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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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Referral & Authorization Submission
Authorization Managment
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Legends
Completed
In the process
Not Completed
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
Plan Discount
$925.08
Your Plan Paid
$1284.00
Your Responsibility
$1249.00
Deductible
$928.00
Coinsurance
$321.00
Your Responsibility
$1,249.00
HRA Paid to Provider
$138.0
Paid Via This Website
$10.0
You Owe
$1284.00
FSA paid to You
$500.00
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 |
Payer Address
Member Address
JOHN SMITH
123 GRIER MANOR CT
MCDONOUGH, GA 45678-9123
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 |
If you have questions or concerns about this
payment, please call the number on the back
of your insurance card or visit www.medical.com.
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 Detail
| 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.
Date: 9/25/2015
Subscriber/Member: MICHELLE COLLINS
Subscriber ID: 894857690302
Claim Number(s): 123456789
Subscriber/Member: MICHELLE COLLINS
Subscriber ID: 894857690302
Claim Number(s): 123456789
View Account Balances
John Wilkes Paid to date Remaining Amount
Your Deductible
In Network
$90
$90
$910
$1000
Out of Network
$910
$910
$90
10% Available
$1000
Your Out of pocket
In Network
$90
$90
$910
$1000
Out of Network
$910
$910
$90
10% Available
$1000
Deb Wilkes Paid to date Remaining Amount
Your Deductible
In Network
$90
$90
$910
$1000
Out of Network
$910
$910
$90
10% Available
$1000
Your Out of pocket
In Network
$90
$90
$910
$1000
Out of Network
$910
$910
$90
10% Available
$1000
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 |
What plan are you looking for?
You will find your plan name on the bottom-right corner of your member ID card.
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County: Butler
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Location: OH
County: Butler
Bartlett, Sarah E MD
Obstetrics & Gynecology
6770 Cincinnati Dayton Rd Ste 100
Liberty Township, OH 45044 Butler
Liberty Township
Hingsbergen, Douglas C MD
Surgery
10 N Locust St Ste D
Oxford, OH 45056 Butler
Oxford
Cangemi, Paul J MD
Orthopedic Surgery
5151 Morning Sun Rd Ste A
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Oxford
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