COLORADO CLAIMS ADMINISTRATION COLORADO KAISER FOUNDATION HEALTHPLAN,INC PO Box 373150 Denver, CO 80237-3150 Questions? Call Customer Service at (800)-382-4661 Weekdays Mon - Fri 9:00AM - 4:00PM MT Weekends N/A Check / EFT #: 1090 Remittance Number: EOPVEN4705 Payment Date: 07/01/2016 Total Payment Amt: 6000.00 Vendor Tax ID No: 84xxxxxxx Vendor ID No: 10xxxxxxxx Vendor NPI No: 14xxxxxxxx HOSPITAL 1234 MAIN ST LONGMONT, CO 80501 ***ACCOUNT SUMMARY*** # of Disallowed 13Not Cov'd Amount Applied to CoPay Other Ins Plan Pays Claims Allowed Amount Amount/Discount Deductible CoIns Claims Payment Total 2 6000.00 0.00 0.00 0.00 0.00 6000.00 6000.00 0.00 Total Payment Amount 6000.00 Method of Payment: Check/EFT Amount 6000.00 Total Payment Amount 6000.00 Other / Claims Related Transactions 0.00 62-20 / 311 Check No: 1090 Citibank, N.A. Date: 07/01/2016 One Penn's Way New Castle, DE 19720 COLORADO CLAIMS ADMINISTRATION COLORADO KAISER FOUNDATION HEALTHPLAN,INC PO Box 373150 Denver, CO 80237-3150 $ ****6000.00**** * Six Thousand Dollars * To the order of HOSPITAL 1234 MAIN ST LONGMONT, CO 80501 VOID Non-Negotiable Pay 1 2 3 4 5 6 7 8 9 10 11 Billed Amount 12 14 15 16 17 18 20 21 22 23 24
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COLORADO CLAIMS ADMINISTRATION
COLORADO
KAISER FOUNDATION HEALTHPLAN,INC
PO Box 373150
Denver, CO 80237-3150
Questions? Call Customer Service at (800)-382-4661 Weekdays Mon - Fri 9:00AM - 4:00PM MT
Weekends N/A
Check / EFT #: 1090
Remittance Number: EOPVEN4705
Payment Date: 07/01/2016
Total Payment Amt: 6000.00
Vendor Tax ID No: 84xxxxxxxVendor ID No: 10xxxxxxxx
Vendor NPI No: 14xxxxxxxxHOSPITAL1234 MAIN STLONGMONT, CO 80501