1. Group Health Employee/Plan Sponsor Liability
Surgical Claim (Partial Rotator Cuff Repair)
ICD10 Code: M75.111
Billed Charges: $20,750.00
Current PPO Plan Out of Network Market Based U&C
Allowed Amount $14,525.00* $20,750.00 $7,906.95
Deductible $2,500.00 $5,000.00 $2,500.00
Co-Insurance
Employee $2,405.00 (20%) $6,300.00 (40%) $1,081.39
Plan Sponsor $9,620.00 (80%) $9,450.00 (60%) $4,325.56
Total Payments
Employee $4,905.00 $11,300.00 $3,581.39
Plan Sponsor $9,620.00 $9,450.00 $4,325.56
Potential Savings
Employee $1,323.61 (27%) $7,718.61 (68%)
Plan Sponsor $5,294.44 (55%) $5,124.44 (54%)
*PPO Plan design allows 70% of charges
$9,620.00 $9,450.00
$4,325.56
$4,905.00
$11,300.00
$3,581.39
$6,225.00
$12,843.00
$0.00
$5,000.00
$10,000.00
$15,000.00
$20,000.00
$25,000.00
Current PPO Plan Out of Network Market Based U&C
Total Payments
Plan Sponsor Employee Disallowed

2. Date of
Service
Rev
Code
HRC Code Mod Description Units Billed
Customer
Red
BillChek
Red Allowed
Reason
Codes(s)*
/2015 490 23412 RT REPAIR ROTATOR CUFF CHRONIC 1.00 20,750.00 0.00 12,843.05 7,906.95 H210
Total Charges: 20,750.00
Customer Reductions: - 0.00
BillCheck Reductions: - 12,843.05
Recommended Allowance: 7,906.95
* Reason Code: H210 Reimbursement is based upon reasonable, usual and customary rate for the facility's geographic area.
Page: 1 of 13/25/2016 4:40 PM
Review & Recommendation
Claimant:
Provider:
Prov Pat No:
3/25/2016
11943917
/2015
ASC
CA
Received Date:
Site:
Bill Trak No:
Claim No:
Customer Doc No:
Date of Injury:
Reviewer:
Claim Type:
Treat State:
Tax ID:
TOS:
POS:
Notes:
NOT PROVIDED
Offsite Ref No:
24
ICD10 1:
2:
3:
4:
5:
M75.111

3. Group Health Employee/Plan Sponsor Liability
Digestive Health Claim
ICD9 Codes 211.3, 211.4, V12.72
Billed Charges $27,750
Current PPO Plan Market Based U&C
Allowed Amount $27,750 $2,499.90
Deductible $2,500 $2,500
Co-Insurance
Employee $4,350* (20%) $2,499.90
Plan Sponsor $20,900 (80%) -0-
Balance Billing -0- -0-
Total Payments
Employee $6,850 $2,499.90
Plan Sponsor $20,900 -0-
Potential Savings
Employee $4,350.10 (64%)
Plan Sponsor $20,900 (100%)
*Employee in network maximum limited to $6,850 under ACA 2016
$20,900.00
$6,850.00
$2,499.90
$25,250
$0.00
$5,000.00
$10,000.00
$15,000.00
$20,000.00
$25,000.00
$30,000.00
Current PPO Plan Market Based U&C
Total Payments
Plan Sponsor Employee Disallowed

4. Date of
Service
Rev
Code
HRC Code Mod Description Units Billed
Customer
Red
BillChek
Red Allowed
Reason
Codes(s)*
2014 490 45385 SG Colonoscopy, flexible, proximal to splenic
flexure; with removal of tumor(s), polyp(s), or
other lesion(s) by snare technique
1.00 12,950.00 0.00 11,283.40 1,666.60 H210
2014 490 45380 59 COLONOSCOPY AND BIOPSY 1.00 14,800.00 0.00 13,966.70 833.30 H201
Total Charges: 27,750.00
Customer Reductions: - 0.00
BillCheck Reductions: - 25,250.10
Recommended Allowance: 2,499.90
* Reason Code: H201 Allowed amount reflects secondary service(s) paid at 50% of reasonable, usual and customary allowance.
Reason Code: H210 Reimbursement is based upon reasonable, usual and customary rate for the facility's geographic area.
Page: 1 of 13/7/2016 12:51 PM
Review & Recommendation
Claimant:
Provider:
Prov Pat No:
9/1/2015
11442899
/2014
ASC
CA
Received Date:
Site:
Bill Trak No:
Claim No:
Customer Doc No:
Date of Injury:
Reviewer:
Claim Type:
Treat State:
Tax ID:
TOS:
POS:
Notes:
NOT PROVIDED
Offsite Ref No:
24
ICD9 1:
2:
3:
4:
5:
211.3
211.4
V12.72

5. Group Health Employee/Plan Sponsor Liability
Substance Abuse Rehabilitation Claim
ICD9 Codes 304.00, 292.0
Billed Charges: $16,800
Current PPO Plan Market Based U&C
Allowed Amount $16,800 $4,750.80
Deductible $2,500 $2,500
Co-Insurance
Employee $2,860* (20%) $450.16
Plan Sponsor $11,440 (80%) $1,800.64
Balance Billing -0- -0-
Total Payments
Employee $4,750.80 $2,950.16
Plan Sponsor $11,440 $1,800.64
Potential Savings
Employee $1,800.64 (38%)
Plan Sponsor $9,639.36 (84%)
*Employee in network maximum limited to $6,850 under ACA 2016
$11,440.00
$1,800.64
$4,750.80
$2,950.16
$609.20 $12,049.20
$0.00
$2,000.00
$4,000.00
$6,000.00
$8,000.00
$10,000.00
$12,000.00
$14,000.00
$16,000.00
$18,000.00
Current PPO Plan Market Based U&C
Total Payments
Plan Sponsor Employee Disallowed

6. Date of
Service
Rev
Code
HRC Code Mod Description Units Billed
Customer
Red
BillChek
Red Allowed
Reason
Codes(s)*
/2015 126 Detox/2 Bed 1.00 2,800.00 0.00 2,008.20 791.80 H210
/2015 126 Detox/2 Bed 1.00 2,800.00 0.00 2,008.20 791.80 H210
/2015 126 Detox/2 Bed 1.00 2,800.00 0.00 2,008.20 791.80 H210
/2015 126 Detox/2 Bed 1.00 2,800.00 0.00 2,008.20 791.80 H210
/2015 126 Detox/2 Bed 1.00 2,800.00 0.00 2,008.20 791.80 H210
/2015 126 Detox/2 Bed 1.00 2,800.00 0.00 2,008.20 791.80 H210
/2015 DIS 1.00 0.00 0.00 0.00 0.00 G113
Total Charges: 16,800.00
Customer Reductions: - 0.00
BillCheck Reductions: - 12,049.20
Recommended Allowance: 4,750.80
* Reason Code: G113 Payment based upon client's recommended allowance
Reason Code: H210 Reimbursement is based upon reasonable, usual and customary rate for the facility's geographic area.
Page: 1 of 13/7/2016 12:50 PM
Review & Recommendation
Claimant:
Provider:
Prov Pat No:
2/5/2016
11821980
/2015
IPH
CA
Received Date:
Site:
Bill Trak No:
Claim No:
Customer Doc No:
Date of Injury:
Reviewer:
Claim Type:
Treat State:
Tax ID:
TOS:
POS:
Notes:
NOT PROVIDED
Offsite Ref No:
21
ICD9 1:
2:
3:
4:
5:
304.00
292.0
CMS Provider:
DRG Reported:
DRG Accepted: 999