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Standard Paper Remittance Date 0710212010
Time 10:02:41
BLUECROSS BLUESHIELD OF TEXAS AIR EVAC EMS INC
0 BOX 660044 PO BOX 106
DALLAS, TX 75266-0044 WEST PLAINS, MO 65775-0106

Pl: 1699758417

CHECKIEFT Date 04/1312018
CHECKIEFT 

PE RF PROV

SERVDATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRPIRC AMT PROVPD

 

 

11115 1111512017 1 A0431 HHET 29071.96 29071.96 0.00 0.00 PR-45 22095.27 6976.69

11115111151201? 106 A0436 HHET 27315.14 27315.14 0.00 0.00 P1245 22321.75 4993.39

11115111151201? 1 93041 109.71 0.00 0.00 0.00 Pl-97 109.71 0.00
REM: M15

11115 1171512017 4 J2405 106.72 106.72 0.00 0.00 104.45 2.27
PT RESP 44521.47 CLAIM TOTALS 56603.53 56493.82 0.00 0.00 44631.18 11972.35
ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 11972.35

Glossary

45

97

M15

Charge exceeds fee schedulefmaximum allowable or contractedllegislated fee arrangement. Usage: This adjustment amount cannot
equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual
reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability)

The benefit for this service is included in the paymentfallowance for another servicelprocedure that has already been adjudicated. Usage:

Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Separately billed servicesitests have been bundled as they are considered components of the same procedure. Separate payment is not
allowed.