Charged Comment Comment

Claim #
2022153A Patient'sMELENUD
Name 93054945ID DOB
05/16/19 DOS
05/27/20 Medicare 22, Page Status
Amount s s
A0930
2022153A ESTELLA O A
92713892 81 22
05/27/20 $450.00 carrier Page
Medicare No: 157 Paidto
No: Need
A0907
2022153A Ruby MELENUD
Pickford 93054945
A ### 22
05/16/19 05/27/20 $300.00 carrier
Medicare 23 Page147 Write OFF
A0909
2022153J Estella O A 81 22
R0068437 01/21/19 05/16/20 $300.00 carrier No:
Member 23, Page 149 Paid
KP014
2022153A LEO Ferry 97615639
7 69 22
05/13/19 05/30/20 $450.00 Payment Page
Medicare No: 159 Paidto
No: Need
A0916
2022153A Anabella KHACHAT C
Miyares 93218856 56 22
05/30/20 $300.00 carrier Page
Medicare 151No: Write
NeedOFFto
A0917
2022153A NVARD
YSABELIT RYAN 93401807
PEREZ F ### 22
05/28/20 $300.00 carrier Page
Medicare 153No: Write
NeedOFFto
A0921 A SOTELO 90531506
E ###
12/17/20 22
03/31/20 $450.00 carrier Page 155No: Write OFF
Contact
2.21E+10 HWANG LENA
OCONNO STEPHANI E 04 22 $450.00 9
Eligibility FL033197 Member
N/A R
OCONNO STEPHANI E 4E+13 ### ### $300.00 Issue 649
Eligibility Page No: Paid
N/A R
OCONNO E
STEPHANI 4E+13 ### ###
05/13/20 $300.00 Issue
Eligibility Page5 No: Paid
N/A R
OCONNO E
STEPHANI 4E+13 ### 22
05/16/20 $300.00 Issue
Eligibility Page7 No: Paid
N/A R
OCONNO E
STEPHANI 4E+13 ### 22 $300.00 Issue
Eligibility Page9 No: Paid
N/A R
OCONNO STEPHANI E 4E+13 ### ### $450.00 Issue 11
Eligibility Page No: Paid
N/A R
OCONNO E
STEPHANI 4E+13 ### ### $450.00 Issue 13
Eligibility Page No: Paid
N/A R
OCONNO STEPHANI E 4E+13 ### ###
05/13/20 $450.00 Issue 15
Eligibility Page No: Paid
N/A R
OCONNO E
STEPHANI 4E+13 ### 22
05/16/20 $450.00 Issue
Eligibility Page17No: Paid
N/A
94999990 R E 4E+13
91566532 ### 22 $450.00 Issue
Responsib 22,19
Page Paid
0003
94999990 JAIME
Mikaela MILLS 96714018
A ### ###
05/17/20 $450.00 ility No: 57
Page Paid
No: Contact
0007 MAE Asinas F 04/24/1998 22 $300.00 59 Member
Claim # Patient's Name ID DOB DOS Charged Comment Comment Status
ELIZABET 93379069 02/21/19 Amount status
s of Group.Pa
s Submitte
H
ELIZABET SANCHEZ 93379069
A 90
02/21/19 ### $450.00 the claim
status ge No: 3 Submitte
of Group.Pa d
H SANCHEZ A 90
04/17/20 ### $300.00 the claim ge
Eligibility 40 No:
Page3 Submitte
d
KOSHAK BRIANNA 2.01E+13 04/17/20 22 ### $450.00 Issue
Eligibility No:Page
36 28 Submitte
d
KOSHAK BRIANNA 2.01E+13 04/17/20 22 ### $450.00 Issue No: 30
Eligibility 34 Page Submitted
KOSHAK BRIANNA 2.01E+13 04/17/20 22 ### $450.00 Issue No: 32 d
Eligibility 38, Page Submitte
KOSHAK BRIANNA 2.01E+13 04/17/20 22 ### $450.00 Issue No:
Eligibility Page No:34 d
KOSHAK BRIANNA 2.01E+13 04/17/20 03 ### $450.00 Issue
Eligibility Page21No: Paid
KOSHAK BRIANNA 2.01E+13 04/17/20 03 ###
05/14/20 $450.00 Issue
Eligibility Page23No: Paid
KOSHAK BRIANNA 2.01E+13 04/17/20 22 22 $450.00 Issue
Eligibility Page25No: Paid
KOSHAK BRIANNA 2.01E+13 04/17/20 22 ### $450.00 Issue 36
Eligibility Page No: Paid
KOSHAK BRIANNA 2.01E+13 04/17/20 22 ###
03/14/20 $450.00 Issue 38
Eligibility Page No: Paid
KOSHAK BRIANNA 95143070
2.01E+13 07/19/20
22 22
05/23/20 $450.00 Issueof Page
status 40No: Paid
1412070 AIDAN Morris 95143070
F 10
07/19/20 22 $300.00 the claim
status of 22,13Page Paid
1412072 AIDAN F
Morris 95143070 10
07/19/20 ###
5/31/202 $300.00 the claim
status of 22No:Page
15 Paid
1412071
92107360 AIDAN MORRIS 92345348 F 10 2 $300.00 the claim No:
status of 23 Page 25 Paid
2755
92107360 Apelian Catherina E
HAMILTO 98111910 ### $300.00 the claim No:
status of Page No: 33 Paid
2670
CDS52413 DYLAN N SMITH D ### $450.00 the claim
Claim 09/30/2033 Paid
4 JALEN NELSON 9.08E+0812/22/2010 ### $300.00 with W9 22, Paid
Claim # Patient's Name ID DOB DOS Charged Comment Comment Status
NM21277 Amount s
AJC90823 08/26/20 Claim Claims No:
CDS25568
NM21277 KARLA REYES ### $440.00 Paid
4869
AJC90832 21
08/17/20 with (W9 NM22096
Claim Claim No:
6
CDS25567
NM21277 Estefany Cerritos ### $440.00 Paid
0143 21 with (W9 NM22096
9
CDS25568
NM21277 Kristel Cerritos AJC90788 ### 08/17/20 $440.00 Claim Claim No: Paid
0371
AJC90788 21
08/24/20 with
Claim(W9 NM22096
Claim No:
0
CDS25568
NM21267 Kristel Cerritos ### $440.00 Paid
0371
AJC90924 21
07/30/20 with
Claim(W9 NM22096
Claim No:
1
CDS27706
NM21267 KAREN BURTON ### $440.00 $35.33, Paid
Kamryn 1066
AJC90857 21 with
Claim(W9 NM22096
5
CDS27706
NM21267 Preston ### ### $440.00 Claim No: Paid
M 7844 with (W9 Claim No:
Kourtni R Preston AJC90778
6 Claim 29137961 Paid
CDS27706
NM21264 ### ### $440.00
2143
ajc90827 08/18/20 with
Claim(W9 NM22096
Claim No:
7
CDS59205
NM21264 Jaelon Henry ### $440.00 Paid
0399
ajc90856 21 with
Claim(W9 NM22096
Claim No:
2
CDS59207
NM21348 SHANTEL BROWN ### ### $440.00 Paid
FERNAND GOMEZ ajc90830 8129 07/27/20 with
Claim(W9 NM22096
Claim No:
0
CDS28307 ### $440.00 Paid
O 8190 21 with (W9 NM22096
2
NM22096 Check No:
AJC90852 09/16/20
CSC88721
NM22096 WHEELER KAYDEN A ### ### $450.00 12- Paid
6329 07/17/20
96042804 22, will Check No:
09/16/20
8
CSC88725
NM22096 BAKER ALANNA ### $300.00 795080,
12-No:
Claim Paid
F 12 22, will
4
CSC88728
NM22096 HOWARD RICHARD W249522 04/22/19 ### $490.00 09/16/20 NM22284 802357, Paid
755 62 22, will
2
CSC88729
NM21347 YOUNG KARMEN AJC91036 08/18/19 09/22/20 $490.00 09/16/20 20220921 CDA1131 Paid
7777 94 21 22, will 92071281
corrected to Allied Submitte
4
CDS14519 KAYDEN WHEELER 9.09E+08
NATHANI ### ### $490.00 02/24/20
paper Pcific IPA, d
4 EL MOGUEL 9.09E+08 ### ### $490.00 resubmit a 02/24/20 22 Paid
ABIE RUIZ 9.09E+08 ### ### $490.00 resubmit a 02/25/20 22 Paid
JAELON KESHISHI
KERISTIA HENRYAJC908270399
AJC90861 ### ### $490.00 resubmit a 02/24/20 22 Paid
N AN 4380
W235688 12/29/199 ### $490.00 resubmit a 22
25942068 Paid
92107360 NICOLLE ARANDA 93701 12/23/19900 9/28/2021$1,080.00
GHALEH 96639302 06/29/19 01/14/20 resubmit a corrected
healthpaper 96
claim
23 withSubmitted
w9
0275 NARINEH FATAEGH
92107360 MAM G 97
03/28/19 22
01/17/20 $300.00 health plan ,
23 Paid
0228
92107360 GARINE VAROZIAALE 23271681 73 22
01/19/20 $300.00 health plan 23 Paid
0278
92107360 MARY N 6.09E+08 09/18/19
99793956 ### 22
01/14/20 $300.00 health plan 23 Paid
0245 TENI VARTANY D 87 22 $300.00 plan Paid
Charged Comment Comment Status
Claim # Patient's Name ID DOB DOS
ZNG6000 05/13/20 02/13/20 Amount Eligibility 42, sRep Need to
s
MCCLURG JOSETTE ZNG6000
80192 05/13/20
02 22
02/25/20 $450.00 Eligibility
Issue Simon
Page L Write
No: NeedOFF
to
80192 05/13/20
MCCLURG JOSETTE ZNG6000 02 22
02/28/20 Issue
$450.00 Eligibility Page44No: Write
NeedOFF
to
MCCLURG JOSETTE ZNG6000
80192 05/13/20
02 22 $450.00 Eligibility
Issue Page46No: Write
NeedOFF
to
MCCLURG JOSETTE ZNG6000
80192 05/13/20
02 ### $450.00 Eligibility
Issue Page48No: Write
NeedOFF
to
80192 05/13/20
MCCLURG JOSETTE ZNG6000 02 ### Issue
$450.00 Eligibility 50 Write
Page No: Need to OFF
MCCLURG JOSETTE ZNG6000
80192 05/13/20
02 ###
03/14/20 $450.00 Eligibility
Issue Page52No: Write
NeedOFF
to
MCCLURG OSORNO
JOSETTE 90880490
80192 02 22 $450.00 statusIssueof 96,54 Page Write theOFF
HAILEHI FLORES 93589944 F ### $490.00 the claim
status of PageNo:No:
1 Submitte
appeal
1412086 MANU MATLOCK 91424656 F ###
05/30/19 ### $490.00 the claim
status of Page5 No: Submitted
1412088 MILDRED HERRERA 92710239 C 89 ### $490.00 the claim 7
status of Page No: Submitte d
1412087 MICHELLE MATEO 97094251 D ###
08/25/19 ### $490.00 the claim 9
status of Page No: Contact d
1412089 MIRIAM ZLOPEZ D
PALO 96831774 96 ### $490.00 the claim 11
status of , Page No: Member
1412093 SAMUEL ENRIQUEMARES 98157824
D ### $490.00 the claim
status of Page 21No: Paid
1412075 ALICIA Z F
91476835 06/14/19 ### $490.00 the claim
status of Page 23No: Appeal
1412091 RONRICO KEARSE C 72 1/5/2022 $490.00 the claim 27 submitted
Charged Comment Comment
Claim # Patient's Name 91476835
ID DOB
06/14/19 DOS Status
Amount status s of Pages No: Appeal
1412091
92107360 RONRICO KEARSE C
HAMILTO 98111910 72 1/5/2022
06/21/20 $490.00 the claim 27 submitted
status of EOB. Page Appeal
0198
92107360 DYLAN
VANIG N SMITH 94629897 D 22
06/22/20 $300.00 the claim
status No:Page
of EOB. 33 submitted
Appeal
0197
22312E00 HAGOP TORIKIAN 95683821 F 22
01/28/20 $300.00 thePageclaim No: 34 submitted
no: 07/25/20 Awaiting
1410 MATHEW MORALES XOH8233
628A6650 E ###
10/26/20 22
05/13/20 $300.00 lity18 Page 23.
to response
Submitte
H
628A6650 Mordecai Evans 48052 03
XOH8233 10/26/20 23 $200.00 no: 87
lity Page Anthem.
to d
Submitte
H
628A6650 Mordecai Evans 48052 03
XOH8233 10/26/20 ### atg no: 87
lity Page Anthem.
to d
Submitte
H
628A6650 Mordecai Evans 48052 03
XOH8233 10/26/20 ### atg no: 87
lity Page Anthem.
to d
Submitte
H
628A6650 Mordecai Evans XOH823348052 10/26/20
03 ### atg no:Page
lity 87 Anthem.
to d
Submitte
H
628A6650 Mordecai Evans XOH823348052 10/26/20
03 ### atg no:Page
lity 87 Anthem.
to d
Submitte
H
628A6650 Mordecai Evans XOH823348052 10/26/20
03 ### atg no:Page
lity 87 Anthem.
to d
Submitte
H
628A6650 Mordecai Evans 48052 03
XOH8233 10/26/20 ### atg no: 87
lity Page Anthem.
to d
Submitte
H
628A6650 Mordecai Evans 48052 03
XOH8233 10/26/20 ### atg no: 87
lity Page Anthem.
to d
Submitte
H
628A6650 Mordecai Evans XOH823348052 10/26/20
03 ### atg no:Page
lity 87 Anthem.
to d
Submitte
H
628A6650 Mordecai Evans XOH823348052 10/26/20
03 ### atg no:Page
lity 87 Anthem.
to d
Submitte
H
628A6650 Mordecai Evans XOH823348052 10/26/20
03 1/8/2023 atg no:Page
lity 87 Anthem.
to d
Submitte
H
628A6650 Mordecai Evans 48052 03
XOH8233 10/26/20 1/8/2023 pcr no: 87
lity Page Anthem.
to d
Submitte
H
628A6650 Mordecai Evans 48052 03
XOH8233 10/26/20 ### atg no: 87
lity Page Anthem.
to d
Submitte
H
628A6650 Mordecai Evans 48052 03
XOH8233 10/26/20 ### atg no: 87
lity Page Anthem.
to d
Submitte
H Mordecai Evans 48052 03 2/6/2023 atg no: 87 Anthem. d
628A6650 XOH8233 10/26/20 lity Page to Submitte
H
628A6650 Mordecai Evans XOH8233
48052 03
10/26/20 ### atg no:Page
lity 87 Anthem.
to d
Submitte
H
628A6650 Mordecai 48052
Evans XOH8233 03
10/26/20 ### atg no:Page
lity 87 Anthem.
to d
Submitte
H
628A6650 Mordecai Evans XOH8233
48052 03
10/26/20 3/7/2023 atg no: 87
lity Page Anthem.
to d
Submitte
H
628A6650 Mordecai Evans XOH8233
48052 03
10/26/20 ### atg no:Page
lity 87 Anthem.
to d
Submitte
H
628A6650 Mordecai Evans XOH8233
48052 03
10/26/20 ### atg no:Page
lity 87 Anthem.
to d
Submitte
H
628A6650 Mordecai 48052
Evans XOH8233 03
10/26/20 ### atg no:Page
lity 87 Anthem.
to d
Submitte
H
628A6650 Mordecai Evans XOH8233
48052 03
10/26/20 4/6/2023 atg no:Page
lity 87 Anthem.
to d
Submitte
H
628A6650 Mordecai Evans XOH8233
48052 03
10/26/20 ### atg no:Page
lity 87 Anthem.
to d
Submitte
H
628A6650 Mordecai 48052
Evans XOH8233 03
10/26/20 ### atg no: 87
lity Page Anthem.
to d
Submitte
H
628A6650 Mordecai 48052
Evans XOH8233 03
10/26/20 ### atg no:Page
lity 87 Anthem.
to d
Submitte
H
628A6650 Mordecai Evans XOH8233
48052 03
10/26/20 5/4/2023 atg no:Page
lity 87 Anthem.
to d
Submitte
H
628A6650 Mordecai Evans XOH8233
48052 03
10/26/20 5/9/2023 atg no:Page
lity 87 Anthem.
to d
Submitte
H Mordecai
SUNG 48052
Evans H7804662 03 ###
01/27/20 atg no: 87 01/23/20
taxonomy Anthem. d
10594999 HEE
SUNG HONG H7804662
7 22
01/27/20 $490.00 taxonomy
. 23,
01/23/20 Paid
10594999 HEE
SUNG HONG H7804662
7 22
01/27/20 $490.00 . 23,
taxonomy 01/17/20 Paid
10611467 HEE HONG 7 22 $600.00 . 23, Paid
 Payer File Name
HealthNet
20220609135839018
HealthNet
20220609135839018
HealthNet
20220609135839018
HealthNet
20220609135839018
HealthNet
20220609135839018
HealthNet
20220609135839018
HealthNet
20220609135839018
Health
Care
20220609135839018
Century
health
20220609135839018
Century
20220609135839018
health
Century
health
20220609135839018
Century
health
20220609135839018
Century
20220609135839018
health
Century
20220609135839018
health
Century
health
20220609135839018
Century
health
20220609135839018
Century
20220609135839018
health
Health
Alliance
20220609135839018
Health
Alliance
20220609135839018
Payer File Name
LA Care
20220809144124276
LA Care
20220809144124276
Century
health
20220614092258049
Century
20220614092258049
health
Century
health
20220614092258049
Century
health
20220614092258049
Century
health
20220614092258049
Century
20220614092258049
health
Century
health
20220614092258049
Century
health
20220614092258049
Century
20220614092258049
health
Century
20220614092258049
health
LA Care
20220809144124276
LA Care
20220809144124276
LA Care
20220809144124276
Medical
Group
20220809144124276
Medical
Group
20220809144124276
Managem
ent20220303150134172
Payer File Name
20220208
Medical
13082864
20220208
Managem
Medical 5
13082864
20220208
Managem
Medical 5
13082864
20220208
Managem
Medical 5
13082864
20220208
Managem
Medical 5
13082864
20220208
Managem
Medical 5
13082864
20220208
Managem
Medical 5
13082864
20220208
Managem
Medical 5
13082864
20220208
Managem
Medical 5
13082864
20220208
Managem
Medical 5
13082864
Managem
5
 20220425
Medical
13594152
20220425
Managem
Medical 3
13594152
20220425
Managem
Medical 3
13594152
20220425
Managem
Medical 3
13594152
Managem 20220517
Medical 3
09174291
Managem
Network 1
20220517091742911
M
Network
20220517091742911
M
Network
20220517091742911
M
Network
20220517091742911
M
Network Medical
20220517091742911
Management
Medical
20221018143414391
Group
Medical
Group
20221018143414391
Medical
Group
20221018143414391
Medical
20221018143414391
Group
Century File Name
Payer
health
20220614092258049
Century
health
20220614092258049
Century
20220614092258049
health
Century
health
20220614092258049
Century
health
20220614092258049
Century
20220614092258049
health
Century
20220614092258049
health
LA Care
20220809144124276
LA Care
20220809144124276
LA Care
20220809144124276
LA Care
20220809144124276
LA Care
20220809144124276
LA Care
20220809144124276
LA Care
20220809144124276
LA Care
20220809144124276
Payer File Name
LA Care
20220809144124276
Medical
20220809144124276
Group
Medical
Group
20220809144124276
LaBlue
Care
20230614161704380
20230614161704380
shield
Blue
shield
20230614161704380
Blue
shield
20230614161704380
Blue
shield
20230614161704380
Blue
20230614161704380
shield
Blue
shield
20230614161704380
Blue
shield
20230614161704380
Blue
20230614161704380
shield
Blue
20230614161704380
shield
Blue
shield
20230614161704380
Blue
shield
20230614161704380
Blue
20230614161704380
shield
Blue
shield
20230614161704380
Blue
shield
20230614161704380
Blue
20230614161704380
shield
 Blue
shield
20230614161704380
Blue
shield
20230614161704380
Blue
20230614161704380
shield
Blue
20230614161704380
shield
Blue
shield
20230614161704380
Blue
shield
20230614161704380
Blue
20230614161704380
shield
Blue
shield
20230614161704380
Blue
shield
20230614161704380
Blue
shield
20230614161704380
Blue
20230614161704380
shield
Blue
shield
20230614161704380
Blue
shield
20230614161704380
Medical 10094716
Group 4
Medical 10094716
Group 4
Medical 10094716
Group 4