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Hello, John David
My Coverage
: Active01/01/08 More details
Plan Name
: Choice Plus
My Coverage
: 1110110
My Coverage
: 7895486245
Plan Details
Deductible
$1,000 Individual
$1,000 Family
Out-of-Pocket Max
$1,000 Individual
$1,000 Family
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Claim and Search
Referral & Authorization Submission
Authorization Managment
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Legends
Total no of days from the date of submission:
Application Status as of today:
Process:
Application Submitted
Function:
Process:
Contract negotiation
Function:
Market
Process:
Contract loading
Function:
PNO
Process:
Credentialing
Function:
PNO
Process:
Provider Contract loading
Function:
Market
Process:
Successful contract enrolment
Function:
PNO
Most Common Pending Reasons
- Incomplete Application
- Incomplete Education/Work History
- Practioner current date & signature
- DOB & SSN of the practioner
- Completed Practioner Authorization with signature and dates
- Missing Humana contract agreement
Process:
Application Submitted
Function:
Process:
Contract negotiation
Function:
Market
Process:
Contract loading
Function:
PNO
Process:
Credentialing
Function:
PNO
Process:
Provider Contract loading
Function:
Market
Process:
Successful contract enrolment
Function:
PNO
What would you like to do today?
Your Claim Summary
Search Option
Begin DOS |
End DOS |
Provider Name |
Receipt Date |
Paid Status |
Charge Amt |
Allowed Amt |
Paid Amt |
Claim Nbr. |
NPI ID |
View Details |
---|---|---|---|---|---|---|---|---|---|---|
Begin DOS |
End DOS |
Provider Name |
Receipt Date |
Paid Status |
Charge Amt |
Allowed Amt |
Paid Amt |
Claim Nbr. |
NPI ID |
View Details |
25-09-2015 | 25-09-2015 | Atlas Medical |
29-09-2015 | Pended | $150.00 | $0.00 | $0.00 | 123456789 | 12345678910 | Details |
20-08-2015 | 25-08-2015 | Memorial Hospital |
21-08-2015 | Denied | $11,150.00 | $0.00 | $0.00 | 234567891 | 45678912365 | Details |
16-07-2015 | 16-07-2015 | Med Pro |
18-07-2015 | Paid | $650.00 | $300.00 | $300.00 | 567894123 | 98745632104 | Details |
15-07-2015 | 15-07-2015 | Laboratory | 18-07-2015 | Paid | $100.00 | $60.00 | $56.00 | 512789456 | 65478932145 | Details |
18-05-2015 | 18-05-2015 | Dr. Smith | 20-05-2015 | Pended | $450.00 | $0.00 | $0.00 | 789456123 | 65896541236 | Details |
10-04-2015 | 10-04-2015 | Dr. Smith | 12-04-2015 | Paid | $100.00 | $70.00 | $50.00 | 852369741 | 12345698910 | Details |
11-03-2015 | 11-03-2015 | Atlas Medical |
16-03-2015 | Denied | $100.00 | $0.00 | $0.00 | 147852369 | 45698512365 | Details |
15-02-2015 | 15-02-2015 | Med Pro | 18-02-2015 | Paid | $650.00 | $300.00 | $300.00 | 987123852 | 98745639514 | Details |
10-02-2015 | 10-02-2015 | Laboratory | 16-02-2015 | Paid | $100.00 | $60.00 | $56.00 | 951357852 | 65357932145 | Details |
18-01-2015 | 18-01-2015 | Dr. Jones | 25-01-2015 | Paid | $450.00 | $250.00 | $250.00 | 654741369 | 75396541236 | Details |
Member Details
John Smith
A123456789
Atlas Medical
123456789
01-01-2015
01-01-2015
N
B12345
999999999
123456789
123456789
05-02-2015
15-02-2015
Mark Burns
Ambulatory
1234567891
EDI
725.30
$592.00
12345
Cleared
456789123
COMPLETED
Paid
Amount Billed $592.00
Your Responsibility
$1,249.00
Detailed Cost
Sr. No. | Begin DOS | Serv Code | Service Description | Charge Amt | Allowed Amt | Deny Amt | Deduct Amt | Exp Code | Last Proc Date |
---|---|---|---|---|---|---|---|---|---|
Sr. No. | Begin DOS | Serv Code | Service Description | Charge Amt | Allowed Amt | Deny Amt | Deduct Amt | Exp Code | Last Proc Date |
1 | 01-01-2015 | 97002 | Therapy Service | $150.00 | $70.00 | $0 | $0 | 0PC | 05-02-2015 |
2 | 01-01-2015 | 27275 | Manipulation, hip joint, requiring general anesthesia | $100.00 | $70.00 | $0 | $0 | 0PC | 05-02-2015 |
3 | 01-01-2015 | 97703 | Therapy Service | $150.00 | $70.00 | $0 | $0 | 0PC | 05-02-2015 |
4 | 01-01-2015 | 99213 | Office Visit | $40.00 | $10.00 | $0 | $0 | 0PC | 05-02-2015 |
5 | 01-01-2015 | 99065 | Therapy Service | $150.00 | $70.00 | $0 | $0 | 0PC | 05-02-2015 |
6 | 01-01-2015 | 93270 | Therapy Service | $150.00 | $70.00 | $0 | $0 | 0PC | 05-02-2015 |
7 | 01-01-2015 | 97010 | Modality | $50.00 | $20.00 | $0 | $0 | 0PC | 05-02-2015 |
8 | 01-01-2015 | 92597 | Prosthetic | $150.00 | $70.00 | $0 | $0 | 0PC | 05-02-2015 |
9 | 01-01-2015 | 92628 | Therapy Service | $150.00 | $70.00 | $0 | $0 | 0PC | 05-02-2015 |
10 | 01-01-2015 | 97112 | Therapy Service | $150.00 | $70.00 | $0 | $0 | 0PC | 05-02-2015 |
JOHN SMITH
123 GRIER MANOR CT
MCDONOUGH, GA 45678-9123
Claim Receipt
Explanation of benefits and claim payments
THIS IS NOT A BILL
Patient/Subscriber
Name: | JOHN SMITH |
Member ID: | 123456789 |
Relationship: | Subscriber |
Group name: | HMO NEW YORK |
Group ID: | Q7207 |
Plan Type: | MHMO |
Birth Date: | 1-18-1952 |
Patient Account: | 123456789 |
Claim Summary
Plan payment has been issued to your provider.
Claim Number: | 894857690302 |
Provider: | FRED K HOOD MD |
Service Date: | 9/18/15 - 9/18/15 |
Processed on: | 9/25/15 |
Benefits Paid to: | EMORY SPECIALTY ASSOCIATES |
Provider Charges | Paid to Provider | What You Owe | ||
---|---|---|---|---|
Total Billed | $364.00 | |||
Plan Discounts | -$240.32 | |||
Excluded Charges | $0.00 | |||
Member Responsibility | ||||
Copay | $0.00 | |||
Deductible | $0.00 | |||
Coinsurance | $0.00 | |||
What we will pay | $123.68 | |||
Claim Totals | $123.68 | $123.68 | $0.00 | Amount you pay Provider |
Notes: Please compare these totals with the bill you receive from your provider.
Claim Receipt
Explanation of benefits and claim payments
MICHELLE COLLINS - 123456789
page 2 of 2
Claim Number: | 894857690302 |
Service Date: | 09/18/15 - 09/18/15 |
Provider: | JOHN K SMITH |
Date Processed: | 09/25/15 |
Provider | Service Date(s) | Service Code | Total Charges | Plan Discounts | Plan Exclusions | Reason Codes | Allowed Amount | Copay | Deductible | Coinsurance | Plan Paid |
---|---|---|---|---|---|---|---|---|---|---|---|
FRED K H In-Network Provider | 9/18/2015 | 93971 | 364 | 240.32 | 0 | 45/0PC | 123.68 | 0 | 0 | 0 | 123.68 |
Claim Totals | 364 | 240.32 | 0 | 123.68 | 0 | 0 | 0 | 123.68 |
Reason Code Descriptions:
45/0PC THIS PROVIDER IS A MEMBER OF YOUR PARTICIPATING PROVIDER ORGANIZATION NETWORK.
SERVICES ARE DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.
Service Procedure Descriptions:
***All procedure(s) codes are supplied to Humana on the claim form by your provider.
Any questions or concerns about these codes should be directed to your provider.***
93971 (X) X RAY
Numbers to Watch: | Annual Limit | Amount Used | Amount Remaining |
---|---|---|---|
Primary Benefits | |||
Participating/In Network Out of Pocket | $5,900.00 | $626.59 | $5,273.41 |
Special Messages:
EXPLANATION OF MEMBER RESPONSIBILITY The estimated member s responsibility amount is based upon information available at the time of claim processing. This amount represents any applicable deductibles, coinsurance, copayments, and non-covered services as outlined in your benefit plan document. It includes any amounts that the member may have previously paid to the provider of service. Also, any amounts denied for additional information may be re-evaluated.
Subscriber/Member: MICHELLE COLLINS
Subscriber ID: 894857690302
Claim Number(s): 123456789
View Account Balances
John Wilkes Paid to date Remaining Amount
Your Deductible
$90
$910
Your Out of pocket
$90
$910
Deb Wilkes Paid to date Remaining Amount
Your Deductible
$90
$910
Your Out of pocket
$90
$910
My Plan
Category
Par Benefits
Non Par Benefit
(Balance Billing can apply)
Individual | $500 | $1,000 |
Family | $1,000 | $2,000 |
Aggregate or Embedded | Embedded | Embedded |
RX Integrated with Medical Deductible | Yes | No |
Out of Pocket Exclusions |
Par Out of Pocket does not reduce Non-par Out of Pocket but Non-par reduces Par*Benefits that DO NOT apply to Out of Pocket
|
|
Individual | $4,000 | $8,000 |
Family | $8,000 | $15,000 |
Lifetime Maximum | Unlimited |
Medical and Pharmacy Integrated Plan Max Out-of-Pockets (MOOP) - (Does not apply to HDHP Plans) |
All PAR provider member cost share will accumulate towards the Plan Maximum Out-of Pocket. This includes medical and pharmacy deductibles, coinsurance and copayments, including any applicable carve-out benefits - excludes any precertification penalties. |
|
Individual | N/A | N/A |
Family | N/A | N/A |
Elective | Not Covered | Not Covered |
Life Threatening / Medically Necessary | SAAOD | SAAOD |
Acupuncture | Not Covered | Not Covered |
Testing | $35 copay then 100% | 40% after non par deductible |
Injections | 100% | 40% after non par deductible |
Serum / Vials | 100% | 40% after non par deductible |
Ground | 70% after par deductible | 80% after par deductible |
Air | 70% after par deductible | 80% after par deductible |
Facility | 70% after par deductible | 40% after non par deductible |
Physician Services | 70% after par deductible | 40% after non par deductible |
Inpatient Room & Board/Ancillary | Same as Medical Inpatient Hospital | Same as Medical Inpatient Hospital |
Professional Services | Same as Medical Inpatient Physician | Same as Medical Inpatient Physician |
Partial Hospitalization | Same as Medical Outpatient Non-Surgical Hospital | Same as Medical Outpatient Non-Surgical Hospital |
Residential treatment | Physician and hospital same as medical inpatient | Physician and hospital same as medical inpatient |
Halfway House | Not Covered | Not Covered |
Outpatient Rehab Therapy | $35 Pcp copay then 100% | 40% after non par deductible |
Outpatient Lab / X-Rays | SAAOD | SAAOD |
Marriage Counseling | Not Covered | Not Covered |
Rental | 70% after par deductible | 40% after non par deductible |
Purchase | 70% after par deductible | 40% after non par deductible |
Repairs & Replacements (see comment) | 70% after par deductible | 40% after non par deductible |
Prosthetics | 70% after par deductible | 40% after non par deductible |
Orthotics | 70% after par deductible | 40% after non par deductible |
Oxygen | 70% after par deductible | 40% after non par deductible |
True Emergency - Facility | 70% after par deductible | 80% after par deductible |
True Emergency - Ancillary | 70% after par deductible | 80% after par deductible |
True Emergency - Physician (including ER Physician, Radiologist, Pathologist, Anesthesiologist, and ancillary services billed by ER Physician, etc.) | 70% after par deductible | 80% after par deductible |
Non-Emergency - Facility | 70% after par deductible | 40% after non par deductible |
Non-Emergency - Ancillary | 70% after par deductible | 40% after non par deductible |
Non-Emergency - Physician (including ER Physician, Radiologist, Pathologist, Anesthesiologist, and ancillary services billed by ER Physician, etc. | 70% after par deductible | 40% after non par deductible |
Emergency Room - MRI, MRA, PET, CAT & SPECT Scans | SAAOD | SAAOD |
ER Copay waived if admitted? | Not Applicable |
Prenatal Care | $35 Pcp / $40 Spec copay then 100% | 40% after non par deductible |
Dependent Daughter Maternity | SAAOD | SAAOD |
Physician Services | SAAOD | SAAOD |
Inpatient Hospital Room & Board & Ancillary Facility Services | SAAOD | SAAOD |
Newborn - Physician Services while Inpatient (well/sick baby) | 70% after par deductible | 40% after non par deductible |
Newborn - Inpatient Facility Charges (well/sick baby) | 70% after par deductible | 40% after non par deductible |
Breast Feeding Counseling | 100% | 40% after non par deductible |
Breast Feeding Support & Supplies (i.e. breast pump) | 100% | 40% after non par deductible |
Well / Sick Baby - Physician Charges | 70% after par deductible | 40% after non par deductible |
Facility/Physician | $55 Copay then 100% | 40% after non par deductible |
Ancillary (labs & x-rays) | 100% | 40% after non par deductible |
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