0030645

I-20 @ Alpine Road Columbia, SC 29219

This is not a bill.

Any amounts you

may owe your provider should not be sent directly to us.

JOHN C LEWIS 19 RAVENSWORTH ROAD TAYLORS SC 29687

008438 0001 of 0005

LABCORP LABCORP

SUMMARY EXPLANATION OF BENEFITS

Claims Processed from 03/06/13 to 03/26/13
March 27, 2013

This summary information is for claims processed for patients covered under your Member ID will also find claim(s) details.

RVB030494482182

You

We produce this report every three weeks. If you have questions about your claims, please

visit our website at www.SouthCarolinaBlues.com or call Customer Service at 800-922-1185 or 800-845-6067 or locally at 864-297-4665 Monday - Thursday 8:00 a.m. - 6:00 p.m. or Friday 8:00 a.m. - 4:30 p.m.

This document outlines your share of the charges for services. You should use this to determine how much you need to pay. If there is a discrepancy, use this summary to discuss the charges with your provider.

Name: JOHN C LEWIS

Patient Relationship to Policyholder:

SELF

Amount We Paid Your Provider(s): ALERE HEALTHCARE BON SECOURS ST FRANCI THE HAND CENTER GHS PIH DBA UMG CANCE UPSTATE PATHOLOGY PA PALMETTO ANESTHESIA A 1,522.42 4,290.80 104.40 392.81 221.40 422.52 13.05 1,092.43

GREENVILLE HOSPITAL S

Amount Your Provider(s) May Bill You: ALERE HEALTHCARE BON SECOURS ST FRANCI THE HAND CENTER GHS PIH DBA UMG CANCE UPSTATE PATHOLOGY PA PALMETTO ANESTHESIA A 0.00 476.76 11.60 43.64 24.60 46.95 1.45 121.38

GREENVILLE HOSPITAL S

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Suspect claims fraud?

Please help us by calling our hotline at 800-763-0703.

Helpful Definitions
Allowed Amount - the amount remaining after any non-covered, deductible or copayment amounts have been subtracted from the amount your provider charged. Your coinsurance, if applicable, will be determined from the allowed amount. Amount Not Covered - the amount, if any, for non-covered services or the amount that is above the allowed charge. Please refer to the remarks on the Summary Explanation of Benefits Claim Details section. Amount Paid to You - the amount we paid you, based on your health plan. Amount Paid to Your Provider - the amount we paid your provider, based on your health plan. Amount We Paid - the amount paid by your health plan for the services you received. Amount Your Provider May Bill You - the amount, if any, you need to pay the provider for this claim. There may be times when you owe nothing. Benefit Period - the period of time during which you must pay any deductible and coinsurance payments that may apply. Payment of claims begins once you meet the deductible. If you reach your out-of-pocket amount and deductible limits, we pay covered expenses in full for the rest of the benefit period, minus any copayments. Deductibles and coinsurance start over with each new benefit period. Coinsurance - the percentage of the allowed amount you pay as your share of the bill. If your health plan pays 80 percent, then 20 percent would be your coinsurance. Copayment - a set fee you pay each time you receive a certain service. Some health plans or services do not have copayments. CDHP (Consumer Driven Health Plan) Paid - the amount paid from your Health Reimbursement Account, if applicable. Deductible - the amount, if any, you are responsible for paying before any amount is payable under your health plan. You do not send this amount to us. You must pay this to your provider. We credit you as having paid your deductible on the claims you and providers send to us. Other Insurance Paid - the amount paid by another insurance company toward services you received. Out-of-Pocket Maximum - the highest total amount of coinsurance you will have to pay during a benefit period.

When Medicare Applies

Medicare Approved AMT (Amount) - the amount Medicare approves for services you received. Medicare Paid - the amount Medicare paid toward services received. Total Benefit Allowed - the amount we would have paid if another insurance company were not involved.

DID YOU KNOW YOU CAN VIEW YOUR EOBS ONLINE? YOU CAN ALSO CHOOSE NOT TO RECEIVE SUMMARY EOBS IN THE MAIL. LOGIN TO MY HEALTH TOOLKIT AT MEMBER.SOUTHCAROLINABLUES.COM TO CHANGE YOUR MAIL OPTIONS, VIEW EOBS AND MUCH MORE.

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0030646
Important Information about Your Appeal Rights

What if I need help understanding this denial? Call us at the Customer Service numbers shown on the first page of your explanation of benefits notice if you need help understanding this notice or our decision to deny a service or coverage.

Who may file an appeal?

You or someone

you name to act for you (your authorized representative) may file an appeal. If you

designate someone to act on your behalf, you must complete a HIPAA Authorization form which you can get by visiting our website or by calling us at the Customer Service

What if I don't agree with this decision? You have a right to appeal any decision not to

numbers shown on the explanation of benefits notice.

008438 0002 of 0005

provide you or pay for an item or service (in whole or in part). Can I provide additional information about my claim? How do I file an appeal? Submit a written request for appeal within 180 days from the date of this notice. Be sure to include the Can I request copies of information relevant to my claim? Yes, you may request Yes.

following information and anything else you think we should know:

copies (free of charge) by contacting us at the Customer Service numbers shown on the explanation of benefits notice, or at the

Name and ID number; patient name; claim number; name of person filing appeal, and whether the person filing the appeal is the covered person, patient, or authorized representative.

appeals address listed on this form.

What happens next?

If you appeal, we will

review our decision and give you our answer in writing. If we still deny the payment,

coverage or service requested or you do not Mail your written request for appeal with the above information to: receive a timely decision, you may be able to ask for an external review of your claim. this case, an independent third party will Piedmont Service Center P.O. Box 6000 Greenville, SC 29606 Other resources to help you: For questions review the denial and make a final decision. In

about your appeal rights or this notice, or for more help, you can call the Employee What if my situation is urgent? If your Benefits Security Administration at 1-866-444-EBSA(3272). You may also

situation meets the definition of urgent under the law, we will conduct your review on an expedited, or faster, basis. Generally, an

receive help through an applicable state consumer assistance program. Contact

urgent situation is one in which your health may be in serious jeopardy or, in the opinion of your physician, you may experience pain that cannot be adequately controlled while you wait for a decision on your appeal. If you

information by state is available at: www.stateconsumerassistance.com.

believe your situation is urgent, you may request an expedited appeal when you contact us.

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SUMMARY EXPLANATION OF BENEFITS CLAIM(S) DETAIL

This is important information about services JOHN C LEWIS your provider for services received. JOHN C LEWIS

received.

The following information shows how much we covered and how much you may owe

Patient:

ID:

RVB030494482182

Patient Relationship to Policyholder:

Claim Number:

3C4953946-00-00

Provider: ALERE HEALTHCARE

Date(s) of Service:

PARTICIPATING PROVIDER
Your Provider Charged Amount Not Covered * Deductible Copayment Allowed Amount Coinsurance

01/01/13 - 01/31/13
Amount We Paid

179.72 1,342.70 TOTAL: 1,522.42

0.00 0.00

0.00 0.00

0.00 0.00

179.72 1,342.70

0.00 0.00

0.00

0.00

0.00

1,522.42

0.00

Your family has satisfied

4,000.00

of the

4,000.00

family deductible for the benefit period that began for this person this benefit period.

01/01/2013

the family out-of-pocket maximum. We paid a total of

15,432.01

Claim Number:

3C6411830-00-00

Provider: BON SECOURS ST FRANCI

Date(s) of Service:

PARTICIPATING PROVIDER
Your Provider Charged Amount Not Covered * Deductible Copayment Allowed Amount Coinsurance

02/19/13 - 02/25/13
Amount We Paid

65.50 292.62 186.00 269.00 321.50 131.00 1,020.00 2,664.50 2,664.50 2,664.50 2,443.00 102.00 102.00 102.00 3,444.50

46.38 (1) 207.95 (1) 132.18 (1) 191.15 (1) 228.44 (1) 93.10 (1) 724.80 (1) 1,893.35 (1) 1,893.35 (1) 1,893.35 (1) 1,735.93 (1) 72.49 (1) 72.49 (1) 72.49 (1) 2,447.61 (1)

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

19.12 84.67 53.82 77.85 93.06 37.90 295.20 771.15 771.15 771.15 707.07 29.51 29.51 29.51 996.89

1.91 8.47 5.38 7.79 9.30 3.79 29.52 77.12 77.11 77.12 70.70 2.95 2.96 2.95 99.69

Page 5 of 10

008438 0003 of 0005

SELF
Amount Provider May Bill You

0.00
Amount Paid to Your Provider

179.72 1,342.70

179.72 1,342.70

1,522.42

1,522.42

This claim contributed

0.00

toward

0030647
Amount Provider May Bill You

476.76
Amount Paid to Your Provider

17.21 76.20 48.44 70.06 83.76 34.11 265.68 694.03 694.04 694.03 636.37 26.56 26.55 26.56 897.20

17.21 76.20 48.44 70.06 83.76 34.11 265.68 694.03 694.04 694.03 636.37 26.56 26.55 26.56 897.20

TOTAL: 16,472.62 11,705.06 0.00 0.00 4,767.56 476.76 4,290.80 4,290.80

Your family has satisfied

4,000.00

of the

4,000.00

family deductible for the benefit period that began for this person this benefit period.

01/01/2013

This claim contributed

476.76

toward

the family out-of-pocket maximum. We paid a total of

13,132.07

Claim Number:

3C6443141-00-00

Provider: THE HAND CENTER

Date(s) of Service:

Amount Provider May Bill You

PARTICIPATING PROVIDER
Your Provider Charged Amount Not Covered * Deductible Copayment Allowed Amount Coinsurance

03/04/13
Amount We Paid

5.80
Amount Paid to Your Provider

110.00

52.00 (2)

0.00

0.00

58.00

5.80

52.20

52.20

Your family has satisfied

4,000.00

of the

4,000.00

family deductible for the benefit period that began for this person this benefit period.

01/01/2013

This claim contributed

5.80

toward

the family out-of-pocket maximum. We paid a total of

8,590.84

Claim Number:

3C6485335-00-00

Provider: GHS PIH DBA UMG CANCE

Date(s) of Service:

Amount Provider May Bill You

PARTICIPATING PROVIDER
Your Provider Charged Amount Not Covered * Deductible Copayment Allowed Amount Coinsurance

03/01/13
Amount We Paid

27.82
Amount Paid to Your Provider

502.00

223.75 (2)

0.00

0.00

278.25

27.82

250.43

250.43

Your family has satisfied

4,000.00

of the

4,000.00

family deductible for the benefit period that began for this person this benefit period.

01/01/2013

This claim contributed

27.82

toward

the family out-of-pocket maximum. We paid a total of

8,841.27

Claim Number:

3C6754581-00-00

Provider: UPSTATE PATHOLOGY PA

Date(s) of Service:

Amount Provider May Bill You

PARTICIPATING PROVIDER
Your Provider Charged Amount Not Covered * Deductible Copayment Allowed Amount Coinsurance

02/25/13
Amount We Paid

24.60
Amount Paid to Your Provider

440.00

194.00 (2)

0.00

0.00

246.00

24.60

221.40

221.40

Your family has satisfied

4,000.00

of the

4,000.00

family deductible for the benefit period that began for this person this benefit period.

01/01/2013

This claim contributed

24.60

toward

the family out-of-pocket maximum. We paid a total of

13,353.47

Page 6 of 10

Claim Number:

3C6770857-00-00

Provider: PALMETTO ANESTHESIA A

Date(s) of Service:

PARTICIPATING PROVIDER
Your Provider Charged Amount Not Covered * Deductible Copayment Allowed Amount Coinsurance

02/25/13
Amount We Paid

825.00

355.53 (2)

0.00

0.00

469.47

46.95

Your family has satisfied

4,000.00

of the

4,000.00

family deductible for the benefit period that began for this person this benefit period.

01/01/2013

the family out-of-pocket maximum. We paid a total of

13,775.99

Claim Number:

3C7075860-00-00

Provider: VASCULAR INSTITUTE PT

Date(s) of Service:

PARTICIPATING PROVIDER
Your Provider Charged Amount Not Covered * Deductible Copayment Allowed Amount Coinsurance

03/08/13
Amount We Paid

133.00

42.56 (2)

0.00

0.00

90.44

9.04

Your family has satisfied

4,000.00

of the

4,000.00

family deductible for the benefit period that began for this person this benefit period.

01/01/2013

the family out-of-pocket maximum. We paid a total of

13,857.39

Claim Number:

3C7142573-00-00

Provider: THE HAND CENTER

Date(s) of Service:

PARTICIPATING PROVIDER
Your Provider Charged Amount Not Covered * Deductible Copayment Allowed Amount Coinsurance

03/11/13
Amount We Paid

110.00

52.00 (2)

0.00

0.00

58.00

5.80

Your family has satisfied

4,000.00

of the

4,000.00

family deductible for the benefit period that began for this person this benefit period.

01/01/2013

the family out-of-pocket maximum. We paid a total of

13,909.59

Claim Number:

3C7161456-00-00

Provider: LABCORP

Date(s) of Service:

PARTICIPATING PROVIDER
Your Provider Charged Amount Not Covered * Deductible Copayment Allowed Amount Coinsurance

03/08/13
Amount We Paid

78.00 68.00 TOTAL: 146.00

71.50 (3) 60.00 (2)

0.00 0.00

0.00 0.00

6.50 8.00

0.65 0.80

131.50

0.00

0.00

14.50

1.45

Page 7 of 10

008438 0004 of 0005

Amount Provider May Bill You

46.95
Amount Paid to Your Provider

422.52

422.52

This claim contributed

46.95

toward

Amount Provider May Bill You

9.04
Amount Paid to Your Provider

81.40

81.40

This claim contributed

9.04

toward

0030648
Amount Provider May Bill You

5.80
Amount Paid to Your Provider

52.20

52.20

This claim contributed

5.80

toward

Amount Provider May Bill You

1.45
Amount Paid to Your Provider

5.85 7.20

5.85 7.20

13.05

13.05

Your family has satisfied

4,000.00

of the

4,000.00

family deductible for the benefit period that began for this person this benefit period.

01/01/2013

This claim contributed

1.45

toward

the family out-of-pocket maximum. We paid a total of

15,445.06

Claim Number:

3C7305057-00-00

Provider: GREENVILLE HOSPITAL S

Date(s) of Service:

Amount Provider May Bill You

PARTICIPATING PROVIDER
Your Provider Charged Amount Not Covered * Deductible Copayment Allowed Amount Coinsurance

03/01/13
Amount We Paid

121.38
Amount Paid to Your Provider

28.00 20.70 245.00 128.20 88.10 123.80 110.50 60.70 48.30 17.50 114.60 85.00 278.20 94.70 46.20 235.00 TOTAL: 1,724.50

7.72 (1) 5.75 (1) 68.05 (1) 35.61 (1) 24.47 (1) 34.38 (1) 30.69 (1) 16.86 (1) 13.41 (1) 4.86 (1) 31.83 (1) 23.61 (1) 77.27 (1) 26.30 (1) 12.83 (1) 97.05 (1)

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

20.28 14.95 176.95 92.59 63.63 89.42 79.81 43.84 34.89 12.64 82.77 61.39 200.93 68.40 33.37 137.95

2.03 1.49 17.70 9.26 6.36 8.94 7.98 4.39 3.49 1.26 8.28 6.14 20.09 6.84 3.34 13.79

18.25 13.46 159.25 83.33 57.27 80.48 71.83 39.45 31.40 11.38 74.49 55.25 180.84 61.56 30.03 124.16

18.25 13.46 159.25 83.33 57.27 80.48 71.83 39.45 31.40 11.38 74.49 55.25 180.84 61.56 30.03 124.16

510.69

0.00

0.00

1,213.81

121.38

1,092.43

1,092.43

Your family has satisfied

4,000.00

of the

4,000.00

family deductible for the benefit period that began for this person this benefit period.

01/01/2013

This claim contributed

121.38

toward

the family out-of-pocket maximum. We paid a total of

16,537.49

Claim Number:

3C7775415-00-00

Provider: GHS PIH DBA UMG CANCE

Date(s) of Service:

Amount Provider May Bill You

PARTICIPATING PROVIDER
Your Provider Charged Amount Not Covered * Deductible Copayment Allowed Amount Coinsurance

03/15/13
Amount We Paid

6.78
Amount Paid to Your Provider

95.00

27.24 (2)

0.00

0.00

67.76

6.78

60.98

60.98

Page 8 of 10

Your family has satisfied

4,000.00

of the

4,000.00

family deductible for the benefit period that began for this person this benefit period.

01/01/2013

the family out-of-pocket maximum. We paid a total of

16,611.07

*REMARKS: THIS HEALTH PLAN REQUIRES PRE-CERTIFICATION FOR ALL SCHEDULED OUTPATIENT PET AND CT SCANS, MRI(S) AND MRA(S). PLEASE COORDINATE HEALTH CARE PROVIDER TO ENSURE THE REQUIRED AUTHORIZATION IS RECEIVED BEFORE THESE SERVICES ARE RENDERED. WITH YOUR

(1)

THIS AMOUNT IS THE DIFFERENCE BETWEEN WHAT THE PROVIDER CHARGED FOR THIS SERVICE AND OUR ALLOWANCE.

(2)

THIS AMOUNT EXCEEDS THE MAXIMUM ALLOWABLE AMOUNT FOR THIS SERVICE.

(3)

MAXIMUM BENEFITS HAVE BEEN ALLOWED.

IF YOU NEED INFORMATION REGARDING THE SPECIFIC TREATMENT AND/OR DIAGNOSIS CODES FILED ON THE CLAIM(S) IN THIS NOTICE, PLEASE CALL THE CUSTOMER SERVICE NUMBER SHOWN ON THE FIRST PAGE OF THIS NOTICE.

Para obtener asistencia en espaol, llame al nmero de atencin al cliente que aparece en la primera pgina de esta notificacin. Upang makakuha ng tulong sa Tagalog, tawagan ang numero ng customer service na makikita sa unang pahina ng paunawang ito.

T11 Din4j7 shi[ hanego sh7k1 idoolwo[ n7n7zingo 47 Nidaalnish7g77 !k1 An7daalwo7g77, customer service, bich8 hod7ilnih. Bikehgo bich8 hane7g77 47 d77 naaltsoos neiy7nil7g77 ak1agi si[tsooz7g77 bik11 77shj33h.

Page 9 of 10

008438 0005 of 0005

. This claim contributed 6.78 toward

0030649

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