NORTHSIDE MEDICAL CENTER — PATIENT FINANCIAL SVCS
1420 Elm St · Springfield IL 62704 · TIN 36-2178451 · NPI 1740293857
Billing entity: NMC HOLDINGS LLC dba NORTHSIDE HEALTH SYS
STMT #884213-A/07
CYCLE 03/28/2026
PAGE 1 OF 3
Guarantor / Resp Party
DOE, JOHN A. (GRP 4471-B)
MRN / FIN / Acct
884213 · F-2210049 · 0032178
Payor / Plan
BCBS-IL PPO / PLAN 340B-Q · SUBSCR ID XJK884213-02
DOS / Adm / Disch
03/12/2026 · 14:22 · 20:41
Rev Cd / POS / Type of Bill
0450 · POS-23 · TOB-131
Auth / Ref
PA-77420981 · REF-N/A · CLAIM 20260312-EDX-041
Itemized charges (CPT/HCPCS · Rev · Mod)
99284-25ED VIS HI COMPLX MDM MOD-251,240.00
71046-TCRAD XR CHEST 2VW TECH COMP 318.60
80053COMP METAB PNL CMP 14 ANALYT 184.00
J1885-JWKETOROLAC TROMETH 15MG IV Q6H 102.00
A9270NON-COV SUPPLY NOS (SEE §14.2b) 47.00
99999-FFFACILITY FEE ALLOC UNBUNDLED 410.00
G0463-XUHOSP OUTPT CLINIC ASSMT UNUSL 88.00
ADJ-CO45CONTRACT ADJ (CO-45) -95.00
GROSS CHARGES$2,254.60
PAYOR REMIT (835 · CARC PR-1/PR-2)-412.00
PENDING ADJUD (SUSP CODE 277-A7) 0.00
PAT RESP (COIN+DEDUCT+NONCOV)$1,842.60
*** REMIT DUE ON/BEFORE 04/30/2026 ***
Per §14.2(b) Patient Responsibility Agreement executed at registration, unremitted balances shall accrue a $35.00 non-refundable late processing charge and, at Provider's sole discretion, may be transferred to third-party recovery (FDCPA 15 U.S.C. §1692 compliant). Discrepancies re: 835 remittance / EOB CARC codes must be submitted in writing to Patient Financial Svcs within thirty (30) calendar days pursuant to §7.4(a)(iii). See reverse for HIPAA §164.522 disclosure schedule.
Detach lower portion · return w/ payment · PFS 1-800-555-0142 opt 4 · Ref MRN+STMT#
In plain English
This is a bill from your March 12 ER visit. Insurance already covered most of it — but the hospital is asking you for $1,842.60 by April 30. $412 of that was never actually sent to your insurance, so you'd be paying money you probably don't owe. Call them first, then pay the rest.
- You owe
- $1,842.60
- Pay by
- April 30, 2026
- Safe to pay now
- $1,430.60
- Dispute first
- $412.00
- $412 (code 99284) was never billed to your insurance — don't pay this part yet.
- A $35 late fee kicks in on May 1, plus 1.5% monthly interest after that.
- The letter mentions collections after 90 days — you have time, but don't ignore it.
- 1Call the billing number and say: “Please re-submit CPT 99284 to my insurance before I pay.”
- 2Pay the undisputed $1,430.60 by April 30 so no late fee hits.
- 3If insurance still denies it, ask for the financial assistance or self-pay discount form.
- 4Save your Explanation of Benefits (EOB) — you'll need it if this goes to collections.
- Patient responsibility
- The part your insurance decided you owe — not always final.
- CPT 99284
- The code for a moderately serious ER visit. Insurance uses it to decide payment.
- EOB
- Explanation of Benefits — your insurer's letter showing what they paid and why.