Premier Access Insurance Co.

P.O. Box 659010

Sacramento, CA 95865-9010
Robert Lucero
668 E 12225 S No. 101
Draper, UT 84020
Explanation of Benefits
Provider: Robert Lucero Group: 14964 - Telecom Technology
Relationship: Spouse
Member ID: 1067830901
Subscriber: Muhammad Ullah Patient: Hina Shakeel
Batch No: EM01012114 NEA No:
Date Received: 01/21/2014
Provider ID: 175041
Program Name: Premier PPO Claim No: 5125801-00
RC Patient
Payment
Plan
Payment
Deductible
Charges
Copay Excluded
Charges
Covered
Expense
Submitted
$
Proc
Code
Units Date Of
Service
Surface Ln OC Tooth
#
$0.00 EP $0.00 $13.00 90% 220 01/20/2014 1 $6.00 $13.00 $19.00 1
$0.00 EP $0.00 $36.00 90% 140 01/20/2014 1 $11.00 $36.00 $47.00 2
TOTAL $49.00 $0.00 $17.00 $0.00 $66.00 $49.00
Primary Paid: $0.00 Benefits Paid: $0.00 Insured Responsibility: $49.00
Procedure Code Description
140 Limited Oral Evaluation - Problem Focused
220 Intraoral-periapical first radiographic image
Reason Code (RC)
Description
EP Exceeds allowed expense for a participating provider.
"Covered Expense" is the Amount allowable under the Dental Benefit Plan / Provider Contract.
To expedite processing, Claims and Pre-authorizations can be submitted electronically through Emdeon and Tesia under Payor ID # CX078.
Electronic attachments can be submitted through National Electronic Attachment (NEA) at www.nea-fast.com.
Claims submitted more than 6 months after services are rendered will be denied for untimely claims submission.
If you are a provider and would like to dispute the amount allowed on this claim, you can call 1-888-715-0760 or visit www.premierlife.com/ProvForms.htm for details on the
Provider Dispute Resolution Mechanism.
If the member or provider has any questions about this claim or would like a review of the decision, please contact Premier Access by either calling 1-888-715-0760 or by
writing to: Premier Access - Grievance Department, P.O Box 659010, Sacramento, CA 95865 - 9010. If the member or provider is not satisfied with Premiers decision and
believe the claim has been wrongly denied or rejected, you may have the matter reviewed by contacting the California Department of Insurance online at:
www.insurance.ca.gov, by calling the department at 1-800-927- HELP or writing to the Department at the following address: California Department of Insurance Consumer
Communications Bureau 300 South Spring Street, South Tower Los Angeles, CA 90013.
You can obtain a copy of your Claims Acknowledgment Notification by visiting our website at : www.premierlife.com.
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