Otal Actual Provider Payment Amount: Payment Method Code:

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Electronic Remittance Advice (X12/835)
Transaction Information
Check ID: Total Actual Provider Payment Amount: Payment Method Code: 882145559 $1,358.90 Automated Clearing House (ACH) 031100283 0934763 99031 075000051 0049239344 10/11/2012 Date: Payer Identifier: 10/15/2012 1391268299

Sender DFI Identifier: Sender Bank Account Number: Receiver Identifier: Receiver or Provider Bank ID Number: Receiver or Provider Account Number: Production Date:

Payer
Name: Identifier: Address: Additional Identifier: Contact: WI MEDICARE 00951 1717 W BROADWAY, MADISON, WI 53701 2U / 00951 WISCONSIN PHYSICIANS SERVICE, Phone: (866) 3591599, WWW.WPSMEDICARE.COM

Payee
Name: Identifier: Address: Additional Identifier: NEUROLOGY ALLIANCE 1194963504 SUITE 504, WEST ALLIS, WI 53227-2455 TJ / 263556891

Claim Reference ID: Status: Total Claim Charge: Claim Payment Amount: Patient Responsibility: Claim Filing Indicator Code: Payer Claim Control Number: Facility Type Code: Patient Name: Patient ID: Provider ID: Claim Received: Outpatient Remark Codes: ClaimID 11843 Svc Date 09/25/2012 Proc / Units 99223 / 1

8705Z5866 19 ( Processed as Primary, Forwarded to Additional Payer(s) ) $450.00 $150.99 $37.75 MB ( Medicare Part B ) 2812276215470 21 BECKER, ARLON O 331260707A ( Health Insurance Claim (HIC) Number ) 1013982149 ( National Provider Identifier (NPI) ) 10/01/2012 MA01, MA18 Not Allowed $261.26 / CO-45 Deduct. Coins / Copay $37.75 / Payment $150.99

Billed / Allowed $450.00 / $188.74 8659Z5866

Claim Reference ID:

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Status: Total Claim Charge: Claim Payment Amount: Patient Responsibility: Claim Filing Indicator Code: Payer Claim Control Number: Facility Type Code: Patient Name: Patient ID: Provider ID: Claim Received: Outpatient Remark Codes: ClaimID 11785 Svc Date 09/20/2012 Proc / Units 99204 / 1

19 ( Processed as Primary, Forwarded to Additional Payer(s) ) $350.00 $123.45 $30.86 MB ( Medicare Part B ) 2812276199920 11 DAVIS, BARBARA 387348386A ( Health Insurance Claim (HIC) Number ) 1013982149 ( National Provider Identifier (NPI) ) 10/01/2012 MA01, MA18 Not Allowed $195.69 / CO-45 Deduct. Coins / Copay $30.86 / Payment $123.45

Billed / Allowed $350.00 / $154.31 8629Z5866

Claim Reference ID: Status: Total Claim Charge: Claim Payment Amount: Patient Responsibility: Claim Filing Indicator Code: Payer Claim Control Number: Facility Type Code: Patient Name: Patient ID: Provider ID: Claim Received: Outpatient Remark Codes: ClaimID 11753 Svc Date 09/18/2012 Proc / Units 95860:26 / 1

19 ( Processed as Primary, Forwarded to Additional Payer(s) ) $550.00 $38.62 $9.65 MB ( Medicare Part B ) 2812276079630 11 DULANEY, BARBARA 356309821A ( Health Insurance Claim (HIC) Number ) 1013982149 ( National Provider Identifier (NPI) ) 10/01/2012 MA01, MA07 Not Allowed $101.73 / CO-45 remark N264 remark N265 $200.00 / CO-4 remark M80 $200.00 / CO-4 remark M80 Deduct. Coins / Copay $9.65 / Payment $38.62

Billed / Allowed $150.00 / $48.27

11754 11755

09/18/2012 09/18/2012

95903:26:59 / 95904:26:59 /

$200.00 / $0.00 $200.00 / $0.00

$0.00 $0.00

Claim Reference ID: Status: Total Claim Charge: Claim Payment Amount: Patient Responsibility: Claim Filing Indicator Code: Payer Claim Control Number: Facility Type Code: Patient Name:

8649Z5866 1 ( Processed as Primary ) $250.00 $80.50 $20.13 MB ( Medicare Part B ) 2812276199760 11 FLOYD, BEATRICE

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Patient ID: Provider ID: Claim Received: Outpatient Remark Codes: ClaimID 11800 Svc Date 09/20/2012 Proc / Units 99214 / 1

420502981A ( Health Insurance Claim (HIC) Number ) 1013982149 ( National Provider Identifier (NPI) ) 10/01/2012 MA01 Not Allowed $149.37 / CO-45 Deduct. Coins / Copay $20.13 / Payment $80.50

Billed / Allowed $250.00 / $100.63 8648Z5866

Claim Reference ID: Status: Total Claim Charge: Claim Payment Amount: Patient Responsibility: Claim Filing...
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