Overview
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Blue Cross Blue Shield · Service date Aug 13, 2026 · Dr. Samuel Ortiz
MRN MRN-PAT-GEN-83 · 73 yrs
No secondary insurance on file for this patient.
No non-insurance payers (foundations, grants, cash pay) are linked to this claim.
Credentialing status unavailable for this provider.
No referring or supervising providers are attached to this encounter.
No additional submission details (referral numbers, authorization numbers, accident information) on this claim.
Encounter-level place of service is the code on Box 24B of the CMS-1500. Per-line overrides appear in the Service lines table below.
| Date of service | CPT code | Modifiers | Diagnoses | Place of service | Qty | Billed | Details |
|---|---|---|---|---|---|---|---|
| Aug 13, 2026 | 99395 | — | E11.9 | 11 - Office | 1 | $240.00 | |
Allowed— Pri ins paym$0.00 Pri ins adj— Pat resp$0.00 Pat bal$0.00 Bal$240.00 | |||||||
| Date of service | Facility | Status | Billed |
|---|---|---|---|
| Aug 12, 2026 | Northstar Family Health - Main | Waiting on provider | $400.00 |
| Jul 28, 2026 | Northstar Family Health - Main | Awaiting info | $400.00 |
| May 24, 2026 | Northstar Family Health - Main | Submitted | $55.00 |
| Aug 12, 2026 | Northstar Family Health - Main | Waiting on provider | $150.00 |
| Jul 20, 2026 | Northstar Family Health - Main | Paid (incorrect) | $2,400.00 |