▲

ZBlue Cross CM PromiseCare/HCMG

CARRIER
1545 W Florida Ave
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 Hemet, CA 92543-3814
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#) XEH910811322
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
Carroll Melinda 03 01 1995 M F
X Carroll Melinda
5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street)

1084 Garrett Way Self X Spouse Child Other 1084 Garrett Way
CITY STATE 8. RESERVED FOR NUCC USE CITY STATE

PATIENT AND INSURED INFORMATION

San Jacinto CA San Jacinto CA
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)

92583 (562 ) 241 0997 92583 ( 562 ) 241 0997

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 03 01 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 09/25/24 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 Urso MaryJo 17b. NPI
1386642783 FROM TO
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB? $ CHARGES

RECONSIDERATION 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. Z3401 B. Z113 C.Z118 D. Z3A10 7 20241004921022300443
23. PRIOR AUTHORIZATION NUMBER
E. Z8279 F. Z531 G.Z3687 H. Z3682
I. J. K. L. 20240918720000200035
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 09 25 24 09 25 24 11 99215 25 ABCD 380 00 1 NPI 1386642783

2 09 25 24 09 25 24 11 81002 D 15 00 1 NPI 1386642783

3 09 25 24 09 25 24 11 99000 BC 20 00 1 NPI 1386642783

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)
852151199 X 006000145427 X YES NO $ 415 00 $ 415 00
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO PH# ( 951 ) 652-8700
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
Seven Star OB/GYN - Hemet Seven Star OB/GYN
apply to this bill and are made a part thereof.) 1225 E Latham Ave Ste A 41889 E Florida Ave
URSO, MARYJO Hemet CA 92543-4423 Hemet CA 92544-5042
09/30/24
SIGNED DATE
a.
NPI
1093318172 b. a.
NPI
1093318172 b.
852151199 ▼
NUCC Instruction Manual available at: www.nucc.org PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12)
11/15/24, 1:26 PM KMSM Provider Portal

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Claim/Encounter Details

* Claims with a status of "IN REVIEW" or "PENDING", may change in the adjudication process. This is not a guarantee of payment.

Status Information
IPA Name: Hemet Community Medical Group
Claim #: 20241004921022300443 Status: FINALIZED
Authorization #: Check:
Date Received: 2024-10-03 Date Paid: 2024-11-04
Vendor: 852151199L
Member Information
Member Name: CARROLL, MELINDA J. Sex: FEMALE
DOB: 03/01/1995 Age: 29.67
Health Plan: BLUE SHIELD-COMM POS ACCESS+
Diagnosis: Z3401 - ENCNTR NRML FIRST PREG,FIRST TRIMES

Provider Information
Provider Name: URSO, MARYJO
Provider ID: 20A8265 Specialty: OBSTETRICS & GYNECOLOGY
Patient Acct. #: 006000145427 Cross Ref ID:
(951) 929-8400 Fax: (951) 929-8411
Place of Service: OFFICE
Process Status
Services
Date Code Description Modif Qty Contract Co-pay Billed Withold Adjust Net
2024-09-25 99215 OFFICE O/P EST HI 40 MIN 25 1 $169.52 $0.00 $380.00 $0.00 $169.52 $0.00
UD203-INCLUDED IN
GLOBAL/PER DIEM
2024-09-25 81002 URINALYSIS NONAUTO W/O 1 $3.13 $0.00 $15.00 $0.00 $3.13 $0.00
SCOPE
UD203-INCLUDED IN
GLOBAL/PER DIEM
2024-09-25 99000 SPECIMEN HANDLING 1 $0.01 $0.00 $20.00 $0.00 $0.01 $0.00
OFFICE-LAB
UD200-NON-PAYABLE
SERVICE
TOTAL: $172.66 $0.00 $415.00 $0.00 $172.66 $0.00

https://ace2.kmsm.com/claim_Details.aspx?g=e6a1eb94-9df8-405a-b8d0-bd6144655ee6&pCLAIMNO=20241004921022300443&pDBKEY=HCMG&P… 1/1
11/25/24, 8:25 AM KMSM Provider Portal

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Claim/Encounter Details

* Claims with a status of "IN REVIEW" or "PENDING", may change in the adjudication process. This is not a guarantee of payment.

Status Information
IPA Name: Hemet Community Medical Group
Claim #: 20240920921022300005 Status: FINALIZED
Authorization #: Check: 369812
Date Received: 2024-09-19 Date Paid: 2024-11-04
Vendor: 852151199L
Member Information
Member Name: CARROLL, MELINDA J. Sex: FEMALE
DOB: 03/01/1995 Age: 29.67
Health Plan: BLUE SHIELD-COMM POS ACCESS+
Diagnosis: Z3201 - ENCNTR PREG TEST,RESULT POSITIVE

Provider Information
Provider Name: URSO, MARYJO
Provider ID: 20A8265 Specialty: OBSTETRICS & GYNECOLOGY
Patient Acct. #: 006000144997 Cross Ref ID:
(951) 929-8400 Fax: (951) 929-8411
Place of Service: OFFICE
Process Status
Services
Date Code Description Modif Qty Contract Co-pay Billed Withold Adjust Net
2024-09-16 99203 OFFICE O/P NEW LOW 30 25 1 $104.95 $40.00 $236.00 $0.00 $0.00 $64.95
MIN
2024-09-16 81025 URINE PREGNANCY TEST 1 $7.75 $0.00 $17.00 $0.00 $0.00 $7.75
TOTAL: $112.70 $40.00 $253.00 $0.00 $0.00 $72.70

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