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23975245351333: Explanation of Benefits 
I MA01104 THIS IS NOTA BILL
RETAIN FOR TAX PURPOSES 
Forwarding SSWICO Requesmd Customer Care lnlamialiaii

eucallenri
mania canine spanninni 

-- imnivnn a
FOR MM 535 SHH
1:5? 53 arcupmimc 

    

Member: SIDNEYVETENS

Mumharln: --
Dale: 01/11/2018

 

For the Period: 12/27/2017 through 01/08/2018

Dear SIDNEY VETENS,

The Information below is a summary of your healihcare claims lor ihe eriod relerericed above.This lnloimatlon is commonly
reieired 10 as an "Explanation oi Benefits" is a summary, allowed byihe claim details. oi now your receni Claims
were recessed. It includes any 00-Day, deductible, colnsurance or non-covered amounts lhai OLI may owe to [he

provi er(s) oi service. Use this EOE lo veriiyliie accuracy and validliy ci any bill you may receive ine provlder(s) lisled

below.

Tmal Amount Billed This is the tolal amount for hiils received for the dates of service 12/27/2017 lhrough
01/08/2015
3591.850 20
Total Amount Paid By Plan This is me amount ihe plan paid for services billed. Please refer lo the Claim

Summary section all this document Var more informalicn.

$2 427 91

Your Financial Responsibllily This is lire ameunl ilie provider cl service may bill you aiierycur plan 
were paid. Typically a plan pamcipani may be billed by the provider pi service

329 613 25 because my may have a deduclible, cc-pay, coinsurance or me service is not
i covered iieelm plan. A bieakdawn ciycurloiai iinancial responsibility is shown
in ma claim derail ior each member,

 
 

 

   

 

 

 

 

 

Pniiem Name we Diiconrir Covered By co-Pny necvcliue Pailani Fiymeni
Cnavga Amounl Aincuni Amnuni F'lzii Amoum Anionni Responsible Amwnl

versus 5650 all so no so 00 $252.31 5297 as su on s1 34 23 5106 92 5210.77
VETENS 390.372 20 318,020.81 so no 537M537 :27.in5.52 so an slim szaua 33 525.000 an
VETENS $164 vemvs Mac in so no so 00 55513 5109.57 so an $0.00 in no :1 08 57
Touls 91.55am 32mm." slum meow: 323,020.35 50.00 mm 523,313.25 mural

 

 

Page 2 o! 3

Claim to: -- valdo uw MEDICAL FOUNDATION

 

 

 

 

 

 

 

 

 

 

 

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

 

 

 

 

 

   

 

 

 

   

   

 

 

 

 

 

 

P: sIDuEv VETENS Fallen! Pmlonuot 
Dam-o! om Vat-I Dllcuunl cos a nu Cunt-Nd By Cn-F'ny mm Plym-nl
s-Mc- coo. Chime Amount Ammo . Amount AmnuM num- Amonm
mos 5252 31 mu Room saovoo so no sm on same MW. sum
Column rom- mm soon so.oo mu: mm sun."
Palient's Res 186.92 
5 Tom Pnym-nl to so.oo
-- valdu: UNIVERSITY oF WISCONSIN HOSPIT
SIDNEV Pans." DOB Pnuem Act" --
ch Dllcuum momma cos Rel-an Cow-I'd fly so. .y onomm. mm 
coo. Amnum Amounl Amount coo. rm. Amount Amounl on Amount
marmaon somoo 52.99747 so on so on man Room um so so oo so on "Mum son. was 62
12/274230"? 25o some 41 woo \2442 soonm soon "@5327 oo-z. "412.02
ammomummy inon'h as
morn/now mm as sozons so oo so an Izuz swan so so on so no Amso so ow. soon on
mono/sow am sos $30.nov. s27 15
12/274 mom om soon was: soy. s25: 22
coma/sow son sosm oo s3o,m 36 311312.91 so on Izoazd yoga>>. swam so on on sum oo w-o sagas so
no
ammo/low. mm o:
momma/a sumo on so no smoos so oo moao tam-mama :soon we: so so on loan Calumn unmno was :1 s2e,o2o no so on snuom mm mo smom 
P: I . onsiblm at: rm Plym-m 
3 1m so no
Clalm w: -- Provldor' or vwscousm HOSPIT
Fallen smuEv VEVENS onom boa:_ Palmtan --
am. on row cos Gav-I'd By Clo-Pay nunualbln pm pm. Paym-nl
Slovch mug. Amnum Amount coo. Amuunl Amounl a n" Amount
mmz-mmz/m 0921' 5164 on $55 43 m: on I214: _?1oa 57 in on on 31m: 57 10M no! 57
Column tonl- nu on so": WJW . sin! (1 sum soon 31:13.51 swam
Patienrs on om will Mn Pawn-"l $105.51
(y Yam Plym-m Io mom" so.on
Claim a: -- Proud. NIVERSITV or WISCONSIN HDSPIT
muons: SIDNEY versus momnoa:_ Pallamm -- IN. DETAIL
om. ov Pmn. Dlunum coo Rulon cnomo By (Du-Pay nnuucnolo Rum. "Inn Paid Plan Plym-nl
5mm. coon com. Amount Amuum Amount Cudl Nan Amount Amnum anlmn Al Amoum
mmoovonno 992M Cnlumn lel stuun snoo so.no soon moor soul 51
. mm" om mm Plymun! s1ons1
"I'm 9 my 3 mo mm": In Member sn.no

 

 

 

ZOIRUIZSBOJ
1277 11277

Page 3 of 3

Reference Info

   

JA4F [12,6l5] 2 of2

 

Enrollee: SIDNEY VETENS
Group: Consolidated Health Plans

  

at?

.
.
as, -

 

 

I Code Description

88305 LEVEL IV SURG PATHOLOGY
121 HOSPITAL
250 HOSPITAL
258 HOSPITAL
273 HOSPITAL
300 HOSPITAL
301 HOSPITAL
310 HOSPITAL
360 HOSPITAL
370 HOSPITAL
623 HOSPITAL
710 HOSPITAL
99214 OFFICE OUTPATIENT VISIT 25 MINUTES

APPEALS INFORMATION

   

Code Description

 

of the first appeal decision. If you still do not agree with our appeal decisron
contact customer service at the number on the back of your insurance card.

 

There is?an appeal process if you disa ree with the determination. You have 90 calendar days following receipt of the notice of adverse bene?t determination
to submit your written appeal to Conso idated Health Plans Appeal Department 20

77 Roosevelt Avenue Springfield, MA 01104. Once our appeal is received a
decision will be made in 15 calendar days. If you do not agree with our a peal decision

ou may file a second appeal within 90 calen ar days following receipt

a third and Inal appeal may be submitted. For additional assistance, you may also

 

 

Patient Stateme

i5; nun

ll
Wall-Free

Alencron al clienle d/spanlble en 

spafiol

VETENs



mm mm

Ll Check l1 address/lnsurance changes are on back

Online Billing

Pails/us smelled uw Health Nil/Chan can

 

choose the convenience o/ paperless 

same and "green"

0 Pay Onlin 

 

Accounl Number Due Date

Upon Revel/at

 

 

 

AmeunIDue Amount Pai
$13491 95 5

 

 

Please make ecks payable and remIH

 

 

uw HEALTH

Please detach and remrn mp puman mm payment

 

Account Number 1

Account Name

Statement Date

Dun Dale

 

 

 

 

 

 

 

 

   

VETENS 02/15/2018 Upon Recelpl .
Date service Description sums charges aiflg'uil'i

 

     

PATIENT: Sldney Vekens
Provider We! Huang, MD

12/27/2017 Vrsnit--
SURG PATH.LEVEL lv
91/23/2015 INSURANCE 

Visit Balance

PATIENT: 5 my DVahns

{42/11/2017 Velm--


PAYMENT - CHP
12/29noi7 PPO (5) CONT ALLOW- CHP

1 Balance

PATIENT. Sidney vutene

 

12m/2017 'Visil#_

01/23/2018 CONTRACTUAL ADJUSTMENT . CHP

Loc uw HOSPITAL CLINICS UW HEALTH

1 L00. UW Er CLINICS UW HEAL TH

    
   
     
     
   
 
    
    

$550.00

75210 77
-$252 31

Current

655.43

Past Due

$156.52

$0.00

$105.51

 

MESSAGES

statement Summary

The balance is your respons/bimy. Please pay in full or Contact us (or

payment arrangemenls an your account.

Excitln News! We are now providln you With just one acwunl Vor holh

hospila and ph siclan billing If you ave
uwhealiho/g/bl lingfaq.

any questions, v'ls'll

Pro/essronal Services Total $186 92
Sen/lees Tulal 513.005 03
Toial Balance Due 313.191 95

 

Page 2 0/2

     
 
  

 

Accoum Mums/:1 A 
02/15/2018 
DUE DAVE AMOUNY DLIE

 

$13119195

 

Accol/M'I NAME 

VETENS
Atanbn al clieme d/sponime an espa/SOL 4 

       

   

 

  
    
     

 

Dam Service Slams charges Axg'hfli 32:2;
1 Lana/awry 32,030 45 7' 
1 0R sen/mes $69124 05
1 1 Pharmacy $509990
Roam and Board 56141700
1 Suppfies $33 20
Treat/HEM and Observation Room $5,152 50
12/21/2017 Fat/em Dre-Payment 7 Thank You 7520030 00
01/04/2015 1 FPO (5) CONT ALLOW- CHP 43259574
01/25/2010 INSURANCE PAYMENT 7 4251000 00
02/06/2015 INSURANCE PAVMENT - CHP $0 00
1 Visit Balance Current

$12,895.46

 

 

 

   

 

 

:oiwo 
Page 1 2 

 

gsomanisc:  Explanation of Benefits gig
Splingheld MAOIIM     llixrl

RETAIN FOR TAX PURPOSES

 

Forwar

9 Service Requested

Customer Care Information

Ouasnm-I
Plus: nun pamem 

on>> . m. Um .sIIyo
Sum-m Imvamx SHIP)

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 "1 uNIvoF WISCONSIN MADISON
a: 
Member: SIDNEY VETENS
Merooer ID: 
one: 04/04/2015
claim In: -- Provider UNIVERSITV or WISCONSIN HOSFIT
Peiierii: SIDNEY verus Paiiem An 11 --
on" or Pmc. Yum can Rani)" com" a, Cir-Ply autumnal: . In Plyn-m
Sawch Codi crow. Amnum Amnunl Codi Amnunl Amounl or Amount
ammo/35.411 no so no so on somoo 55 so
ammo/17 250 some so go no so no R0002 ".729 so so no so on 9.275 65 s: 420 52
gono 31.45403 may. susaoo
ammo/17 25o swuzz gono so no s1ro22 so no wozz may. s1ro22
ammo/ammo/17 3m s1.er1 35 gono so no 31.571 15 so no 3137'35100'1- s1 571 15
ammo/17 am 35510 gono sasm mm. 565")
ammo/17 31o 55134 on go no so no 3594 no so no so on $555 on may. 3594 no
ammo/17 zoo 355.134 on snieni 71 so no Inmz $3.22 21 so no so on 31.222 23 may. 53 222 z:
ammo/17 370 31.577 47 go no so no 31.577 so no so on 31.377 47 may. s1 on 
ammo/17 370 32.962 Isms :o no so no so on soon 0% :o oo
ammo/17 52: so 25 go no 5525 so no Isms :o no so no so on soon 0% :o oo
ammo/17 71o somso gono so1o2oo Isms soon 0% 
Culumn Iml: senomn :51.eo1 or sun" mun man man non-non nun."
Paliem's Responsiorlr $2,133.53 m" "Wm 

 

 

 

 

CHIZENSBANK 57"" 0000000630
Cunsahdated Mum P7 --z11o Issue Dam . Momma

 
   
   

 

 

 

 

 

A Nalhaway Camp: mourn
"$17,941 .47
FAY SEVENTEEN THOUSAND NI TY-ONE AN 4 II Void if!" 90 days


TO THE SIDNEY VETENS

ORDER
OF


 

 

 

 

 

 

Page 2 of 2

SERVICES

REMARKS

Description

Code

Description

121
250
258

HOSPITAL
HOSPITAL
HOSPITAL

R0002
I0002
I9383

Your individual out of pocket amount has been met.
This is a PPO Provider discount. You are not responsible for this amount.
NEGOTIATED DISCOUNT APPLIED. PATIENT NOT RESPONSIBLE FOR
THIS AMOUNT

273
300
301
310
360
370
623
710

HOSPITAL
HOSPITAL
HOSPITAL
HOSPITAL
HOSPITAL
HOSPITAL
HOSPITAL
HOSPITAL

Code

PAYMENTS
Payment To

Check #

Amount

SIDNEY VETENS

0000000630

$17,941.47

APPEALS INFORMATION
There is an appeal process if you disagree with the determination. You have 90 calendar days following receipt of the notice of adverse benefit determination
to submit your written appeal to Consolidated Health Plans Appeal Department 2077 Roosevelt Avenue Springfield, MA 01104. Once your appeal is received a
decision will be made in 15 calendar days. If you do not agree with our appeal decision you may file a second appeal within 90 calendar days following receipt
of the first appeal decision. If you still do not agree with our appeal decision a third and final appeal may be submitted. For additional assistance, you may also
contact customer service at the number on the back of your insurance card.

X

ENDORSE CHECK HERE

DEPOSITORY BANK ENDORSEMENT

DO NOT WRITE/SIGN/STAMP BELOW THIS LINE