00 00 ZZ 993 ZZ 994 180514 1943 ^ 00501 003042910 0 T { HB RITSA RBXMO 20180514 1943441 3042910 X 005010X279A1 271 0001 005010X279A1 0022 11 123456701 20180514 1943438 1 20 1 PR 2 blue_cross_blue_shield_il PI 621 2 1 21 1 2B 2 BCBS MOP SV 1699849786XXXXXXXXX994X 3 2 22 0 2 123456701 994BXMO IL 1 WULKOWICZ JASON R MI QMF921053892 Q4 BCB921053892 6P IB1804 704 S EAST AVE OAK PARK IL 60304 D8 19640927 M Y 18 001 25 291 RD8 20180101-99991231 343 D8 20180131 1 30 Blue Choice Preferred D 33 THE FOLLOWING MUSCLE MANIPULATION MAXIMUM MAY BE COMBINED WITH OTHER THERAPY SERVICES. 1 1 AL 88 MH W U 47 48 U W INPATIENT FACILITY STAYS REQUIRE PREAUTHORIZATION ZZ 21 U 47 48 U W 2120 X3 2 CUSTOMER SERVICE IC TE 8009728088 2120 A IND 47 48 23 .4 U Y DAILY ROOM AND BOARD B IND 47 48 36 850 U Y DAILY ROOM AND BOARD EXCLUDED PROVIDER TYPES - 0Q,SF,0T,0D,0W,0O C IND 30 23 2850 U Y DAILY ROOM AND BOARD;EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL CARE - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL;URGENT CARE INSTITUTIONAL;MUSCLE MANIPULATION - PROFESSIONAL;OFFICE VISIT - PROFESSIONAL;SPECIAL MEDICAL VISITS - INSTITUTIONAL C FAM 30 23 8550 U Y DAILY ROOM AND BOARD;EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL CARE - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL;URGENT CARE INSTITUTIONAL;MUSCLE MANIPULATION - PROFESSIONAL;OFFICE VISIT - PROFESSIONAL;SPECIAL MEDICAL VISITS - INSTITUTIONAL G FAM 30 23 13100 U Y DAILY ROOM AND BOARD;EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL CARE - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL;URGENT CARE INSTITUTIONAL;MUSCLE MANIPULATION - PROFESSIONAL;OFFICE VISIT - PROFESSIONAL;SPECIAL MEDICAL VISITS - INSTITUTIONAL G IND 30 23 6550 U Y DAILY ROOM AND BOARD;EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL CARE - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL;URGENT CARE INSTITUTIONAL;MUSCLE MANIPULATION - PROFESSIONAL;OFFICE VISIT - PROFESSIONAL;SPECIAL MEDICAL VISITS - INSTITUTIONAL J IND 47 48 36 0 U Y DAILY ROOM AND BOARD PENALTY WILL BE THE LESSER OF 50% OF ALLOWED AMOUNT OR $1000 A IND 51 23 .4 U W EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL A IND UC 23 .4 U W EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL A IND 52 23 .4 U W EMERGENCY MEDICAL CARE - PROFESSIONAL A IND 86 23 .4 U Y EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL B IND 86 27 1000 U Y EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL A IND 33 23 .4 U Y MUSCLE MANIPULATION - PROFESSIONAL F IND 33 23 P6 15 U W MUSCLE MANIPULATION - PROFESSIONAL 15 VISITS PER 1 YEAR CALENDAR BEGIN FOR ALL PLACES OF TRTMNT. THIS IS AN INDIVIDUAL BENEFIT MAXIMUM. INCLUDED PROVIDER TYPES - BY,B0 F IND 33 23 P6 25 U W MUSCLE MANIPULATION - PROFESSIONAL 25 VISITS PER 1 YEAR CALENDAR BEGIN FOR ALL PLACES OF TRTMNT. THIS IS AN INDIVIDUAL BENEFIT MAXIMUM. EXCLUDED PROVIDER TYPES - BY,B0 A IND 98 23 .4 U Y OFFICE VISIT - PROFESSIONAL F IND 98 23 P6 15 U W OFFICE VISIT - PROFESSIONAL 15 VISITS PER 1 YEAR CALENDAR BEGIN FOR ALL PLACES OF TRTMNT. THIS IS AN INDIVIDUAL BENEFIT MAXIMUM. INCLUDED PROVIDER TYPES - BY,B0 A IND BZ 27 0 U Y PHYSICAL HISTORY - PROFESSIONAL F IND BZ 23 P6 15 U W PHYSICAL HISTORY - PROFESSIONAL 15 VISITS PER 1 YEAR CALENDAR BEGIN FOR ALL PLACES OF TRTMNT. THIS IS AN INDIVIDUAL BENEFIT MAXIMUM. INCLUDED PROVIDER TYPES - BY,B0 A IND 47 50 23 .4 U Y SPECIAL MEDICAL VISITS - INSTITUTIONAL A IND 47 48 23 .5 U N DAILY ROOM AND BOARD 50% COVERAGE PAYMENT LEVEL OF ALLOWED AMOUNT FOR ALL PLACES OF TRTMNT. APPLIES TO ALL CONDITIONS. PATIENT MAY BE RESP FOR AMT OVER THE ALLOWED AMT. EXCLUDED PROVIDER TYPES - 0Q,0T,0U,0V,0N A IND 47 48 23 .5 U N DAILY ROOM AND BOARD SPECIALIST - 50% COVERAGE PAYMENT LEVEL OF ALLOWED AMOUNT FOR ALL PLACES OF TRTMNT. EXCLUDED CONDITION(S) ALCOHOLISM DIAGNOSIS/DRUG ADDICTION DIAGNOSIS/MENTAL DIAGNOSIS/NON-SERIOUS MENTAL ILLNESS. /PERVASIVE DEVELOPMENTAL DISORDERS/SERIOUS MENTAL ILLNESS INCLUDED PROVIDER TYPES - 0Q,0T,0U,0V,0N B IND 47 48 36 1500 U N DAILY ROOM AND BOARD C IND 47 48 23 15000 U N DAILY ROOM AND BOARD C FAM 47 48 23 45000 U N DAILY ROOM AND BOARD J IND 47 48 36 500 U N DAILY ROOM AND BOARD PER ADMISSION PENALTY WILL BE $500. C IND 51 23 2850 U N EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL C FAM 51 23 8550 U N EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL G FAM 51 23 13100 U N EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL G IND 51 23 6550 U N EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL C IND UC 23 2850 U N EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL C FAM UC 23 8550 U N EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL G FAM UC 23 13100 U N EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL G IND UC 23 6550 U N EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL C IND 52 23 2850 U N EMERGENCY MEDICAL CARE - PROFESSIONAL C FAM 52 23 8550 U N EMERGENCY MEDICAL CARE - PROFESSIONAL G FAM 52 23 13100 U N EMERGENCY MEDICAL CARE - PROFESSIONAL G IND 52 23 6550 U N EMERGENCY MEDICAL CARE - PROFESSIONAL A IND 86 23 .5 U N EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL 50% COVERAGE PAYMENT LEVEL OF ALLOWED AMOUNT FOR ALL PLACES OF TRTMNT. APPLIES TO ALL CONDITIONS. PATIENT MAY BE RESP FOR AMT OVER THE ALLOWED AMT. EXCLUDED PROVIDER TYPES - 0Q,0T,0U,0V,0N C IND 86 23 15000 U N EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL C FAM 86 23 45000 U N EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL A IND 33 23 .5 U N MUSCLE MANIPULATION - PROFESSIONAL 50% COVERAGE PAYMENT LEVEL OF ALLOWED AMOUNT FOR ALL PLACES OF TRTMNT. APPLIES TO ALL CONDITIONS. PATIENT MAY BE RESP FOR AMT OVER THE ALLOWED AMT. EXCLUDED PROVIDER TYPES - 0Q,0T,0U,0V,0N C IND 33 23 15000 U N MUSCLE MANIPULATION - PROFESSIONAL C FAM 33 23 45000 U N MUSCLE MANIPULATION - PROFESSIONAL A IND 98 23 .5 U N OFFICE VISIT - PROFESSIONAL 50% COVERAGE PAYMENT LEVEL OF ALLOWED AMOUNT FOR ALL PLACES OF TRTMNT. APPLIES TO ALL CONDITIONS. PATIENT MAY BE RESP FOR AMT OVER THE ALLOWED AMT. EXCLUDED PROVIDER TYPES - 0Q,0T,0U,0V,0N C IND 98 23 15000 U N OFFICE VISIT - PROFESSIONAL C FAM 98 23 45000 U N OFFICE VISIT - PROFESSIONAL A IND BZ 23 .5 U N PHYSICAL HISTORY - PROFESSIONAL 50% COVERAGE PAYMENT LEVEL OF ALLOWED AMOUNT FOR ALL PLACES OF TRTMNT. APPLIES TO ALL CONDITIONS. PATIENT MAY BE RESP FOR AMT OVER THE ALLOWED AMT. EXCLUDED PROVIDER TYPES - 0Q,0T,0U,0V,0N C IND BZ 23 15000 U N PHYSICAL HISTORY - PROFESSIONAL C FAM BZ 23 45000 U N PHYSICAL HISTORY - PROFESSIONAL A IND 47 50 23 .5 U N SPECIAL MEDICAL VISITS - INSTITUTIONAL 50% COVERAGE PAYMENT LEVEL OF ALLOWED AMOUNT FOR ALL PLACES OF TRTMNT. APPLIES TO ALL CONDITIONS. PATIENT MAY BE RESP FOR AMT OVER THE ALLOWED AMT. EXCLUDED PROVIDER TYPES - 0Q,0T,0U,0V,0N A IND 47 50 23 .5 U N SPECIAL MEDICAL VISITS - INSTITUTIONAL SPECIALIST - 50% COVERAGE PAYMENT LEVEL OF ALLOWED AMOUNT FOR ALL PLACES OF TRTMNT. EXCLUDED CONDITION(S) ALCOHOLISM DIAGNOSIS/DRUG ADDICTION DIAGNOSIS/MENTAL DIAGNOSIS/NON-SERIOUS MENTAL ILLNESS. /PERVASIVE DEVELOPMENTAL DISORDERS/SERIOUS MENTAL ILLNESS INCLUDED PROVIDER TYPES - 0Q,0T,0U,0V,0N C IND 47 50 23 15000 U N SPECIAL MEDICAL VISITS - INSTITUTIONAL C FAM 47 50 23 45000 U N SPECIAL MEDICAL VISITS - INSTITUTIONAL D BENEFIT ABBREVIATIONS - 0Q=MEDICARE APPROVED ECF,SF=SKILLED NURSING,0T=MEDICARE APPROVED HOME HEALTH SERVICE (COORDINATED HOME CARE),0D=COORDINATED HOME CARE,0W=JOINT COMMISSION ON ACCREDITATION OF HOSPITALS (JCAH) APPROVED EXTENDED CARE FACILITY (ECF), 0O=EXTENDED CARE/SKILLED NURSING FACILITY,BY=NAPRAPATH UNSOLICITEABLE,B0=NAPRAPATH UNSOLICITEABLE,0U=MEDICARE APPROVED FREESTANDING DIALYSIS CENTER,0V=ST LIC AMBUL SURGICTR,0N=NON-PLAN PROVIDER C IND 30 29 2850 U Y DAILY ROOM AND BOARD;EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL CARE - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL;URGENT CARE INSTITUTIONAL;MUSCLE MANIPULATION - PROFESSIONAL;OFFICE VISIT - PROFESSIONAL;SPECIAL MEDICAL VISITS - INSTITUTIONAL C FAM 30 29 8550 U Y DAILY ROOM AND BOARD;EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL CARE - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL;URGENT CARE INSTITUTIONAL;MUSCLE MANIPULATION - PROFESSIONAL;OFFICE VISIT - PROFESSIONAL;SPECIAL MEDICAL VISITS - INSTITUTIONAL G FAM 30 29 13100 U Y DAILY ROOM AND BOARD;EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL CARE - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL;URGENT CARE INSTITUTIONAL;MUSCLE MANIPULATION - PROFESSIONAL;OFFICE VISIT - PROFESSIONAL;SPECIAL MEDICAL VISITS - INSTITUTIONAL G IND 30 29 6550 U Y DAILY ROOM AND BOARD;EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL CARE - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL;URGENT CARE INSTITUTIONAL;MUSCLE MANIPULATION - PROFESSIONAL;OFFICE VISIT - PROFESSIONAL;SPECIAL MEDICAL VISITS - INSTITUTIONAL F IND 33 29 P6 15 U W MUSCLE MANIPULATION - PROFESSIONAL 15 VISITS PER 1 YEAR CALENDAR BEGIN FOR ALL PLACES OF TRTMNT. THIS IS AN INDIVIDUAL BENEFIT MAXIMUM. INCLUDED PROVIDER TYPES - BY,B0 F IND 33 29 P6 25 U W MUSCLE MANIPULATION - PROFESSIONAL 25 VISITS PER 1 YEAR CALENDAR BEGIN FOR ALL PLACES OF TRTMNT. THIS IS AN INDIVIDUAL BENEFIT MAXIMUM. EXCLUDED PROVIDER TYPES - BY,B0 F IND 98 29 P6 15 U W OFFICE VISIT - PROFESSIONAL 15 VISITS PER 1 YEAR CALENDAR BEGIN FOR ALL PLACES OF TRTMNT. THIS IS AN INDIVIDUAL BENEFIT MAXIMUM. INCLUDED PROVIDER TYPES - BY,B0 F IND BZ 29 P6 15 U W PHYSICAL HISTORY - PROFESSIONAL 15 VISITS PER 1 YEAR CALENDAR BEGIN FOR ALL PLACES OF TRTMNT. THIS IS AN INDIVIDUAL BENEFIT MAXIMUM. INCLUDED PROVIDER TYPES - BY,B0 C IND 47 48 29 15000 U N DAILY ROOM AND BOARD C FAM 47 48 29 45000 U N DAILY ROOM AND BOARD C IND 51 29 2850 U N EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL C FAM 51 29 8550 U N EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL G FAM 51 29 13100 U N EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL G IND 51 29 6550 U N EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL C IND UC 29 2850 U N EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL C FAM UC 29 8550 U N EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL G FAM UC 29 13100 U N EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL G IND UC 29 6550 U N EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL C IND 52 29 2850 U N EMERGENCY MEDICAL CARE - PROFESSIONAL C FAM 52 29 8550 U N EMERGENCY MEDICAL CARE - PROFESSIONAL G FAM 52 29 13100 U N EMERGENCY MEDICAL CARE - PROFESSIONAL G IND 52 29 6550 U N EMERGENCY MEDICAL CARE - PROFESSIONAL C IND 86 29 15000 U N EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL C FAM 86 29 45000 U N EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL C IND 33 29 15000 U N MUSCLE MANIPULATION - PROFESSIONAL C FAM 33 29 45000 U N MUSCLE MANIPULATION - PROFESSIONAL C IND 98 29 15000 U N OFFICE VISIT - PROFESSIONAL C FAM 98 29 45000 U N OFFICE VISIT - PROFESSIONAL C IND BZ 29 15000 U N PHYSICAL HISTORY - PROFESSIONAL C FAM BZ 29 45000 U N PHYSICAL HISTORY - PROFESSIONAL C IND 47 50 29 15000 U N SPECIAL MEDICAL VISITS - INSTITUTIONAL C FAM 47 50 29 45000 U N SPECIAL MEDICAL VISITS - INSTITUTIONAL P 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 SUCH AS DEDUCTIBLE MAY CHANGE AS ADDITIONAL CLAIMS ARE PROCESSED. 250 0001 1 3042910 1 003042910