ABCDEFGHIJKLMNOPQ
2
Pivot Point Counseling, LLCProvider TIN/NPI #46-5581549
3
4
 Patient DOBPrefixPlatform*Membership#*Patient Last Name*Patient First Name*From Date*Thru DateProvider Number* Claim # *Proc/Rev/HCPC Code* Billed Amount*Provider Comments* (Select Issue)PR Audit IndicatorCase Comments (Free Form) add all case and control numbersReference #:
5
10/24/2008XIKFACETS XIK904850990KellyNoah12/3/2412/3/241043044977 G0081752120099205
+90838		270.76Authorization IssueProvider is in network but continues to be rejected as though they are not credentialed
6
03/08/2010XIMFACETS XIM904787838GarciaMaziel12/27/2412/27/241043044977G0081744570099205
+90838		270.76Authorization IssueProvider is in network but continues to be rejected as though they are not credentialed
7
02/22/1991XIMFACETS XIM996994201SlyghJoseph2/11/252/11/251043044977G0481F20750099205
+90838		270.76Authorization IssueProvider is in network but continues to be rejected as though they are not credentialed
8
04/08/1992QXLFACETS QXL960278601DarlingtonJohn11/22/2511/22/251043044977F3391934590099205
+90838
+99417		335.96Authorization IssueProvider is in network but continues to be rejected as though they are not credentialed
9
03/16/2004XIKFACETS XIK904779695WysongAllison1/28/251/28/251043044977G0291985810099205
+90838		275.99Authorization IssueProvider is in network but continues to be rejected as though they are not credentialed
10
05/28/1997XIBFACETSXIB928779312RubioBenjamin2/26/252/26/251043044977G0591C03140099205148.80Authorization IssueProvider is in network but continues to be rejected as though they are not credentialed
11
04/06/2004XIBFACETS XIB961623701BurillJasper11/15/2511/15/251043044977 F3231G23020099205
+90838		344.36Authorization IssueProvider is in network but continues to be rejected as though they are not credentialed
12
11/7/2001XIKFACETS XIK925723322CameronKristen5/20/255/20/251043044977G1431A78920099205
+90838
+99417		295.48Authorization Issue
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101