Statement Messages

Objective: The purpose of this report is to show all the Message Mnemonics along with the corresponding Message.
Print Date: November 18, 2010
Mnemonic Message

10 Per office agreement please remit payment within 10 days. A $20 billing fee will be assessed to any balance carried over to the next billing cycle. If
you need to make payment arrangements please contact the Office immediately at 401-438-3300. Thank
1020 Your insurance company has sent you a notice requesting information. Please contact them with the necessary reply. Then notify our office so that
we may bill them for these services.
1060 The balance due is your responsibility as your doctor no longer participates with your health plan. Please remit balance due. Thank you.

1080 In order to process your claim your insurance company needs information from you. Please contact them or pay in full immediately.

10DAYS Your account is past due. Your account will be forwarded to a collection agency if payment is not received within 10 days.

1120 Lighthouse MD will now be handling the billing for this practice. Thank you.

1140 To avoid having your account turned over to an outside collection agency, which may affect your credit rating, please remit your balance owed
today.
121 We have billed your insurance for the above services but have not received payment. Please remit the balance due. Thank you.

121 We have not received payment from your insurance company. The balance is now your responsibility.

1220 Copays are due at time of service, please remit within ten days.

1260 Per your insurance company they have made payment directly to you. The balance is now your responsibility, please remit in full.

1280 Member's responsibility because services were provided by a non-network provider.

1300 This statement does not reflect any outstanding insurance or patient balances for DOS prior to 5/3/04.

1320 Your insurance denied for not medically necessary. Thank you.

1340 Insurance action pending receipt of information.

1380 Medicare has paid you in error for laboratory testing. Please remit within ten days.

1400 Please note that this is a credit balance.

1420 Medicare does not pay for routine services and your secondary insurance also has denied this claim. Pursuant to Medicare guidelines, the balance
is your responsibility.
14622 Please indicate the physician or practice you are calling or e-mailing in regards to when making your inquiry

1470 Provider is not part of Hospital Free Care. Please contact the office directly to make payment arrangements. Thank you.

15 We have billed your insurance company. They did not respond. The balance due is your responsibility.

1570 Please forward Auto Liability information.

1620 Balance has been applied to your co-pay or deductible.

1621 Your insurance company has applied this to your copay or deductible. This is your responsibilty

1670 If paying by credit card, the minimum amount that can be charged is forty dollars ($40.00). If you have any questions, please direct them to our
billing phone number as noted above.
16873 Your insurance had paid you directly. Please remit your payment to our office within 5 business days.

1TERM Your insurance carrier states that another insurance is primary. Please contact us with this insurance information.

21 Please contact our office with your complete auto insurance so that we may submit a claim. Thank you.

25 Your co-payment is $25.00

2I We have billed your secondary insurance. They did not respond. Please follow up with them.

2ND The balance due is your copay for your secondary insurance.

2TERM Your insurance carrier states that your coverage was expired at the time of service. Please remit the balance. Thank you

30 Your account is 30 days past due. Please remit payment now.

302 Another insurance is primary according to your insurance. Please contact us with this information.

303 Your coverage was expired according to your insurance at the time of service. Please remit the balance. Thank you.

304 Your claim has been denied for lack of proper authorization. Please remit. Thank you.

305 Your PCP information is either incorrect or missing according to your insurance. Please call them to verify this information.

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Mnemonic Message

307 Your primary care physician did not authorize this service. Please remit the balance. Thank you.

308 Automobile accidents are not covered by your insurance company. Please remit the balance due. Thank you.

309 Your check was returned to us for insufficient funds. Please remit. Thank you.

30P Thank you for your payment.

30PD Your account is now 30 days past due. Your prompt payment is appreciated. Please contact Sharon at x232 with any questions.

30PD Your account is now 30 days past due. Your prompt payment is appreciated. Please contact Sharon at x233 with any questions

310 Both insurances have processed your claim. The balance is your responsibility. Please remit. Thank you.

311 Your copay has not been paid in full per your insurance company. The balance is your responsibility. Thank you.

315 Medicare has paid its portion of the bill. If you have secondary insurance, please contact us with this information. If not, the balance is your
responsibility. Thank you.
317 Your insurance company has informed us that this is a non-covered service. The balance is your responsibility. Thank you.

318 A First Report of Injury form was not sent to your workers' compensation carrier. Please contact your employer regarding this.

320 Your copay from your primary insurance has been applied to your deductible by your secondary insurance. The balance is your responsibility.
Thank you.
321 This claim was denied by the workers compensation carrier because they state that it is not work related. We need your health insurance
information. Thank you.
322 Your insurance has denied your claim stating that it exceeds the referral treatment limit. The balance is your responsibility. Thank you.

324 We have sent a copy of your account to your attorney. To date, we have not received payment. Please remit the balance due. Thank you.

325 There is confusion as to which of your insurance plans is primary. Please resolve and contact us with your primary insurance information. Thank
you.
326 The maximum benefit for these services has been exhausted. Please remit the balance due. Thank you.

328 Your insurance carrier states that this claim is related to workers' compensation. Please contact us with this information. Thank you.

505 This service is not covered by your insurance.

506 Fax was sent to you.

507 You have more mail

508 Please pay this balance. It is now past due.

509 The facility fee is similar to an emergency room fee although it has no procedure (CPT) code. The facility fee (25% of charges) may be added to
your bill if you are not a current Town of New Shoreham taxpayer and do not work on Block Island. Island residents support the Medical Center
through taxes paid to the town. This fee is charged to help maintain the Block Island Medical Center.
511 Your account is 60 days past due. Please remit payment now.

512 Your account is 90 days past due. Please remit payment now.

513 Your account is 120 days past due. Please remit payment now.

515 We have not received your payment this month. Please remit payment now.

516 We have not received a payment from you for 60 days. Please remit payment now.

517 Your account is now 90 days overdue. Please remit payment now.

518 Your account is seriously overdue by 120 days. Please remit payment now.

519 This claim was denied by your workers compensation, as a notice of controversy has been filed. please remit payment today.

560 Your insurance does not cover this service.

60PD Your account is now 60 days past due. Your prompt payment is appreciated or please contact Sharon at x233 to make payment arrangements.

90D Your account is now 90 days past due. Failure to respond immediately may result in further collection actions.

90PD Your account is now 90 days past due. Failure to respond immediately may result in further collection actions. Please contact Sharon at x232 to
make arrangements.
AUTH Your claim has been denied for lack of proper authorization. Please remit the balance. Thank you.

B Blue Shield has paid it's portion. The balance is now your responsibility.

B25 Budget payments must equal to 25% of your balance and must be received on a monthly basis to avoid collection status.

BCD Blue Cross and Blue Shield has retracted payment stating your coverage was not effective for this date of service. If you had other insurance during
this time please contact our office, otherwise, the balance is your responsbility.

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Mnemonic Message

BCF This balance has been carried forward from Compusense. Please remit payment. Thank You.

BUD Thank you for setting up a Payment Plan. Please remit the agreed upon amount.

BYR Your insurer states you have already used your routine eye benefit. Therefore the balance is now your responsibility

C Your insurance company has paid its portion of the bill. The balance is your responsibility.

CALL Please call. An adjustment can be given and small monthly payment schedule set up.

CCO CCO 2NDRY

CCO 2NDRYBoth insurances have processed your claim. The balance is your responsibility. Please remit. Thank you.

CLE We are unable to submit this to your insurance because you didn't order your contact lenses here

CNA Your insurance company did not add this dependant to your plan, please call your insurance.

CNB We cannot bill your health insurance company for the services rendered until we have a signed consent form on file. Please contact our billing
office. Thank you.
CO The balance due is your copay. Please remit. Thank you.

CO Per your insurance company, your copay has not been paid in full. The balance is your responsibility. Thank you.

CO1 The balance due is your copay. Please remit. Thank you.

COIN Your insurance company has applied this balance to your co-insurance. Therefore the balance due is your responsibility.

COMM Your insurance carrier denied the claim. Please contact them to verify your active enrollment with a Commonwealth Plan. Otherwise, the balance is
your responsibility.
CON Conditions which existed prior to enrollment are not covered.

COPAY This balance is yours. Your insurance has paid their portion.

COPAY Your insurance has paid their portion. The balance is your responsibility.

CRI Check returned for insufficient funds.

D This balance is after your deductible has been applied. Please remit payment.

DDBL Your insurance company has informed us that the balance has been applied to your deductible. Please remit. Thank you.

DDBL Your insurance company has informed us that the balance has been applied to your deductible. Please remit. Thank you.

DE Your insurance company has applied this balance to your deductible. It is now your responsibility. Thank You.

DED Medicare has applied this balance to your deductible. If you have secondary insurance, please contact us with this information. If not, the balance is
your responsibility. Thank you.
DEP Balance after your insurance processed their portion of the bill. Your deposit has been applied.

DI Your claim rejected for incorrect demographic information. Please contact our office to update your account or remit balance due. Thank you

DIS Please disregard overdue/collections message.

DN1 Your claim has rejected for incorrect insurance or demographic information. Please contact our office to update your account or remit balance due.
Thank you
DOB Patient DOB does not match DOB on file.

EDUD Your employer hasn't met the deductible on their insurance policy. Please contact your employer regarding this balance.

ENRO Member must enroll in CommCare to receive benefits. Member must call 1-877-MA-ENROLL.

FC Please be advised the physicians accept Freecare at 50% of your original bill. The balance will be your responsibility. Please feel free to call with
any questions. Thank you.
FH If you are in financial hardship, please be advised we do accept monthly payment plans. Please call our office for payment details.

FINAL FINAL NOTICE!!Please be advised this is the final notice on your account. Since we have not received payment on this account it MAY BE turned
over to the doctor for Collection consideration.
FLORIDAMED
Please indicate the physician or practice you are calling or e-mailing in regards to when making your inquiry.

FN FINAL NOTICE! This is the last statement that will be sent to you. Unless paid at once the account will be turned over for collection agency action.

FP Please be advised, as a courtesy we have sent a claim form to your insurance company. It is your responsibility to follow up with your insurance
company to facilitate claim payment. Thank You
FREE Please be advised we do not accept Free Care.

HHC Medicare does not pay for physical therapy and home health care simultaneously. They've denied your claim, please remit payment.

HSN Your Health Safety Net coverage does not cover this physician's bill. Please contact the office directly to make payment arrangements. Thank you.

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Mnemonic Message

I The insurance information you provided is insufficient. Please remit the balance due or contact us with your new information. Thank you.

IC Please call our office if you have insurance coverage and we will bill them. Thank you.

IDP Your insurance has denied payment.

IN We do not have your correct subscriber number for your insurance. Please call our office, thank you.

INV Your insurance identification # is either invalid or missing. Please contact our office with this information.

IP Your insurance company states that they sent payment directly to you. Please remit the balance due. Thank you.

IP1 Your insurance company paid you directly. Please send the payment to us and we will accept as payment in full.

MCAP Your m-cap discount applied your payment is due immediately.

MCC2 Balance after Medicare and your secondary insurance.

MCCA Medicare Part A does not cover physician services. The balance is your responsibility. Please remit payment.

MI Information from you has been requested by your insurance company. They will not pay your claim until you respond. Therefore, the balance is
your responsibility.
MNC Your coverage was expired at the time of service. Please remit the balance due or contact us with new information. Thank you.

MOI Medicare has denied this claim stating that you have another coverage primary. Please contact our office immediately with correct insurance
information. Thank You.
MORE Your copayment is higher than you paid at the time of service. Please remit the additional amount due.

NCF A first report of injury form was not sent to your workers compensation carrier. Please contact your employer regarding this.

NCI PLEASE COMPLETE THE BACK OF THIS STATEMENT WITH YOUR INSURANCE INFORMATION AND SEND IT BACK TO US, SO WE MAY
BILL YOUR INSURANCE COMPANY FOR THIS BALANCE.
NCP Your insurance denied these services saying that they occurred prior to the insurance effective date, the balance is your responsibility.

NE Gap in insurance has denied your claim. Please remit the balance due or contact us with new insurance information. Thank you.

NFC Your Health Insurance states that this service is the liability of a no-fault carrier. Please contact our office with the correct billing information or
contact your insurance to resolve directly.
NHP Neighborhood Health Plan has paid your claim at the MassHealth allowable rate. Since your plan is the commercial product, your claim should have
been paid in full. Please contact NHP to have your claim reprocessed or this balance will be your respons
NIC You are not covered by this insurance for this date of service. Please call us if you have other coverage. Thank you.

NJBC Our records show that BCBS has remitted payment to you, please contact our office to review your account

NOMCAL Medi-CAL states you are not eligible for coverage this month. Please contact billing if you have other coverage. Thank you.

NOREF Your insurance denied this for no PCP referral. Without a referral backdated to cover this visit, you are responsible for payment of this balance.

NPCP Per your insurance, you were not seen by your PCP and no referral was done by your PCP, therefore, the balance is your responsibility.

NPP Non-participating Provider

NPP The balance due is your responsibility as your doctor is not a participating provider with your health plan. Please remit balance due. Thank you.

NPP

NPP The balance due is your responsibility as your doctor is not a participating provider with your health plan. Please remit balance due. Thank you.

NPP The balance due is your responsibility as your doctor is not a participating provider with your health plan. Please remit balance due. Thank you.

NPP The balance due is your responsibility as your doctor is not a participating provider with your health plan. Please remit balance due. Thank you.

NS Fee for no show of scheduled office appointment.

OS This provider does not participate with your out of state Medicaid program. You are responsible for this balance. Thank you.

OT 97110 through 97777 represent occupational therapy billing codes.

PARTB Your Medicare Part B was not in effect at the time of service. The balance is your responsibility.

PAT Your insurance has processed its portion of the bill. The balance is your responsibility.

PAY If you have insurance for this service, please contact our office immediately. Otherwise, please pay promptly. Thank you

PC Thank you for your recent payment.

PCB PLEASE COMPLETE THE BACK OF THIS STATEMENT WITH YOUR INSURANCE INFORMATION AND SEND IT BACK TO US, SO WE MAY
BILL YOUR INSURANCE COMPANY FOR THIS BALANCE.IF YOU DO NOT HAVE INSURANCE, PLEASE REMIT THE BALANCE DUE.
PCN Print Cardholder Name

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Mnemonic Message

PCP Your insurance carrier states that your PCP information is either incorrect or missing. Please call them to verify this information.

PCP Your insurance carrier states that your PCP information is either incorrect or missing. Please call them to verify this information.

PCPR Your ins. states you have not selected a PCP. You must have a PCP AND a valid referral with them for the date of this visit or they will not pay this
claim. Please call them immediately.
PDB Your primary insurance applied balance to your deductible. Your secondary insurance did not pay your primary's deductible. The balance due is
yours.
PEND Insurance action pending receipt of information.

PIP Your auto insurance cannot process claim until PIP application is complete. Please contact your auto insurance with this information.

PPA Your prompt payment is appreciated. Please contact Sharon at ext. 232 with any questions.

PPB Please pay your balance within 10 days so we can avoid sending your account to Collections. Paying your bill will protect your credit rating. Thank
you.
PRE Your insurance will not pay for the surgery because of pre-existing conditions. You are responsible for the balance.

PRE Your insurance denied this claim due to a pre-existing condition. Therefore the balance due is your responsibility

PROB There is a problem with your insurance coverage. You may call us for details but you will need to contact your insurance company directly to
resolve.
PT BALANCE
This is your balance after all your insurance plans have considered this claim.

PU Glasses have been requested by Dr/ resident. Please return with payment or guarantor information so we may process the order.

REF No referral on file. Please send us a referral so that we can rebill your insurance company.

RPP Please remit payment promptly. Please contact our office is you have any questions.

RRB Your request to reduce your bill has been denied-the balance is your responsibility.

RTN Your insurance states your plan doesn't cover eye exams for glasses. This balance is your responsibility.

SOC Medi-CAL states you have a share of cost. Please remit payment or contact the billing office.

TERM Your insurance carrier states that your coverage was expired at the time of service. Please remit the balance. Thank you.

THANK Thank you.

UMR United Medical Resources has denied your services as not being a medical necessity. Please appeal this decision with your insurance or remit the
payment of this balance in full.
WC Your account is past due. Your account will be forwarded to a collection agency if payment is not received within 10 days. Your employer/Workers
Compensation carrier denied this claim. Please follow up with your employer.
WC YOUR EMPLOYER/WC CARRIER DENIED CLAIM. PLEASE FOLLOW UP WITH YOUR EMPLOYER

WC This charge is related to a Workers Compensation injury, please call our office with complete carrier information.

WC18 We have billed your employer for this service, however, the claim was returned due to an incorrect address.

WC26 Your employers workers compensation insurer has no report of injury on file. Please contact your employer directly to resolve.

WC39 Your health insurance company has informed us that this is a work related injury. Please contact us with your workers compensation information.

WCI We have been informed that this service is work related, please contact our office with the necessary workers compensation information so that we
may submit a claim for you. Thank You.
WEB Please visit our website at www.dermatology-pc.com

Primary Deductible

Secondary Deductible

Tertiary Deductible

Another insurance is your primary per your insurance. Please check with your insurance company.

Per your insurance, you were not provided by your PCP was for this date of service and no referral was given.

Your insurance company requires more information to process this claim.

Insurance Deductible/Copay

Any bills not resolved in 90 days will be forwarded to collections. In the event that you are in financial hardship, we can work out a payment plan.

Your insurance has paid their portion. The balance is your responsibilty

YOUR INSURANCE COMPANY WILL NOT PROCESS THIS CLAIM UNTIL THEY RECEIVE A COMPLETED CLAIM FORM FROM YOU.
BALANCE IS YOUR RESPONSIBILITY

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Mnemonic Message

FC Message: Please be advised the physicians accept Freecare at 50%. A payment of 50% of the balance is your responsibilty. Please call our
office if you have any questions. Thank You.
After review of your written dispute by the physicians group it was decided that you are liable for the billed services.

Medicare Part A will not cover these services. The balance is your responsibilty.

Due to your free care status at the time these physician services were rendered, the Caritas Emergency Medical Group has agreed to a 25%
reduction. Payment for the remaining balance is your responsibility.
If you have insurance that may cover these balances or if you have any questions, please contact our office.

Your balance is overdue. Please contact our office to make payment arrangements.

Payment is due immediately in order to avoid referral of this account to a collection agency.

After 30 Days, a 12% interest may be applied to any outstanding balance unless other arrangements are made with Main Street Family Practice.
Should the account not be paid, it will be forwarded to a collections service, and you will be responsible fo
NOTICE: THIS IS A BILL. BASED UPON INFORMATION FROM YOUR HEALTH PLAN, YOU OWE THE AMOUNT SHOWN

This invoice represents for laboratory services performed on a biopsy specimen submitted by your Doctor. Thsi bill is different

Patients are responsible for the balance unless proper Insurance or Referral information is provided.

Thank you for making regular payments.

Zostervax vaccine is not covered by your insurance, you are responsible for the balance.

Please be advised we do not accept credit cards. Please contact our office for other payment options.

Your insurance can not identify you with the information we have on file. PLEASE COMPLETE THE BACK OF THIS STATEMENT WITH YOUR
INSURANCE INFORAMTION AND SEND IT BACK TO US, SO WE MAY BILL YOUR INSURANCE COMPANY FOR THIS BALANCE.
Per your insurance company, prior authorization needed. Please submit payment.

Please call your insurance company if you dispute this charge

Your account is now 120 days past due. Failure to respond immediately may result in further collection actions. Please contact Sharon at x232 to
make arrangements.
YOUR FEDERAL BS HAS/WILL BE PAYING YOU FOR SERVICES PROVIDED BY US. PLEASE FORWARD THEIR PAYMENT IMMEDIATELY,
AND CONTACT OUR OFFICE TO DISCUSS THE REMAINING BALANCE. THANK YOU
Please pay your balance within 10 days so we can avoid sending your account to Collections. Paying your bill will protect your credit rating. Thank
you
Medicare has denied this claim for date of death precedes date of serivce. A copy of the patient's death certificate is required in order to process
this claim. Please send a copy to our office.
This claim was denied by the workers compensation carrier because they state that it is not work related. Please give us your health insurance
information ASAP.
Your insurance denied these services saying that they occurred prior to the insurance effective date, the balance is your responsibility. Please remit
the balance due.
Your insurance denied these services saying that they occurred prior to the insurance effective date, the balance is your responsibility. Please remit
the balance due.
Refer to practice name when making inquiries.

NOTICE: THIS IS A BILL. BASED UPON INFORMATION FROM YOUR HEALTH PLAN, YOU OWE THE AMOUNT SHOWN

Your insurance has paid its portion of the bill. The balance is your responsibility.

The balance due is your responsibility as your doctor is not a participating provider with your health plan. Please remit balance due. Thank you.

Afterours has partnered with the Salvation Army where 100% of your donations will be used to supply much needed medical supplied to the Haiti
relief effort. Donation Amt__________ Please include this page with your remittance. Thank you
For additional payment options please see our website at http://osofamily.com/

All patient payments are applied to the oldest balance.

Dermatology and Skin Care Associates PC, Address: 10 Laurel Ave, Wellesley, MA 02481, Office Phone: (781) 235-8155 , Billing questions:
(800) 478-6675
Norwalk patients only: To pay with a credit card call 203-847-2400. Please give us the patients name, date of birth, cc account number, expiration
date and the amount you wish to pay. Your receipt will be mailed to you.
SEE BILLING NOTE

According to your insurance, you have a copay on xrays.

If paying by credit card please include the 3 digit security code found on the back of the card as well as the billing zip code.

Questions? Please call Debbie T. at Doctors' Resource Specialists at 602.467.4732

If you would like to make a payment over the phone, please contact the clinic to pay by credit card.

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This balance reflects all insurance payments received as of the date of this statement. Questions or concerns, please call. If paying by credit card
please print cardholder name.
This balance is now past due. Failure to respond can result in forfeiture of time of service or insurance discounts. Questions or concerns, please call
us. If paying by credit card please print cardholder name.
Questions? Please call Dawn at Doctors' Resource Specialists at 602.424.7946

Questions? Please call Donna at Doctors' Resource Specialists at 602.439.6797

Please disregard previous statement from Prince Georges Multi Specialty Surg Center correct payee is John E Bubser DPM

Blue Cross has reprocessed your claim at a different rate. The balance is your responsibility.

Insurance info was received over the filing limit, pt responsibility.

If paying by credit card please print cardholder name.

Your insurance company has processed the claim directly to you. Please remit payment

-Your account is 90 days past due, we will now begin to charge a 1.5% monthly interest rate to your account and 18% annually. In the event of
non-payment, the patient will be responsible for any outstanding balance plus any legal fees (in the amount
Questions? Please call Doctors' Resource Specialists. Marla 602.467.4727 or Kristy 602.467.4755

Questions? Please call Linda S. at Doctors' Resource Specialists at 602.467.4724

To make online payments please visit www.bostwicklaboratories.com and navigate to our Patients section.

To make online payments please visit www.bostwicklaboratories.com and navigate to our Patients section.

Medicaid has denied claim due to spans eligible and ineligible periods of coverage.

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