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CalOptima Direct

CARRIER
PO Box 11037
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 Orange, CA 92856
PICA Page 01 of 01 PICA ▼
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1) ▲
HEALTH PLAN BLK LUNG
(Medicare#) (Medicaid#) (ID#/DoD#) (Member ID#) X (ID#) (ID#) (ID#) 97977950d
2. PATIENT'S NAME (Last Name, First Name, Middle Initial 3. PATIENT'S BIRTH DATE 4. INSURED'S NAME (Last Name, First Name, Middle Initial)
MM DD YY SEX
Anaya Angie 09 25 1995 M F
X Anaya Angie
5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street)

2170 S Habor Blvd Apt 229 Self X Spouse Child Other 2170 S Habor Blvd Apt 229
CITY STATE 8. RESERVED FOR NUCC USE CITY STATE

PATIENT AND INSURED INFORMATION

Anaheim CA Anaheim CA
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)

92802 (657 ) 944 1447 92802 ( 657 ) 944 1447

9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH
MM DD YY SEX
YES
X NO 09 25 95 M F
X
b. RESERVED FOR NUCC USE b. AUTO ACCIDENT? PLACE (State) b. OTHER CLAIM ID (Designated by NUCC)

YES X NO
c. RESERVED FOR NUCC USE c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME

YES X NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES (Designated by NUCC) d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

YES NO If yes,, complete items 9, 9a and 9d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below.
below.

SIGNED Signature On File DATE 06/27/23 SIGNED SIGNATURE ON FILE ▼

14. DATE OF CURRENT ILLNESS ,INJURY or PREGNANCY (LMP) 15. OTHER DATE 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION ▲
MM DD YY MM DD YY MM DD YY MM DD YY
QUAL.
QUAL. FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM DD YY MM DD YY
DN Ahad George 17b. NPI
1932421559 FROM 06 27 23 TO
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB? $ CHARGES
Corrected Claim
YES X NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. Relate A-L to service line below (24E) ICD Ind. 0 22. RESUBMISSION
CODE ORIGINAL REF. NO.
A. Z302 B. Z641 C. O34211 D. Z3A39 7 231927189100
242401431000
23. PRIOR AUTHORIZATION NUMBER
E. Z370 F. G. H.
I. J. K. L.
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
From To DIAGNOSIS DAYS EPSDT

PHYSICIAN OR SUPPLIER INFORM ATION

PLACE OF (Explain Unusual Circumstances) ID. RENDERING
OR Family
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS Plan QUAL. PROVIDER ID. #

1 06 27 23 06 27 23 21 58611 51 AB 160 00 1 NPI 1932421559

2 NPI

3 NPI

4 NPI

5 NPI

6 NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. Revd for NUCC use
(For govt. claims, see back)
461026958 X 007800041339 X YES NO $ 160 00 $ 160 00
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH# ( 714 ) 635-4424
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
Orange County Global Medical Center George Ahad MD Inc
apply to this bill and are made a part thereof.) 1001 N Tustin Ave 947 S Anaheim Blvd Suite 240
AHAD, GEORGE Santa Ana CA 92705-3502 Anaheim CA 92805-5584
07/09/23
SIGNED DATE
a.
NPI
1982697678 b. a.
NPI
1528319449 b.
461026958 ▼
NUCC Instruction Manual available at: www.nucc.org PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12)
 Claim #: 242401431000
CIN 97977950D Date of Service 6/27/2023 Check # 3003370
Date Received 8/23/2024 Date Paid 8/28/2024 Status Finalized

MEMBER INFO PROVIDERS

Member Name ANGIE ANAYA Payment Ahad, George
CIN 97977950D Provider ID 00A111064
Date of Birth 09/25/1995 (Age 29) Address 947 S Anaheim Blvd Suite 240
Gender Female Anaheim, CA 92805

Spoken Language English Phone 714-774-8870

Written Language English Fax 714-635-5704
Health Network CalOptima Community Network

Line of Business Medi-Cal Service Ahad, George

PCP AltaMed Medical Group-Garden Grove Provider ID 00A111064
Eligibility Date 7/1/2020-Current Address 947 S Anaheim Blvd Suite 240
Address ********** Anaheim, CA 92805

ANAHEIM, CA 92802 Phone 714-635-4424

Phone Fax 887-325-2198
Email **********

SERVICES
Service Period Code Modifiers Billed Qty Billed Amt Payable

6/27/2023-6/27/2023 58611 AG 1 $160.00 $0.00

The payable amount may not reflect the final claims payment. Please review the Remittance Advice (RA) for final claims detail.

Service Code Service Description

58611 LIG/TRNSXJ FALOPIAN TUBE CESAREAN DEL/ABDML SURG

DIAGNOSIS
Diagnoses Code Diagnoses Description

Z30.2 Encounter for sterilization

Z64.1 Problems related to multiparity
O34.211 MATERNAL CARE LW TRANS SCAR PREV CESAREAN DEL
Z3A.39 39 weeks gestation of pregnancy
Z37.0 Single live birth

EXPLANATION OF BENEFITS
EOB
Code Qty Date Code Billed Allowed Disallowed Coinsurance Copay Deductible Paid

58611 1 6/27/2023 - $160.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00

TOTAL : $160.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00

INTEREST PAID: $0.00

Unless otherwise indicated, your claim has been paid at contracted rates. Under the Knox-Keene Act of the State of California, the
patient to whom the services were rendered is not liable and cannot be billed for any portion of this bill except for copayments and
non-benefit items.