ASHLink Remittance Advice - 37443

Remittance Advice Detail

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Payment#37443,IssueDate:08/22/2011 Today'sDate:8/27/2011 ClaimNumber:28324097
CopyrightAmericanSpecialtyHealth,Inc.Allrightsreserved. Today's Date:8/27/2011 Member: FARLESS, GLYNN Group#: 2498662-GLACT-OAP1@CHI74 Date Received: 8/2/2011

ID Number: Health Plan: Processed:

000238931 CIGNA TN OAP SF 8/9/2011

Processing Summary
Date Paid:8/22/2011 Tax ID #:621020380 Total Amount Billed: Total Allowed Amount: Less Deductions Copay: Patient Responsibility: Admin Fee: Claim Paid Amount: * Plus Interest: Tax: Direct Deposit Bonus: ETP Incentive Bonus: Amount Paid: Payment#:37443 Payable To:ROBERTRATNIPDC $150.00 $26.00 $0.00 $25.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.00 $1.00 Amount:$0.00

Diagnosis Code 353.1 724.4 729.1

* If there is a secondary payor involved, they should coordinate benefits with this amount.

Date(s) of Service Date 07/15/2011 CPT Code 98941 Description CHIRO MANIPULATIVE TMNT, SPINAL, 3-4 REGIONS CHIRO MANIPULATIVE TREATMENT SPINAL, 3-4 REGIONS CHIRO MANIPULATIVE TREATMENT SPINAL, 3-4 REGIONS Charges 50.00 Amount Allowed 0.00 11 Payment Code(s)

07/16/2011

98941-AT

50.00

26.00

07/19/2011

98941-AT

50.00

0.00

14

PaymentCode(s)
11 14 This service is considered mutually exclusive with another service billed on the same date of service. (97) The Clinical Treatment Form (CTF) required per your provider contract for medical necessity review has not been received. You may resubmit this claim once the CTF is processed. (16) Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate Payment is included in the allowance for another service/procedure.

16 97

ClaimNumber:28125897
CopyrightAmericanSpecialtyHealth,Inc.Allrightsreserved. Today's Date:8/27/2011 Member: IVERLETT, RAYMOND Group#: 3333770-R002-OAP6@C1024 Date Received: 7/18/2011

ID Number: Health Plan: Processed:

U42421729 CIGNA TN OAP SF 7/25/2011

Processing Summary
Date Paid:8/22/2011 Tax ID #:621020380 Total Amount Billed: Total Allowed Amount: Less Deductions Copay: Co-Insurance: COB: Not Allowed Amount: Admin Fee: Claim Paid Amount: * Payment#:37443 Payable To:ROBERTRATNIPDC $76.00 $52.00 $0.00 $6.36 $50.98 $50.98 $0.00 $0.00 Amount:$0.00

Diagnosis Code 739.3 353.1 721.3

8/27/2011

Page 1 of 5 pages

Payment#37443,IssueDate:08/22/2011 ASHLink Remittance Advice - 37443 Today'sDate:8/27/2011 ClaimNumber:28324097

CopyrightAmericanSpecialtyHealth,Inc.Allrightsreserved. Today's Date:8/27/2011 Member: FARLESS, GLYNN Group#: 2498662-GLACT-OAP1@CHI74 Date Received: 8/2/2011

ID Number: Health Plan: Processed:

000238931 CIGNA TN OAP SF 8/9/2011

Processing Summary
Date Paid:8/22/2011 Tax ID #:621020380 Total Amount Billed: Total Allowed Amount: Less Deductions Copay: Patient Responsibility: Admin Fee: Claim Paid Amount: * Plus Interest: Tax: Direct Deposit Bonus: ETP Incentive Bonus: Amount Paid: Payment#:37443 Payable To:ROBERTRATNIPDC $150.00 $26.00 $0.00 $25.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.00 $1.00 Amount:$0.00

Diagnosis Code 353.1 724.4 729.1

* If there is a secondary payor involved, they should coordinate benefits with this amount.

Date(s) of Service Date 07/15/2011 CPT Code 98941 Description CHIRO MANIPULATIVE TMNT, SPINAL, 3-4 REGIONS CHIRO MANIPULATIVE TREATMENT SPINAL, 3-4 REGIONS CHIRO MANIPULATIVE TREATMENT SPINAL, 3-4 REGIONS Charges 50.00 Amount Allowed 0.00 11 Payment Code(s)

07/16/2011

98941-AT

50.00

26.00

07/19/2011

98941-AT

50.00

0.00

14

PaymentCode(s)
11 14 This service is considered mutually exclusive with another service billed on the same date of service. (97) The Clinical Treatment Form (CTF) required per your provider contract for medical necessity review has not been received. You may resubmit this claim once the CTF is processed. (16) Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate Payment is included in the allowance for another service/procedure.

16 97

ClaimNumber:28125897
CopyrightAmericanSpecialtyHealth,Inc.Allrightsreserved. Today's Date:8/27/2011 Member: IVERLETT, RAYMOND Group#: 3333770-R002-OAP6@C1024 Date Received: 7/18/2011

ID Number: Health Plan: Processed:

U42421729 CIGNA TN OAP SF 7/25/2011

Processing Summary
Date Paid:8/22/2011 Tax ID #:621020380 Total Amount Billed: Total Allowed Amount: Less Deductions Copay: Co-Insurance: COB: Not Allowed Amount: Admin Fee: Claim Paid Amount: * Plus Interest: Tax: Direct Deposit Bonus: ETP Incentive Bonus: Amount Paid: Payment#:37443 Payable To:ROBERTRATNIPDC $76.00 $52.00 $0.00 $6.36 $50.98 $50.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Amount:$0.00

Diagnosis Code 739.3 353.1 721.3 729.1

* If there is a secondary payor involved, they should coordinate benefits with this amount.

8/27/2011

Date(s) of Service Date CPT Code Description Charges Amount Payment

Page 2 of 5 pages

16 97

Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarksRemittance Advice - 37443 ASHLink codes whenever appropriate Payment is included in the allowance for another service/procedure.

ClaimNumber:28125897
CopyrightAmericanSpecialtyHealth,Inc.Allrightsreserved. Today's Date:8/27/2011 Member: IVERLETT, RAYMOND Group#: 3333770-R002-OAP6@C1024 Date Received: 7/18/2011

ID Number: Health Plan: Processed:

U42421729 CIGNA TN OAP SF 7/25/2011

Processing Summary
Date Paid:8/22/2011 Tax ID #:621020380 Total Amount Billed: Total Allowed Amount: Less Deductions Copay: Co-Insurance: COB: Not Allowed Amount: Admin Fee: Claim Paid Amount: * Plus Interest: Tax: Direct Deposit Bonus: ETP Incentive Bonus: Amount Paid: Payment#:37443 Payable To:ROBERTRATNIPDC $76.00 $52.00 $0.00 $6.36 $50.98 $50.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Amount:$0.00

Diagnosis Code 739.3 353.1 721.3 729.1

* If there is a secondary payor involved, they should coordinate benefits with this amount.

Date(s) of Service Date CPT Code Description CHIRO MANIPULATIVE TREATMENT SPINAL, 3-4 REGIONS CHIRO MANIPULATIVE TREATMENT SPINAL, 3-4 REGIONS Charges Amount Allowed 26.00 Payment Code(s)

05/10/2011

98941-AT

38.00

05/24/2011

98941-AT

38.00

26.00

Notes ASH is researching the disallowed amount with the Health Plan. An updated RA will be issued upon resolution with the Health Plan ClaimNumber:28321711
CopyrightAmericanSpecialtyHealth,Inc.Allrightsreserved. Today's Date:8/27/2011 Member: PIATT JR, JACOB Group#: 2498662-GLACT-OAP1@CHI88 Date Received: 8/2/2011

ID Number: Health Plan: Processed:

000184533 CIGNA TN OAP SF 8/9/2011

Processing Summary
Date Paid:8/22/2011 Tax ID #:621020380 Total Amount Billed: Total Allowed Amount: Less Deductions Copay: Patient Responsibility: Admin Fee: Claim Paid Amount: * Plus Interest: Tax: Direct Deposit Bonus: ETP Incentive Bonus: Amount Paid: Payment#:37443 Payable To:ROBERTRATNIPDC $50.00 $26.00 $0.00 $25.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.00 $1.00 Amount:$0.00

Diagnosis Code 724.4 353.1 729.1

* If there is a secondary payor involved, they should coordinate benefits with this amount.

Date(s) of Service Date CPT Code Description CHIRO MANIPULATIVE TREATMENT SPINAL, 3-4 REGIONS Charges Amount Allowed 26.00 Payment Code(s)

07/28/2011

98941-AT

50.00

8/27/2011

Page 3 of 5 pages

issued upon resolution with the Health Plan ASHLink Remittance Advice - 37443 ClaimNumber:28321711
CopyrightAmericanSpecialtyHealth,Inc.Allrightsreserved. Today's Date:8/27/2011 Member: PIATT JR, JACOB Group#: 2498662-GLACT-OAP1@CHI88 Date Received: 8/2/2011

ID Number: Health Plan: Processed:

000184533 CIGNA TN OAP SF 8/9/2011

Processing Summary
Date Paid:8/22/2011 Tax ID #:621020380 Total Amount Billed: Total Allowed Amount: Less Deductions Copay: Patient Responsibility: Admin Fee: Claim Paid Amount: * Plus Interest: Tax: Direct Deposit Bonus: ETP Incentive Bonus: Amount Paid: Payment#:37443 Payable To:ROBERTRATNIPDC $50.00 $26.00 $0.00 $25.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.00 $1.00 Amount:$0.00

Diagnosis Code 724.4 353.1 729.1

* If there is a secondary payor involved, they should coordinate benefits with this amount.

Date(s) of Service Date CPT Code Description CHIRO MANIPULATIVE TREATMENT SPINAL, 3-4 REGIONS Charges Amount Allowed 26.00 Payment Code(s)

07/28/2011

98941-AT

50.00

ClaimNumber:28324127
CopyrightAmericanSpecialtyHealth,Inc.Allrightsreserved. Today's Date:8/27/2011 Member: PRICHARD, AMANDA Group#: 3333826-STACT-OAP1@CHI74 Date Received: 8/2/2011

ID Number: Health Plan: Processed:

000131119 CIGNA TN OAP SF 8/9/2011

Processing Summary
Date Paid:8/22/2011 Tax ID #:621020380 Total Amount Billed: Total Allowed Amount: Less Deductions Copay: Patient Responsibility: Admin Fee: Claim Paid Amount: * Plus Interest: Tax: Direct Deposit Bonus: ETP Incentive Bonus: Amount Paid: Payment#:37443 Payable To:ROBERTRATNIPDC $90.00 $25.00 $0.00 $25.00 $0.00 Diagnosis Code $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 729.1 723.3 Amount:$0.00

* If there is a secondary payor involved, they should coordinate benefits with this amount.

Date(s) of Service Date CPT Code Description CHIRO MANIPULATIVE TREATMENT SPINAL, 1-2 REGIONS CHIRO MANIPULATIVE TREATMENT SPINAL, 3-4 REGIONS Charges Amount Allowed 25.00 Payment Code(s)

07/26/2011

98940-AT

40.00

07/26/2011

98941-AT

50.00

0.00

11

PaymentCode(s)
11 This service is considered mutually exclusive with another service billed on the same date of service. (97) Payment is included in the allowance for another service/procedure.

8/27/2011

97

Page 4 of 5 pages

REGIONS

ASHLink Remittance Advice - 37443

ClaimNumber:28324127
CopyrightAmericanSpecialtyHealth,Inc.Allrightsreserved. Today's Date:8/27/2011 Member: PRICHARD, AMANDA Group#: 3333826-STACT-OAP1@CHI74 Date Received: 8/2/2011

ID Number: Health Plan: Processed:

000131119 CIGNA TN OAP SF 8/9/2011

Processing Summary
Date Paid:8/22/2011 Tax ID #:621020380 Total Amount Billed: Total Allowed Amount: Less Deductions Copay: Patient Responsibility: Admin Fee: Claim Paid Amount: * Plus Interest: Tax: Direct Deposit Bonus: ETP Incentive Bonus: Amount Paid: Payment#:37443 Payable To:ROBERTRATNIPDC $90.00 $25.00 $0.00 $25.00 $0.00 Diagnosis Code $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 729.1 723.3 Amount:$0.00

* If there is a secondary payor involved, they should coordinate benefits with this amount.

Date(s) of Service Date CPT Code Description CHIRO MANIPULATIVE TREATMENT SPINAL, 1-2 REGIONS CHIRO MANIPULATIVE TREATMENT SPINAL, 3-4 REGIONS Charges Amount Allowed 25.00 Payment Code(s)

07/26/2011

98940-AT

40.00

07/26/2011

98941-AT

50.00

0.00

11

PaymentCode(s)
11 This service is considered mutually exclusive with another service billed on the same date of service. (97) Payment is included in the allowance for another service/procedure.

97

8/27/2011

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