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Hospital StayEOB-2024-001189
Denver General Hospital
Service Date: October 8, 2024
$8,945.67
Total Charged
Financial Breakdown
$8,945.67
Total Charged
$7,834.23
Medicare Paid
$1,111.44
You Paid
$892.00
Deductible Applied
$219.44
Coinsurance Applied
Service Details
Services Provided
| Service | Code | Qty | Charged | Allowed | Paid |
|---|---|---|---|---|---|
| Initial hospital care, high complexity | 99223 | 1 | $567.89 | $445.67 | $445.67 |
| Room and board (3 days) | 0100 | 3 | $2,340.00 | $2,100.00 | $2,100.00 |
| Cardiac catheterization | 93458 | 1 | $4,567.89 | $4,200.00 | $4,200.00 |
| Pharmacy services | 0250 | 1 | $789.45 | $750.00 | $750.00 |
Diagnosis Information
Primary Diagnosis
I25.9
Chronic ischemic heart disease, unspecified
Secondary Diagnoses
E11.9
Type 2 diabetes mellitus without complications
I10
Essential hypertension
Provider Information
- Provider:
- Denver General Hospital
- Provider Type:
- Hospital
- NPI:
- 9876543210
- Facility:
- Denver General Hospital
- Place of Service:
- Inpatient Hospital (21)
Claim Information
- Claim ID:
- EOB-2024-001189
- Service Date:
- October 8, 2024
- End Date:
- October 11, 2024
- Processed Date:
- October 18, 2024
- Status:
- APPROVED
- DRG Code:
- 189
Coverage Analysis
Medicare Coverage
Covered Service
Part AThis service is covered under your Medicare plan. Your deductible of $892.00 was applied.
Cost Breakdown
Provider Charged:$8,945.67
Medicare Allowed:$7,603.82
Medicare Paid:$7,834.23
Deductible Applied:$892.00
Coinsurance (20%):$219.44
Your Responsibility:$1,111.44
AI Analysis
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