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Related post: Date on which the remittance advice was issued PROV ID: This field will contain the Medicaid Provider ID and the NPI Date on which the check was issued Provider ID No.: This field will contain the NPI and the Medicaid Provider ID Dollar amount. This amount must equal the Net Total Paid Amount under the Grand Total subsection plus the total sum of the Financial Transaction section. Version 2009 - 1 (10/01/09) Page 33 of 54 Section One - EFT Notification For providers who have selected electronic funds transfer (or direct deposit), an EFT transaction is processed when the provider has claims approved during the cycle and the approved amount is greater than the recoupments, if any, scheduled for the cycle. This section indicates the amount of the EFT. TO: CITY PHARMACY DATE: 2007-08-06 PAYMENT IN THE ABOVE AMOUNT WILL BE DEPOSITED VIA AN ELECTRONIC FUNDS TRANSFER. Version 2009 - 1 (10/01/09) Page 34 of 54 Information on the EFT Notification Page Provider�s name (as recorded in the Medicaid files) Date on which the remittance advice was issued PROV ID: This field will contain the Medicaid Provider ID and the NPI Provider�s Name - Amount transferred to the provider�s account. This amount must equal the Net Total Paid Amount under the Grand Total subsection plus the total sum of the Financial Transaction section. Version 2009 - 1 (10/01/09) Page 35 of 54 Section One - Summout (No Payment) A summout is produced when the provider has no positive total payment for the cycle and, therefore, there is no disbursement of moneys. TO: ABC PHARMACY DATE: 08/06/2007 NO PAYMENT WILL BE RECEIVED THIS CYCLE. SEE REMITTANCE FOR DETAILS. Version 2009 - 1 (10/01/09) Page 36 of 54 Information on the Summout Page Provider Name (as recorded in Medicaid files) Date on which the remittance advice was issued PROV ID: This field will contain the Medicaid Provider ID and the NPI Notification that no payment was made for the cycle (no claims were approved) Provider name and address Version 2009 - 1 (10/01/09) Page 37 of 54 Section Two - Provider Notification This section is used to communicate important Meloxicam Buy messages to providers. MEDICAL ASSISTANCE (TITLE XIX) PROGRAM TO: CITY PHARMACY ETIN: 111 PARK AVENUE PROVIDER NOTIFICATION ANYTOWN, NEW YORK 11111 PROV ID: 00123456/1123456789 REMITTANCE ADVICE MESSAGE TEXT * ELECTRONIC FUNDS TRANSFER (EFT) FOR PROVIDER PAYMENTS IS NOW AVAILABLE * PROVIDERS WHO ENROLL IN EFT WILL HAVE THEIR MEDICAID PAYMENTS DIRECTLY DEPOSITED INTO THEIR CHECKING OR SAVINGS ACCOUNT. THE EFT TRANSACTIONS WILL BE INITIATED ON WEDNESDAYS AND DUE TO NORMAL BANKING PROCEDURES, THE TRANSFERRED FUNDS MAY NOT BECOME AVAILABLE IN THE Buy Meloxicam PROVIDER�S CHOSEN ACCOUNT FOR UP TO 48 HOURS AFTER TRANSFER. PLEASE CONTACT YOUR BANKING INSTITUTION REGARDING THE AVAILABILITY OF FUNDS. PLEASE NOTE THAT EFT DOES NOT WAIVE THE TWO-WEEK LAG FOR MEDICAID DISBURSEMENTS. TO ENROLL IN EFT, PROVIDERS MUST COMPLETE AN EFT ENROLLMENT FORM THAT CAN BE FOUND AT WWW.EMEDNY.ORG. CLICK ON PROVIDER ENROLLMENT FORMS WHICH CAN BE FOUND IN THE FEATURED LINKS SECTION. DETAILED INSTRUCTIONS WILL ALSO BE FOUND THERE. AFTER SENDING THE EFT ENROLLMENT FORM TO CSC, PLEASE ALLOW A MINIMUM TIME OF SIX TO EIGHT WEEKS FOR PROCESSING. DURING THIS PERIOD OF TIME YOU SHOULD REVIEW YOUR BANK STATEMENTS AND LOOK FOR AN EFT TRANSACTION IN THE AMOUNT OF $0.01 WHICH CSC WILL SUBMIT AS A TEST. YOUR FIRST REAL EFT TRANSACTION WILL TAKE PLACE APPROXIMATELY FOUR TO FIVE WEEKS LATER. IF YOU HAVE ANY QUESTIONS ABOUT THE EFT PROCESS, PLEASE CALL THE EMEDNY CALL CENTER NOTICE: THIS COMMUNICATION AND ANY ATTACHMENTS MAY CONTAIN INFORMATION THAT IS PRIVILEGED AND CONFIDENTIAL UNDER STATE AND FEDERAL LAW AND IS INTENDED ONLY FOR THE USE OF THE SPECIFIC INDIVIDUAL(S) TO WHOM IT IS ADDRESSED. THIS INFORMATION MAY ONLY BE USED OR DISCLOSED IN ACCORDANCE WITH LAW, AND YOU MAY BE SUBJECT TO PENALTIES UNDER LAW FOR IMPROPER USE OR FURTHER DISCLOSURE OF INFORMATION IN THIS COMMUNICATION AND ANY ATTACHMENTS. IF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR, PLEASE IMMEDIATELY NOTIFY NYHIPPADESKCSC.COM OR CALL 1-800-541-2831. PROVIDERS WHO DO NOT HAVE ACCESS TO E-MAIL SHOULD CONTACT 1-800-343-9000. Version 2009 - 1 (10/01/09) Page 38 of 54 Information on the Provider Notification Page Provider�s name and address Date on which the remittance advice was issued Name of section: Provider Notification PROV ID: This field will contain the Medicaid Provider ID and the NPI Version 2009 - 1 (10/01/09) Page 39 of 54 Section Three - Claim Detail This section provides a listing of all new claims that were processed during the specific cycle plus claims that were previously pended and adjudicated (paid or denied) during the specific cycle. This section may also contain pending claims from previous Meloxicam 7.5 Tablets cycles that still remain in a pend status. MEDICAL ASSISTANCE (TITLE XIX) PROGRAM TO: CITY PHARMACY REMITTANCE STATEMENT PHARMACY 111 PARK AVENUE PROV ID: 00123456/1123456789 ANYTOWN, NEW YORK 11111 REMITTANCE NO: 070806000006 PRESCRIP CLIENT ID CLIENTSERVICE TION NO. ITEM CODE QUANTITY NUMBER NAMEDATETCNCHARGED PAID STATUS ERRORS 4267229 00173044100 54.000 BZ12345K NICHOLS05/01//07 07267-000000605-0-2100.000.00 DENY 00162 4267240 00904391660 5.000 BZ12345K NICHOLS05/15/07 07267-000000614-0-1 50.000.00 DENY 00162 0426722 00904391660 5.000 CD54321J RYDER05/25/07 07267-000000573-0-1 30.000.00 DENY 00142 00144 0042664 00002411260 1.000 CD54321J RYDER05/01/07 07267-000000453-2-2 60.000.00 DENY 00142 00144 * = PREVIOUSLY PENDED CLAIM * = NEW PEND TOTAL AMOUNT ORIGINAL CLAIMSDENIED240.00NUMBER OF CLAIMS4 NET AMOUNT ADJUSTMENTS DENIED0.00NUMBER OF CLAIMS0 NET AMOUNT VOIDS DENIED0.00NUMBER OF CLAIMS0 NET AMOUNT VOIDS - ADJUSTS 0.00NUMBER OF CLAIMS0 Version 2009 - 1 (10/01/09) Page 40 of 54 MEDICAL ASSISTANCE (TITLE XIX) PROGRAM TO: CITY PHARMACY REMITTANCE STATEMENT PHARMACY 111 PARK AVENUE PROV ID: 00123456/1123456789 ANYTOWN, NEW YORK 11111 REMITTANCE NO: 070806000006 PRESCRIP CLIENT ID CLIENTSERVICE TION NO. ITEM CODE QUANTITY NUMBER NAMEDATETCNCHARGED PAID STATUS ERRORS 0042663 00002411260 5.000 BB12345K FREDERICKS 04/15/07 07267-000000437-2-1100.00100.00 PAID 0042663 00002411260 5.000 BB12345K FREDERICKS 04/15/07 07188-000000437-2-2 10.00 80.00- ADJT ORIGINAL 0426722 00904391660 1.000 BB12345K FREDERICKS 05/25/07 07267-000000562-0-0 5.91 5.91 PAID 0426711 00002411260 1.000 CG54321J CARRS05/10/07 07267-000000260-0-0 28.97 28.97 PAID 0426712 00002411260 1.000 CG54321J CARRS05/20/07 07267-000000263-0-0 50.00 50.00 PAID * = PREVIOUSLY PENDED CLAIM * = NEW PEND TOTAL AMOUNT ORIGINAL CLAIMSPAID84.88NUMBER OF CLAIMS3 NET AMOUNT ADJUSTMENTS PAID 90.00NUMBER OF CLAIMS1 NET AMOUNT VOIDS PAID 0.00NUMBER OF CLAIMS0 NET AMOUNT VOIDS - ADJUSTS 20.00NUMBER OF CLAIMS1 Version 2009 - 1 (10/01/09) Page 41 of 54 MEDICAL ASSISTANCE (TITLE XIX) PROGRAM TO: CITY PHARMACY REMITTANCE STATEMENT PHARMACY 111 PARK AVENUE PROV ID: 00123456/1123456789
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