Attachment P EOB IMAGE_0380_Redacted.pdf

Page 2H_N3 ci l nS e a eSpecial note Health Advantage serves as benefits claims administrator for your health plan. Health Advantage is not the Plan Administrator and does not provide any insurance for your plan;

instead, your plan is sponsored by your employer and all benefits under the plan are self-funded by your employer. The Plan Administrator (your employer or someone appointed by your employer) for your plan has final authority over all plan benefits design and plan administration.

e e ew o R r vi f a- cl imRe-review of a claim al h d te t A an et agHealth Advantage Member Response Coordinator

P.O. Box 8069 Little Rock, AR 72203-8069

Please provide us with copies of any paperwork you have (EOBs, doctor bills, etc.) and your comments. Be sure to include the claim number found on your EOB.

ow t e l a e i b n i sH o p l o e a d n f eHow to appeal a denial of benefits If you believe you were denied benefits due to you under the terms of your health plan, you have the right to appeal. In order to appeal, you must send an appeals request form as part of your timely, written request either (a) by FAX to 501-683-6516 or (b) by mail to the following address:

E pl y e ne oe e i s ip o e s siEmployee Benefits Division A tn: l D rt n ea r menAttn: Appeals Department x 610. 61P x 15P.O. Box 15610 R k, 231l 23L t e oc R 72Little Rock, AR 72231

The deadline to appeal deadline to appeal deadline to appeal is 180 days after the Explanation of Benefits (EOB) form is mailed to you. Please note you m must must complete your health plan's internal appeal process by the deadline before you can file a lawsuit.

You may appoint an Authorized Representative to purse an appeal on your behalf, but your Plan requires that you and your chosen Authorized Representative must first sign the Plan's approved Authorized Representative form. The Plan's approved form can be obtained by contacting Health Advantage Customer Service to request a copy. In preparing your appeal request, you or your Authorized Representative have the right to examine documents relevant to the claim(s) you are appealing.

If your EOB refers to a Coverage Policy as the basis for a benefit decision, or to some other internal rule or guideline used by your health plan to determine availability of benefits, you have the right to request a copy of such Coverage Policy, rule or guideline, free of charge.

If your EOB refers to medical necessity or the experimental/investigational nature of a treatment as the basis for a benefits decision, you have the right to request and receive, free of charge, an explanation of the scientific or clinical basis for the decision.

Please note Customer Service calls and informal Health Advantage review procedures are not not not the same as an appeal, nor a substitute for an appeal. You are not required to use either of these other options. And even if you request and receive an informal Health Advantage review decision, you still must complete your health plan's internal appeal process by the plan's appeal deadline. If you fail to complete the appeal process by the deadline, your benefits claim may be barred.

If a claim is denied and you don't understand why, please call customer service at 1-800-482-8416. If, after speaking with customer serivce, the claim is still denied and you believe it should have been paid by the plan, you may ask in writing for a re-review. Please send your request to:

t C Net Charged Net Charged - For in-network services, the amount remaining after the member discount is deducted; may also be referred to as the "Allowance," the "Allowable Charge" or the "Maximum Allowable Charge" where in-network providers are concerned; however, non-participating providers may bill you for any part of the total charges not paid by your plan.

d e ed l h l d sa u i nAdditional helpful definitions l w , l o ab e ha ge M u w rl , A l w b har e M mum l l CAllowance, Alllowable Charge or Maximum Allowable ChargeAllowance, Alllowable Charge or Maximum Allowable Charge- The amount that your benefit plan defines as the total benefit available for a given treatment, drug, device or service under the plan, regardless of how much a provider may charge. For in-network providers, both your responsibility to provider and your plan's deductible, copay, and/or coinsurance percentage are calculated based on the Allowance, Allowable Charge or Maximum Allowable Charge. For out-of-network providers, your plan's deductible, copay and/or coinsurance percentage is still calculated based on the Allowance, Allowable Charge or Maximum Allowable Charge, but the out-of-network provider may bill you for any part of the total charges not paid by your plan.

duct b ect bDeductibleDeductible - The amount you typically must pay to providers for services before your benefit plan starts paying its share of covered expenses.

d m de u Provider adjustment Provider adjustment - The amount the doctor or hospital must write off and/or the amount that has been withheld from the doctor or hospital payment subject to the terms and conditions of the contractual agreement with the doctor or hospital. The doctor or hospital cannot bill you for this amount.

t hea pl co er ge al h co r eOther health plan coverageOther health plan coverage- The amount paid by any other primary health plan coverage (if applicable).

paCopayCopay- A fixed amount you pay for a covered service.

i Coinsurance- Coinsurance- Once you've paid your deductible, you may also pay a percentage of the Allowance, Allowable Charge or Maximum Allowable Charge; your percentage share is called "coinsurance."

u se s ud ser Excluded services Excluded services - Services that are not covered under your benefit plan.