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Claim Detail   DME Reconciliation
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Rx: 2122951 Fill Date: 12/08/2021 Refill: 6 Payer Status: Processed-P Fwd
Recon Status:    Processed-P Bill 2nd
Amt Submitted: 247.82 Print 1500 Primary
Disp Fee Submitted: 0.00 Print EOB
EOB Max Allow: 242.82 Request Help  
EOB Disp Fee Max Allow: 0.00   Store: FRYS PRESCRIPTION PHCY
FDS Max Allow: 242.82 Action: Payer: Region C
Disp Fee Max Allow: 0.00
Reset Status		 Cross: TX HEALTH & HUMAN SERVICES COMMI
Amt Expected: 194.26 Batch: C1091140003042021
Product Paid: 194.26 Patient: RANGEL
Disp Fee Paid: 0.00 Group: MEDICAID
Total Paid: 194.26 EZID: 13936343
Copay: 48.56 Remit: 4513097
Disp Fee CoPay: 0.00 Check: 042000013645006
Deductible: 0.00 Posted: 1/18/2022 9:27:17 AM
To Secondary: 48.56    
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 Cal72.32 194.26 639
Claim Adjustments
HCPCSAmountPaidDescription
B4152 5.00 Charge exceeds fee schedule/maximum allowable or contracted/legislated 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)
B4152 48.56 Coinsurance Amount
Claim Payment Remarks
Description
Alert: No coinsurance may be collected as patient is a Medicaid/Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance.
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
139816364547305212295112/8/2021 48.56 48.56 Processed-S Reconciled
138685694471417212295111/8/2021 194.26 194.26 Processed-P Fwd Processed-P Bill 2nd
139025394493117212295111/8/2021 194.26 48.56 Processed-S Accepted variance batch
138694334472326212295110/8/2021 194.26 48.56 Processed-S Accepted variance batch
138490634460140212295110/8/2021 194.26 194.26 Processed-P Fwd Processed-P Bill 2nd
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
13672987435509221229518/8/2021 48.56 48.56 Processed-S Reconciled
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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