HomeMy WebLinkAboutClaim #705 - D. NielsenX-c
CITY OF PALM DESERT
CITY CLERK DEPARTMENT
STAFF REPORT
REQUEST: CLAIM AGAINST THE CITY (#705) BY DIANE NIELSEN IN THE AMOUNT
OF $9,295.04
SUBMITTED BY: Rachelle Klassen, City Clerk
DATE: September 13, 2012
CONTENTS: • Staff Report
• Recommendations of Claims Adjusters and Staff
• Claim No. 705
Recommendation
By Minute Motion, reject the Claim and direct the City Clerk to so notify the
Claimant.
Background
Based on a review of the subject Claim and the recommendation of the Claims Adjuster,
Risk Manager, City Attorney, and staff, it is recommended that the Claim be rejected.
Discussion of this item should be held in Closed Session pursuant to Government Code Section
54956.9(b), potential litigation.
Fiscal Analysis
City of Palm Desert participates in the self-insurance pool of the California Joint Powers Insurance
Authority (CJPIA). Action to reject the subject Claim does not have a fiscal impact on the City at
this time.
Submitted by: Appr ved,
C
R the le D. Klassen, M ,City Clerk Jon ..0,
Wohlmuth, City Manager
rdk
Attachments (as noted) CITY C(WNCILACT N
APPROVED-'.._.,_._ nFNIED
RECEIVED OTHER
MEETING DATE L- I - :)L 0 I D--
AYES:
NOES: N(
ABSENT:
ABSTAIN:
VERIFIED BY. -
Original on File with City Clerk's Of Ice
0
2012 AUG 23 PH 12:42
(Allf, 11!A11Bl`N & C,()N'1VkNV
August 21, 2012
TO: The City of Palm Desert
ATTENTION: Rachelle D.Klassen, City Clerk
RE: Claim
Claimant
D/Event
Rec'd Y/Office
Our File
Nielsen vs. The City of Palm Desert
Diane Nielsen
12/8/2011
4/4/2012
S-1634336-PMQ
We have received and reviewed the above claim and request that you take the action indicated below:
CLAIM REJECTION: Send a standard rejection letter to the claimant.
Please provide us with a copy of the notice sent, as requested above. If you have any questions please
contact the undersigned.
Very truly yours,
CARL WARREN & COMPANY
Ri d D. Marque
cc: CJPIA w/enc.
Attn.: Executive Director
GOPYTO D'�r— ,
DATE
AN EMPLOYEE -OWNED COMPANY
770 S. Placentia Avenue i Placentia CA 92870
P. O. Box 25180 1 Santa Ana, CA 92799-51 P,0
wwvv carlwarren.crij, i Tel, 714-572-5200 1 800 5172-6900 1 Fax 866-254-44-)3
CA License No 260729f3
GPAOM D� OC'CE
2112 AUG 23 PM 12.- 43
uoe)k Ve6n
August 22, 2012
John M. Wohlmuth
Rachelle D. Klassen
City of Palm Desert
73-510 Fred Waring Drive
Palm Desert, CA 92260
Via U.S. Mail, Certified/Return Receipt
Dear Ms. Klassen & Mr. Wohlmuth:
The purpose in writing this letter is to put the city on formal notice of demand for
reimbursement of my out of pocket expenses due to an injury sustained in the Freedom Park
on Deember 8, 2011. My out of pocket expenses to date are $4,795.04 with an estimated
future expenses of $4,500.00 for the remaining surgery I have not had yet.
I previously advised you of this injury on March 22, 2012. 1 was then contacted by Peter
McNulty from Carl Warren & Company. Currently, after months of misinformation from him
on the responsible party, Mr. McNulty advises you have withdrawn your tender to Merchants
Landscape, the landscape contractor. Apparently, the language he thought was in the contract
cannot be found. I fail to see how your inability to place the liability elsewhere releases the
claim entirely. He advises me "our investigation is continuing". I have asked him the nature of
his investigation, but have received no response.
I can no longer put my life on hold or suffer possible further injury to the remaining wrist/hand
on which I have not had surgery.
COPY TO
S
DATE ;?- 3 --
City of Palm Desert 0 to Page 2
At this time, I am asking for nothing more than reimbursement of actual expenses (including
future) of $9,295.04 this would release you of all liability. However, if we cannot come to a
mutually agreeable conclusion to this, I will have to involve an attorney. As I'm sure you realize,
the monetary claim is bound to increase at that point. That really is not my intention but I have
been more than patient in this matter.
If you are formally denying this claim, I demand to be advised in writing.
Sincerely,
Diane Nielsen
E
Klassen, Rachelle
From:
Greenwood, Mark
Sent:
Monday, April 09, 2012 10:47 AM
To:
Klassen, Rachelle
Subject:
Claim No. 705
Rachelle,
It is recommended that Claim No. 705 be denied as there is no indication of the specific location or that the
sidewalk is out of compliance.
Mark Greenwood, P.E.
Director of Public Works
City of Palm Desert
RECEIVED
CITY CLER K 'S OFFICE CITY OF PALM DESERT
PALM DESERT. CA
. .5
CLAIM AGAINST THE CITY OF PALM DESERT ASSIGNED CLAIM NO.::2L
(For Damage(s) to Person(s) or Personal Property) ypl2 APR -4 PM I : 31
Received by:
via: U.S. Mail Interoffice Mail Over -the -Counter
A CLAIM MUST BE FILED WITH THE CITY CLERK OF THE CITY OF PALM DESERT WITHIN SIX
MONTHS AFTER WHICH THE INCIDENT OR EVENT OCCURRED. BE SURE YOUR CLAIM IS
AGAINST THE CITY OF PALM DESERT, NOT ANOTHER PUBLIC ENTITY. WHERE SPACE IS
INSUFFICIENT, PLEASE USE ADDITIONAL PAPER AND IDENTIFY INFORMATION BY
PARAGRAPH NUMBER. COMPLETED CLAIMS MUST BE MAILED OR DELIVERED TO THE CITY
CLERK, CITY OF PALM DESERT, 73-510 FRED WARING DRIVE, PALM DESERT, CA 92260.
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Palm Desert, California:
The undersigned respectfully submit(s) the following claim and information relative to damage(s) to
person(s) and/or personal property:
1. CLAIMANT INFORMATION:
NAME
rid
PHONE NO --.I DATE OF BIRTH: —
SOCIAL SECURI, r NO. - - DRIVER'S LICENSE RT.�
2. Name, telephone number and post office address to which claimant desires notices to be
sent, if other than above: I
3. Occurrence or event from which the claim arises:
a. DATE: I oZ 1 J?. TIMFx /a!3 O c. PLACE (exact and specific
d. How and under what circumstances did damage or injury occur? Specify the particular
occurrence, event, act or ommialon you claim c;ayse�d the i j�{ry or damage. (Use
additional paper if necessary.) -,I- fLAnj W!)11 t t?r �Il.o 'Paz .L
e. What particular action by tke City, ,,o,m�it""s
injury? AD Inaa� �( �
Page 1 of 2
caused the alleged damage or
4. Give a general description of the indebtedness, obligation, injury, damage, or loss incurred
so far as it may be known at t time of prese tation of the claim If there were no
inj ies, state "no 1Juries � e i .L
5. Give the name(s) of the City employee(s) causing the damage or injury:
6. Name and address of any other person(s) injured:
7. Name and address of the owner of any damaged property:
S. Damages claimed:
a. Amount claimed as of this date:
b. Estimated amount of future costs:
c. Total amount claimed:
d. Basis for computation of amounts
estimates, etc.): C'.Laai"fb
9.
es,
10. Any additional information, including police reports, which might be helpful in considering
this claim:
WARNING:IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM! PENAL CODE 72;
INSURANCE CODE 556.1).
I have read the matters and statements made in the above claim, and I know the same to be true of
my own knowledge, except as to those matters stated upon information or belief as to such matters
I believe the same to be true. I certify under penalty of perjury that the foregoing is TRUE AND
CORRECT.
Signed this � day of , 20; at.r
SIGNATURE OOFCLAIMAINT SIGNATURE OF CLAIMAN
Office of the City Clerk, Palm Desert, California DOC. NO. DATE FILED
Page 2 of 2
0
March 22, 2012
CITY OF PALM DESERT
City Hall — Risk Management
73-510 Fred Waring Drive
Palm Desert, CA 92260
Attention: Mr. Stephen Aryan
Risk Manager
Re: Diane M. Nielsen
Date of Loss December 8, 2011
Location - Freedom Park, Palm Desert, CA
Dear Mr. Aryan:
On December 8, 2011, Van Tanner, of my office, notified Gary Greenwood by telephone of the slip and
fall at the Freedom Park resulting in injuries to my hands, shoulder and knee.
This fall resulted from a raised walkway at the Park which was subsequently inspected by the City and
repaired.
The fall caused injuries resulting in medical treatment and on -going nerve damage particularly to my
hands. Attached you will find bills, Explanation of Benefits and prescriptions receipts which are being
remitted for claim reimbursement.
Please contact me at your earliest convenience to discuss this matter and expedite my claim. Thank
you.
Diane M. Nielsen
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Anthem.9!
Health. Join In. "wt "
P.O. BOX 70000
VAN NUYS, CA 91470-0001
1JALAYU1:1 t1UM i" 201211:11 U11uu ibuti
20120225 000175 Env 17,03711 of 9
EXPLANATION OF BENEFITS uuvia
ISSUE DATE PAGE E065637
February 24, 2012 00001 OF 00003
IIIII"1'��II'1�1"��111'����11111'I�'ll�'1'I�II�IIII���J��III�I Subscriber's Ham:
Identification Number:
******************AUTO**3-DIGIT 922 Group Number:
7037 2 AT 0'.374 32 Group Name:
DIANE M. NIELSEN
Product:
DIANE M. NIELSEN
SMALL GROUP PPO
F101
Sequence Number: 1508967763 201200542
Patient's Name: DIANE NIELSEN Provider of Services: DESERT ORTHOPEDIC CENTER
Claim Number: 12054ST1341 Place of Service: Outpatient
Claim Processed Date: 02124112 Patient Acct. Number: A002556790
Claim Received Date: 02/23112 This claim was processed in 1 day.
Paid Amount: $0.00
It is your responsibility to pay: $187.93 It is not your responsibility to pay: $347.06
Thank you for usina a Network Particioatina Pravider_
SERVICE
DATE(s)
TYPE OF SERVICE
TOTAL
BILLED
OTHER
AMOUNTIS)
PATIENT
SAVINGS
APPLIED TO
DEDUCTIBLE
COINSURANCE
COPAYMENT
AMOUNT
CLAIMS
PAYMENT
02117112
Office Visit
167.76
94.37/01
63.30102
0.00
02117112
SURGERY-BONEIMUSCLE
188.62
106.69101
83.03102
0.00
02117112
1 SURGERY-SONEIMUSCLE
188.62
147.10101
41.62102
0.00
TOTAL THIS CLAIM
634.99
0.00
347.06
187.93
0.00
0.0061
Member's Medical Deductible Applied to Date: $323.99
DETAIL MESSAGE:
01 - This is the amount in excess of the allowed expense for a participating provider. Thej
member, therefore, is not responsible for this amount.
02 - This amount has been applied to the member's medical deductible.
* You can learn more about the services listed by calling the customer service phone
number on the back of your ID card. We can tell you the diagnosis and treatment
codes included on your claim, along with the descriptions for those codes.
FOR INFORMATION CALL: CUSTOMER SERVICE DEPARTMENT AT: (800) 627-8797
VISIT US ON THE INTERNET AT WWW. ANTFHIEM, ccONNMlCA
MAIL ALL INQUIRIES ANTHEM BLUE CROSS
OR CLAIMS TO P 0 BOX 60007
LOS ANGELES, CA 90060-0007
Williams
I N(7)""I" 1 L
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Lift and Health Insurance Company are independent licensees of the Blue Cross
Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies,inc The Blue cross nano and symbol are registered marks of the Blue Cross Association.
Nnthem .0!
Health. Join In. '" "-
20120302 009862 Env 11,03714 of 9
GLLYY
EXPLANATION OF BENEFITS
P O BOX 70000
VAN NUYS. CA 91470-0001
ISSUE DATE E: PAGE E047891
March 1, 2012 00001 OF 00003
Subscriber's N — : DIANE M. NIELSEN
Identification Number:
******************AUTO**3-DIGIT 922 Group Number:
7037 2 AT 0.374 32 Group Name: SMALL GROUP PPO
IDSAIweh1 MELSiN
Product: PPO
Sequence Number: 1013981554 201201284
Patient's Name: DIANE NIELSEN Provider of Services: EISENHOWER EXPRESS CLINIC
Claim Number: 1205BOW1213 Place of Service: Office
Claim Processed Date: 02127112 Patient Acct. Number: 000523217NFBC
Claim Received Date: 02127112 This claim was processed in 1 day.
Paid Amount: $56.96 To: EISENHOWER EXPRESS CLINIC
It is your responsibility to pay: $30.00 It is not your responsibility to pay: $122.04
Thank you for usina a Network Particinatine Provider.
COINSURANCE
SERVICE
TYPE OF SERVICE
TOTAL
OTHER
PATIENT
APPLIED TO
COPAYMENT
CLAIMS
DATE W
BILLED
AMOUNT(S)
SAVINGS
DEDUCTIBLE
AMOUNT
PAYMENT
02114112
Office Visit
209.00
122.04101
30.00102
56.96
TOTAL THIS CLAIM
209.00
0.00
122.04
0.00
30.00
66.96'
Member's Medical Deductible Applied to Date: $323.9
DETAIL MESSAGE:
01 - This is the amount in excess of the allowed expense for a participating provider. The
member, therefore, is not responsible for this amount.
02 - This amount is the Home and Office copayment amount specified by the terms of the
member's benefit agreement.
* You can learn more about the services listed by calling the customer service phone
number on the back of your ID card. We can tell you tfie diagnosis and treatment
codes included on your claim, along with the descriptions for those codes.
FOR INFORMATION CALL: CUSTOMER SERVICE DEPARTMENT AT: (800) 627-8797
VISIT US ON THE INTERNET AT WWW.ANTHEM.COMICA
MAIL ALL INQUIRIES ANTHEM BLUE CROSS
OR CLAIMS TO P 0 BOX 60007
LOS ANGELES, CA 90060-0007
English: If you need assistance in Spanish to understand this document,. you may request it
for free by calling customer service at the number on your identification card or in your
enrollment booklet.
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross
Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies,lnc. The Blue cross name and symbol are registered marks of the Blue Cross Association.
VAt:At UWc%VVV* W LU1LUj1UtlUUJbdb
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VAN NUYSOCA1���� 91470.0001 EXPLANATION OF BENEFITS
ISSUE DATE PAGE E044905
h Marc7, 2012 E
00001 OF 00003
11111i1'11I6'116111II'11��IIIII'1�'ll�'I'1�11�1111a��Ja�lll�l Subscribor's Name:
Identification Number:
******************AUTO**3-DIGIT 422 Group Number:
7037 2 AT 0.374 32 Group Mama:
DIANE M. NIELSEN
Product:
DIANE M. NIELSEN
SMALL GROUP FPO
PPO
Sequence Number: 1013981554 201201931
Patient's Name: DIANE NIELSEN Provider of Services: EISENHOWER MEDICAL CENTER
Claim Number: 12067CB8880 Place of Service: Outppatient
Claim Processed Date: 03107112 Patient Acct. Number: 1206001423
Claim Received Date: 03107112 This claim was processed in 1 day.
Paid Amount: $0.00
It is your responsibility to pay: $95.37 It is not your responsibility to pay: $311.13
COINSURANCE
SERVICE
TYPE OF SERVICE
TOTAL
OTHER
PATIENT
APPLIED TO
COPAYMENT
CLAIMS
DATE W
BILLED
AMOUNT(S)
SAVINGS
DEDUCTIBLE
AMOUNT
PAYMENT
02117112
Drug Non -Oral Admin
17.50
7.00101
10.60102
0.00
02117/12
SURGERY-BONE/MUSCLE
389.00
304.13101
84.87102
0.00
TOTAL THIS CLAIM
406.60
0.00
311.13
96.37
0.00
0.00,
Member's Medical Deductible
lied to Date: $419.36
DETAIL MESSAGE:
01 - This is the amount in excess of the allowed expense for a participating provider. The
member, therefore, is not responsible for this amount.
02 - This amount has been applied to the member's medical deductible.
* You can learn more about the services listed by calling the customer service phone
number on the back of yourID card. We can tell you the diagnosis and treatment
codes included on your claim, along with the descriptions for those codes.
FOR INFORMATION CALL: CUSTOMER SERVICE DEPARTMENT AT: _(800)627-8797
VISIT US ON THE INTERNET AT WWW.ANTHHEM.c_ICA
MAIL ALL INOUIRIES ANTHEM BLUE CROSS
OR CLAIMS TO P 0 BOX 60007
LOS ANGELES, CA 90060-0007
English: If you need assistance in Spanish to understand this document, you ma request it
for free by calling customer service at the number on your identification cardyor in your
enrollment booklet.
T "i �I E36 I L�
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licans»s of the Blue Cross
Association. ® ANTHEM is a registered trademark of Anthem Insurance Companios.inc. The Blue cross nano and symbol are registered marks of the Blue Cross Association.
EISENHOWER MEDICAL CENTER
39000 BOB HOPE DR.
RANCHO MIRAGE, CA 92270
Patient Name: DIANE MARIE NIELSEN
Medical Record Number: 00058800
lll'�III�II�I����II�IIIIIIIIIIIIII�iII'�lll�ll�ll'I���III1I1��1 943M207
DIANE MARIE NIELSEN
Please check box it above address is incorrect or insurance
Information has changed, and indicate change(s) on reverse side.
Account Patient
Number Name
A1202400999 DIANE MARIE NIELSEN
Billed Charges
Total Adjustments
Total Insurance Payments
Total Patient Payments
F PAYM BY vlsA MASTERCARD, DISCOVER OR NIIERMN OIPRESS, RLL our BELOW
❑vim = ❑MAOrERCARD = ❑DISCOVER RM ❑AMER.EMM
CAM NUMSER
M"ATz AMOUNT
SIONATN!
MUST INCLUDE 9 DIGIT
SECURITY CODE FROM
O�CAM
CARDHOLDERSBACK
NAME:
STATEMENT DATEt
PAY THIS AMOUNT
ACCOUNT NO.
02/12/12
$70.41
SHOW AMOUNT
PAID HERE
mosmimmo MAKE CHECKS PAYABLE / REMIT TO:
EISENHOWER MEDICAL CENTER
DEPT. NO. 7969
LOS ANGELES CA 90084-0001
II�I�III�IIII���II�I��I��III���II��III��II�TIII�I�rl�l��l1��11
Account Balance
Estimated Insurance Liability
Patient Responsibility
PLEASE DETACH AND RETURN TOP PORTION WITH
YOUR PAYMENT IN ENCLOSED ENVELOPE
Admit Discharge Pat F
Date Date Type C
01/06/12 01/06/12 OOP SI
167.00
96.59CR
0.00
0.00
70.41
0.00
70.41
Thank you for choosing Eisenhower Medical Center for your healthcare needs.
Our records indicate that the balance listed above is due at this time.
If you have questions regarding the balance due, or additional insurance
information that may be necessary to resolve this balance, please contact
our business office at (800) 453-6012 and a representative will assist you.
DIANE MARIE NIELSEN
Eisenhower Medical Center
Medical Service
EDOC OFFICE VISIT
Attending Physician
ALLEN,ANDREW C
PLEASE RETAIN FOR YOUR RECORDS
AMOUNT DUE
$70.41
STATEMENT
m111111111111111111111ith1111111111111111Jill 111 SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION
- DESERT
ORTHOPEDIC
CENTER
STATEMENT
ADDRESSEE:
1111111Igo gill 111i11
Nielsen, Diane
O Please check box if above address is incorrect or insurance information has
changed, and indicate change(s) on reverse side.
IF PAYING BY CREDIT CARD, FILL OUT BELOW
CHECK CARD USING FOR PAYMENT
®AMERICAN EXPRE DISCOVEF� MASTERCAR ..� 4 VISA
CARD NUMBER
CW
AMOUNT
SIGNATURE
EXP. DATE
E
01/27/12
PAY THIS AMOUNT
$74.27
ACCOUNTNBR
177259
SHOW AMOUNT
PAID HERE $
REMIT TO:
Desert Orthopedic Center
39000 Bob Hope Dr
Rancho Mirage, CA 92270
PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMEN'
(760)568-2684
DESCRIPTION OF
INSUR
PATIENT
I
INSUR
PATIENT
DATE
PATIENT�PROVIDERJERVIC
SERVICE
CHARGE
RECEIPT
RECEIPT
ADJUST
BALANCE
BALANCE
12/16/11
Diane Allen
Co a Co a Collected
0.00
30.00 30.00 0.00 $0.00
12/16/1
ane Allen
992
ce out atient vis'
$99.14
.9 .00 12.49
t) 6
iane Allen
Ce out aUent vl It est. ex...
=0.00 $94.37 0. 3
Thank vou for chosing DOC for
Xgur medical care.
1111 IN
YCOMPANYM3URANCE �<.
. "
ALREADD ,gyp
T
,1 �l
S HARE OF YOUR BILL ,s'
Thfs statement is for the
amount yau owe. .
�,.f
ACCOUNT NBR
CURRENT
30 DAYS
60 DAYS
90 DAYS
120 DAYS
TOTAL ACCOUNT BALANCE
177259
$74.27
$0.00
$0.00
$0.00
$0.00
$74.27
MESSAGE:
Billing Questions Contact (760) 766-1239 PLEASE PAY
THIS AMOUNT »»»» $74.27
" PAYMENT DUE UPON RECEIPT' THANK YOU "
STATEMENT PAGE:1
W hem-0
Health. Join In. 1 —
P 0 Box 70000
VAN NUYS. CA 91470.0001
�.nrnru��o�rru �• cuc vcvoaawmv
20120131 011117 Env 18,1381 1 of 3
zv5zb
EXPLANATION OF BENEFITS
ISSUE DATE PAGE E058137
January 30, 2012 00001 OF 00003
sillSubscriber's Name: DIANE M. NIELSEN
Identification Number:
****************AUTO**5-DIGIT 92253 Group Number:
8138 1 AV 0.350 42 Group Name: SMALL GROUP PPO
DIANE M NIELSEN
Patient's Name: DIANE NIELSEN
Claim Number: 12030BY1084
Claim Processed Date: 01130112
Claim Received Date: 01130112
Product:
PPO
Sequence Number: 1013981554 201200827
Provider of Services: EISENHOWER MEDICAL CENTER
Place of Service: Outppatient
Patient Acct. Number: 1202400999
This claim was processed in 1 day.
Paid Amount: $0.00
It is your responsibility to pay: $72.68 It is not your responsibility to pay: $94.32
COINSURANCE
SERVICE
TYPE OF SERVICE
TOTAL
OTHER
PATIENT
APPLIED TO
COPAYNENT
CLAIMS
DATE(s)
BILLED
AMOUNT(S)
SAVINGS
DEDUCTIBLE
AMOUNT
PAYMENT
01106/12
Office Visit
167.00
94.32101
72.68102
0.00
TOTAL THIS CLAIM
167.00
0.00
94.32
72.68
0.00
0.00,
Member's Medical Deductible Applied to Date: $136.06
DETAIL MESSAGE:
01 - This is the amount in excess of the allowed expense for a participating provider. The
member, therefore, is not resppoonsible for this amount.
02 - This amount has been ap lied to the member's medical deductible.
You can learn more abou the services listed by calling the customer service phone
number on the back of yourID card. We can tell you the diagnosis and treatment
codes included on your claim, along with the descriptions for those codes.
FOR INFORMATION CALL: CUSTOMER SERVICE DEPARTMENT AT: 800 627-8797
VISIT US ON THE INTERNET AT WWW.ANTHEM.COMICA
MAIL ALL INQUIRIES ANTHEM BLUE CROSS
OR CLAIMS TO P 0 BOX 60007
LOS ANGELES, CA 90060-0007
English: If you need assistance in Spanish to understand this document,, you ma request it
for free by calling customer service at the number on your identification card yor in your
enrollment booklet.
0
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross
Association 0 ANTHEM is a registered trademark of Anthem Insurance Companiss.Inc The Blue cross name and symbol are registered marks of the Blue Cross Association
knLhem.m!
Health. Join In. u"`""
P O BOX 70000
VAN NUYS. CA 91470-0001
l.McnruuWO vWQ ij tVllul 1LGwjl
20120111009M - Env111.07814 of
GYLYJ
EXPLANATION OF BENEFITS
ISSUE DATE PAGE E046274
January 10, 2012 00001 OF 00003
'IfIIIIIIIIIdI�IIu��'IIf1111�1III Billie lSubscriber's Militia: DIANE M. NIELSEN
Identification Number:
******************AUTO**3-DIGIT 922 Group Number:
11078 2 AT 0.490 50 Group Nana: SMALL GROUP PPO
DIANE M. NIELSEN
_ Product: PPO
Sequence Number: 1508967753 201200085
Patient's Name: DIANE NIELSEN Provider of Services: DESERT ORTHOPEDIC CENTER
Claim Number: 120108MOS71 Place of Service: Outpatient
Claim Processed Date: 01110112 Patient Acct. Number: A002538751
Claim Received Date: 01110/12 This claim was processed in 1 day.
Paid Amount: $0.00
It is your responsibility to pay: $63.38 It is not your responsibility to pay: $94.37
Thank unit fnr utxinn a Nettatnrk Partininatinn Prnvider_
COINSURANCE
SERVICE
TYPE OF SERVICE
TOTAL-
OTHER
PATIENT
APPLIED TO
COPAYMENT
CLAIMS
DATEIs)
BILLED
AMOUNTIS)
SAVINGS
DEDUCTIBLE
AMOUNT
PAYMENT
01106112
Office Visit
167.76
94.37101
63.38102
0.00
TOTAL THIS CLAIM
167.75
0.00
94.37
63.39
0.00
0.00'
Member's Medical Deductible Applied to Date: $63.38
DETAIL MESSAGE:
01 - This is the amount in excess of the allowed expense for a participating provider. The
member, therefore, is not responsible for this amount.
02 - This amount has been applied to the member's medical deductible.
* You can learn more about the services listed by calling the customer service phone
number on the back of yourID card. We can tell you the diagnosis and treatment
codes included on your claim, along with the descriptions for those codes.
FOR INFORMATION CALL: CUSTOMER SERVICE DEPARTMENT AT: (800) 627-8797
VISIT US ON THE INTERNET AT WWANTHEWCOMICA
MAIL ALL INQUIRIES ANTHEM BLUE CROSS
OR CLAIMS TO P 0 BOX 60007
LOS ANGELES, CA 90060-0007
English: If you need assistance in Spanish to understand this document,you may request it
for free by calling customer service at the number on your identification card or in your
enrollment booklet.
dwrai A 1 '* L
pw"&M 4""' N 0 T A 8
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross
Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies,Inc. The Blue cross name and symbol are registered marks of the Blue Cross Association
4nthern"10.
Health. Join In.1°"r"-
P O BOX 70000
VAN NUYS. CA 91470-0001
..nu+r.n.a ovoo �. cvi i �cu�ow �.oa
20111226 010687 Env 111.47114 of 6
EXPLANATION OF BENEFITS Z/ /511
ISSUE DATE PAGE E049881
December 24, 2011 00001 OF 00003
fs'11lilt Subscriber's Nerve: DIANE H. NIELSEN
Identification Number:
******************AUTO**3-DIGIT 922 Group Number:
11471 2 AT 0.490 48 Group Heme: SHALL GROUP PPO
DIANE M. NIELSEN
Product: PPO
Sequence Number: 1508967753 201103246
Patient's Name: DIANE NIELSEN Provider of Srvices: DESERT ORTHOPEDIC CENTER
Claim Number: 11355BOB189 Place of Service• Outpatient
Claim Processed Date: 12122/11 Patient Acct. Number: A002532134
Claim Received Date: 12121111 This claim was processed in 1 day.
Paid Amount: $165.41 To: DESERT ORTHOPEDIC CENTER
It is your responsibility to pay: $70.89 It is not your responsibility to pay: $382.86
Thank you for using a Network Particioatina Provider.
SERVICE
DATEIs)
TYPE OF SERVICE
TOTAL
BILLED
OTHER
AMOUNTIS)
PATIENT
SAVINGS
APPLIED TO
DEDUCTIBLE
COINSURANCE
COPAYMENT
AMOUNT
CLAIMS
PAYMENT
12116111
Office Visit
399.63
267.90101
42.49102
99.14
12116111
SURGERY-BONEIMUSCLE
188.62
106.69101
24.91102
68.12
12116111
Radiology -Extremity
31.01
19.37101
3.49102
8.16
TOTAL THIS CLAIM
619. 16
0.00
382.86
0, 00
70. 89
165. 41'
Member's Medical Deductible Applied to Date: $500.00
DETAIL MESSAGE:
01 - This is the amount in excess of the allowed expense for a participating provider. The
member, therefore is not responsible for this amount.
02 - This balance is the member's coinsurance responsibility.
* You can learn more about the services listed by callingg the customer service phone
number on the back of yourID card. We can tell you tfie diagnosis and treatment
codes included on your claim, along with the descriptions for those codes.
FOR INFORMATION CALL: CUSTOMER SERVICE DEPARTMENT AT: (800) 627-8797
VISIT US ON THE INTERNET AT WWW.ANTHEN.ICA
MAIL ALL IN()UIRIES ANTHEM BLUE CROSS
OR CLAIMS TO P 0 BOX 60007
LOS ANGELES, CA 90060-0007
'00""T A 01003"' 1 L L
T H 1 1"" 11
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Lifs and Health Insurance Company are independent licenswa of the Blue Cross
Association. 0 ANTHEM is a registered trademark of Anthem Insurance Compeniea,lnc. The Blue cross nams and symbol are registered marks of the Blue Cross Association.
knthem.0
Health. Join In. u* ""
P o eox 70000
VAN NUYS. CA 91470-0001
I:AtAVUU/ UUYV, �f� 2101LU1Ln000 JL.all
20120119 007529 Env 122,47911 of 3
iysit
EXPLANATION OF BENEFITS
ISSUE DATE PAGE E038451
January 18, 2012 00001 OF 00003
�a�ll�ai�aalll�llirlllrl�li�l���ld�e��i4la�diil�a��n,,,,l Subscriber's Made:
Identification Number:
******************AUTO**3-DIGIT 922 Group Number:
22479 1 AT 0.374 69 Group Neme:
DIANE M. NIELSEN
Product:
DIANE M. NIELSEN
SMALL GROUP PPO
PPO
Sequence Number: 1013981554 201200499
Patient's Name: DIANE NIELSEN Provider of Services: EISENHOWER MEDICAL CENTER
Claim Number: 12017CE5637 Place of Service: Outpatient
Claim Processed Date: 01117/12 Patient Acot. Number: 1201200225
Claim Received Date: 01117112 This claim was processed in 1 day.
Paid Amount: $110.48 To: EISENHOWER MEDICAL CENTER
It is vour responsibilitv to pav: $47.34 It is not vour responsibility to pav: $333.93
SERVICE
DATEIs1
TYPE OF SERVICE
TOTAL
BILLED
OTHER
AMOUNT(S)
PATIENT
SAVINGS
APPLIED TO
DEDUCTIBLE
COINSURANCE
COPAYMENT
AMOUNT
CLAIMS
PAYMENT
12116111
Drug Non -Oral Admin
8.76
3.66101
1.63102
3.57
12116/11
Radiology -Extremity
94.00
26.16101
20.36102
47.50
12116111
SURGERY-BONE/MUSCLE
389.00
304.13101
26.46102
59.41
TOTAL THIS CLAIM
491.76
0.00
333.93
0.00
47.34
110.48'
Member's Medical Deductible Applied to Date: $500.00
DETAIL MESSAGE:
01 This is the amount in excess of the allowed expense for a participating provider. The
member, therefore is not responsible for this amount.
02 - This balance is the member's coinsurance responsibility.
* You can learn more about the services listed by calling the customer service phone
number on the back of yourID card. We can tell you the diagnosis and treatment
codes included on your claim, along with the descriptions for those codes.
FOR INFORMATION CALL: CUSTOMER SERVICE DEPARTMENT AT: 800 627-8797
VISIT US ON THE INTERNET AT WWW.ANTHEM.COMICA
MAIL ALL INQUIRIES ANTHEM BLUE CROSS
OR CLAIMS TO P 0 BOX 60007
LOS ANGELES, CA 90060-0007
English: If you need assistance in Spanish to understand this document,, you ma request it
for free by calliBTLL
T
vi Is our ide ' i io cardyor in your
enrollment booklet. T "I'll,
Anthem SILO Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licenaess of the Blue Cross
Association. 4D ANTHEM is a registered trademark of Anthem Insurance Companies,Irc. The Blue cross name and symbol are registered marks of the Blue Cross Association.
Anthem.*
Health. Join In. fu-c—
P O. BOX 70000
VAN NUYS. CA 91470.0001
CAEAP013 BOWS Ry" ,`,` 20111231800 J789
20111224 014008 Env 111,47111 of 6
JbYY9
EXPLANATION OF BENEFITS
ISSUE DATE PAGE E07475;
December 23, 2011 00001 OF 00003
�IIn��111gIJJllildll�g�lag'llll'�'�I�Is�ll�l�ll�'Id'u��'In Subscriber's Nam: DIANE M. NIELSEN
Identification Number:
******************AUTO**3-DIGIT 422 Group Number:
11471 2 AT 0.490 48 Group Name: SMALL GROUP PPO
DIANE M. NIELSEN
Product: PPO
Sequence Number: 1568416147 201101379
Patient's Name: DIANE NIELSEN Provider of Services: DESERT ADVANCED IMAGING
Claim Number: 11354CF6008 Place of Service: Office
Claim Processed Date: 12120111 Patient Acct. Number: 602459136
Claim Received Date: 12120111 This claim was processed in 1 day.
Paid Amount: $22.11 To: DESERT ADVANCED IMAGING
It is your responsibility to pay: $9.48 It is not your responsibility to pay: $58.41
Thank you for using a Network Particioatina Provider.
COINSURANCE
SERVICE
TYPE OF SERVICE
TOTAL
OTHER
PATIENT
APPLIED TO
COPAYMENT
CLAIMS
DATE(s)
BILLED
AMOUNT(S)
SAVINGS
DEDUCTIBLE
AMOUNT
PAYMENT
12109111
Radiology -Extremity
90.00
68.41101
9.48/02
22.11
TOTAL THIS CLAIM
90.00
0.00
68.41
0.00
9.48
22.116
Member's Medical Deductible Applied to Date: $500.00
DETAIL MESSAGE:
01 - This is the amount in excess of the allowed expense for a participating provider. The
member, therefore is not responsible for this amount.
02 - This balance is the member's coinsurance responsibility.
* You can learn more about the services listed by calling the customer service phone
number on the back of yourID card. We can tell you the diagnosis and treatment
codes included on your claim, along with the descriptions for those codes.
FOR INFORMATION CALL: CUSTOMER SERVICE DEPARTMENT AT: _(800) 627-8797
VISIT US ON THE INTERNET AT WWW.ANTTHEM.COM1CA
MAIL ALL INOUIRIES ANTHEM BLUE CROSS
OR CLAIMS TO P 0 BOX 60007
LOS ANGELES, CA 90060-0007
English: If you need assistance in Spanish to understand this document, you may request it
for free by calling customer service at the number on your identification card or in your
enrollment booklet.
AMOM
'T I , A, %`3
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life, and Health Insurance Company are independent licensees of the Blue Cross
Association. 0 ANTHEM is a registered trademark of Anthem Insurance Companies,fnc. The Blue cross name and symbol are registered marks of the Blue Cross Association.
Anthem.9
Health. Join In. "M`r'--
P O BOX 70000
VAN NUYS, CA 91470.0001
% ACMYWr UVWO [U1LU1 lznuu J101/0
20120108 008538 Env 111,07811 of 6
Z1 bIlY
EXPLANATION OF BENEFITS
�1i�1111�111'II'��'" ��IhI111ah11uJfJuu'�I'91�'�11"I�11�
******************AUTO**3-DIGIT 922
11078 2 AT 0.490
DIANE M. NIELSEN
ISSUE DATE PAGE E040005
January 7, 2012 00001 OF 00003
Subscriber's Haws: DIANE N. NIELSEN
Identification Number: "-
Group Number:
50 Group Nam: SNALL GROUP PPO
Product:
f7i7
Sequence Number: 1013981554 201200063
Patient's Name: DIANE NIELSEN Provider of Services: EISENHOWER EXPRESS CLINIC
Claim Number: 12004BR5900 Place of Service: Office
Claim Processed Date: 01104112 Patient Acct. Number: 000463168NFBC
Claim Received Date: 01104/12 This claim was processed in 1 day.
Paid Amount: $56.96 To: EISENHOWER EXPRESS CLINIC
It is your responsibility to a $30.00 It is notyourresponsibility to pay: $122.04
Thank you for usina a Network Particioatina Provider.
COINSURANCE
SERVICE
TYPE OF SERVICE
TOTAL
OTHER
PATIENT
APPLIED TO
COPAYMENT
CLAIMS
DATE(s)
BILLED
AMOUNTIS)
SAVINGS
DEDUCTIBLE
AMOUNT
PAYMENT
11129111
office Visit
209.00
122.04101
30.00102
66.96
TOTAL THIS CLAIM
209.00
0.00
122.04
0.00
30.00
66. 96'
Member's Medical Deductible Applied to Date: $500.00
DETAIL MESSAGE:
01 - This is the amount in excess of the allowed expense for a participating provider. The
member, therefore, is not responsible for this amount.
02 - This amount is the Home and Office copayment amount specified by the terms of the
member's benefit agreement.
* You can learn more about the services listed by calling th customer service phone
number on the back of your ID card. We can tell you the d7agnosis and treatment
codes included on your claim, along with the descriptions for those codes.
FOR INFORMATION CALL: CUSTOMER SERVICE DEPARTMENT AT: (800) 627-8797
VISIT US ON THE INTERNET AT WWW.ANTHEM.COMICA
MAIL ALL INQUIRIES ANTHEM BLUE CROSS
OR CLAIMS TO P 0 BOX 60007
LOS ANGELES, CA 90060-0007
English: If you need assistance in Spanish to understand this document you may request it
for free by calling customer service at the number on your identification card or in your
enrollment booklet.
Anthsm Blue Cross is the trade name, of Blue Cross of California. Anthem BlueCross and Anthem Blue Cross Life and Health Insurance Company are Independent licensees of the Blue Cross
Association- m ANTHEM is a registered trademark of Anthem Insurance Companiss,lnc. The Blue crop name and symbol are registered marks of the Blue Cross Association.