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P627402800N P627402800N

P.O. BOX 2459 SPOKANE, WA 99210-2459


201305102005 IO

11432 0.0104

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SUGANYA BAKTHAVATCHALU 197 HICKORY HEIGHTS DR BRIDGEVILLE, PA 15017-1077

95699515U00 Claim Number: SUGANYA BAKTHAVATCHALU Employee Name: SUGANYA BAKTHAVATCHALU Patient Name: MEMBER Relationship: Patient Account No.: 00452382 Plan Number: AMERINET INC Planholder: MICHAEL M BIANCO, DMD Provider: 05/10/13 Date:

INSURED EXPLANATION OF BENEFITS - THIS IS NOT A BILL Important! Save this statement for tax purposes.
Line No. 1 2 3 4 5 Submitted ADA Codes/Description D9220/GEN ANESTHESIA D7240/IMPACTION FBI D7240/IMPACTION FBI D7240/IMPACTION FBI D9221/ANESTHESIA +15 Alt Code Tooth No. 16 17 32 Date of Service 03/15/13 03/15/13 03/15/13 03/15/13 03/15/13 Submitted Charge 380.00 300.00 300.00 300.00 150.00 1430.00 Considered Charge 218.00 300.00 300.00 300.00 150.00 1268.00 Covered Charge 218.00 300.00 300.00 300.00 150.00 1268.00 Deductible Amount 50.00 Coverage Percent 90% 90% 90% 90% 90% 121.80 Benefit Amount 151.20 270.00 270.00 270.00 135.00 1096.20

TOTALS

50.00

BENEFIT SUMMARY TOTAL BENEFIT PAYABLE......... HIGHER ALLOWABLE.................. PAID BY OTHER INSURANCE..... ADJUSTMENTS............................... TOTAL BENEFIT PAID.................. PATIENT'S RESPONSIBILITY.....

$1096.20 $1268.00 $0.00 $0.00 $1096.20 $171.80

Year to Date Information


YOU HAVE REACHED $50.00 OF YOUR INDIVIDUAL DEDUCTIBLE OF $50.00 FOR BENEFIT YEAR BEGINNING 01/01/13. YOU HAVE REACHED $1,181.20 OF YOUR INDIVIDUAL MAXIMUM OF $1,200.00 FOR BENEFIT YEAR BEGINNING 01/01/13. Remarks: A DENTALGUARD PARTICIPATING DENTIST HAS BEEN UTILIZED YOU SAVED MONEY AND GOT MORE VALUE FROM YOUR DENTAL BENEFITS BY SEEING A GUARDIAN PARTICIPATING DENTIST. YOU HAVE USED $0.00 OF YOUR PERSONAL MAXIMUM ROLLOVER ACCOUNT. $400.00 REMAINS IN YOUR ACCOUNT

Payment Amount: $1,096.20 Payee:MICHAEL M BIANCO, DMD


Comments Current Dental Terminology 2012 American Dental Association. All rights reserved. This Explanation of Benefits does not reflect any payments you have made to the provider of services. Log on to www.GuardianAnytime.com for helpful, secure information about your Guardian benefits. Look up coverage amounts, check the status of a claim, print forms and plan materials and so much more! Fraud affects all of us! If you know or suspect that fraud is taking place, call us on our exclusive FRAUD HOTLINE 800-477-5908, Monday through Friday, 9:00 AM to 4:00 PM (Eastern Time), or visit our web site at http://www.GuardianAnytime.com (select "Contact Us" and then "Report Fraud"). You can access Guardian`s privacy notice on www.GuardianAnytime.com under the Privacy Policies link. CLAIMANTS RIGHT OF APPEAL You are entitled to receive, upon request and free of charge, copies of documentation and other relevant information related to your claim for benefits. You have a right to appeal this benefit decision by writing to Guardian within 180 days of receipt of this EOB. Guardian will review and notify you of its decision within 60 (disability appeals within 45) days (or less if your state requires a shorter response time) after receipt of your request. You have the right to bring a civil action under ERISA section 502(a) following an adverse benefit determination and you may have other alternative dispute resolution options under your plan. Contact your employer, the Department of Labor and/or the applicable state insurance regulatory agency for more information regarding your options and your rights under ERISA section 502(a).

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