Eob 3 (8 pages) Done

School: Brigham Young University, Idaho - Course: PC 103 - Subject: Accounting

PLEASE REVIEW LAST PAGE OF THIS DOCUMENT FOR FURTHER DESCRIPTION OF EXPLANATION CODES Remittance Advice KL:2118^21458277^3914666456^P^2^true^L:KL WELLCARE OF KENTUCKY, INC.P.O. BOX31370 TAMPA, FL 33631 Payee:COMPASS INVESTMENTS LLCCheck Date:6/17/2021Tax ID:844711702NPI#:1184221038 Check Number:1006201480Check Amount:$0.00Vendor:891748LOB:KMD Page 2 of 7 Dates ofServiceBilledProcedure/ModifierPaidProcedure/ModifierBilledUnitsPaidUnitsDeniedUnitsBilledAllowedCo-PayAmountCo-InsAmountDeductibleAmountOtherCarrier2% CMSMandateCMS MIPS AdjPaidExplanation Code Provider:BARRETT MELISSANPI#:1265900765Provider ID#:N2557472Patient ID#:20260163DRG Code:Total PR:0.00 Member:ESTEPP MARIE DClm#:1367316536Interest:0.00Add-on:0.00Pt Acct:51221962Clm Lvl PR:0.00 6/3/2021 -90837PSYCHOTHERAPY, 6090837PSYCHOTHERAPY, 60 101360.000.000.000.000.000.000.000.000.00NOFEE 0.00360.000.000.000.000.000.000.000.000.00 Provider Totals Provider NameNPI #Provider #BilledAllowedCo-PayAmountCo-InsAmountDeductibleAmountOtherCarrierInterestPaid2% CMSMandate CMS MIPS AdjPaid BARRETT MELISSA 11842210381265900765360.000.000.000.000.000.000.000.000.000.00 Vendor Totals BilledAllowedCo-PayAmountCo_InsAmountDeductibleAmountOtherCarrierInterestPaid2% CMSMandate CMS MIPS AdjPaid 360.000.000.000.000.000.000.000.000.000.00

Explanation of Payment Codes and Comments KL:2118^21458277^3914666456^P^3^true^L:KL WELLCARE OF KENTUCKY, INC.P.O. BOX31370 TAMPA, FL 33631 Page 3 of 7 Payee:COMPASS INVESTMENTS LLCCheck Date:6/17/2021Tax ID:844711702NPI#:1184221038 Check Number:1006201480Check Amount:$0.00Vendor:891748LOB: KMD NOFEEDENIED: CODE IS NOTA COVERED SERVICE ON YOUR FEE SCHEDULE In compliance with 42 CFR 455.18 and 455.19, I understand that payment and satisfaction of this claim will be from Federal and State funds, and that any false claims, statements, documents, or concealment of material fact, may be prosecuted under applicable Federal and/or State laws. Contracted providers participating in provider network(s) for Medicare Advantage plans may request an appeal of a denial determination. Appeals must be submittedwithin 90 daysof the date on this remittance advice. Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may request reconsideration of a Medicare Advantage plan denial determination. Requests for reconsideration must be submitted within 60 daysof the date on this remittance advice and a signed waiver of liability (WOL) statement will be required. Medicaid providers must submit requests for appealwithin 60 daysof the date of this notice. Appeals and requests for reconsideration of a denial determination must be submitted in writing to the address identified below and include at a minimum: a summary of the appeal or reconsideration request, the member's name, member's identification number, date of service(s), reason(s) why the denial should be reversed and copies of related documentation and/or applicable medical records to support appropriateness of the services rendered. Appeals and requests for reconsideration for medical necessity or authorization related issues should be sent to: Appeals Department, PO Box 31368, Tampa, FL 33631-3368. All disputes between the health plan and in-network and out-of-network providers shall be solely between such providers and the health plan. The member shall not be charged for any of the disputed costs