000001 PO BOX 30541 Salt Lake City, UT 84130-0541 UMR How To Read Your EOB SAMPLE 00001 001 JOE PATIENT 123 ABC LANE ANYTOWN USA 99999-9999 CONCERNS? T QUESTIONS? Contact your Customer Service Representative at 1-866-684-8090. U INTERNET: Online services are available 24 hours a day at www.umr.com. . Claim payment detail Claim status Benefit information Eligibility Order an ID card Many other services! V APPEAL: You may file an appeal of the claim decision by sending a written request and pertinent information within 180 days from the date of this Notice to "Claims Appeal Unit, P.O. Box 30546, Salt Lake City, UT 84130-0546.” Refer to your current benefit booklet for information on the appeal process. After you have exhausted the mandatory appeal levels that are described in your benefit booklet, you have the right to bring a civil action under section 502(a) of the Employee Retirement Income Security Act (ERISA). STOP FRAUD! W HELP If you know or suspect any illegal activity concerning claims, contact our anti-fraud unit by calling our toll-free number 1-800-356-5803. You do not need to identify yourself. Refer to your benefit booklet for more details on Claim determination. © 2010 United HealthCare Services, Inc. UM0088-CPS 07-10 No part of this document may be reproduced without permission. Please retain this statement for future reference. C Provider: Physician,Joe,MD PO Box 30541 Salt Lake City, UT 84130-0541 1-866-684-8090 www.umr.com Service Description Amount Not Payable 908 See Note Section $50.00 SAMPLE Amount Billed $25.00 Less Deductible B Allowable Amount $25.00 D Patient Account: 05050505aa $100.00 EXPLANATION OF BENEFITS NOTICE - THIS IS NOT A BILL 01-01-08 Dates of Service From: To: Plan Benefit Amount Employee Member Number Patient Notice Date Employer Name Employer Number % $20.00 Amount Paid $20.00 Page Dist Code Joe Patient 999999999 Joe Patient 02-01-08 Customer Inc. 7670-00-999999 Provider May Bill You $55.00 E Claim Control Number: 08171769999 80 P members to call if they suspect illegal activity regarding claims. 01-01-08 WIndicates the toll-free telephone number for O to file appeals. This information is provided in the members’ SPD (Summary Plan Description). Also indicates the members’ right to file civil action. 99283 - Emergency Care VIndicates the specific time frame for members $55.00 paid. regarding eligibility and claim information. N MPercentage at which the Allowable charges are U Web Site address for members to access $20.00 difference between the “Amount Billed” and the “Amount Not Payable” and/or “Less Deductible” columns. members to call with questions regarding the Explanation of Benefits. UM0088-CPS 08-08 L C harges allowed for payment – this is the TUMR toll-free telephone number for L M K Amount applied to the deductible. (see back page of this flyer) K were not allowed – see Notes Section. Cover Page Explanations: $20.00 J R efers to codes used to explain charges that amounts applied to individual/family deductibles, out-of-pocket and lifetime maximums, if applicable. Payment Amount: $20.00 see comment code. SProvides benefit period and benefit levels, J ICharges not allowed according to the Plan – checks were issued. I hospital, physician or other health care provider. RList of individuals or organizations to whom H H Amount charged for the services by the Section” column. Lists the specific code and its definition. $25.00 hospital, physician or other health care provider. G G D ates(s) services were performed by the QExplains codes provided in the “See Notes $50.00 Service description T9999 will print if dollars are available to be reimbursed from HRA. the hospital, physician or other health care provider, if applicable. Payment Date: 09-01-08 performed by the hospital, physician or other health care provider. F F Services and/or procedures that were POnly amount you are responsible to pay to $100.00 to each claim received. TOTALS E UMR assigns a unique claim control number Q physician or other health care provider. OAmount that UMR paid to the provider. Applied To Date $1,500.00 $200.00 Met $300.00 $205.00 $305.00 D A ccount number assigned by the hospital, Charge reduced due to provider’s discount. provider that performed the services. Note Section CHospital, physician or other health care NAmount actually payable by the Plan. 908 which the claim was processed. R BFields include member information under Payment To: XYZ Clinic S EOB Field Explanations: Benefit Period Benefit Level $1,000,000 Lifetime Maximum $200 Ind Cal Yr Deductible $400 Fam Cal Yr Deductible $400 Ind Out-Of-Pocket $800 Fam Out-Of-Pocket 01-01-08 01-01-08 01-01-08 01-01-08 How To Read Your EOB 000001 PO BOX 30541 Salt Lake City, UT 84130-0541 UMR How To Read Your EOB SAMPLE 00001 001 JOE PATIENT 123 ABC LANE ANYTOWN USA 99999-9999 CONCERNS? T QUESTIONS? Contact your Customer Service Representative at 1-866-684-8090. U INTERNET: Online services are available 24 hours a day at www.umr.com. . Claim payment detail Claim status Benefit information Eligibility Order an ID card Many other services! V APPEAL: You may file an appeal of the claim decision by sending a written request and pertinent information within 180 days from the date of this Notice to "Claims Appeal Unit, P.O. Box 30546, Salt Lake City, UT 84130-0546.” Refer to your current benefit booklet for information on the appeal process. After you have exhausted the mandatory appeal levels that are described in your benefit booklet, you have the right to bring a civil action under section 502(a) of the Employee Retirement Income Security Act (ERISA). STOP FRAUD! W HELP If you know or suspect any illegal activity concerning claims, contact our anti-fraud unit by calling our toll-free number 1-800-356-5803. You do not need to identify yourself. Refer to your benefit booklet for more details on Claim determination. © 2010 United HealthCare Services, Inc. UM0088-CPS 07-10 No part of this document may be reproduced without permission. Please retain this statement for future reference.