questions? call customer service at (800)-382-4661 xxxxxxx
TRANSCRIPT
COLORADO CLAIMS ADMINISTRATION
COLORADO
KAISER FOUNDATION HEALTHPLAN,INC
PO Box 373150
Denver, CO 80237-3150
Questions? Call Customer Service at (800)-382-4661 Weekdays Mon - Fri 9:00AM - 4:00PM MT
Weekends N/A
Check / EFT #: 1090
Remittance Number: EOPVEN4705
Payment Date: 07/01/2016
Total Payment Amt: 6000.00
Vendor Tax ID No: 84xxxxxxxVendor ID No: 10xxxxxxxx
Vendor NPI No: 14xxxxxxxxHOSPITAL1234 MAIN STLONGMONT, CO 80501
***ACCOUNT SUMMARY***
# of
Disallowed 13Not Cov'd Amount
Applied to CoPay Other Ins Plan Pays
Claims Allowed Amount Amount/Discount Deductible CoIns
Claims Payment Total 2 6000.00 0.00 0.00 0.00 0.00 6000.00
6000.00 0.00
Total Payment Amount 6000.00
Method of Payment:
Check/EFT Amount 6000.00
Total Payment Amount 6000.00
Other / Claims Related Transactions 0.00
62-20 / 311 Check No: 1090
Citibank, N.A. Date: 07/01/2016
One Penn's Way
New Castle, DE 19720
COLORADO CLAIMS ADMINISTRATION
COLORADO
KAISER FOUNDATION HEALTHPLAN,INC
PO Box 373150
Denver, CO 80237-3150
$ ****6000.00****
* Six Thousand Dollars *
To
the
order
of
HOSPITAL1234 MAIN ST LONGMONT, CO 80501
VOID
Non-Negotiable
Pay
12
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56
7
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11Billed Amount 12 14 15
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Explanation of Payment
Payment Date: 07/01/2016
Page 1 of 2
# Service
Dates
Service
Code
Service
Mod
Billed Amount Disallowed
Amount/Discount
Not Cov'd Amount Applied to
Deductible
CoPay Other Ins Plan Pays Remark Code(s)
Allowed Amount CoIns
POS: TOB: 811 Claim #: 1150229Patient Name: Detelle J Jimea Patient ID / MRN: 00xxxxxx
Provider: CARLYNE D COOL Provider NPI: 19xxxxxxxx LOB: HMO - HMO COMMERCIAL
Patient Acct No (Provider):CR_TC_01 Vendor TIN: 84xxxxxxxx Auth #:
1 06/16/2016
06/16/2016
H0048 3000.00
3000.00
0.00 0.00 3000.00
Total 3000.00
3000.00
0.00 0.00 0.00 0.00
0.00
0.00 3000.00
Claim Payment Total 3000.00
Method of Payment:
Check / EFT Amount 3000.00
Total Payment Amount 3000.00
POS: TOB: 811 Claim #: 1150230Patient Name: Ledebur Jimea Patient ID / MRN: 42xxxxxxxx
Provider: CARLYNE D COOL Provider NPI: 19xxxxxxxx LOB: HMO - HMO COMMERCIAL
Patient Acct No (Provider):CR_TC_01 Vendor TIN: 84xxxxxxxx Auth #:
1 06/17/2016
06/17/2016
H0048 3000.00
3000.00
0.00 0.00 3000.00
Total 3000.00
3000.00
0.00 0.00 0.00 0.00
0.00
0.00 3000.00
Claim Payment Total 3000.00
Method of Payment:
Check / EFT Amount 3000.00
Total Payment Amount 3000.00
Claim Remark Codes and Descriptions will be located here if applicable
2527 28
29 31
30
32 33 34
35
36 37 38
3940
4142
43
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46
47
4849
26
45
51
53
5455
56
57
52- Interest Paid would show here if applicable
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78
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Please review your EOP carefully.
Contracted Commercial Providers: You have the right to appeal our decision
If you don't agree with this decision, in whole or in part, you may submit a signed written appeal within
45 days from the date of this notice to:
Kaiser Permanente Colorado - Provider Appeals
Claims Administration Department
ATTN: Provider Appeals
PO Box 372970
Denver, CO 80237
Fax: 720-857-4770
MEDICARE ADVANTAGE: Noncontracted Providers rendering services to Medicare
Advantage, Kaiser Permanente Senior Advantage members: You have the right to
appeal our decision
Non-contracted providers have the right to ask Kaiser Permanante to review our decision by asking
for an appeal.
Appeal: Ask Kaiser Permanente for an appeal within 60 days of the date of this notice.
Requests for reconsideration of a denied claim must be submitted in writing and should include:
• Your name and address
• Signed Waiver of Liability statement (See reverse side for Waiver of Liability Statement)
• Copy of original claim
• Remittance notification showing the denial
• Any clinical records or other information that explains why you should be reimbursed for
the item or service.
Mail/fax your written request to:
Kaiser Permanente Colorado - Provider Appeals
Claims Administration Department
ATTN: Provider Appeals
PO Box 372970
Denver, CO 80237
Fax: 720-857-4770
Once we receive the required information, we will give you a decision on your appeal within
60 calendar days. If we find in your favor, payment will be made to you at the applicable
Medicare rate. If we do not receive the required Waiver of Liability we will not review your
request. We will send you a Notice of Dismissal of Appeal Request.
You have the right to ask an independent reviewer contracted with Medicare to review our
decision. Please follow the instructions on the Notice of Dismissal of Appeal Request.
____________________________________________________________________________________________
WAIVER OF LIABILITY STATEMENT
____________________________
Enrollee’s Medicare/HIC Number
__________________________________________________________
Enrollee’s name
__________________________________________________________ ____________________________
Provider Dates of Service
Kaiser Foundation Health Plan of Colorado
I hereby waive any right to collect payment from the above-mentioned enrollee for the aforementioned
services for which payment has been denied by the above-referenced health plan. I understand that
the signing of this waiver does not negate my right to request further appeal under 42 CFR 422.600.
____________________________________________________________________________________________
Signature Date