EFTA00311382.pdf

Unitedltealthears Insurance Company GREENSBORO SMALL GROUP P 0 BOX 740800 ATLANTA. GA 30374-0800 UnitedHealthcare May 12, 2015 Claim Information Patient: Jeff roy Epstein Maine Acct.: 1 15289 LH Date of Service: 07/28/2014 Provider. Minnick Cannavo, MD. JEFFREY EPSTEIN Claim IM 854905597/EG108422 6100 RED HOOK QUARTER B-3 Claim 0: 4791351186 ST THOMAS VI 00802-0000 Member. Jeffrey Epstein MemberID: 854905597 ;Group: SOUTH3N TRUST COMDAilf Dear Jeffrey Epstein: I Group.: GA272805/1W000 Letter IO: OVP7001 We make every effort to process claims accurately, but sometimes errors occur. We overpaid you on a claim for you and need a refund. Please repay us 51,797.22 within 45 days of the date on this letter. Thank you and we apologize for any inconvenience this causes you Claim overpayment details • Reason for owirpayment: We didn't pay the correct amount for this service. • Check date: 11/12/14 • Check number. QC09089752 • Amount of check sent to you: $1,797.22 (This amount may include other claim payments.) • Correct amount paid for this claim: $0.00 • Patient responsibility (what you owe) for this claim: $0.00 Mail your payment and this letter to: GREENSBORO SMALL GROUP P 0 BOX 740800 ATLANTA. GA 30374-0800 We suggest you keep a copy for,. r cords. If we do not get the refund. some state laws may allow us to deduct the amount due from future claim payments. You may have additional rights about this claim. For more information or further explanation, please check your Health Statement, Explanation of Benefits or other courage documents. If you haw questions about this letter or other questions related to your health insurance, please call the toll-free member phone number listed on your health plan ID card. Sincerely. UnitedHealthcare EFTA00311382 EFTA00311383  UnitedHealtticard eme a Albstelmith OvaOATS, UnitedHealthcare Insurance Company es GREENSBORO SMALL GROUP P O BOX 740800 ATLANTA, GA 30374-0800 Have more questions about your darn? Visit www.myuhc.com for all your claim and benefit intormafon. s.7 May 13, 2015 134BADADORUKGPS0002001-05106-01 Member/Patient Information JEFFREY EPSTEIN 6100 RED HOOK QUARTER B-3 Member/Patient: JEFFREY EPSTEIN ST THOMAS, VI 00802 Member ID: A854905597 Relationship: EE Group Name: SOUTHERN TRUST COMPANY Group St 0272605 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Claims Summary Detailed claim information is located on the following page(s). Dollar Amount Description Amount Billed to you. $6,422.82 This is the total amount that your provider billed for the services that were provided Plan Discounts include $600.00 Your plan negotiates discounts with providers to save you money. This amount may also services that you are not responsible to pay. Your Plan Paid $5,822.82 This is the portion of the amount billed that was paid by your plan. Total amount you owe the provideds) The portion of the Amount Billed you owe the provider(s). This amount does not reflect any C ..) payment you may have already made at the time you received care. This amount may $0.00 include your deductible, co-pay, coinsurance and/or non covered charges. This amount does not include any payments made to the subscriber. If a payment was made directly to the subscriber, you/the subscriber is responsible for paying the physician, facility or other health care professional. ' Men coordination of benefits applies, this amount will include payments made to the subscriber. Page 1 of 4 STD-EOB Use this EOB statement as a reference or retain as needed 000:0070i573301 EFTA00311384  5A0:0:0011:0:048 I/O 15131617f0-AFJ t2SP4 UnitedHealthcare UntiedHealthcare Insurance Company 0 GREENSBORO SMALL GROUP May 13. 2015 P O BOX 74O8O0 A 800 Have more questions about your claim? Phone: Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY EPSTEIN Provider O CANNAVO Claim Number 479135118601 Patient Account Number: 1 15289 UH Your itemized Res sibir to Provider Date(s) of Type of Service Notes' Amount Plan Your Plan Amount You Service Billed (-) Discounts (9 Paid (4) Deductible N) Copay (•) Coinsurance N) Mon Covered ("9 Owe 07/28/2014 ANESTHESIA IT $8.000.00 $600.00 $5400.00 $0.00 $0 00 $000 $0.00 $0.00 Claim Total: 0.000.00 $100.00 $5.400.00 $0.00 $0.00 $0.00 NOM $0.00 "This total does not reflect any payments / copays you made at the time of service Please wait for a provider biN before making a payment Claim Detail for JEFFREY EPSTEIN Provider. D CANNAVO Claim Number: 479135118601 Patient Account Number: 1 15289 UH Your Itemized Res•onsibilit to Provider' Date(s) of Type of Service Notes' Amount Plan Your Plan Amount You Service Billed (9 Discounts (4 Paid (4) Deductible (-; Copay (-) Coinsurance i-) Non Covered l') Owe 07/28,2014 CLM EXPENSE 5U $422.82 $0.00 $422.82 $000 INTEREST Claim Total: $422.52 $0.00 $422.82 $0.50 "This total does not reflect any payments / copays you made at the time of service Please wait for a provider bill before making a payment. Notes* SU - THIS AMOUNT REPRESENTS INTEREST PAID. IT - THIS PHYSICIAN OR HEALTH CARE PROVIDER IS OUT-OF-NETWORK. BASED ON AN AGREEMENT WITH MULTIPLAN, THE PROVIDER HAS ACCEPTED A DISCOUNT FOR THIS SERVICE. THE DISCOUNT SHOWN IS YOUR SAVINGS AND IS NOT INCLUDED IN THE AMOUNT YOU OWE. IF YOU HAVE PAID THE PHYSICIAN OR HEALTH CARE PROVIDER MORE THAN THE AMOUNT YOU OWE, PLEASE CALL THEM FOR A REFUND. STD-EOB Page 2 of4 Use this EO8 statement as a reference or retain as needed 0000:0704673307 EFTA00311385  BLOX09'0750(04410-15133-817/0.SJ 125N UnitedilealthcarE AtraiOSO TISICAMMY UnitedHealthcare Insurance Company May 13, 2015 GREENSBORO SMALL GROUP P O BOX 740800 OO Have more questions about your claim? Phone: Visit www.myuhc.com for all your claim and benefit Information. address: UnitedHealthcare Appeals, P.O. Box 30573, Salt S A review of this benefit determination may be requested by submitting your appeal to us in writing at the following you receive this statement. If you request a review of your claim denial, Lake City, UT 84130-0573. The request for your review must be made within 180 days from the date we will complete our review not later than 30 days atter we receive your request for review. atr, all required reviews of your claim have been completed. If your plan is governs by ERISA, you may have the right to file a civil action under ERISA If by submitting comments, documents or other relevant information to You or your authorized representative, such as a family member or physician, may appeal the decision the appeal address referenced above. at the above address. You may request copies (free of charge) of information relevant to your claim by contacting us Availability of Consumer Assistance/Ombudsman Services by ERISA, you can contact the Employee Benefits Security There may be other resources available to help you understand the appeals process. If your plan is governed Services Health Insurance Assistance Administration atSil. If your plan is not govemed by ERISA, you can contact the Department of Health and Human Team eta. Your state consumer ae-sistance program may also be able to assist you at Division of Banking and Insurance 1131 King Street, Suite 101 Christiansted, St. Croix, VI 00820 www.ltg.gov.vi you may be able to request an external review of your claim by an If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, independent third party, who will review the denial and issue a final decision. receive or service you were told would be free, call- Insurance fraud adds millions to the cost of health care. If services are listed which you did not Meet Your Needs Online request an ID card, refill prescriptions if eligible, obtain more information on At almost anytime day or night, you can review claims, check eligibility, locate a network physician, EOB content and morel For immediate, secure self-service visit www.myuhc.com. Myuhc Registration register, The information required for registration is on your insurance ID card You can register and begin using myuhc In the same session. Navigate to www.myuhc.com to (first name, last name, member ID, group number and date of birth). Page 3 of 4 STD-EOO Use this EOB statement as a reference or retain as needed IX030T10.673107 EFTA00311386  BAC0)9P07000350 143 15133-6170-AFJ 1294 UnitedHealthcare Allwatlit Cauglatel UnitedHealthcare Insurance Company GREENSBORO SMALL GROUP May 13, 2015 P O BOX 740800 ho Have more questions about your claim? Phone: Visit www.myuhc.com for all your claim and benefit information. Maintaining the privacy and security of individuals' personal information is very important to us at UnitedHealthcare. To protect your privacy, we implemented strict confidentiality practices. These practices include the ability to use a unique individual identifier. You may see the unique individual identifier on UnitedHealthcare correspondence, including medical ID cards (if applicable), letters, explanation of benefits (EOBs), and provider remittance advices (PRAs). If you have any questions about the unique individual identifier or its use, please contact your customer care professional at the number shown at the top of this Statement. Please call the number included in this document or on the back of your ID card if you need diagnosis and/or treatment code information regarding the services referenced in this communication. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2014 JEFFREY Annual (-)Applied to (=)Remaining FAMILY Annual HApplied to (w)Remaining Amount Date Balance Amount Date Balance Relationship: EE IN NETWORK IN NETWORK Out of Pocket $5,000.00 $200.00 $4,800.00 Out of Pocket 52.500.00 $200.00 52.300 03 OUT OF NETWORK OUT OF NETWORK Deductible $1,000.00 $500.00 $500.00 Deductible $50000 $500.00 Met Out of Pocket $10.030.00 $1,125.03 59,974.97 Out of Pocket 55.000.00 $1.142.19 $3.057.81 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of Doductibler The deductible is the faced dollar amount that you pay each year toward efigible this EOB statement health care services before your plan benefits are payable. Once the deductible has been met the co-payment and/or coinsurance period of your plan may begin. Please refer to your plan documents for specific information regarding what services apply to the deductible. Out of Pocket The out of pocket maximum is the dollar amount you pay before your plan Plan Year. The dates your plan benefit maximums are applicable. benefit starts paying at 100% for eligible health care services. Please refer to your plan documents for specific information on what costs apply to the maximum amount STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 010000704671307 EFTA00311387  100IWon ISMAR1 UnitedHealthcard AUNSHIlittfrallCarin UnitedHeatthcare Insurance Company GREENSBORO SMALL GROUP P 0 BOX 740800 ATLANTA, GA 30374-0800 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. 131BADADORUFIGPS0002001-05106-03 May 13, 2015 JEFFREY EPSTEIN Member/Patient Information 6100 RED HOOK QUARTER B-3 Member/Patient- JEFFREY EPSTEIN ST THOMAS. VI 00802 Member ID: A854905597 Relationship: EE Group Name: SOUTHERN TRUST COMPANY Group 0: 0272805 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Claims Summary Detailed claim information is located on the following page(s). c Dollar Amount Description Amount Billed 51,796.94 This is the total amount that your provider billed for the services that were provided to you. Plan Discounts $1,432.98 Your plan negotiates discounts with providers to save you money. This amount may also include services that you are not responsible to pay. Your Plan Paid $251.40 This Is the portion of the amount billed that was paid by your plan. Total amount you owe the provider(s) The portion of the Amount Billed you owe the provider(s). This amount does not reflect any payment you may have already made at the time you received care. This amount may include your deductible, co-pay, coinsurance and/or non covered charges. This amount does not indude any payments made to the subscriber. If a payment was made directly to the subscriber, you/the subscriber Is responsible for paying the physician, facility or other health care professional. ' Wien coordination of benefits applies, this amount will include payments made to the subscriber. Page 1 of 7 STD-EOB Use this EOB statement as a reference or retain as needed 000000701673311 EFTA00311388  BA4:00100190X62a/D-15113-81763.AFJ 12SN Unitedllealthcare kle.sOkedargaaref UnitedHealthcare Insurance Company GREENSBORO SMALL GROUP May 13, 2015 P O BOX 740800 ATLANTA :137t.1400 Have more questions about your claim? Phone: Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY EPSTEIN Provider. QUEST DIAGNOSTICS Claim Number: 504161738801 Patient Account Number 156189349 i Your Itemized Res. •nsibll to Provider Date(s) of Type of Service Notes' Amount Plan Your Plan Amount You Service Billed (9 Discounts (4 Paid (a) Dnductible (*) Copay (•) Coinsurance (•) Non Covered (=) Owe 04/24/2015 LABORATORY FT $18.35 $15.35 $2.40 $0.00 $0 .00 SO 60 SO 00 $0.60 SERVICES 04/24/2015 LABORATORY FT $234.16 $188.04 $36.90 $0.00 $0.00 $9.22 $0.00 $922 SERVICES 04/2492015 LABORATORY IT $9329 $75.58 314.17 $0.00 $0.00 $3.54 $0.00 $3.54 SERVICES 04/24/2015 LABORATORY IT $232.54 $192.67 $31.90 $0.00 $0.00 $7.97 $0.00 $7.97 SERVICES 04/24/2015 LABORATORY IT $110.77 $90.55 $16.18 $0.00 $0.00 $4.04 $0.00 $4.04 SERVICES 04/24/2015 LABORATORY IT $71.39 $58.36 $10.42 $0.00 $0.00 $2.61 $0.00 $2.61 SERVICES Claim Total: $760.50 4620.56 $111.97 SO.00 $0.00 $27.95 $0.00 $27.98 "This total does not reflect any payments / copays you made at the time of service Please wait for a provider bill before making a payment. STD•EOB Page 2 of 7 Use this EOB statement as a reference or retain as needed 000000701873311 EFTA00311389  GAC:010•02•000:61.MD.15133.111783.AFJ 129.1 Unitedflealthcar Aurits...swenv JnitedHealthcare Insurance Company May 13. 2015 3REENSBORO SMALL GROUP 2 O BOX 740800 kTLANiii..4.800 Have more questions about your dalm? Phone: Visit www.myuhc.com for all your daim and benefit information. Claim Detail for JEFFREY EPSTEIN Claim Number 5O4161738802 Patient Account Number: 156189349 Provider: QUEST DIAGNOSTICS Your Itemized Res nalbil to Provider Amount You Date(s) of Type of Service Notes' Amount Plan Your Plan Copy (.) Coinsurance (•) Non Covered (-) Owe Billed (4 Discounts (4 Paid (m) Deductible (a') Service 50.00 30,00 $1123 $0.00 311231 04/24/2015 LABORATORY IT $21897 $162.80 $44.94 SERVICES $0.00 $5.27 $0.00 $527 IT $159.89 $133.52 $2110 $0.00 04/24/2015 LABORATORY SERVICES s0.00 $18.5. $0.00 $16.50 $376.66 $21111.32 $88.04 $0.00 Claim Total: 'This total does not reflect any payments / °spays you made at the time of senfice. Please wait for a provider bill before making a payment Page 3 of 7 STD-E08 Use this EOB statement as a reference or retain as needed 000000704573311 EFTA00311390  BACC01097=054410.15133.6170-AFJ UnitedHealthcare A Urnalwil0.04 UMW/ UnitedHealthcare Insurance Company 0 GREENSBORO SMALL GROUP May 13, 2015 P O BOX 740800 ATLANTA1.11.100 Have more questions about your claim? Phone- Visit wvnv.myuhc.com for al your claim and benefit information. Claim Detail for JEFFREY EPSTEIN Provider: GUEST DIAGNOSTICS Claim Number 504181738901 Patient Account Number 156189349 Your lionized Res nsl • to Provider Date(s) of Type of Service Notes• Amount Plan Your Plan Service Billed (4 Discounts (-) Paid (s r-. e•.ucGDl• C••ay . a • " 04/242015 LABORATORY IT 3151.35 Si 16.88 $27.58 *0.00 $6.89 $0.00 . SERVICES 04/24/2015 LABORATORY IT $211.45 $176.69 $27.81 $0.00 $0.00 $8.95 $0.00 $8 SERVICES 04/24/2015 LABORATORY IT $144.47 $132.41 $9.85 $0.00 $0.00 52.41 $0.00 $2.41 SERVICES 04/24/2015 LABORATORY 14 $49.75 $0 00 $0.00 $0.00 $0.00 $0.00 $49.75 $49. SERVICES 04/24/2015 LABORATORY IT $3425 $31.29 $2.93 $0.00 $0.00 $073 $0.00 $0. SERVICES 04/24/2015 LABORATORY IT $8581 $58.84 $5.42 $0.00 $0.00 $1.35 $0.00 $1 SERVICES Claim Total: $657.58 $611.11 $73.39 0.00 $0.011 110.33 $49.75 $68.1 . This total does not reflect any payments / copays you made at the time of service. Please wait fore provider bill before making a payment. Notes* 14 - PAYMENT FOR THIS SERVICE OR SUPPLY IS DENIED BASED ON OUR REIMBURcFUFNT POLICY. THIS SERVICE WAS INCLUDED *I A SERVICE ALREADY REPORTED OR TT IS NOT PAID SEPARATELY. IF YOU USED A NETWORK PROVIDER, YOU DON'T OWE ANYTHING. - THIS PHYSICIAN OR HEALTH CARE PROVIDER IS OUT-OF-NETWORK. BASED ON AN AGREEMENT VVM-I MULTIPLAN, THE PROVIDER HAS ACCEPTED A DISCOUNT FOR THIS SERVICE. THE DISCOUNT SHOWN IS YOUR SAVINGS AND IS NOT INCLUDED IN THE AMOUNT YOU OWE. IF YOU HAVE PAID THE PHYSICIAN OR HEALTH CARE PROVIDER MORE THAN THE AMOUNT YOU OWE, PLEASE CALL THEM FOR A REFUND. You have the right to receive, upon request and free of charge, a copy of the internal rule, guideline or protocol that we relied upon in making the non-coverage decision for your claim. STD•EOB Page 4 of 7 Use this EOB statement as a reference or retain as needed 00[000704073311 EFTA00311391  BALIC0109311X0554A0.1513341763.AFJ 1734 UnitedHeakhcare PUN!~ &ROCS/ MitedHealthcare Insurance Company May 13. 2015 3REENSBORO SMALL GROUP O BOX 740800 Have more questions about your claim? VILANSS30 Thone: -0800 Visit www.myuhc.com for all your claim and benefit information. thcare Appeals, P.O. Box 30573, Salt review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHeal If you request a review of your claim denial, _ake City, UT 84130-0573. The request for your review must be made within 180 days from the date you receive this statement. Ne will complete our review not later than 30 days after we receive your request for review. of your claim have been completed. f your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews documents or other relevant information to You or your authorized representative, such as a family member or physician. may appeal the decision by submitting comments, :he appeal address referenced above. You may request copies (free of charge) of information relevant to your claim by contacting us at the above address. Availability of Consumer Assistance/Ombudsman Services by ERISA, you can contact the Employee Benefits Security There may be other resources available to help you understand the appeals process. If your plan is governed Insurance Assistance Administration at If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Team at Your state consumer assistance program may also be able to assist you at: Division of Banking and Insurance 1131 King Street, Suite 101 Christiansted, St. Croix, VI 00820 www.ltg.gov.vi may be able to request an extemal review of your claim by an If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you independent third party, who will review the denial and issue a final decision. service you were told would be free, call Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or Meet Your Needs Online an ID card, refill prescriptions if eligible, obtain more information on Al almost anytime day or night, you can review claims, check efigibility, locate a network physician, request EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration required for registration is on your insurance ID card You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information (first name, last name, member ID, group number and date of birth). Page S of 7 STD-EOB Use this EOB statement as a reference or retain as needed OCOX47046733I I EFTA00311392 II11111111111111 EFTA00311393 Unite dHeeithcare insurance Company GREENSBORO SMALL GROUP P 0 BOX 740800 ATLANTA. GA 30374-0800 UnitedHealthcare' MEE =re May 14, 2015 Claim Information Patient: Jaffrey Epstein I Patient Acct VV07208913 Date of Service: 04/22/2015 Provider: M3unt Sinai Hosptal =cm JEFFREY EPSTEIN ; Claim Mk 8549055971E/008273 6100 RED HOOK QUARTER B-3 Claim II: 5035975308 ST THOMAS VI 00802-0000 i Member: Jellray Epstein Member ID: 854905597 Group: SOUTieN TRUST coMPANw