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Claim Detail   DME Reconciliation
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Rx: 2122951 Fill Date: 08/08/2021 Refill: 2 Payer Status: Processed-S
Recon Status:    Reconciled
Amt Submitted: 247.82 Print 1500 Primary
Disp Fee Submitted: 0.00 Print EOB
EOB Max Allow: 247.82 Request Help  
EOB Disp Fee Max Allow: 0.00   Store: FRYS PRESCRIPTION PHCY
Unpaid from Primary: 48.56 Action: Payer: Texas Medicaid
Disp Fee Max Allow: 0.00
Reset Status		 Cross: N/A
Amt Expected: 48.56 Batch: C1090230004642021
Product Paid: 48.56 Patient: RANGEL
Disp Fee Paid: 0.00 Group:
Total Paid: 48.56 EZID: 13672987
Copay: 0.00 Remit: 4355092
Disp Fee CoPay: 0.00 Check: 053340819
Deductible: 0.00 Posted: 10/4/2021 12:14:42 PM
Non-Patient Bal: 0.00    
Total Balance: 0.00
    
     
Product Detail
HCPCSDescriptionModifierPaidQty
B4152Enteral Formula, Nutritionally Complete, Calorically Dense (equal To Or Greater Than 1.5 Kcal/ml) With Intact Nutrients, Includes Proteins, Fats, Carbohydrates, Vitamins And Minerals, May Include Fiber, Administered Through An Enteral Feeding Tube, 100 Cal  48.56 639
Claim Adjustments
HCPCSAmountPaidDescription
B4152 199.26 The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)
Claim Payment Remarks
None for this transaction
Other 835 Transactions for this Rx (all refills)
ClaimRemit IDRxFill DateSubmitPaidPayer StatusPayee Status
14206629475731421229516/8/2022 202.44 202.44 Processed-P Fwd Processed-P Bill 2nd
14221117477424221229516/8/2022 51.12 51.12 Processed-S Reconciled
14187201473801021229515/8/2022 202.44 202.44 Processed-P Fwd Processed-P Bill 2nd
14198708474817421229515/8/2022 51.12 51.12 Processed-S Reconciled
14127421467667621229514/8/2022 202.44 202.44 Processed-P Fwd Processed-P Bill 2nd
14149005469462321229514/8/2022 51.12 51.12 Processed-S Reconciled
14085685464331921229513/8/2022 204.48 204.48 Processed-P Fwd Processed-P Bill 2nd
14037782460180621229512/8/2022 204.48 204.48 Processed-P Fwd Processed-P Bill 2nd
14056855462024121229512/8/2022 51.12 51.12 Processed-S Reconciled
14007235457161521229511/8/2022 204.48 204.48 Processed-P Fwd Processed-P Bill 2nd
14022692458554221229511/8/2022 51.12 51.12 Processed-S Reconciled
139363434513097212295112/8/2021 194.26 194.26 Processed-P Fwd Processed-P Bill 2nd
139816364547305212295112/8/2021 48.56 48.56 Processed-S Reconciled
139025394493117212295111/8/2021 194.26 48.56 Processed-S Accepted variance batch
138685694471417212295111/8/2021 194.26 194.26 Processed-P Fwd Processed-P Bill 2nd
138490634460140212295110/8/2021 194.26 194.26 Processed-P Fwd Processed-P Bill 2nd
138694334472326212295110/8/2021 194.26 48.56 Processed-S Accepted variance batch
13698425437304521229519/8/2021 194.26 194.26 Processed-P Fwd Processed-P Bill 2nd
13741112440407521229519/8/2021 194.26 48.56 Processed-S Accepted variance batch
13640069432740221229518/8/2021 194.26 194.26 Processed-P Fwd Processed-P Bill 2nd
13592690428975221229517/8/2021 194.26 194.26 Processed-P Fwd Processed-P Bill 2nd
13631492431986421229517/8/2021 48.56 48.56 Processed-S Reconciled
EZDataWarehouse Prescription History (all refills)
  ReconciledRXRefillFill DateStatPay SeqCarrierClaim
 1 2122951126/8/2022A202DME2ND 51.12
 2 2122951126/8/2022A21DMEC 202.44
 3 2122951115/8/2022A202DME2ND 51.12
 4 2122951115/8/2022A21DMEC 202.44
 5 2122951115/8/2022C21DMEC 255.60
 6 2122951104/8/2022A202DME2ND 51.12
 7 2122951104/8/2022A21DMEC 202.44
 8 2122951104/8/2022C21DMEC 255.60
 9 212295193/8/2022A202DME2ND 51.12
 10 212295193/8/2022A21DMEC 204.48
 11 212295193/8/2022C21DMEC 255.60
 12 212295182/8/2022C202DME2ND 51.12
 13 212295182/8/2022C21DMEC 204.48
 14 212295171/8/2022A202DME2ND 51.12
 15 212295171/8/2022A21DMEC 204.48
 16 212295171/8/2022C21DMEC 255.60
 17 2122951612/8/2021A202DME2ND 48.56
 18 2122951612/8/2021A21DMEC 194.26
 19 2122951612/8/20212 1DMEC 242.82
 20 2122951511/8/2021A202DME2ND 48.56
 2113902539 2122951511/8/2021A21DMEC 194.26
 22 2122951511/8/20212 1DMEC 242.82
 23 2122951410/8/2021A202DME2ND 48.56
 2413869433 2122951410/8/2021A21DMEC 194.26
 25 2122951410/8/20212 1DMEC 242.82
 26 212295139/8/2021C202DME2ND 48.56
 2713741112 212295139/8/2021C21DMEC 194.26
*28 212295128/8/2021A202DME2ND 48.56
 29 212295128/8/2021A21DMEC 194.26
 30 212295128/8/20212 1DMEC 242.82
 31 212295117/8/2021A202DME2ND 48.56
 32 212295117/8/2021A21DMEC 194.26
 33 212295117/8/2021C21DMEC 242.82
*Current DW claim chosen to reconcile against
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