PSMI Health Plans PO Box 19002 Provo, UT 84605-9002 Toll Free: 800-557-5820 Fax: 801-356-0788
Claim #: 200311170001 Patient Acct: 00722T0P03
	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  DEFAS A. POST  PROFESSIONAL STAFF MANAGEMENT, INC  FUTURE VISION LAND  12/10/2003				Facility/Group Name: Provider/Dept Name: First Date of Service: Last Date of Service: Claim No: Check No:		PEDIATRIC CENTER  MCDONALD, RON MD  11/03/2003  11/03/2003  200311170001
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
Off Visit-PCP Office visit continued		60.00 44.00	56.30 28.78	IHC IHC	10.00 0.00	0.00 0.00	46.30 28.78	100% 100%	46.30 28.78	10.00 0.00
									75.08	10.00
Explanation of Codes: IHC: Network Discount - IHC IHC: Network Discount - IHC Claim received on 2003-11-10 and paid on 2003-12-10 Other Comments: If you have not already paid your portion, the health care provider's payment address is: MCDONALD, RON MD/PEDIATRIC CENTER: 35 NORTHLAND DRIVE SLC, UT 83210
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