PROVIDER VOUCHER OTHER INSURANCE

00435 9875667 000522 0000961 00001/00002 k00425 1351 WILLIAM HOWARD TAFTROAD FOR RELATED INQUIRES PLEASE CALL OR WRITE: ANTHEM BLUE CROSS AND BLUE SHIELD P.O. BOX 105557 ATLANTA, GA 30348 XXX-XXX-XXXX 00435 9875667 001 092013 XYZ CLINIC PROVIDER NUMBER TAX ID 123 E SOUTH STREET 123456789 XXXXX9999 ANY TOWN WI 53333-3333 REFERENCE NUMBER PAYMENT DATE 701099999 05/02/2016 Note: If payment is made via check these fields will not be present EFT DATE 05/04/2016 SERVICE DATES FROM/TO PROCEDURE CVD/NCVD CHARGES ALLOWED PROVIDER VOUCHER OTHER INSURANCE DOLLARS PROVIDER'S LIABILITY SUBSCRIBER' S LIABILITY APPROVED TO PAY PAID RSN * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ACCOUNT RECEIVABLES CREATED* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * SUB ID: AN99999999 PATIENT: LAST NAME FIRST NAME CLAIM#: ############## PATIENT ACCT/PRESCRIPTION#: 999999999 01/15/16 3 1 99203 -$262.00 -$106.19 $0.00 $0.00-21.24-84.95-84.95 01/15/16 234567890 3 4 73030 -$140.00 -$51.90 $0.00 $0.00-10.38-41.52-41.52 CLAIM ----------------- -$402.00 -$158.09 $0.00 $0.00-31.62-126.47-126.47 SUB ID: AN99999999 PATIENT: LAST NAME FIRST NAME CLAIM#: ############## PATIENT ACCT/PRESCRIPTION#: 999999999 01/15/16 3 1 99203 $262.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 01/15/16 234567890 3 4 73030 $140.00 $51.90 $0.00 $0.00 $0.00 $51.90 $51.90 A AR #9999999999 HAS BEEN CREATED FOR $74.57 CLAIM ----------------- $402.00 $51.90 $0.00 $0.00 $0.00 $51.90 $51.90 A - AN ACCOUNTS RECEIVABLE WAS ESTABLISHED DUE TO A PROVIDER BILLING ERROR (Z428) Accounts Receivable is created when the claim is adjusted and triggers the request Net difference between original payment of 126.47 and adjusted payment of 51.90 is 74.57 C O N T I N U E PAGE 1 OF 2 833402287 004 / 950

00435 9875667 000522 0000961 00001/00002 k00425 1351 WILLIAM HOWARD TAFTROAD FOR RELATED INQUIRES PLEASE CALL OR WRITE: ANTHEM BLUE CROSS AND BLUE SHIELD P.O. BOX 105557 ATLANTA, GA 30348 XXX-XXX-XXXX 00435 9875667 001 092013 XYZ CLINIC PROVIDER NUMBER TAX ID 123 E SOUTH STREET 123456789 XXXXX9999 ANY TOWN WI 53333-3333 REFERENCE NUMBER PAYMENT DATE 701099999 05/02/2016 EFT DATE 05/04/2016 SERVICE DATES FROM/TO PROCEDURE CVD/NCVD CHARGES ALLOWED PROVIDER VOUCHER OTHER INSURANCE DOLLARS PROVIDER'S LIABILITY SUBSCRIBER' S LIABILITY APPROVED TO PAY PAID RSN * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ADJUSTMENT CLAIMS* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * SUB ID: AN88888888 PATIENT: LAST NAME FIRST NAME CLAIM#: 20161234567890 PATIENT ACCT/PRESCRIPTION#: 8888888888 01/02/16 1 2 25605 -$1,769.00 -$502.79 $0.00 $0.00 -$1,769.00 $0.00 $0.00 537891012 1 3 99253 -$327.18 -$98.83 $0.00 $0.00 -$98.83 $0.00 $0.00 CLAIM ----------------- -$2,096.18 -$601.62 $0.00 $0.00 -$1,867.83 $0.00 $0.00 SUB ID: AN88888888 PATIENT: LAST NAME FIRST NAME CLAIM#: 20161234567890 PATIENT ACCT/PRESCRIPTION#: 8888888888 01/02/16 1 2 25605 $1,769.00 $502.79 $0.00 $0.00 $139.23 $363.56 $363.56 AB 537891012 1 3 99253 $235.00 $80.28 $0.00 $0.00 $0.00 $80.28 $80.28 B CLAIM ----------------- $2,004.00 $583.07 $0.00 $0.00 $139.23 $443.84 $443.84 CDE A - AN IN-NETWORK DEDUCTIBLE HAS BEEN APPLIED TO THIS SERVICE (Z238) B - ACCORDING TO YOUR PROVIDER AGREEMENT, YOU MAYONLY BILL THE PATIENT THE SHOWN IN THE SUBSCRIBER LIABILITY COLUMN. (Z338) C - WE PREVIOUSLY PAID $0.00 FOR THIS CLAIM. THE CORRECT PAYMENT SHOULD HAVE BEEN $443.84. AN ADDITIONAL PAYMENT HAS BEEN MADE FOR THE DIFFERENCE. (Z989) D - A DEDUCTIBLE OF $98.83 WAS REQUIRED (Z760) E - A COINSURANCE OF $40.40 WAS REQUIRED (Z762) SUBS: -$92.18 -$18.55 $0.00 $0.00 -$1,728.60 $443.84 $443.84 IMPORTANT NOTE: YOU ARE NOT PERMITTED TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION ABOUT INDIVIDUALS THAT YOU ARE CURRENTLY NOT TREATING. THIS APPLIES TO PROTECTED HEALTH INFORMATION ACCESSIBLE IN ANY ONLINE TOOL, OR SENT IN ANY OTHER MEDIUM INCLUDING MAIL, EMAIL, FAX, OR OTHER Note that the amount payable has not been impacted by the Accounts Receivable -$92.18 -$18.55 $0.00 $0.00 -$1,728.60 $443.84 $443.84 PAGE 2 OF 2 833402287 004 / 950

*An Independent Licensee of the Blue Cross and Blue Shield Association 62-22 CHECK NO. 101099999 311 WELLS FARGO BANK, NA TAX ID: XXXXX5701 1351 WILLIAM HOWARD TAFT ROAD DATE PAYEE NO. 5/2/2016 123456789 CHECK REF. 101099999 VOID 180 DAYS AFTER DATE PAY XYZ CLINIC TO THE 123 E SOUTH STREET $***443.84 ORDER ANY TOWN WI 53333-3333 THE SUM OFFOUR HUNDRED FORTY THREE DOLLARS AND 84/100 John Smith Authorized Signature Revision Date: January 2017 for illustration purposes only Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin (BCBSWi), Compcare Health Services Insurance Corporation (Compcare) and Wisconsin Collaborative Insurance Company (WCIC). BCBSWi underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association.

PO Box 105557 Atlanta, GA 30348-5557 1 of 2 00016 *0004250* XYZ Clinic 123 E South Street Any Town, WI 53333-3333 *000425020101* Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association.

PO Box 105557 Atlanta, GA 30348-5557 2 of 2 00016 March 1, 2016 RE: Dates of Service: Date of service Claim Number: Claim number A/R Number: Assigned Accounts Receivable (AR) number Contract Number: Subscriber identification number Subscriber: Subscriber name Patient: Patient name Provider: Provider Identification number (e.g. NPI) Provider Name: Provider name Reason for refund: Reason for refund (e.g. provider billing error) *000425020101* Our records indicate that an error in payment was made in the amount of $000.00 by check 000000000, dated (Date), on the above mentioned claim. We are requesting that a refund in the amount of $000.00 be made to: Central Region CCOA Lockbox PO Box 73651 CLEVELAND, OH 44193-1177 The claim information listed above sets forth the reason for the overpayment recovery request. You may obtain more information about the decision by calling the phone number listed on the back of the member s identification card. If you are a participating provider, please refer to the provider manual or your provider contract for information regarding appeal rights you have and how to appeal a decision. If we do not receive a written appeal from you within 30 days, we will initiate the recoupment process and recovery the identified overpayment amount from future remittances. Even after we recover the overpayment, you might have a longer period to appeal this decision as set forth in the provider manual or your provider contract. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association.

Thank you for your attention to this matter. Please return a copy of this letter with your refund. If you believe this overpayment is not correct, please advise Anthem Blue Cross and Blue Shield of your reason and send all overpayment correspondence to the address listed at the upper left hand corner of this notice. If payment or appeal is not received within the next 30 days, we will initiate the recoupment process or send this to collections if necessary. Please disregard this letter if refund has already been made. Provider is required to return, destroy or further protect the misrouted PHI received due to recent incorrect payment of services. Misrouted PHI includes information about members that a provider is not currently treating. You are required to immediately destroy misrouted PHI or safeguard the PHI for as long as it is retained. In no event are you permitted to misuse or re-disclose misrouted PHI. Other Carrier Name: Address: City, State, Zip: Phone: N84

00435 9875667 000522 0000961 00001/00002 k00425 1351 WILLIAM HOWARD TAFTROAD FOR RELATED INQUIRES PLEASE CALL OR WRITE: ANTHEM BLUE CROSS AND BLUE SHIELD P.O. BOX 105557 ATLANTA, GA 30348 XXX-XXX-XXXX 00435 9875667 001 092013 XYZ CLINIC PROVIDER NUMBER TAX ID 123 E SOUTH STREET 123456789 XXXXX9999 ANY TOWN WI 53333-3333 REFERENCE NUMBER PAYMENT DATE 701099999 05/02/2016 Note: If payment is made via check these fields will not be present EFT DATE 05/04/2016 SERVICE DATES FROM/TO PROCEDURE CVD/NCVD CHARGES ALLOWED PROVIDER VOUCHER OTHER PROVIDER'S INSURANCE LIABILITY DOLLARS SUBSCRIBER'S LIABILITY APPROVED TO PAY PAID RSN * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * PPO PAID CLAIMS* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * SUB ID: AN99999999 PATIENT: LAST NAME FIRST NAME CLAIM#: 20161234567890 PATIENT ACCT/PRESCRIPTION#: 999999999 3 2 66405 $639.00 $162.50 $0.00 $0.00 $0.00 $162.50 $162.50 A 234567890 3 1 99204 $309.00 $162.17 $0.00 $0.00 $162.17 $0.00 $0.00 AB 3 9 J1030 $21.00 $3.87 $0.00 $0.00 $21.00 $0.00 $0.00 C CLAIM ----------------- $969.00 $328.54 $0.00 $0.00 $183.17 $162.50 $162.50 A - ACCORDING TO YOUR PROVIDER AGREEMENT, YOU MAY ONLY BILL THE PATIENT THE SHOWN IN THE SUBSCRIBER LIABILITY COLUMN (Z338) B - THERE IS A SUBSCRIBER COPAYMENT FOR THIS SERVICE (Z199) C - YOUR PATIENT'S HEALTH CARE COVERAGE DOESN'T PAY FOR THIS SERVICE BECAUSE IT'S NOT A BENEFIT. THE SUBSCRIBER IS LIABLE FOR YOUR CHARGE -M713 SUB ID: AN99999999 PATIENT: LAST NAME FIRST NAME CLAIM#: 20161234561234 PATIENT ACCT/PRESCRIPTION#: 999999999 01/17/16 B 2 644483 $792.00 $102.74 $0.00 $0.00 $0.00 $102.74 $102.74 A 01/17/16 234567890 01/17/16 B 2 644483 $525.00 $64.71 $0.00 $0.00 $0.00 $64.71 $64.71 A 01/17/16 CLAIM ----------------- $1,317.00 $167.45 $0.00 $0.00 $0.00 $167.45 $167.45 A - ACCORDING TO YOUR PROVIDER AGREEMENT, YOU MAY ONLY BILL THE PATIENT THE SHOWN IN THE SUBSCRIBER SUBS: $2,286.00 $495.99 $0.00 $0.00 $183.17 $329.95 $329.95 C O N T I N U E PAGE 1 OF 2 833402287 004 / 950

*An Independent Licensee of the Blue Cross and Blue Shield Association 62-22 CHECK NO. 101099999 311 WELLS FARGO BANK, NA TAX ID: XXXXX5701 1351 WILLIAM HOWARD TAFT ROAD DATE PAYEE NO. 5/2/2016 123456789 CHECK REF. 101099999 VOID 180 DAYS AFTER DATE PAY XYZ CLINIC TO THE 123 E SOUTH STREET $***255.38 ORDER ANY TOWN WI 53333-3333 THE SUM OFTWO HUNDRED FIFTY FIVE DOLLARS AND 38/100 John Smith Authorized Signature Revision Date: January 2017 for illustration purposes only Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin (BCBSWi), Compcare Health Services Insurance Corporation (Compcare) and Wisconsin Collaborative Insurance Company (WCIC). BCBSWi underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association.

National Account Processing System - Accounts Receivable (AR) Provider Tips 1 The claim adjustment starts the process. 2 The adjusted claim results in an "Accounts Receivable (AR) Created" record on the provider (voucher) remittance advice. 3 These records do not affect the total amount paid on the remittance advice. 4 Providers should note the AR number listed on the patient account to match to the request letter that follows. 5 The day after the "Accounts Receivable" record appears on the provider (voucher) remittance advice, a request letter is sent. 6 Upon receipt of the letter, providers can request immediate recoupment by contacting the provider service at the telephone number appearing on the (voucher) remittance advice or 800-676-BLUE (2582). 7 If a full refund is received with 30 days, it will be applied to the AR created and the AR will not be applied/recouped. 8 Refunds that are less than the full amount requested will have the remaining balance due recouped. 9 If a refund is not received within 30 days, the Account Receivable (AR) is applied to the provider (voucher) remittance advice. 10 The AR is deducted from the total amount payable on the provider (voucher) remittance advice and not off-set by any particular payable claim. 11 Providers should reverse the amount paid in their patient account to have funds available to balance the remittance advice. 12 If the amount payable is not sufficient to satisfy the AR in full, the remaining negative balance is carried forward to the future remittance advice.