1010101010101010101010 1111000011001100000011 1011100010011001011010 1000000101000001111101 1010100000111001010000 1100110010000001110001 1000011010101101100000 1111000100010101011101 1000001001001000110000 1101000001111010011011 1010100101111110000110 1111001011101001110101 1111001101011100111010 1100110000100001000011 1000000011111011101100 1011000101001101110101 1100001000001010000010 1100101100001101100001 1000010110110110001110 1010100101101011110011 1100010011100000001000 1111111111111111111111 Statement Date: Subscriber Name: Subscriber ID: Member Name: Member ID Number: 100 Church Street New York,NY 10007 267-1.19-01726N21.nop 06/26/2023 PEDRO ALDAS ALVAREZ 420000125446700 PEDRO ALDAS ALVAREZ 420000125446700 1-4 EP PEDRO ALDAS ALVAREZ 1791 GLEASON AVE APT 1R BRONX NY 10472-4745-4745 Explanation of Benefits (EOB) This Is Not a Bill Below is an explanation of your benefits with your Healthfirst Health Plan. It shows how much was billed and the amount you owe. If you do owe anything, you will receive a bill from your doctor or healthcare provider(s). Look at this statement carefully and make sure it is correct. Please do not send any money to Healthfirst. If you have any questions about your claim(s), please log on to www.MyHFNY.org or call Member Services at 1-888-250-2220 (TTY 1-888-542-3821), Monday to Friday, 8am-8pm. Please Keep a Copy of This Document for Your Records Claim Summary Claim Number Amount Charged 0206152332101 0306122399022 Total $381.00 $509.33 $890.33 Allowed Amount $148.61 $21.76 $170.37 Plan Year to Date --- Individual Amount Covered by Plan Amount Applied to Deductible $0.00 $0.00 $0.00 Copayment/ Coinsurance $0.00 $0.00 $0.00 Total Amount You Owe $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Limits --- Individual YTD Applied to Deductible:* Amount Covered by Plan $3004.12 $0 $0 YTD Applied to Out of Pocket:* Member's Responsibility $0.00 Plan Year to Date --- Family Amount Covered by Plan $0 $0 Limits --- Family $3004.12 YTD Applied to Deductible:* $0 $0 YTD Applied to Out of Pocket:* Member's Responsibility $0.00 $0 $0 *INCLUDES Ancilliary and Pharmacy Benefits NOTE: If you are terminated for nonpayment of your plan premium, you could be responsible for the full amount of charges included in this EOB. THIS IS NOT A BILL --- Keep This Notice Your Records EP19_14 Page 1 of 8 Claim Number: 0206152332101 Claim Type: MEDICAL Date of Service Service Code Service Description 06/05/2023 99204-95 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVAL Claim Total: Provider Name: SARAH KIM, NP Amount Charged Allowed Amount Amount Covered by Plan Service Code Service Description 06/05/2023 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Claim Total: Copay/ Coinsurance Total Amount You Owe Notes $381.00 $148.61 $0.00 $0.00 $0.00 $0.00 $381.00 $148.61 $0.00 $0.00 $0.00 $0.00 Claim Number: 0306122399022 Claim Type: MEDICAL Date of Service Amount Applied to Deductible 03 Provider Name: BELLEVUE HOSPITAL Amount Charged Allowed Amount Amount Covered by Plan Amount Applied to Deductible Copay/ Coinsurance Total Amount You Owe Notes $509.33 $21.76 $0.00 $0.00 $0.00 $0.00 $509.33 $21.76 $0.00 $0.00 $0.00 $0.00 03 PJ Notes: 03 - MEMBER NOT ENROLLED ON DOS PJ - PRICED USING EAPG EP19_14 THIS IS NOT A BILL --- Keep This Notice Your Records Page 2 of 8 1010101010101010101010 1111000011010000001101 1011100010011001000010 1000000101000000101111 1010100000111001000100 1100110010000001010011 1000011010101101111110 1111000100010101011101 1000001001001000000000 1101000001111000101011 1010100101110000100110 1111001011101100001101 1111001101110000111010 1100110000001110100101 1000000000010000000110 1011000100011101000101 1100001111110100110010 1100101110010011110001 1000001011101100101110 1010101100111011110011 1100010011100100001000 1111111111111111111111 'H¿QLWLRQRI([SODQDWLRQRI%HQH¿WV7HUPV • $OORZHG$PRXQW±The agreed-upon amount your healthcare provider accepts as his/her in-network fee. $PRXQW$SSOLHGWR'HGXFWLEOH±The amount you pay for healthcare services before your plan will pay benefits. $PRXQW&KDUJHG±The amount your healthcare provider billed for services. $PRXQW&RYHUHGE\3ODQ±The amount that Healthfirst will pay for the service(s). 7RWDO$PRXQW<RX2ZH±This is the amount you owe for any in-network or pre-authorized out-of-network care. Your provider may bill you directly, as applicable, and you may be held financially responsible for the cost of non-emergent services that were not pre-authorized and/or delivered by a non-participating provider. These amounts will not be reflected on your EOB. &RLQVXUDQFH± A percentage of the allowed amount that you are responsible for. &RSD\PHQW±A fixed dollar amount you pay when you visit a healthcare provider. 0HPEHU5HVSRQVLELOLW\±This is the amount that you are responsible for. This can include Deductible, Copayments, and Coinsurance. 1RWHV±When present, these notes provide general information about the claim and may also provide a specific explanation of activity that occurred. For example, if the claim was denied because your provider submitted the same claim twice, a note would tell you that we rejected the claim as a duplicate. <7'$SSOLHGWR'HGXFWLEOH±Your plan year-to-date deductible that has been met so far. <7'$SSOLHGWR2XWRI3RFNHW±Your plan year-to-date out-of-pocket amount that you pay directly to a healthcare provider for services. This can include Deductible, Copayments, and Coinsurance. *UDFH3HULRG±Members have a premium payment grace period during which their enrollment will remain active. A member who does not pay their premium within their grace period will be disenrolled and claims for services delivered during the grace period may be denied. A member who does not pay their premium within their grace period will be disenrolled and claims for services delivered during the grace period may be denied. EP19_14 THIS IS NOT A BILL --- Keep This Notice Your Records Page 3 of 8 267-1.19-01726N21.nop 2-4 EP Important Information About Your Rights For more information about your rights, call us What If I Do Not Agree With This Decision? An appeal can be filed for denials related to medical necessity/utilization review, and a grievance can be filed for denials based on member ineligibility and other administrative issues not related to medical necessity/utilization review. Appeals and grievances must be filed within 180 calendar days after the date on which you receive this notice. Failure to act within 180 calendar days may result in forfeiture of your right to appeal. We may, however, give you more time to appeal if you have a good reason for missing the deadline. Who May File a Grievance or an Appeal? You or someone you name to act for you (your authorized representative) may file a grievance or an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others also already may be authorized under State law to act for you. You can call us at 1-888-250-2220 to learn how to name your authorized representative. lf you have a hearing or speech impairment, please call us at TTY 1-888-542-3821. You may send in supporting medical records, doctors' letters, or other information that explains why we should pay for the service. Call your doctor if you need this information to help you with your appeal. We must give you a decision no later than 60 calendar days after we receive your appeal. How Do I File a Grievance or an Appeal? You or your authorized representative (see left for more information on authorized representatives) may file a grievance or appeal in person, in writing, or by phone. If mailing a grievance or appeal, please send it to the following address: Healthfirst Action Appeals Unit P.O. Box 5166 New York, NY 10274-5166 If filing a grievance or appeal by phone, please call Member Services at: 1-888-250-2220 (TTY 1-888-542-3821) Other Resources To Help You: New York State Department of Financial Services. Toll free: 1-800-342-3736 If you want someone to act for you, you and your authorized representative must sign, date, and send us an authorization naming that person to act for you. If you need help filing an appeal, you may contact the state independent Consumer Assistance Program at: What Do I Include With My Appeal? Community Health Advocates 633 Third Avenue, 10th Floor New York, NY 10017 You should include your name, address, member ID number, reasons for appealing, and any evidence you wish to attach. Or call toll free: 1-888-614-5400, or email [email protected] Website: www.communityhealthadvocates.org Please review the services listed above. Check to see if any services are for an emergency or if a doctor in Healthfirst's network referred you for out-of-network services without your agreement or knowledge. If so, this might be part of a "surprise bill". As such, you may have to pay nothing more than your cost sharing under your plan. Please go to www.healthfirst.org/idr for more information. If you think the services in question are part of a surprise bill you received, please fill out an "Assignment of Benefits" form and follow the instructions on our site for submission. For more information on Healthfirst non-discrimination and language access policy, please go to HfNonDiscrimination.org. EP19_14 THIS IS NOT A BILL --- Keep This Notice Your Records Page 4 of 8 1010101010101010101010 1111000011010100000001 1011100010011001000100 1000000101000000100101 1010100000111000101100 1100110010000001101011 1000011010101101010000 1111000100010101011101 1000001001001010110000 1101000001111010001011 1010100101111111000110 1111001011101101000101 1111001101000000000010 1100110000011101101101 1000000000000110100010 1011000100010001101101 1100000111101010111010 1100101000100110000001 1000111111011110011110 1010001100001101100111 1101100011100110001000 1111111111111111111111 Your Rights and Protections Against Surprise Medical Bills When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible. What is “balance billing” (sometimes called “surprise billing”)? When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. “Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit. “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an innetwork facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service. You’re protected from balance billing for: Emergency services If you have an emergency medical condition and get emergency services from an out-of-network provider or hospital, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in a stable condition. Certain services at an in-network hospital or ambulatory surgical center When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s innetwork cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. EP19_14 THIS IS NOT A BILL --- Keep This Notice Your Records Page 5 of 8 267-1.19-01726N21.nop 3-4 EP If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. You can’t give up your protections for these other services if they are a surprise bill. Surprise bills are when you’re at an innetwork hospital or ambulatory surgical facility and a participating doctor was not available, a nonparticipating doctor provided services without your knowledge, or unforeseen medical services were provided. Services referred by your in-network doctor Surprise bills include when your in-network doctor refers you to an out-of-network provider without your consent (including lab and pathology services). These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. You may need to sign a form (available on the Department of Financial Services’ website at http://www.dfs.ny.gov) for the full balance billing protection to apply. You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network. When balance billing isn’t allowed, you also have these protections: x You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly. x Generally, your health plan must: o Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”). o Cover emergency services by out-of-network providers. o Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits. o Count any amount you pay for emergency services or out-of-network services toward your innetwork deductible and out-of-pocket limit. If you think you’ve been wrongly billed, contact the New York State Department of Financial Services at (800) 342-3736 or [email protected]. Visit http://www.dfs.ny.gov for information about your rights under state law. EP19_14 1/31/22 THIS IS NOT A BILL --- Keep This Notice Your Records Page 6 of 8 1010101010101010101010 1111000011011000011011 1011100010011001001000 1000000101000000000111 1110100000111000110100 1100110010000001100111 1000011010101101110000 1111000100010101100101 1000001001001000001000 1101000001111001101101 1010100101110011011110 1111001011100111100001 1111001101110101101110 1100110000011110000101 1000000010011100000000 1011000100001000100101 1100000101001111001010 1100100010100000110001 1000101000110010101010 1010011101011101110011 1101000011101110001000 1111111111111111111111 Notice of Non-Discrimination Healthfirst complies with Federal civil rights laws. Healthfirst does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Healthfirst provides the following: Free aids and services to people with disabilities to help you communicate with us, such as: – Qualified sign language interpreters – Written information in other formats (large print, audio, accessible electronic formats, other formats) Free language services to people whose first language is not English, such as: – Qualified interpreters – Information written in other languages If you need these services, call Healthfirst at 1-866-305-0408. For TTY services, call 1-888-542-3821. If you believe that Healthfirst has not given you these services or treated you differently because of race, color, national origin, age, disability, or sex, you can file a grievance with Healthfirst by: Mail: Healthfirst Member Services, P.O. Box 5165, New York, NY, 10274-5165 Phone: 1-866-305-0408 (for TTY services, call 1-888-542-3821) Fax: 1-212-801-3250 In person: 100 Church Street, New York, NY 10007 Email: http://healthfirst.org/members/contact/ You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights by: Web: Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Mail: U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F, HHH Building Washington, DC 20201 Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html Phone: 1-800-368-1019 (TTY 800-537-7697) EP19_14 THIS IS NOT A BILL --- Keep This Notice Your Records Page 7 of 8 267-1.19-01726N21.nop 4-4 EP EP19_14 THIS IS NOT A BILL --- Keep This Notice Your Records Page 8 of 8