Footnote: a) An internal rule, guideline, protocol or similar criterion was relied upon in making this determination, a copy of which will be provided free of charge upon request.  If the determination was based upon a medical judgment, an explanation of the scientific or clinical judgment for this determination, applying terms of the plan to the claimant’s medical circumstances, will be provided free of charge upon request.  Footnote:b)Please contact Boon-Chapman Customer Service at 800-252-9653 if you are unable to find this provision in the Summary Plan Description (Plan Booklet).

Claims Appeals – You have a right to appeal this determination.  If you disagree with this determination, you must submit proof that the claim for benefits is covered and payable under the Plan’s provisions, including (a) all facts and theories supporting your claim, (b) a statement of the reasons for disagreement with the handling of the claim, and (c) any material/information that indicates that the claims does not fall within the referenced Plan provision.  If you do so, it may be that some or all of this claim will be payable under the Plan.  This Plan allows for appeal of an adverse benefit determination.  Each appeal provides full and fair review of an adverse determination in compliance with the Employee Retirement Income Security Act of 1974 (“ERISA”) and the regulations issued there under.  Claimant will be provided free of charge with a complete description of the Plan’s review procedures and the applicable time limits by calling Boon-Chapman Customer Service at 800-252-9653.  briefly, with 180 days following receipt of this notice, the claimant may file an appeal which must be in writing and mailed to Boon-Chapman, P.O. Box9201, Austin, Texas 78766.  If the claimant provides the Plan with all information needed to address the appeal, the Plan will respond to the appeal no later than 30 days after receipt of the appeal. You are entitled to receive, free of charge upon request, reasonable access to, and copies of, all documents, records and other information relevant to your claim benefits.  If you receive an adverse benefit determination following the final appeal, you have the right to bring civil action under section 502(a) of ERISA.

Patient Account: C8953452 Provider: Memorial Hospital SSN: 123-45-6789 Prepared On: 05/09/2003

Boon-Chapman code for the type of service provided.  Box 2-A lists the definition of these codes.

Any amounts excluded by the plan.  There will always be a denied reason code in Box 6 for any amounts not covered.  This amount will also be included in Box 9.

Boon-Chapman code identifying the reason for any amounts shown in Box 4 or 6.  An explanation of this code appears in Box 6-A.

Amounts in this column are preferred provider discounts and will be written off by the provider.  There will always be a reason code in Box 6 to identify this amount as a discount. This amount will not be included in Box 9.

This is the amount of the claim that will be considered for benefits.  It is calculated by subtracting any not covered amounts and discounts from the total charge.

This is the amount the patient will need to pay the provider.  It includes amounts shown in Box 4 and 8 as well as the patient’s co-insurance amount (i.e. if the Plan pays 80% of eligible charges, the patient responsibility will include the 20% that should be paid by the patient).