Health Plans it Indiana Unlversiiy Health Plans PO Box 11196 Porlland, ME 041041196 Need to update your information or have Questions? it you need to update your mailing address or have questions regarding this document or your benetrts, Visit our website at or call the JOSHUA PERRY number below: (use) ass-5915 Subscriber WERRV Subset ID Gmup Name ndiana University EOB Printed Date: 11/25/2015 Explanation of Benefits - This is not a bill. An Expianallnn ot taenetits (EOB) summatizes a recent claim tot senrices received and tiled with your insurance plan the cost associated with those slecSSy and who is responsible tot paying those costs. You! healthcate provider or lacility rriay bill you directly tor any amount owed. To ensure you have a good record at your health care expenses tor the year and there are no errors or incorrect charges against your tu Health Plans benefits keep your seas tor your records along with any other health care bills, Vou can also access your EOE online Via the IU Health Plans member portal at Summary of Claim(s) Submitted in. are included {allowing this page) Term: This Means: Von! Totals: This is the amount your provider billed to your plan tor the services you reoerved Please Note this am" amount does not reilect discounts the plan has negotiated wttri ""67 '7 This is the payment amount that in Health Plans and your participating provider have agreed will be accepted tor the type ot sen/toes you received Please Note- this arrangement may not appty to hore pertictpatthg providers it you have duestioris on your 505 ora Dillwu've received please contact 92 a Member Services. 5 i This is the dittetehce between the Bliied Amount and the Allowed Amount This represent your . savings based on the contracted iate iU Heam Ptahs has negotiated your participating provider Please Note this arrangement may not apply to honparticipatirrg providers. ti you have questions "215' 25 on your 505 ora bill you've recein please contact Member Services In Health Plans Paid This is the amount tu Health Plans paid to your provider. 545.339 u: 3 other insurance Paid This is the amount paid by your other insurance canieh it you have one to your provider so no This is the amount applied to the yearty deductible amount you are responsible tor paying betote IU "mm; Health Plans begins to pay tor your ooveted sen/toes Please Note 'NorlsCol/erea' amounts will not 32 59 count towards meeting the yeariy deductible and yourprovidermay bill you direcl/y tor these charges 3 CD-ply This is the tee you are responsible to pay tot certain services per your hearth plan so no 5 This is the peioentage oi the Allowed Amnunl you are respohsibtetot alter your yeaity deductible swan m, 2 has been met 2 This is the amount you are responsible tor paying betasuse a service was by your plan, or a provider or lacility was outside ol in Health Flans' nelwmk 3" Amt-tum lieu owe This is the amount you may be responsible tor paying ateasebtote. This may not include oopays 321.467 to Plan Status - (for 01/01/2018 - 12/31/2018) These totals are correct as of the last claim shown on this document. If you received services more recently, unprocessed claims for those service will not yet be reflected in the totals shown here. Check your IU Health Plans member portal for your most up-to-date claims. Family Deductible: This is the amount applied to your family deductible for the plan year. $5,000.00 of $5000 met for your IN Network Tier 1 Calendar Year Deductible (In-Network Benefits) Family Out of Pocket Max: This is the amount applied to your family out of pocket max for the plan year. $6,000.00 of $6000 met for your IN Network Tier 1 Calendar Year OOP Max (In-Network Benefits) 535422588 8 5.5.55 simfim catntuuwn wuoo .3225.an 885,8 8,8 3258 8,8 885,8 8,8 8858 3,838 885,8>> C8888 85:85.88 8.8 8.8 8.88 8.8 8.8 8.8 8.8 8.58 8.88 8.88 8:23 0338 85 2883.5 8.8 8.8 3.8 8.8 8.8 8.8 8.8 8.8 8.8 8.28 85.5. 8338233 88 283.5 8.8 8.8 8.58 8.8 8.8 8.8 8.8 828 8.58 5.88 85.5. 8338233 88 283.5 8.8 8.8 888 8.8 8.8 8.8 8.8 888 888 8.88 898.3. 028 536251 88 28.3.5 8.8 8.8 8.818 8.8 8.8 8.8 8.8 2.28 8.818 8.558 898.5 88 28.3.5 8,8 8,8 2,28 8,8 8,8 8,8 8,8 2,28 8,28 38,5 203053 83 288,5 8,8 8,8 8,88 8,8 8,8 8,8 8,8 8,88 8,88 8,88 38,5 203053 83 283,5 8.8 8.8 8.88 8.8 8.8 8.8 8.8 8.38 5:88 8.:8 85.5. 209.0me 88 283.5 8.8 8.8 8.88 8.8 8.8 8.8 8.8 288 8.88 8.58 85.5. 52,885? 88 283.5 8.8 8.8 888 8.8 8.8 8.8 8.8 8.88 888 8.58 85.5. 52,885? 88 283.5 8.8 8.8 8.28 8.8 8.8 8.8 8.8 8.88 8.28 8.88 898.5 52,885? 88 28.3.5 8.8 8.8 8.88 8.8 8.8 8.8 8.8 8.38 8.88 8.58 898.5 58886.81 88 28.3.5 8,8 8,8 2,58 8,8 8,8 8,8 8,8 8,38 888,5 5388526 :8 283,5 8,8 8,8 8,88 8,8 8,8 8,8 8,8 588 8,88 38,5 5388526 :8 283,5 8.8 8.8 .38 8.8 8.8 8.8 8.8 8.88 8.8 2.38 85.5. 80:30:. 88 283.5 8.8 8.8 8.38 8.8 8.8 8.8 8.8 3.8 8.38 8.58 85.5. 80:30:. 88 288.35 8.858 8.8 5.38.38 8.8 8.838 8.8 8.858 3.8.88 8.838 8.838 3:25: 582?; 88 2835 who>> Eafi an" 3.28 8&2 :55 :35 :55 38 58.33 38 5.65 .26 82 be 888 225.63 33.3 38 5.2.3 828 2.682; 53888 8:55 23:3 8 (mo 2.. 5.3: is: .m a 8255 3228 .el 8 EEG 25% 35.5.; 8:82 50> .0 32> 3.5% m_ scam "=98 EEO arofimfi: "Emu mOw . . 5889? "2mm :82; .56 8525 E85 "Em: 95.0 Eco) a 5.23 "Em: 5955 GBP85 GBP18: 38838 . 382.38 .380 3,28 Coinsurance Amount The member's out of pocket maximum has been met Services rendered by an out of network provider. In-network benefits applied by manual override. The claim line has been repriced by First Health. 27 28 147 148 533 Upon your request, you are entitled to receive, free of charge, copies of all documents, records, and the identity of medical or vocational experts consulted by the Plan in determining benefits. In lieu of copies, you may be given reasonable access to the documents. IU Health Plans will notify you of the decision on your request no later than 60 days from the date your request is received. To access your complete Member Contract, sign-in to the IU Health Plans Member Portal at www.iuhealthplans.org. Once logged in, click on‘My Plan Documents’. Your appeal must give the reason(s) you believe the claim was improperly denied and include any additional relevant information or documents in support of your appeal. Failure to file a timely appeal may prevent you from any further review of this benefit decision in State or Federal Court of Law. Send your appeal to: IU health Plans, 950 N. Meridian Street, Suite 200, Indianapolis, IN 46204, Attention: Appeals. If you disagree with the decision on your claim, you (or a representative you have authorized) may file a written appeal. The appeal will need to be filed within the timeframes allowed by your specific plan, generally within 180 days of the denial of your claim. What if I need to make an appeal to a claim? Description Explanation Code