Paloma! Hea'm
2185 armada Pkwy
(A 520251

nesday, Dnobm 212019


HEALTH

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lumen: VUHUA mu
Medina? Retard 
Flnarma' 
Date or 11/5/2019
anary Insurante rm
swme Frocaduru Degulphan 
"Omar Es|imamd Ehzrges 
"Eshma'ed 1am {harges 5 21,232 as
"Estvmaxen percentage payable 39%
"Estlmalefi permntagc payable Dvuvide
Suhlcta' 3 5,230 51
wnem 5 Eo-Insurante 2m;
Evbmtal 5 1,555 
Panem's rcmamlr'g Deducnmc 234 mu
Fanem's Cupey

00? Max Cakulal 139 
"Palvem cop Max 5 5,239 00
"rum Paticnx 65Estimate far the hospital bill only Vuur andlI-rv nmvidm will bill van sap-many.

"25mm on palm!" responsibility can my hind on Insurance benefits and/Dr

 

BILLING 
PLEASE CALL:

    

544-250-3770

l/you oo no1 l-aye lnsurance you may b5
ellalole tor coverage mrougr call/ornla
Exchange or otnernrograrns Mad/carer
Meolealo. Healrny Farm/195' or CA Erma/en's
Seryloas Palomar Haalln olters llnanoal
programs Please contact
344725073771) 10/ an You may also
seek lrorn lne CDnsu/ne/
Ass/stance oenler a1(877l73473258

IMPORTANT MESSAGE

Thank you 1or chaosmg Palomar
Healln 1or your neallhcare services
Your lnsu/ance nas processed your
claim and me remalmng balanoe is
now due by you 1/ you have
aodltional Insurance coverage lna1
neeos 1o be billed, please contact
our customer service department 1or
assislance THIS BILL CONTAINS
CHARGES ONLY.
CHARGES ARE
SEPARATELY

To oaelly anu secuuly pay
Your nmlner ulslt our
war/Elle at

Palomerealm.org

November 22 2019

Patient Name:
AdmitlDischarge Date:

Total Charges:
Total Insurance Payments:
Total Insurance Adlustments;
natal Patient Payments:
Total Patient Adjustments:
Total Amount Due Now:

DETAIL CHARGES

CODE
IV 


LABORATORY

OR SERVICES
PATHOLIHYSTOL
PHARMACY
RECOVERY ROOM
STERILE SUPPLY

PALOMAR HEALTH
PROCESSING CENTER
Box 21808
Columbia SC 2922171808

1

VUHUA QIU

-- mm-

YUHUA QIU
10/31/2019 11/05/2015
$221219,"
$518912
$271453 47
$1073 20
(513.820 62)
$9318?
AMOUNT
$2330 00
$596 60
$252 60
$190 00
$55 00
$23 10
$101369 00
$166 94
$44 A0
$31361 00
$4325 00

$933 87

Page. 1 /2

$933.57
10/31/2019

FALOMAR HEALTH

Po BOX 745696
LOS CA 90074-8696

Blue Shield ol California

pa 
crime 019592772559

no on

CLAIM SUMMARY AT A GLANCE

5" blue of colifornio

niece cl Calilnmia
Ar me Blue smug Amciaaon

This is NOT a Bill
Reiain lnryour along any provider bills.

Explanation of Beneliis (EOE) is 10 noiify you lilai
we have processed your claim. it clarifies your paymeni
responsibility or reimbursemeni.

Your claim inlornlalion is also available in My
Plan seclinn nl I1 you
iiave any uuesiinns about dncumeni, please call one
of our claims represenialives ai 25 650.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Paileni Name quuA mu Subscriber ID: Claim Number: --
Palienl responsm ty: sz'am'm Vuur claim was received 11/12/19 and processed in 1 dayisi
(Amnuni you nald ar owe provider) .
aid POMERADO HOSPITAL.
Amnuniwe paid: $5,769.72 dpt'bl Slat
. 2 ii: I us:
Nelwork savings: 511542115
(Amnumsmd by my a The deduoiible iias been rnei 2019.
Amnuni billed by Provider: 522,219.64
DETAIL Provider: POMERADO 
Exclusilemvider v" Pall-m Raounsihilw
Service Tyne arsewiee and Amount Amount Amount w. Paid Mari Covered neuunibie anbaymmu Mum
Dale Procedure Number silica Allow-d Vhabunpgyoblgadfl Cnimurancl
ion mm"
1i/05/i9 SurgicalSeruices 44 4" lion non m4 mm
0250 
1i/05/i9 Surgical Services 252 0253 
33532:" saw" 498 an lozzs (Lou on 192 23 no
33532:" 4,325,110 l,67o.sl L150 21 on 27 45 492 95
SurgicalSeruices
mo 23 in 10,35 7.59 non non 326
Surgical Services so an 23 '6 non non 695
main 
Surgical Services main 
1i/05/i9 Surgical Services main 
SurgicalSeruices
0305 55m 2l.zs 14.36 non non 637
1i/05/i9 3392"" saw" 166 94 64.44 45." on on is 33

 

 

 

 

 

 

 

Please see reverse :iua iar more 

Blue Shield of California

 

 

 

 

 

 

 

 

Pans 2 at 3
Helpful Definition] 'Sefl you! [widened n! Emeline to! additional 
Amount Billed Deductible
rm zmnum yournmvider billed inr the services you raceivad rm dollar amum |ha|ynu must pay comm sen/ins: my. year nature we aim
Amount Allowed' paying hansfik undar your Dian You are responsible inrihis zmeuni
The mom" we used to calculate your benaliis forth! Services nmvidad Non Covered
Amount WI Paid Th8 Damon the Amount Billsd lint coverad by your plan You an for
rm zmnum w! naid to your providar or ymi mi: amnuni
Patient Run-mummy
rm nmdatemiiliad icnpaymnii inrwhich you are responsible provider It consists oi Daductible.
percenuge at in: cns| (coinsurance) for which you are responsible ham on your Conaymanllcoilisuranca. am Mon comm zmnunis
Dlali banali lor "Ii: amour" Network Savinm
Dal-(using a Blue 5mm network provider
The day or din: the palm" received Sarvices
Questions? Contact us directly by telephone. letter or Contact US:
online by visiting We will be
able to answer most of your questions immediately: P- 0 - BOX 272540
33333332. Siva? 95927454"
documents, records and other information we used in (888) 256'3650

evaluating your claim. at no cost to you.

If you are not satisfied with our response to your inquiry, you (or your prowder or a representative on your behalf)
may initiate a grievance by calling, writing or by completing a Grievance Form. You may obtain the form by

calling us, or by Visiting our web site at W. Submit your letter or completed form to
Blue Shield Appeals and Grievance. P. O. Box 5588. El Dorado Hills CA 95762 0011 or online at

We Will provide you with a response within 30 days. You may file grievances for at
least 180 days folloWing any incident or action with which you are not satisfied.

The California Department of Managed Health Care is responsible for regulating health care service plans. If you
have a grievance against your health plan, you should first telephone your health plan at (888) 256-3550 and use
your health plan's grievance process before contacting the depanment. Utilizing this grievance procedure does not
prohibit any potential legal rights or remedies that may be available to you. If you need help With a grievance
involving an emergency, a grievance that has not been satisfactorily resolved by your health plan. or a grievance
that has remained unresolved for more than 30 days. you may call the department for assistance. You may also be
eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will proVide an
impanial review of medical decisions made by a health plan related to the medical necessity of a proposed service
or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment
disputes for emergency or urgent medical services. The depanment also has a toll-free telephone number
(1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's
Internet Web site Wan! has complaint forms, IMR application forms and instructions
online.

You have the right to request an IMR through the Depanment of Managed Health Care (DMHC), as indicated in
the paragraph above. You may apply for IMR if A) your provider has recommended a health care service as
medically necessary, or B) you have received urgent care or emergency serVices that a proVider determined was
medically necessary, or C) you. in absence of a provider recommendation or the receipt of urgent care or
emergency services. have been seen by an in-plan prDVider for the diagnosis or treatment of the medical condition
for which you seek independent review. You can contact the DMHC directly.

If your employer's health plan is governed by the Employee Retirement Income Security Act (ERISA), you may
have the right to bring civil action under Section 502(a) of ERISA if all required reviews of your claim have been
completed and your claim has not been approved. Additionally, you and your plan may have other voluntary
alternative dispute resolution options, such as mediation.

Blue Shield Cali'amia

comlwiu

Providuv: PDMERADD HDSWAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Exclut I vaidav Vu
Slrvila Typo 0! Sonic! and Amount Amount Amount WI Nan Swami Dmuni Cnpaymlm/ Noll]
Dam Numb" Eillud Allwm Von my meder Cnimulanul
01041110101110.1101 Used Ia mum>> mm" "gm
50mm; 0:11:10; 

11/05/19 33590;" SWCES 10,309.00 4,002.43 2001 70 0 00 0 00 1.20073
11/05/19 3359015" SWCES 2,330.00 099.30 029.335?" 129 60 50.03 35.37.94 26.11/05/19 36390;" SWCES 45 00 17.00 12.11/05/19 36390;" SWCES 00 00 33.20 23.9.01 6.11/05/19 335%'53' SWCES 10710 41.34 20.11/05/19 335%'53' SWCES 104 90 40.49 20.34 0 00 0 00 1215
3,301.00 1,297.35 900.Claim Tnlals: 22.21964 5,709.72 0.00 334.32 2.412.75

 

 

 

Mmees
We have renewed a claim mnne aneve re1erence0 00100111 and have pam 0011011 Mammy 10 am prawder.

D1agnos1s and 1rea1men1 eades hIHed on 1111s e1a1m and men meamngs can he reeues1e0 Dy eamaeung Cusmmer Semee.

Thank you for choosing Blue Shield.

To see me exua semees and suppon avaname 10 you. go 10