*------------------- 271 Returned --------------------* ISA*00* *00* *ZZ*822287119 *ZZ*701100357 *190228*1045*^*00501*000025489*0*P*:~ GS*HB*822287119*701100357*20190228*104539*85*X*005010X279A1~ ST*271*0001*005010X279A1~ BHT*0022*11*PROVTest600*20190228*14510000~ HL*1**20*1~ NM1*PR*2*VT MEDICAID*****FI*822287119~ PER*IC*HP Provider Relations*TE*8009251706*TE*8028794450~ HL*2*1*21*1~ NM1*1P*2*McLellan Psychotherapy PLC*****XX*1093292666~ REF*EO*701100357~ HL*3*2*22*0~ TRN*1*0108934574*1822287119~ NM1*IL*1*LAST*FIRST****MI*4012687~ N3*58 CHESTNUT AVE~ N4*RUTLAND*VT*057010000~ DMG*D8*20120321*F~ EB*1*IND*1^33^47^48^86^98^AL^MH^UC*MC*MEDICAID - C4**0~ DTP*307*RD8*20190115-20190115~ EB*1*IND*35^50^88*MC*MEDICAID - C4**0~ DTP*307*RD8*20190115-20190115~ EB*N**96*MC*PCP ANNA MCCLOY~ DTP*307*RD8*20190101-23821231~ HL*4**20*1~ NM1*PR*2*VT MEDICAID*****FI*822287119~ PER*IC*HP Provider Relations*TE*8009251706*TE*8028794450~ HL*5*4*21*1~ NM1*1P*2*McLellan Psychotherapy PLC*****XX*1093292666~ REF*EO*701100357~ HL*6*5*22*0~ TRN*1*0108934575*1822287119~ NM1*IL*1*LAST2*FIRST2*M***MI*1685312~ N3*294 WEST STREET~ N4*RUTLAND*VT*057010000~ DMG*D8*20050722*F~ EB*1*IND*1^33^47^48^86^98^AL^MH^UC*MC*MEDICAID - C4**0~ DTP*307*RD8*20190115-20190115~ EB*1*IND*35^50^88*MC*MEDICAID - C4**0~ DTP*307*RD8*20190115-20190115~ EB*N**96*MC*PCP ALLISON ADAMS~ DTP*307*RD8*20160601-23821231~ HL*7**20*1~ NM1*PR*2*VT MEDICAID*****FI*822287119~ PER*IC*HP Provider Relations*TE*8009251706*TE*8028794450~ HL*8*7*21*1~ NM1*1P*2*McLellan Psychotherapy PLC*****XX*1093292666~ REF*EO*701100357~ HL*9*8*22*0~ TRN*1*0108934576*1822287119~ NM1*IL*1*LAST3*FIRST3*S***MI*1707327~ N3*419 OLD TURNPIKE RD*B~ N4*MOUNT HOLLY*VT*057580000~ DMG*D8*20061203*F~ EB*1*IND*1^33^47^48^86^98^AL^MH^UC*MC*MEDICAID - C0**0~ DTP*307*RD8*20190115-20190115~ EB*1*IND*35^50^88*MC*MEDICAID - C0**0~ DTP*307*RD8*20190115-20190115~ EB*F**30*MC*EXHAUSTED SERVICE LIMIT FOR INTERIM VISUAL EXAM.*30~ DTP*307*D8*20190115~ EB*F**30*MC*EXHAUSTED SERVICE LIMIT FOR VISUAL COMP. EXAM.*30~ DTP*307*D8*20190115~ EB*F**30*MC*EXHAUSTED SERVICE LIMIT FOR FRAME FITTING.*30~ DTP*307*D8*20190115~ EB*F**30*MC*EXHAUSTED SERVICE LIMIT FOR EYEGLASS FRAMES.*30~ DTP*307*D8*20190115~ EB*F**30*MC*EXHAUSTED SERVICE LIMIT FOR EYEGLASS LEFT LENS.*30~ DTP*307*D8*20190115~ EB*F**30*MC*EXHAUSTED SERVICE LIMIT FOR EYEGLASS RIGHT LENS.*30~ DTP*307*D8*20190115~ HL*10**20*1~ NM1*PR*2*VT MEDICAID*****FI*822287119~ PER*IC*HP Provider Relations*TE*8009251706*TE*8028794450~ HL*11*10*21*1~ NM1*1P*2*McLellan Psychotherapy PLC*****XX*1093292666~ REF*EO*701100357~ HL*12*11*22*0~ TRN*1*0108934577*1822287119~ NM1*IL*1*LAST4*FIRST4*R***MI*1677546~ N3*PO BOX 343~ N4*RUTLAND*VT*057020000~ DMG*D8*20030826*F~ EB*1*IND*1^33^47^48^86^98^AL^MH^UC*MC*MEDICAID - C4**0~ DTP*307*RD8*20190115-20190115~ EB*1*IND*35^50^88*MC*MEDICAID - C4**0~ DTP*307*RD8*20190115-20190115~ EB*N**96*MC*PCP STEPHEN WOOD~ DTP*307*RD8*20181101-23821231~ HL*13**20*1~ NM1*PR*2*VT MEDICAID*****FI*822287119~ PER*IC*HP Provider Relations*TE*8009251706*TE*8028794450~ HL*14*13*21*1~ NM1*1P*2*McLellan Psychotherapy PLC*****XX*1093292666~ REF*EO*701100357~ HL*15*14*22*0~ TRN*1*0108934578*1822287119~ NM1*IL*1*LAST5*FIRST5****MI*3519405~ N3*109 TABOR RD*C/O FIRSTPARENT LASTPARENT~ N4*SHREWSBURY*VT*057380000~ DMG*D8*20060724*F~ EB*1*IND*1^33^47^48^86^98^AL^MH^UC*MC*MEDICAID - F5**0~ DTP*307*RD8*20190115-20190115~ EB*1*IND*35^50^88*MC*MEDICAID - F5**0~ DTP*307*RD8*20190115-20190115~ EB*N**96*MC*PCP THEODORE JOHNSON~ DTP*307*RD8*20161101-23821231~ HL*16**20*1~ NM1*PR*2*VT MEDICAID*****FI*822287119~ PER*IC*HP Provider Relations*TE*8009251706*TE*8028794450~ HL*17*16*21*1~ NM1*1P*2*McLellan Psychotherapy PLC*****XX*1093292666~ REF*EO*701100357~ HL*18*17*22*0~ TRN*1*0108934579*1822287119~ NM1*IL*1*LAST6*FIRST6*E***MI*1666143~ N3*19 CHATTERTON PARK~ N4*PROCTOR*VT*057650000~ DMG*D8*20000207*F~ EB*1*IND*1^33^47^48^86^98^AL^MH^UC*MC*MEDICAID - C4**0~ DTP*307*RD8*20190115-20190115~ EB*1*IND*35^50^88*MC*MEDICAID - C4**0~ DTP*307*RD8*20190115-20190115~ EB*N**96*MC*PCP MARK MESSIER~ DTP*307*RD8*20170401-23821231~ HL*19**20*1~ NM1*PR*2*VT MEDICAID*****FI*822287119~ PER*IC*HP Provider Relations*TE*8009251706*TE*8028794450~ HL*20*19*21*1~ NM1*1P*2*McLellan Psychotherapy PLC*****XX*1093292666~ REF*EO*701100357~ HL*21*20*22*0~ TRN*1*0108934580*1822287119~ NM1*IL*1*LAST7*FIRST7*S***MI*2577040~ N3*6 JUNEBERRY LANE*APT 209~ N4*RUTLAND*VT*057010000~ DMG*D8*20080316*F~ EB*1*IND*1^33^47^48^86^98^AL^MH^UC*MC*MEDICAID - C4**0~ DTP*307*RD8*20190115-20190115~ EB*1*IND*35^50^88*MC*MEDICAID - C4**0~ DTP*307*RD8*20190115-20190115~ EB*N**96*MC*PCP JAYME HUGHES~ DTP*307*RD8*20170301-23821231~ EB*F**30*MC*EXHAUSTED SERVICE LIMIT FOR VISUAL COMP. EXAM.*30~ DTP*307*D8*23821231~ HL*22**20*1~ NM1*PR*2*VT MEDICAID*****FI*822287119~ PER*IC*HP Provider Relations*TE*8009251706*TE*8028794450~ HL*23*22*21*1~ NM1*1P*2*McLellan Psychotherapy PLC*****XX*1093292666~ REF*EO*701100357~ HL*24*23*22*0~ TRN*1*0108934581*1822287119~ NM1*IL*1*LAST8*FIRST8*D***MI*1647208~ N3*72 LIDSTONE LANE~ N4*WALLINGFORD*VT*057730000~ DMG*D8*20050127*F~ EB*1*IND*1^33^47^48^86^98^AL^MH^UC*MC*MEDICAID - C4**0~ DTP*307*RD8*20190115-20190115~ EB*1*IND*35^50^88*MC*MEDICAID - C4**0~ DTP*307*RD8*20190115-20190115~ EB*N**96*MC*PCP INDRA LOVKO~ DTP*307*RD8*20111201-23821231~ EB*F**30*MC*EXHAUSTED SERVICE LIMIT FOR INTERIM VISUAL EXAM.*30~ DTP*307*D8*23821231~ EB*F**30*MC*EXHAUSTED SERVICE LIMIT FOR VISUAL COMP. EXAM.*30~ DTP*307*D8*23821231~ SE*163*0001~ GE*1*85~ IEA*1*000025489~ Subscriber Member: FIRST LAST Account: 4012687 ---* Benefit Type: Active Coverage Start Date: 2019-01-15 End Date: 2019-01-15 Coverage Level: IND Coverage Type: 1^33^47^48^86^98^AL^MH^UC Plan Type: Medicare Part C Plan Description: MEDICAID - C4 Benefit Type: Active Coverage Start Date: 2019-01-15 End Date: 2019-01-15 Coverage Level: IND Coverage Type: 35^50^88 Plan Type: Medicare Part C Plan Description: MEDICAID - C4 Benefit Type: N Start Date: 2019-01-01 End Date: 1969-12-31 Coverage Type: 96 Plan Type: Medicare Part C Plan Description: PCP ANNA MCCLOY Subscriber Member: FIRST2 LAST2 M Account: 1685312 ---* Benefit Type: Active Coverage Start Date: 2019-01-15 End Date: 2019-01-15 Coverage Level: IND Coverage Type: 1^33^47^48^86^98^AL^MH^UC Plan Type: Medicare Part C Plan Description: MEDICAID - C4 Benefit Type: Active Coverage Start Date: 2019-01-15 End Date: 2019-01-15 Coverage Level: IND Coverage Type: 35^50^88 Plan Type: Medicare Part C Plan Description: MEDICAID - C4 Benefit Type: N Start Date: 2016-06-01 End Date: 1969-12-31 Coverage Type: 96 Plan Type: Medicare Part C Plan Description: PCP ALLISON ADAMS Subscriber Member: FIRST3 LAST3 S Account: 1707327 ---* Benefit Type: Active Coverage Start Date: 2019-01-15 End Date: 2019-01-15 Coverage Level: IND Coverage Type: 1^33^47^48^86^98^AL^MH^UC Plan Type: Medicare Part C Plan Description: MEDICAID - C0 Benefit Type: Active Coverage Start Date: 2019-01-15 End Date: 2019-01-15 Coverage Level: IND Coverage Type: 35^50^88 Plan Type: Medicare Part C Plan Description: MEDICAID - C0 Benefit Type: Limitation Start Date: 2019-01-15 Coverage Type: Health Plan Benefit Coverage Plan Type: Medicare Part C Plan Description: EXHAUSTED SERVICE LIMIT FOR INTERIM VISUAL EXAM. Coverage Period: 30 Benefit Type: Limitation Start Date: 2019-01-15 Coverage Type: Health Plan Benefit Coverage Plan Type: Medicare Part C Plan Description: EXHAUSTED SERVICE LIMIT FOR VISUAL COMP. EXAM. Coverage Period: 30 Benefit Type: Limitation Start Date: 2019-01-15 Coverage Type: Health Plan Benefit Coverage Plan Type: Medicare Part C Plan Description: EXHAUSTED SERVICE LIMIT FOR FRAME FITTING. Coverage Period: 30 Benefit Type: Limitation Start Date: 2019-01-15 Coverage Type: Health Plan Benefit Coverage Plan Type: Medicare Part C Plan Description: EXHAUSTED SERVICE LIMIT FOR EYEGLASS FRAMES. Coverage Period: 30 Benefit Type: Limitation Start Date: 2019-01-15 Coverage Type: Health Plan Benefit Coverage Plan Type: Medicare Part C Plan Description: EXHAUSTED SERVICE LIMIT FOR EYEGLASS LEFT LENS. Coverage Period: 30 Benefit Type: Limitation Start Date: 2019-01-15 Coverage Type: Health Plan Benefit Coverage Plan Type: Medicare Part C Plan Description: EXHAUSTED SERVICE LIMIT FOR EYEGLASS RIGHT LENS. Coverage Period: 30 Subscriber Member: FIRST4 LAST4 R Account: 1677546 ---* Benefit Type: Active Coverage Start Date: 2019-01-15 End Date: 2019-01-15 Coverage Level: IND Coverage Type: 1^33^47^48^86^98^AL^MH^UC Plan Type: Medicare Part C Plan Description: MEDICAID - C4 Benefit Type: Active Coverage Start Date: 2019-01-15 End Date: 2019-01-15 Coverage Level: IND Coverage Type: 35^50^88 Plan Type: Medicare Part C Plan Description: MEDICAID - C4 Benefit Type: N Start Date: 2018-11-01 End Date: 1969-12-31 Coverage Type: 96 Plan Type: Medicare Part C Plan Description: PCP STEPHEN WOOD Subscriber Member: FIRST5 LAST5 Account: 3519405 ---* Benefit Type: Active Coverage Start Date: 2019-01-15 End Date: 2019-01-15 Coverage Level: IND Coverage Type: 1^33^47^48^86^98^AL^MH^UC Plan Type: Medicare Part C Plan Description: MEDICAID - F5 Benefit Type: Active Coverage Start Date: 2019-01-15 End Date: 2019-01-15 Coverage Level: IND Coverage Type: 35^50^88 Plan Type: Medicare Part C Plan Description: MEDICAID - F5 Benefit Type: N Start Date: 2016-11-01 End Date: 1969-12-31 Coverage Type: 96 Plan Type: Medicare Part C Plan Description: PCP THEODORE JOHNSON Subscriber Member: FIRST6 LAST6 E Account: 1666143 ---* Benefit Type: Active Coverage Start Date: 2019-01-15 End Date: 2019-01-15 Coverage Level: IND Coverage Type: 1^33^47^48^86^98^AL^MH^UC Plan Type: Medicare Part C Plan Description: MEDICAID - C4 Benefit Type: Active Coverage Start Date: 2019-01-15 End Date: 2019-01-15 Coverage Level: IND Coverage Type: 35^50^88 Plan Type: Medicare Part C Plan Description: MEDICAID - C4 Benefit Type: N Start Date: 2017-04-01 End Date: 1969-12-31 Coverage Type: 96 Plan Type: Medicare Part C Plan Description: PCP MARK MESSIER Subscriber Member: FIRST7 LAST7 S Account: 2577040 ---* Benefit Type: Active Coverage Start Date: 2019-01-15 End Date: 2019-01-15 Coverage Level: IND Coverage Type: 1^33^47^48^86^98^AL^MH^UC Plan Type: Medicare Part C Plan Description: MEDICAID - C4 Benefit Type: Active Coverage Start Date: 2019-01-15 End Date: 2019-01-15 Coverage Level: IND Coverage Type: 35^50^88 Plan Type: Medicare Part C Plan Description: MEDICAID - C4 Benefit Type: N Start Date: 2017-03-01 End Date: 1969-12-31 Coverage Type: 96 Plan Type: Medicare Part C Plan Description: PCP JAYME HUGHES Benefit Type: Limitation Start Date: 1969-12-31 Coverage Type: Health Plan Benefit Coverage Plan Type: Medicare Part C Plan Description: EXHAUSTED SERVICE LIMIT FOR VISUAL COMP. EXAM. Coverage Period: 30 Subscriber Member: FIRST8 LAST8 D Account: 1647208 ---* Benefit Type: Active Coverage Start Date: 2019-01-15 End Date: 2019-01-15 Coverage Level: IND Coverage Type: 1^33^47^48^86^98^AL^MH^UC Plan Type: Medicare Part C Plan Description: MEDICAID - C4 Benefit Type: Active Coverage Start Date: 2019-01-15 End Date: 2019-01-15 Coverage Level: IND Coverage Type: 35^50^88 Plan Type: Medicare Part C Plan Description: MEDICAID - C4 Benefit Type: N Start Date: 2011-12-01 End Date: 1969-12-31 Coverage Type: 96 Plan Type: Medicare Part C Plan Description: PCP INDRA LOVKO Benefit Type: Limitation Start Date: 1969-12-31 Coverage Type: Health Plan Benefit Coverage Plan Type: Medicare Part C Plan Description: EXHAUSTED SERVICE LIMIT FOR INTERIM VISUAL EXAM. Coverage Period: 30 Benefit Type: Limitation Start Date: 1969-12-31 Coverage Type: Health Plan Benefit Coverage Plan Type: Medicare Part C Plan Description: EXHAUSTED SERVICE LIMIT FOR VISUAL COMP. EXAM. Coverage Period: 30