Member Services:
1-800-251-7722
8:00 am - 6:00 pm, Monday - Thursday
8:00 am - 5:00 pm, Friday
175 Scott Swamp Road, P.O. Box 4050
Farmington, CT 06034-4050
4 For all claims & benefit information go to
www.connecticare.com/members
Electronic Service Requested
4 Go online for convenient, self-service
capabilities and other helpful information.
<BARCODE>
JOE SAMPLE
PO BOX 123456
SOMEWHERE, CT 00000-0000
Statement Date: Member Name: Member ID#: Plan Year:
06/01/13
JOE SAMPLE
12345678901
06/1/13 - 05/31/14
YOUR CLAIM SUMMARY includes claims processed by ConnectiCare in the week prior to the statement date noted
above. If you owe your health care provider for services, the provider will bill you directly. This statement is not a bill.
AMOUNT BILLED by your health care providers (physicians,
hospital, etc.) for services rendered.
$x.xx
PLAN DISCOUNTS are savings we pass along to you when you go to
participating providers. This is the amount participating providers have
agreed to reduce their charges for ConnectiCare members.
- $x.xx
CONNECTICARE PAID this amount for billed services.
- $x.xx
AMOUNT YOU PAY to your health care provider(s), including deductibles,
copays, coinsurance or non-covered services as outlined in your plan. This
amount may include charges you have already paid to your provider.
= $x.xx
For claim details see the following page(s).
DEDUCTIBLES & MAXIMUMS AT-A-GLANCE
In-Network Deductible
Out-of-Network Deductible
Out-of-Pocket Maximum
You Owe
per Plan Year
You Paid
to Date
$1500.00
$x.xx
$3000.00
$x.xx
$2500.00
$x.xx
Go paperless! Sign up for electronic delivery at www.connecticare.com/members
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DEFINITIONS:
Amount Allowed The amount that our participating providers have agreed to accept as payment. When you
use non-participating providers, you may be responsible for the difference between the
Amount Billed and Amount Allowed.
Claim Notes
Two-digit codes to provide additional information about how the claim was processed.
Copay
A flat dollar amount you pay for certain services. This amount may have already been
collected when you were at your health care provider’s office.
Coinsurance
A cost-sharing feature associated with some plans, where the member and ConnectiCare
each pay a percentage of the cost for the covered services.
Deductible
The amount you must pay out-of-pocket for certain medical services before your plan
coverage begins. Non-covered services do not count toward meeting your plan deductible.
Maximum
The point at which benefit coverage reaches a limit as outlined by your plan. If you reach
the maximum, you will have no more cost-share through the remainder of the plan year.
Plan Year
A 12-month period during which plan deductibles, maximums or other cost-share apply. It
may follow a calendar year or start on your renewal date, depending on your benefit plan.
MEMBER RIGHTS TO APPEAL:
You have the right to appeal a denied claim up to 180 days after the initial denial by writing to ConnectiCare Member
Appeals, PO Box 4061, Farmington, CT 06034-4061. For more information, please refer to your Certificate of Coverage,
Membership Agreement, Summary Plan Description, or other plan document. If you do not file in a timely manner, you
may lose your right to appeal. If ConnectiCare fails to follow the requirements of our appeal process, you may seek an
external review or proceed with other available remedies under applicable law.
If this denial was based on a medical necessity decision you will receive a letter explaining the criteria used to make the
decision. This will include an explanation of the scientific or clinical judgment upon which the denial was based as well as
a description of the external appeals process which may be available to you.
If you believe you have been given erroneous information and need other assistance, contact the following:
In Connecticut
Office of the Healthcare Advocate
PO Box 1543
Hartford, CT 06114
Phone: 1-866-466-4446 E-mail: [email protected]
State of CT Insurance Dept.
PO Box 816
Hartford, CT 06142-0816
Phone: 1-860-297-3910
In Massachusetts
Health Care for All
30 Winter St. Suite 1004
Boston, MA 02108
Phone: 1-800-272-4232
If your plan is subject to ERISA, you may have the right to bring a civil action under section 502(a) of the
Employee Retirement and Income Security Act if your claim is not approved.
4If you need help having ConnectiCare materials translated from English to a different language,
please call Customer Service at 877-373-1206.
4Si necesita ayuda para tener materiales ConnectiCare traducidos del ingles a otro idioma, por
favor llame a servicio al cliente al 877-373-1206.
4Jesli potrzebujesz pomocy, posia dajace materialow ConneciCare tlumaczone z angielskiego
na inny jezyk, prosze zadzwon obslugi klienta na 877-373-1206.
Health care fraud leads to higher costs for all. To report suspected fraud, call our Fraud Hotline
at 1-888-4KO-FRAUD (1-888-456-3728) or e-mail [email protected]
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Statement Date: Member Name: Member ID#: Plan Year:
06/01/13
JOE SAMPLE
12345678901
06/1/2013 - 05/31/14
Payment Detail
Amount
Billed
Plan
Discount
Your Payment Responsibility
Amount ConnectiCare
Allowed
Paid
Deductible
Not
Copay Coinsurance Covered
You
Pay
Claim
Notes
Provider Name: Dr. Smith (Non-participating Provider)
Claim Number: 12345678910
06/01/13 PHYSICIANS VISITS
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
03
06/01/13 SURGERY
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
03
Subtotal:
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
Provider Name: Dr. Jones (Participating Provider)
Claim Number: 12345622222
06/01/13 PHYSICIANS VISITS
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
Subtotal:
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
xx.xx
TOTAL:
$xx.xx
$xx.xx
$xx.xx
$xx.xx
$xx.xx
$xx.xx
$xx.xx
$xx.xx
$xx.xx
03
Claim Notes
03
AMOUNT ALLOWED IS WHAT THE PROVIDER HAS AGREED TO ACCEPT AS PAYMENT
3 of 3