Cigna Health and Life Insurance Company Q. I. SCRANTON CLAIM OFFICE .. . PO. BOX 182223 CHATTANOOGA TN 37422-7223 . I a. Cigna Health and Life Insurance CompanyAS AGENT FOR UBS FINANCIAL SERVICES INC. Customer service Call the number on the back of your ID card or (800) 244-6224 (1 lfyou have any questions about this document, BENJAMIN HYN DEN please call Customer Service at the number above. Please have your reference number ready. Service date January 16, 2018 THIS IS NOT A BILL. ?defence "3 Your health care professional may bill you directly for any amount that you owe. Provider Network Status: IN NETWORK Account name Account . . Explanation of benefits for a claim received for BENJAMIN HYNDEN, Reference Patient's relationship to Subscriber: SUBSCRIBER Subscriber Name: BENJAMIN HYNDEN Summary ofa claim for services on January 16, 2018 for services provided by GULF COAST MED CTR Amount Billed This was the amount that was billed for your visit on 01/16/2018. Discount $3 890 43 You saved $3,890.43. CIGNA negotiates discounts with health care professionals and facilities to help you save money. What your plan paid $162807 Your plan paid $2,628.07 to GULF COAST MED CTR. This is the amount you owe after your discount, your plan paid, and what your accounts paid. People usually owe because they may have a deductible, have to pay a percentage ofthe covered amount, or for care not covered by their plan. Any amount you paid since care was received may reduce the amount you owe. What I owe $3,656.25 You saved $6,518.50 (or 64%) off the total amount billed. This is a total of your discount and what your plan paid. YOU saved 64W0 To maximize your savings, visit or call customer service to estimate treatment costs, or to compare cost and quality of in?network health care professionals and facilities. H701A 7/09 PLEASE SEE CLAIM DETAILS ON PAGE 3. Page I of4 Glossary Amount billed: The amount charged by the health care professional or facility (physician, hospital, etc.) for services provided to you or your covered dependents. Amount not covered: The portion of the amount billed that was not covered or eligible for payment under your plan. Examples include charges for services or products that are not covered by your plan, duplicate claims that are not your responsibility and any charges submitted that are above the maximum amount your plan pays for out-of?network care. Deductible: The portion of submitted charges applied towards your deductible. Your deductible is the amount you need to pay each year before your plan starts paying bene?ts. You meet your deductible by using the money in your health care account, then your own money. Copay: A flat fee you pay for certain covered services such as doctor visits or prescriptions. You can use the money in your reimbursement account to pay this fee. Discount: The amount you save by using a health care professional or facility (doctor, hospital, etc) that belongs to a Cigna network. Cigna negotiates lower rates with its in-network doctors, hospitals and other facilities to help you save money. In-network: A group of health care professionals and facilities (doctors, hospitals, labs, etc) that offer discounts on services based on their relationship with CIGNA. Using in-network services gives you significant discounts, which help you stretch your health care account money further. Out?of-network: Health care professionals and facilities (doctors, hospitals, labs, etc) that do not belong to the CIGNA network. Depending on your plan, you can use out?of?network services, but you may pay more for the same services, and you might have to file a separate claim for reimbursement. What your plan paid: The portion of the billed amount that was paid by your health care plan. What I owe: The portion ofthe billed amount that is your responsibility. This amount might include your deductible, coinsurance, any amount over the maximum reimbursable charge, or products or services not covered by your plan. Federal Rights of review and appeal If you have any questions about this explanation of benefits, please call Customer Service at the toll?free number on the front ofthis form. If you're not satisfied with this decision, you can start the Appeal process by sending a written request to the address listed in your plan materials within 180 days of receipt of this explanation of benefits (unless a longer time frame is provided by applicable state law or permitted by your plan). Please follow the steps below to make sure that your appeal is processed in a timely manner. Send a copy of this explanation of benefits along with any relevant additional information (eg benefit documents, medical records) that helps to determine if your claim is covered under the plan. Contact Customer Service if you need help or have further questions. Be sure to include: 1) Your name 2) Account number from the front of this form 3) ID number from the front ofthis form 4) Name of the patient and relationship and 5) "Attention: Appeals Unit" on all supporting documents. Contact Customer Service at the number on the front of this form to request access to and copies of all documents, records and other information about your claim, free of charge. You will be notified of the final decision in a timely manner, as described in your plan materials. Ifyour plan is governed by ERISA, you may also bring legal action under section 502(a) of ERISA following our review and decision. Page 2 of4 Claim received for BENIAMINI HYNDEN Referencell Cigna. ID THISISNOTABILL Claim detail CIGNA received this claim on January 23, 2018 and processed it on January 25, 2018. Amount Service Amount not Covered Copay/ What yourplan See dates Typeof service billed Discount covered amount Deductible paid paid Coinsurance* notes GULF COAST MED CT R, Reference 01/16/18 LABORATORY 17.00 6.46 0.00 10.54 10.54 0.00 0 0.00 A0 01/16/18 LABORATORY 73.00 27.74 0.00 45.26 45.26 0.00 0 0.00 A0 01/16/18 LABORATORY 42.00 15.96 0.00 26.04 26.04 0.00 0 0.00 A0 01/16/18 LABORATORY 45.00 17.10 0.00 27.90 27.90 0.00 0 0.00 A0 01/16/18 LABORATORY 41.00 15.58 0.00 25.42 25.42 0.00 0 0.00 A0 01/16/18 CATSCAN 8,897.00 3,380.86 0.00 5,516.14 2,864.08 2,121.65 80 530.41 A0 01/16/18 EMERGENCYROOM 1,021.00 387.98 0.00 633.02 0.00 506.42 80 126.60 A0 01/16/18 DRUGS 38.75 38.75 0.00 0.00 0.00 0.00 0 0.00 A0 Total $10,174.75 $3,890.43 $0.00 $6,284.32 $2,999.24 $2,628.07 $657.01 *After you have met your deductible, the costs of covered expenses are shared by you and your health plan. The percentage of covered expenses you are responsible for is called coinsurance. What I need to know for my next claim You?ve paid a total of $0.00 toward your $4,000 outof network family deductible Your $3,000 in network family deductible has been met for 2018 You?ve paid a total of $0.00 toward your $6,000 outof network family out of pocket expenses You?ve paid a total of $3,666. 10 toward your $4,500 in network family out of pocket expenses for 2018 for 2018 for 2018 You?ve paid a total of 5 10,885.25 toward your Unlimited all medical bene?ts individual lifetime maximum Notes A0 - YOU FOR USING OPEN ACCESS PLUS NETWORK. THE DISCOUNT SHOWN IS HOW MUCH YOU SAVED. YOU NEED TO PAY THAT AMOUNT. IF YOU ALREADY PAID YOUR HEALTH CARE PROFESSIONAL MORE THAN THE I AMOUNT, PLEASE ASK FOR A REFUND. HEALTH CARE PROFESSIONAL: YOUR CIGNA AGREEMENT DOES NOT ALLOW YOU TO BILL THE PATIENT FOR THE DIFFERENCE. IF YOU ARE IN INDIANA, CALIFORNIA OR TENNESSEE, PLEASE CONTACT CIGNA CUSTOMER SERVICE AT 1.800.88CIGNA (882.4462) FOR INFORMATION ON YOUR DISCOUNTED RATE. RETAIN THIS FOR YOUR RECORDS. Page 3 014 NM 0 Claim received for BENIAMINI HYNDEN Reference Cigna? ID THIS IS NOTA BILL Additional appeal information related to the Patient Protection and Affordable Care Act of 2010 If you would like to requestinformation about the speci?c diagnosis and treatment codes submitted by yourHealth Care Professional, please either contact your Health Care Professional, or go to or call the Customer Service number on the back of your ID card. If you are not satis?ed with the ?nal internal review, you may be able to ask for an independent, external review of our decision, as determined by your plan and any state or federal requirements. For questions about yourappeal rights or for assistance, you can contact the Employee Bene?ts Security Administration at {3272) or If you have difficulty reading English, we offer language assistance. For help please call the Customer Service number on your ID card. Si tiene problemas para leer el texto en ingl?s, Ie ofrecemos asistencia de idiomas. Para obtener ayuda, por favor, llame al numero de Servicio al cliente que ?gura en su tarj eta de identi?cacibn. Si vous avez des dif?cult?s a lire l?anglais, nous offrons une assistance linguistique. Pour toute aide, veuillez composer Ie numero du Service ala clientele qui se trouve sur votre carre d?identi?cation. Fur den Fall, class Sie den englischen Text nicht verstehen, bieten wir Unterstiitmng an. Rufen Sie in diesem Fall bitte die auf lhrer Versicherungskarte angegebene Kundenservice-Nummer an. Kung nahihirapan ka sa pagbabasa ng wikang lngles, nag-aalok kami ng tulong sa wika. Para sa tulong pakitawagan ang numero ng Serbisyo ng Customer sa iyong ID card. Wm? seesaw/tease f?lfi?lk?ki?l?f?ii??f?b? ?kitf?l?ii?? Bilagriaua Bizaad n?dltd? nil nanitl'ahgo. saad bee nikd?adoowoligii hblb. Akri?a?a?yeed biniiy? rat shoodi Aka ?anidaalwo?go dabinaanishigii bich?i? hodiilnih ?i naaltsoos bee nee hdzinigii bikaa?gi bib??sh bee hane?? yisdzoh. H701A 7/09 RETAIN THIS FOR YOUR RECORDS. . Page 4 of 4