Unitedealthare lan tatement Understanding your health plan ...

1 UnitedHealthcare | Plan Statement Understanding your health plan statement. Service Center ACCESS. UNITEDHEALTH. Box BOX1234. Anywhere, 740372. US 12345-6789. ATLANTA, GA 30374-0372. health Plan Name United HealthCare services , Inc. Member ID Number Address Change? Please contact your employer's benefit department. DPS$$$PKG. SUSAN TEST. 123 Main St. Member ID. 123456789 A unique employee number that protects your Anywhere US 12345-6789. FEEHEGFGHGEGEHEGFFHEHFEHFEEHHHHFFFFGEHFG GGGFGGEEEEGEFFFHHHHEFFEGF. Statement Period Statement Period 4/15/19-5/10/19. 03/24/17 - 03/30/17. Social Security number. THIS. THISISIS. NOT A BILL. NOT A BILL Statement Period Customer CustomerCare Care1-888-888-8888. 1-800-718-1293. Visit VisitYour YourWebsite Website Your benefit plan activity during a period of time. Have you visited your member website lately? If not, you've missed out on a lot of important information.

2 Not only can you find your current Message Center account balance and track your claims activity but there are also a variety of tools to help you manage your health . So if you haven't logged in for a while, check out the site today. Don't worry if you forgot your password -- you can get a reminder on the website. The website address is on the back of your ID card. medical Medicalclaims where claims payments where may be payments mayneeded from you: be needed from you: Messages that promote better health awareness. Pay your Applied To Claims processed between 04/15/19. 03/24/17 to 05/10/19. 03/30/17 provider(s) when Deductible What You Owe (if applicable). they bill you 05/07/19 services 01/27/17 forBRADLEY. servicesfor provided provided by Test by 'DESERT Provider'. REGIONAL' $ $ $ $ Claim Number: 1234567890123. $ Provider Billed: $ Payments and Discounts: -$ -$ Total: $ $ $ $ The amount you need to pay your health care professional For more For more information informationabout aboutthese theseclaims, claims,please pleaserefer toto refer the medical the 'MedicalClaim Claim Details' section Details' of this section document, of this the the document, Explanation of Benefits, Explanation of Benefits, or visit: or visit: This This isis not not a Your provider bill.

3 Your a bill. provider will will bill bill you you directly directly unless unless you you have havealready alreadypaid paidthem. Pleasecheck checkyour yourrecords. records. These charges represent your responsibility as defined by your health benefit plan. They may include your deductible, coinsurance, or a product or service if you did not pay at the time you received services . These charges represent your responsibility as defined by your health benefit plan. They may include your deductible, coinsurance, or a product or that is not an eligible expense. If you have coverage with another insurance carrier or Medicare, these charges may not include any product or service in servicethe which that is not other an eligible insurance expense. carrier If youwas or Medicare haveprimary. coverage with another In addition, insurance the amount carrier in the "Payoryour Medicare, these provider(s) charges when may they bill notarea you" include anymay above product or include service in made payments whichto the other the insurance subscriber.

4 Carrier Please oryour see Medicare wasdocuments coverage primary. Infor addition, the amount in the Pay your provider(s) when they bill you area above more information. may include payments made to the subscriber. Please see your coverage documents for more information. * If you have a health Reimbursement Account (HRA) or a Flexible Spending Account (FSA), that payment may have been made after this statement was created and will be reflected on your next statement. Please see the next page for more information Page 1. IDRS PG: KEY=0 1000000SC09244, EID=014409700, ALTID=014409700, of 7 POL=0022631, FYMD=090917, TYMD=091012. Your Account Balances UHG-0908490-00000177-E. 05/10/19 for Plan Year 01/01/19. Your Account Balances as of 10/12/2009 01/01/09 to 12/31/19. 12/31/09. health Reimbursement Account (HRA). Beginning Used Remaining Your Account Balances (if applicable). $1, Healthcare health careaccounts $ accountsthat thatemployers employers fund fund for for covered covered workers workers or $ or retired retired persons.

5 Persons.. Financial balances for your health reimbursement account (HRA). or flexible spending account (FSA). Flexible Spending Account (FSA). Beginning Used Remaining Tracking Your Deductibles and Limits $ $ NO FUNDS REMAINING $ "Abenefit A benefitplan planthat thatlets letsemployees employees put put pre-tax pre-tax dollars dollars in in special special accounts accountsto tohelp helppay paymedical medicalcosts, costs,child childcare, care,and andother otherhealth healthcare careservices.. services . Summary of your deductible and out-of-pocket limit and Tracking Your Deductibles and Maximums balances. Your health statement contains both network and out- of-network balance information. You also will be able to Your Deductibles as of 05/10/19 01/01/19 -to12/31/. 10/12/09 for Plan Year 01/01/09 12/31/1909. In-Network Out-of-Network Annual SUSAN S. AppliedR Remaining emaining Annual USAN S. SUSAN. AppliedR Remaining emaining see both your out-of-network deductible and out-of-pocket $1, $ $ $1, $ NONE USED $1, BRADLEY BRADLEY balance summaries.

6 $1, $ $ $1, $ NONE USED $1, CONTINUED. FAMILY (Employee and spouse) FAMILY (Employee and spouse). $2, $ $1, $3, $ NONE USED $3, 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 Deductible: Thehas been met, amount you the co-payment could and/or owe during coinsurance a coverage periodperiod of youryour for services planhealth may begin. benefitYour planplan will before covers then pay a certain your percentage plan begins to your eligible health care services and you will pay a smaller percentage until the out-of-pocket maximum has been met. Please see the next page for more information Page 2 of 7. Customer Care 1-888-888-8888. medical Claims Where Payments Are Not Needed From You medical claims where payments are not needed from you: continued Claims for NADA: Processed between 03/24/18.

7 04/15/19 to 03/30/18. 05/10/19. A B C D E. Provider Billed Plan Discount Allowed Amount health Plan Paid Copay A: Total amount billed by your health care professional or facility 04/17/19 services provided by TEST PROVIDER' before any network discounts are applied. Claim Number: 1234567890123 $ -$ $ -$ .. THIS CLAIM WAS PROCESSED ON 04/29/19. T HANK YOU FOR USING A NETWORK PHYSICIAN OR OTHER health CARE P ROFESSIONAL. WE HAVE APPLIED THE CONTRACTED. B: T. he discount health care professionals and facilities in our FEE. THE PATIENT IS NOT RESPONSIBLE FOR THE DIFFERENCE BETWEEN THE AMOUNT CHARGED BY THE PHYSICIAN OR health . CARE PROFESSIONAL AND THE AMOUNT ALLOWED BY THE CONTRACT, EXCEPT IN SITUATIONS WHERE THERE IS AN ANNUAL. BENEFIT MAXIMUM FOR THIS SERVICE. THE PATIENT IS ALSO RESPONSIBLE FOR ANY COPAY, DEDUCTIBLE AND COINSURANCE. AMOUNTS. network agree to give you as a member. C: The amount the plan allows for health care services .

8 D: Amount paid by your benefit plan for covered expenses. E: A. fixed fee that medical plan subscribers must pay for their use of specific medical services covered by the plan. This may have been paid when you received services . Depending on your benefit plan, your statement may have medical Claim Details additional columns or sections. THIS IS NOT A BILL - Please compare this information to the bill you receive from your provider, then pay the provider directly when they bill you. Member ID 123456789. medical Claim Details Claims for NADA. Date of Service: 05/07/19. Provider: 'TEST PROVIDER' F G. Claim #: 0123456789012. Process Date: 05/09/19 H I. Group Name: TEST CUSTOMER. Group #: 01234567 J K. Service Type Provider Billed Plan Discount Allowed Amount health Plan Paid Copay Total You Owe Detailed information from a claim for services you received. It will A. A. A. $ $ $ -$ -$ -$ .. -$ -$ -$ .. $ $ $ display what you may need to pay.

9 This information can be used Total A=LABORATORY services . $ -$ $ -$ $ $ to support coordination of benefits for a secondary carrier or Total You Owe Provider: $ proof of claim for an external FSA. Provider:$. F: Total amount billed by your health care professional or facility before any network discounts are applied. G: T. he discount health care professionals and facilities in our network agree to give you as a member. H: The amount the plan allows for health care services . I: Amount paid by your benefit plan for covered expenses. J: A. fixed fee that medical plan subscribers must pay for their use of specific medical services covered by the plan. This may have been paid when you received services . K: Amount you owe. Columns will be shown only if part of your benefit plan. Contact your UnitedHealthcare representative for additional information. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates.

10 Administrative services provided by United HealthCare services , Inc. or their affiliates. B2C 6/19 2019 United HealthCare services , Inc. 19-12654.