Page 1

UnitedHealthcare Services Inc

PO Box 19032
Green Bay WI 543079032
Phone: (800) 232-5432
Electronic Payments and Statements Payment Date: 03/22/2017
TIN: *****2797
NPI: 1518943778
HARDEEP S DHALIWAL MD PA
3871 LONG PRAIRIE RD Payment Number: 1E000000002073193
FLOWER MOUND TX 750281569 Electronic Provider Remittance Advice Payment Amount: $77.40

Account Patient Name / Subscriber ID / Rendering Provider Claim # / Group Policy Number
Number Patient ID Corrected ID Claim Type /
Product Name

Date(s) of Description Amount Claim / Prov Adj Amount Deduct/ Paid to Adj RMK Patient
Service of Service Charged Service Discount Allowed Coins/ Provider Reason Code Resp
Adj Copay Code

10303 CHARLES W CHADWELL/ 005372476 00537247600000401

005372476

02/13/2017- HC:93000 $50.00 -$50.00 -- -- -- $0.00 18 N522 --

02/13/2017

02/13/2017- HC:90471 $35.00 -- -$6.00 $29.00 -- $29.00 45 --

02/13/2017

02/13/2017- HC:99204: $190.00 -$190.00 -- -- -- $0.00 18 N522 --

02/13/2017
25

02/13/2017- HC:90715: $85.00 -- -$36.60 $48.40 -- $48.40 45 --

02/13/2017
GA

Subtotal $360.00 -$240.00 -$42.60 $77.40 $0.00 $77.40 $0.00

"--" indicates payer has not supplied this information. Total Paid to Provider : $77.40

N522 - Duplicate of a claim processed, or to be processed, as a

crossover claim.
18 - Exact duplicate claim/service (Use only with Group Code OA
except where state workers' compensation regulations requires
CO)
45 - Charge exceeds fee schedule/maximum allowable or
contracted/legislated fee arrangement. (Use only with Group
Codes PR or CO depending upon liability) This change effective
11/1/2015: Charge exceeds fee schedule/maximum allowable or
contracted/legislated fee arrangement. Note: this 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)

Page 1