FSPOS607 FAX To: ‘Company’ Fax Phone From: Fax: Phone: E-mail NOTES: 1/2/2020 9:07:25 AM PAGE 1/003 Fax Server Kathy Unauthorized interception of this facsimile could be a violation of federal and state law. We are required to safeguard privileged, confidential and/or protected health information by applicable law. The information in this document is for the sole use of the person(s) or company named above. If this you have received this fax in error, please contact us by phone immediately to arrange for retum of the documents. If you have difficulty with this transmission, please contact the number above. Date and time of transmission: Thursday, January 2, 2020 9:07:14 AM. Number of pages including this cover sheet: 03FSPOS607 1/2/2020 9:07:25 AM PAGE 2/003 Fax Server UMR PO BOX 0541 SALT LAKE CITY UT #4190.0561 MASEDIAT: oF 99K LISA LEE 1003 CRANE ST KEY LARGO FL 93037-2716 QUESTIONS | CONCERNS Contact 1-868-926-2404 INTERNET: Oniine Services are avaliable 24 hours a day at www.umr.com, You may fle an appeal of the claim decision by sending a written request and pertinent information (ea: office notes, lab results, operative notesiteports, and medical history) within 180 days from the date ofthis Notice to "Claims. Appeal Unit, P.O. Box 20546, Salt Lake City, UT 84130-0546". Refor to your current benetit Booket for information on the appeal process. A printable appeal form may also be accessed at www.umr.com to atlach to your request for appeal. I your plan is governed by the Employee Fetirement income Secunty Act (ERISA), you may have the right to bring a civ action under section $02(a) of ERISA after you have exhausted the mandatory appeal leve's thal are described in your benetit booklet. You may supply additonal information with your appeal. You may request copies (free of charge) of information relevant to your Gaim by contacting us at the above address. ‘OTHER RESOURCES TO HELP YOU: For questions about your appeal rights, this notice, or for assistance if your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 866-444-EBSA (3272). If your pian is not governed by ERISA, you can contact the Department of Healt and Human Services Health Insurance Assistance Team at 1-888-998-2789, EXTERNAL REVIEW OPTION: If we continue to deny the payment, coverage or service requested, or if you do not receive a timely decision, you may be able to request an extemal review of your claim by an independent third party, who will review the denial and Issue a final decision. Your written request must be received by UMR within four (4) months of the date you receive this notice. HELP STOP FRAUD: It you know or suspect any illegal activity concerning claims, contact our anti-fraud unit by calling 1-800-356-5803. You do not need to identily yourset Reter to your benefit booklet for more details on claim determination. Please cal! the number iocated above if you need diagnosis andor treatment code information for this claim.Fax Server 3/003 1/2/2020 9:07:25 AM PAGE FSPOS607 Pago 1 Dist Code! 89) PO BOX 30841 Si KE CITY UT 64 130-0541 EXPLANATION OF BENEFITS NOTICE - THIS IS NOT A BILL Provider: GAICZIMOZMD Patient Account: 170051 Claim Control Number: 19256008207 Service Description Emen EIST oeductle Amour "amount" "Amount “Paid NEDICALEXAMINATICN i tees Go-pay” Allowable 14; Pian Benetit! “Amount [Provider $000 seo. sa aoe, momar ret ‘ena Laval “Kpied Te Baie ‘Senet Covel ‘ippled Te Baie SS,Q00NNET IND DEDUCTIBLE wi TEGRATICN $86,000 IND RX APPLIED TO QUT-OF POT $735 $12,000 FAMEX APPLIED TOOUT-CEPOCT sat S28.200CUT NET FAM OUT OF POC wiNTEGRATION S84