Optimum Payment Run #735 Remittance Advice · 2013. 6. 20. · PRACTICE 7016085 STATEMENT 735 DATE...
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Dear Faizal Mohammed Optometrists, Please find below a summary of the remittances attached to this document. The summary includes a breakdown of each medical aid and administration costs. Should any of the following be unclear, please do not hesitate to contact the Preferred Provider Call Centre for assistance All the transactions, on the attached remittance, marked with an asterisk (*) are NOT paid due to credits for that specific medical aid. Please refer to previous remittances. The transactions not marked are summarized by this coversheet and will be paid to your practice. FAIZAL MOHAMMED OPTOMETRISTS (7016085) P O BOX 2248 NEWCASTLE KWAZULU NATAL 2940 Preferred Provider Negotiators PO Box 12450 Centrahil 6006 Tel: (041) 506-5900 Fax: (041) 506-5750 Email: [email protected] Call Centre: 086 110 1477 STATEMENT 735 DATE 18/06/2013 Practice Payments Invoice Medical Patient Discount Settlement Paid Bestmed R5,031.00 R1,170.00 R3,861.00 R0.00 R150.00 R1,020.00 Bonitas R4,560.00 R3,730.00 R830.00 R0.00 R450.00 R3,280.00 Carecross Remedi R830.00 R830.00 R0.00 R0.00 R150.00 R680.00 Polmed R4,010.00 R4,010.00 R0.00 R0.00 R300.00 R3,710.00 Total R14,431.00 R9,740.00 R4,691.00 R0.00 R1,050.00 R8,690.00 Member Payments Invoice Medical Patient Discount Settlement Paid Total R0.00 R0.00 R0.00 R0.00 R0.00 R0.00
Transcript of Optimum Payment Run #735 Remittance Advice · 2013. 6. 20. · PRACTICE 7016085 STATEMENT 735 DATE...
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Dear Faizal Mohammed Optometrists, Please find below a summary of the remittances attached to this document. The summary includes abreakdown of each medical aid and administration costs. Should any of the following be unclear, please do not hesitate to contact the Preferred Provider Call Centre forassistance
All the transactions, on the attached remittance, marked with an asterisk (*) are NOT paid due to credits forthat specific medical aid. Please refer to previous remittances. The transactions not marked are summarizedby this coversheet and will be paid to your practice.
FAIZAL MOHAMMED OPTOMETRISTS (7016085)P O BOX 2248NEWCASTLEKWAZULU NATAL2940
Preferred Provider NegotiatorsPO Box 12450
Centrahil6006
Tel: (041) 506-5900Fax: (041) 506-5750
Email: [email protected] Centre: 086 110 1477
STATEMENT 735
DATE 18/06/2013
Practice Payments Invoice Medical Patient Discount Settlement Paid
Bestmed R5,031.00 R1,170.00 R3,861.00 R0.00 R150.00 R1,020.00
Bonitas R4,560.00 R3,730.00 R830.00 R0.00 R450.00 R3,280.00
Carecross Remedi R830.00 R830.00 R0.00 R0.00 R150.00 R680.00
Polmed R4,010.00 R4,010.00 R0.00 R0.00 R300.00 R3,710.00
Total R14,431.00 R9,740.00 R4,691.00 R0.00 R1,050.00 R8,690.00
Member Payments Invoice Medical Patient Discount Settlement Paid
Total R0.00 R0.00 R0.00 R0.00 R0.00 R0.00
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PRACTICE 7016085
STATEMENT 735
DATE 18/06/2013
#2045257 - THEMBELIHLE N MANGELE (REF# 18620 - Acc# 18620) 18/06/2013Additional Rejection Codes: 24, 25 Preferred Provider Transaction #4861642
Qty Code Description Rej # Invoice Medical Patient Discount Settlement Paid1 70001 EXAM R400.00 R400.00 R0.00 R0.00 R0.00 R400.001 61125 M/F 25 R570.00 R310.00 R260.00 R0.00 R0.00 R310.001 61125 M/F 25 R570.00 R310.00 R260.00 R0.00 R0.00 R310.001 61625 HARD COAT 24 R149.00 R0.00 R149.00 R0.00 R0.00 R0.001 61625 HARD COAT 24 R149.00 R0.00 R149.00 R0.00 R0.00 R0.001 61825 F/TINT 24 R209.00 R0.00 R209.00 R0.00 R0.00 R0.001 61825 F/ TINT 24 R209.00 R0.00 R209.00 R0.00 R0.00 R0.001 63725 SUMMIT CD 24 R600.00 R0.00 R600.00 R0.00 R0.00 R0.001 63725 SUMMIT CD 24 R600.00 R0.00 R600.00 R0.00 R0.00 R0.001 70405 FRAME 25 R1,575.00 R150.00 R1,425.00 R0.00 R150.00 R0.00
R5,031.00 R1,170.00 R3,861.00 R0.00 R150.00 R1,020.00
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PRACTICE 7016085
STATEMENT 735
DATE 18/06/2013
#27703730320 - NOMUSA CECILIA MATIWANE (REF# 28175 - Acc#28175) 13/06/2013
Additional Rejection Codes: None Preferred Provider Transaction #4858556
Qty Code Description Rej # Invoice Medical Patient Discount Settlement Paid1 70001 EXAM R400.00 R400.00 R0.00 R0.00 R0.00 R400.001 61121 LENS R140.00 R140.00 R0.00 R0.00 R0.00 R140.001 61121 LENS R140.00 R140.00 R0.00 R0.00 R0.00 R140.001 70406 FRAME R150.00 R150.00 R0.00 R0.00 R150.00 R0.00
R830.00 R830.00 R0.00 R0.00 R150.00 R680.00
#02023904473 - GERHARDUS P GELDENHUYS (REF# 11264 - Acc#11264) 13/06/2013
Additional Rejection Codes: None Preferred Provider Transaction #4858998
Qty Code Description Rej # Invoice Medical Patient Discount Settlement Paid1 61124 LENS R310.00 R310.00 R0.00 R0.00 R0.00 R310.001 61124 LENS R310.00 R310.00 R0.00 R0.00 R0.00 R310.001 70405 FRAME R600.00 R600.00 R0.00 R0.00 R150.00 R450.00
R1,220.00 R1,220.00 R0.00 R0.00 R150.00 R1,070.00
#02002815208 - KESHVEER SINGH (REF# 24984 - Acc# 24984) 15/06/2013Additional Rejection Codes: None Preferred Provider Transaction #4860692
Qty Code Description Rej # Invoice Medical Patient Discount Settlement Paid1 70001 EXAM R400.00 R400.00 R0.00 R0.00 R0.00 R400.001 61121 S/V R140.00 R140.00 R0.00 R0.00 R0.00 R140.001 61121 S/V R140.00 R140.00 R0.00 R0.00 R0.00 R140.001 70405 FRAME R600.00 R600.00 R0.00 R0.00 R150.00 R450.00
R1,280.00 R1,280.00 R0.00 R0.00 R150.00 R1,130.00
#27703179015 - THOMAS JAMES DREYER (REF# 25370 - Acc# 25370) 15/06/2013Additional Rejection Codes: 25 Preferred Provider Transaction #4860673
Qty Code Description Rej # Invoice Medical Patient Discount Settlement Paid1 70001 EXAM 25 R400.00 R0.00 R400.00 R0.00 R0.00 R0.001 61121 S/V 25 R140.00 R0.00 R140.00 R0.00 R0.00 R0.001 61121 S/V 25 R140.00 R0.00 R140.00 R0.00 R0.00 R0.001 70405 FRAME 25 R150.00 R0.00 R150.00 R0.00 R0.00 R0.00
R830.00 R0.00 R830.00 R0.00 R0.00 R0.00
#02024939100 - JAICHUND HARIPARSAD THULASEE (REF# 6490 - Acc#6490) 18/06/2013
Additional Rejection Codes: None Preferred Provider Transaction #4861601
Qty Code Description Rej # Invoice Medical Patient Discount Settlement Paid1 70001 EXAM R400.00 R400.00 R0.00 R0.00 R0.00 R400.00
R400.00 R400.00 R0.00 R0.00 R0.00 R400.00
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PRACTICE 7016085
STATEMENT 735
DATE 18/06/2013
#415780220 - AYESHA TIMOL (REF# 13560 - Acc# 13560) 13/06/2013Additional Rejection Codes: None Preferred Provider Transaction #4858587
Qty Code Description Rej # Invoice Medical Patient Discount Settlement Paid1 70001 EXAM R400.00 R400.00 R0.00 R0.00 R0.00 R400.001 61121 LENS R140.00 R140.00 R0.00 R0.00 R0.00 R140.001 61121 LENS R140.00 R140.00 R0.00 R0.00 R0.00 R140.001 70405 FRAME R150.00 R150.00 R0.00 R0.00 R150.00 R0.00
R830.00 R830.00 R0.00 R0.00 R150.00 R680.00
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PRACTICE 7016085
STATEMENT 735
DATE 18/06/2013
#000149717 - KENNETH MNQAYI (REF# 24592 - Acc# 24592) 13/06/2013Additional Rejection Codes: None Preferred Provider Transaction #4858613
Qty Code Description Rej # Invoice Medical Patient Discount Settlement Paid1 70001 EXAM R400.00 R400.00 R0.00 R0.00 R0.00 R400.001 61125 LENS R570.00 R570.00 R0.00 R0.00 R0.00 R570.001 61125 LENS R570.00 R570.00 R0.00 R0.00 R0.00 R570.001 70405 FRAME R900.00 R900.00 R0.00 R0.00 R150.00 R750.00
R2,440.00 R2,440.00 R0.00 R0.00 R150.00 R2,290.00
#000126705 - ZANELE HADEBE (REF# 29224 - Acc# 29224) 13/06/2013Additional Rejection Codes: None Preferred Provider Transaction #4858573
Qty Code Description Rej # Invoice Medical Patient Discount Settlement Paid1 70001 EXAM R400.00 R400.00 R0.00 R0.00 R0.00 R400.001 61121 LENS R140.00 R140.00 R0.00 R0.00 R0.00 R140.001 61121 LENS R140.00 R140.00 R0.00 R0.00 R0.00 R140.001 70405 FRAME R890.00 R890.00 R0.00 R0.00 R150.00 R740.00
R1,570.00 R1,570.00 R0.00 R0.00 R150.00 R1,420.00
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PRACTICE 7016085
STATEMENT 735
DATE 18/06/2013
Herewith please find a list of rejection codes and their descriptions pertaining to the above mentioned claims
Code Description
24 Item / service is not covered by the insured benefit
25 Benefit Exceeded / Exhausted
