0030645 I-20 @ Alpine Road Columbia, SC 29219
This is not a bill.
Any amounts you
may owe your provider should not be sent directly to us. JOHN C LEWIS 19 RAVENSWORTH ROAD
008438 0001 of 0005
TAYLORS SC 29687
SUMMARY EXPLANATION OF BENEFITS Claims Processed from 03/06/13 to 03/26/13
This summary information is for claims processed for patients covered under your Member ID will also find claim(s) details.
March 27, 2013
RVB030494482182
.
You
We produce this report every three weeks. If you have questions about your claims, please
visit our website at www.SouthCarolinaBlues.com or call Customer Service at 800-922-1185 or 800-845-6067 or locally at 864-297-4665 Monday - Thursday 8:00 a.m. - 6:00 p.m. or Friday 8:00 a.m. - 4:30 p.m.
This document outlines your share of the charges for services. You should use this to determine how much you need to pay. If there is a discrepancy, use this summary to discuss the charges with your provider.
Name: JOHN C LEWIS
Patient Relationship to Policyholder:
Amount We Paid Your Provider(s): ALERE HEALTHCARE
1,522.42
BON SECOURS ST FRANCI
4,290.80
THE HAND CENTER
104.40
GHS PIH DBA UMG CANCE
392.81
UPSTATE PATHOLOGY PA
221.40
PALMETTO ANESTHESIA A
422.52
LABCORP GREENVILLE HOSPITAL S
13.05 1,092.43
Amount Your Provider(s) May Bill You: ALERE HEALTHCARE BON SECOURS ST FRANCI
0.00 476.76
THE HAND CENTER
11.60
GHS PIH DBA UMG CANCE
43.64
UPSTATE PATHOLOGY PA
24.60
PALMETTO ANESTHESIA A
46.95
LABCORP GREENVILLE HOSPITAL S
1.45 121.38
Page 1 of 10
SELF
Suspect claims fraud?
Please help us by calling our hotline at 800-763-0703.
Helpful Definitions Allowed Amount - the amount remaining after any non-covered, deductible or copayment amounts have been subtracted from the amount your provider charged. Your coinsurance, if applicable, will be determined from the allowed amount. Amount Not Covered - the amount, if any, for non-covered services or the amount that is above the allowed charge. Please refer to the remarks on the Summary Explanation of Benefits Claim Details section. Amount Paid to You - the amount we paid you, based on your health plan. Amount Paid to Your Provider - the amount we paid your provider, based on your health plan. Amount We Paid - the amount paid by your health plan for the services you received. Amount Your Provider May Bill You - the amount, if any, you need to pay the provider for this claim. There may be times when you owe nothing. Benefit Period - the period of time during which you must pay any deductible and coinsurance payments that may apply. Payment of claims begins once you meet the deductible. If you reach your out-of-pocket amount and deductible limits, we pay covered expenses in full for the rest of the benefit period, minus any copayments. Deductibles and coinsurance start over with each new benefit period. Coinsurance - the percentage of the allowed amount you pay as your share of the bill. If your health plan pays 80 percent, then 20 percent would be your coinsurance. Copayment - a set fee you pay each time you receive a certain service. Some health plans or services do not have copayments. CDHP (Consumer Driven Health Plan) Paid - the amount paid from your Health Reimbursement Account, if applicable. Deductible - the amount, if any, you are responsible for paying before any amount is payable under your health plan. You do not send this amount to us. You must pay this to your provider. We credit you as having paid your deductible on the claims you and providers send to us. Other Insurance Paid - the amount paid by another insurance company toward services you received. Out-of-Pocket Maximum - the highest total amount of coinsurance you will have to pay during a benefit period.
When Medicare Applies Medicare Approved AMT (Amount) - the amount Medicare approves for services you received. Medicare Paid - the amount Medicare paid toward services received. Total Benefit Allowed - the amount we would have paid if another insurance company were not involved.
DID YOU KNOW YOU CAN VIEW YOUR EOBS ONLINE? YOU CAN ALSO CHOOSE NOT TO RECEIVE SUMMARY EOBS IN THE MAIL. LOGIN TO MY HEALTH TOOLKIT AT MEMBER.SOUTHCAROLINABLUES.COM TO CHANGE YOUR MAIL OPTIONS, VIEW EOBS AND MUCH MORE.
Page 2 of 10
0030646 Important Information about Your Appeal Rights
What if I need help understanding this
Who may file an appeal?
denial? Call us at the Customer Service
you name to act for you (your authorized
numbers shown on the first page of your
representative) may file an appeal.
explanation of benefits notice if you need help
designate someone to act on your behalf, you
understanding this notice or our decision to
must complete a HIPAA Authorization form
deny a service or coverage.
which you can get by visiting our website or
You or someone
If you
by calling us at the Customer Service What if I don't agree with this decision?
numbers shown on the explanation of benefits
You have a right to appeal any decision not to
notice.
008438 0002 of 0005
provide you or pay for an item or service (in whole or in part).
Can I provide additional information about my claim?
Yes.
How do I file an appeal? Submit a written request for appeal within 180 days from the
Can I request copies of information
date of this notice.
relevant to my claim?
Be sure to include the
Yes, you may request
following information and anything else you
copies (free of charge) by contacting us at the
think we should know:
Customer Service numbers shown on the explanation of benefits notice, or at the
Name and ID number; patient name; claim
appeals address listed on this form.
number; name of person filing appeal, and whether the person filing the appeal is the
What happens next?
covered person, patient, or authorized
review our decision and give you our answer
representative.
in writing.
If you appeal, we will
If we still deny the payment,
coverage or service requested or you do not Mail your written request for appeal with
receive a timely decision, you may be able to
the above information to:
ask for an external review of your claim.
In
this case, an independent third party will review the denial and make a final decision.
Piedmont Service Center P.O. Box 6000 Greenville, SC
Other resources to help you:
29606
For questions
about your appeal rights or this notice, or for more help, you can call the Employee What if my situation is urgent?
Benefits Security Administration at
If your
situation meets the definition of urgent under
1-866-444-EBSA(3272).
the law, we will conduct your review on an
receive help through an applicable state
expedited, or faster, basis.
consumer assistance program.
Generally, an
You may also
Contact
urgent situation is one in which your health
information by state is available at:
may be in serious jeopardy or, in the opinion
www.stateconsumerassistance.com.
of your physician, you may experience pain that cannot be adequately controlled while you wait for a decision on your appeal.
If you
believe your situation is urgent, you may request an expedited appeal when you contact us.
Page 3 of 10
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Page 4 of 10
008438 0003 of 0005 SUMMARY EXPLANATION OF BENEFITS CLAIM(S) DETAIL
This is important information about services JOHN C LEWIS
received.
The following information shows how much we covered and how much you may owe
your provider for services received. JOHN C LEWIS
Patient:
Claim Number:
RVB030494482182
ID:
3C4953946-00-00
Your Provider
Amount Not
Charged
Covered *
Deductible
Patient Relationship to Policyholder:
Provider: ALERE HEALTHCARE
Date(s) of Service:
PARTICIPATING PROVIDER
01/01/13 - 01/31/13
Copayment
Allowed
SELF
Amount Provider May Bill You
Coinsurance
Amount
0.00 Amount We
Amount Paid to
Paid
Your Provider
179.72
0.00
0.00
0.00
179.72
0.00
179.72
179.72
1,342.70
0.00
0.00
0.00
1,342.70
0.00
1,342.70
1,342.70
0.00
0.00
1,522.42
0.00
1,522.42
1,522.42
TOTAL: 0.00
1,522.42
4,000.00
Your family has satisfied
of the
Claim Number:
3C6411830-00-00
Your Provider
Amount Not
Charged
Covered *
Deductible
family deductible for the benefit period that began
15,432.01
01/01/2013
.
0.00
This claim contributed
toward
for this person this benefit period.
0030647
the family out-of-pocket maximum. We paid a total of
4,000.00
Provider: BON SECOURS ST FRANCI
Date(s) of Service:
PARTICIPATING PROVIDER
02/19/13 - 02/25/13
Copayment
Allowed
Coinsurance
Amount
Amount Provider May Bill You
476.76 Amount We
Amount Paid to
Paid
Your Provider
65.50
46.38 (1)
0.00
0.00
19.12
1.91
17.21
17.21
292.62
207.95 (1)
0.00
0.00
84.67
8.47
76.20
76.20
186.00
132.18 (1)
0.00
0.00
53.82
5.38
48.44
48.44
269.00
191.15 (1)
0.00
0.00
77.85
7.79
70.06
70.06
321.50
228.44 (1)
0.00
0.00
93.06
9.30
83.76
83.76
131.00
93.10 (1)
0.00
0.00
37.90
3.79
34.11
34.11
1,020.00
724.80 (1)
0.00
0.00
295.20
29.52
265.68
265.68
2,664.50
1,893.35 (1)
0.00
0.00
771.15
77.12
694.03
694.03
2,664.50
1,893.35 (1)
0.00
0.00
771.15
77.11
694.04
694.04
2,664.50
1,893.35 (1)
0.00
0.00
771.15
77.12
694.03
694.03
2,443.00
1,735.93 (1)
0.00
0.00
707.07
70.70
636.37
636.37
102.00
72.49 (1)
0.00
0.00
29.51
2.95
26.56
26.56
102.00
72.49 (1)
0.00
0.00
29.51
2.96
26.55
26.55
102.00
72.49 (1)
0.00
0.00
29.51
2.95
26.56
26.56
3,444.50
2,447.61 (1)
0.00
0.00
996.89
99.69
897.20
897.20
Page 5 of 10
TOTAL: 11,705.06
16,472.62
0.00
4,000.00
Your family has satisfied
of the
the family out-of-pocket maximum. We paid a total of
Claim Number:
3C6443141-00-00
Your Provider
Amount Not
Charged
Covered *
110.00
Deductible
4,000.00
of the
3C6485335-00-00
Your Provider
Amount Not
Charged
Covered *
502.00
Deductible
4,000.00
of the
3C6754581-00-00
Your Provider
Amount Not
Charged
Covered *
440.00
Your family has satisfied
01/01/2013
.
Date(s) of Service:
PARTICIPATING PROVIDER
03/04/13
Copayment
Allowed
0.00
4,000.00
58.00
Deductible
01/01/2013
.
Date(s) of Service:
03/01/13
Copayment
Allowed
0.00
4,000.00
of the
278.25
the family out-of-pocket maximum. We paid a total of
5.80
This claim contributed
toward
Amount We
Amount Paid to
Paid
Your Provider
250.43
family deductible for the benefit period that began
01/01/2013
.
250.43
This claim contributed
27.82
toward
for this person this benefit period.
Date(s) of Service:
02/25/13
Copayment
Allowed
0.00
Amount Provider May Bill You
24.60
Coinsurance
246.00
24.60
family deductible for the benefit period that began
13,353.47
52.20
27.82
27.82
PARTICIPATING PROVIDER
4,000.00
Your Provider
Amount Provider May Bill You
Coinsurance
Provider: UPSTATE PATHOLOGY PA
0.00
Amount Paid to
Paid
for this person this benefit period.
Amount
194.00 (2)
toward
5.80
52.20
PARTICIPATING PROVIDER
8,841.27
476.76
Amount We
5.80
Provider: GHS PIH DBA UMG CANCE
4,000.00
This claim contributed
Amount Provider May Bill You
Coinsurance
family deductible for the benefit period that began
8,590.84
4,290.80
for this person this benefit period.
Provider: THE HAND CENTER
0.00
the family out-of-pocket maximum. We paid a total of
Claim Number:
4,290.80
Amount
223.75 (2)
Your family has satisfied
476.76
family deductible for the benefit period that began
13,132.07
0.00
the family out-of-pocket maximum. We paid a total of
Claim Number:
4,000.00
4,767.56
Amount
52.00 (2)
Your family has satisfied
0.00
for this person this benefit period.
Page 6 of 10
Amount We
Amount Paid to
Paid
Your Provider
221.40
01/01/2013
.
This claim contributed
221.40
24.60
toward
008438 0004 of 0005 Claim Number:
3C6770857-00-00
Your Provider
Amount Not
Charged
Covered *
825.00
Deductible
4,000.00
of the
3C7075860-00-00
Your Provider
Amount Not
Charged
Covered *
133.00
Deductible
4,000.00
of the
Amount Not
Charged
Covered *
110.00
Deductible
4,000.00
of the
3C7161456-00-00
Your Provider
Amount Not
Charged
Covered *
46.95
01/01/2013
Date(s) of Service:
PARTICIPATING PROVIDER
03/08/13
Copayment
Allowed
0.00
.
90.44
Deductible
46.95
toward
9.04 Amount We
Amount Paid to
Paid
Your Provider
81.40
01/01/2013
.
81.40
9.04
This claim contributed
toward
for this person this benefit period.
Date(s) of Service:
PARTICIPATING PROVIDER
03/11/13
Copayment
Allowed
0.00
Amount Provider May Bill You
5.80
Coinsurance
58.00
Amount We
Amount Paid to
Paid
Your Provider
5.80
52.20
family deductible for the benefit period that began
13,909.59
422.52
This claim contributed
9.04
Provider: THE HAND CENTER
4,000.00
Your Provider
Amount Provider May Bill You
Coinsurance
family deductible for the benefit period that began
13,857.39
Amount Paid to
Paid
for this person this benefit period.
Provider: VASCULAR INSTITUTE PT
4,000.00
Amount We
422.52
family deductible for the benefit period that began
13,775.99
0.00
the family out-of-pocket maximum. We paid a total of
Claim Number:
4,000.00
469.47
Amount
52.00 (2)
Your family has satisfied
46.95
Coinsurance
0030648
3C7142573-00-00
Your Provider
Allowed
0.00
0.00
the family out-of-pocket maximum. We paid a total of
Claim Number:
Copayment
Amount Provider May Bill You
Amount
42.56 (2)
Your family has satisfied
02/25/13
0.00
the family out-of-pocket maximum. We paid a total of
Claim Number:
Date(s) of Service:
PARTICIPATING PROVIDER
Amount
355.53 (2)
Your family has satisfied
Provider: PALMETTO ANESTHESIA A
01/01/2013
.
52.20
5.80
This claim contributed
toward
for this person this benefit period.
Provider: LABCORP
Date(s) of Service:
PARTICIPATING PROVIDER
03/08/13
Copayment
Allowed
Coinsurance
Amount
Amount Provider May Bill You
1.45 Amount We
Amount Paid to
Paid
Your Provider
78.00
71.50 (3)
0.00
0.00
6.50
0.65
5.85
5.85
68.00
60.00 (2)
0.00
0.00
8.00
0.80
7.20
7.20
131.50
0.00
0.00
14.50
1.45
13.05
13.05
TOTAL: 146.00
Page 7 of 10
4,000.00
Your family has satisfied
of the
the family out-of-pocket maximum. We paid a total of
Claim Number:
3C7305057-00-00
Your Provider
Amount Not
Charged
Covered *
Deductible
4,000.00
family deductible for the benefit period that began
15,445.06
01/01/2013
.
1.45
This claim contributed
toward
for this person this benefit period.
Provider: GREENVILLE HOSPITAL S
Date(s) of Service:
PARTICIPATING PROVIDER
03/01/13
Copayment
Allowed
Amount Provider May Bill You
121.38
Coinsurance
Amount
Amount We
Amount Paid to
Paid
Your Provider
28.00
7.72 (1)
0.00
0.00
20.28
2.03
18.25
20.70
5.75 (1)
0.00
0.00
14.95
1.49
13.46
18.25 13.46
245.00
68.05 (1)
0.00
0.00
176.95
17.70
159.25
159.25
128.20
35.61 (1)
0.00
0.00
92.59
9.26
83.33
83.33
88.10
24.47 (1)
0.00
0.00
63.63
6.36
57.27
57.27
123.80
34.38 (1)
0.00
0.00
89.42
8.94
80.48
80.48
110.50
30.69 (1)
0.00
0.00
79.81
7.98
71.83
71.83
60.70
16.86 (1)
0.00
0.00
43.84
4.39
39.45
39.45
48.30
13.41 (1)
0.00
0.00
34.89
3.49
31.40
31.40
17.50
4.86 (1)
0.00
0.00
12.64
1.26
11.38
11.38
114.60
31.83 (1)
0.00
0.00
82.77
8.28
74.49
74.49
85.00
23.61 (1)
0.00
0.00
61.39
6.14
55.25
55.25
278.20
77.27 (1)
0.00
0.00
200.93
20.09
180.84
180.84
94.70
26.30 (1)
0.00
0.00
68.40
6.84
61.56
61.56
46.20
12.83 (1)
0.00
0.00
33.37
3.34
30.03
30.03
235.00
97.05 (1)
0.00
0.00
137.95
13.79
124.16
124.16
510.69
0.00
0.00
1,213.81
121.38
1,092.43
1,092.43
TOTAL: 1,724.50
4,000.00
Your family has satisfied
of the
the family out-of-pocket maximum. We paid a total of
Claim Number:
3C7775415-00-00
Your Provider
Amount Not
Charged
Covered *
95.00
27.24 (2)
Deductible
4,000.00
family deductible for the benefit period that began
16,537.49
.
This claim contributed
121.38
toward
for this person this benefit period.
Provider: GHS PIH DBA UMG CANCE
Date(s) of Service:
PARTICIPATING PROVIDER
03/15/13
Copayment
Allowed
Coinsurance
Amount
0.00
01/01/2013
0.00
67.76
Page 8 of 10
6.78
Amount Provider May Bill You
6.78 Amount We
Amount Paid to
Paid
Your Provider
60.98
60.98
008438 0005 of 0005 Your family has satisfied
4,000.00
of the
the family out-of-pocket maximum. We paid a total of
4,000.00
family deductible for the benefit period that began
16,611.07
01/01/2013
.
This claim contributed
6.78
toward
for this person this benefit period.
*REMARKS: THIS HEALTH PLAN REQUIRES PRE-CERTIFICATION FOR ALL SCHEDULED OUTPATIENT PET AND CT SCANS, MRI(S) AND MRA(S). PLEASE COORDINATE
WITH YOUR
HEALTH CARE PROVIDER TO ENSURE THE REQUIRED AUTHORIZATION IS RECEIVED BEFORE THESE SERVICES ARE RENDERED.
(1)
THIS AMOUNT IS THE DIFFERENCE BETWEEN WHAT THE PROVIDER CHARGED FOR THIS SERVICE AND OUR ALLOWANCE.
(2)
THIS AMOUNT EXCEEDS THE MAXIMUM ALLOWABLE AMOUNT FOR THIS SERVICE.
(3)
MAXIMUM BENEFITS HAVE BEEN ALLOWED.
IF YOU NEED INFORMATION REGARDING THE SPECIFIC TREATMENT AND/OR DIAGNOSIS CODES FILED ON THE CLAIM(S) IN THIS NOTICE, PLEASE CALL THE CUSTOMER SERVICE NUMBER SHOWN ON THE FIRST PAGE OF THIS NOTICE.
Upang makakuha ng tulong sa Tagalog, tawagan ang numero ng customer service na makikita sa unang pahina ng paunawang ito.
T’11 Din4j7 shi[ hane’go sh7k1 i’doolwo[ n7n7zingo 47 Nidaalnish7g77 !k1 An7daalwo’7g77, customer service, bich’8’ hod7ilnih. Bik’ehgo bich’8’ hane’7g77 47 d77 naaltsoos neiy7’nil7g77 ak1a’gi si[tsooz7g77 bik11’ 77shj33h.
Page 9 of 10
0030649
Para obtener asistencia en español, llame al número de atención al cliente que aparece en la primera página de esta notificación.
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Page 10 of 10
