-

EXPLANATION OF BENEFIT PAYMENTS

THIS IS NOT A BILL
Statement Date: 05/24/13

..

BlueCross ~~~!a~hield

A nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association

Customer Service

1.1.1 1.111.11 1111.1111.1111.1111 1.11111.1.1111.111 11.1 000217

UZAIR N MUKADAM 11345 STRATTON AVE # U120 EDEN PRAIRIE MN 55344-4428

Phone: TOLL-FREE: 877-790-2583

Mail:

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Group Name: Group Number: Enrollee Name: Enrollee 10: Coverage: Patient Patient Name or Initial: Birth MonthNear:

SBAMffECHNOLOGY CONSUL TANTSBA 007028068-0003 UZAIRN MUKADAM 917206083 HOSPITAL/PHYSICIAN AYESHAMUKADAM

BLUECROSS BLUESHIELDOFMICHIGAN SECS- WRlmN, MAIL CODE X300 600 E.LAFAVEm BLVD. DETROIT MI482262998

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View your benefits and manage your plan online at bcbsm.com. For self-funded plans, we have no financial risk or obligation for your claims.

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Name of Hospital, Physician or Provider

Total Provider Charges

(-) Less BCBSM Paid

(-) Less Provider Discount

(-) Less Other Insurance Paid

(=)

Equals Your Balance*

OBSTETRICS & GYNECOLOGY

95.00 $ 95.00 $

49.75 49.75 $

15.25 15.25 $

0.00 0.00

30.00

Totals:

I$

30.00

"Note: The amount in the 'Equals Your Balance' column includes any copayments, deductibles, sanctions and non-covered Charges.

Totals for: FAMILY Deductible required for year: Deductible applied year to date:
The family deductible has not been met.

01/01/13 to 12/31/13

Totals for: AYESHAMUKADAM Deductible required for year: Deductible applied year to date:
The patient deductible has not been met.

01/01/13 to 12/31/13

$ $

10,000.00

627.53

$ $

5,000.00

627.53

Para ayuda en espafiol, lIameal mimero de servicio al cliente [customerservice] que se encuentra en este aviso 6 en el reverse de su tarjeta de identificaci6n.
MAKE YOUR LIFE EASIER! GET ALL YOUR BENEFIT STATEMENTS ONLINE. IT'S SIMPLE. IT'S SAFE. IT'S SECURE. YOUR EOB STATEMENTS ARE AVAILABLE TO YOU ANY TIME, ANY DAY, WHENEVER YOU CHOOSE. REGISTER NOW AT BCBSM.COM/EOB ..

Page

of

MDEOB131440414284

EXPLANATION OF BENEFIT PAYMENTS

THIS IS NOT A BILL
Statement Date:
05/24/13

.. ..

BlueCross ~~~~a~hield

A nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association

~~ ~
Service Date(From/To):05/13/13 Claim Received on: 05/16/13 Provider Name: OBSTETRICS & GYNECOLOGY Provider Status: PARTICIPATING Referring Provider: Service Type: MEDICAL CARE Procedure: OFFICE/OUTPATIENT VISIT EST Procedure Code: 99212 Claim Number: 26131381704600 Total Charge Amount approved by BCBSM for this service. . . . . . . . . Minus copayment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BCBSM processed on OS/24/13 and paid provider... Savings because provider participates with BCBSM . .. + Total Covered $ Your Balance

95.00 79.05 30.00 49.75 15.25 65.00

------

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MDEOB131440414286

EXPLANATION OF BENEFIT PAYMENTS

THIS IS NOT A BILL
Statement Date: 05/24/13 ..

...

BlueCross Blue Shield

of Michigan

A nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association

Customer Service

1.1.11.1 11 1 1.11.11.1 11.111.1.11.1 11.1 010228

rifi'1}. UZAIR N MUKADAM ~ 11345 STRATTON AVE # U120 EDEN PRAIRIE MN 55344-4428

Phone: TOLL-FREE: 877-790-2583

Mail:

Group Name: Group Number: Enrollee Name: Enrollee 10: Coverage: Patient Name or Initial: Patient Birth MonthNear:

SBAMITECHNOLOGY CONSULTANTS BA 007028068-0003 UZAiR N MUKADAM 917206083 HOSPITAL/PHYSICIAN AYESHA MUKADAM 03/84

BLUE CROSS BLUE SHIELD OFMICHIGAN SECS - WRlffiN. MAILCODE X300 600 E.LAFAYEffi BLVD. DETROIT MI482262998

View your benefits and manage your plan online at bcbsm.com. For self-funded plans, we have no financial risk or obligation for your claims.

Nameof Hospital, ~hysicianor Provider

Total Provider
Charqes

(-) Less
BCBSM Paid

(-) LessProvider Discount

(-) LessOther InsurancePaid

(=) EqualsYour

Balance*

OBSTETRICS & GYNECOLOGY

375.00

264.94 264.94 $

110.06 110.06 $

0.00 0.00 1$

0.00 0.00

Totals:

375.00 $

'Note: The amount in the 'Equals Your Balance' column includes any copayrnents,deductibles,sanctions and non-coveredcharges.

Totals for: FAMILY Deductible required for year: Deductible applied year to date:
The family deductible has not been met.

01101/13

to 12/31/13 $ 10,000.00 s 627.53

Totals for: AYESHA MUKADAM Deductible required for year: Deductible applied year to date:
The patient deductible has not been met.

01/01/13

$ $

to 12/31113 5,000.00 627,53

Para ayuda en espafiol, Ilame al nurnero de servicioal cliente [customer service] que se encuentraen este aviso 6 en el reverso~e su tarjeta de identificaci6n.
MAKE YOUR LIFE EASIER! GET.ALL YOUR BENEFIT STAT~MENTS ONLINE. IT'S SIMPLE, IT'S SAFE. IT'S SECURE. YOUR EOB STATEFI.1ENTSARE AVAILABLE TO,.YOU ANY TIME. ANY DAY. WHENEVER YOU CHOOSE. REGISTER NOW AT BCBSM ..~O/Eo'B. .:' ',:" '., . .
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Page

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MEOBP131440410493.

EXPLANATION OF BENEFIT PAYMENTS

THIS IS NOT A BILL
Statement Date:
05/24/13
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BlueCross ~~~!:hield

A nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association

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Service Date(From/To): 05/08/13 Claim Received on: 05/09/13 Provider Name: Provider Status: Referring Provider: Service Type: Procedure: Procedure Code: Claim Number: OBSTETRICS & GYNECOLOGY PARTICIPATING

Total Charge .. : Amount approved by BCBSM for this service BCBSM processed on 05/24/13 and paid provider ...

76.00 42.50 42.87 33.13 76.00

LAB TESTS ASSAY OF PROGESTERONE

84144 26131312328000

Savings because provider participates with BCBSM . .. + Total Covered $ Your Balance .

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$
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Service Date(FromITo) : 05/08/13 Claim Received on: 05/09/13 Provider Name: OBSTETRICS & GYNECOLOGY Provider Status: PARTICIPATING Referring Provider: Service Type: LAB TESTS Procedure: CHORIONICGONADOTROPINTEST Procedure Code: 84702 Claim Number: 26131312328000

Total Charge Amount approved by BCBSM for this service

54.00 22.61 22.81 3l.19 54.00

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BCBSM processed on 05/24/13 and paid provider ... Savings because provider participates with BCBSM . .. + Total Covered $ Your Balance

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0.001
3.06

...
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Service Date(FromITo): Claim Received on: Provider Name: Provider Status: Referring Provider: Service Type: Procedure: Procedure Code: Claim Number:

05/08/13 05/09/13 OBSTETRICS & GYNECOLOGY PARTICIPATING

Total Charge

: .

13.00

Amount approved by BCBSM for this service

LAB TESTS ROUTINEVENIPUNCTURE

36415 26131312328000

BCBSM processed on 05/24/13 and paid provider ... Savings because provider participates with BCBSM . .. + Total Covered $ Your Balance

----:-::-~

,:::::::::::::::::::::::::::::::..,

3.09 9.91 13.00

1$
$

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0.001

Service Date(FromITo): Claim Received on: Provider ,Name: Provider Status: Referring Provider: Service Type: Procedure: Procedure Code: Claim Number:

05/13/13 05/16/13 OBSTETRICS & GYNECOLOGY PARTICIPATING

Total Charge

232.00 194.46 196.17 35.83 232.00

Amount approved by BCBSM for this service

X-RAYS TRANSVAGINAL US OBSTETRIC

76817 26131381704500

BCBSM processed on 05/24/13 and paid provider ... Savings because provider participates with BCBSM . .. + Total Covered $ Your Balance .

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MEOBP131440410495

MAKE CHECKS

PAYABLE TO:

IF PAYING BY CREDIT CARD, FILL OUT BELOW.

CHECK CARD USING FOR PAYMENT

SUBURBANRADIOLOGICCONSULTANTS, LTD. 4801 W 81ST ST SUITE 108 MINNEAPOLIS,MN 55437-1191

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180
CARD NUMBER SIGNATURE

MASTERCARD

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DISCOVER

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0
VISA AMERICAN EXPRESS SIGNATURE CODEEXP. DATE

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STATEMENT DATE

ACCT. #

PAY THIS AMOUNT

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~

Pleasecall 952-837-9700if you have any questions. Tax 10:41-0969027 Business Hours: 7:30AM - 4:00PM Mon - Fri Toll Free: 800-940-7497 Online payments: www.subrad.com
ADDRESSEE:

05/08/13 * Signature Code = 3 Digit code on

M66231233344
SHOW AMOUNT PAID HERE

35.67

back of MASTERCARD, DISCOVER and VISA Signature Code = 4 Digit code on front of AMERICAN EXPRESS

REMIT TO:

~
00 ci

AYESHA UZAIR MUKADAM EDEN PRAIRIE MN 55344-4478

Page 1

s ~d~ 11345 STRATTON AVE APT 120

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SUBURBAN RADIOLOGIC CONSULTANTS, LTD. 4801 W 81ST ST. #108 MINNEAPOLIS MN 55437-1191

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PAYMENT IS DUE UPON RECEIPT

Please detach and return top portion with your payment.

Account Number M66231233344

Date Loc Exam Code

Patient Name AYESHA UZAIR MUKADAM

ICD-9-CM
PREVIOUS BALANCE

Referrinq Physician HEEGAARD,ERIC

Amount
35.67

Description of Service

THIS ACCOUNT IS NOW DELINQUENT. PLEASE REMIT PROMPTLY.

Location Codes: 1. Inpatient Hospital 2. Outpatient Hospital 3. Diagnostic Office 4. Nursing Home 5. Emergency Room

Total Due:

$35.67

Suburban Radiologic Consultants, LTO. - 4801 W 81st St. #108 - Minneapolis, MN 55437-1191

Toll Free Phone: 800-940-7497

BB FAIRVIEW
DO NOT MAIL PAYMENTS/CORRESPONDENCE 100 S. Owasso Blvd West I St. Paul, MN 55117 TO THIS ADDRESS

PLEASE MAIL PAYMENTS/CORRESPONDENCE TO: FAIRVIEW HEALTH SERVICES PO BOX 9372 MINNEAPOLIS MN 55440-9372
ADDRESSEE:

Please Note:
Payments are applied to the oldest outstanding balance at the time the self pay payment is received. If you have additional accounts not included in your current Payment Plan arrangement please call our office to have them added. Topay your Fairview bill online go to:
billpay.fairview.org

AYESHA UZAIR MUKADAM 11345 STRATTON AVE APT 120 EDEN PRAIRIE MN 55344-4478

To requestan Itemized Bill, pleasecall: 612-672-7030.

For Billing Inquiries: 612-672-6724
Toll Free: 1-888-702-4073 Monday to Thursday 8:00 a.m. - 4:30 p.rn, Friday 9:00 a.m. - 4:30 p.m.

DATE
05/28/13

: CODES : CPT/REV/HCPC
:

Date of Service 1/16/2013

CHARGES ; Visit # 12000512038 - AYESHA UZAIR MUKADAM INSURANCE PAYMENT - COMMERCIAL PREVIOUS VISIT BALANCE DESCRIPTION

PAYMENTSI , ADJUSTMENTS $0.00

INSURANCE BALANCE $0.00 $0.00

PATIENT BALANCE $482.13 $482.13

Outstanding Balance: MonthlyPaymentPlan:

Total Due:

$482.13 $0.00 $482.13

TO ENSURE PROPER CREDIT, RETURN LOWER PORTION IN THE ENCLOSED ENVELOPE - - - - - - - - _ ... - .- - - - - - - - ......... - - - - - - - - - - - - - - - - - - - - - -_.::'!-- - - - - - - - - - - - - - - ... ""'-=-- - - -_- - - - - ~ - - -.- - - - - - - - - - --=---~ --~- - - - - - !"'"_- - "",_- - - - - - - - - - --

Please check if above address is incorrect and indicate change on reverse side.

gB

FAIRVIEW
SIGNATURE EXP. DATE

MONTHLY PAYMENT PLAN AMOUNT

0.00

$482.13

FAIRVIEW HEALTH SERVICES PO Box 9372 MINNEAPOLIS MN 55440-9372

0000010730380000482130205281300010730384

P5616onooI

Morgan White Administrators, Inc Po Box 16708 Jackson, MS 39236 Electronic Service Requested
3-DIGIT 26773 0.3584 AT 0.381 553

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Morgan-White Administrators, Inc. contact us at 888-888-2519

201305213Jms

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Group Code: 4STDTC2 Processed Date: 05/16/2013 Check Date: 05/20/20 13 Check Number: -218825 Payee:U MN MED CTR FAIRVIEW Tax ID: 410991680

11111111111111111111111111111111111111111111111111111111111111111
Uzair

11345 STRATTON AVE U 120 EDEN PRAIRIE, MN 55344-4428

Mukadam

241

Explanation of Benefits
***THIS IS NOT A BILL*** PLEASE MAKE ALL PAYMENTS TO THE PROVIDER
....
Service 01/16-01/16/13 Description of Service HOSP Totals Total PendlNot Charged Covered Memo 482.13 000 62 482,13 000 Discount Memo 0.00 0,00 Amount Allowed 482,13 482,13 Copay Memo Deductible 482.13 II 482.13

. ~.A,i"";f;!>~'l.~0f<: ])4".,'

~tlitus: EMPLOYE,E'. Date)~.eceived:O~/l ;J/:Z.OI3

:
Plan Payment 0,00 0.00 482.13

CoOther Insurance Memo Insurance 000 0.00 0,00 0,00 Patient Responsibility:

Totals for: Uzair Mukadam

Deductible max for year: I,000.00 Deductible taken for year:482.13 Co-Insurance max for year:O.OO Co-Insurance taken for year:O.OO Benefit max:4,000.00 Benefit paid:O,OO

* Summary of Dednctibles and Copayments (these totals are based on our information to date and may not reflect all outstanding claims.

Statement Totals
Explanation Codes
II 62

Total Charged 482.13

PendlNot Covered 000

PPO Discount 0.00

Amonnt Allowed 482.13

Copay Deductible 482,13

CoInsurance 0,00

Other Insurance 0.00

Plan Payment 0,00

APPLIED TOWARDS DEDUCTIBLE. PLEASE BE ADVISED OUR TOTAL CHARGE IS THE DEDUCTIBLEI AND OR CO-INSURANCE AMOUNT SHOWN ON YOUR MAJOR MEDICAL EXPLANATIONOF BENEFITS.