PAGE: 1
ANTHEM BLUE CROSS
P.O. BOX 60007
LOS ANGELES, CA 90060
PROVIDER REMITTANCE DATA
REMITTANCE NOTICE
REPORT DATE: 05/11/2026
PRINT DATE: 05/11/2026
PRINT TIME: 09:18:42 AM
CEDARLINE MEDICAL CENTER, SACRAMENTO
PROVIDER NPI: 1730345829
TAX ID: 94-2788907
2100 HALCYON PARKWAY
SACRAMENTO, CA 95816
DATE: 05/11/2026
CHECK/EFT #: EFT 0094471882
SERV DATE
UNITS
PROC
MODS
BILLED
ALLOWED
DEDUCT
COINS
GRP/RC-AMT
PROV PD
NAME DONNELLY, MARGARET R HIC XEH829104677 ACNT CMCS-202604-073318 TCN 262604188270 ICN ABCX-2026-0418827
0414 041926
5
DRG690
94500.00
14050.00
0.00
0.00
CO-45 61080.00
14050.00
REM: CO-45 — contractual amount above the negotiated case rate.
0414 041926
1
DRG-ADJ
19370.00
0.00
0.00
0.00
CO-50 19370.00
0.00
REM: N527 — additional payment denied; DRG differential adjusted CO-50.
PT RESP 0.00 CLM STATUS 1 CLAIM TOTALS 94500.00 14050.00 0.00 0.00 19370.00 14050.00
ADJ TO TOTALS: INTEREST 0.00 LATE FILING CHARGE 0.00 NET 14050.00
TOTALS:
# OF
CLAIMS
BILLED
AMT
ALLOWED
AMT
DEDUCT
AMT
COINS
AMT
TOTAL
RC-AMT
PROV PD
AMT
PROV
ADJ AMT
CHECK
AMT
1
94500.00
14050.00
0.00
0.00
19370.00
14050.00
0.00
14050.00
GLOSSARY: CLAIM ADJUSTMENT REASON CODES
CO-45
Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
CO-50
These are non-covered services because this is not deemed a 'medical necessity' by the payer.
N527
Medical necessity not established. The payer requires clinical documentation to support the service.