LOGAN ORAL SURGERY

3125 N MAIN ST STE 103

NORTH LOGAN, UT 843411547

PROVIDER REMITTANCE ADVICE

Draft: E1743744

Claim: 220919200274 Account: 7907 Subscriber ID: 1741000045299

Date Processed: 01/13/23 Original Claim: Reversal Claim:
Subscriber: HOUSE, BRIAN R Patient: HOUSE, SEAN M Provider: MATSON, SCOTT
Adjustment/
Procedure Service Service Billed Remark
Code Date From Date To Amount Allowed Deductible Coinsurance Copay Adjustment Codes Paid Notes
7220 04/28/22 04/28/22 240.00 0.00 0.00 0.00 0.00 58.95 CO-45 0.00 92
181.05 PR-96
N30
Claim Totals 240.00 0.00 0.00 0.00 0.00 240.00 0.00
Notes:
92-Services Have Been Determined To Be Ineligible As Per Review By Pehp Dental Review.

Claim: 221018200321 Account: 19975 Subscriber ID: 1741000336902

Date Processed: 01/13/23 Original Claim: Reversal Claim:
Subscriber: JOHNSON, SARAH L Patient: JOHNSON, JONATHAN J Provider: MATSON, SCOTT
Adjustment/
Procedure Service Service Billed Remark
Code Date From Date To Amount Allowed Deductible Coinsurance Copay Adjustment Codes Paid Notes
0140 08/24/22 08/24/22 60.00 39.41 0.00 5.47 0.00 23.00 OA-23 31.53
Claim Totals 60.00 39.41 0.00 5.47 0.00 23.00 31.53
Notes:
31.53 Was Applied To The Insured's Yearly Dental Maximum Limit
Total Accumulation To The Insured's Yearly Dental Maximum Limit Is 306.59

Claim: 221020200136 Account: 19820 Subscriber ID: 1741000858365

Date Processed: 01/13/23 Original Claim: Reversal Claim:
Subscriber: ENGLAND, JASON A Patient: ENGLAND, MICHAEL A Provider: MATSON, SCOTT
Adjustment/
Procedure Service Service Billed Remark
Code Date From Date To Amount Allowed Deductible Coinsurance Copay Adjustment Codes Paid Notes

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 Adjustment/
Procedure Service Service Billed Remark
Code Date From Date To Amount Allowed Deductible Coinsurance Copay Adjustment Codes Paid Notes
0140 07/20/22 07/20/22 60.00 0.00 0.00 0.00 0.00 60.00 CO-163 0.00 50
N479
Claim Totals 60.00 0.00 0.00 0.00 0.00 60.00 0.00
Notes:
50-We Must Have An Explanation Of Benefits From Your Primary Carrier We Are Pending Payment Of This Bill Until This Info Is Received Please Submit A Copy Of This Information To Pehp

Claim: 221020200137 Account: 19815 Subscriber ID: 1741000858365

Date Processed: 01/13/23 Original Claim: Reversal Claim:
Subscriber: ENGLAND, JASON A Patient: ENGLAND, KATELYN R Provider: MATSON, SCOTT
Adjustment/
Procedure Service Service Billed Remark
Code Date From Date To Amount Allowed Deductible Coinsurance Copay Adjustment Codes Paid Notes
7240 10/06/22 10/06/22 350.00 0.00 0.00 0.00 0.00 350.00 CO-163 0.00 50
N479
7240 10/06/22 10/06/22 350.00 0.00 0.00 0.00 0.00 350.00 CO-163 0.00 50
N479
7240 10/06/22 10/06/22 350.00 0.00 0.00 0.00 0.00 350.00 CO-163 0.00 50
N479
7240 10/06/22 10/06/22 350.00 0.00 0.00 0.00 0.00 350.00 CO-163 0.00 50
N479
9222 10/06/22 10/06/22 175.00 0.00 0.00 0.00 0.00 175.00 CO-163 0.00 50
N479
9223 10/06/22 10/06/22 175.00 0.00 0.00 0.00 0.00 175.00 CO-163 0.00 50
N479
Claim Totals 1750.00 0.00 0.00 0.00 0.00 1750.00 0.00
Notes:
50-We Must Have An Explanation Of Benefits From Your Primary Carrier We Are Pending Payment Of This Bill Until This Info Is Received Please Submit A Copy Of This Information To Pehp

Claim: 221020200138 Account: 14661 Subscriber ID: 1741000858365

Date Processed: 01/13/23 Original Claim: Reversal Claim:
Subscriber: ENGLAND, JASON A Patient: LINDSAY, KORTNI RAY Provider: MATSON, SCOTT
Adjustment/
Procedure Service Service Billed Remark
Code Date From Date To Amount Allowed Deductible Coinsurance Copay Adjustment Codes Paid Notes
7240 10/06/22 10/06/22 350.00 0.00 0.00 0.00 0.00 350.00 CO-163 0.00 50
N479
7240 10/06/22 10/06/22 350.00 0.00 0.00 0.00 0.00 350.00 CO-163 0.00 50
N479
7240 10/06/22 10/06/22 350.00 0.00 0.00 0.00 0.00 350.00 CO-163 0.00 50
N479
9222 10/06/22 10/06/22 175.00 0.00 0.00 0.00 0.00 175.00 CO-163 0.00 50
N479
9223 10/06/22 10/06/22 175.00 0.00 0.00 0.00 0.00 175.00 CO-163 0.00 50
N479
Claim Totals 1400.00 0.00 0.00 0.00 0.00 1400.00 0.00

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Notes:
50-We Must Have An Explanation Of Benefits From Your Primary Carrier We Are Pending Payment Of This Bill Until This Info Is Received Please Submit A Copy Of This Information To Pehp

Claim: 221020200139 Account: 20246 Subscriber ID: 1741000858365

Date Processed: 01/13/23 Original Claim: Reversal Claim:
Subscriber: ENGLAND, JASON A Patient: LINDSAY, BAYLEE J Provider: MATSON, SCOTT
Adjustment/
Procedure Service Service Billed Remark
Code Date From Date To Amount Allowed Deductible Coinsurance Copay Adjustment Codes Paid Notes
7240 10/06/22 10/06/22 350.00 0.00 0.00 0.00 0.00 350.00 CO-163 0.00 50
N479
7240 10/06/22 10/06/22 350.00 0.00 0.00 0.00 0.00 350.00 CO-163 0.00 50
N479
7240 10/06/22 10/06/22 350.00 0.00 0.00 0.00 0.00 350.00 CO-163 0.00 50
N479
7240 10/06/22 10/06/22 350.00 0.00 0.00 0.00 0.00 350.00 CO-163 0.00 50
N479
9222 10/06/22 10/06/22 175.00 0.00 0.00 0.00 0.00 175.00 CO-163 0.00 50
N479
9223 10/06/22 10/06/22 175.00 0.00 0.00 0.00 0.00 175.00 CO-163 0.00 50
N479
0140 10/06/22 10/06/22 60.00 0.00 0.00 0.00 0.00 60.00 CO-163 0.00 50
N479
Claim Totals 1810.00 0.00 0.00 0.00 0.00 1810.00 0.00
Notes:
50-We Must Have An Explanation Of Benefits From Your Primary Carrier We Are Pending Payment Of This Bill Until This Info Is Received Please Submit A Copy Of This Information To Pehp

Claim: 221027200186 Account: 12879 Subscriber ID: 1741000394063

Date Processed: 01/13/23 Original Claim: Reversal Claim:
Subscriber: BOHMAN, JARED Patient: BOHMAN, JARED Provider: MATSON, SCOTT
Adjustment/
Procedure Service Service Billed Remark
Code Date From Date To Amount Allowed Deductible Coinsurance Copay Adjustment Codes Paid Notes
7286 10/20/22 10/20/22 400.00 229.46 0.00 45.89 0.00 170.54 CO-45 183.57
Claim Totals 400.00 229.46 0.00 45.89 0.00 170.54 183.57
Notes:
183.57 Was Applied To The Insured's Yearly Dental Maximum Limit
Total Accumulation To The Insured's Yearly Dental Maximum Limit Is 809.75

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Adjustment/Remark Code Descriptions
45-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)
96-Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
23-The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)
163-Attachment/other documentation referenced on the claim was not received.
N30-Patient ineligible for this service.
N479-Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).

Remittance Totals Billed Amount Allowed Deductible Coinsurance Copay Adjustment Paid
Total Paid on draft# E1743744 5720.00 268.87 0.00 51.36 0.00 5453.54 215.10

If you send claims electronically to Medicare, you no longer need to send them to PEHP. PEHP is now a COBA stakeholder processing Medicare crossover claims. For more information about
PEHP providers and benefits, visit our website at [Link].

(Español): Para obtener asistencia en Español, llame al (801-366-7555 or 800-765-7347). 4