aetna Statement date: May 201 Member: DREW NI Greup name: AUSTIN INDEPENDENT DISTRICT Your payment summary Page 2 mi 4 Patient Drew [self] Drew {eeltji Previder ?ueet Diagneetice St. David's Medical Center ?r'eur plan paid Amount Sent t-a 222.221 I[Illuee?t Diegneetiee Et. Davide Medical Center Send date 522? i" 51'2512'1?? ?reu ewe er already paid Amount $222 22 21.44026 Tetal: Your claims up close Claim fer Drew {self} 3? 51.553503 en Eil?i?l? Member rate hmuunt billed A or net payable iFtemarl-te] Applied tn deductible Amount remainan Your copay Plan F325 '3 Your neineuranee llI'eu may I en 41'2?? 111 en - di?? i" 150 50 LLITIEIHE cm ?1.131? 253 an - 259- I?llr THE en 4131? - 41'5?? Eli-El STERELE nu 11'2?? - 41'5?? ITE en ?Eli? - 425m 113 en dill? - #511? 305 DJ: an . 324 SEAN en - #51'15' 35D EMEHG HUGH an - 41'5?? 45-0 DRUGEIDETAIL CGDE en IIJEHT - 4151]" BEE St. David's Medical Cen ter WHEELDEI EE-JJEIB 1.52122] 1.414?l] 515.25 ZTEDU 14,521.39 2 42 .944236 24.90152 2.50390 5543.02 13.54101) EETEHE l1] [1.1 [1'2 [1'2 11} 4.?04 3'3 21.39310 EEDDJIID 5.35.32 22.40252 [1 nee]; END 36 [E?cl'hl END 35 5230 [211%] Centinued en next page aetna $tatement date: fo'layr 231? Member: DREW CALVER {ireup name: AUSTIN INDEPENDENT DISTRICT Claim for Drew {self} Page 3 pl 4 Ameunt lrlem ber Pending er Applied ta ?I'eur Ameunt Plan Your ?r'eu r1435:I Received an 5i15ill' billed rate net payable i deductible papa}.I remaining pays eeineuranee ewe {Remarks} I 1 Refer te Remarlts Seetlen I23 [34 Tetals: 94334.29 31' 239 34 32.23334 53.33933 1 443 33 31.44333 ?feu can find all numbered claim remarks in ?feur Claim Remarks' aeetlen. Claim for Drew {self} Ameunt Member Pending er Applied te Teur Ameunt Plan Teur he may Received en 341513? billed rate nelpayable deduellble :epay remaining . pays eeinsuranee ewe [Remarksl A 3 [l I CARDIAC CATH LAE 33,231.33 t1] en 44'2?? - 431 ECH CCARDICLCC if 1.34333 '11] an 442?? - 4i5i1T 4-33 EKCIECC en 4l2i12 - 415m 3.29? 33 i1] 1'33 13.33333 en arenr - 4i3i1? 331 Medical Center Refer te Remarks 3eetien i3] Tet-ale: meet 03 Van can find all numbered elaim remarks in "fear Claim Remarlaer seetien. Claim for Drew {self} Amount . Illember Pending er Appliedte ?r?eur Ambunt Plan ?r?eur ?r'eu may Received an 3'13?? billed rate net payable deductible eepay remaining page eeinauranea ewe iRemarks} A 3 I PRCTEIH. H3 33.33 11.33 11 99 11I 93.39413: en 3331? 33141 EILCICID 32 33 3.49 3.49 3.49 [133% A3 en 5331? I 33221 ASSAY. 22? 22 222.22 {4i 22]r 22 en El?n? 33333 LIPID PROFILE en El?il? 132.22. 3.93 3.93 3.93 [133%] 33-331 METABCLIC 33.23 3.41 341 341 [13333] PANEL en 3453 I 33353 lElluesl Diagnostics Cenlin Lied en next page Statement date: May 201 i" Page It at 4 at" atz Member: DREW csLyEa Group name: AUSTIN INDEPENDENT DISTRICT lElaim for Drew (self) Amount Member Pending or Applied to "four Ameunt Plan "four ?fou may Received on than? billed rate not payable deductible copay remaining pays coinsurance owe [Hemaritsl A .. I: I Refer to Remarks Bastien [3i Tetels: 522.20 3?.39 22? 22 3?.3e 3? 39 522122 ?fou can find all numbered claim remarks in "four Claim Remarks' section. Your Claim Remarks General Remarks: The payment fer this seryice is included In the contracted andlor case rate paid to the proylder. ?t?cu are not responsible for this amount; except for applicable copay, deductible, coinsurance. was] for administrative use only] Your preyider may haye sent diagnosis codes with yeur claim- ?i'ou may obtain these ccdes and their meanings by contacting us at the number listed at the of the ?rst page. We will alse provide yeur treatment codes and their meanings. if they do not appear on this statement. If you have questions about your diagnosis or your treatment please contact your proyic?er. Your plan does not ceyar charges for. or related to. services or supplies that we consider to be experimental or inyestigatic nal. Your benefit balances to date 12mm? Annual Amcunt Ameunt Balances limit used remaining {self} Medical in Heft-Jerk Maximum Sayings Deductible 31 .ICIIGEIHCI Medical In Maximum Sayings lEcii?lsurance? SSHUUDD - SELEIEI includes beth Medical and Pharmacy A complete list of your benefit balances and plan limits can be found on ycur secure member website. Be Active Make time tc get same exercise every day Whether its taking the stairs. geing for a wall: or working out at the gym. it all counts! Physical activity can deliver many health bene?ts. More Information Do you have questions? Call us free of charge at the toll-free number on the first page of this statement or on your member ID card. Appeals Please send your written appeal along with a copy of this entire EOB to this address: Appeals Resolution Team PO Box 14464 Lexington, KY 40512 If you disagree with a claim decision, you can ask us to review it. The process is called an appeal. You or someone you name to act for you, your authorized representative, can ask for this review. Call our Member Services Department using the telephone number displayed on the member ID card or send your written request to the above address. Your request should include: - Name, date of birth, and address - MemberlD number - Group ID and name of your group, usually your employer - Any other claim documents or records or other facts you would like us to consider. This could be new details that you did not give us the first time. You have the right to look at the relevant documents we used to make our decision on your claim. A copy of the specific rule, guideline, or protocol relied upon in the adverse benefit determination will be provided free of charge upon request by you or your authorized representative. You can ask for these (free of charge) by calling or writing us. You have 180 days from the time you get this explanation to appeal. You might even have more time if your plan brochure or Summary Plan Description says so. When to expect a decision - If your plan allows for one appeal we'll let you know our decision 60 days after we get your appeal request. Some states might require a different time period. - Your plan may allow two appeals. In that case, we will let you know our first decision 30 days from the date we receive your appeal request, unless your state gives us a different amount of time. If you don't agree with that first decision, you have a second chance to appeal. What happens next If you appeal, we will review our decision and provide you with a written determination. 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. Employer sponsored plans If you don't agree with our final decision, you may have the right to bring a lawsuit under Section 502(3) of a law called ERISA. Check with your employee benefits coordinator to see which appeals process your plan allows and if your plan is governed by ERISA. Coordination of benefits If you are covered by more than one health benefit plan, you should file all your claims with each plan. Your privacy Your health information is confidential. Any information you give us will be kept private. When contacting us about this notice or for help with other questions, please be prepared to provide your member name, member ID, and date of birth. Prevent fraud If you suspect fraud or abuse involving these services or would like to report other healthcare fraud-related issues, please call the toll?free hotline at 1-800-338-6361 or e-mail us at aetnasiu@aetna.com. Resources available to help you Need help understanding this notice or our decision? Call us free of charge at the toll-free number on your medical ID card. There are also other resources available to help you. Most plans are now subject to health care reform law. Call us or ask your employer if your plan is subject to the law. If it is, you can also contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272) for help, if your health plan is provided by your employer. M-TRA-DFLT Aetna Life Insurance Company complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability. Aetna Life Insurance Company provides free aids/services to people with disabilities and to people who need language assistance. If you need a quali?ed interpreter, written information in other formats, translation or other services, call the number on your ID card. If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting: Civil Rights Coordinator, PO Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779), Tel: 800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), E-Mail: CRCoordinator@aetna.com. You can also file a Civil rights complaint with the U.S. Department of Health and Human Services, Of?ce for Civil Rights Complaint Portal, available at or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, Building, Washington, DC 20201, or at 800?368-1019, 800-537-7697 (TDD). TTY: 711 For language assistance in your language call the number listed on your ID card at no cost. (English) Para obtener asistencia linguistica en espa?ol, llame sin cargo a1 numero que ?gura en su tarj eta de identi?caci?n. (Spanish) 33$ ID (Chinese) Pour une assistance linguistique en francais appeler 1e numero indiqu? sur votre carte d'identit? sans frais. (French) Para sa tulong sa wika na nasa Tagalog, tawagan ang nakalistang numero sa iyong ID card nang walang bayad. (Tagalog) Bendti gen Sie Hilfe oder Informationen auf Deutsch? Rufen Sie kostenlos die auf Ihrer Versicherungskarte aufgefuhrte Nummer an. (German) (Arabic) ?may-'3? awn; a? ?sun 31?well 52511 a-lc Juan? ?Quail 4511?) ,9 3mm? (Gujarati) oimrr?ui outau a?tet are claret aud?l Sis 142 Child store UR 8125 mi crate SIG 311. :?ta?wjili. IDjj? 1?5 L?o (Japanese) E01 '21 ?gig/WEI EE ID Phat g?l?i? Eil?H (Korean) (Laotian) (Persian) re?ll Augie QM ?24? ml ail-HUS Gals J-J 45 tel 61449)?! at use m?w? ob.) 44. 6.14% ab; nonylimb nossoHHTe no 6ecnnaTH0My HOMepy, yKa3aHH0My Bamefi ID-icapre yrrocrosepeHI/m mmuocrn. (Russian) (Urdu) De duoc h5 tror ngon ng?' bang (ngon ngfr), hay goi mi?n phi d?n so du'oc ghi tr?n the ID cua quy vi. (Vietnamese)