34
Sample Explanation of Benefits Statement
Bravo Health Texas, Inc. P8790028002
7551 Callaghan Road, Suite 310 San Antonio, TX 78229
Forwarding Service Requested
TEST
1 0. 3840 SP 0.370 Date: 06/29/2006
liiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillillillI
Vendor 9370
Get Well Medical Care, P.A. Voucher Number: 64687
PO BOX 3012 Check ID: P6041
San Antonio, TX 78229-1234 Check Number: 058522
Explanation of Payment
Member ID: 449999999 Option: BSEL Provider Acct. No. AB-458518
Member Name: SMITH, JOHN Claim Number: 205062201700120 Provider Name: William Physician
From Date of
Service
To Date of
Service
Service
Code
Billed
Amount
Allowed
Amount
Copay
Coinsurance
Deductible Adjustment Interest Payment Reason
Code
05/13/2008
05/13/2008 99213 253.00 94.49 25.00 0.00 0.00 0.00 69.49
253.00 94.49 25.00 0.00 0.00 0.00 69.49 Claims Totals
Vendor Totals
253.00 94.49 25.00 0.00 0.00 0.00 69.49
Remark Code Explanation
***IF APPLICABLE IMPORTANT INFORMATION REGARDING APPEAL RIGHTS IS ATTACHED***
Sample Bravo Health Payment Check
Bravo Health Texas, Inc. 65-320 CHECK NO.: 0058522
7551 Callaghan Road, Suite 310
San Antonio, TX 78229
AMOUNT
*******69.49
PAY Sixty Nine & 49/100 dollars
TO THE Get Well Medical Care, P.A.
ORDER OF PO BOX 3012
San Antonio, TX 78229-1234
Wachovia Bank N.A.
Philadel
hia, PA 19102
