4101272699940017480

Transaction ID: 3010406011
Transaction Date: Sep 12, 2015 9:48 am
Customer ID: 10210
COLINA-LAGOA, DANELY Subscriber

MEMBER ID VMDH17159087
DOB Nov 05, 1986
GENDER Female
PLAN / COVERAGE DATE Feb 01, 2015 - Dec 31, 9999
DATE OF SERVICE Sep 12, 2015
Either the patient's ID, name, date of birth, or address in the response does not match the information sent in the request. The
response reflects the correct information. To avoid future errors in submission, please update this information in your computer system.
Subscriber Information
260 PALEMO AVE SUITE 9
CORAL GABLES, FL 33134-6606
MEMBER ID VMDH17159087
GROUP NUMBER 99999

PLAN SPONSOR NAME QHP INDIVIDUAL UNDER65
PLAN DATE Jan 01, 2015 - Dec 31, 2015
Plan / Product Information

ACTIVE COVERAGE
INSURANCE TYPE
PLAN / PRODUCT
Service Types
Preferred Provider Organization (PPO)
EVERYDAY HEALTH PLAN 1431-R1
Payer Details
Health Benefit Plan Coverage

Diagnostic Lab
Other or Additional Payers
PAYER FLORIDA BLUE

PAYER ID BCBSF
CONTACT INFORMATION
LAST UPDATE DATE
Feb 14, 2015
MEMBER HAS VERIFIED ONLY BCBSF COVERAGE
Blue Cross Blue Shield of Florida

P: 800-727-2227
PAYER CONTACT
BLUEOPTIONS 1431
PO BOX 1798
JACKSONVILLE, FL 32231-0014
SERVICE TYPES
Health Benefit Plan Coverage

Diagnostic Lab
Provider Details
REQUESTING PROVIDER
NPI 1417960626
SUBMITTER ID G6656
Pre-existing Information
STATUS Pre-existing Condition
LEVEL Individual
SERVICE TYPE Plan Waiting Period
PRE-EXISTING IS WAIVED
Benefit Disclaimer
UNLESS OTHERWISE REQUIRED BY STATE LAW, THIS NOTICE IS NOT A GUARANTEE OF PAYMENT. BENEFITS ARE SUBJECT TO ALL
CONTRACT LIMITS AND THE MEMBER'S STATUS ON THE DATE OF SERVICE. ACCUMULATED AMOUNTS MAY CHANGE AS ADDITIONAL CLAIMS
ARE PROCESSED.
Coverage and Benefits Information
Diagnostic Lab - 5
ACTIVE COVERAGE
INSURANCE TYPE
PLAN / PRODUCT

Contact Information - Diagnostic Lab

NAME
TYPE
BLUEOPTIONS 1431
Payer
PO BOX 1798
Co-Payment - Diagnostic Lab

IN NETWORK
INDIVIDUAL
PLACE OF SERVICE
$0.00
Visit
10 %
Visit
50 %
Visit
50 %
Visit
10 %
Visit
Independent Laboratory
NO AUTHORIZATION REQUIRED
Co-Insurance - Diagnostic Lab

IN NETWORK
INDIVIDUAL
PLACE OF SERVICE
Outpatient Hospital
FACILITY BENEFIT
OUT OF NETWORK
INDIVIDUAL
PLACE OF SERVICE
Outpatient Hospital
FACILITY BENEFIT
OUT OF NETWORK
INDIVIDUAL
PLACE OF SERVICE
Independent Laboratory
INDIVIDUAL
NETWORK NOT APPLICABLE
PHYSICIAN BENEFIT
Deductible - Diagnostic Lab

IN NETWORK
INDIVIDUAL
PLAN / COVERAGE DATE
IN NETWORK
Jan 01, 2015 - Dec 31, 2015
FAMILY
Jan 01, 2015 - Dec 31, 2015
$5,000.00
- $862.11
Calendar Year
$4,137.89
Remaining
$10,000.00
- $862.11
$9,137.89
OUT OF NETWORK
INDIVIDUAL
OUT OF NETWORK
Jan 01, 2015 - Dec 31, 2015
FAMILY
Jan 01, 2015 - Dec 31, 2015
Year to Date
Calendar Year
Year to Date
Remaining
$10,000.00
- $0.00
Calendar Year
$10,000.00
Remaining
$20,000.00
- $0.00
Calendar Year
$20,000.00
Remaining
$6,350.00
- $1,166.96
Calendar Year
Year to Date
Year to Date
Out of Pocket (Stop Loss) - Diagnostic Lab

IN NETWORK
INDIVIDUAL
$5,183.04
IN NETWORK
FAMILY
OUT OF NETWORK
OUT OF NETWORK
INDIVIDUAL
FAMILY
Year to Date
Remaining
$12,700.00
- $1,166.96
Calendar Year
$11,533.04
Remaining
$12,800.00
- $0.00
Calendar Year
$12,800.00
Remaining
$25,000.00
- $0.00
Calendar Year
$25,000.00
Remaining
Year to Date
Year to Date
Year to Date
Health Benefit Plan Coverage - 30

ACTIVE COVERAGE
INSURANCE TYPE
PLAN / PRODUCT

Contact Information - Health Benefit Plan Coverage

NAME
TYPE
BLUEOPTIONS 1431
Payer
PO BOX 1798
Deductible - Health Benefit Plan Coverage

IN NETWORK
INDIVIDUAL
IN NETWORK
Jan 01, 2015 - Dec 31, 2015
FAMILY
Jan 01, 2015 - Dec 31, 2015
$5,000.00
- $862.11
Calendar Year
$4,137.89
Remaining
$10,000.00
- $862.11
$9,137.89
OUT OF NETWORK
INDIVIDUAL
OUT OF NETWORK
Jan 01, 2015 - Dec 31, 2015
FAMILY
Jan 01, 2015 - Dec 31, 2015
Year to Date
Calendar Year
Year to Date
Remaining
$10,000.00
- $0.00
Calendar Year
$10,000.00
Remaining
$20,000.00
- $0.00
Calendar Year
$20,000.00
Remaining
$6,350.00
- $1,166.96
Calendar Year
Year to Date
Year to Date
Out of Pocket (Stop Loss) - Health Benefit Plan Coverage

IN NETWORK
INDIVIDUAL
$5,183.04
IN NETWORK
FAMILY
OUT OF NETWORK
OUT OF NETWORK
INDIVIDUAL
FAMILY
Year to Date
Remaining
$12,700.00
- $1,166.96
Calendar Year
$11,533.04
Remaining
$12,800.00
- $0.00
Calendar Year
$12,800.00
Remaining
$25,000.00
- $0.00
Calendar Year
$25,000.00
Remaining
Year to Date
Year to Date
Year to Date

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Transaction ID: 3010406011

Transaction Date: Sep 12, 2015 9:48 am

Customer ID: 10210

COLINA-LAGOA, DANELY Subscriber

GROUP NUMBER 99999

Plan / Product Information

Health Benefit Plan Coverage

Other or Additional Payers

PAYER FLORIDA BLUE

LAST UPDATE DATE

Feb 14, 2015

MEMBER HAS VERIFIED ONLY BCBSF COVERAGE

Blue Cross Blue Shield of Florida

Health Benefit Plan Coverage

Coverage and Benefits Information

Preferred Provider Organization (PPO)

Contact Information - Diagnostic Lab

Co-Payment - Diagnostic Lab

Co-Insurance - Diagnostic Lab

Deductible - Diagnostic Lab

PLAN / COVERAGE DATE

Jan 01, 2015 - Dec 31, 2015

PLAN / COVERAGE DATE

Jan 01, 2015 - Dec 31, 2015

PLAN / COVERAGE DATE

Jan 01, 2015 - Dec 31, 2015

PLAN / COVERAGE DATE

Jan 01, 2015 - Dec 31, 2015

Out of Pocket (Stop Loss) - Diagnostic Lab

Health Benefit Plan Coverage - 30

Preferred Provider Organization (PPO)

Contact Information - Health Benefit Plan Coverage

Deductible - Health Benefit Plan Coverage

PLAN / COVERAGE DATE

Jan 01, 2015 - Dec 31, 2015

PLAN / COVERAGE DATE

Jan 01, 2015 - Dec 31, 2015

PLAN / COVERAGE DATE

Jan 01, 2015 - Dec 31, 2015

PLAN / COVERAGE DATE

Jan 01, 2015 - Dec 31, 2015

Out of Pocket (Stop Loss) - Health Benefit Plan Coverage

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