Aetna Life Insurance Company *001525*M280SUPP*011023*

PO Box 30017
Pittsburgh PA 15222-0330 Explanation of Benefits
Statement date: May 10, 2023
Member: Gilbert E Wellenreiter
Member ID: 101055627900
Plan name: Medicare (C01) ESA PPO
Page 1 of 8
Gilbert E Wellenreiter QUESTIONS? Contact us at
235 N MAIN ST https://Health.AetnaMedicare.com
WINCHESTER IL 62694 Member Services: 1-855-223-4807
TTY/TDD: 711
Hours of Operation: 8 AM to 8 PM CST,
Monday through Friday
Precertification: 800-624-0756
Or write to the address shown above

Monthly Report
Medical and Hospital Claims
processed in April 2023
Claims are bills sent to the plan by your doctors Please retain this statement to keep track of
and others who provide your care. This includes services you have received and how much you
any requests for payments, or bills, that you send have spent "out-of-pocket".
directly to Medicare (C01) ESA PPO for care you
have received. This report covers medical and Fraud
hospital care only. We send a separate report on Fraud impacts Medicare and can lead to higher

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Part D prescription drugs if you have a drug plan health care costs. Some examples of current fraud
with us. This information is not a complete schemes to be on the lookout for include:
description of benefits. Call 1-855-223-4807 (TTY: • People using your Medicare or health plan
711) for more information. member number for services you never received
• People calling you to ask for your Medicare or
This is not a bill health plan numbers (never give those out)
This monthly report of claims we have processed • People trying to bribe you to use a doctor you
tells what care you have received, what the plan don't know, to get services you may not need
has paid, and how much you have paid out of • People going door-to-door to sell you healthcare
pocket (or can expect to be billed). Look over the items or services (only your doctor knows
information about your claims - does it seem what you need)
correct? If you owe anything, your doctors and • People offering you money or other incentives
other health care providers will send you a bill. In for health care services you don't need
the claim details section, the amounts shown under • More information can be found here:
"Your share" can be either of the following: https://www.aetnamedicare.com/en/footers/fraud-
• A payment you have already made to the waste-abuse.html
provider
• Or the maximum amount you may owe If you notice something suspicious that might be
dishonest billing, you can report it by calling us at
If you have questions or think there might be a the number on your ID card or 1-800-MEDICARE
mistake, start by calling the doctor's office or other (1-800-633-4227), 24 hours a day, 7 days a week.
service provider. Ask them to explain the claim. If (TTY users should call 1-877-486-2048.)
you still have questions, call Member Services
using the phone number shown above.

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Statement date: May 10, 2023

Member: Gilbert E Wellenreiter
Member ID: 101055627900
Page 2 of 8

You're covered for preventive care

services
Don't forget that your Medicare plan covers
preventive visits. Talk to your doctor to make sure
you are up-to-date on these exams and
screenings. To learn more, see your Evidence of
Coverage (EOC). You can call Member Services by
referring to the first page of this statement or your
Member ID card.

Note: If you receive other care during your

preventive service visit, you may have to pay a
copayment or coinsurance for those services.

Important information
Cut down on paper. Save time by getting your
Explanation of Benefits (EOB) statements online.
They are quicker to access for view and print. Log
into your secure member website and sign up to
receive your EOBs online.
Out-of-network/non-contracted providers are under

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no obligation to treat Aetna members, except in
emergency situations. Please call our customer
service number or see your Evidence of Coverage
for more information, including the cost-sharing that
applies to out-of-network services.
Participating health care providers are independent
contractors and are neither agents nor employees of
Aetna. The availability of any particular provider
cannot be guaranteed, and provider network
composition is subject to change.

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 Statement date: May 10, 2023
Member: Gilbert E Wellenreiter
Member ID: 101055627900
Page 3 of 8

Here is your Current Financial Summary

Totals for medical and Amount the Total cost Plan's share Your share
hospital claims providers have (amount the plan has
billed the plan approved)
Totals for this month $34,774.23 $5,127.50 $4,355.11 $769.13
(for claims processed
4/1/23 - 4/30/23)
Totals for 2023 $47,076.26 $6,950.28 $5,812.42 $1,110.87
(all claims processed
through 4/30/23)

Yearly Limit - this limit gives you financial protection Deductible

This limit tells the most you will have to pay in As of April 30, 2023, you have had $1,160.44 in For most covered services, the
“out-of-pocket” costs (copays, coinsurance, out-of-pocket costs that count toward your $1,300.00 plan pays its share of the cost
and your deductible) for medical and hospital out-of-pocket maximum for covered services in 2023. only after you have paid your
services covered by the plan. Combined (in-network + out-of-network) limit yearly plan deductible.
The yearly limit is called your "out-of-pocket In 2023, $1,300.00 is the most you will have to pay for As of April 30, 2023, you have
maximum". It puts a limit on how much you covered services you get from all providers (in-network paid the full amount of your
have to pay, but it does not put a limit on how providers + out-of-network providers combined). $110.00 in-network yearly plan
much care you can get. As of April 30, 2023, you have had $1,160.44 in deductible in 2023.
out-of-pocket costs that count toward your $1,300.00
Your out-of-pocket spending for optional
combined out-of-pocket maximum for covered services
supplemental services will not count toward
in 2023.
your yearly out-of-pocket maximum. This
means:
• Once you have reached your limit in
out-of-pocket costs, you stop paying out

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of pocket for all services.
• You keep getting your covered medical
and hospital services as usual, and the
plan will pay the full cost for the rest of
the year.

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 Statement date: May 10, 2023
Member: Gilbert E Wellenreiter
Member ID: 101055627900
Page 4 of 8

Payment summary
Provider Amount Send to Send date
BHATTARAI, MUKUL $55.78 SIU PHYSICIANS & SURGEONS, INC. 4/11/23
BARNES-JEWISH HOSPITAL $4,195.53 BARNES-JEWISH HOSPITAL 4/25/23
CHEEMA, ASAD M. $103.80 SIU PHYSICIANS & SURGEONS, INC. 4/11/23

Details for claims processed in April 2023

Remember, this report is NOT A BILL. If you have not already paid the amount shown for “Your share”, wait until you get a bill from the provider.
If you get a bill that is higher than the amount shown for “Your share”, call us at Member Services (phone numbers are on first page).
Asad M. Cheema
In-network OR Out-of-network provider
Description and Amount the Total cost Notes Plan's share Your share
Date of Service provider billed (amount the
the plan plan approved)
Claim Number: ELPC4CCTH02
OFFICE O/P EST MOD $365.00 $124.61 0001 $103.80 $18.69
30-39 MIN on 2/8/23 0002
99214 You pay 15% of the total amount for
services from an in-network or
out-of-network provider

Totals $365.00 $124.61 $103.80 $18.69

You can find all numbered notes in the 'Notes' section after the final claim.

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 Statement date: May 10, 2023
Member: Gilbert E Wellenreiter
Member ID: 101055627900
Page 5 of 8

Mukul Bhattarai
In-network OR Out-of-network provider
Description and Amount the Total cost Notes Plan's share Your share
Date of Service provider billed (amount the
the plan plan approved)
Claim Number: E9RV3CNTB00
TTE W/DOPPLER, $759.00 $66.97 0001 $55.78 $10.05
COMPLETE on 3/13/23 0002
93306 You pay 15% of the total amount for
services from an in-network or
out-of-network provider

Totals $759.00 $66.97 $55.78 $10.05

You can find all numbered notes in the 'Notes' section after the final claim.

Barnes-Jewish Hospital
In-network OR Out-of-network provider
Description and Amount the Total cost Notes Plan's share Your share
Date of Service provider billed (amount the
the plan plan approved)
Claim Number: EKAC5BF0S01
PHARMACY on 4/3/23 $6.55 $6.55 0003 $0.00 $0.00
250

MED-SUR SUPPLIES on $269.26 $269.26 0003 $0.00 $0.00

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4/3/23 270

continued

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 Statement date: May 10, 2023
Member: Gilbert E Wellenreiter
Member ID: 101055627900
Page 6 of 8

Barnes-Jewish Hospital
In-network OR Out-of-network provider
Description and Amount the Total cost Notes Plan's share Your share
Date of Service provider billed (amount the
the plan plan approved)
Claim Number: EKAC5BF0S01
GUIDE WIRE on 4/3/23 $1,379.25 $1,379.25 0003 $0.00 $0.00
C1769

CATHETER, GUIDING $1,054.66 $1,054.66 0003 $0.00 $0.00

on 4/3/23 C1887

STERILE SUPPLY on $153.79 $153.79 0003 $0.00 $0.00

4/3/23 272

INTRODUCER/SHEATH $29.02 $29.02 0003 $0.00 $0.00

on 4/3/23 C1894

RIA ASSAY, BLOOD $339.00 $339.00 0003 $0.00 $0.00

ALDOSTERONE on
4/3/23 82088
RIA ASSAY PLASMA $90.00 $90.00 0003 $0.00 $0.00
CORTISOL on 4/3/23
82533

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continued

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 Statement date: May 10, 2023
Member: Gilbert E Wellenreiter
Member ID: 101055627900
Page 7 of 8

Barnes-Jewish Hospital
In-network OR Out-of-network provider
Description and Amount the Total cost Notes Plan's share Your share
Date of Service provider billed (amount the
the plan plan approved)
Claim Number: EKAC5BF0S01
VENOUS SAMPLING BY $19,168.00 $4,935.92 0002 $4,195.53 $740.39
CATHETER on 4/3/23
75893 You pay 15% of the total amount for
services from an in-network or
out-of-network provider

SELECTIVE CATHETER $5,130.00 $5,130.00 0003 $0.00 $0.00

PLACEMENT on 4/3/23
36012
INSERTION OF $2,565.00 $2,565.00 0003 $0.00 $0.00
CATHETER, VEIN on
4/3/23 36500
INSERTION OF $2,565.00 $2,565.00 0003 $0.00 $0.00
CATHETER, VEIN on
4/3/23 36500
US GUID VASC ACSS $455.00 $455.00 0003 $0.00 $0.00
SITE PERM on 4/3/23
76937
INJ., COSYNTROPIN, $438.60 $438.60 0003 $0.00 $0.00

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0.25 MG on 4/3/23 J0834

continued

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 Statement date: May 10, 2023
Member: Gilbert E Wellenreiter
Member ID: 101055627900
Page 8 of 8

Barnes-Jewish Hospital
In-network OR Out-of-network provider
Description and Amount the Total cost Notes Plan's share Your share
Date of Service provider billed (amount the
the plan plan approved)
Claim Number: EKAC5BF0S01
FENTANYL CITRATE $4.45 $4.45 0003 $0.00 $0.00
INJECTION on 4/3/23
J3010
MIDAZOLAM HCL PER $1.50 $1.50 0003 $0.00 $0.00
1MG/49 MX on 4/3/23
J2250
FENTANYL CITRATE $1.15 $1.15 0003 $0.00 $0.00
INJECTION on 4/3/23
J3010
Totals $33,650.23 $4,935.92 $4,195.53 $740.39
You can find all numbered notes in the 'Notes' section after the final claim.

Notes:
0001 - You do not have to pay this. CMS/Medicare recently changed reimbursement levels. We applied your cost share from the approved
amount. We have adjusted the payment to the provider. This did not affect your cost share. [M52]
0002 - We considered this service at the contracted rate for your provider. [P12]
0003 - You only owe the copay, deductible or coinsurance under your plan. The charge for this service is part of the contracted or case rate the
provider agreed to accept. [V64]

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You have the right to make an appeal or complaint

Making an appeal is a formal way of asking us to For plan contact information
change our decision about your coverage. You can Member Services number: Please refer to the
make an appeal if we deny a claim. You can also first page of this statement or your Member ID card
make an appeal if we approve a claim but you
For hearing impaired assistance: Please refer to
disagree with how much you are paying for the
item or services. For information about making an the first page of this statement
appeal, call us at Member Services by referring to Plan hours of operation: Please refer to the first
the first page of this statement or your Member ID page of this statement
card. For claim denials resulting in member
financial responsibility, see the additional appeal Other resources
rights attached to this statement. Center for Medicare and Medicaid Services
(CMS) Medicare hours of operation:
This claim was processed in accordance with the 24 hours a day, 7 days a week
terms of your plan. This document is an official 1-800-MEDICARE (1-800-633-4227)
written notice of determination. TTY users should call 1-877-486-2048

Not all health services are covered. See Evidence Privacy

of Coverage for a complete description of plan Protecting the privacy of member health
benefits, exclusions, limitations and conditions of information is our top priority. When contacting us
coverage. Plan features and availability may vary about this notice or for help with other questions,
by service area. please be prepared to provide the Member's
name, Member ID, address and date of birth.
©2023 Aetna Inc.
Fraud
If you suspect fraud or abuse involving the

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services described in this Explanation of Benefits
or would like to report other healthcare fraud
related issues, please call the toll-free Hotline at
1-800-338-6361 or contact us by E-Mail at
AETNASIU@AETNA.COM.

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Notice of Denial of Payment

Important: This notice explains your right to appeal time and will explain why more time is needed. If
our decision. Read this notice carefully. If you need your appeal is for payment of a medical service/item
help, you can call one of the numbers listed under or Part B drug you've already received, we'll give you
“Get help & more information”. a written decision within 60 days.
Your request was denied How to ask for an appeal with Aetna Medicare
We've denied the payment of medical services/ Step 1: You, your representative, or your doctor
items or Part B drug listed under “Details for claims must ask us for an appeal. Your written request must
processed” requested by you or your doctor. include:
- Your name
Why did we deny your request?
- Address
If we denied the payment of medical services/items
- Member number
or Part B drug listed under “Details for claims
- Reasons for appealing
processed,” you will find the reason listed under
- Any evidence you want us to review, such as
“Notes”.
medical records, doctors' letters, (such as a doctor's
This request may have been denied under your supporting statement), or other information that
Medicare Part B benefit; however, coverage/ explains why you need the medical service/item or
payment for the requested drug(s) may be eligible Part B drug. Call your doctor if you need this
for coverage under Medicare Part D. If you think information.
Medicare Part B should cover this drug for you, you
If you're asking for an appeal and missed the
may appeal.
deadline, you may ask for an extension and should
You have the right to appeal our decision include your reason for being late.
You have the right to ask Aetna Medicare to review We recommend keeping a copy of everything you
our decision by asking us for an appeal. send us for your records. You can ask to see the
Plan Appeal medical records and other documents we used to
Ask Aetna Medicare for an appeal within 60 days of make our decision before or during the appeal. At no

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the date of this notice. We can give you more time if cost to you, you can also ask for a copy of the
you have a good reason for missing the deadline. guidelines we used to make our decision.
See section titled “How to ask for an appeal with Step 2: Mail, fax, or deliver your appeal
Aetna Medicare” for information on how to ask for a Mail: Aetna Medicare Appeal Unit, P.O. Box 14067,
plan level appeal. Lexington, KY 40512
If you want someone else to act for you Fax: 1-724-741-4953
You can name a relative, friend, attorney, doctor, or Deliver: 1425 Union Meeting Road, Blue Bell,
someone else to act as your representative. If you PA 19422
want someone else to act for you, call us at the Website: www.aetnamedicare.com/en/contact-us/
Member Services number listed on the first page of appeals-grievances.html
your Explanation of Benefits statement to learn how
What happens next?
to name your representative. TTY users call 711.
If you ask for an appeal and we continue to deny
Both you and the person you want to act for you
your request for payment of a medical service/item
must sign and date a statement confirming this is
or Part B drug, we'll automatically send your case to
what you want. You'll need to mail or fax this
an independent reviewer. If the independent
statement to us. Keep a copy for your records.
reviewer denies your request, the written
Important Information About Your decision will explain if you have additional appeal
Appeal Rights rights.

Standard Appeal: We'll give you a written decision Get help & more information
on a standard appeal within 30 days for medical - Member Services Number: Please refer to the first
service/item or 7 days for Part B drug after we get page of this statement or your Member ID card.TTY
users call 711.
your appeal. Our decision might take longer if you
- Hours of Operation: Please refer to the first page of
ask for an extension, or if we need more information
about your case. We'll tell you if we're taking extra this statement
- 1-800-MEDICARE (1-800-633-4227), 24 hours, 7

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days a week. TTY users call: 1-877-486-2048

- Medicare Rights Center. 1-888-HMO-9050
- Elder Care Locator: 1-800-677-1116 or
www.eldercare.acl.gov to find help in your
community.
You have the right to get Medicare information in an
accessible format, like large print, Braille, or audio.
You also have the right to file a complaint if you feel
you've been discriminated against. Visit
Medicare.gov/about-us/accessibility-
nondiscrimination-notice, or call 1-800-MEDICARE
(1-800-633-4227) for more information. TTY users
can call 1-877-486-2048.

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1-855-223-4807

1-855-223-4807

1-855-223-4807

1-855-223-4807

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1-855-223-4807

1-855-223-4807

1-855-223-4807

1-855-223-4807

1-855-223-4807
 *001525*M280SUPP*011029*

1-855-223-4807

1-855-223-4807

1-855-223-4807

1-855-223-4807

1-855-223-4807

F001525000007000007000J280SUPP080F
1-855-223-4807

1-855-223-4807

1-855-223-4807

1-855-223-4807