Clgni Bax lasusl mammogram 3742275051 AL Cigna. THIS IS NOT A BILL. Customer servke Call me number on the back dlydurln card or human-2n lfyou have any quesuanx abour rm; dammenl, please all Cusmmel Servlze ar rhe number above. Plans have yaurrlarm number ready. Service dale July 15. 2019 CIaimk/ID Vouv health care professional may pill you direnly -- (or any menu: lhalyou owe. Explana on of benefits Provider netwmk status OUT OF NHWORK Account name Account '0 fora da'lm recelved for BENASSO, Cla'lm Patienl's relallonship to subscriber: Dependem Subscr'rbe -- Summary of a claim for services on July 25, 2019 for services plowded by ERIC. Amoum SH 6700 Dl'szoum $0.00 332:?" $1,167.00 :fij'm'p'a" $0.00 Whatlowe $1,167.00 was me ampum (harwas billed lpryourvisir on Clgna negotlates healm cave plofesslo BI: and laul'ru'esm help you save mun Uslng an In~nerwolk opnm Is one way ypu (an save, Vrsir or (all Cusmmer Serer me learn more. This ls me portion orypur rhar's narcayered byyoul plan. You may or may um need :0 pay mas amount See me Moles senior. on me lollowrng pages for more lnformallurl. Vow plan nor pay any ofme amoums could be because you haven-r mnypur deducliple yet 0! your plan daesn'r covev me servlces yaa This is me amoum you awe arrer you! dismunL your plan paid. and whar your accounls pard. People usually awe hemuse urey may have a dedunible, nayexo paya pevzemage dime covered amauau orlpr (are nm eavered pymeir plan Anyamounlyou paid when yau received Lave may leducs me amoum you owe. mung-panel". Ind-1' :a .5 50> .5. 25 I GBP8.23): .N <> .22 3.. E332 59.5353>> 2.. .6. 3.89.3.5 {5.2.9.3 as. 3.35.: a 30.3.2.3 a. .5535 3.3.252 Eggs. .3. subawfisu E. Ea. 8,23" 8.2 33252 a 3.. aubuvfifiu 2.. .2 Estesfifiafiiau {Bags Sinnfivsgo. 3.333352 hangs. .uwxafifis a. usruauuv igiizoesa $68.3 5&228. 233252 a so) $2.233 ass. {2.853% 2.63382 5.5.. an) .EbeuEE 2.. s. {3.22. a. 383 3.9.22.2 8.83.255 a GBP2 333225 2.. 3. $.58 Ssasggis 8.83.222 a .5. E33 .8 265. 2 Ea $23.59 $225.33. .2 .9. :5 unanssn 553 .85.: meziai Eu: E. 55.3 33,5qu {5:8 2: 2.5.53 22 3.3.2855 3. 2 2:53 a .2. M. 3.23 a o. a 5.5.35.5 3E ".533 3.8 a a. 5333. 2a a: $555.. .5 :92. 32333583 23>> .633. 8.315 3.3 3.3 8.3 3,3 33 3.3 Sun--.5 ES. mma 3.3--.-- Sd 8.0 and 8d 8.35 can. ozmmko I. 225. 55.5 $2.523 <<3.568 .33 ESE. HIS 2:53 3.22325 Bin am .22. 3 5.. 5.. 2.5.5 $.55 32 w. 22 s. 5.3.x 5 .2. Easy. 255 .955 . . a .. E_u_v 1 .5. .3332 EEO nesw ASSISTING SERVICES, LLC Benasso lsabel - Dear Mrs. Benasso, My name is Eric Griffith. I am the surgical ussis'am who helped Dr Genuurio with your Knee Arthroscopy on 7/25/2019. I am writing this letter as a courtesy to remind you at my presence during your surgery' On I submitted a claim to Cignu requesting payment for my services. At this moment it is too early to know if they will cover my services but the claim was submitted. Again, this is not a hill iust a reminder that I was present during your surgery and that a claim is submitted on my behalt' if you have any questions please cla not hesitate to conflict the Warm regards, Eric Griffith CSFA, CST Eric Griffith's Assisting Services (EGAS) 3:38 03:. :51 amino 98.. I _wmwm_ wmawwo 3032--1. 013--? . 2: 9m .25 2 gm. _mu:m_ .m a: :2 38.9. 35:8 36.6: 06:2 5.3.. 5828 :5 .253 3.: 22:558.. 5 :2 :53 GBP332.: 232: 25:: 35:3}. 38:. .58 2.53 mi 52 :25 2:552. a: $2.815.: $85: no :2 :26 8:32 06:: .2 338:. m3 :3 :2 2.: a. 5.. 03:. .12.: 3.. 2:25 2 :2 05:: :33 3.3. 2 :2 33:; an 32:8 3.30:5 5 9. 81mm 2 a: 025:3} 22:2: 522:8 Ea Ea saw E: 2.25 a. :2 8:52. .325: .3 5 .55 838:: 22:: 32$: :m .32. $2.5 :2 3 853: a: 31358:. 2: Swan: 3: :02 9m 38.2.3.2; e. :a $928. 2.83. :2 3e 2 m: :32: mi 23.3 2.: 253 2:25. o: 2 .2. 8: so ".5223 o. 2.6 ea 3.32.. E: s. :2 :m .2322. .: maimK 2.: on 9:51.. a: 24.1.52. a. mm . .2: 932%. 85.2 :2 5533.50 05:: :36? 8.: ma. 9, 9:51: 33: 8:52." :2 a: 3: as. 92:: a: a m: 225% cm a 53 82:2. 5: 52:38 2.22:. "a 32:3. 38% a .: 382:: 22:03. .25: Emma". 99$ cigria PO Box "3061 I. 41' Cigna. iliNA ii ii Cus'lomer servlte Call the numberon (be back ofyoul ID card or 1-366-494-1111 Ifyou have anyqueslruns abour ihix doeumem, please call CunomerSM/lce ur me number ubave Please haveynur claim nun-me! ready. Service date July 15, mi 9 THIS ISNOYABILL. Vour heakh care professional may bill you direcily -- for any amoum than you owe. nawork status IN Account name Aceaum ll Explanation of benefits -- ror a claim received for EENASSO, Ciaim il-- Patierit's relationship to subscriber. Dependent Subscriber Summary ofa claim for services on July 25, 2019 for services provided by SKY MEDICAL CENTER, Amourii Billed $96,337.00 This was meamaum lhatwas billed ioryourvisii en saved 592,153.90. Cigna negotiams diseaums wiili heaith pmfesslonals and lacilities 59276300 ro help you save mdney. What my plan paid Crgna paid $3,2I6.sfl id SKY MEDICAL can-rm 53,21 6.60 This is me amaum yau awe alier your discoum, what your plan paid, and whar your acmunls aaid. People usuaiiy ewe because ihey may have a have paya pereemage of me WM owe 5357-40 covered amount, ariar care rm! Leveled iheir lan. Any amoumyou paid when you received (ale may reduce me amoum you owe. Vuu saved $95,979.60 (or ism) oflihetotai amuunl billed. This isa lmal eryeur discoum and what your plan paid. You saved 1 00% TD maximize yeur savings, VISII MyCigna.mm or call customei sewize esumere ireaimerii eosis, or Io eempare (051 and qualily af inrneiwelk health care pmiessionals arid -- vanaws 2.. .5 <<28m: 55) :8 2: 225 I 00.0 00.0 0 00.0 00.0 00.0 00.0 00.0 00.0 5505.5 0 00.0 00.0 0 00.0 00.0 00.0 00.0 00.0 00.0 00.? 0 mek0 00.0 00.0 0 00.0 00.0 00.0 00.0 00.0 00.0 8.0m" {mama 00.0 00.0 00.0 00.0 00.0 00.0 00.0 00.0 00.N .v 00.0 00.0 0 00.0 00.0 00.0 00.0 00.0 00.0 00.00N {3&0 00.0 00.0 0 00.0 00.0 00.0 00.0 00.0 00.0 00.0mm >Km003m 0 {make 000 00.0 0 00.0 00.0 00.0 00.0 00.0 00.0 00.9" tag--2m 0 :an0 00.0 00.0 0 00.0 00.0 00.0 00.0 00.0 00.0 00.0m~ 0 mek0 00.0 00.0 0 00.0 00.0 00.0 00.0 00.0 00.0 )waxDm UDA 00 00.0 _N.m 00.0 00.0 00.?hm.m 00.0 00.mwn.N0 00.n00.$ )xmmEDm :meo 00.0 00.0 0 00.0 00.0 00.0 00.0 00.0 00.0 >xm0~5m 00.0 00.0 0 00.0 00.0 00.0 00.0 00.0 00.0 00600.0 >cwwx=m _\mn\n0 00.0 00.0 0 00.0 00.0 00.0 00.0 00.0 00.0 0m.m?~ )wazam 0Zm~?0 00.0 00.0 0 00.0 00.0 00.0 00,0 00.0 00.0 09mm Ewuxam 00.0 00.0 0 00.0 00.0 00.0 00.0 00.0 00.0 00.nm )mmUmsm 0 (misc 00.0 00.0 0 00.0 00.0 00.0 00.0 00.0 00.0 09mm 00.0 00.0 0 80 00.0 00.0 00.0 00.0 00.0 00.00 Ewgaw 0 00.0 00.0 0 00.0 00.0 00.0 00.0 00.0 00.0 00.00m >cmUc3m :meo 00.0 00.0 0 00.0 00.0 00.0 00.0 00.0 00.0 >zm002m 0 00.0 00.0 0 00.0 000 0:0 80 00.0 00.0 3.00m 550sz _\mN\n0 00.0 00.0 0 00.0 00.0 80 00.0 00.0 00.0 8.00m 0 mek0 00.0 00.0 0 00.0 00.0 00,0 00.0 00.0 00.0 0m.0mm._. 3392.5 0 Cm~?0 smewmam (O 5.243.: 5 Same x00 00 memmnhofl :30: is. in. 33.358 .2: ".952 .38 8% its 3 GBP5 sum 55 i is 3.8.2 5.. $.55 3an Es; .23 .2253 S: 3353232 fi .0 0: 5. es: .3. 3,392 550 :28 .5: m. < mum; 55> z_595" 338 32.5.55 1.1 iiex. .38 YES SEES uni. 5.5.325 .qu < Creollon Dole lo 20"? muse mm: Fallen! Name aox 'zuzn hicmoun, VA ammo ISABEL - BMASSO Pullenmumbe is I HeleG'l'lOn of Hosplful Servlces -- "e Hoxpflal Number Number -- 27150 TSASEL BENASSO Pallem Type OUTPATIENT SURGICAL SERVICES Arrocheo is lisl ol hosprol services you requesred for care you leceived ol SKY MEDLCAL CENTEQ oh 07/25/20Wr07/25/201 9. Please have rs nor a bill, The 'olol on rhe final page is 'he ombuhl you owe lor 'hese services You should already have received a bill lrom rhe hospllol which ihcludes lhe roble below This Table shows lhe ombuhl you owe and how ll was colculoled. The wow you owe may include copay, oeoucribleg o, nonrcoveled charges ACCOUNT ACTIVITY Accouhl Number -- Dare 0' Service 7/25/2019 Yolal Amounl for Services" $3,567.30 insurance F'uvmems To Dale 3: 321660 Due From lhsurahce 3 0,00 Puliem Paymems To Dale 3 350 70 Foymenls lo Dale 5 3,557.30 Account Balance 5 00 YOU OWE SD 0 "Torol Amouhl Fol Hosphol Serylces is The rorol umoum rhe hospllol expecls lo receive services one, all discouhls have been applied. This is ol your hosoiiol services only orher involved your care who do not worl< my me hosprlol such as your physieioh, a lab, or orherspeclolisrs, rhoy bill sepbrorely fol lhelr services. If you have quesllons about this or oboul sluiemehls received from The hospllul, please call lass) 47577937 TO SKY RIDGE MEDICAL PAGE CENTER. PLEASE FOR YOUR RECORDS. Creahon .201? moot mm my Mum, Nam, \2520 memo/m, v. 232mm ISAIEL - BENASSO . . . Puflem Number Date: of Service IIemIzaIion of Hospital SerVIces -- 07/25/2019--07/25/2019 Hospliul Number Medical locord Numbu -- 27150 ISABEL BENASSO Patient Nae OUIPATIENT SURGICAL SERVICES Hemlmnon 0/ Hosp: cl Sen/ices cow DATE HCPS uan DESCRIPUON 025D - PHARMACY 07/25/19 00000 1 FENTANYL ZML AMP 732.00 07/25/19 00000 1 HYDROMOR INJ 3 229.50 07/25/19 00000 1 FENTANYL ZML AMP 8 732.00 07/25/19 00000 2 FENTANYL 2ML AMP 5 732.00 07/25/19 00000 1 LIDO 2% 20ML 3 209.50 07/25/19 00000 1 0.25% 30ML 5 209450 Subtolal: 5 2,814.50 0258 - IV 07/25/19 00000 1 SOD CHL 0.9% 30ML 5 209.50 Subtotal: 5 105.50 0272 - LE 07/25/19 00000 4 SOLUTION IRR LR 3L ARTHM 5 568.00 07/25/19 00000 1 SUTURE ETHL 3-0 18 1669H 39.00 07/25/19 00000 6 SUTURE ABS 2-0 P52 J111T 612.00 07/25/19 00000 1 ASCPC ANG AGR 4MM $610.00 07/25/19 00000 1 SUTR UHMWPE SHTR 3 1,006.00 07/25/19 00000 1 HANDLE SHARP SHOOTER 5 3,303.00 07/25l19 00000 1 TUBING IRR INFL $751100 07/25/19 00000 1 PROBE SUE 135MM SE 3 1,475 00 Sublolal: 3.350.011 0301 07/25/19 084703 1 HCG QUAUTATIVE SERUM 3 327.00 Subtotal: 5 321.00 0360 - OR SERVICES 07/25/19 00000 147 OR LEVEL 5 45893.00 Subtotal: 3 46,093.00 0370 - 07/25/19 00000 6 ANESTHESIA EACH 15 MIN 7374.00 07/25/19 00000 1 ANESTHESIA1ST HR 3 4,870.50 Subtotal: 5 12244.50 ASSIGNED To my RIDGE PAGE 3 CENTER. PLEASE RETAIN FOR YOUR RECORDS. ltemizaiion of Hospital Services REV CODE DATE HCPS UNITS DESCRIPTION AMOUNW 6636- 66665 REQUIRING DET c0615 5: 66 671251196? 6.12704 6666 :52: 67/25/16 0J2550 266 Me i PROMETHAZINE 635. 6 . .Cj. $23600 LACTATED RINGERS 1000 377.50 Subtotal: 2,175.56 7 67/25/16 611166" '0?125f19 0630699 67/25/16 617126 06137 5ELF- ADMINISTRABLE DRU9 67/26/16 6 {:66 6 266616 9. 67/25/16 66666 2 ACETAMIN TABLET . [371251'19? 66666 6i 6 61 SCOP Hm To 1166 PATCH 6 07/25/19 66666 1 6 Subtotal: 165.00 6716-. I?uscovenv ROOM . 6? 67125116 66666 :6 6 61 6: 554 66 67/25/19 66666 5 RECOVERY EACH 66 M16156 16 666 .66 Subtotal: 22,614.00 Amount Before Adjustments/Discounts: 96,337.00 Adjustments] Discounts: 92,769.70 Total Amount for Hospital Services: 3 3,567.30 k7 Tou 6156 not being asked to pay Hie iteml'zed amounts 6? 9' listed above. The amount you one ail/966111 insurance 5' payments anti adjustments will b69111 your hospital bill *This15 not a' bill and does not reflect what you are being asked to Pay. This 15 an itemization of hospital services which hospitals are required to provide upon request and includes amounts from the hospitals master list of charges which every hospital' is required to maintain. more information please call (866) 475- 7537. . INSURANGE BENEFITS ASSIGNED TO SKY RIDGE MEDICAL ?"1955 31"; PAGE 4 CENTER. PLEASE RETAIN FOR YOUR RECORDS 93? Vii/5.1" i- Clgna A re Bax f: chamnooga, 3741: ml 4' Cigna. HEALTH AND lNi COMPANY Cummev service Call lhe numbev an we back ofyoul ID (am a! buss-49441 1 I llyou have anyquexrluns about document, please (all a! the number ahave. Please haveynur claim number ready. Servke date July 17. 2019 THIS IS NOTA BILL. You! health (ale plelessional may you dlrectly for any amount that yuu owe, Provider nelwork s'atus lN NETWORK Account name/Aanum It -- Explanatlon of benefits for a claim lecelved for BENASSO, Claim ll -- Patlent's relationship to Deppndent Summary ofa claim for services on July 27, 2019 for servlces provlded by HATCH, R. MD. Amounl allied $1,223.00 This was lheamuum max was foryuuvvlsi! on 07/27/2019. Dismm $568 40 Van Lived 55am. Clgna negotiales discounls health me pvofess'lonals and lacllifies . helpyuu save money. Whal my plan paid Clgna pald $554.50 I0 CAREPOKNT EMERGENEV PLLC. 5654.60 Is (he amounl you owe afier you! whal your plan pald. and what your atmums Owe $0 00 pald. People usually awe because may may have a deducnble, haveto pay a pevcenlag! unne - covered amoum, av lav (are rim covered by meh plan. My amuum you paid when you recelyea (ave may reduce me amount you owe. vuu saved (m omhe lolal amaum is a lolal and what you! plan paid. You saved 1 00% To maximlle or all cusmmel service": estimaxe xrenlmem msxs, 0! compare cost and auelny of Ill--network health care pmlesslanals and fa -- mm 33%: En 2.: $355 22532555: 5 ESE as 55 2 359". a a: a. SEEK EB 3.53 a 2 355qu 5 Si 5.3558 3 5. .EzOuwx "50> GBP15 awfuwis mi 5 {SufiaimEs 8.25.: "$99532 $52222 EUR532: 5355558 2. 52 5.5.55 53323 .332? Sana Es 2.55:: :2 $5552.55 at 55353589553 <<53.2.5 55 55.532 383?. .22 a .3565 5555533 2:9 5:535 $839.8 58.2.3" savage 333 3a E2 a 5335 Exiting me i its}: 5025.353 55 3.25.3 8.3.3 :52 a GBP552: 525.52%: us .5 ioeifiefig es 853d a 232.: as. stanzas we a. "35.6% 5222.5 555 8.83 sax--E59 Ssfirsse a van 2.2 3:33:33 25% Signs 8.25382 a Sun Eu: 2: E_m_u ta: .8 265. 9 umw: 22:5 3:235 ma: <<35.55% .2532>> GBP552.53. GBP559: 2 E55: 35 :5 Ennis 5%:5 55533.33% 55.39% asnbusea 552% $538 .aczass 3'8 5 EERE w: GBP53 BEBE $2523 NE SE .58: 5&2; Sin E55 2: GBP3 536:2" 59225 agar? S53 8.: Si: 8.8 8.8 8,8 86me 8.32m .53 60.0 and a 69.0 86 and cod 8.6 oo.cm aqu $81 a :hN\hc Mmu 8d 85 and and and and 00.0 SOOK >Umevxm2m VOL 8.0 8.0 8-- cwemm and 8d OWEW 8.0 DYOMV DD. EDGE GZmUwaw a {Name --Ng CU xm>ZmD On I 5 .55 d: .z 9305.: .55: use: 23. 35538 21 is 2.5.5 YES :58an 12.5 we; 35. 0mm ulg or ml; .233: 5: 23.5 .23 <<225% =23?35w? 22 em 5.9.x .6 5.3: E. 25qu 25C =mumD NU adu mmax .szOUwz 55> 10m nib 225: 'mv_>zwm mo "in "2(m NE 20 nij mae mzmaufi 5133.52 at mm3EMERGENCY PHYSICIAN STATEMENT EMERGENCY PLLC -- PO BOX 112325 {19/112019 Due Date 10/08/2019 - Your Balance $568.40 Undewtdudmu yum fi- n7/27/2m9 99235 cane/2mg \ns.(lmm Mauedxo (lgna os/ao/zmg Payment cam V223 on 07/27/2019 MEDICALCENTER NKHOLAS HATCH MD These (havges an fuv me Emerqanty W5. en's :eNKesand ave nnunduded in youvhowml you have any quesxlens sham um; um mam an no! ms mpmamuamzzsogsz To avold 953k human Tuan bummer! 73mm mm: standard lime Pa nonmemwmune mum Spundmg Azzaumsand Hem 5am; auwnn may be used <cesfl56001 -ov pay mg Iheiallowmg opnons scan (he QR code on (he "gm pay by Dhane mm use the payment $pr below Eusuns mm mm mnomn RETURN ww PAYMENY EMERGENCY MED, FLLC 05731 PO BOX 95408 OKLAHOMA 0W OK mums ISABEL BENASSO $56340 "Mum um mm mm mm": ISABEL BENASSO $568.40 For Inqulrles can taco-flaws: MAKE pm CAREPOINT EMERGENCY MED, PLLC PO BOX (72325 DENVER 00 302174323 can, PO Box YMMV Ig na. WCECOMW Customer service Call me humps: on the ID card or "mum I lfyou have nnyquestl'omaboutrhixdawmem, atkhe number above. Please haueyaln :Iulm numbenmdy. Service date July 25, 2019 THIS IS NOT A BILL. Clalm It ID Voulheahh (are professlonal may dlveclly -- icy any amoum mar you owe. Provlder network slams OUT OF NHWORK Account name (Attoull! Explanation of benefits -- for a clalm veceived for ISABEL BENASSO, Claxm Pauent's relationship to subscriber. Dependent SubsCriber_ Summary ofa claim for services on July 25, 2019 for services provl'ded by PULSE RX, Amount Billed 5550000 u7/25/2019. Cigna negotlates dismums heahh cave pwlesslonals and laclliues (0 help you save money. Dlscoun! $0.00 Usmg an in-nelwuvk oplion ls one way you can save. My:igna.cam or an Cusmmel Sewlce leam move. Amour" $6 500 00 This is lhe :uveled byyourplan.JPYou may or may nm need to pay covered - mas amount See me Notes semen on the lollowlng pages for more lnlonnafion. 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I 2322 42w 10.10:: xmnOxUm. van 3: Complex Claim Unit (CCU) 7555 Goodwin Road Chattanooga, TN 31421 Augustza,2019 (1 Isabel Benasso RE: Isabel Bonasso Customer or -- Authorization Cude Not Applicable a: Service Provider. Pulse Rx Group Account at- Claim Reference Datets) ol Service Claim Total Charge Charges Not Paid By Your health Plan 07/25/2010 -- $6,500.00 $6500.00 07/25/2019 elzdt Cigna Health Managenient,lnc,-- C955 b0+? Dear Isabel Benassn. gin--39,2 4.513 140' We received claim--orservroes received between 07/ [2019 5/2019 lrom Pulse Rx You are reoeiving this leflerbecause, as noted on your Explanation o1 Benefits. there is a servieewe cannot cover under your benefit plan because it is oonsidered experimental, investigational or unprovenforlhe diagnosis, The dollar amounl otthe service nol covered. the description. and reason why the service is not covered is noted below. Please see your Explanation of Benefits statement lor inlorrnation regarding coverage for other servioes provided. Nola:We sent this Iaflorto meet fadmal and slate Details about this service - Thetotal charges not paid forthe sen/ice listed below is $6500.00. . Payment was requested for the below service with a primary diagnosis ol/371 OF VEIN. All oigna predui: and senioes are provided exdustvety by Olmruugh ups/alng subsfliarles elcigna Calm/anon, indudng Gig/la Heoih and Lie lneirranoe Romany. conned/out General Insurance Comanny, Clgna sens/oral Heal/i, inc. end HMO ur servloa misery subsidiaries oi cone Health Tire Clone name. logo, end oher cigne marks are uwnud bycigna hullamnl Preparer, lric. Please reierto your ID oeidlor lire crgne whsida/y hat mules er admniseis youths/I811 nhn. coon/rum