EXPLANATION OF BENEFITS PO Box 7344 Chicago, IL 60680-7344 An EOB is a statement showing how claims were processed. This is not a bill. Your provider(s) may bill you directly for any amount you may owe. KEEP FOR YOUR RECORDS. Log In to Blue Access for MembersSM at bcbsil.com to see plan and claim details or to contact us through our secure Message Center. Have questions about this EOB? Customer Advocates are here to help! 1-888-979-4516 TOTAL OF CLAIM Amount Billed SUBSCRIBER INFORMATION ACTIVE SALARIED Member ID#: PATIENT: SERVICE DATE: PROVIDER: CLAIM #: Processed: Discounts and reductions Amount billed Pathology 340.00 Laboratory Services 826.00 491.00 Pathology CLAIM TOTALS $0.00 (1 ) PLAN PROVISIONS Service Description - $1,657.00 You may have to pay your provider Group #: SERVICE DETAIL - CLAIM $1,657.00 Discounts, reductions and payments $1,657.00 YOUR RESPONSIBILITY Amount covered (allowed)* (1) 28.70 311.30 (1) 450.04 375.96 (1) 181.12 309.88 $659.86 $997.14 Deductible and copay amount Coinsurance $0.00 $0.00 Amount not covered $0.00 *Amount covered (allowed) reflects the savings we ve negotiated with your provider for this service. Your deductible, coinsurance and copay are based on the allowed amount. Your share of coinsurance is a percentage of the allowed amount after the deductible is met. (1) The amount billed is greater than the amount allowed for this service. Based on our agreement with this provider, you will not be billed the difference. Total covered benefits approved for this claim: $997.14 to SUMMARY (1) PLAN PROVISIONS Amount covered (allowed)* Deductible and copay amount Coinsurance Total on YOUR RESPONSIBILITY $997.14 Deductible and copay amount $0.00 $0.00 Coinsurance $0.00 $0.00 Amount not covered $0.00 You may have to pay your provider $0.00 $997.14 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Health Care Fraud Hotline: 800-543-0867 Health care fraud affects health care costs for all of us. If you suspect any person or company of defrauding or attempting to defraud Blue Cross and Blue Shield of Illinois, please call our toll-free hotline. All calls are confidential and may be made anonymously. For more information about health care fraud, please go to bcbsil.com IMPORTANT INFORMATION (Retain for your records) If we have denied your claim for benefits, in whole or in part, for a treatment or service, rescinded (see your Benefit Booklet for details) your coverage, or denied or limited your eligibility, this document serves as part of your notice of the denial decision. Your Right to Appeal You may appeal if you think you have been denied benefits in error. For all levels of appeals and reviews described below, you may give a written explanation of why you think we should change our decision and you may give any documents you want to add to make your point. For appeals, you may also make a verbal statement about your case. Send a written appeal request to: Blue Cross and Blue Shield of Illinois Claim Review Section PO Box 2401 Chicago, IL 60690 To file an appeal or if you have questions, please call 1-888-979-4516 (TTY/TDD: 711), send a fax to 888-235-2936, or send a secure email using our Message Center by logging into Blue Access for MembersSM (BAM) at bcbsil.com Authorized Representative You can name a person to act for you (including an attorney) on your appeal or external review known as an “authorized representative.” To use an authorized representative, you must first complete the necessary form. Call us at the number above to request the form, or to get more information if the person this document was sent to cannot act on his or her own. In urgent care situations, a doctor may act as your authorized representative without completing the form. Standard Appeal You, or an authorized representative (see above process for choosing someone to act for you), may appeal in writing or by phone. To send an appeal in writing use the contact information above and include any added information you want to give us as well as: • A copy of the decision letter or Explanation of Benefits (EOB) • The reference number or claim number (often found on the decision letter or EOB) You can get copies free of charge of your relevant claim documents, including the rules, codes and guidelines we used in making a decision. To request the copies, use the contact information above. Unless your plan says otherwise, you have 180 calendar days from the date you received this notice to file your appeal. We will send you a written decision for appeals that need medical review within 30 calendar days What happens next? after we receive your appeal request, or if you are appealing before getting a service. All other appeals will be answered within 60 calendar days. Expedited (Urgent) Appeal You, your authorized representative, or your doctor, can ask for an expedited appeal if you or your doctor believe that your life or health could be threatened by waiting for a standard appeal. To do so, you, your doctor, or your authorized representative, should call us at 1-888-979-4516 (TTY/TDD: 711) or fax your request to 918-551-2011. You have 180 calendar days to file your expedited appeal request. You may also ask for an Expedited External (Outside) Review, as described below, at the same time by calling 877-850-4740. If you qualify for this type of appeal, we will give you a decision by phone within 72 hours after we What happens next? receive your appeal request. bcbsil.com Page 2 Your Right to a Standard External (Outside) Review You may ask for an external review with an Independent Review Organization (IRO) if your appeal was denied based on any of the reasons below. You may also ask for external review if we failed to give you a timely decision as stated in the Standard Appeal section above, and your claim was denied for one of these reasons: • A decision about the medical need for or the experimental status of a recommended treatment • A condition was considered pre-existing • Your health care coverage was rescinded (see your Benefit Booklet for details) If your case qualifies for external review, an IRO will review your case (including any data you d like to add), at no cost to you, and make a final decision. To ask for an external review, complete the necessary form found at insurance.illinois.gov/externalreview and submit it to the address listed in the Department of Insurance section below. BCBSIL will also provide the forms upon request. Unless your plan says otherwise, you have 4 months from the date you received the decision notice to file your external review request. See the Department of Insurance section in this notice or contact us for more information. If you qualify for an External Review, an IRO will review your case and mail you its decision within What happens next? 45 calendar days. That decision is final and binding on BCBSIL and you. Expedited (Urgent) External Review You can ask for this type of review if: • failure to get treatment in the time needed to complete an Expedited Appeal or an External Review would seriously harm your life, health or ability to regain maximum function; • the request is about an admission, availability of care, continued stay or health care service that you received with emergency services, before your discharge from a facility; • the request for treatment is experimental or investigational and your health care provider states in writing that the treatment would be much less effective if not promptly started; or, • we failed to give you a decision within 72 hours of your request for an expedited appeal The IRO that does the expedited external review will decide if the covered person needs to complete the expedited (urgent) appeal process before the Expedited (Urgent) External Review can be started. If you think your case may qualify for an Expedited External Review, call 877-850-4740. See the Department of Insurance section below for more information. What happens next? If you qualify for this type of review, the IRO will give you a decision within 72 hours. Notice about Provider Appeals If you used an in-network provider, your provider may be able to file an appeal request for benefits you've been denied. You and your provider may file appeals separately and at the same time. Deadlines for filing appeals or external review requests are not delayed by appeals made by your provider UNLESS you have chosen your provider to act for you as your authorized representative. Choosing your provider to act for you must be done in writing. If your provider is acting on your behalf, then the provider must meet the deadlines you would have to meet to file such requests. Additional Rights If you receive your benefits through an employer, you may also have the right to bring an action under Section 502(a) of a law called ERISA. To learn more, call the Employee Benefits Security Administration at 866-444-EBSA (3272). bcbsil.com Page 3 Department of Insurance The Illinois Department of Insurance (IDOI) offers consumer assistance. If your standard or expedited (urgent) external review request does not qualify for review by your plan or its representatives, you may file an appeal with the IDOI at the Springfield address below. Also, if you have questions about your rights, wish to file a complaint or wish to take up your matter with the IDOI, you may use either address below. IDOI External Review Unit IDOI, Office of Consumer Health Insurance 320 W. Washington St. 122 S. Michigan Ave .,19th Floor Springfield, Illinois 62767-0001 Chicago, Illinois 60603 Review Request: 877-850-4740 Complaints: 877-527-9431 Fax: 217-557-8495 Email: DOI.InfoDesk@illinois.gov IDOI Web: https://mc.insurance.illinois.gov Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability. To receive language or communication assistance free of charge, please call us at 855-710-6984. If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance. Office of Civil Rights Coordinator 300 E. Randolph St. 35th Floor Chicago, Illinois 60601 Phone: TTY/TDD: Fax: Email: 855-664-7270 (voicemail) 855-661-6965 855-661-6960 CivilRightsCoordinator@hcsc.net You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services 200 Independence Avenue SW Room 509F, HHH Building 1019 Washington, DC 20201 Phone: TTY/TDD: Complaint Portal: Complaint Forms: bcbsil.com 800-368-1019 800-537-7697 https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html Page 4 bcbsil.com Page 5