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Countryman � . • �Clr��Y'�� u� � 9 2o�z NOTICE OF CLAIM FORM to the City of Saint Paul Minnesota �I�� t Minnesota State Statute 466.OS states that "...every person...wfio claims damages from tmy municipality...shall cause to be presented to tiee �overning body of the municipatity within 180 days afier the alleged loss or injury is disco�ered a notice stating the time,place,and circumstances thereaf,and the amount of compensation or other relief demanded." Piease complete this form in its enfirety by elearly typing or printing your answer to each question. If more space is needed,attach additional sheets. Please note that you w�l not be contacted by telephone to clarify answers,so provide as much information as necessary to ezplain your claim,amd the ainonnt of compensation being requested. Yon will receive a written acla�owledgement once your form is received. The prceess can t�ke up to ten weeks or longer depending on the nature of your claim. This form must 6e signed,and both pages completed. If something dces uot apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL,MN 55102 , First Name Middle Initial� Last Name �� G�u��?'t' I! ----- I �mm�any or Business Name __ � Are You an Insurance Company? Yes No If Yes, Claim Number? I� Street Address�� 1�/l(�S!/j'� � . City �� G� State ��Z//l/. Zip Code�� Daytime Phone((��)a!3-S��c� Gell Phone.(��-j��Evening Telephone( ) -�� Date of Accident/Injury or Date Discovered 1 Q' (�tO�' l� Time�am!� i Please state,in detail,what occurred(happeiied),and why you are submitting a claim.Please indicate why or how you feel the City of Saint Paul or its employees are involved d/or responsible for your ges_ Cc.( -t�c._ �. cr �e i�t�F�'��a!��—� ��^-- C�,i -v v' -k l � �, ,.Q f/� Q9-�(� P � G'<i� � l � u E U �.p 1P�fQ� !� f s r.�s a�-c� � Ir' t/G� C�' ��/ J , ease c eck the box(es) t most closely r��esent the reason for co eting this form: � �' O My vehicle was damaged in an accident �My vehicle was damaged during a tow �My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow I �My vehicle was wrongfully towed and/or ticketed ❑I was injured on City property p O�kcr type of properly damage—please spec'fy A �Other type of injury—please specify U�' G��/'<l/e-- In order to process your claim you need to inclade conies of all auplicable docdm nts.� ��`��S• For the claims types listed below,please be sure to include t�e documents indicated or it will delay the handling of your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a copy for yourself before submitting your claim form. O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds $500.00;or the actua.l bills and/or receipts for the repairs O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt O Other pmperty damage claims: two repair estimates if the damage exceeds$500.00;or the actual bills and/or receipts for the repaus;detailed list of damaged items O Injury claims:medical bills,receipts O Photographs are always welcome to document and support your claim but will not be retinned. Page 1 of 2—Please complete and return both pages of Claim Form f Failure to complete and return both pages will result in delay in the handling of your claim. All Claims-please completE this section Were there witnesses to the incident? Yes No Unknown (circle) Provide their names, addresses and telephone numbers. j Were the police or law enforcement called? Yes No Unknown (circle) If yes,what de�artment or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street, intersectinn r°t'*�"^�--�k c:•f.^^71itv_ ; cl sest 1 dm k,etc.,,Please be as detaile as po sible. necessary, attaoh,a di gram. . _�.� �,�� 1 ��.c�2 l�c/ u Please indicate tlie amount you are seekin in compensation or what you would like the City to do to resolve this claim to our satisfaction. � -G �'�� `� �� — tn� U/�c� 2�P S - (�:5�. �� J �� i Vehicle Claims-please complete this section check box if this section does not applv ' Your Vehicle: Year Make Model � License Plate Number State Color � Registered Owner Driver of Vehicle ,_ Area Damaged _-_ __ __ . _ _ ._ _ City Vehicle Year Make Model ,_.. , _. _. .. ._. _ _ ._ _ License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged � _ . Iniurv Claims-please comnlet this section _ ❑ check box if this section does not a 1 How were y u injured? ` � w � What�art s)o your body were injured? -- � �� I S _� . I I�tave you sought medical treatment? Yes No Planning to Seek Treatment(circle) When did you receive treatment? Q � � ' y (provide date(s)) Name of Medical Provider s): /iL�� /�l� Address ; %0 Telephone (o S/- a - �� Did you miss work as a result of our in When did you miss work? Q'' �: �� __�es (� - No �rovide date(s)) Name of your Employer: ' � Address /kl�an- �'-t� ! Telephone S - l `7� ��-J heck here if you are attaching more pages to this claim form. Number of additional pages�. - l,��l�.3 y�lw�S o-�-c�c�icfa�� By signing this form,you are stating that all information you have provided is true and c�orrect to the best S�� of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed �(o '�� Print the Name of tlie Person who Completed this Form: CC�� -��1'�J Signature of Person Making the Claim: Revised February 2011 - � � �.�� 'ti/�r/�� y` ��, � , - 1 , �7�. 75 �/z�� t � ' ' ��'�e — La�-�� o�lc�zfe � �wu o.�, H� �a-�-� �-�-�-#��. �U �, 3�, � o��'1 i � �a,4.e- �..�c-� � G-.�T9-r�i�n, w�i� `��2 C�3� � r Co I �'. 37 �� a-�l l t �✓d.��- j� . ��'�i�.� �, 9�� a3�. a� �7, t� ��z�( i� �-�,�, � �- T� �� t� �� " �--� �,1;�. � �� 'I� � � �� . � � �� 3 $S. S� '! Z7 ��r �� (�� -� � � �. �,-.� lDy�. ��° °��/�� . �,c� � � � ° g�s � � � ��, �5 �� — � � � ��, c��s. � 1 � � � � . ��. �3 . - - f-�o `��'� 0 ��,,Y►.� c�� , �r�c A . �.� �-�i.�.3 ' 3�! � e� 3t ( t Z -�-� � � � ��" a�. �.� � o� Co - II �'�' l� f>, /5 I -�-^ �� _ I�', I �� "�v�v►� . ��ivm� ��7 ` ! �� I l� � _ �. 35 � � �� ', � � I i � ; � I� ; ' Explanation of Health Care Benefits � BlueCross BlueShield �.� � of Minnesota 7800 01010000001516 An Independent licansee ol the Blue Cross an0&ue Shidd AssodaUon P.O.aox 64560 THIS IS NOT A BILL. This is an explanation of the cialm processed St.Paul,MN 55164-0560 based on your,plan beneiits in efiect when the service was periormed. Please keep this form for your tax records. Easily find a provider , see your claims , your plan, health programs and wellness info all in one place . Visit the myBlueCross online member center . Sign in at MARGARET COUNTRYMAN www.bluecrossmn . com/mnservcoop I 1717 SIMPSON ST '� ST PAUL MN 55113-6257 ��'��I��I��I�� Year to Date Deductible 1 , 1 2 9. 2 5 , Contact:For Customer Service-Please Call: (651) 662-5517 ORTOLLFREE 1-888-878-0136 Patient ID Group/Policy Date Date Claim Number Received Processed XZ2582860 CHISAGO COUNTY OCP1700HA 11/03/11 11/04/11 1307946748000 Subscriber/MemberName MARGARET COUNTRYMAN � PatlentName MARGARET COUNTRYMAN Provider ST PAUL RADIOLOGY PA Patient Control Number 8 613 4 F 101 S 9 3 4 4 Dates of Service From From From From From To 10 2 7 11 To To T To Descriptlon L A B/X—R A Y Charges 6 8. 0 0 Provider Responsibility Amount 2 3 . 3 8 Aliowed Amount 4 4. 6 2 Amount Paid By Other Insurance Deductlble Amount 4 4. 6 2 Copay Amount Coinsurance Amount Pald Amount Patient Noncovered Amount Amount You Owe 4 4. 6 2 Notes Id 1 I I Notes Total Charges ' 1 YOUR PROVIDER IS PARTICIPATING. THE AMOUNT LISTED AS PROVIDER 68 . 00 RESPONSIBILITY IS NOT YOUR RESPONSIBILITY . REFER TO THE COVERAGE INFORMATION SECTION IN YOUR PLAN DOCUMENTATION . TotaleenefltAmount 0 . 00 Total Amount Patd by Otherinsurance 0 . 00 Total Amount You Owe 44 . 62 See reverse side for Complalnt/Appeal,Fraud and other important informatlon. I • Explanation of Health Care Benefits ' �� BlueCross BlueShield � � � of Minnesota �eoo 01010000001516 An 1nCependent 1lcensee ot Ne B/ue Cross and 8lue Shield AssodaUOn P.O.Box 64560 THIS IS NOT A BILL. This IS an explanatlon ot the claim processed St.Paul,MN 55164-0560 based on your,plan beneflts In ef(ect when the servtce was performed. Please keep this form for your tax records. Easily find a provider, see your claims , your plan, health programs and wellness info all in one place. Visit the myBlueCross online member center . Sign in at MARGARET COUNTRYMAN www.bluecrossmn . com/mnservcoop 1717 SIMPSON ST ST PAUL MN 55113-6257 ��„�� Year to Date�eductible 1 , 1 2 9 . 2 5 Contact:For Customer Servlce-Please Call: (651) 662-5517 OR TOLL FREE 1-888-878-0136 Patient ID Group/Pollcy Date Date Recelved Processed Clalm Number XZ2582860 CHISAGO COUNTY OCP1700HA 11/03/11 11/04/11 1307946748000 Subscriber/Member Name M A R G A R E T C 0 U N T R Y M A N � PatientName MARGARET COUNTRYMAN Provider ST PAUL RADIOLOGY PA Patlent Control Number 8 613 4 F 1018 9 3 4 4 Dates of Service From From From From From To 10 2 7 11 To To T To Description L A B/X—R A Y Charges 6 8. 0 0 Provider Responsibiiity Amount 2 3 . 3 8 Allowed Amount 4 4. 6 2 Amount Paid By Other Insurance Deducttbie Amount 4 4. 6 2 Copay Amount Coinsurance Amount Pald Amount I Patlent Noncovered Amount Amount You Owe 4 4. 6 2 Notes Id 1 Notes Total Charges 1 YOUR PROVIDER IS PARTICIPATING. THE AMOUNT LISTED AS PROVIDER 68 . 00 RESPONSIBILITY IS NOT YOUR RESPONSIBILITY . REFER TO THE COVERAGE INFORMATION SECTION IN YOUR PLAN DOCUMENTATION. TotalBenefltAmount 0 . 00 Total Amount Paid by Otherl�surance 0 . 00 Totat Amount You Owe 44 . 62 See reverse side tor Complaint/Appeal,Fraud and other important Informatlon. � • Explanation of Health Care Benefits �: � BlueCross BlueShieid . � of Minnesota �soo 01010000001512 A W An Indqoandent daensee of the&ue Cross anC Blue Sh/eld Assodadon P.O.Box 64660 THIS IS NOT A BILL. This Is an explanation of the claim processed St.Paul,MN 55164-0560 based on your plan benefits In effect when the service was performed. Please keep this form for your tax records. Gasily find a provider , see your claims , your I plan , health programs and wellness info all in I one place. Visit the myBlueCross online i member center . Sign i.n at � MARGARET COUNTRYMAN www.bluecrossmn . com/mnservcoop 1717 SIMPSON ST ST PAUL MN 55113-6257 i i ��I��I� Year to Date Deductible 4 8 6 . 3 9 � Contact:For Customer Service-Please CaIL• � (651) 662-5517 OR TOLL FREE 1-888-878-0136 � Patient ID Group/Policy Date Date i Recelved Processed Ciaim Number XZ2582860 CHISAGO COUNTY OCP1700HA 11/O1/11 11/02/11 1306906024000 j SubscrlbeNMemberName MARGARET COUNTRYMAN j PatlentName MARGARET COUNTRYMAN � Provider UNITED HOSPITALIST SERVICES OF THE AMC I � Patlent Control Number E P 10 2 2 6 5 0 4 6 2 0 � i Dates of Service From 2 From From From From � To 10 2 9 11 To To T To Descriptlon M E D I C A L � Charges 3 9 6. 0 0 � Provider Responsibility Amount 10 .4 4 � Allowed Amount 3 8 5 . 5 6 � Amount Paid By Other Insurance Deductlble Amount 3 8 5 . 5 6 I Copay Amount � Colnsurance Amount I Paid Amount Patlent Noncovered Amount Amount You Owe 3 8 5 . 5 6 Notes Id 1 Notes Total Charges 1 YOUR PROVIDER IS PARTICIPATING. THE AMOUNT LISTED AS PROVIDER 396 . 00 I RESPONSIBILITY IS NOT YOUR RESPONSIBILITY . REFER TO THE ' COVERAGE INFORMATION SECTION IN YOUR PLAN DOCUMENTATION. TotaieenefltAmount 0 . 00 Total Amou�t Pald by Othertnsurance 0 .00 Total Amount You Owe 385 . 56 See reverse slde for Complaint/Appeal,Fraud and other Important Information. � . Important information � � For hearing and speech impaired telephone access, please call (651) 662-8700 or toll free at 1-888-878-0137 TTY/TDD. � Call the confidential hotline to report suspected fraud, misuse, abuse, or waste of health care benefits at (651) 662-8363 or toll free at 1-500-382-2000 extension 28363. • A claim that is incomplete, as noted on the reverse side of this form, will be processed when we receive all the necessary information. ; • We may use internal and external rules and guidelines to make an adverse benefit determination. You may ask for any relevant documents, records, or other information used to process your claim. You may ask for the scientific or clinical judgment used for a claim denied as investigative or not medically necessary. This information is available free of charge upon request. You can name a representative by completing an Authorization to Release Information form. Please contact customer service to obtain the necessary forms. � • The "Amount You Owe" box on the reverse side shows the amount you owe under your Plan (i.e. deductible, copayments, coinsurance, patient noncovered amount). If you disagree with this amount, please refer to the i Complaint / Appeal section below. ; • The "Total Amount You Owe" box on the reverse side shows the amount that may be eligible for reimbursement ; under a health reimbursement arrangement, health savings account, medical savings account, voluntary employees' j beneficiary association, or flexible spending account. • If you are a member of a self-insured group plan, the medical plan is that of the employer. Blue Cross and Blue Shield of Minnesota provides administrative claims payment services only and does not assume any financial risk j or obligation with respect to claims. I Definitions � Preexistinq condition - A condition that existed prior to your enrollment date and for which medical advice, diagnosis, care, or treatment was recommended or received but does not include genetic information or pregnancy. �� Medically necessary - Health care services that are: (a) in accord with generally accepted standards of inedical � practice; (b) clinically appropriate; (c) not primarily for convenience; and (d) not more costly than an alternative � service. ; Investigative - A drug, device, diagnostic procedure, technology, or medical treatment or procedure that reliable � evidence does not permit conclusions concerning its safety, effectiveness, or effect on health outcomes I Complaint /Appeal Information I ; Your claim was processed based on the information submitted. You or your authorized representative may appeal an � adverse benefit determination (ABD). You must exhaust these appeal procedures before filing any legal action. An ABD j includes a denial, reduction, termination of or failure to make a payment for a benefit, or a rescission of coverage. t'� First, visit www.mybluecross.com to find additional information under plan details and plan activity at the web address � on your member ID card. If you still have questions, contact customer service. If you are still not satisfied, we will provide you a form to file your complaint. This form is available on our web site at www.bluecrossmn.com, under members, complaints/appeals. If you need assistance we will complete the form and Fnail it to you for your signature. , You must file an appeal within 180 days following receipt of an ABD. Some plans allow a longer time. Your Plan documents describe appeal timelines. You will have the opportunity to review the claim file, present evidence and testimony and submit written comments, documents, records, and other information relating to your claim. We will take all submissions into account in making our decision. Further Appeals If you are not satisfied with the outcome of your appeal, you may request a second, voluntary internal review, or an external review. The appeal outcome notification letter will describe any further appeal rights and how to pursue them. Note: Individual/family contract and some group contract members may proceed directly to an external review following the appeal outcome notification. Note: Fully insured and Minnesota government-sponsored plan members must pay a filing fee of $25.00 when requesting an external review. This fee is refunded if the ABD is overturned and may be waived in cases of undue financial hardship. A member of a group plan that is subject to the Employee Retirement Income Security Act (ERISA) who has exhausted the complaint / appeal process has the right to file suit under section 502(a) of ERISA. � Explanation of Health Care Benefits � � � BlueCross BlueShieid . � of Minnesota �soo oloi000000i5l: � � An lndependent ifcensee o/the&ue Cross and&ue Shldd Assodatlon P.O.eox 64560 THIS IS NOT A BILL. This is an explanation of the claim processed St.Paul,MN 65164-0560 based on your plan benefits in effect when the service was performed. Please keep this form for your tax records. Gasily find a provider , see your claims , your ' plan , health programs and wellness info all in I one place . Visit the myBlueCross online I member center . Sign in at : MARGARET COUNTRYMAN www. bluecrossmn . coin/mnservcoop 1717 SIMPSON ST i ST PAUL MN 55113-6257 I �� Year to Date Deductlble 4 8 6 . 3 9 II Contact:For Customer Service-Please Call: (651) 662-5517 ORTOLLFREE 1-888-878-0136 Patient ID Group/Pollcy Date Date Recelved Processed Claim Number XZ2582860 CHISAGO COUNTY OCP1700HA 11/O1/11 11/02/11 1306906024000 Subscrlber/Member Name M A R G A R E T C O U Pl T R Y M A N PatientName MARGARET COUNTRYMAN Provider UNITED HOSPITALIST SERVICES OF THE AMC Patlent Control Number E P 10 2 2 6 5 0 4 6 2 0 Dates of Service From From From From From To 10 2 9 11 To To Ta To Descriptlon M E D I C A L Charges 3 9 6 . 0 0 Provider Responsibllity Amount 10 . 44 Allowed Amount 3 8 5 . 5 6 Amount Paid By Other Insurance Deductible Amount 3 8 5 . 5 6 �opay Amount I Colnsurance Amount I Paid Amount I�I 'atient Noncovered Amount 4mount You Owe 3 8 5 . 5 6 ' Jotes Id 1 lotes Total Charges 1 YOUR PROVIDER IS PARTICIPATING. THE AMOUNT LISTED AS PROVIDER 396 . 00 RESPONSIBILITY IS NOT YOUR RESPONSIBILITY . REFER TO THE COVERAGE INFORMATION SECTION IN YOUR PLAN DOCUMENTATION . TotalBenefitAmount 0 . 00 Total Amount Pald by Otherinsurance 0 . 00 Total Amount You Owe 385 . 56 �ee reverse side for Complaint/Appeal,Fraud and other important information. � Explanation of Health Care Beneflts � � � BlueCross BlueShield . � of Minnesota �aoo oiol000000151 An lndependent dasnsee ot Ne&ue Cross and Blue ShlMO Aswdatlon P.O.Box 64560 THIS IS NOT A BILL. This is an explanatlon of the clalm processed St. Paul,MN 55164-0560 based on your plan benefits in effect when the service was performed. Please keep this form for your tax records. Easily find a provider , see your claims , your plan , health programs and wellness info all in one place . Visit the myBlueCross onlize member center . Sign in at MARGARET COUNTRYMAN www.bluecrossmn . com/mnservcoop 1717 SIMPSON ST ST PAUL MN 55113-6257 ��l�� Year to Date Deductible 1 , 0 2 6 . 8 8 Contact:For Customer Service-Please Call: (651) 662-5517 ORTOLLFREE 1-888-878-0136 Patient ID Group/Policy Date Date Claim Number Recelved Processed I XZ2582860 CHISAGO COUNTY OCP1700HA 11/O1/11 11/02/11 1305957750000 SubscriberlMemberNama MARGARET COUNTRYMAN PatlentName MARGARET COUNTRYMAN � Provider ST PAUL RADIOLOGY PA � Patlent Control Number 8 613 4 F 1018 8 511 I Dates of Service From From From From From I I To 10 2 7 11 To To Tp To Descrfption L A B/X—R A Y Charges 16 0 . 0 0 � Provlder Responsibiilty Amount 5 5 . 6 5 I Allowed Amount 10 4 . 3 5 Amount Pald By Other Insurance Deductible Amount 10 4. 3 5 :opay Amount :oinsurance Amount 'aid Amount 'atient Noncovered Amount �mount You Owe 10 4 . 3 5 �otes Id 1 otes Total Charges 1 YOUR PROVIDER IS PARTICIPATING. THE AMOUNT LISTED AS PROVIDER 160 . 00 RESPONSIBILITY IS NOT YOUR RESPONSIBILITY . REFER TO THE COVERAGE INFORMATION SECTION IN YOUR PLAN DOCUMENTATION. TotalBenefltAmount 0 . 00 Total Amount Pald by Otherinsurance 0 . 00 Total Amount You Owe 104 . 35 ee reverse side for Complalnt/Appeal,Fraud and other Important Information. Explanation of Health Care Benefits � BlueCross BlueShield �.� � of Minnesota �soo 01010000001514 A W An)ndqoenden►1loensee ol►he&ue Cross and Blue Sh/dd Assodatlon P.O.Box 64560 THIS IS NOT A BILL. This is an explanatlon of the claim processed i St. Paul,MN 55164-0660 based on your plan benefits in effect when the service was performed. Please keep this form for your tax records. Easily find a provider, see your claims , your plan, health programs and wellness info all in one place. Visit the myBlueCross online , member center . Sign in at i MARGARET COUNTRYMAN www. bluecrossmn. com/mnservcoop li 1717 SIMPSON ST ST PAUL MN 55113-6257 i i ��iiii��ii��i��iii��ii��ii��iii�) Year to Date Deductible 1 , 0 2 6. 8 8 i Contact:For Customer Service-Please Call: � (651) 662-5517 ORTOLLFREE 1-888-878-0136 ' Patlent ID Group/Policy Date Date I Clalm Number I Received Processed i XZ2582860 CHISAGO COUNTY OCP1700HA 11/O1/11 11/02/11 1305957750000 � Subsariber/Member 1�Eame � MARGARET COUNTRYMAN I PatlentName MARGARET COUNTRYMAN Provider ST PAUL RADIOLOGY PA ; Patlent Control Number 8 613 4 F 1018 8 511 i Dates of Service From � 1 From Fr m From From �� To 10 2 7 11 To Tp To Tp i Description L A B/X-R A Y � � Charges 16 0 . 0 0 ' Provider Responsibility Amount 5 5 . 6 5 I Allowed Amount 10 4. 3 5 ! I Amount Pald By Other Insurance � Deductibie Amount 10 4. 3 5 ' Copay Amount � Coinsurance Amount �� Paid Amount I Patlent Noncovered Amount Amount You Owe 10 4. 3 5 Notes Id 1 Notes Total Charges 1 YOUR PROVIDER IS PARTICIPATING. THE AMOUNT LISTED AS PROVIDER 160 . 00 RESPONSIBILITY IS NOT YOUR RESPONSIBILITY . REFER TO THE COVERAGE INFORMATION SECTION IN YOUR PLAN DOCUMENTATION. TotalBenefltAmount 0 . 00 Total Amount Paid by Otherinsurance 0 . 00 Total Amount You Owe 104. 35 See reverse slde for Complaint/Appeal,Fraud and other Important informatlon. i � Important information - r • For hearing and speech impaired telephone access, please call (651) 662-8700 or toll free at 1-888-878-0137 TTY/TDD. � Call the confidential hotline to report suspected fraud, misuse, abuse, or waste of health care benefits at (651) 662-8363 or toll free at 1-800-382-2000 extension 28363. n ted on the reverse side of this form, will be rocessed when we receive all the • A claim that is incomplete, as o P � necessary information. • We may use internal and external rules and guidelines to make an adverse benefit determination. You may ask for any relevant documents, records, or other information used to process your claim. You may ask for the scientific or i v ilable clinical judgment used for a claim denied as investigative or not medically necessary. This information s a a � free of char e upon request. You can name a representative by completing an Authorization to Release Information 9 form. Please contact customer service to obtain the necessary forms. • The "Amount You Owe" box on the reverse side shows the amount you owe under your Plan (i.e. deductible, copayments, coinsurance, patient noncovered amount). If you disagree with this amount, please refer to the Complaint / Appeal section below. • The "Total Amount You Owe" box on the reverse side shows the amount that may be eligible for reimbursement under a health reimbursement arrangement, health savings account, medical savings account, voluntary employees' �III , beneficiary association, or flexible spending account. • If you are a member of a self-insured group plan, the medical plan is that of the employer. Blue Cross and Blue 'n n ial risk Shield of Minnesota provides administrative claims payment services only and does not assume any fi a c or obligation with respect to claims. Definitions Preexisting condition - A condition that existed prior to your enrollment date and for which medical advice, diagnosis, care, or treatment was recommended or received but does not include genetic information or pregnancy. Medically necessary - Health care services that are: (a) in accord with generally accepted standards of inedical practice; (b) clinically appropriate; (c) not primarily for convenience; and (d) not more costly than an alternative rvi se ce. Investigative - A drug, device, diagnostic procedure, technology, or medical treatment or procedure that reliable � evidence does not permit conclusions concerning its safety, effectiveness, or effect on health outcomes Complaint /Appeal Information ' Your claim was processed based on the information submitted. You or your authorized representative may appeal an adverse benefit determination (ABD). You must exhaust these appeal procedures before filing any legal action. An ABD includes a denial, reduction, termination of or failure to make a payment for a benefit, or a rescission of coverage. First, visit www.mybluecross.com to find additional information under plan details and plan activity at the web address on your member ID card. If you still have questions, contact customer service. If you are still not satisfied, we will provide you a form to file your complaint. This form is available on our web site at www.bluecrossmn.com, under members, complaints/appeals. If you need assistance we will complete the form and mail ii to you for your signature. You must file an appeal within 180 days following receipt of an ABD. Some plans allow a longer time. Your Plan documents describe appeal timelines. You will have the opportunity to review the claim file, present evidence and testimony and submit written comments, documents, records, and other information relating to your claim. We will take all submissions into account in making our decision. Further Appeals If you are not satisfied with the outcome of your appeal, you may request a second, voluntary internal review, or an external review. The appeal outcome notification letter will describe any further appeal rights and how to pursue them. Note: Individual/family contract and some group contract members may proceed directly to an external review following the appeal outcome notification. Note: Fully insured and Minnesota government-sponsored plan members must pay a filing fee of $25.00 when requesting an external review. This fee is refunded if the ABD is overturned and may be waived in cases of undue financial hardship. A member of a group plan that is subject to the Employee Retirement Income Security Act (ERISA) who has exhausted the complaint / appeal process has the right to file suit under section 502(a) of ERISA. ' � Explanation of Health Care Benefits �� BlueCross BlueShieid . � of Minnesota �soo 01010000001515 a, An lndqoendent llcensee oi the Blue qoss and Blue Shidd Assodatlon P.O.Box 64560 THIS IS NOT A BILL. This is an explanatlon of the clalm processed St.Paul,MN 55t64-0560 based on your plan benefits in effect when the service was performed. Please keep this form for your tax records. Easily find a provider, see your claims , your plan , health programs and wellness info all in one place. Visit the myBlueCross online member center . Sign in at MARGARET COUNTRYMAN www.bluecrossmn . com/mnservcoop 1717 SIMPSON ST ST PAUL MN 55113-6257 ��„�� Year to Date Deductible 1 , 0 8 4. 6 3 Contact:For Customer Service-Please CaIL• (651) 662-5517 ORTOLLFREE 1-888-878-0136 Patlent ID Group/Policy Date Date Received Processed Claim Number I XZ2582860 CHISAGO COUNTY OCP1700HA 11/O1/11 11/02/11 1305957819000 I!� S�+4�riberlMember Name M A R G A R E T C O II N T R Y M A N � PatientName MARGARET COUNTRYMAN � i Provider ST PAUL RADIOLOGY PA i Patient Control Number 8 613 4 F 1018 8 511 Dates of Service From 2 From Fr m From From To 10 2 6 11 Tp To Tp To Descrlptlon L A B/X—R A Y Charges 8 8 . 0 0 Provider Responslbility Amouni 3 0 . 2 5 � Allowed Amount 5 7 . 7 5 Amount Paid By Other Insurance Deductlble Amount 5 7 . 7 5 Copay Amount Coinsurance Amount Paid Amount Patient Noncovered Amount Amount You Owe 5 7 . 7 5 Notes Id 1 Notes Total Charges 1 YOUR PROVIDER IS PARTICIPATING. THE AMOUNT LISTED AS PROVIDER 88 . 00 RESPONSIBILITY IS NOT YOUR RESPONSIBILITY . REFER TO THE COVERAGE INFORMATION SECTION IN YOUR PLAN DOCUMENTATION. TotalBenefitAmount 0. 00 Total Amount Pald by Otherinsurance 0 . 00 Total Amount You Owe 57 . 75 See reverse side for Complalnt/Appeal,Fraud and other Important information. Important information • For hearing and speech impaired tetephone access, please call (651) 662-8700 or toll free at 1-888-878-0137 TTY/TDD. • Call the confidential hotline to report suspected fraud, misuse, abuse, or waste of health care benefits at (651) 662-8363 or totl free at 1-800-382-2000 extension 28363. • A claim that is incomplete, as noted on the reverse side of this form, will be processed when we receive all the necessary information. • We may use internal and external rules and guidelines to make an adverse benefit determination. You may ask for any relevant documents, records, or other information used to process your claim. You may ask for the scientific or clinical judgment used for a claim denied as investigative or not medically necessary. This information is available free of charge upon request. You can name a representative by completing an Authorization to Release Information form. Please contact customer service to obtain the necessary forms. • The "Amount You Owe" box on the reverse side shows the amount you owe under your Plan (i.e. deductible, copayments, coinsurance, patient noncovered amount). If you disagree with this amount, please refer to the Complaint / Appeal section below. ' • The "Total Amount You Owe" box on the reverse side shows the amount that may be eligible for reimbursement under a health reimbursement arrangement, health savings account, medical savings account, voluntary employees' beneficiary association, or flexible spending account. • If you are a member of a self-insured group plan, the medical plan is that of the employer. Blue Cross and Blue Shield of Minnesota provides administrative claims payment services only and does not assume any financial risk or obligation with respect to claims. Definitions � Preexisting condition - A condition that existed prior to your enrollment date and for which medical advice, diagnosis, care, or treatment was recommended or received but does not include genetic information or pregnancy. Medically necessary - Health care services that are: (a) in accord with generally accepted standards of inedical practice; (b) clinically appropriate; (c) not primarily for convenience; and (d) not more costly than an alternative service. ' Investigative - A drug, device, diagnostic procedure, technology, or medical treatment or procedure that reliable evidence does not permit conclusions concerning its safety, effectiveness, or effect on health outcomes Complaint /Appeal Information Your claim was processed based on the information submitted. You or your authorized representative may appeal an ; adverse benefit determination (ABD). You must exhaust these appeal procedures before filing any legal action. An ABD includes a denial, reduction, termination of or failure to make a payment for a benefit, or a rescission of coverage. � First, visit www.m bluecross.com to find additional information under plan details and plan activity at the web address Y on your member ID card. If you still have questions, contact customer service. If you are still not satisfied, we will provide you a form to file your complaint. This form is available on our web site at www.bluecrossmn.coml under members, complaints/appeals. If you need assistance we will complete the fo�m and mail it to you for your signat�are. You must file an appeal within 180 days following receipt of an ABD. Some plans allow a longer time. Your Plan documents describe appeal timelines. You will have the opportunity to review the claim file, present evidence and testimony and submit written comments, documents, records, and other information relating to your claim. We will take all submissions into account in making our decision. Further Appeals If you are not satisfied with the outcome of your appeal, you may request a second, voluntary internal review, or an external review. The appeal outcome notification letter will describe any further appeal rights and how to pursue them. Note: Individual/family contract and some group contract members may proceed directly to an external review following the appeal outcome notification. Note: Fully insured and Minnesota government-sponsored plan members must pay a filing fee of $25.00 when requesting an external review. This fee is refunded if the ABD is overturned and may be waived in cases of undue financial hardship. A member of a group plan that is subject to the Employee Retirement Income Security Act (ERISA) who has exhausted the complaint / appeal process has the right to file suit under section 502(a) of ERISA. Explanation of Health Care Benefits � �� BlueCross BlueShield �.� � of Minnesota �aoo oioi000000i5l� An lndepend�t llcensee ol Ne Blue Cross and&ue Shldd AssodaBon P.O. Box 64b60 THIS IS NOT A BILL. This Is an explanation of the claim processed St.Paul,MN 55164-0560 based on your plan benefits In effect when the servlce was performed. Please keep this form for your tax records. Easily find a provider , see your claims , your plan , health programs and wellness info all in one place. Visit the myBlueCross online member center . Sign in at MARGARET COUNTRYMAN www. bluecrossmn . com/mnservcoop 1717 SIMPSON ST ST PAUL MN 55113-6257 ��I�I��I�I��'��I��'��I�� Year to Date Deductible 1 , 0 8 4 . 6 3 Contact:For Customer Service-Please Call: (651) 662-5517 ORTOLLFREE 1-888-878-0136 Patient ID Group/Poticy Date Date Clalm Number Recelved Processed XZ2582860 CHISAGO COUNTY OCP1700HA 11/O1/11 11/02/11 1305957819000 Subscriber/Member Name M A R G A R E T C O U N T R Y M A N PatientName MARGARET COUNTRYMAN Provider ST PAUL RADIOLOGY PA Patient Control Number 8 613 4 F 1018 S 511 Dates of Servlce From From Fr m From From To 10 2 6 11 To To To To Descriptlon L A B/X-R A Y Charges 8 8 . 0 0 Provfder Responsibility Amount 3 0 . 2 5 Allowed Amount 5 7 . 7 5 Amount Pald By Other Insurance DeduCtlble Amount 5 7 . 7 5 Copay Amount Coinsurance Amount Pald Amount Patient Noncovered Amount Amount You Owe 5 7 . 7 5 Notes Id 1 Votes Total Charges 1 YOt7R PROVIDER IS PARTICIPATING. THE AMOUNT LISTED AS PROVIDER 88 . 00 RESPONSIBILITY IS NOT YOUR RESPONSIBILITY . REFER TO THE COVERAGE INFORMATION SECTION IN YOUR PLAN DOCUMENTATION . TotalBenefttAmount 0 . 00 Total Amount Pald by Otherinsurance 0 . 00 Total Amount You Owe 57 . 75 See reverse side for Complalnt/Appeal,Fraud and other important Informatlon. � Expianation of Health Care Benefits . � �� BlueCross BlueShieid �.� � of Minnesota �soo 01010000001513 An lndependent liaensee of the&ue Cross and Blue Shleld Assoaatlon P.O.Box 64560 THIS IS NOT A BILL. This is an explanatlon of the clalm processed St.Paul,MN 55164-0560 based on your plan benefits in effect when the servfce was performed. Please keep this form for your tax records. Easily find a provider , see your claims , your plan, health programs and wellness info all in one place. Visit the myBlueCross online member center . Sign in at MARGARET COt1NTRYMAN www.bluecrossmn. com/mnservcoop 1717 SIMPSON ST ST PAUL MN 55113-6257 I�I�I��I�I��II��II��II��II��I�I��I��'I�� Year to Date Deductible 9 2 2 . 5 3 Contact:For Customer Service-Please Call: (651) 662-5517 ORTOLLFREE 1-888-878-0136 Patient ID Group/Policy Date Date Claim Number Received Processed XZ2582860 CHISAGO COUNTY OCP1700HA 11/Ol/11 11/02/11 1306906061000 Subscriber/MemberName MARGARET COUNTRYMAN PatlentName MARGARET COUNTRYMAN Provider UNITED HOSPITALIST SERVICES OF THE AMC Patlent Control Number E P 10 2 2 6 5 0 4 6 3 0 Dates of Service From 2'7 From From From From To 10 2 9 11 To To To To Descriptlon M E D I C A L Charges 4 4 8. 0 0 Provider Responslbllity Amount 11 . 8 6 Allowed Amount 4 3 6 . 14 Amount Paid By Other Insurance Deductible Amount 4 3 6. 14 Copay Amount Colnsurance Amount Paid Amount Patient Noncovered Amount Amount You Owe 4 3 6 . 14 Notes Id 1 Notes Totai Charges 1 YOUR PROVIDER IS PARTICIPATING. THE AMOUNT LISTED AS PROVIDER 448 . 00 RESPONSIBILITY IS NOT YOUR RESPONSIBILITY . REFER TO THE COVERAGE INFORMATION SECTION IN YOUR PLAN DOCUMENTATION. TotalBenefitAmount 0 . 00 Total Amount Paid by Otherinsurance 0 . 00 Total Amount You Owe 436. 14 See reverse sl[!e for Complalnt/Appeal,Fraud and other Important Information. Important information • For hearing and speech impaired telephone access, please call (651) 662-8700 or toll free at 1-888-878-0137 TTY/TDD. � Call the confidential hotline to report suspected fraud, misuse, abuse, or waste of health care benefits at (651) 662-8363 or toll free at 1-500-382-2000 extension 28363. • A claim that is incomplete, as noted on the reverse side of this form, will be processed when we receive all the necessary information. • We may use internal and external rules and guidelines to make an adverse benefit determination. You may ask for any relevant documents, records, or other information used to process your claim. You may ask for the scientific or clinical judgment used for a claim denied as investigative or not medically necessary. This information is available free of charge upon request. You can name a representative by compieting an Authorization to Release Information form. Please contact customer service to obtain the necessary forms. • The "Amount You Owe" box on the reverse side shows the amount you owe under your Plan (i.e. deductible, copayments, coinsurance, patient noncovered amount). If you disagree with this amount, please refer to the Complaint / Appeal section below. • The "Total Amount You Owe" box on the reverse side shows the amount that may be eligible for reimbursement under a health reimbursement arrangement, health savings account, medical savings account, voluntary employees' beneficiary association, or flexible spending account. • If you are a member of a self-insured group plan, the medical plan is that of the employer. Blue Cross and Blue Shield of Minnesota provides administrative claims payment services only and does not assume any financial risk or obligation with respect to claims. Definitions Preexisting condition - A condition that existed prior to your enrollment date and for which medical advice, diagnosis, care, or treatment was recommended or received but does not include genetic information or pregnancy. Medically necessary - Health care services that are: (a) in accord with generally accepted standards of inedical practice; (b) clinically appropriate; (c) not primarily for convenience; and (d) not more costly than an alternative service. Investigative - A drug, device, diagnostic procedure, technology, or medical treatment or procedure that reliable evidence does not permit conclusions concarning its safety, effectiveness, or effect on health outcomes Complaint /Appeal Information Your claim was processed based on the information submitted. You or your authorized representative may appeal an adverse benefit determination (ABD). You must exhaust these appeal procedures before filing any legal action. An ABD includes a denial, reduction, termination of or failure to make a payment for a benefit, or a rescission of coverage. First, visit www.mybluecross.com to find additional information under plan details and plan activity at the web address on your member ID card. If you still have questions, contact customer service. If you are still not satisfied, we will provide you a form to file your complaint. This form is available on our web site at www.bluecrossmn.com, under members, complaints/appeals. If you need assistance we wilf complete the form and mail it to you for your signature. You must file an appeal within 180 days following receipt of an ABD. Some plans allow a longer time. Your Plan documents describe appeal timelines. You will have the opportunity to review the claim file, present evidence and testimony and submit written comments, documents, records, and other information relating to your claim. We will take all submissions into account in making our decision. Further Appeals If you are not satisfied with the outcome of your appeal, you may request a second, voluntary internal review, or an external review. The appeal outcome notification letter will describe any further appeal rights and how to pursue them. Note: Individual/family contract and some group contract members may proceed directly to an external review following the appeal outcome notification. Note: Fully insured and Minnesota government-sponsored plan members must pay a filing fee of $25.00 when requesting an external review. This fee is refunded if the ABD is overturned and may be waived in cases of undue financial hardship. A member of a group plan that is subject to the Employee Retirement Income Security Act (ERISA) who has exhausted the complaint / appeal process has the right to file suit under section 502(a) of ERISA. � Explanation of Health Care Benefits � � � BlueCross BlueShieid �.� � of Minnesota �aoo oioi000000i5i; r An Indqvend�t llcansee ol the B/ue Cross and B/ue Shidd Assodatlon P.O.Box 64560 THIS IS NOT A BILL. This Is an explanatlon of the claim processed St.Paul,MN 55164-0560 based on your pian benefits in effect when the service was performed. Please keep this form for your tax records. Easily find a provider , see your claims , your plan, health programs and wellness info all in one place. Visit the myBlueCross online member center . Sign in at MARGARET COUNTRYMAN www.bluecrossmn . com/mnservcoop 1717 SIMPSON ST ST PAUL MN 55113-6257 ��11��I� Year to Date Deductible 9 2 2 . 5 3 Contact:For Customer Service-Please Call: (651) 662-5517 ORTOLLFREE 1-888-878-0136 Patient ID Group/Pollcy Date Date Claim Number Received Processed XZ2582860 CHISAGO COUNTY OCP1700HA 11/O1/11 11/02/11 1306906061000 Subscriber/MemberName MARGARET COUNTRYMAN PatlentName MARGARET COUNTRYMAN Provider UNITED HOSPITALIST SERVICES OF THE AMC Patlent Control Number E P 10 2 2 6 5 0 4 6 3 0 Dates of Service From From From From From To 10 2 9 11 Tp To Tp To Descriptlon M E D I C A L Charges 4 4 8 . 0 0 Provider Responsibility Amount 11 . 8 6 Allowed Amount 4 3 6 . 14 Amount Paid By Other Insurance Deductible Amount 4 3 6 . 14 Copay Amount Cofnsurance Amount Paid Amount Patient Noncovered Amount Amount You Owe 4 3 6 . 14 Notes Id 1 Jotes Total Charges 1 YOUR PROVIDER IS PARTICIPATING. THE AMOUNT LISTED AS PROVIDER 448 . 00 RESPONSIBILITY IS NOT YOUR RESPONSIBILITY . REFER TO THE COVERAGE INFORMATION SECTION IN YOUR PLAN DOCUMENTATION. 7otalBenefitAmount 0 . 00 Total Amount Paid by Otherinsurance 0 . 00 Total Amount You Owe 436 . 14 See reverse side for Complalnt/Appeal,Fraud and other Important Information. m r o 0 0 0 o N N � +_+ � Z o 0 0 0 0 � � F N � € ~ N N Z � C � a Q� a � � W o °o oo�o. o c°.i o ° ¢' ` � c� u' o � � � 2 p p' p V ' � � �O P P O N . t/} 0 C _ , a � '�' m t�i � � z _ _ ♦ Y � a • - � Q a °oo °o °o °oo � � ♦ 'p � � ul � ao� 000 = � o � ~ U � W � C• C � � W � � � V O Z a Q N �, y w v � oa, a' °-' � � °. 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