Atlanta GA 30374-0376

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DONALD R NELSON
A
20728 SEINE AVE
LAKEWOOD CA 90715-3602

This is not a bill

It is simply a statement of the medical services you received and details on how you

and your plan will share costs. It is called an Explanation of Benefits (EOB). The EOB is

generated when your provider (or pharmacy, if applicable) submits a claim for services you

received.

Do not use this to pay any outstanding bill.

The company does not discriminate on the basis of race, color, national origin, sex, age, or

disability in health programs and activities.

We provide free services to help you communicate with us, such as letters in other

languages or large print. Or, you can ask for an interpreter. To ask for help, please call the

member toll-free phone number listed on your ID card.

ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a

su disposición. Llame al 1-844-808-4553, TTY: 711.

1-844-808-4553, TTY: 711.

CEEB TOOM: Yog koj hais Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj.

Thov hu rau tus xov tooj hu deb dawb uas teev mauj nyob rau ntawm koj daim yuaj cim qhia

tus kheej.
Your January 2022 Explanation of Benefits

February 15, 2022

This is not a bill. Hello DONALD R NELSON,

If you owe anything, your provider will send you a bill. Inside you'll find a summary of claims for January. It shows what the

plan paid and how much you've paid (or will be billed by your

What’s inside? provider). It's called your Explanation of Benefits (EOB).

Questions? We’re here to help.

Your current cost summary
Call if you have questions about claims or benefits, finding providers

near you, suspicious claims or billing, information in this document, or

Your out-of-pocket costs issues about your plan.

Call us toll-free at 1-844-808-4553, TTY/RTT 711, 24 hours a day, 7

Your medical and hospital claims processed
days a week. Or visit www.myAARPMedicare.com.

You can also report suspicious or dishonest billing to Medicare at

Have questions or think there’s been a mistake?
1-800-633-4227, 24 hours a day, 7 days a week (TTY users should call

1-877-486-2048).

Your plan information

Part C (medical and hospital) member ID: 3610524

Plan: AARP Medicare Advantage Freedom Plus (HMO-POS)

Go paperless.

Visit your plan website to get your EOB online.

EOB ID 423436692-H0543-210-000 This is not a bill. MID 3610524

Material ID Y0066_Combined_EOB_C 1
 Your medical and hospital cost summary

This chart is a summary of claims processed in January 2022 and total year to date. Your share includes amounts paid

toward your copays, coinsurance, and deductible. Your share may also include costs that don’t count toward your

out-of-pocket maximum, such as denied claims or services. If you owe anything, your provider will send you a bill.

Total cost (allowed

Providers billed plan Plan paid Your share
amount)

Totals for January $1,536.00 $972.00 $972.00 $0.00

Totals for 2022 $1,536.00 $972.00 $972.00 $0.00

See Your medical and hospital claims processed in January 2022 for specific claim details.

EOB ID 423436692-H0543-210-000 This is not a bill. MID 3610524

Material ID Y0066_Combined_EOB_C 2
 Your annual medical and hospital out-of-pocket costs

Your out-of-pocket costs (copayments, coinsurance and deductible) show the most money you will have to pay for covered

services in a plan year (based on date of service). Some items and services will not count toward that maximum (see your

Evidence of Coverage (EOC) to learn more). The amounts listed may include claims in-process and claims paid as of the date

noted on page 1 of this EOB. The amounts could change depending on when claims are paid and/or adjusted.

2022 In-Network Annual Out-of-Pocket Maximum

Your plan has a $800.00 out-of-pocket maximum. You have $800.00 left $0.00 of $800.00 paid

to pay for covered services for this plan year. The plan pays 100% of the

costs after you meet your out-of-pocket maximum.

0 400 800

2021 In-Network Annual Out-of-Pocket Maximum

Your plan has a $1,000.00 out-of-pocket maximum. You have $0.00 left $1,000.00 of $1,000.00 paid

to pay for covered services for this plan year. The plan pays 100% of the

costs after you meet your out-of-pocket maximum.

0 500 1,000

EOB ID 423436692-H0543-210-000 This is not a bill. MID 3610524

Material ID Y0066_Combined_EOB_C 3
 Your medical and hospital claims processed in January 2022

This chart shows your medical and hospital claims processed in January.

Provider: OPTION CARE ENT-SANTE FE SPRINGS Total cost

Provider
Network Provider (allowed Plan paid Your share
billed plan
Claim #: 2022012100229000001091-00 amount)

September 10, 2021 – October 7, 2021 $224.00 $224.00 $224.00 $0.00

HOME INFUS TX CATH CARE/MAINT SIMPLE PER DIEM

Billing code S5498

Totals $224.00 $224.00 $224.00 $0.00

Provider: OPTION CARE ENT-SANTE FE SPRINGS Total cost

Provider
Network Provider (allowed Plan paid Your share
billed plan
Claim #: 2022012100229000000782-00 amount)

October 8–21, 2021 $112.00 $112.00 $112.00 $0.00

HOME INFUS TX CATH CARE/MAINT COMPLEX PER DIEM

Billing code S5501

Totals $112.00 $112.00 $112.00 $0.00

Questions? Call toll-free 1-844-808-4553, TTY/RTT 711, 24 hours a day, 7 days a week.

EOB ID 423436692-H0543-210-000 This is not a bill. MID 3610524

Material ID Y0066_Combined_EOB_C 4
 Your medical and hospital claims processed in January 2022

Provider: ROYAL MAJESTY HOME CARE Total cost

Provider
Network Provider (allowed Plan paid Your share
billed plan
Claim #: 33003610524010061-00 amount)

November 2, 2021 $0.00 $106.00 $106.00 $0.00

Adjustments that apply to the entire claim:

Billing code CLAIM

November 3, 2021 $0.00 $0.00 $0.00 $0.00

Billing code 3DA11

November 3, 2021 $200.00 $0.00 $0.00 $0.00

NURSING CARE THE HOME REGISTERED NURSE PER DIEM

Billing code T1030

• Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.

Totals $200.00 $106.00 $106.00 $0.00

Questions? Call toll-free 1-844-808-4553, TTY/RTT 711, 24 hours a day, 7 days a week.

EOB ID 423436692-H0543-210-000 This is not a bill. MID 3610524

Material ID Y0066_Combined_EOB_C 5
 Your medical and hospital claims processed in January 2022

Provider: ROYAL MAJESTY HOME CARE Total cost

Provider
Network Provider (allowed Plan paid Your share
billed plan
Claim #: 33003610524010057-00 amount)

November 28, 2021 $0.00 $212.00 $212.00 $0.00

Adjustments that apply to the entire claim:

Billing code CLAIM

December 1, 2021 $0.00 $0.00 $0.00 $0.00

Billing code 3DA11

December 1, 2021 $200.00 $0.00 $0.00 $0.00

NURSING CARE THE HOME REGISTERED NURSE PER DIEM

Billing code T1030

• Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.

December 2, 2021 $200.00 $0.00 $0.00 $0.00

NURSING CARE THE HOME REGISTERED NURSE PER DIEM

Billing code T1030

• Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.

Totals $400.00 $212.00 $212.00 $0.00

Questions? Call toll-free 1-844-808-4553, TTY/RTT 711, 24 hours a day, 7 days a week.

EOB ID 423436692-H0543-210-000 This is not a bill. MID 3610524

Material ID Y0066_Combined_EOB_C 6
 Your medical and hospital claims processed in January 2022

Provider: ROYAL MAJESTY HOME CARE Total cost

Provider
Network Provider (allowed Plan paid Your share
billed plan
Claim #: 33003610524010058-00 amount)

December 5, 2021 $0.00 $106.00 $106.00 $0.00

Adjustments that apply to the entire claim:

Billing code CLAIM

December 8, 2021 $0.00 $0.00 $0.00 $0.00

Billing code 3DA11

December 8, 2021 $200.00 $0.00 $0.00 $0.00

NURSING CARE THE HOME REGISTERED NURSE PER DIEM

Billing code T1030

• Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.

Totals $200.00 $106.00 $106.00 $0.00

Questions? Call toll-free 1-844-808-4553, TTY/RTT 711, 24 hours a day, 7 days a week.

EOB ID 423436692-H0543-210-000 This is not a bill. MID 3610524

Material ID Y0066_Combined_EOB_C 7
 Your medical and hospital claims processed in January 2022

Provider: ROYAL MAJESTY HOME CARE Total cost

Provider
Network Provider (allowed Plan paid Your share
billed plan
Claim #: 33003610524010059-00 amount)

December 12, 2021 $0.00 $106.00 $106.00 $0.00

Adjustments that apply to the entire claim:

Billing code CLAIM

December 15, 2021 $0.00 $0.00 $0.00 $0.00

Billing code 3DA11

December 15, 2021 $200.00 $0.00 $0.00 $0.00

NURSING CARE THE HOME REGISTERED NURSE PER DIEM

Billing code T1030

• Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.

Totals $200.00 $106.00 $106.00 $0.00

Questions? Call toll-free 1-844-808-4553, TTY/RTT 711, 24 hours a day, 7 days a week.

EOB ID 423436692-H0543-210-000 This is not a bill. MID 3610524

Material ID Y0066_Combined_EOB_C 8
 Your medical and hospital claims processed in January 2022

Provider: ROYAL MAJESTY HOME CARE Total cost

Provider
Network Provider (allowed Plan paid Your share
billed plan
Claim #: 33003610524010060-00 amount)

December 19, 2021 $0.00 $106.00 $106.00 $0.00

Adjustments that apply to the entire claim:

Billing code CLAIM

December 22, 2021 $0.00 $0.00 $0.00 $0.00

Billing code 3DA11

December 22, 2021 $200.00 $0.00 $0.00 $0.00

NURSING CARE THE HOME REGISTERED NURSE PER DIEM

Billing code T1030

• Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.

Totals $200.00 $106.00 $106.00 $0.00

Questions? Call toll-free 1-844-808-4553, TTY/RTT 711, 24 hours a day, 7 days a week.

EOB ID 423436692-H0543-210-000 This is not a bill. MID 3610524

Material ID Y0066_Combined_EOB_C 9
 Have questions or think there’s been a mistake?

Part C (medical and hospital):

• If you have questions about a claim or think there

might be a mistake, start by calling your provider.

• If you still have questions, you can also contact us. We

can help with questions about:

– Claims or benefits

– Finding providers near you

– Suspicious claims or billing

– Information in this document

– Any issues about your plan

• You have the right to make an appeal or complaint,

which is a formal way to ask us to change our coverage

decision. You can also make an appeal if we deny a claim or

if we approve a claim but you disagree with how much you

are paying for the item or services. Contact us for more

information.

Contact Us

Customer Service

Toll-free 1-844-808-4553, TTY/RTT 711, Learn more at

24 hours a day, 7 days a week www.myAARPMedicare.com

You can report suspicious or dishonest billing to Member Services at the number above or Medicare at 1-800-633-4227,

24 hours a day, 7 days a week (TTY users should call 1-877-486-2048).

EOB ID 423436692-H0543-210-000 This is not a bill. MID 3610524

Material ID Y0066_Combined_EOB_C 10