Healeo

Enterprise Health Systems

Healeo Wellness Center

1200 Medical Plaza, Suite 500

San Diego, CA 92101

Phone: (858) 555-2040

Email: billing@healeo.com

Website: www.healeo.com

INVOICE

Invoice Number: INV-2026-10482
Issue Date: March 9, 2026
Due Date: March 23, 2026
Invoice Status: Pending Payment
Account Number: ACC-48291
Patient ID: PT-20481
MRN: MRN-882194

Patient Information

Patient Name Olivia Bennett
Patient ID PT-20481
MRN MRN-882194
Date of Birth February 12, 1991
Billing Address 4827 West Park Ave
San Diego, CA 92110
Mobile Phone (619) 555-1834
Email olivia.bennett@email.com
Guarantor Self

Insurance Information

Insurance Provider BlueCross PPO
Plan Name BlueCross Preferred Silver
Member ID BC-44920184
Group Number GRP-2043
Claim Number CLM-8829184
Claim Status Processed
EOB Reference EOB-2026-33819
Adjudication Summary Claim processed with contractual adjustment applied

Visit / Provider Information

Rendering Provider Dr. Maya Thompson, MD
Supervising Provider Dr. Ethan Cole, MD
Clinic Location Healeo Wellness Center – Downtown
Department Internal Medicine
Date of Service March 6, 2026
Visit Type Follow-Up Consultation
Place of Service Outpatient Clinic
Authorization Number AUTH-29384
Diagnosis Summary Follow-up care and medication management

Service Details

Date of Service CPT/HCPCS Description Dx Code Mod Qty Unit Price Charge Ins. Adj Patient Resp
03/06/2026 99213 Established Patient Office Visit F12.20 25 1 $180.00 $180.00 -$100.00 $80.00
03/06/2026 90833 Medication Management F41.1 95 1 $140.00 $140.00 -$80.00 $60.00
03/06/2026 99000 Administrative Processing Fee N/A — 1 $105.00 $105.00 -$60.00 $45.00
Total Charges $425.00
Insurance Payments -$240.00
Contractual Adjustments -$60.00
Discounts $0.00
Previous Balance $0.00
Payments Received $0.00
Credits Applied $0.00
Outstanding Balance $125.00
Due Date March 23, 2026

Note to Patient

Your insurance has processed this claim. The remaining balance reflects your patient responsibility after insurance payments and contractual adjustments. Please contact Healeo Patient Billing with any questions.

Payment Information

Amount Due $125.00
Payment Terms Due upon receipt / Net 14
Accepted Payment Methods
Credit Card Debit Card ACH Transfer HSA/FSA Card
Online Payment Portal
pay.healeo.com
Billing Support

Healeo Patient Billing

(858) 555-2040

billing@healeo.com

Remittance Address

Healeo Billing Department

PO Box 8292

San Diego, CA 92101

CONFIDENTIAL HEALTHCARE INFORMATION

This document contains protected health information (PHI) subject to HIPAA privacy regulations.

For billing questions, contact Healeo Patient Billing at (858) 555-2040 or billing@healeo.com

Generated: March 9, 2026 at 2:14 PM PST • INV-2026-10482