PSMI Health Plans PO Box 19002 Provo, UT 84605-9002 Toll Free: 800-557-5820 Fax: 801-356-0788
Claim #: 19991026P001 Patient Acct: 00722T0P01
	POST, MARK 1234 AVENUE ROAD #12 APPLETON, UT 82216

Employee Explanation of Benefits Statement
Employee: Employee SSN: Patient Name: Group Name: Unit Name: Print Date:	MARK POST  111111111  MARK POST  PROFESSIONAL STAFF MANAGEMENT, INC  FUTURE VISION LAND  11/30/1999				Facility/Group Name: Provider/Dept Name: First Date of Service: Last Date of Service: Claim No: Check No:		MIDNIGHT PHYSICIANS  PAYNE, JANE MD  10/12/1999  10/12/1999  19991026P001
Services or Benefit Description		Billed Charges	Allowed or Contract Amt	Expl. Code	Co-Pay	Deductible	Total Covered Expenses	Plan Pays	Payable By Plan	Your Responsibility
Hosp ER (Prof)		65.00	0.00	27	0.00	0.00	0.00	0%	0.00	65.00
									0.00	65.00
Explanation of Codes: 27: No benefits when patient's coverage not in force Claim received on 1999-10-25 and paid on 1999-11-30 Other Comments: Coverage ended on 09 30 1998 If you have not already paid your portion, the health care provider's payment address is: PAYNE, JANE MD/MIDNIGHT PHYSICIANS: PO BOX 45020 EUREKA VILLA, UT 87501
NOTICE: Federal laws governing employee benefit plans give you the right to appeal if you do not agree with the manner in which this benefit payment was made. Your appeal must be in writing and must state clearly the reasons why you believe this payment is incorrect. You must also include any documentation or information which supports your appeal. The same federal laws require the Plan to respond to your appeal within 60 days from the date your appeal is received, or within 120 days under special circumstances.
DATA - Claim has not been adjudicated yet PEND - Claim has been pended to wait for additional information needed to adjudicate it PROC - Claim has been processed and is awaiting payment DONE - Claim has been paid