P645302801V

1570 Midway Pl.

Menasha, WI 54952 202210193920

1 OF 8 F
Address Service Requested
ALL FOR AADC 530
4628 1.8304 AB 0.488

ENV 4628
GABRIEL LOPEZ PADILLA 43
1216 HAGERER ST
RACINE, WI 53402-4817

Immunizations are an important part of your health care. Make sure to stay up-to-date on your scheduled vaccines
to protect yourself, your family and the community. Thank you for being a Network Health member.

If you do not agree with this decision, please review the attachment.

If you suspect fraud, please contact customer service or email us at

MedicareSIU@networkhealth.com

For customer service call

800-378-5234
TTY for the hearing impaired
800-947-3529
Monday – Friday, 8 a.m. to 8 p.m.
 P645302801V

ENV 4628 1 OF 8 B
 202210193920

L6453028003
MONTHLY REPORT

Medical and Hospital Claims

Processed in September 2022
Network Health Medicare Go (PPO)

For GABRIEL LOPEZ PADILLA
Member ID: 700132691
This is not a bill:
 This monthly report of claims we have processed tells what
care you have received, what the plan has paid and how
much you have paid out-of-pocket (or can expect to be
billed).
 If you owe anything, your doctors and other health
care providers will send you a bill.
 This report covers medical and hospital care only.
We send a separate report on Part D prescription
drugs.
 If you notice something suspicious that might be
dishonest billing, you can report it by calling
1-800-MEDICARE (1-800-633-4227), 24 hours a
day, seven days a week. (TTY users should call
1-877-486-2048.)
Network Health Medicare Advantage Plans include MSA, HMO and PPO plans with
a Medicare contract. NetworkCares is a PPO SNP plan with a Medicare contract and
a contract with the Wisconsin Medicaid program. Enrollment in Network Health
Medicare Advantage Plans depends on contract renewal.
networkhealth.com
Customer Service
If you have questions, call us at 800-378-5234
We are here Monday–Friday from 8 a.m. to 8 p.m.
TTY / TDD only: 800-947-3529
Customer Service has free language interpreter services available for non-English
speakers.
The benefit information provided is a brief summary, not a complete description of
benefits. For more information, contact the plan. Benefits, formulary, pharmacy
network, provider network, premium, copayments and coinsurance may change each
year.

Y0108_2661-01-0320_C Accepted Page 1

CONTINUED

ENV 4628 2 OF 8 F
 202210193920

L6453028003
TOTALS Amount providers have Total cost (amount the
for medical and hospital claims Plan’s share Your share
billed the plan plan has approved)
Totals for this month (for claims processed from $74,299.12 $0.00 $0.00 $0.00
September 01, 2022 to September 30, 2022)

Totals for 2022 (all claims processed through $177,209.50 $44,908.93 $43,066.80 $1,842.13
September 30, 2022)

Page 2
CONTINUED

ENV 4628 2 OF 8 B
 202210193920

YEARLY LIMIT - this limit gives you financial protection
This limit tells the most you will have to pay in “out-of-pocket” costs,
copayments and coinsurance for medical and hospital services covered by
the plan.
L6453028003
As of September 30, 2022, (for plan year 2022), you have had
$1,842.13 in out-of-pocket costs that count toward your $6,500.00
out-of-pocket maximum for covered services.

This yearly limit is called your “out-of-pocket maximum.” It puts a limit

on how much you have to pay, but it does not put a limit on how much
care you can get.
Combined (in-network + out-of-network) limit
Your out-of-pocket spending for non-Medicare covered expenses such as
routine hearing, hearing aids, routine dental, home medical monitoring,
In 2022, $6,500.00 is the most you will have to pay for covered
meals programs and other non-covered services will not count toward
services you get from all providers (in-network providers + out of
your yearly out-of-pocket maximum. This means:
network providers combined).
 Once you have reached your limit in out-of-pocket costs,
you stop paying out of pocket for all services except As of September 30, 2022, (for plan year 2022), you have had
non-covered services. $1,842.13 in out-of-pocket costs that count toward your $6,500.00
combined out-of-pocket maximum for covered services.
 You keep getting your covered medical and hospital
services as usual, and the plan will pay the full cost
for the rest of the year. Your out-of-pocket spending
for services that are not covered by Medicare does not
count toward your out-of-pocket maximum.

Page 3
CONTINUED

ENV 4628 3 OF 8 F

Details for claims processed in September 2022
Look over the information about your
claims - does it seem correct?
 If you have questions or think there might
be a mistake, start by calling the doctor’s
office or other service provider. Ask them
to explain the claim.
 If you still have questions, call us at
Customer Service (phone numbers are in a
box on page 1).
You have the right to make an appeal or complaint
 Making an appeal is a formal way of asking us to
change our decision about your coverage. You
can make an appeal if we deny a claim. You can
also make an appeal if we approve a claim but
you disagree with how much you are paying for
the item or services. For information about
making an appeal, call us at Customer Service
(phone numbers are in a box on page 1).
Page 4
CONTINUED
202210193920
L6453028003
Remember, this report is NOT A BILL:
 If you have not already paid the
amount shown for “your share,” wait
until you get a bill from the provider.
 If you get a bill that is higher than the
amount shown for “your share,” call
us at Customer Service (phone
numbers are in a box on page 1).
ENV 4628 3 OF 8 B
 202210193920

L6453028003
Provider: ASCENSION ALL SAINTS HOSPIT Date of Amount the Total cost
Claim Number: 22244E00948 service provider billed (amount the plan
In-network provider the plan approved) Plan’s share Your share
Room & Board - Semi-private Two Bed-General 01/12/2022 $18,227.00 $0.00 $0.00 $0.00
Classification DENIED
0120 (Look below for
information about
your appeal
rights.)
Pharmacy-General Classification 01/12/2022 $3,669.62 $0.00 $0.00 $0.00
0250 DENIED
(Look below for
information about
your appeal
rights.)
Pharmacy-Generic Drugs 01/12/2022 $1,608.15 $0.00 $0.00 $0.00
0251 DENIED
(Look below for
information about
your appeal
rights.)
IV Therapy-General Classification 01/12/2022 $784.00 $0.00 $0.00 $0.00
0260 DENIED
(Look below for
information about
your appeal
rights.)

Page 5
CONTINUED

ENV 4628 4 OF 8 F
 202210193920

Medical/Surgical Supplies & Devices-Non Sterile 01/12/2022 $445.50 $0.00 $0.00 $0.00

L6453028003
Supply DENIED
0271 (Look below for
information about
your appeal
rights.)
Medical/Surgical Supplies & Devices-Sterile 01/12/2022 $3,266.10 $0.00 $0.00 $0.00
Supply DENIED
0272 (Look below for
information about
your appeal
rights.)
Medical/Surgical Supplies & Devices-Other 01/12/2022 $2,427.75 $0.00 $0.00 $0.00
Implant DENIED
0278 (Look below for
information about
your appeal
rights.)
Laboratory-General Classification 01/12/2022 $1,127.00 $0.00 $0.00 $0.00
0300 DENIED
(Look below for
information about
your appeal
rights.)
Laboratory-Chemistry 01/12/2022 $3,191.00 $0.00 $0.00 $0.00
0301 DENIED
(Look below for
information about
your appeal
rights.)

Page 6
CONTINUED

ENV 4628 4 OF 8 B
 202210193920

Laboratory-Immunology 01/12/2022 $490.00 $0.00 $0.00 $0.00

L6453028003
0302 DENIED
(Look below for
information about
your appeal
rights.)
Laboratory-Hematology 01/12/2022 $2,250.00 $0.00 $0.00 $0.00
0305 DENIED
(Look below for
information about
your appeal
rights.)
Laboratory-Bacteriology & Microbiology 01/12/2022 $766.00 $0.00 $0.00 $0.00
0306 DENIED
(Look below for
information about
your appeal
rights.)
Laboratory-Urology 01/12/2022 $40.00 $0.00 $0.00 $0.00
0307 DENIED
(Look below for
information about
your appeal
rights.)
Laboratory Pathological-Histology 01/12/2022 $349.00 $0.00 $0.00 $0.00
0312 DENIED
(Look below for
information about
your appeal
rights.)

Page 7
CONTINUED

ENV 4628 5 OF 8 F
 202210193920

Radiology - Diagnostic-Arteriography 01/12/2022 $5,790.00 $0.00 $0.00 $0.00

L6453028003
0323 DENIED
(Look below for
information about
your appeal
rights.)
Radiology - Diagnostic-Chest X-Ray 01/12/2022 $596.00 $0.00 $0.00 $0.00
0324 DENIED
(Look below for
information about
your appeal
rights.)
CT Scan-Head Scan 01/12/2022 $2,270.00 $0.00 $0.00 $0.00
0351 DENIED
(Look below for
information about
your appeal
rights.)
Operating Room Services-General Classification 01/12/2022 $10,607.00 $0.00 $0.00 $0.00
0360 DENIED
(Look below for
information about
your appeal
rights.)
Anesthesia-General Classification 01/12/2022 $4,303.00 $0.00 $0.00 $0.00
0370 DENIED
(Look below for
information about
your appeal
rights.)

Page 8
CONTINUED

ENV 4628 5 OF 8 B
 202210193920

Respiratory Services-General Classification 01/12/2022 $1,142.00 $0.00 $0.00 $0.00

L6453028003
0410 DENIED
(Look below for
information about
your appeal
rights.)
Respiratory Services-Inhalation Services 01/12/2022 $348.00 $0.00 $0.00 $0.00
0412 DENIED
(Look below for
information about
your appeal
rights.)
Physical Therapy-General Classification 01/12/2022 $132.00 $0.00 $0.00 $0.00
0420 DENIED
(Look below for
information about
your appeal
rights.)
Occupational Therapy-General Classification 01/12/2022 $528.00 $0.00 $0.00 $0.00
0430 DENIED
(Look below for
information about
your appeal
rights.)
Occupational Therapy-Evaluation or Re-Evaluation 01/12/2022 $502.00 $0.00 $0.00 $0.00
0434 DENIED
(Look below for
information about
your appeal
rights.)

Page 9
CONTINUED

ENV 4628 6 OF 8 F
 202210193920

Emergency Room-General Classification 01/12/2022 $2,080.00 $0.00 $0.00 $0.00

L6453028003
0450 DENIED
(Look below for
information about
your appeal
rights.)
Pulmonary Function-General Classification 01/12/2022 $438.00 $0.00 $0.00 $0.00
0460 DENIED
(Look below for
information about
your appeal
rights.)
Cardiology-General Classification 01/12/2022 $277.00 $0.00 $0.00 $0.00
0480 DENIED
(Look below for
information about
your appeal
rights.)
Cardiology-Echocardiology 01/12/2022 $2,625.00 $0.00 $0.00 $0.00
0483 DENIED
(Look below for
information about
your appeal
rights.)
Recovery Room-General Classification 01/12/2022 $2,617.00 $0.00 $0.00 $0.00
0710 DENIED
(Look below for
information about
your appeal
rights.)

Page 10
CONTINUED

ENV 4628 6 OF 8 B
 202210193920

Treatment/Observation Room-Treatment Room 01/12/2022 $537.00 $0.00 $0.00 $0.00

L6453028003
0761 DENIED
(Look below for
information about
your appeal
rights.)
Other Diagnostic Services-Peripheral Vascular Lab 01/12/2022 $866.00 $0.00 $0.00 $0.00
0921 DENIED
(Look below for
information about
your appeal
rights.)
TOTALS: $74,299.12 $0.00 $0.00 $0.00
DENIED
(Look below for
information about
your appeal
rights.)

Things to know about your denied claim:

 NOTE: We have denied all or part of this claim. However, you are not  If you have questions, you can contact:
responsible for paying the billed amount because you received this
service from a Network Health Plan provider. o Our Customer Service (phone numbers are in a box on page 1)

o 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven

days a week. (TTY users should call 1-877-486-2048.)

Page 11
CONTINUED

ENV 4628 7 OF 8 F