Fax server P0Sds8 = 12/31/2019 1:15:54 PM PAGE 1/005 Fax Server UMR ——s To: 3057687766 Employee name: Johnny Huston From UM: Employes ID: 20193453 Date & Time: 12/91/2019 19:14:27 CST Patient name: Heather Huston Patient bith date: 7130/1994 leed more information? Ifyou need adkitional information, please call 877-203-2414. When prompted for the employee's member ID, enter the falloning passcode: 788720. 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 P0S4s8 = 12/31/2019 1:15:54 PM PAGE 2/005 Fax Server Claim Fax UMR —_— 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:788720. You wil then be connected with a customer service representative. This passcode is only valid one time and expires two weeks after the date ofthis fax. Employee name: Johnny Huston Group number: 76413550 Employee ID: 20193453 Employer: ‘American Airlines Pationt name: Heather Huston Effective date! o1vor2019 Patient birth date: o7ig0/1994 ‘Termination date: Active Pationt account number: 168720 Dato of sorvice requested osi27r2019 Provider network AMERICAN AIRLINES-UHC CHOICE PLUS [claim number 19189163376 [Service datos. [06/27/2019 - 06/27/2019] Amount billed $756.00] [claim type Medical Processed date. [07/12/2019 [Amount pala $0.00] [Claim status [Comploiea Provider name: |Gajic,Zvko.ZMD Pationt responsbilty: $300.09] Status detail Provider taxiD: _Jesto47152. [Other insurance pai $0.09] Network status: [Not available (Claim Detail [Servicing provider name:| Gallo Zivko.Z.MD [Amount bile $300.00] [Service dates: loser 2019 - 06/27/2019 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: lorareot9 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 [ass332033 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 $233.00] [Service dates: fosver/2019 - 06/27/2019 Provider discount $233.00] Procedure code: jesse JAmount not payable: $0.09]Fax server P0S438 12/31/2019 1:15:54 PM PAGE 3/005) = Fax server [Occurrence 0 [Allowablo amount $0.00 [Clinical remark [Amount paid: $0.00] [Processed date: lornareote Patient responsibilty $0.09] Type of service Medical service Deductible: $0.09] [ANSI lat [Consurance: $0.00] [Copay: $0.09] Payment type! Number Pail [other insurance: $0.09] [chock [45332083 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. Servicing provider name] Gale. Zivko.Z. MD [Amount bile $77.00] [Service dates: fosver 2019 - 06/27/2019 Provider discount $77.00| Procedure code: fo6s72 [Amount not payable! $0.09] [Oceurrenco! lo [Allowable amount $0.09] [Clinical remark [Amount paid: $0.09] [Processed date: loraeote Patient responsibilty $0.09] Type of service Medical service Deductible: $0.09] fans lat [Coinsurance: $0.09] [Copay: $0.00] Payment type! Number: [Paid ta [Other insurance: $0.09] [eheck [asaaa2039 Provider [wrth $0.09] [Other amounts not paid: [Description Is 0.00 [Adkitional information Necded To Process Your Claim Has Been Requasted From Your Provider. The |Charge(s) On This Claim Are Denied And Will Be Reconsidered if The Information is Received In A [Timely Manner. Follow Up With Your Provider To Ensure A Prompt Response To Our Request. Rofer [To Claims Procedure In Your Benofit Booklet For Addtional Information. [Servicing provider names] Gallo Zivko.Z.MD [Amount bile: $77.00] [Service dates foar27/2019 - 06/27/2019 Provider discount $77.00] Procedure code: [e6s72 [Amount not payable: $0.00] [Occurrence lo [Allowable amount $0.09] [Clinical remark [Amount pais: $0.09] [Processed date: lorareots Patient responsbilty $0.09] Type of service Medical service Deductible: $0.00] faNst [at [Coinsuranco: $0.09] [Copay: $0.00] Payment type! Number: Paid to [Other insurance: $0.09] [Check [ass392033 Provider [wrth $0.09] [omer amounts not paid: [Desorption Is 0.00 [Additional information Nooded To Process Your Claim Has Boon Requested From Your Providor. The |Charge(s) On This Claim Are Denied And Will Be Reconsidered if The Information Is Received In A [Timely Manner. Follow Up With Your Provider To Ensure A Prompt Response To Our Request. Rofer [To Claims Procedure In Your Benofit Bookit For Ackltional information.Fax server P0S4s8 = 12/31/2019 1:15:54 PM PAGE 4/005 Fax Server [Servicing provider name:| Gallo Zivko.Z.MD [Amount bile: $36.00] Service dates fosv27/2019 - 06/27/2019 Provider discount $36.00] Procedure code: [at003 [Amount not payable: $0.09] [Oceurrence: lo [Allowable amount $0.00] [Clinical remark [Amount paid: $0.09] Processed date lorareots Patient responsbilty $0.09] Type of service: Diagnostic ab Deduciibte: $0.09] ANSI At [Consurance: $0.09] |Copay: $0.09] Payment type Number Pai [other insurance: $0.00] [oheck [ass392053 Provider [withho: $0.09] [oxner amounts not paid: [Description Is 0.00 [Additional information Neoded To Process Your Claim Has Been Requested From Your Provider. The |Charge(s) On This Claim Are Denied And Will Be Reconsidered If The Information Is Rcelved In A Timely Manner. Follow Up With Your Pravider To Ensure A Prompt Response To Our Request. Refer [To Claims Procedure In Your Benefit Bookiet For Ackltional Information. [Servicing provider name:|Gale ZimoZ.MD [Amount billed $19.00] [Service dates: fosvar/2019 - 06/27/2019 Provider discount $19.00] Procedure code: [s2360 [Amount not payable: $0.09] [Occurrence lo [Allowable amount $0.00] [Clinical remark [Amount paid: $0.09] [Processed date: lozaeote Patient responsibilty: $0.09] [Type of service Drugs. Deducibte: $0.09] ANSI Aa [Coinsurance: $0.00] [Copay: $0.09] Payment type! Number Paid to [other insurance: $0.00] [chock [453392033 Provider [wrth $0.09] [Other amounts not paid: [Description fs 0.00 Jadcitional information Needed Ta Process Your Claim Has Been Requested From Your Provider. The |Charge(s) On This Claim Are Denied And Will Be Reconsidered If The Information Is Rcelved In A ‘Timely Manner. Follow Up With Your Provider To Ensure A Prampt Response To Our Request. Refer HTo Claims Procedure In Your Benet Bookiet For Additional Information. Servicing provider name:|Gale.Zivko.Z.MD [Amount bile $8.00] [Service dates: fosvar/2019 - 062 i2019 Provider discount $8.09] Procedure code: [so6s6 JAmount not payable: $0.09] [Occurrence lo [Allowabie amount $0.09] [Clinical remark [Amount paid: $0.00] [Processed date: lorareote Patient responstbilty: $0.09] [Type of service Drugs. Deducrbte: $0.09] ANSI At [Consurance: $0.00] [Copay’ $0.00] Payment type! Number: [Paid to [Other insurance: $0.09] [chock [459992083 Provider [wrth $0.09] [Other amounts not paid: [Description is 0.00 [Adtional information Nooded To Procoss Your Claim Has Boon Requastod From Your Provider. The |Charge(s) On This Claim Are Denied And Will Be Reconsidered if The Information ls Received In AFax server P0S438 12/31/2019 1:15:54 PM PAGE 9/005) = =-Fax server [Timely Manner. Follow Up With Your Provider To Ensure A Prompt Response To Our Request. Refer [To Claims Procedure In Your Beneftt Booklet For Adltional information. [Servicing provider name:|Gaje ZimoZ.MD [Amount bile: $8.09] Service dates [06/27/2019 - 06/27/2019 Provider discount $8.00] [Procedure code: lsre8s [Amount not payable: $0.09] [oceurrence! lo [Allowable amount $0.09] [Clinical remark [Amount paia: $0.09] Processed date: lorrareote Pationt responsibilty $0.09] Type of service: Drugs, Deductible: $0.09] [ANSI [at [Coinsurance: $0.09] [Copay’ $0.00| Payment type: Number Pail Jother insurance: $0.09] [chock [asa902003 Provider [withhoe: $0.09] [Other amounts not paid: [Description Is 0.00 [Additional Information Needed To Process Your Claim Has Been Requested From Your Provider. The |Chargo(s) On This Claim Are Donied And Will Bo Reconsidered If The Information is Received In A. Timely Manner. Follow Up With Your Pravider To Ensure A Prampt Respanso To Our Request. Refer [To Claims Procedure In Your Benefit Booklet For Ackdtional information