BlueButtonText-2.txt

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MYMEDICARE.GOV PERSONAL HEALTH INFORMATION
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**********CONFIDENTIAL***********
Produced by the Blue Button (v2.0)
02/04/2015 9:18 AM


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Demographic
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Source: MyMedicare.gov

Name: JOHN DOE
Date of Birth: 1/1/1910
Address Line 1: 123 ANY ROAD
Address Line 2: 
City: ANYTOWN
State: IN
Zip: 46250
Phone Number: 215-248-0684
Email: 
Part A Effective Date: 2/1/2014
Part B Effective Date: 2/1/2014

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Emergency Contact
--------------------------------

Source: Self-Entered

Contact Name: Billy Bigelow2
Address Type:Home
Address Line 1: 1234 Carnival Lane
Address Line 2: Lobster Bay, ME 11112
City: 
State: 
Zip: 11111
Relationship: Friend
Home Phone: 
Work Phone: 
Mobile Phone: 
Email Address: 

Contact Name: Enoch Snow
Address Type:Home
Address Line 1: 2345 Fish Head Cove
Address Line 2: Lobster Bay, ME 11112
City: 
State: 
Zip: 
Relationship: Friend
Home Phone: 
Work Phone: 
Mobile Phone: 
Email Address: 

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Self Reported Medical Conditions
--------------------------------

Source: Self-Entered

Condition Name: Allergies
Medical Condition Start Date: 1/29/2013
Medical Condition End Date: 

Condition Name: Arthritis
Medical Condition Start Date: 8/1/1960
Medical Condition End Date: 12/31/1980

Condition Name: Broken Wrist
Medical Condition Start Date: 2/6/1910
Medical Condition End Date: 2/6/2013

Condition Name: Other
Medical Condition Start Date: 2/1/2011
Medical Condition End Date: 

Condition Name: Other
Medical Condition Start Date: 2/28/2012
Medical Condition End Date: 

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Self Reported Allergies
--------------------------------

Source: Self-Entered

Allergy Name: Antibotic
Type: Drugs
Reaction: 
Severity: 
Diagnosed: 
Treatment: 
First Episode Date: 
Last Episode Date: 
Last Treatment Date: 
Comments: 

Allergy Name: Corn
Type: Food
Reaction: Blisters
Severity: Mild
Diagnosed: Yes
Treatment: Other
First Episode Date: 
Last Episode Date: 
Last Treatment Date: 
Comments: 

Allergy Name: Milk
Type: Food
Reaction: Anaphylaxis
Severity: Severe
Diagnosed: Yes
Treatment: Epinephrine (Epi-Pen)
First Episode Date: 3/21/1985
Last Episode Date: 3/31/2012
Last Treatment Date: 3/31/2012
Comments: 

Allergy Name: Other - other
Type: Other - other
Reaction: 
Severity: 
Diagnosed: 
Treatment: 
First Episode Date: 
Last Episode Date: 
Last Treatment Date: 
Comments: 

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Self Reported Implantable Device
--------------------------------

Source: Self-Entered

Device Name: COronary stent
Date Implanted: 11/27/2005

Device Name: Knee replacement
Date Implanted: 2/2/2014

Device Name: Pace maker
Date Implanted: 2/28/2012

Device Name: foot
Date Implanted: 9/9/1984

Device Name: hearing aid
Date Implanted: 1/1/2013

Device Name: nov20
Date Implanted: 12/15/2007

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Self Reported Immunizations
--------------------------------

Source: Self-Entered

Immunization Name: shingles
Date Administered:2/3/2010
Method: Injection
Were you vaccinated in the US: Yes
Comments: 
Booster 1 Date: 2/4/2011
Booster 2 Date: 4/6/2012
Booster 3 Date: 

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Self Reported Labs and Tests
--------------------------------

Source: Self-Entered

Test/Lab Type: Test
Date Taken: 1/2/2013
Administered by: Inova
Requesting Doctor: Dr. John Doe
Reason Test/Lab Requested: 
Results: 
Comments: 

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Self Reported Vital Statistics
--------------------------------

Source: Self-Entered

Vital Statistic Type: Glucose
Date: 2/7/2008
Time: 12:00 AM
Reading/Value: 322
Comments: 

Vital Statistic Type: Glucose
Date: 4/3/2009
Time: 12:02 PM
Reading/Value: 24
Comments: fwrqwrgreg

Vital Statistic Type: Glucose
Date: 5/14/2009
Time: 12:17 PM
Reading/Value: 134
Comments: rwrtrt

Vital Statistic Type: Otro - other
Date: 1/1/1939
Time: 12:00 AM
Reading/Value: other
Comments: 

Vital Statistic Type: Pulse
Date: 4/6/2013
Time: 12:00 AM
Reading/Value: 333
Comments: 

Vital Statistic Type: Pulse
Date: 3/2/2011
Time: 12:09 AM
Reading/Value: 80
Comments: wwqrgtrt

Vital Statistic Type: Temperature
Date: 6/5/2009
Time: 8:06 AM
Reading/Value: 100
Comments: fwqerqwr

Vital Statistic Type: Temperature
Date: 4/4/2008
Time: 9:02 AM
Reading/Value: 99
Comments: 

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Family Medical History
--------------------------------

Source: Self-Entered

Family Member: Daughter
Type: Maternal
DOB:1/1/1994
DOD: 
Age: 31
Type: Allergy
Description: Dyes
Type: Condition
Description: Diabetes, Type 2
Description: Skin Cancer

Family Member: Brother
Type: 
DOB:4/4/2012
DOD: 
Age: 
Type: Allergy
Description: Chemotherapy
Type: Condition
Description: Alzheimer's Disease

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Drugs
--------------------------------

Source: Self-Entered

Drug Name: Abacavir TAB 300MG
Supply: 60 Every 1 Month
Orig Drug Entry: Abacavir

Drug Name: Abilify Maintena INJ 300MG
Supply: 1 X Vial Every 1 Month
Orig Drug Entry: Abilify Maintena

Drug Name: Amlodipine Besylate TAB 10MG
Supply: 30 Every 1 Month
Orig Drug Entry: Amlodipine Besylate

Drug Name: Amlodipine Besylate TAB 2.5MG
Supply: 30 Every 1 Month
Orig Drug Entry: Amlodipine Besylate

Drug Name: Amlodipine Besylate TAB 5MG
Supply: 30 Every 1 Month
Orig Drug Entry: Amlodipine Besylate

Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 10-10MG
Supply: 30 Every 1 Month
Orig Drug Entry: Amlodipine Besylate/Atorvastatin Calcium

Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 10-20MG
Supply: 30 Every 1 Month
Orig Drug Entry: Amlodipine Besylate/Atorvastatin Calcium

Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 10-40MG
Supply: 30 Every 1 Month
Orig Drug Entry: Amlodipine Besylate/Atorvastatin Calcium

Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 10-80MG
Supply: 30 Every 1 Month
Orig Drug Entry: Amlodipine Besylate/Atorvastatin Calcium

Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 5-10MG
Supply: 30 Every 1 Month
Orig Drug Entry: Caduet

Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 5-80MG
Supply: 30 Every 1 Month
Orig Drug Entry: Amlodipine Besylate/Atorvastatin Calcium

Drug Name: Androgel Pump GEL 1.62%
Supply: 2 X 75GM Pump Bottle (sold in a package of 1 pump bottle) Every 1 Month
Orig Drug Entry: Androgel Pump

Drug Name: Drospirenone/Ethinyl Estradiol TAB 3-0.03MG
Supply: 28 Every 1 Month
Orig Drug Entry: Yasmin 28

Drug Name: Gabapentin CAP 100MG
Supply: 90 Every 1 Month
Orig Drug Entry: Gabapentin

Drug Name: Gabapentin SOL 250/5ML
Supply: 1 X 470ML Bottle Every 1 Month
Orig Drug Entry: Gabapentin

Drug Name: Jakafi TAB 10MG
Supply: 60 Every 1 Month
Orig Drug Entry: Jakafi

Drug Name: Losartan Potassium/Hydrochlorothiazide TAB 100-25
Supply: 30 Every 1 Month
Orig Drug Entry: Losartan Potassium/Hydrochlorothiazide

Drug Name: Montelukast Sodium TAB 10MG
Supply: 90 Every 3 Month
Orig Drug Entry: Montelukast Sodium

Drug Name: Omeprazole CAP 20MG
Supply: 30 Every 1 Month
Orig Drug Entry: Omeprazole

Drug Name: Rabavert INJ
Supply: 2 X Vial (sold in a package of 2) Every 12 Month
Orig Drug Entry: Rabavert

Drug Name: Tabloid TAB 40MG
Supply: 30 Every 1 Month
Orig Drug Entry: Tabloid

Drug Name: Vagifem TAB 10MCG
Supply: 8 Every 1 Month
Orig Drug Entry: Vagifem

Drug Name: Zafirlukast TAB 20MG
Supply: 60 Every 1 Month
Orig Drug Entry: Zafirlukast

Drug Name: Zaleplon CAP 10MG
Supply: 30 Every 1 Month
Orig Drug Entry: Zaleplon

Drug Name: Zaltrap INJ 100/4ML
Supply: 1 X 4ML Vial Every 1 Month
Orig Drug Entry: Zaltrap

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Preventive Services
--------------------------------

Source: MyMedicare.gov

Description: ABDOMINAL AORTIC ANEURYSM
Next Eligible Date: 2/1/2014
Last Date of Service: 

Description: CARDIOVASCULAR
Next Eligible Date: 2/1/2014
Last Date of Service: 

Description: PPV
Next Eligible Date: 2/1/2014
Last Date of Service: 

Description: PROSTATE
Next Eligible Date: 2/1/2014
Last Date of Service: 3/26/2012

Description: PSA
Next Eligible Date: 2/1/2014
Last Date of Service: 3/26/2012

Description: ANNUAL WELLNESS VISIT
Next Eligible Date: 2/1/2015
Last Date of Service: 

Description: ALCOHOL MISUSE SCREENING
Next Eligible Date: 
Last Date of Service: 

Description: CARDIOVASCULAR DISEASE (BEHAVIORAL THERAPY)
Next Eligible Date: 
Last Date of Service: 

Description: COLORECTAL
Next Eligible Date: 
Last Date of Service: 4/21/2011

Description: DEPRESSION SCREENING
Next Eligible Date: 
Last Date of Service: 

Description: DIABETES
Next Eligible Date: 
Last Date of Service: 5/21/2012

Description: HIGH INTENSITY BEHAVIORAL COUNSELING
Next Eligible Date: 
Last Date of Service: 

Description: OBESITY COUNSELING
Next Eligible Date: 
Last Date of Service: 

Description: PHYSICAL
Next Eligible Date: 
Last Date of Service: 

Description: SMOKING CESSATION (counseling to stop smoking)
Next Eligible Date: 
Last Date of Service: 

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Providers
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Source: Self-Entered

Provider Name: ANGELO SCOTTI
Provider Address: 180 WHITE RD LITTLE SILVER, NJ 07739
Type: Physician & Other Healthcare Professional
Specialty: 
Medicare Provider: Yes

Provider Name: DOUGLAS KNOX
Provider Address: 1104 E 23RD ST LAWRENCE, KS 66046
Type: Physician & Other Healthcare Professional
Specialty: 
Medicare Provider: Yes

Provider Name: SIAMAK RASSADI
Provider Address: 1331 N 7TH ST PHOENIX, AZ 85006
Type: Physician & Other Healthcare Professional
Specialty: Cardiac Electrophysiology,Cardiovascular Disease (Cardiology)
Medicare Provider: May Accept Medicare

Provider Name: PETER LEAVITT
Provider Address: 2965 NECONNERS AVE BEND, OR 97701
Type: Physician & Other Healthcare Professional
Specialty: 
Medicare Provider: Yes

Provider Name: JOHN KENNEDY
Provider Address: 8888 KEYSTONE XING INDIANAPOLIS, IN 46240
Type: Physician & Other Healthcare Professional
Specialty: 
Medicare Provider: Yes

Provider Name: REBECCA KELLY
Provider Address: 7250 CLEARVISTA DR INDIANAPOLIS, IN 46256
Type: Physician & Other Healthcare Professional
Specialty: Addiction Medicine
Medicare Provider: Yes

Provider Name: RILEY HOSPITAL - PEDS DIALYSIS
Provider Address: 705 RILEY HOSPITAL DRIVE INDIANAPOLIS, IN 46202
Type: Dialysis Facility
Specialty: 
Medicare Provider: Not Available

Provider Name: FMC - SHADELAND STATION
Provider Address: 7155 SHADELAND STATION STE 130 INDIANAPOLIS, IN 46256
Type: Dialysis Facility
Specialty: 
Medicare Provider: Not Available

Provider Name: IU HEALTH - HOME DIALYSIS
Provider Address: 8803 N. MERIDIAN ST., STE 150 INDIANAPOLIS, IN 46260
Type: Dialysis Facility
Specialty: 
Medicare Provider: Not Available

Provider Name: MESA VISTA OF BOULDER
Provider Address: 2121 MESA DRIVE BOULDER, CO 80304
Type: Nursing Home
Specialty: 
Medicare Provider: Yes

Provider Name: FAIRBANKS
Provider Address: 8102 CLEARVISTA PARKWAY INDIANAPOLIS, IN 46256
Type: Hospital
Specialty: 
Medicare Provider: Not Available

Provider Name: ALLIANCE HOME HEALTH SERVICES INC
Provider Address: 9615 N COLLEGE AVE INDIANAPOLIS, IN 46280
Type: Home Health
Specialty: 
Medicare Provider: Not Available

Provider Name: THE VIRGINIAN
Provider Address: 9229 ARLINGTON BLVD FAIRFAX, VA 22031
Type: Nursing Home
Specialty: 
Medicare Provider: Yes

Provider Name: KINDRED TRANSITIONAL CARE & REHAB-ALLISON POINTE
Provider Address: 5226 E 82ND ST INDIANAPOLIS, IN 46250
Type: Nursing Home
Specialty: 
Medicare Provider: Yes

Provider Name: INDIANA HEART HOSPITAL THE
Provider Address: 8075 N SHADELAND AVE INDIANAPOLIS, IN 46250
Type: Hospital
Specialty: 
Medicare Provider: Not Available

Provider Name: COMMUNITY HOSPITAL NORTH
Provider Address: 7150 CLEARVISTA DR INDIANAPOLIS, IN 46256
Type: Hospital
Specialty: 
Medicare Provider: Not Available

Provider Name: FORUM AT THE CROSSING
Provider Address: 8505 WOODFIELD CROSSING BLVD INDIANAPOLIS, IN 46240
Type: Nursing Home
Specialty: 
Medicare Provider: Not Available

Provider Name: BEAUMONT HOSPITAL, TROY
Provider Address: 44201 DEQUINDRE ROAD TROY, MI 48085
Type: Hospital
Specialty: 
Medicare Provider: Not Available

Provider Name: DAVITA - EAGLE HIGHLANDS
Provider Address: 6925 SHORE TERRACE INDIANAPOLIS, IN 46254
Type: Dialysis Facility
Specialty: 
Medicare Provider: Not Available

Provider Name: FMC - CARMEL
Provider Address: 12400 NORTH MERIDIAN ST., STE 200 CARMEL, IN 46032
Type: Dialysis Facility
Specialty: 
Medicare Provider: Not Available

Provider Name: DSI - NW INDIANAPOLIS RENAL CENTER
Provider Address: 6488 CORPORATE DRIVE INDIANAPOLIS, IN 46268
Type: Dialysis Facility
Specialty: 
Medicare Provider: Not Available

Provider Name: GEORGE WASHINGTON UNIV HOSPITAL
Provider Address: 900 23RD ST NW WASHINGTON, DC 20037
Type: Hospital
Specialty: 
Medicare Provider: Not Available

Provider Name: DAVITA - CARMEL HEALTH AND LIVING
Provider Address: 118 MEDICAL DRIVE, SUITE 114 CARMEL, IN 46032
Type: Dialysis Facility
Specialty: 
Medicare Provider: Not Available

Provider Name: FMC-INDIANAPOLIS MIDTOWN
Provider Address: 3007 DR ANDREW J BROWN AVENUE INDIANAPOLIS, IN 46205
Type: Dialysis Facility
Specialty: 
Medicare Provider: Not Available

Provider Name: MILLER'S SENIOR LIVING COMMUNITY
Provider Address: 8400 CLEARVISTA PL INDIANAPOLIS, IN 46256
Type: Nursing Home
Specialty: 
Medicare Provider: Yes

Provider Name: TEST QT
Provider Address:  COEBURN, VA 24230
Type: Home Health
Specialty: 
Medicare Provider: Not Available

Provider Name: ADVANCED HOME CARE, INC
Provider Address: 165 PLAZA ROAD, SUITE 20 WISE, VA 24293
Type: Home Health
Specialty: 
Medicare Provider: Not Available

Provider Name: TEST NHC QT
Provider Address:  0 24230
Type: Nursing Home
Specialty: 
Medicare Provider: Not Available

Provider Name: HERITAGE HALL WISE
Provider Address: 9434 COEBURN MOUNTAIN ROAD WISE, VA 24293
Type: Nursing Home
Specialty: 
Medicare Provider: Yes

Provider Name: QT JAN 15 TEST
Provider Address: 121 HOME STREET COEBURN, VA 24230
Type: Hospital
Specialty: 
Medicare Provider: Not Available

Provider Name: NORTON COMMUNITY HOSPITAL
Provider Address: 100  15TH ST NW NORTON, VA 24273
Type: Hospital
Specialty: 
Medicare Provider: Not Available

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Pharmacies
--------------------------------

Source: Self-Entered

Pharmacy Name: Castleton Integrative Health 8208 Allisonville Rd Indianapolis, IN 46250
Pharmacy Phone: 317-849-1222

Pharmacy Name: Costco Pharmacy Indianapolis, IN 462506110 East 86th Street Castleton, IN 46250
Pharmacy Phone: 317-558-1452

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Plans
--------------------------------

Source: MyMedicare.gov

Contract ID/Plan ID: S1111/801
Plan Period: 12/01/2012 - current
Plan Name: 
Marketing Name: 
Plan Address:     
Plan Type: 11 - Medicare Prescription Drug Plan

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Employer Subsidy
--------------------------------

Source: MyMedicare.gov


--------------------------------
Primary Insurance
--------------------------------

Source: MyMedicare.gov


--------------------------------
Other Insurance
--------------------------------

Source: MyMedicare.gov

MSP Type: 
Policy Number: 30002
Insurer Name: UNITEDHEALTH GROUP
Insurer Address: 601 OFFICE CENTER DRIVE FORT WASHINGTON, PA 19034
Effective Date: 10/01/1984
Termination Date: 

--------------------------------
Claim Summary
--------------------------------

Source: MyMedicare.gov

Claim Number: 11122233330000
Provider: No Information Available
Provider Billing Address:    
Service Start Date: 01/05/2014
Service End Date: 01/05/2014
Amount Charged: $135.00
Medicare Approved: $92.53
Provider Paid: $74.02
You May be Billed: $18.51
Claim Type: DME
Diagnosis Code 1: 32723
Diagnosis Code 2: 78051

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Claim Lines for Claim Number: 11122233330000
--------------------------------


Line number:  1
Date of Service From:  01/05/2014
Date of Service To:  01/05/2014
Procedure Code/Description:  E0601 - Continuous Positive Airway Pressure (Cpap) Device
Modifier 1/Description:  MS - Six Month Maintenance And Servicing Fee For Reasonable And Necessary Parts And Labor Which Are
Modifier 2/Description:  KX - Requirements Specified In The Medical Policy Have Been Met
Modifier 3/Description:  
Modifier 4/Description:  
Quantity Billed/Units:  1
Submitted Amount/Charges:  $135.00
Allowed Amount:  $92.53
Non-Covered:  $42.47
Place of Service/Description:  12 - Home
Type of Service/Description:  R - Rental of DME
Rendering Provider No:  DMEPROVIDR
Rendering Provider NPI:  

--------------------------------

--------------------------------

Claim Number: 11122233320000
Provider: No Information Available
Provider Billing Address:    
Service Start Date: 01/05/2014
Service End Date: 01/05/2014
Amount Charged: $135.00
Medicare Approved: $90.45
Provider Paid: $72.36
You May be Billed: $18.09
Claim Type: DME
Diagnosis Code 1: 32723
Diagnosis Code 2: 78051

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Claim Lines for Claim Number: 11122233320000
--------------------------------


Line number:  1
Date of Service From:  01/05/2014
Date of Service To:  01/05/2014
Procedure Code/Description:  E0601 - Continuous Positive Airway Pressure (Cpap) Device
Modifier 1/Description:  MS - Six Month Maintenance And Servicing Fee For Reasonable And Necessary Parts And Labor Which Are
Modifier 2/Description:  KX - Requirements Specified In The Medical Policy Have Been Met
Modifier 3/Description:  
Modifier 4/Description:  
Quantity Billed/Units:  1
Submitted Amount/Charges:  $135.00
Allowed Amount:  $90.45
Non-Covered:  $44.55
Place of Service/Description:  12 - Home
Type of Service/Description:  R - Rental of DME
Rendering Provider No:  DMEPROVIDR
Rendering Provider NPI:  

--------------------------------

--------------------------------

Claim Number: 2333444555100
Provider: No Information Available
Provider Billing Address:    
Service Start Date: 01/05/2014
Service End Date: 01/05/2014
Amount Charged: * Not Available *
Medicare Approved: * Not Available *
Provider Paid: * Not Available *
You May be Billed: * Not Available *
Claim Type: PartB
Diagnosis Code 1: 7392
Diagnosis Code 2: 7241
Diagnosis Code 3: 7393
Diagnosis Code 4: 7391

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Claim Lines for Claim Number: 2333444555100
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Line number:  1
Date of Service From:  01/05/2014
Date of Service To:  01/05/2014
Procedure Code/Description:  98941 - Chiropractic Manipulative Treatment, 3 To 4 Spinal Regions
Modifier 1/Description:  GA - Waiver Of Liability Statement Issued As Required By Payer Policy, Individual Case
Modifier 2/Description:  
Modifier 3/Description:  
Modifier 4/Description:  
Quantity Billed/Units:  1
Submitted Amount/Charges:  * Not Available *
Allowed Amount:  * Not Available *
Non-Covered:  * Not Available *
Place of Service/Description:  11 - Office
Type of Service/Description:  1 - Medical Care
Rendering Provider No:  PARTBPROV
Rendering Provider NPI:  

Line number:  2
Date of Service From:  01/05/2014
Date of Service To:  01/05/2014
Procedure Code/Description:  G0283 - Electrical Stimulation (Unattended), To One Or More Areas For Indication(S) Other Than Wound
Modifier 1/Description:  GY - Item Or Service Statutorily Excluded, Does Not Meet The Definition Of Any Medicare Benefit Or,
Modifier 2/Description:  
Modifier 3/Description:  
Modifier 4/Description:  
Quantity Billed/Units:  1
Submitted Amount/Charges:  * Not Available *
Allowed Amount:  * Not Available *
Non-Covered:  * Not Available *
Place of Service/Description:  11 - Office
Type of Service/Description:  1 - Medical Care
Rendering Provider No:  PARTBPROV
Rendering Provider NPI:  

--------------------------------

--------------------------------

Claim Number: 2333444555500
Provider: No Information Available
Provider Billing Address:    
Service Start Date: 01/05/2014
Service End Date: 01/05/2014
Amount Charged: $1,022.50
Medicare Approved: $782.33
Provider Paid: $625.86
You May be Billed: $156.47
Claim Type: PartB
Diagnosis Code 1: 70700

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Claim Lines for Claim Number: 2333444555500
--------------------------------


Line number:  1
Date of Service From:  01/05/2014
Date of Service To:  01/05/2014
Procedure Code/Description:  A0428 - Ambulance Service, Basic Life Support, Non-Emergency Transport, (Bls)
Modifier 1/Description:  RH
Modifier 2/Description:  
Modifier 3/Description:  
Modifier 4/Description:  
Quantity Billed/Units:  1
Submitted Amount/Charges:  $275.00
Allowed Amount:  $208.99
Non-Covered:  $66.01
Place of Service/Description:  41 - Ambulance - Land
Type of Service/Description:  9 - Other Medical Services
Rendering Provider No:  PARTBPROV
Rendering Provider NPI:  

Line number:  2
Date of Service From:  01/05/2014
Date of Service To:  01/05/2014
Procedure Code/Description:  A0428 - Ambulance Service, Basic Life Support, Non-Emergency Transport, (Bls)
Modifier 1/Description:  HR - Family/Couple With Client Present
Modifier 2/Description:  
Modifier 3/Description:  
Modifier 4/Description:  
Quantity Billed/Units:  1
Submitted Amount/Charges:  $275.00
Allowed Amount:  $208.99
Non-Covered:  $66.01
Place of Service/Description:  41 - Ambulance - Land
Type of Service/Description:  9 - Other Medical Services
Rendering Provider No:  PARTBPROV
Rendering Provider NPI:  

Line number:  3
Date of Service From:  01/05/2014
Date of Service To:  01/05/2014
Procedure Code/Description:  A0425 - Ground Mileage, Per Statute Mile
Modifier 1/Description:  RH
Modifier 2/Description:  
Modifier 3/Description:  
Modifier 4/Description:  
Quantity Billed/Units:  44
Submitted Amount/Charges:  $472.50
Allowed Amount:  $364.35
Non-Covered:  $108.15
Place of Service/Description:  41 - Ambulance - Land
Type of Service/Description:  9 - Other Medical Services
Rendering Provider No:  PARTBPROV
Rendering Provider NPI:  

--------------------------------

--------------------------------

Claim Number: 2333444555200
Provider: No Information Available
Provider Billing Address:    
Service Start Date: 01/05/2014
Service End Date: 01/05/2014
Amount Charged: * Not Available *
Medicare Approved: * Not Available *
Provider Paid: * Not Available *
You May be Billed: * Not Available *
Claim Type: PartB
Diagnosis Code 1: 2163

--------------------------------
Claim Lines for Claim Number: 2333444555200
--------------------------------


Line number:  1
Date of Service From:  01/05/2014
Date of Service To:  01/05/2014
Procedure Code/Description:  99213 - Established Patient Office Or Other Outpatient Visit, Typically 15 Minutes
Modifier 1/Description:  
Modifier 2/Description:  
Modifier 3/Description:  
Modifier 4/Description:  
Quantity Billed/Units:  1
Submitted Amount/Charges:  * Not Available *
Allowed Amount:  * Not Available *
Non-Covered:  * Not Available *
Place of Service/Description:  22 - Outpatient Hospital
Type of Service/Description:  1 - Medical Care
Rendering Provider No:  PARTBPROV
Rendering Provider NPI:  

--------------------------------

--------------------------------

Claim Number: 2333444555300
Provider: No Information Available
Provider Billing Address:    
Service Start Date: 01/05/2014
Service End Date: 01/05/2014
Amount Charged: * Not Available *
Medicare Approved: * Not Available *
Provider Paid: * Not Available *
You May be Billed: * Not Available *
Claim Type: PartB
Diagnosis Code 1: 28521
Diagnosis Code 2: 5854

--------------------------------
Claim Lines for Claim Number: 2333444555300
--------------------------------


Line number:  1
Date of Service From:  01/05/2014
Date of Service To:  01/05/2014
Procedure Code/Description:  J2916 - Injection, Sodium Ferric Gluconate Complex In Sucrose Injection, 12.5 Mg
Modifier 1/Description:  
Modifier 2/Description:  
Modifier 3/Description:  
Modifier 4/Description:  
Quantity Billed/Units:  10
Submitted Amount/Charges:  * Not Available *
Allowed Amount:  * Not Available *
Non-Covered:  * Not Available *
Place of Service/Description:  11 - Office
Type of Service/Description:  1 - Medical Care
Rendering Provider No:  PARTBPROV
Rendering Provider NPI:  

Line number:  2
Date of Service From:  01/05/2014
Date of Service To:  01/05/2014
Procedure Code/Description:  36000 - Insertion Of Needle Or Catheter Into A Vein
Modifier 1/Description:  
Modifier 2/Description:  
Modifier 3/Description:  
Modifier 4/Description:  
Quantity Billed/Units:  1
Submitted Amount/Charges:  * Not Available *
Allowed Amount:  * Not Available *
Non-Covered:  * Not Available *
Place of Service/Description:  11 - Office
Type of Service/Description:  2 - Surgery
Rendering Provider No:  PARTBPROV
Rendering Provider NPI:  

Line number:  3
Date of Service From:  01/05/2014
Date of Service To:  01/05/2014
Procedure Code/Description:  90765 - Intravenous Infusion, For Therapy, Prophylaxis, Or Diagnosis (Specify Substance Or Drug); In
Modifier 1/Description:  
Modifier 2/Description:  
Modifier 3/Description:  
Modifier 4/Description:  
Quantity Billed/Units:  1
Submitted Amount/Charges:  * Not Available *
Allowed Amount:  * Not Available *
Non-Covered:  * Not Available *
Place of Service/Description:  11 - Office
Type of Service/Description:  1 - Medical Care
Rendering Provider No:  PARTBPROV
Rendering Provider NPI:  

Line number:  4
Date of Service From:  01/05/2014
Date of Service To:  01/05/2014
Procedure Code/Description:  90775 - Therapeutic, Prophylactic Or Diagnostic Injection (Specify Substance Or Drug); Each Addition
Modifier 1/Description:  
Modifier 2/Description:  
Modifier 3/Description:  
Modifier 4/Description:  
Quantity Billed/Units:  1
Submitted Amount/Charges:  * Not Available *
Allowed Amount:  * Not Available *
Non-Covered:  * Not Available *
Place of Service/Description:  11 - Office
Type of Service/Description:  1 - Medical Care
Rendering Provider No:  PARTBPROV
Rendering Provider NPI:  

Line number:  5
Date of Service From:  01/05/2014
Date of Service To:  01/05/2014
Procedure Code/Description:  99211 - Established Patient Office Or Other Outpatient Visit, Typically 5 Minutes
Modifier 1/Description:  25 - Significant, Separately Identifiable Evaluation And Management Service By The Same Physician On
Modifier 2/Description:  
Modifier 3/Description:  
Modifier 4/Description:  
Quantity Billed/Units:  1
Submitted Amount/Charges:  * Not Available *
Allowed Amount:  * Not Available *
Non-Covered:  * Not Available *
Place of Service/Description:  11 - Office
Type of Service/Description:  1 - Medical Care
Rendering Provider No:  PARTBPROV
Rendering Provider NPI:  

--------------------------------

--------------------------------

Claim Number: 2333444555400
Provider: No Information Available
Provider Billing Address:    
Service Start Date: 01/05/2014
Service End Date: 01/05/2014
Amount Charged: $38.00
Medicare Approved: $9.38
Provider Paid: $7.50
You May be Billed: $1.88
Claim Type: PartB
Diagnosis Code 1: 9593
Diagnosis Code 2: E8889

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Claim Lines for Claim Number: 2333444555400
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Line number:  1
Date of Service From:  01/05/2014
Date of Service To:  01/05/2014
Procedure Code/Description:  73110 - X-Ray Of Wrist, Minimum Of 3 Views
Modifier 1/Description:  26 - Professional Component: Certain Procedures Are A Combination Of A Physician Component And A Tec
Modifier 2/Description:  
Modifier 3/Description:  
Modifier 4/Description:  
Quantity Billed/Units:  1
Submitted Amount/Charges:  $38.00
Allowed Amount:  $9.38
Non-Covered:  $28.62
Place of Service/Description:  22 - Outpatient Hospital
Type of Service/Description:  4 - Diagnostic x-ray
Rendering Provider No:  PARTBPROV
Rendering Provider NPI:  

Claim Number: 11122233310000
Provider: No Information Available
Provider Billing Address:    
Service Start Date: 01/05/2014
Service End Date: 01/05/2014
Amount Charged: $135.00
Medicare Approved: $90.45
Provider Paid: $72.36
You May be Billed: $18.09
Claim Type: DME
Diagnosis Code 1: 32723
Diagnosis Code 2: 78051

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Claim Lines for Claim Number: 11122233310000
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Line number:  1
Date of Service From:  01/05/2014
Date of Service To:  01/05/2014
Procedure Code/Description:  E0601 - Continuous Positive Airway Pressure (Cpap) Device
Modifier 1/Description:  MS - Six Month Maintenance And Servicing Fee For Reasonable And Necessary Parts And Labor Which Are
Modifier 2/Description:  KX - Requirements Specified In The Medical Policy Have Been Met
Modifier 3/Description:  
Modifier 4/Description:  
Quantity Billed/Units:  1
Submitted Amount/Charges:  $135.00
Allowed Amount:  $90.45
Non-Covered:  $44.55
Place of Service/Description:  12 - Home
Type of Service/Description:  R - Rental of DME
Rendering Provider No:  DMEPROVIDR
Rendering Provider NPI: