12/13/24, 12:50 PM TriZetto Provider Solutions® : TriZetto Provider Solutions, Inc.
SITE 4F8U| USER 078Skumar|
Claim Detail
Claim File: GClinicForWomen20241212 $544.00 #2.
This claim has been returned to you for correction. Claim ID: 241213161315
Worked: Worked by: Worked on:
Date of Service: 11/04/2024 - 11/04/2024 Place of Service: 11 Charge: $192.00
Admission Date: Discharge Date: Submission Date: 12/13/2024
Insurer: SO MEDICARE NORIDIAN Payer ID: 01182 Insured ID: 5N36AC4AW89
Patient: GODINEZ, VICKY Account Number: 007800063170 Patient ID: 5N36AC4AW89
DocSite ID: Office: SEVEN STAR OB/GYN - ANAHEIM
Provider Tax ID: XXXXX1199 NPI Billing: 1093318172
Provider: AHAD, GEORGE Provider ID: NPI Rendering: 1932421559
Referred by: AHAD, GEORGE Ref. Provider ID: NPI Referring: 1932421559
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Payer Report
12/13/2024 - PAYER ACKNOWLEDGEMENT REPORT
Payer has acknowledged initial receipt of claim file.
Payer Report
12/13/2024 - 277 PAYER REJECTION REPORT
Billing Provider: Acknowledgement/Rejected for relational field in error : Submitter not approved for
electronic claim submissions on behalf of this entity
GEDI Report
12/13/2024 - RECORD OF CLAIMS RECEIVED Reference #: 241213161315
Claim Status Inquiry is unavailable for this Payer.
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