Check Summary Transaction Date: February 02, 2024

Florida Blue Payee Tax ID: 592120945 Payee Name: THE BOUGAINVILLA HOUSE INC
4800 DEERWOOD CAMPUS PARKWAY Payee ID: 1962835488 Payee Address: 1721 SE 4TH AVE
JACKSONVILLE, FL 32246 Check/EFT Trace Number: 211203740 Fort Lauderdale, FL 333162515
Payment Amount: 722.60
Check/EFT Date: 02/02/2024
Production End Cycle Date: 02/02/2024

Page 1
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Claim Summary
Payer Name: Florida Blue Patient Name: ARONOWICZ, GABRIELLA S Claim Charge Amount: $500.00
Claim Number: Q100001118790575 Patient ID: VMAH6008839504 Claim Payment Amount: $32.04
Claim Date: 01/23/2024-01/23/2024 Patient Control Number: 23-03027-08651 Patient Responsibility: $60.00
Payee Name: THE BOUGAINVILLA HOUSE Group/Policy: 99999U5A01
INC Contract Header:
Check/EFT Trace Number: 211203740 Original Ref Number: Q100001118790575
Check/EFT Date: 02/02/2024 Facility Type:
Rendering Provider Name: ANNA BINDER Claim Frequency:
Rendering Provider ID: 1003952029 Claim Received Date: 01/26/2024
Claim Status Code: 1
Line Details Results: 1
Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
7744222430Z1 01/23/2024 - HC:90847 / / 1 LIABN $92.04 (B6) $500.00 CO-45 $407.96 $32.04
01/23/2024 BCPI PR-3 $60.00
PCNTR
N381
Code Descriptions
REMARK CODE(S):
N381=Consult our contractual agreement for restrictions/billing/payment information related to these charges.
PAYER CODE(S):
LIABN=In network provider utilized. Therefore no patient responsibility.
BCPI=Copayment Required for In-Network Provider
PCNTR=Allowed amount based on agreement.
AMT CODE(S):
B6=Allowed - Actual
GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility
CLAIM ADJUSTMENT REASON CODE(S):

Page 2
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
CLAIM ADJUSTMENT REASON CODE(S):
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)
3=Co-payment Amount
CLAIM STATUS CODE(S):
1=Processed as Primary

Page 3
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Claim Summary
Payer Name: Florida Blue Patient Name: ARONOWICZ, GABRIELLA S Claim Charge Amount: $500.00
Claim Number: Q100001118136025 Patient ID: VMAH6008839504 Claim Payment Amount: $0.00
Claim Date: 01/22/2024-01/22/2024 Patient Control Number: 23-03027-08583 Patient Responsibility: $24.90
Payee Name: THE BOUGAINVILLA HOUSE Group/Policy: 99999U5A01
INC Contract Header:
Check/EFT Trace Number: 211203740 Original Ref Number: Q100001118136025
Check/EFT Date: 02/02/2024 Facility Type:
Rendering Provider Name: ANNA BINDER Claim Frequency:
Rendering Provider ID: 1003952029 Claim Received Date: 01/24/2024
Claim Status Code: 1
Line Details Results: 1
Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
7736054919Z1 01/22/2024 - HC:90853 / / 1 LIABN $24.90 (B6) $500.00 CO-45 $475.10 $0.00
01/22/2024 BCPI PR-3 $24.90
PCNTR
N381
Code Descriptions
REMARK CODE(S):
N381=Consult our contractual agreement for restrictions/billing/payment information related to these charges.
PAYER CODE(S):
LIABN=In network provider utilized. Therefore no patient responsibility.
BCPI=Copayment Required for In-Network Provider
PCNTR=Allowed amount based on agreement.
AMT CODE(S):
B6=Allowed - Actual
GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility
CLAIM ADJUSTMENT REASON CODE(S):

Page 4
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
CLAIM ADJUSTMENT REASON CODE(S):
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)
3=Co-payment Amount
CLAIM STATUS CODE(S):
1=Processed as Primary

Page 5
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Claim Summary
Payer Name: Florida Blue Patient Name: ARONOWICZ, GABRIELLA S Claim Charge Amount: $500.00
Claim Number: Q100001118136062 Patient ID: VMAH6008839504 Claim Payment Amount: $76.66
Claim Date: 01/09/2024-01/09/2024 Patient Control Number: 23-03027-08582 Patient Responsibility: $60.00
Payee Name: THE BOUGAINVILLA HOUSE Group/Policy: 99999U5A01
INC Contract Header:
Check/EFT Trace Number: 211203740 Original Ref Number: Q100001118136062
Check/EFT Date: 02/02/2024 Facility Type:
Rendering Provider Name: ANNA BINDER Claim Frequency:
Rendering Provider ID: 1003952029 Claim Received Date: 01/24/2024
Claim Status Code: 1
Line Details Results: 1
Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
7736054481Z1 01/09/2024 - HC:90837 / / 1 LIABN $136.66 (B6) $500.00 CO-45 $363.34 $76.66
01/09/2024 BCPI PR-3 $60.00
PCNTR
N381
Code Descriptions
REMARK CODE(S):
N381=Consult our contractual agreement for restrictions/billing/payment information related to these charges.
PAYER CODE(S):
LIABN=In network provider utilized. Therefore no patient responsibility.
BCPI=Copayment Required for In-Network Provider
PCNTR=Allowed amount based on agreement.
AMT CODE(S):
B6=Allowed - Actual
GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility
CLAIM ADJUSTMENT REASON CODE(S):

Page 6
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
CLAIM ADJUSTMENT REASON CODE(S):
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)
3=Co-payment Amount
CLAIM STATUS CODE(S):
1=Processed as Primary

Page 7
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Claim Summary
Payer Name: Florida Blue Patient Name: CATALDI, ANNE MARIE Claim Charge Amount: $-500.00
Claim Number: Q100001056634237 Patient ID: XJBH3596297702 Claim Payment Amount: $-134.33
Claim Date: 03/30/2023-03/30/2023 Patient Control Number: 22-12935-03934 Patient Responsibility: $0.00
Payee Name: THE BOUGAINVILLA HOUSE Group/Policy: J585900101
INC Contract Header:
Check/EFT Trace Number: 211203740 Original Ref Number: Q100001056634237
Check/EFT Date: 02/02/2024 Facility Type:
Rendering Provider Name: ANNA BINDER Claim Frequency:
Rendering Provider ID: 1003952029 Claim Received Date: 05/11/2023
Claim Status Code: 22
Line Details Results: 1
Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
6886243486Z1 03/30/2023 - HC:90837 / 95 / 1 LIABN $134.33 (B6) $-500.00 CO-45 $-365.67 $-134.33
03/30/2023 PCNTR
N381
Code Descriptions
REMARK CODE(S):
N381=Consult our contractual agreement for restrictions/billing/payment information related to these charges.
PAYER CODE(S):
LIABN=In network provider utilized. Therefore no patient responsibility.
BCPI=Copayment Required for In-Network Provider
PCNTR=Allowed amount based on agreement.
AMT CODE(S):
B6=Allowed - Actual
GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility
CLAIM ADJUSTMENT REASON CODE(S):
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)
3=Co-payment Amount
CLAIM STATUS CODE(S):

Page 8
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
CLAIM STATUS CODE(S):
1=Processed as Primary
22=Reversal of Previous Payment

Page 9
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Claim Summary
Payer Name: Florida Blue Patient Name: CATALDI, ANNE MARIE Claim Charge Amount: $500.00
Claim Number: M0001R1804474285 Patient ID: XJBH3596297702 Claim Payment Amount: $134.33
Claim Date: 03/30/2023-03/30/2023 Patient Control Number: 22-12935-03934-1 Patient Responsibility: $0.00
Payee Name: THE BOUGAINVILLA HOUSE Group/Policy: J585900101
INC Contract Header:
Check/EFT Trace Number: 211203740 Original Ref Number: Q100001056634237
Check/EFT Date: 02/02/2024 Facility Type:
Rendering Provider Name: ANNA BINDER Claim Frequency:
Rendering Provider ID: 1003952029 Claim Received Date: 05/11/2023
Claim Status Code: 1
Line Details Results: 1
Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
7723217931Z1 03/30/2023 - HC:90837 / 95 / 1 LIABN $134.33 (B6) $500.00 CO-45 $365.67 $134.33
03/30/2023 PCNTR
N381
Code Descriptions
REMARK CODE(S):
N381=Consult our contractual agreement for restrictions/billing/payment information related to these charges.
PAYER CODE(S):
LIABN=In network provider utilized. Therefore no patient responsibility.
BCPI=Copayment Required for In-Network Provider
PCNTR=Allowed amount based on agreement.
AMT CODE(S):
B6=Allowed - Actual
GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility
CLAIM ADJUSTMENT REASON CODE(S):
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)
3=Co-payment Amount
CLAIM STATUS CODE(S):

Page 10
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
CLAIM STATUS CODE(S):
1=Processed as Primary
22=Reversal of Previous Payment

Page 11
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Claim Summary
Payer Name: Florida Blue Patient Name: CATALDI, ANNE MARIE Claim Charge Amount: $-500.00
Claim Number: Q100001054008897 Patient ID: XJBH3596297702 Claim Payment Amount: $-134.33
Claim Date: 04/06/2023-04/06/2023 Patient Control Number: 22-12935-03261-1 Patient Responsibility: $0.00
Payee Name: THE BOUGAINVILLA HOUSE Group/Policy: J585900101
INC Contract Header:
Check/EFT Trace Number: 211203740 Original Ref Number: Q100001054008897
Check/EFT Date: 02/02/2024 Facility Type:
Rendering Provider Name: ANNA BINDER Claim Frequency:
Rendering Provider ID: 1003952029 Claim Received Date: 05/01/2023
Claim Status Code: 22
Line Details Results: 1
Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
6851543422Z1 04/06/2023 - HC:90837 / 95 / 1 LIABN $134.33 (B6) $-500.00 CO-45 $-365.67 $-134.33
04/06/2023 PCNTR
N381
Code Descriptions
REMARK CODE(S):
N381=Consult our contractual agreement for restrictions/billing/payment information related to these charges.
PAYER CODE(S):
LIABN=In network provider utilized. Therefore no patient responsibility.
BCPI=Copayment Required for In-Network Provider
PCNTR=Allowed amount based on agreement.
AMT CODE(S):
B6=Allowed - Actual
GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility
CLAIM ADJUSTMENT REASON CODE(S):
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)
3=Co-payment Amount
CLAIM STATUS CODE(S):

Page 12
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
CLAIM STATUS CODE(S):
1=Processed as Primary
22=Reversal of Previous Payment

Page 13
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Claim Summary
Payer Name: Florida Blue Patient Name: CATALDI, ANNE MARIE Claim Charge Amount: $500.00
Claim Number: M0001R1800236255 Patient ID: XJBH3596297702 Claim Payment Amount: $134.33
Claim Date: 04/06/2023-04/06/2023 Patient Control Number: 22-12935-03261-1 Patient Responsibility: $0.00
Payee Name: THE BOUGAINVILLA HOUSE Group/Policy: J585900101
INC Contract Header:
Check/EFT Trace Number: 211203740 Original Ref Number: Q100001054008897
Check/EFT Date: 02/02/2024 Facility Type:
Rendering Provider Name: ANNA BINDER Claim Frequency:
Rendering Provider ID: 1003952029 Claim Received Date: 05/01/2023
Claim Status Code: 1
Line Details Results: 1
Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
6851543422Z1 04/06/2023 - HC:90837 / 95 / 1 LIABN $134.33 (B6) $500.00 CO-45 $365.67 $134.33
04/06/2023 PCNTR
N381
Code Descriptions
REMARK CODE(S):
N381=Consult our contractual agreement for restrictions/billing/payment information related to these charges.
PAYER CODE(S):
LIABN=In network provider utilized. Therefore no patient responsibility.
BCPI=Copayment Required for In-Network Provider
PCNTR=Allowed amount based on agreement.
AMT CODE(S):
B6=Allowed - Actual
GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility
CLAIM ADJUSTMENT REASON CODE(S):
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)
3=Co-payment Amount
CLAIM STATUS CODE(S):

Page 14
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
CLAIM STATUS CODE(S):
1=Processed as Primary
22=Reversal of Previous Payment

Page 15
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Claim Summary
Payer Name: Florida Blue Patient Name: FUCILE ROBERTS, Claim Charge Amount: $500.00
Claim Number: H100001118790609 JERONIMO Claim Payment Amount: $120.78
Claim Date: 01/23/2024-01/23/2024 Patient ID: SRA3HZN69571790 Patient Responsibility: $20.00
Payee Name: THE BOUGAINVILLA HOUSE Patient Control Number: 23-12006-08655
INC Group/Policy:
Check/EFT Trace Number: 211203740 Contract Header:
Check/EFT Date: 02/02/2024 Original Ref Number: H100001118790609
Rendering Provider Name: ANNA BINDER Facility Type:
Rendering Provider ID: 1003952029 Claim Frequency:
Claim Status Code: 1 Claim Received Date: 01/26/2024

Line Details Results: 1

Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
7744222468Z1 01/23/2024 - HC:90837 / / 1 BCPR $140.78 (B6) $500.00 CO-45 $359.22 $120.78
01/23/2024 PREDD PR-3 $20.00
PPSCH
N381
Code Descriptions
REMARK CODE(S):
N381=Consult our contractual agreement for restrictions/billing/payment information related to these charges.
PAYER CODE(S):
LIABN=In network provider utilized. Therefore no patient responsibility.
BCPI=Copayment Required for In-Network Provider
PCNTR=Allowed amount based on agreement.
BCPR=Co-payment is required.
PREDD=Charge exceeds allowance limit for this service
PPSCH=Payment based on maximum allowable amount.
AMT CODE(S):
B6=Allowed - Actual
GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility

Page 16
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
CLAIM ADJUSTMENT REASON CODE(S):
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)
3=Co-payment Amount
CLAIM STATUS CODE(S):
1=Processed as Primary
22=Reversal of Previous Payment

Page 17
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Claim Summary
Payer Name: Florida Blue Patient Name: JENNINGS, JOHN Claim Charge Amount: $500.00
Claim Number: H100001118136092 Patient ID: BXE805509025 Claim Payment Amount: $0.00
Claim Date: 01/18/2024-01/18/2024 Patient Control Number: 22-12895-08589 Patient Responsibility: $140.78
Payee Name: THE BOUGAINVILLA HOUSE Group/Policy:
INC Contract Header:
Check/EFT Trace Number: 211203740 Original Ref Number: H100001118136092
Check/EFT Date: 02/02/2024 Facility Type:
Rendering Provider Name: ANNA BINDER Claim Frequency:
Rendering Provider ID: 1003952029 Claim Received Date: 01/24/2024
Claim Status Code: 1
Line Details Results: 1
Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
7736055858Z1 01/18/2024 - HC:90837 / / 1 BDED $140.78 (B6) $500.00 CO-45 $359.22 $0.00
01/18/2024 PREDD PR-1 $140.78
PPSCH
N381
Code Descriptions
REMARK CODE(S):
N381=Consult our contractual agreement for restrictions/billing/payment information related to these charges.
PAYER CODE(S):
LIABN=In network provider utilized. Therefore no patient responsibility.
BCPI=Copayment Required for In-Network Provider
PCNTR=Allowed amount based on agreement.
BCPR=Co-payment is required.
PREDD=Charge exceeds allowance limit for this service
PPSCH=Payment based on maximum allowable amount.
BDED=This claim is subject to an in-network deductible.
AMT CODE(S):
B6=Allowed - Actual
GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility

Page 18
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
CLAIM ADJUSTMENT REASON CODE(S):
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)
3=Co-payment Amount
1=Deductible Amount
CLAIM STATUS CODE(S):
1=Processed as Primary
22=Reversal of Previous Payment

Page 19
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Claim Summary
Payer Name: Florida Blue Patient Name: ROBERTS, SARAH A Claim Charge Amount: $500.00
Claim Number: H0001R1902308540 Patient ID: CYF5552069AB Claim Payment Amount: $115.78
Claim Date: 01/08/2024-01/08/2024 Patient Control Number: 22-12342-08402 Patient Responsibility: $25.00
Payee Name: THE BOUGAINVILLA HOUSE Group/Policy:
INC Contract Header:
Check/EFT Trace Number: 211203740 Original Ref Number: H0001R1902308540
Check/EFT Date: 02/02/2024 Facility Type:
Rendering Provider Name: ANNA BINDER Claim Frequency:
Rendering Provider ID: 1003952029 Claim Received Date: 01/13/2024
Claim Status Code: 1
Line Details Results: 1
Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
7700557512Z1 01/08/2024 - HC:90837 / / 1 BCPR $140.78 (B6) $500.00 CO-45 $359.22 $115.78
01/08/2024 PREDD PR-3 $25.00
PPSCH
N381
Code Descriptions
REMARK CODE(S):
N381=Consult our contractual agreement for restrictions/billing/payment information related to these charges.
PAYER CODE(S):
LIABN=In network provider utilized. Therefore no patient responsibility.
BCPI=Copayment Required for In-Network Provider
PCNTR=Allowed amount based on agreement.
BCPR=Co-payment is required.
PREDD=Charge exceeds allowance limit for this service
PPSCH=Payment based on maximum allowable amount.
BDED=This claim is subject to an in-network deductible.
AMT CODE(S):
B6=Allowed - Actual
GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility

Page 20
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
CLAIM ADJUSTMENT REASON CODE(S):
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)
3=Co-payment Amount
1=Deductible Amount
CLAIM STATUS CODE(S):
1=Processed as Primary
22=Reversal of Previous Payment

Page 21
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Claim Summary
Payer Name: Florida Blue Patient Name: SEIDNER, CHANA Claim Charge Amount: $500.00
Claim Number: H100001118136054 Patient ID: PXN100011058661 Claim Payment Amount: $115.78
Claim Date: 01/12/2024-01/12/2024 Patient Control Number: 22-12947-08571 Patient Responsibility: $25.00
Payee Name: THE BOUGAINVILLA HOUSE Group/Policy:
INC Contract Header:
Check/EFT Trace Number: 211203740 Original Ref Number: H100001118136054
Check/EFT Date: 02/02/2024 Facility Type:
Rendering Provider Name: ANNA BINDER Claim Frequency:
Rendering Provider ID: 1003952029 Claim Received Date: 01/24/2024
Claim Status Code: 1
Line Details Results: 1
Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
7736053610Z1 01/12/2024 - HC:90837 / 95 / 1 BCPR $140.78 (B6) $500.00 CO-45 $359.22 $115.78
01/12/2024 PREDD PR-3 $25.00
PPSCH
N381
Code Descriptions
REMARK CODE(S):
N381=Consult our contractual agreement for restrictions/billing/payment information related to these charges.
PAYER CODE(S):
LIABN=In network provider utilized. Therefore no patient responsibility.
BCPI=Copayment Required for In-Network Provider
PCNTR=Allowed amount based on agreement.
BCPR=Co-payment is required.
PREDD=Charge exceeds allowance limit for this service
PPSCH=Payment based on maximum allowable amount.
BDED=This claim is subject to an in-network deductible.
AMT CODE(S):
B6=Allowed - Actual
GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility

Page 22
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
CLAIM ADJUSTMENT REASON CODE(S):
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)
3=Co-payment Amount
1=Deductible Amount
CLAIM STATUS CODE(S):
1=Processed as Primary
22=Reversal of Previous Payment

Page 23
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Claim Summary
Payer Name: Florida Blue Patient Name: SHANDLER, NESHAMA Claim Charge Amount: $500.00
Claim Number: M0001R1885618914 Patient ID: XEA911610405 Claim Payment Amount: $130.78
Claim Date: 11/22/2023-11/22/2023 Patient Control Number: 22-12406-07711-2 Patient Responsibility: $10.00
Payee Name: THE BOUGAINVILLA HOUSE Group/Policy:
INC Contract Header:
Check/EFT Trace Number: 211203740 Original Ref Number: 09020233370432100
Check/EFT Date: 02/02/2024 Facility Type:
Rendering Provider Name: ANNA BINDER Claim Frequency:
Rendering Provider ID: 1003952029 Claim Received Date: 12/02/2023
Claim Status Code: 1
Line Details Results: 1
Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
7728943065Z1 11/22/2023 - HC:90837 / / 1 BCPR $140.78 (B6) $500.00 CO-45 $359.22 $130.78
11/22/2023 PREDD PR-3 $10.00
PPSCH
N381
Code Descriptions
REMARK CODE(S):
N381=Consult our contractual agreement for restrictions/billing/payment information related to these charges.
PAYER CODE(S):
LIABN=In network provider utilized. Therefore no patient responsibility.
BCPI=Copayment Required for In-Network Provider
PCNTR=Allowed amount based on agreement.
BCPR=Co-payment is required.
PREDD=Charge exceeds allowance limit for this service
PPSCH=Payment based on maximum allowable amount.
BDED=This claim is subject to an in-network deductible.
AMT CODE(S):
B6=Allowed - Actual
GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility

Page 24
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
CLAIM ADJUSTMENT REASON CODE(S):
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)
3=Co-payment Amount
1=Deductible Amount
CLAIM STATUS CODE(S):
1=Processed as Primary
22=Reversal of Previous Payment

Page 25
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Claim Summary
Payer Name: Florida Blue Patient Name: SHANDLER, NESHAMA Claim Charge Amount: $-500.00
Claim Number: H100001105328003 Patient ID: XEA911610405 Claim Payment Amount: $-130.78
Claim Date: 11/22/2023-11/22/2023 Patient Control Number: 22-12406-07711 Patient Responsibility: $0.00
Payee Name: THE BOUGAINVILLA HOUSE Group/Policy:
INC Contract Header:
Check/EFT Trace Number: 211203740 Original Ref Number: H100001105328003
Check/EFT Date: 02/02/2024 Facility Type:
Rendering Provider Name: ANNA BINDER Claim Frequency:
Rendering Provider ID: 1003952029 Claim Received Date: 12/02/2023
Claim Status Code: 22
Line Details Results: 1
Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
7565825184Z1 11/22/2023 - HC:90837 / / 1 BCPR $140.78 (B6) $-500.00 CO-45 $-359.22 $-130.78
11/22/2023 PREDD PR-3 $-10.00
PPSCH
N381
Code Descriptions
REMARK CODE(S):
N381=Consult our contractual agreement for restrictions/billing/payment information related to these charges.
PAYER CODE(S):
LIABN=In network provider utilized. Therefore no patient responsibility.
BCPI=Copayment Required for In-Network Provider
PCNTR=Allowed amount based on agreement.
BCPR=Co-payment is required.
PREDD=Charge exceeds allowance limit for this service
PPSCH=Payment based on maximum allowable amount.
BDED=This claim is subject to an in-network deductible.
AMT CODE(S):
B6=Allowed - Actual
GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility

Page 26
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
CLAIM ADJUSTMENT REASON CODE(S):
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)
3=Co-payment Amount
1=Deductible Amount
CLAIM STATUS CODE(S):
1=Processed as Primary
22=Reversal of Previous Payment

Page 27
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Claim Summary
Payer Name: Florida Blue Patient Name: SHANDLER, NESHAMA Claim Charge Amount: $500.00
Claim Number: H100001117687503 Patient ID: XEA911610405 Claim Payment Amount: $130.78
Claim Date: 09/20/2023-09/20/2023 Patient Control Number: 22-12406-06425-3 Patient Responsibility: $10.00
Payee Name: THE BOUGAINVILLA HOUSE Group/Policy:
INC Contract Header:
Check/EFT Trace Number: 211203740 Original Ref Number: H100001088087336
Check/EFT Date: 02/02/2024 Facility Type:
Rendering Provider Name: ANNA BINDER Claim Frequency:
Rendering Provider ID: 1003952029 Claim Received Date: 01/23/2024
Claim Status Code: 1
Line Details Results: 1
Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
7728725754Z1 09/20/2023 - HC:90837 / 95 / 1 BCPR $140.78 (B6) $500.00 CO-45 $359.22 $130.78
09/20/2023 PREDD PR-3 $10.00
PPSCH
N381
Code Descriptions
REMARK CODE(S):
N381=Consult our contractual agreement for restrictions/billing/payment information related to these charges.
PAYER CODE(S):
LIABN=In network provider utilized. Therefore no patient responsibility.
BCPI=Copayment Required for In-Network Provider
PCNTR=Allowed amount based on agreement.
BCPR=Co-payment is required.
PREDD=Charge exceeds allowance limit for this service
PPSCH=Payment based on maximum allowable amount.
BDED=This claim is subject to an in-network deductible.
AMT CODE(S):
B6=Allowed - Actual
GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility

Page 28
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
CLAIM ADJUSTMENT REASON CODE(S):
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)
3=Co-payment Amount
1=Deductible Amount
CLAIM STATUS CODE(S):
1=Processed as Primary
22=Reversal of Previous Payment

Page 29
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Claim Summary
Payer Name: Florida Blue Patient Name: SHANDLER, NESHAMA Claim Charge Amount: $500.00
Claim Number: H100001117687497 Patient ID: XEA911610405 Claim Payment Amount: $130.78
Claim Date: 09/06/2023-09/06/2023 Patient Control Number: 22-12406-06247-3 Patient Responsibility: $10.00
Payee Name: THE BOUGAINVILLA HOUSE Group/Policy:
INC Contract Header:
Check/EFT Trace Number: 211203740 Original Ref Number: H100001086693980
Check/EFT Date: 02/02/2024 Facility Type:
Rendering Provider Name: ANNA BINDER Claim Frequency:
Rendering Provider ID: 1003952029 Claim Received Date: 01/23/2024
Claim Status Code: 1
Line Details Results: 1
Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
7728725582Z1 09/06/2023 - HC:90837 / 95 / 1 BCPR $140.78 (B6) $500.00 CO-45 $359.22 $130.78
09/06/2023 PREDD PR-3 $10.00
PPSCH
N381
Code Descriptions
REMARK CODE(S):
N381=Consult our contractual agreement for restrictions/billing/payment information related to these charges.
PAYER CODE(S):
LIABN=In network provider utilized. Therefore no patient responsibility.
BCPI=Copayment Required for In-Network Provider
PCNTR=Allowed amount based on agreement.
BCPR=Co-payment is required.
PREDD=Charge exceeds allowance limit for this service
PPSCH=Payment based on maximum allowable amount.
BDED=This claim is subject to an in-network deductible.
AMT CODE(S):
B6=Allowed - Actual
GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility

Page 30
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
CLAIM ADJUSTMENT REASON CODE(S):
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)
3=Co-payment Amount
1=Deductible Amount
CLAIM STATUS CODE(S):
1=Processed as Primary
22=Reversal of Previous Payment

Page 31
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Claim Summary
Payer Name: Florida Blue Patient Name: VAZAIOS, DANIELLE R Claim Charge Amount: $500.00
Claim Number: H100001118790623 Patient ID: XEA911256794 Claim Payment Amount: $0.00
Claim Date: 01/23/2024-01/23/2024 Patient Control Number: 23-07019-08644 Patient Responsibility: $25.35
Payee Name: THE BOUGAINVILLA HOUSE Group/Policy:
INC Contract Header:
Check/EFT Trace Number: 211203740 Original Ref Number: H100001118790623
Check/EFT Date: 02/02/2024 Facility Type:
Rendering Provider Name: ANNA BINDER Claim Frequency:
Rendering Provider ID: 1003952029 Claim Received Date: 01/26/2024
Claim Status Code: 1
Line Details Results: 1
Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
7744222331Z1 01/23/2024 - HC:90853 / / 1 BDED $25.35 (B6) $500.00 CO-45 $474.65 $0.00
01/23/2024 PREDD PR-1 $25.35
PPSCH
N381
Code Descriptions
REMARK CODE(S):
N381=Consult our contractual agreement for restrictions/billing/payment information related to these charges.
PAYER CODE(S):
LIABN=In network provider utilized. Therefore no patient responsibility.
BCPI=Copayment Required for In-Network Provider
PCNTR=Allowed amount based on agreement.
BCPR=Co-payment is required.
PREDD=Charge exceeds allowance limit for this service
PPSCH=Payment based on maximum allowable amount.
BDED=This claim is subject to an in-network deductible.
AMT CODE(S):
B6=Allowed - Actual
GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility

Page 32
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
CLAIM ADJUSTMENT REASON CODE(S):
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)
3=Co-payment Amount
1=Deductible Amount
CLAIM STATUS CODE(S):
1=Processed as Primary
22=Reversal of Previous Payment

Page 33
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Claim Summary
Payer Name: Florida Blue Patient Name: VAZAIOS, DANIELLE R Claim Charge Amount: $175.00
Claim Number: H100001118790632 Patient ID: XEA911256794 Claim Payment Amount: $0.00
Claim Date: 01/24/2024-01/24/2024 Patient Control Number: 23-07019-08619 Patient Responsibility: $85.96
Payee Name: THE BOUGAINVILLA HOUSE Group/Policy:
INC Contract Header:
Check/EFT Trace Number: 211203740 Original Ref Number: H100001118790632
Check/EFT Date: 02/02/2024 Facility Type:
Rendering Provider Name: ANNA BINDER Claim Frequency:
Rendering Provider ID: 1003952029 Claim Received Date: 01/26/2024
Claim Status Code: 1
Line Details Results: 1
Line Ctrl Nmbr Dates of Rend Prov Rev Sub Proc / Adjud Proc / Remark / Supp Info (AMT) Charge Adjustments Adj Amount Payment
Service ID Modifier / Modifier / Units Payer Code (Qty)
Units
7744218584Z1 01/24/2024 - HC:99213 / 95 / 1 BDED $85.96 (B6) $175.00 CO-45 $89.04 $0.00
01/24/2024 PREDD PR-1 $85.96
PPSCH
N381
Code Descriptions
REMARK CODE(S):
N381=Consult our contractual agreement for restrictions/billing/payment information related to these charges.
PAYER CODE(S):
LIABN=In network provider utilized. Therefore no patient responsibility.
BCPI=Copayment Required for In-Network Provider
PCNTR=Allowed amount based on agreement.
BCPR=Co-payment is required.
PREDD=Charge exceeds allowance limit for this service
PPSCH=Payment based on maximum allowable amount.
BDED=This claim is subject to an in-network deductible.
AMT CODE(S):
B6=Allowed - Actual
GROUP CODE(S):
CO=Contractual Obligations
PR=Patient Responsibility

Page 34
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
CLAIM ADJUSTMENT REASON CODE(S):
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)
3=Co-payment Amount
1=Deductible Amount
CLAIM STATUS CODE(S):
1=Processed as Primary
22=Reversal of Previous Payment

Page 35
Check/EFT Trace Number: 211203740 Transaction Date: 02/02/2024
Do you disagree with this determination?
For providers not participating with Florida Blue Medicare Advantage that disagree with this determination, an appeal and waiver of liability must be filed within 60 calendar days after the date of this
Remittance Advice.
View Appeal Form
View Waiver of Liability
Providers are prohibited from charging cost sharing to beneficiaries for Medicare Part A and B services when provided to certain individuals who are dually eligible for Medicare and Medicaid.

Page 36