6/17/ MARY SMITH 123 ANYWHERE ST ANYCITY, MA 01234

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1 -82 Start-Set _ANYWHERE_ST _ _ _ _ _ _ _ 1600 Crown Colony Drive Quincy, MA Forwarding Services Requested 6/17/ MARY SMITH 123 ANYWHERE ST ANYCITY, MA You re receiving this Activity Summary to help you better understand the claims we ve processed and to track your progress in satisfying your financial responsibility (e.g., deductible and out-of-pocket dollar amounts) under your health plan. This Activity Summary is not a bill. You will be mailed an Activity Summary for any month that we processed claims for services you received. You will not receive a separate Explanation of Benefits for individual medical claims. How to use your Activity Summary 1. Review your Activity Summary. See the reverse side for definitions of key words used. 2. Wait to receive a bill from your provider. 3. Compare your provider s bill with the information in your Activity Summary for accuracy. Be sure that the type of service noted on the Summary is the same as the service stated on your provider s bill. 4. Remember to check the following: Your own records. You already may have paid a portion of your provider s bill (e.g., you may have paid your copayment amount at the time you received care). Explanation code. Refer to the explanation code for more details on how the claim was processed. For example, the code might indicate that we need additional information to process the claim. Your provider s bill will usually match the Amount You Owe column in this Activity Summary. For additional benefit information, including your financial responsibilities, please refer to your Schedule of Benefits or Summary of Benefits. Your information is available online You also can view your Activity Summary online through HPHConnect, your secure member account at You ll also find up-to-date information on claims we have received, your plan s Schedule of Benefits or Summary of Benefits and many other helpful resources. If you don t have an HPHConnect account yet, visit click on the Members page and look for the Create an account section. Questions? If you have any questions, please call Member Services at (888) Our representatives are available to assist you weekdays between 8:00 a.m. and 5:30 p.m., and until 7:30 p.m. on Monday and Wednesday evenings. For TTY service, call (800) Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care and its affiliates, Harvard Pilgrim Health Care of New England and HPHC Insurance Company.

2 Key Words in Your Activity Summary DEFINITIONS 1. Provider Charge The dollar amount the provider (e.g., physician, hospital or clinician) billed Harvard Pilgrim for this service. 2. Amount Denied The dollar amount Harvard Pilgrim did not pay. If an amount appears in this field, refer to the Explanation Code for the reason. 3. Explanation Code This code will explain whether the claim was paid or denied and the reason for the action taken. 4. Harvard Pilgrim Negotiated Rate The dollar amount Harvard Pilgrim pays the provider or pharmacy based on our contract with that participating provider or pharmacy. 5. Harvard Pilgrim Paid The dollar amount Harvard Pilgrim paid for each service. 6. Deductible Applied The dollar amount applied to the yearly deductible you must pay before your health plan begins paying for certain covered services. This means you may be required to pay all or part of a provider bill until you have paid your full deductible amount. 7. Coinsurance A percentage of the cost of covered services that you must pay, when applicable. 8. Your Copayment A fixed dollar amount you pay for certain covered services. You may have already paid your copayment at the time of the visit. This field may also include any penalties a member may incur if prior approval is not received when required. 9. Amount You Owe Total amount you are responsible for paying. This may include a deductible, copayment, coinsurance and/or denied amounts. Your right to appeal You have the right to request a review of a claim that results in liability to you (i.e., you owe money to a health care provider). You must notify us within 180 days of the date on the front of this notice. For Maine residents with coverage through a Maine-based employer or individual plan, you must generally notify us within 365 days of the date on the front of this notice. Send your request for review to: Harvard Pilgrim Health Care Member Appeals Analyst, Member Services Dept Crown Colony Drive, Quincy, MA PHONE: (888) FAX: (617) We will complete the review no later than 30 business days after we receive your request (20 business days for a firstlevel medical appeal for members with coverage through a Maine-based employer or individual plan). If, after all reviews have been completed, we have not granted your appeal, you have the right to file a civil action under Section 502(a) of the Employee Retirement Income Security Act ( ERISA ), unless your plan is a governmental, church or non-group plan exempt from ERISA. Members with coverage through a Maine-based plan may also file a complaint with the Maine Bureau of Insurance after all internal appeals have been exhausted by calling (207) within Maine or (800) outside of Maine. Refer to your Benefit Handbook for additional information about your appeal rights and our appeals procedure. We may need more information to process your claim Check the Explanation Code field. If the code says we need more information about the claim, you or your provider must send the information within 45 days from the date of this notice. If you or your provider fails to submit the information by this deadline, the claim, or a portion of it, may remain denied without further review. If the code says that the claim was denied because we haven t received your other insurance questionnaire, please complete, sign and return the form Harvard Pilgrim sent to you via US Mail. Once we receive it, we will be able to continue processing the claim. If you have not received this form or have any questions, call (888) , ext You can also get a copy online at in the Members section. Help us prevent fraud Always review your Activity Summary to verify that the information provided is correct. Call us at (888) if there is an error you believe is a result of a fraudulent act. Amounts above Usual, Customary and Reasonable (UCR) Charge For claims submitted by non-participating providers, the most Harvard Pilgrim will pay is the UCR charge. This is an amount Harvard Pilgrim has determined to be within the normal range charged by providers for the same or similar services and products. It does not include applicable copayments, coinsurance and/or deductibles. To learn how the UCR charge is determined, please refer to your Benefit Handbook. * *

3 Want a copy of a previous Activity Summary, your latest claims information or your detailed plan coverage? Log in to HPHConnect, your secure member account, at FAMILY DEDUCTIBLE SUMMARY YEAR-TO-DATE IN-NETWORK OUT-OF-NETWORK Annual Applied Remaining Annual Applied Remaining Joseph B. $1, $ $79.52 $1, $ $ Mark L. $1, $34.56 $ $1, $ $ Amy R. $1, $ $ $1, $ $79.52 Edward G. $1, $0.00 $ $1, $34.56 $ Family $2, $1, $ $2, $1, $ Your Deductible Summary reflects all medical, behavioral health and pharmacy claims that have been processed as of 2/28/2010. FAMILY OUT-OF-POCKET MAXIMUM SUMMARY YEAR-TO-DATE IN-NETWORK OUT-OF-NETWORK Annual Applied Remaining Annual Applied Remaining Joseph B. $2, $ $1, $2, $ $1, Mark L. $2, $34.56 $1, $2, $ $1, Amy R. $2, $ $1, $2, $ $1, Edward G. $2, $0.00 $2, $2, $34.56 $1, Family $4, $1, $2, $4, $1, $2, Your Out-of-Pocket Maximum Summary reflects all medical, behavioral health and pharmacy claims that have been processed as of 2/28/2010. DEDUCTIBLE: A dollar amount you must pay yearly before certain services are covered under your health plan. This means you may be required to pay all or part of a provider bill until you have paid your full deductible amount. OUT-OF-POCKET MAXIMUM: A limit on the dollar amount you are required to pay yearly. Once you reach this amount, you no longer have to pay for covered health care services for the remainder of the plan year. PAGE 3

4 Joseph B. Smith ACTIVITY DETAILS 2/1/2010-2/28/2010 MEDICAL CLAIMS Date(s) of Service Provider Amount Explanation Harvard Harvard Deductible Coinsurance Your Amount Claim Number Charge Denied Code Pilgrim Pilgrim Applied Copayment You Owe Provider Negotiated Paid Description Rate 2/11/ OFFICE VISIT FOR E&M, EST. PATIENT 15 MIN $ $0.00 $72.46 $52.46 $0.00 $0.00 $20.00 $20.00 UNRINALYSIS WITHOUT MICROSCOPY, AUTO $14.00 $0.00 $3.84 $3.84 $0.00 $0.00 $0.00 $0.00 * * Total for this claim $ $0.00 $76.30 $56.30 $0.00 $0.00 $20.00 $ /17/ Dr. Happy OFFICE CONSULTATION FOR NEW OR EST. $ $0.00 $ $ $0.00 $0.00 $20.00 $20.00 PATIENT 40 MINUTES URINALYSIS; REAGNT STRIPS, ANY#COMPTS; $16.00 $0.00 $14.00 $0.00 $14.00 $0.00 $0.00 $14.00 W-O MICROCOPY Total for this claim $ $0.00 $ $ $14.00 $0.00 $20.00 $ /28/ Dr. Hand CHIROPRACTIC MANIPULATION TREATMENT $70.00 $0.00 $64.00 $44.00 $0.00 $0.00 $20.00 $20.00 (CMT) SPINAL, ONE TO TWO REGIONS Total for this claim $70.00 $0.00 $64.00 $44.00 $0.00 $0.00 $20.00 $20.00 Total for all Medical Claims $ $0.00 $ $ $14.00 $0.00 $60.00 $74.00 This section lists new and adjusted medical claims processed during this summary period. If you ve received behavioral health services, you will receive an Explanation of Benefits from United Behavioral Health (UBH). Call UBH at (888) if you have questions about your behavioral health claims. Explanation Codes PR46-46-DENIED-CLAIM/AUTTH FILED BEYOND FILING LIMIT-NO PNT LIABILITY PRAD - AD-AUTH NO MATCH: THE DATES OF SERVICE DO NOT MATCH PRRE - RE-MEMBER S AGE IS NOT VALID FOR PRIMARY DIAGNOSIS PAGE 4

5 Joseph B. Smith ACTIVITY DETAILS 2/1/2010-2/28/2010 PHARMACY CLAIMS Date Filled Harvard Pilgrim Deductible Coinsurance Your Amount Rx Number Negotiated Applied Copayment You Owe Drug Name Rate Prescribing Clinician Pharmacy 2/11/2010 $ $0.00 $0.00 $ $ M ZYFLO CR TAB 600MG 2/11/2010 $41.03 $0.00 $0.00 $25.00 $25.00 M ASACOL TAB 400MG EC 2/17/2010 $11.56 $0.00 $0.00 $10.00 $10.00 M ERYTHROMYCIN OIN OP Dr. Happy Total for all Pharmacy Claims $ $0.00 $0.00 $ $ This section lists all your submitted and adjusted pharmacy claims covered by Harvard Pilgrim during this summary period. PAGE 5