UnitedHealthcare Community Plan

UnitedHealthcare Community & State

P.O. Box 5290
Kingston NY 12402
PHONE: 1-800-600-9007 Pennsylvania

PAYMENT DATE: 04/23/22

PAYEE TAX NUMBER: 363999311
PAYEE NPI: 1477671345
DPS$$$PKG PAYEE ID: 001329064502
NORTHSHORE CLINICAL LAB PAYEE NAME: NORTHSHORE CLINICAL
4751 N KEDZIE AVE FL 1 LAB
CHICAGO IL 60625-4420 PAYMENT NUMBER: 2022042318200804
PAYMENT AMOUNT: $101.51
GRP ID: PAPH
RA REFERENCE ID: 2022042318200804

PROVIDER REMITTANCE ADVICE

PROVIDER REMITTANCE AT A GLANCE

NET PAYABLE $101.51

OVERPAYMENT AMOUNT

RECOVERED AMOUNT

NET PAID AMOUNT $101.51

PLEASE SEE NEXT PAGE FOR MORE INFORMATION

STD-PRA-363999311-5200000000114660848 Page 1 of 6
 UnitedHealthcare Community Plan
UnitedHealthcare Community & State STD-PRA
P.O. Box 5290
Kingston NY 12402 PROVIDER
PHONE: 1-800-600-9007
REMITTANCE ADVICE
Pennsylvania

PAYMENT DATE: 04/23/22

PAYEE TAX NUMBER: 363999311
PAYEE ID: 001329064502
PAYEE NAME: NORTHSHORE CLINICAL
NORTHSHORE CLINICAL LAB LAB
4751 N KEDZIE AVE FL 1 PAYMENT NUMBER: 2022042318200804
CHICAGO IL 60625-4420 PAYMENT AMOUNT: $101.51
GRP ID: PAPH
RA REFERENCE ID: 2022042318200804

PATIENT: DESTINY L WASHINGTON

SUBSCRIBER ID: 118973917 SUBSCRIBER NAME: DESTINY L WASHINGTON PROMPT PAY DISC: $0.00 CLAIM NUMBER: 22E364968500 PATIENT ACCOUNT: WASDE038-7405034

MEMBER ID: 4501507828 INTEREST AMOUNT: $0.00 PCP NUMBER: 003224073002 REMIT DETAIL: Professional Claim PRODUCT DESC.: PA Medicaid Healthy Plus

SERVICING PROV NPI: 1477671345 SERVICING PROV NM: NORTHSHORE CLINICAL LAB PCP NAME: PARGOLA, EILEEN F. w/Copay and Limits

BILLING NPI: 1477671345

CARRIER ID:

DATE(S) OF DESCRIPTION OF SERVICE UNITS BILLED AMT DISALLOW ALLOWED AMT DEDUCT AMT COPAY/COINS COB PMT AMT WITHHOLD PAID TO PATIENT RESP AUTH# RMK CD GRP CD/
SERVICE AMT AMT AMT PROVIDER AMT RSN CD

AMT

12/20/21 - billing code G2023 POS/ Bill Type 1 $35.00 $25.00 $10.00 $0.00 $0.00 $10.00 $0.00 CO45
12/20/21 81

12/20/21 - billing code U0003 POS/ Bill Type 1 $135.00 $55.00 $80.00 $0.00 $0.00 $80.00 $0.00 CO45
12/20/21 81
12/20/21 - billing code U0005 POS/ Bill Type 1 $35.00 $35.00 $0.00 $0.00 $0.00 $0.00 N425 CO96,
12/20/21 81 CO45

CLAIM NUMBER: 22E364968500 $205.00 $115.00 $90.00 $0.00 $0.00 $90.00 $0.00 N425
SUBTOTAL:

SUBSCRIBER ID: 118973917 SUBSCRIBER NAME: DESTINY L WASHINGTON PROMPT PAY DISC: $0.00 CLAIM NUMBER: 22E385636000 PATIENT ACCOUNT: WASDE038-7405037

MEMBER ID: 4501507828 INTEREST AMOUNT: $0.00 PCP NUMBER: 003224073002 REMIT DETAIL: Professional Claim PRODUCT DESC.: PA Medicaid Healthy Plus

SERVICING PROV NPI: 1477671345 SERVICING PROV NM: NORTHSHORE CLINICAL LAB PCP NAME: PARGOLA, EILEEN F. w/Copay and Limits

BILLING NPI: 1477671345

CARRIER ID:

DATE(S) OF DESCRIPTION OF SERVICE UNITS BILLED AMT DISALLOW ALLOWED AMT DEDUCT AMT COPAY/COINS COB PMT AMT WITHHOLD PAID TO PATIENT RESP AUTH# RMK CD GRP CD/

SERVICE AMT AMT AMT PROVIDER AMT RSN CD

AMT

12/20/21 - billing code 87811 POS/ Bill Type 1 $60.00 $48.49 $11.51 $0.00 $0.00 $11.51 $0.00 CO45
12/20/21 81

CLAIM NUMBER: 22E385636000 $60.00 $48.49 $11.51 $0.00 $0.00 $11.51 $0.00
SUBTOTAL:

TOTAL PAYABLE TO PROVIDER $101.51

STD-PRA-363999311-5200000000114660848 Page 2 of 6
 STD-PRA

PROVIDER
REMITTANCE ADVICE
Pennsylvania

PAYMENT DATE: 04/23/22

PAYEE TAX NUMBER: 363999311
PAYEE ID: 001329064502
PAYEE NAME: NORTHSHORE CLINICAL
LAB
PAYMENT NUMBER: 2022042318200804
PAYMENT AMOUNT: $101.51
GRP ID: PAPH
RA REFERENCE ID: 2022042318200804

PROVIDER TOTALS
SERVICE PROVIDER ID BILLED DISALLOW CONSIDERED ALLOWED AMT DEDUCT AMT COPAY/COINS COB PMT AMT WITHHOLD PAID TO PATIENT RESP INTEREST PROMPT PAY

AMOUNT AMT AMT AMT AMT PROVIDER AMT AMOUNT DISCOUNT

AMT

001329064002 $265.00 $163.49 $0.00 $101.51 $0.00 $0.00 $0.00 $0.00 $101.51 $0.00 $0.00 $0.00

PAYEE TOTALS
PAYEE ID BILLED DISALLOW DISCOUNT ALLOWED AMT DEDUCT AMT COPAY/COINS COB PMT AMT WITHHOLD PAID TO PATIENT RESP INTEREST PROMPT PAY

AMOUNT AMT AMT AMT AMT PROVIDER AMT AMOUNT DISCOUNT

AMT

001329064502 $265.00 $163.49 $0.00 $101.51 $0.00 $0.00 $0.00 $0.00 $101.51 $0.00 $0.00 $0.00

REMARKS
CO45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.

CO96 Non-covered charge(s).

N425 Statutorily excluded service(s).

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 STD-PRA

PROVIDER
REMITTANCE ADVICE
Pennsylvania

PAYMENT DATE: 04/23/22

PAYEE TAX NUMBER: 363999311
PAYEE ID: 001329064502
PAYEE NAME: NORTHSHORE CLINICAL
LAB
PAYMENT NUMBER: 2022042318200804
PAYMENT AMOUNT: $101.51
GRP ID: PAPH
RA REFERENCE ID: 2022042318200804

Provider Communications

To contact Provider Services, please call 1-800-600-9007 or you may reach out to your Physician Advocate.

Balance Billing

Billing or balance billing UnitedHealthcare Community Plan Medicaid members is prohibited and may violate federal and state medical assistance rules and regulations.

Doing Business With Us

Would you rather view this document online?

Link users can access UnitedHealthcare Community Plan provider remittance advice in Document Vault as soon as they’re generated – no more waiting for the mail. You can use Document Vault to download PDF files

or print your documents. You can even turn off mailed delivery of these documents. Learn more at UHCprovider.com/documentvault. Not yet a Link user? Visit UHCprovider.com/link to learn about all our self-service

tools.

Online Service for UnitedHealthcare Community Plan

Please visit UHCprovider.com for valuable resources such as Care Provider Manuals, reimbursement policies, newsletters, forms and clinical practice guidelines. UHCprovider.com is also your gateway to our

self-service tools on Link. You can use Link to get eligibility information, check claim status, submit claim reconsideration requests and much more.

Connect With Us Electronically

Electronic data interchange (EDI), electronic funds transfer and electronic remittance advice may help reduce the time spent checking eligibility, submitting claims and posting payments. Visit UHCprovider.com/edi or

contact EDI Support at ac_edi_ops@uhc.com or 800-210-8315.

National Provider Identifier Information

The National Provider Identifier (NPI) number is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care

providers. When covered health care providers, health plans and health care clearinghouses submit claims/encounter data, they will use the NPI in the administrative and financial transactions adopted under HIPAA.

The NPI number is required on all claims submissions and subsequent encounters. Claims may be denied if the rendering provider’s NPI number is missing or invalid (if required for the Provider Type). Failure to do so

may result in a denied claim.

NPI information can be updated using the following methods:

Phone: 877-842-3210

Online: UHCprovider.com/demoupdate

COB Primary Carrier Information

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 STD-PRA

PROVIDER
REMITTANCE ADVICE
Pennsylvania

PAYMENT DATE: 04/23/22

PAYEE TAX NUMBER: 363999311
PAYEE ID: 001329064502
PAYEE NAME: NORTHSHORE CLINICAL
LAB
PAYMENT NUMBER: 2022042318200804
PAYMENT AMOUNT: $101.51
GRP ID: PAPH
RA REFERENCE ID: 2022042318200804

When UnitedHealthcare is the secondary payer, additional COB primary carrier information can be obtained by accessing the claim detail in the claimsLink application found at UHCprovider.com.

Corrected Claims

If the outcome of a claim results in the need to submit a corrected claim, the provider may do so in accordance with your provider contract. For proper adjudication, please ensure the following information is listed on the

claim form:

∙ CMS 1500

∙ Enter the appropriate claim frequency code in Box 22 left justified in the left-hand side of the field

∙ 7 – Replacement of prior claim

∙ 8 – Void/cancel of prior claim

∙ Enter original claim number under Original Ref No. Box 22

∙ UB04

∙ Enter the appropriate claim frequency code in the 3rd position of the Type of Bill in Box 4

∙ 7 – Replacement of prior claim

∙ 8 – Void/cancel of prior claim

∙ Enter original Claim number in Document Control Number Box 64

∙ Electronic Submissions

∙ Submit original claim number in Loop 2300, REF segment, REF02 element where REF01=F8

∙ Submit the frequency code in Loop 2300, CLM segment, CLM05-3 element

Make sure to resubmit the entire claim as originally submitted (even line items that were previously paid correctly). Following the National Uniform Billing Committee (NUBC) claim frequency guidelines, when sending a

replacement or void claim, the entire original or previous submission must be replaced or voided.

Appeals Procedures

For UnitedHealthcare Community Plan for Families disputes:

Network providers may dispute a denial of payment herein by UnitedHealthcare Community Plan.

Disputes from participating providers must be made in writing within forty-five (45) days of the date of the UnitedHealthcare Community Plan Remittance Advice and must be sent to:

UnitedHealthcare Community Plan, Pennsylvania, Inc.,

Grievance and Appeals Department

STD-PRA-363999311-5200000000114660848 Page 5 of 6
 STD-PRA

PROVIDER
REMITTANCE ADVICE
Pennsylvania

PAYMENT DATE: 04/23/22

PAYEE TAX NUMBER: 363999311
PAYEE ID: 001329064502
PAYEE NAME: NORTHSHORE CLINICAL
LAB
PAYMENT NUMBER: 2022042318200804
PAYMENT AMOUNT: $101.51
GRP ID: PAPH
RA REFERENCE ID: 2022042318200804

c/o UHCCP Administrative Services

P.O. Box 31364

Salt Lake City, UT 84131-0364

The appeal must include a letter detailing the dispute, a copy of the Remittance Advice, and related medical records and/or other supporting information. Non-participating providers may appeal within one hundred

eighty (180) days in the format described above and to the same address. Payments by UnitedHealthcare Community Plan for services rendered to members enrolled though the Medicare, Medicaid or

Medicaid-expansion programs are subject to applicable law addressing fraud and abuse in such programs. By accepting such payment, the provider acknowledges that such law applies and agrees to comply

therewith.

Billing Alerts

UnitedHealthcare enrolls members through the Medicare, Medicaid or Medicaid-expansion programs and payment for the services our members receive is payment in full - balance billing, other than co-pays and

deductibles, is prohibited. By accepting payment from UnitedHealthcare, the provider agrees to abide by the laws, regulations and agency policies that govern such programs, including the prohibitions on fraud,

waste and abuse. You can report possible fraud, waste or abuse anonymously by calling 1-877-766-3844. If you have any questions, contact UnitedHealthcare at 1-800-600-9007.

Medical records, if necessary, should be submitted to:

Medical claim [RMO] Address:

UnitedHealthcare Community Plan

P.O. Box 8207

Kingston, New York 12402-8207

OptumInsight Denials (R10 or R11) for Medical Records fax directly to (877) 285-9063 or (877) 285-9098, or forward by mail to: OptumInsight, Attn: Medical Records, PO Box 105067, Atlanta, GA 30348

*Please note that if the Medical Records are not submitted to OptumInsight, there could be delays in the processing of your claims* Confirmation of a member’s eligibility is accurate as of the time of your call. It

does not guarantee payment of your claim. Eligibility status may change at any time, including retroactive enrollment or termination.

Provider Information

IF YOUR PAYEE NAME, BILLING ADDRESS AND/OR PAYEE TAXPAYER IDENTIFICATION NUMBER (TIN) ARE NOT CORRECTLY DISPLAYED ON THIS EXPLANATION OF BENEFITS, PLEASE CORRECT THE

INFORMATION IN THE SPACE BELOW AND RETURN THIS SECTION TO UnitedHealthcare Community Plan DBM Claims, P.O. Box 16900, Phoenix, AZ 85020.

∙ PAYEE NAME: ____________________________________

∙ BILLING ADDRESS: ____________________________________

____________________________________

____________________________________

∙ TAX ID: ____________________________________

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