Meziel Dennis Morales

ORTHO INSURANCE BREAKDOWN DATE: 09/08/2020 REP NAME: Latishia REFERENCE #: D6617 TEAM MEMBER: Meziel Dennis NOTES PATIENT INFORMATION PATIENT FIRST NAME PATIENT LAST NAME PATIENT DOB SUBSCRIBER FIRST NAME SUBSCRIBER LAST NAME RELATIONSHIP TO PATIENT SUBSCRIBER DOB SUBSCRIBER SSN OR ID # GROUP # GROUP/EMPLOYER NAME INSURANCE INFORMATION INSURANCE CARRIER Blue Shield pf CA INSURANCE PHONE # - INSURANCE ADDRESS P.O BOX 30567 Salt Lake City, UT- INSURANCE PAYOR ID # 52133 IN OR OUT OF NETWORK IN EFFECTIVE DATE CALENDAR OR CONTRACT YEAR MAXIMUM PERCENTAGE Pediatric Plan 06/01/2020 CALENDAR CONTRACT YEAR: NO MAXIMUM 50% DEDUCTIBLE WAIVED NONE YEAR TO DATE USED $0.00 if only medically necessary / subject to review WAITING PERID NO AGE LIMIT 19 FULL TIME STUDENT NO ADULT COVERAGE NO AGE? TX IN PROGRESS COVERED NO 10%inital pay and followed by the payment frequencies PHASE 1 COVERED (8050/8060) NO LIMITED TX COVERED (8030/8040) NO AUTHORIZATION MANDATORY BILL/AUTOPAY BILLING FREQUENCY YES AUTOPAY QUARTERLY