EFTA00311382.pdf

Unitedltealthears Insurance Company GREENSBORO SMALL GROUP P 0 BOX 740800 ATLANTA. GA 30374-0800 May 12, 2015 JEFFREY EPSTEIN 6100 RED HOOK QUARTER B-3 ST THOMAS VI 00802-0000 Dear Jeffrey Epstein: UnitedHealthcare Claim Information Patient: Jeff roy Epstein Maine Acct.: 1 15289 LH Date of Service: 07/28/2014 Provider. Minnick Cannavo, MD. Claim IM 854905597/EG108422 Claim 0: 4791351186 Member. MemberID: ;Group: I Group.: Letter IO: Jeffrey Epstein 854905597 SOUTH3N TRUST COMDAilf GA272805/1W000 OVP7001 We make every effort to process claims accurately, but sometimes errors occur. We overpaid you on a claim for you and need a refund. Please repay us 51,797.22 within 45 days of the date on this letter. Thank you and we apologize for any inconvenience this causes you Claim overpayment details • Reason for owirpayment: We didn't pay the correct amount for this service. • Check date: 11/12/14 • Check number. QC09089752 • Amount of check sent to you: $1,797.22 (This amount may include other claim payments.) • Correct amount paid for this claim: $0.00 • Patient responsibility (what you owe) for this claim: $0.00 Mail your payment and this letter to: GREENSBORO SMALL GROUP P 0 BOX 740800 ATLANTA. GA 30374-0800 We suggest you keep a copy for,. r cords. If we do not get the refund. some state laws may allow us to deduct the amount due from future claim payments. You may have additional rights about this claim. For more information or further explanation, please check your Health Statement, Explanation of Benefits or other courage documents. If you haw questions about this letter or other questions related to your health insurance, please call the toll-free member phone number listed on your health plan ID card. Sincerely. UnitedHealthcare EFTA00311382 EFTA00311383 eme UnitedHealthcare Insurance Company GREENSBORO SMALL GROUP P O BOX 740800 ATLANTA, GA 30374-0800 UnitedHealtticard a A lbstelmith Ova OATS, Have more questions about your darn? Visit www.myuhc.com for all your claim and benefit intormafon. es s.7 134BADADORUKGPS0002001-05106-01 JEFFREY EPSTEIN 6100 RED HOOK QUARTER B-3 ST THOMAS, VI 00802 May 13, 2015 Member/Patient Information Member/Patient: JEFFREY EPSTEIN Member ID: A854905597 Relationship: EE Group Name: SOUTHERN TRUST COMPANY Group St 0272605 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Claims Summary Detailed claim information is located on the following page(s). Dollar Amount Description Amount Billed $6,422.82 This is the total amount that your provider billed for the services that were provided to you. Plan Discounts $600.00 Your plan negotiates discounts with providers to save you money. This amount may also include services that you are not responsible to pay. Your Plan Paid $5,822.82 This is the portion of the amount billed that was paid by your plan. C Total amount you owe the provideds) ..) The portion of the Amount Billed you owe the provider(s). This amount does not reflect any $0.00 payment you may have already made at the time you received care. This amount may include your deductible, co-pay, coinsurance and/or non covered charges. This amount does not include any payments made to the subscriber. If a payment was made directly to the subscriber, you/the subscriber is responsible for paying the physician, facility or other health care professional. ' Men coordination of benefits applies, this amount will include payments made to the subscriber. STD-EOB 000:0070i573301 Use this EOB statement as a reference or retain as needed Page 1 of 4 EFTA00311384 5A0:0:0011:0:048 I/O 15131617f0-AFJ t2SP4 UntiedHealthcare Insurance Company GREENSBORO SMALL GROUP AP O BOX 74O8O0 800 Phone: UnitedHealthcare 0 May 13. 2015 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY EPSTEIN Provider O CANNAVO Claim Number 479135118601 Patient Account Number: 1 15289 UH Date(s) of Service Type of Service Notes' Amount Billed (-) Plan Discounts (9 Your Plan Paid (4) Deductible Your itemized Res sibir to Provider Amount You N) Copay (•) Coinsurance N) Mon Covered ("9 Owe 07/28/2014 ANESTHESIA IT $8.000.00 $600.00 $5400.00 $0.00 $0 00 $000 $0.00 $0.00 Claim Total: 0.000.00 $100.00 $5.400.00 $0.00 $0.00 $0.00 NOM $0.00 Claim Detail for JEFFREY EPSTEIN Provider. D CANNAVO Claim Number: 479135118601 Date(s) of Type of Service Notes' Amount Plan Your Plan Service Billed (9 Discounts (4 Paid (4) 07/28,2014 CLM EXPENSE INTEREST 5U $422.82 $0.00 $422.82 Claim Total: $422.52 $0.00 $422.82 Notes* SU - THIS AMOUNT REPRESENTS INTEREST PAID. "This total does not reflect any payments / copays you made at the time of service Please wait for a provider biN before making a payment Patient Account Number: 1 15289 UH Your Itemized Res•onsibilit to Provider' Amount You Deductible (-; Copay (-) Coinsurance i-) Non Covered l') Owe "This total does not reflect any payments / copays you made at the time of service Please wait for a provider bill before making a payment. $000 $0.50 IT - THIS PHYSICIAN OR HEALTH CARE PROVIDER IS OUT-OF-NETWORK. BASED ON AN AGREEMENT WITH MULTIPLAN, THE PROVIDER HAS ACCEPTED A DISCOUNT FOR THIS SERVICE. THE DISCOUNT SHOWN IS YOUR SAVINGS AND IS NOT INCLUDED IN THE AMOUNT YOU OWE. IF YOU HAVE PAID THE PHYSICIAN OR HEALTH CARE PROVIDER MORE THAN THE AMOUNT YOU OWE, PLEASE CALL THEM FOR A REFUND. STD-EOB Use this EO8 statement as a reference or retain as needed Page 2 of4 0000:0704673307 EFTA00311385 BLOX09'0750(04410-15133-817/0.SJ 125N UnitedHealthcare Insurance Company GREENSBORO SMALL GROUP P O BOX 740800 OO Phone: UnitedilealthcarE AtraiOSO TISICAMMY May 13, 2015 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit Information. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30573, Salt Lake City, UT 84130-0573. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review not later than 30 days atter we receive your request for review. If your plan is governs by ERISA, you may have the right to file a civil action under ERISA If all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the appeal address referenced above. You may request copies (free of charge) of information relevant to your claim by contacting us at the above address. S a tr, Availability of Consumer Assistance/Ombudsman Services There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration atSil. If your plan is not govemed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team eta. Your state consumer ae-sistance program may also be able to assist you at Division of Banking and Insurance 1131 King Street, Suite 101 Christiansted, St. Croix, VI 00820 www.ltg.gov.vi If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call- Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and morel For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc In the same session. Navigate to www.myuhc.com to register, The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). STD-EOO Use this EOB statement as a reference or retain as needed Page 3 of 4 IX030T10.673107 EFTA00311386 BAC0)9P07000350 143 15133-6170-AFJ 1294 UnitedHealthcare Insurance Company GREENSBORO SMALL GROUP P O BOX 740800 Pho hone: UnitedHealthcare Allwatlit Cauglatel May 13, 2015 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Maintaining the privacy and security of individuals' personal information is very important to us at UnitedHealthcare. To protect your privacy, we implemented strict confidentiality practices. These practices include the ability to use a unique individual identifier. You may see the unique individual identifier on UnitedHealthcare correspondence, including medical ID cards (if applicable), letters, explanation of benefits (EOBs), and provider remittance advices (PRAs). If you have any questions about the unique individual identifier or its use, please contact your customer care professional at the number shown at the top of this Statement. Please call the number included in this document or on the back of your ID card if you need diagnosis and/or treatment code information regarding the services referenced in this communication. Summary of Deductible and Out of Pocket Plan Year: 2014 JEFFREY Annual (-)Applied to Amount Date Relationship: EE IN NETWORK Out of Pocket 52.500.00 $200.00 52.300 03 OUT OF NETWORK OUT OF NETWORK Deductible $1,000.00 $500.00 $500.00 Deductible $50000 $500.00 Met Out of Pocket $10.030.00 $1,125.03 59,974 .97 Out of Pocket 55.000.00 $1.142.19 $3.057.81 Account Summary (=)Remaining Balance FAMILY IN NETWORK Annual HApplied to (w)Remaining Amount Date Balance Out of Pocket $5,000.00 $200.00 $4,800.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement Out of Pocket The out of pocket maximum is the dollar amount you pay before your plan benefit starts paying at 100% for eligible health care services. Please refer to your plan documents for specific information on what costs apply to the maximum amount STD-EOB Doductibler The deductible is the faced dollar amount that you pay each year toward efigible health care services before your plan benefits are payable. Once the deductible has been met the co-payment and/or coinsurance period of your plan may begin. Please refer to your plan documents for specific information regarding what services apply to the deductible. Plan Year. The dates your plan benefit maximums are applicable. Use this EOB statement as a reference or retain as needed Page 4 of 4 010000704671307 EFTA00311387 ISMAR1 100 I Won UnitedHeatthcare Insurance Company GREENSBORO SMALL GROUP P 0 BOX 740800 ATLANTA, GA 30374-0800 UnitedHealthcard A UNSHIlittfrallCarin Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. 131 BADADORUFIGPS0002001-05106 -03 JEFFREY EPSTEIN 6100 RED HOOK QUARTER B-3 ST THOMAS. VI 00802 May 13, 2015 Member/Patient Information Member/Patient- JEFFREY EPSTEIN Member ID: A854905597 Relationship: EE Group Name: SOUTHERN TRUST COMPANY Group 0: 0272805 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Claims Summary Detailed claim information is located on the following page(s). c Dollar Amount Description Amount Billed 51,796.94 This is the total amount that your provider billed for the services that were provided to you. Plan Discounts $1,432.98 Your plan negotiates discounts with providers to save you money. This amount may also include services that you are not responsible to pay. Your Plan Paid $251.40 This Is the portion of the amount billed that was paid by your plan. Total amount you owe the provider(s) The portion of the Amount Billed you owe the provider(s). This amount does not reflect any payment you may have already made at the time you received care. This amount may include your deductible, co-pay, coinsurance and/or non covered charges. This amount does not indude any payments made to the subscriber. If a payment was made directly to the subscriber, you/the subscriber Is responsible for paying the physician, facility or other health care professional. ' Wien coordination of benefits applies, this amount will include payments made to the subscriber. STD-EOB 000000701673311 Use this EOB statement as a reference or retain as needed Page 1 of 7 EFTA00311388 BA4:00100190X62a/D-15113-81763.AFJ 12SN UnitedHealthcare Insurance Company GREENSBORO SMALL GROUP P O BOX 740800 ATLANTA t. :137 1400 Phone: Unitedllealthcare kle.sOkedargaaref May 13, 2015 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY EPSTEIN Provider. QUEST DIAGNOSTICS Claim Number: 504161738801 Patient Account Number 156189349 Date(s) of Service Type of Service Notes' Amount Billed (9 Plan Discounts (4 Your Plan Paid (a) Dnductible Your Itemized Res. •nsibll to Provider (*) Copay (•) Coinsurance (•) Non Covered (=) i Amount You Owe 04/24/2015 LABORATORY SERVICES FT $18.35 $15.35 $2.40 $0.00 $0 .00 SO 60 SO 00 $0.60 04/24/2015 LABORATORY SERVICES FT $234.16 $188.04 $36.90 $0.00 $0.00 $9.22 $0.00 $922 04/2492015 LABORATORY SERVICES IT $9329 $75.58 314.17 $0.00 $0.00 $3.54 $0.00 $3.54 04/24/2015 LABORATORY SERVICES IT $232.54 $192.67 $31.90 $0.00 $0.00 $7.97 $0.00 $7.97 04/24/2015 LABORATORY SERVICES IT $110.77 $90.55 $16.18 $0.00 $0.00 $4.04 $0.00 $4.04 04/24/2015 LABORATORY SERVICES IT $71.39 $58.36 $10.42 $0.00 $0.00 $2.61 $0.00 $2.61 Claim Total: $760.50 4620.56 $111.97 SO.00 $0.00 $27.95 $0.00 $27.98 STD•EOB "This total does not reflect any payments / copays you made at the time of service Please wait for a provider bill before making a payment. Use this EOB statement as a reference or retain as needed Page 2 of 7 000000701873311 EFTA00311389 GAC:010•02•000:61.MD.15133.111783.AFJ 129.1 JnitedHealthcare Insurance Company 3REENSBORO SMALL GROUP 2 O BOX 740800 kTLANiii..4.800 Phone: Unitedflealthcar Aurits...swenv May 13. 2015 Have more questions about your dalm? Visit www.myuhc.com for all your daim and benefit information. Claim Detail for JEFFREY EPSTEIN Provider: QUEST DIAGNOSTICS Claim Number 5O4161738802 Patient Account Number: 156189349 Date(s) of Service Type of Service Notes' Amount Billed (4 Plan Discounts (4 Your Plan Paid (m) Deductible 50 .00 Your Itemized Res (a') Copy 30,00 nalbil to Provider (.) Coinsurance (•) Non Covered (-) $0 .00 Amount You Owe 311231 04/24/2015 LABORATORY SERVICES IT $21897 $162.80 $44.94 $1123 04/24/2015 LABORATORY SERVICES IT $159.89 $133.52 $2110 $0.00 $0.00 $5.27 $0.00 $527 Claim Total: $376.66 $21111.32 $88.04 $0.00 s0.00 $18.5. $0.00 $16.50 STD-E08 'This total does not reflect any payments / °spays you made at the time of senfice. Please wait for a provider bill before making a payment Use this EOB statement as a reference or retain as needed Page 3 of 7 000000704573311 EFTA00311390 BACC01097=054410.15133.6170-AFJ UnitedHealthcare Insurance Company GREENSBORO SMALL GROUP P O BOX 740800 ATLANTA 1.11.100 Phone- UnitedHealthcare 0 A Urnalwil 0.04 UMW/ May 13, 2015 Have more questions about your claim? Visit wvnv.myuhc.com for al your claim and benefit information. Claim Detail for JEFFREY EPSTEIN Provider: GUEST DIAGNOSTICS Claim Number 504181738901 Date(s) of Type of Service Notes• Amount Plan Service Billed (4 Discounts (-) 04/242015 LABORATORY IT 3151.35 Si 16.88 SERVICES 04/24/2015 LABORATORY IT $211.45 $176.69 SERVICES 04/24/2015 LABORATORY IT $144.47 $132.41 SERVICES 04/24/2015 LABORATORY 14 $49.75 $0 00 SERVICES 04/24/2015 LABORATORY IT $3425 $31.29 SERVICES 04/24/2015 LABORATORY IT $8581 $58.84 SERVICES Claim Total: $657.58 $611.11 Notes* Your Plan Paid (s $27.58 $27.81 $9.85 $0.00 $2.93 $5.42 $73.39 Patient Account Number 156189349 e•.ucGDl• r-. Your lionized Res nsl • C••ay . to Provider • " a *0.00 $6.89 $0.00 . $0.00 $0.00 $8.95 $0.00 $8 $0.00 $0.00 52.41 $0.00 $2.41 $0.00 $0 .00 $0.00 $49.75 $49. $0.00 $0.00 $073 $0.00 $0. $0.00 $0.00 $1.35 $0.00 $1 0.00 $0.011 110.33 $49.75 $68.1. This total does not reflect any payments / copays you made at the time of service. Please wait fore provider bill before making a payment. 14 - PAYMENT FOR THIS SERVICE OR SUPPLY IS DENIED BASED ON OUR REIMBURcFUFNT POLICY. THIS SERVICE WAS INCLUDED *I A SERVICE ALREADY REPORTED OR TT IS NOT PAID SEPARATELY. IF YOU USED A NETWORK PROVIDER, YOU DON'T OWE ANYTHING. - THIS PHYSICIAN OR HEALTH CARE PROVIDER IS OUT-OF-NETWORK. BASED ON AN AGREEMENT VVM-I MULTIPLAN, THE PROVIDER HAS ACCEPTED A DISCOUNT FOR THIS SERVICE. THE DISCOUNT SHOWN IS YOUR SAVINGS AND IS NOT INCLUDED IN THE AMOUNT YOU OWE. IF YOU HAVE PAID THE PHYSICIAN OR HEALTH CARE PROVIDER MORE THAN THE AMOUNT YOU OWE, PLEASE CALL THEM FOR A REFUND. You have the right to receive, upon request and free of charge, a copy of the internal rule, guideline or protocol that we relied upon in making the non-coverage decision for your claim. STD•EOB Use this EOB statement as a reference or retain as needed Page 4 of 7 00[000704073311 EFTA00311391 BALIC0109311X0554A0.1513341763.AFJ 1734 MitedHealthcare Insurance Company 3REENSBORO SMALL GROUP O BOX 740800 Thone: VILANSS30 -0800 UnitedHeakhcare PUN!~ &ROCS/ May 13. 2015 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30573, Salt _ake City, UT 84130-0573. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, Ne will complete our review not later than 30 days after we receive your request for review. f your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician. may appeal the decision by submitting comments, documents or other relevant information to :he appeal address referenced above. You may request copies (free of charge) of information relevant to your claim by contacting us at the above address. Availability of Consumer Assistance/Ombudsman Services There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at Your state consumer assistance program may also be able to assist you at: Division of Banking and Insurance 1131 King Street, Suite 101 Christiansted, St. Croix, VI 00820 www.ltg.gov.vi If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an extemal review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call Meet Your Needs Online Al almost anytime day or night, you can review claims, check efigibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). STD-EOB Use this EOB statement as a reference or retain as needed Page S of 7 OCOX47046733 I I I I 11111111111111 EFTA00311392 EFTA00311393 Unite dHeeithcare insurance Company GREENSBORO SMALL GROUP P 0 BOX 740800 ATLANTA. GA 30374-0800 UnitedHealthcare' MEE =re May 14, 2015 Claim Information Patient: Jaffrey Epstein I Patient Acct VV07208913 Date of Service: 04/22/2015 JEFFREY EPSTEIN Provider: M3unt Sinai Hosptal ; Claim Mk 8549055971E/008273 =cm 6100 RED HOOK QUARTER B-3 Claim II: 5035975308 ST THOMAS VI 00802-0000 i Member: Jell ray Epstein Member ID: 854905597 Group: SOUTieN TRUST coMPANw Group f: GA272605flM000 Dear Jeffrey Epstein: • Letter ID: SUBR004 We received a claim for you for health care services on 04/22/2015. Before we can process the claim, we need to know if these services were related to an accident or injury. We work with Optume on accident and injury claims to determine if we are to pay the claim or another insurance company is responsible, such as auto insurance or workers compensation. If you have already been in contact with Opium or completed a questionnaire from UnitedHealthcare about this claim, please ignore this letter. You may receive additional letters if there is more than one claim related to the accident or injury. You only need to answer the questionnaire once. Please call Opium toll-free ate between 7 a.m. and 7 p.m. Central Time. Have the intimation below when calling. Is the claim due to an accident or injury? Yes or No. 1. If yes, you will be asked details about the accident or injury, including where or when it happened and when the condition started. 2. You will also be asked about any other insurance, such as auto or workers compensation What will happen next with your claim We are holding your claim for 45 days so that you are able to provide us with the intimation needed. • Once we get the information, we will process the claim within 15 days. • If you do not respond within 45 days, unfortunately, we may have to deny the claim because of the missing information. We must process claims within time periods required by federal and state regulations. Thank you for your help. We look forward to taking care of this for you as quickly as possible. Sincerely. UnitedHealthcare EFTA00311394 EFTA00311395 GREENSBORO SMALL GROUP P O BOX 740800 ATLANTA, GA 30374-0800 www.myuhc.com Address Change? Please contact your employerb benefit department 13aositaiNuriCcSDoc2001-osicitbi JEFFREY EPSTEIN 6100 RED HOOK QUARTER B-3 ST THOMAS VI 00802 UnitedHealthcar6 Urrbowet. CMS? Croy UritedHealthcare Insurance Company THIS IS NOT A BILL Member ID 854905597 Statement Period 04/22/15 - 05/13/15 Customer Care Wear Sunglasses Ultraviolet (UV) rays from the sun cannot only hurt your skin but your eyes, too. Strong sunlight can bum the corneas of your eyes and long-term exposure can lead to eye disease. The best way to protect your eyes from the sun is to wear sunglasses designed to screen UV radiation. The good news is that sunglasses do not have to be expensive to be effective. Look for glasses that block 90 to 100 percent of both WA and UVB Eght Medical claims where payments may be needed from you: Claims processed between 04/22/16 to 05/13/15 !04/24/15 services for JEFFREY provided by 'QUEST DIAGNOSTICS i Claim Number: 0504181738801 ;Provider Billed: $780.50 Payments and Discounts: -$732.52 04/24/15 services for JEFFREY provided by 'QUEST DIAGNOSTICS ;Claim Number. 0504181738802 :Provider Billed: $370.80 Payments and Discounts: -$382.36 Pay your provider(s) when t bill •U $27.98 !04/24/15 services for JEFFREY provided by 'QUEST DIAGNOSTICS !Claim Number: 0504181738901 !Provider Baled: $667.56 Payments and Discounts: -$589.50 $10.60 Total: $112.56 For more Information about these claims, please refer to the Explanation of Benefits or Vat: www.rnvuhc.cota. This Is not a NIL Your provider will bill you directly unless you have already paid diem. Please check your records. These charges represent your responcibity as defined by your health benefit plan. They may include your deductible, coma/ranee, or a product or service Ihat is not an eligible expense. II you have coverage with another insurance carrier or Medicare. these charges may not include any product or service in which the other insurance carrier or Medicare was primary. In addition. the amount in the 'Pay your provider(s) when they bill yet: area above may include payments mad. to the subaciber. Please see your coverage documents for more information. Please see the next page for more information Page 1 of 4 UHG•0272605-000726V .P EFTA00311396 Your Deductibles as of 05/13/16 for Plan Year 01/01/16 - 12/31/16 Out-of-Network Annual ARMS Remaining Deductible: The deductible is the feed dollar amount that you pay each year toward eligible heath care services before your plan benefits are payable. Once the deducSs has been met, the co-payment and/or coinsurance 5500.00 $500.00 $0.00I pined of your plan may begin. Plum refer to your plan documents for specific information regarding what services apply to the deductible. JEFFREY Your Out of Pocket Maximums as of 06/13/16 for Plan Year 01/01/15 - 12/31/15 In-Network Out-of-Network Annual Applied Remaining Annual Applied I JEFFREY I FIEFFREY $2,500.00 $0.00 $2,500.00; $6,000.00 5707.81 NONE USED Remaining ■ $4,292.10 Out of Pocket Maximum: The out of pocket maximum is the dollar amount you pay before your plan benefit starts paying at 10041) for eligible health care services. Please refer to your plan documents for specific information on what costs apply to the maimum amount Medical claims where payments are not needed from you: Claims for JEFFREY Processed between 04/22/16 to 06/13/15 07/28/14 services provided byt CANNAVO' Clean Number: 047012e110e01 • THIS CLAM WAS PROCESSED ON 05/12/15. • THIS PHYSICIAN OR HEALTH CARE PROVIDER'S OUT-OF-NETWORK. BASED ON AN AGREEMENT WITH MULTIPLAN, THE PROVIDER HAS ACCEPTED A DISCOUNT FOR THISSEME. THE DISCOUNT SHOWN IS YOUR SAVINGS AND IS NOT INCLUDED IN THE AMOUNT YOU OWE. IF YOU HAVE PAID THE PHYSICIAN OR HEALTH CARE PROVIDER MORE THAN THE AMOUNT YOU OWE, PLEASE CALL THEM FOR A REFUND. r Provider Plan Billed Discount Allowed Amount Health Mari] Paid , 07/28/14 services preAded by T)CANNiWo' Claim Number: 047913611S4101 58,000.00 -$800.00 $5,400.00 -$5,400.00 $422.82 • THIS CLAM WAS PROCESSED ON 05/12/1 S. • THIS AMOUNT REPRESENTS INTEREST PAX). For more information about your claims, please visit: gnew.mvuhc.corg. $422.82 -$422.82 Please see the next page for more information Page 2 of 4 Customer Care UHG•0272605.0007261 I-I, EFTA00311397 1311BADADORUHGPS13002001-06141-02 Get the most out of your plan Website Registration: Register today online at ‘Anonv.mvuhc.corn, so that you can begin using your personal webeitel You'll need your ID card handy to register. The Dynamic Duo Vitemm D and calcium do more than give you strong bones and teeth. Several recent studies show that when taken together. vitamin D and calcium ward off premenstrual syndrome. It can also reduce the risk of colon polyps by up to 36 percent, end reduce the risk of hip fractures by 26 percent On its own, vitamin D may reduce the risk of several cancers and calcium may help lower blood pressure. Add a glass of milk or orange juice to your diet to power up with this dynamic duo! Benefits of taking a walk Taking a walk oan be a refreshing change of pace. The ai can clear your mind and reduce stress, which can be helpful for weight loss. Research shows that stress can increase levels of cortisol, a hormone that may increase appetite and promote fat storage. Getting outside will help to decrease stress levels and feelings of hunger. About Your Rights You have the right to receive, upon request and free of charge, a copy of the internal rule, guideline or protocol that we relied upon In making the non-coverage decision for your claim. Medical or Pharmacy Claims Only A review of this benefit determination may be requested by submitting your appeal to us In writing at the following address: UnitedHealthcare Appeals, P.O. Box 30573, Salt Lake City, UT 84130-0573. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review not later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the appeal address referenced above. You may request copies (free of charge) of information relevant to your claim by contacting us at the above address. Availability of Consumer Assistance/Ombudsman Services There may be other resources available to help you understand the a eals rocess. If our plan is governed by ERISA, you can contact the Employee Benefits Security Administration at If your plan is not governed by ERISA ou can contact the Department of Health and Human Services Health Insurance Assistance Team at . Your state consumer assistance program may also be able to assist you at: Division of Banking and Insurance 1131 King Street, Suite 101 Christiansted, St. Croix, VI 00820 www.ltg.gov.vi If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call Please call the number included in this document or on the back of your ID card if you need diagnosis and/or treatment code information regarding the services referenced in this communication. Please see the next page for more information Page 3 of 4 Customer Care VHC3-02726OS-00072611-P EFTA00311398 Maintain ng the privacy and security of individuals• personal information is very important to se at UndwHeahhcans. To protect your privacy, we implemented auict confidentiality practices. These practices include the ability to use a unique mdrvidual identifier. You may see the unique individual identifier on UnitedHealthcare correspondence, including medical ID cards (if applicable), letters, explanation of benefits (EOBs), and provider remittance advises (PRAs). H you have any questions about the uniq JO individual identifier or its uso, please contact your customs, care prolossional at the number shown at the bottom of ths Statement Contact us Questions? You can reach Customer Cate at our toll free number, Monday enough Friday or log into your personal website at www.rnvuhc COM. Please see the next page for more information Page 4 of 4 Customer Care UHG•0272605.00072611.P EFTA00311399