HIPAA 835 Transaction Detail (1 of 1 in file: C:\Users\User\Dropbox\Trizetto Electronic EOB Files\P87

Claim Payments Data

Payer Payer ID
UNITED HEALTHCARE INSURANCE COMPANY 87726
UNITED HEALTHCARE INSURANCE COMPANY 87726
UNITED HEALTHCARE INSURANCE COMPANY 87726
UNITED HEALTHCARE INSURANCE COMPANY 87726
UNITED HEALTHCARE INSURANCE COMPANY 87726
UNITED HEALTHCARE INSURANCE COMPANY 87726
UNITED HEALTHCARE INSURANCE COMPANY 87726
UNITED HEALTHCARE INSURANCE COMPANY 87726
UNITED HEALTHCARE INSURANCE COMPANY 87726
UNITED HEALTHCARE INSURANCE COMPANY 87726
ser\Dropbox\Trizetto Electronic EOB Files\P87726D272335313U-1250802006-321.10-20170124-UHC.RMT)

Payee (Provider) ID (NPI) Patient Control #

PREVENTIVE DIAGNOSTICS INC FI:272335313 PRE147122
PREVENTIVE DIAGNOSTICS INC FI:272335313 PRE147122
PREVENTIVE DIAGNOSTICS INC FI:272335313 PRE147122
PREVENTIVE DIAGNOSTICS INC FI:272335313 PRE129764
PREVENTIVE DIAGNOSTICS INC FI:272335313 PRE129764
PREVENTIVE DIAGNOSTICS INC FI:272335313 PRE129764
PREVENTIVE DIAGNOSTICS INC FI:272335313 PRE129764
PREVENTIVE DIAGNOSTICS INC FI:272335313 PRE129764
PREVENTIVE DIAGNOSTICS INC FI:272335313 PRE129764
PREVENTIVE DIAGNOSTICS INC FI:272335313 PRE146219
006-321.10-20170124-UHC.RMT)

Patient Patient ID Claimed Allowed Total Adjustment

WILLIAM DYBECK MI:947632880 $695.68 $305.36 0.00
WILLIAM DYBECK MI:947632880 $695.68 $305.36 0.00
WILLIAM DYBECK MI:947632880 $695.68 $305.36 0.00
IRENE LEVEK MI:856680921 ### 0.00
IRENE LEVEK MI:856680921 ### 0.00
IRENE LEVEK MI:856680921 0.00 0.00
IRENE LEVEK MI:856680921 $1131.18 $492.81 0.00
IRENE LEVEK MI:856680921 $1131.18 $492.81 0.00
IRENE LEVEK MI:856680921 $1131.18 $492.81 0.00
ROBERT MEINHART MI:967451022 $53.04 $22.28 0.00
Patient Amount Paid Amount Insured Insured ID Rendering Prvoider
$299.26
$299.26
$299.26
$-424.05
$-424.05
$-424.05
$60.12 $424.05
$60.12 $424.05
$60.12 $424.05
$21.84
Provider NPI Claim Status Payer Claim Control # Remark Code
1 NYC6677098900
1 NYC6677098900
1 NYC6677098900
22 NYC6457912100
22 NYC6457912100
22 NYC6457912100
1 NYC6685783900
1 NYC6685783900
1 NYC6685783900
1 SYR7336730100
Service Line # Proc Code Modifiers Claimed Allowed Total Adjustment
1 HC:R0070 $431.92 $192.20 $243.56
2 HC:Q0092 $62.18 $26.62 $36.09
3 HC:76700 TC $201.58 $86.54 $116.77
1 HC:93925 $201.58 $214.81 $-422.27
2 HC:R0070 $-431.92 $-188.36 $-243.56
3 HC:Q0092 $-62.18 $-20.88 $-41.30
1 HC:93925 $637.08 $273.99 $422.27
2 HC:R0070 $431.92 $192.20 $243.56
3 HC:Q0092 $62.18 $26.62 $41.30
1 HC:93971 26,LT $53.04 $22.28 $31.20
 Paid Svc Start Svc End Revenue Code Unit Paid Remark Code
$188.36 12/04/2016 12/04/2016 1
$26.09 12/04/2016 12/04/2016 1
$84.81 12/04/2016 12/04/2016 1
$-214.81 08/11/2016 08/11/2016 1
$-188.36 08/11/2016 08/11/2016 1
$-20.88 08/11/2016 08/11/2016 1
$214.81 08/11/2016 08/11/2016 1
$188.36 08/11/2016 08/11/2016 1
$20.88 08/11/2016 08/11/2016 1
$21.84 11/01/2016 11/01/2016 1
Co-Pay Adj CO:45 Adj CO:253
$239.72 $3.84
$35.56 $0.53
$115.04 $1.73
$-54.80 $-363.09 $-4.38
$-239.72 $-3.84
$-5.32 $-35.56 $-0.42
$54.80 $363.09 $4.38
$239.72 $3.84
$5.32 $35.56 $0.42
$30.76 $0.44
HIPAA 835 Transaction Header (1 of 1 in file: C:\Users\User\Dropbox\Trizetto Electronic E
HIPAA 835 Header Information
Descripton
Transaction Handle Code:
Total Amount
Check or EFT #
Payment Date
Credit Debit
Payment Method : Format

Payer
Address
City, State Zip
Bank
Account
Payer ID

Payee
Bank
Account
Address
City, State Zip
835 has total 2 Claim Payment Groups

Payment Group 1 of 2 in this transaction

Description
TS3 Data (Provider Summary Information)
No Data

TS2 Data (Provider Supplemental Summary Info)

No Data

Payment Group 2 of 2 in this transaction

Description
TS3 Data (Provider Summary Information)
No Data

TS2 Data (Provider Supplemental Summary Info)

No Data
file: C:\Users\User\Dropbox\Trizetto Electronic EOB Files\P87726D272335313U-1250802006-321.1
Provider Level Adjustments
Value Provider NPI
I NO DATA
$321.10
1250802006
2017/01/24
C
ACH : CCP

UNITED HEALTHCARE INSURANCE COMPANY

9900 BREN ROAD
MINNETONKA, MN 553439664
01: 124384877
DA: 1470858534
1411289245: 000087726

PREVENTIVE DIAGNOSTICS INC

01: 021000021
DA: 613578991
544 PARK AVE SUITE 620
BROOKLYN, NY 11205

Value

Value
335313U-1250802006-321.10-20170124-UHC.RMT)
der Level Adjustments
Fiscal Period Date adjustment ID Reason Amount