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 09-10 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 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 P $55.00 E Claim Control Number: 08171769999 80 members to call if they suspect illegal activity regarding claims. Dates of Service From: To: 01-01-08 WIndicates the toll-free telephone number for O are paid. to file appeals. This information is provided in the members’ SPD (Summary Plan Description). Also indicates the members’ right to file civil action. $20.00 MPercentage at which the Allowable charges VIndicates the specific time frame for members UM0088-CPS 08-08 difference between the “Amount Billed” and the “Amount Not Payable” and/or “Less Deductible” columns. regarding eligibility and claim information. N L C harges allowed for payment – this is the U Web Site address for members to access $20.00 K Amount applied to the deductible. members to call with questions regarding the Explanation of Benefits. Payment Amount: $20.00 were not allowed – see Notes Section. TUMR toll-free telephone number for 99283 - Emergency Care J R efers to codes used to explain charges that (see back page of this flyer) L M see comment code. Cover Page Explanations: K ICharges not allowed according to the Plan – amounts applied to individual/family deductibles, out-of-pocket and lifetime maximums, if applicable. $25.00 hospital, physician or other health care provider. SProvides benefit period and benefit levels, J H Amount charged for the services by the checks were issued. I hospital, physician or other health care provider. RList of individuals or organizations to whom $50.00 G D ates(s) services were performed by the Section” column. Lists the specific code and its definition. Payment Date: 09-01-08 performed by the hospital, physician or other health care provider. QExplains codes provided in the “See Notes H F Services and/or procedures that were G to each claim received. F E UMR assigns a unique claim control number the hospital, physician or other health care provider, if applicable. $100.00 physician or other health care provider. POnly amount you are responsible to pay to Applied To Date $1,500.00 $200.00 Met $300.00 $205.00 $305.00 D A ccount number assigned by the hospital, TOTALS provider that performed the services. Q CHospital, physician or other health care Charge reduced due to provider’s discount. which the claim was processed. Note Section OAmount that UMR paid to the provider. 908 BFields include member information under R NAmount actually payable by the Plan. 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 09-10 No part of this document may be reproduced without permission. Please retain this statement for future reference.