Fax server P0S440 = 1/2/2020 8:11:33 AM PAGE 1/004 Fax Server To: 3087687766 Employee name: Kovin Nosalok From UM, Employes ID: 20004947 Date & Time: 01/02/2020 08:10:11 OST Patient name: Colby Nosalek Patient birth date: 03/31/2008 leed more information? Ifyou need adkitional information, please call 877-203-2414. When prompted for the employee's member ID, enter the falloning ppasscodo: 052089. You will thon be connected with a customer servico representative, This passcode is only valid one time and expires two weeks after the date ofthis fax. ditional Notes Every effort is made to be sure that the information given to you today is accurate. Ifa conflict exists between the information provided to you and tho terms ofthe plan, the torms of the plan will control. Final dotormination of coverago and pationt responsbilly is made al the time the claim is received and processed. The information contained inthis fax transmission i intended solely forthe individual named above and may contain confidential andlor privileged information. Therefore, this fax must be secured and protected in accordance with state and federal laws regarding the treatment of confidential information, medical privacy or other requirements (legal or business practice). If you, the reader ofthis fax cover sheet, are not the individual named above or an authorized representative ofthe individual named above, you are hereby notified that any review, dissemination, use, copying or retention ofthis fax or any pat ofthe information herein is Strictly prohibited. Ityou have received ths fax in error, please natty the sender immediately by phone and destroy this fax. Thank you.Fax server P0S440 Claim Fax 1/2/2020 8:11:35 AM PAGE 2/004 Please refer to the disclaimer on the first page for important information. Ifyou need adcitional information, please call 877-203-2414. When prompted for the employee's member ID, enter the falloning ppasscode:052089. You wil then be connected with a customer service representative. This passcode Is only valid one time and expires two weeks after the date of this fax. Employee name: Employee ID: Pationt name: Patient birth date: Pationt account number: Provider network Kevin Nosalek Group number: 20004847, Employer Colby Nosalek Effective date 09/31/2009 Termination date: 16a763 Date of service requested: UNITEDHEALTHCARE CHOICE PLUS Fax Server UMR —_— 76419586 Notes Ine. 1012019 Active osi2a/2019 [Claim number [iotestor6r2 [Service dates: [06/26/2019 - 06/28/2019] Amount bled. $377.00] [claim type Medical Processed date [a7iasi2019 [Amount paid $0.09] [ciaimstatus: [Completed Provider name: [GajiezWkoZMD_ Patient responsibilty: | $300.00] Status detail Provider tax ID: [es1047 152 [other insurance paic: | $0.00] Network status: [Not avaliable (Claim Detail [Servicing provider name:|Gajc.Zivko.Z.MD [Amount bile $300.00] [Service dates! fosvearz019 - 06/28/2019 Provider discount $0.09] Procedure code: fes2oa [Amount not payable: $0.09] [Occurrence lo [Allowable amount $300.00] [Clinical remark [Amount paid: $0.09] Processed date: forresr2019 Pationt responsibilty $300.00] Type of service Medical examination Deductible: $0.09] [ANSI lat [Consurance: $0.00] $0.09] Payment ype Number Pai $0.00] [Check fase 15852 Provider [wrth $0.09] [Other amounts not paid: [Description Is 0.00 [Additional information Nooded To Process Your Claim Has Boon Requostod From Your Provider. The |Charge(s) On This Claim Are Denied And Will Be Reconsidered If The Information ls Received In A Timely Manner. Follow Up With Your Provider To Ensure A Prompt Response To Our Request. Refer [To Claims Procodure In Your Bonofit Bookict For Ackltional information. Servicing provider name: [Gale ZikoZ.MD [Amount bile $77.00] [Service dates! fosvear20'9 - 06/28/2019 Provider discount $77.00 Procedure code: [azaao JAmount not payable: $0.09]Fax server P0S440 1/2/2020 & 33 AM PAGE 3/004 Fax Server [Occurrence 0 [Allowablo amount $0.00 [Clinical remark [Amount paid: $0.00] [Processed date: loresreote Patient responsibilty $0.09] Type of service Diagnostic lab Deductible: $0.09] [ANSI lat [Consurance: $0.00] [Copay: $0.09] Payment type! Number Pail [other insurance: $0.09] [chock [456615852 Provider [wrth $0.09] [other amounts not paid: [Description Is 0.00 [Aditional information Nooded To Procoss Your Claim Has Boon Requested From Your Provider. The |Charge(s) On This Claim Are Denied And Will Be Reconsidered If The Information ls Received In A [Timely Manner. Follow Up With Your Provider To Ensure A Prompt Response To Our Request. Refer HTo Claims Procedure In Your Benofit Bookiet For Addtional Information. [claim number: [19280000324 [Service dates: [06/28/2019 - 06/28/2019] Amount billed. $377.00] [Claim ype Medical Procossed date: [10/17/2019 [Amount paid! $0.00] [claim status: [Completed Provider name: [GajieZivko.ZMD_ Patient responsibilty: | $0.00] [Status detail: Provider tax ID: [asto47ts2 [Other insurance pai: | $0.00] Network status: [Your claim was processed al the in-network lovel of benafis, (Claim Detail [Servicing provider name:|Gaje ZimaZ.MD [Amount bile $300.00] Service dates fosr2a/2019 - 06/28/2019 Provider discount $0.00] [Procedure code: [29203 [Amount not payable: $300.09] [oceurrence! lo [Allowable amount $0.09] [ctinical remark [Amount paid: $0.09] Processed date: orr72019 Patient responsibilty $0.09] Type of service: Medioal examination Deductible: $0.09] [ANSI 18 [Coinsurance: $0.09] [Copay’ $0.00| Payment type! Number: [Paid to [Other insurance: $0.09] [chock lare6aae43 Provider [withhoe: $0.09] [Other amounts not paid: [Descrption: [$300.00 [Charge(s) Denied: Duplicates Of Charges For A Previously Processed Claim Servicing provider name] Gale. Zimko.Z.MD [Amount bile $77.00] Service dates: fosv2a/2019 - 06/28/2019 Provider discount $0.00] [Procedure code: leraeo [Amount not payable: $77.00 [occurrence lo [Allowable amount $0.09] [ctinieal remark [Amount pac! $0.09] Processed date: 101772019 Pationt rosponstbilty: $0.09] Type of service: Diagnostic lab Deductible: $0.09]Fax server P0Sd40 = =—-1/2/2020 3 AM PAGE 4/004 =Fax Server [ANSI 18 [Coinsurance: $0.00] [Copay: $0.09] Payment type! Number: [Paid to [other insurance: $0.09] [eheck lareeaaeas Provider [wrth $0.09] [other amounts not paid: [Description [s_ 77.00 [Charge(s) Denied: Duplicates Of Charges For A Previously Processed Cl [claim number. [19347008715 [Sorvice dates: [06/28/2019 - 06/28/2019] Amount biled $377.00] [Claim type Medical Processed date’ [Amount paid! $30.09] [claim status: | n-Pracess, Provider name: [GajieZivko.ZMD_ Patient responsibilty: | $0.00] [Status detail [Recelved- Will Process Promptly [Provider tax ID: [651047152 [Otner insurance pac: | $0.00] Network status: [Not avaliable