P5010 5762 GLP 201601151 557557211-Se0ted02. 7a aaty-e7-59O72CONSEO7.U [Total Charges Diagnosis Codes. 09 475719 2.8182 3.70894 4.70052 SNES (Sexiee Une ifomaton ate Units or Deseripion Wouters ox charees bereacon 1 90215 12s 255.00 (Pein isa messanes at Tine ‘Source Wessage, 2015 azi Pe PAYER (CLAIM RECEIVED BY THE PAYER. az0n8 1193 AM PAYER, PAYER ACKNOWLEDGES RECEIPT OF ‘THIS CLAIM, THIS CLAIM HAS BEEN ACCEPTED INTO THE PAYER'S ADJUDICTION SYSTEM 12 INFO: 300-603) e205 1193.4 PAYER (CLAIM RECEIVED BY THE PAYER. pros 255M PAYER CLAIM RECEIVED SY THE PAYER. farsoors 134 PM PAYER (SLAM RECEIVED BY THE PAYER. 2015 1198 AM PAYER ‘Waring - A220:PR CLAIM HAS BEEN AQCEPTED INTO ADJUDICATION, ACCEPTED FOR PROCESSING. PAYER hnezors s207 PM PAYER ‘Waring -A2:20:FR CLAIM HAS BEEN ASGEPTED INTO ADJUDICATION. | ACCEPTED FOR PROCESSING. PAYER hisiaons sear PM. PAYER CLAIM RECEIVED SY THE PAYER, 272015 4193 AM PAYER CLAIM RECEIVED BY THE PAYER, hngeors 1297 PM, PAYER, PAYER ACKNOWLEDGES RECEIPT OF PagePROOF OF CLAIMS FILING AND TIMELINESS. August 25, 2016 "THIS CUA, THIS GLAM HAS BEEN ACCEPTED INTO THE PAYERS, ‘ADJUDICTION SYSTEM. [X12 INFO: zo00-cu4H ‘Atachments: [eas 1500 [e068 Cader Supooring Oocumetaton Based on this ifomaton, we request mmadite payment ol he ebove relerence claim in eccrcence wi the bene quoted athe tine ofthe pants adrian. We request a response the appeal win 14 cays of your rece Score, Prowaers Signste, Dato, Page?