Fax server P0S43s9 = 12/31/2019 11 1/003 Fax server To: 9057687766 Employeo namo: Julio Hurl From uUMR Employee ID: 20195490 Date & Time: 1291/2019 11:08:35 CST Patient name: Julie Hurl Pationt birth date: 1105/1963 leed more information? Ifyou need adkitional information, please call 877-303-2414. When prompted for the employee's member ID, enter the falloning ppasscodo: 792689. You will thon be connected with a customer servico representative, This passcode is only valid one time and expires two weeks after the date ofthis fax. ditional Notes Every effort is made to be sure that the information given to you today is accurate. Ifa conflict exists between the information provided to you and tho terms ofthe plan, the torms of the plan will control. Final dotormination of coverago and pationt responsbilly is made al the time the claim is received and processed. The information contained inthis fax transmission i intended solely forthe individual named above and may contain confidential andlor privileged information. Therefore, this fax must be secured and protected in accordance with state and federal laws regarding the treatment of confidential information, medical privacy or other requirements (legal or business practice). If you, the reader ofthis fax cover sheet, are not the individual named above or an authorized representative ofthe individual named above, you are hereby notified that any review, dissemination, use, copying or retention ofthis fax or any pat ofthe information herein is Strictly prohibited. Ityou have received ths fax in error, please natty the sender immediately by phone and destroy this fax. Thank you.Fax server P0S43s9 = 12/31/2019 11 0 AM PAGE 2/003 Fax Server Claim Fax UMR —_— Please refer to the disclaimer on the first page for important information. Ifyou need adcitional information, please call 877-203-2414. When prompted for the employee's member ID, enter the falloning ppasscode:782689. You wil hen be connected with a customer service representative. This passcode is only valid one time and expires two weeks after the date ofthis fax. Employee name: Julie Hum Group number: 76419550 Employee ID: 20195490 Employer ‘American Airlines Pationt name: Jule Hum Effective date: 1/01/2020 Patient bith date: 11/08/1963 Termination date: Active Pationt account number: 168222 Date of sorvice requested: 06/22/2019 Provider network AMERICAN AIRLINES-UHC CHOICE PLUS [Claim number [19176167511 [Service dates: [06/22/2019 - 06/22/2019] Amount biled. $300.00] [claim type Medical Processed date: fo7/izi2019 [Amount paid $0.09] [ciaimstatus: [Completed Provider name: [GajiezWkoZMD_ Patient responsibilty: | $300.00] Status detail Provider tax ID: [es1047 152 [other insurance paic: | $0.00] Network status: [Not avaliable (Claim Detail [Servicing provider name:| Gallo Zivko.Z.MD [Amount bile $300.00] [Service dates: fosvezr2019- 06/22/2019 Provider discount $0.09] Procedure code: fes2oa [Amount not payable: $0.09] [Occurrence lo [Allowable amount $300.00] [Clinical remark [Amount paid: $0.09] Processed date: lorareot9 Pationt responsibilty $300.00] Type of service Medical examination Deductible: $0.09] [ANSI lat [Consurance: $0.00] $0.09] Payment ype Number Pai $0.00] [Check [ass332033 Provider [wrth $0.09] [Other amounts not paid: [Description Is 0.00 [Additional information Nooded To Process Your Claim Has Boon Requostod From Your Provider. The |Charge(s) On This Claim Are Denied And Will Be Reconsidered If The Information ls Received In A Timely Manner. Follow Up With Your Provider To Ensure A Prompt Response To Our Request. Refer [To Claims Procodure In Your Bonofit Bookict For Ackltional information.Fax server P0S43s9 = 12/31/2019 il 0 AM PAGE 3/003 Fax Server [Claim number: _|19290019833, [Sorvice dates: _|06/22/2019 - 06/20/2019] Amount billed $300.00] [Claim type Medical Processed date: 10/25/2019 [Amount paid! $0.00] [claim status: [Completed Provider name: [GajieZivko.ZMD_ Patient responsibilty: | $0.00] Status detail Provider tax ID: [es1047 152 [Otner insurance pac: | $0.00] Network status: [Your claim was processed al the in-network level of benefis, (Claim Detail Servicing provider namo:|Gale.Ziko.Z.MD [Amount billed $300.00] [Service dates: fosvazie0t9 - oBi22i2019 Provider discount $30.09] Procedure code: fes203 JAmount not payable: $300.00] [Occurrence lo [Allowable amount $0.09] [Clinical remark [Amount paid: $0.00] [Processed date: 1025/2019 Patient responsibilty: $0.09] Type of service Medical examination Deductible: $0.00] ANSI 8 [Coinsurance: $0.09] [Copay’ $0.09] Paymort typo! Number: [Paid to [Other insurance: $0.09] [Chock [as1025087 Provider [wth $0.09] [Other amounts not paid: [Descrption: [$300.00 [chargo(s) Denied: Duplicates Of Charges For A Previously Processed Claim. [Claim number [19350020829 [Service dates: [06/22/2019 - 06/22/2019] Amount biled $300.00] [Claim ype Medical Processed dat [Amount paid $0.09] [Claim status: | In Procoss, Provider name: [Gajie.Zvko.ZMD_ Pationt responsibilty: | $0.00] [Status detail | Received Will Process Promplly [Provider tax ID- [651047152 [Other insurance pac: | $0.00] Network status: Not available