Claim 820220130515734

Status: Completed

JAMES M DRISKILL

Provider: OBAKHUME, CHINYERE ANTHONIA PMHNP

: Out of network
Date of service: Jan 04, 2022
Date paid: Jan 14, 2022
Processed date: Jan 14, 2022

Total billed charges: $530.00

Amount Humana paid: $0.00

Humana discounts: $0.00

Plan exclusion: $530.00

Benefit exclusions: $0.00

Your share: $0.00

Applied to deductible: $0.00

Copay: $0.00

Coinsurance: $0.00

Your appeal rights

If a medical claim for services already received has been denied you can ask Humana to reconsider its decision.

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Out of network

When you go to a provider who is not in your network, you may pay more for your care. You may also have to file your own claims. Some plans do not provide any coverage for care received from out-of-network providers, except under certain circumstances, including but not limited to emergency and urgently needed services. Check your coverage details or contact Humana for more information.

Your share

Your share is the amount you may owe your provider after your plan benefits have been applied. Humana members with both Medicare and Medicaid coverage may not be responsible for this amount and should contact the provider for additional details.

Humana discounts

Humana has special rates with in-network providers that may give you discounts on the amount you owe your provider. These are savings to you and, are not included in the amount you pay.

Plan exclusion

A portion of your bill may be removed, or excluded, from the total amount you owe. This is done based on the amount your provider is allowed to charge for that benefit or service. Please check the reason codes in your claim statement for more details.

Benefit exclusions

Benefit exclusions can be:

Any billed services that are not covered by your plan
Costs you may have to pay if you use an out-of-network provider

You will not be charged when an exclusion is due to billing errors or missing information needed to complete a claim. Those exclusions are the doctor’s responsibility and will not be added to the amount you pay.

Please check the reason codes in your SmartSummary Explanation of Benefits (EOB) for more details.

Amount Humana paid

The amount your Humana plan pays toward your claim(s).

Maximum out-of-pocket

The most money you will be required to pay for covered medical services and prescription drugs in a calendar year. This amount includes copayments, deductibles and coinsurance.

Plan paid

The amount your plan paid toward your claim(s).

Part B

Medicare medical insurance helps pay for doctors' services, outpatient hospital care, durable medical equipment and some medical services not covered by Part A. This claim was processed under the Part B benefit.

Part D

This claim was processed under the Part D benefit. Part D covers prescription drug coverages through Medicare-approved prescription drug plans offered by private companies. Part D plans are available to anyone eligible for Medicare benefits under Part A or enrolled in Part B.

DDW (Drug Discount Wrap)

This program assists Humana members when they need to buy drugs that are not a covered benefit. This claim was processed as a DDW.

Centers for Medicare and Medicaid Services (CMS) excluded

This claim type covers medicines that are excluded by Medicare (CMS), but may or may not be covered under a plan benefit.

DMR (Direct Member Reimbursement)

DMR is used to reimburse Humana members. This occurs when a member paid out of pocket in place of using their insurance. This claim processed under DMR.

OTC (Over the Counter)

These are medicines sold directly to a consumer. They do not need a prescription from a healthcare professional. This drug was processed as an OTC drug.

PA (Prior Authorization)

There are certain drugs Humana must approve before your plan will cover them. This claim was processed with a prior authorization number.

Claim details

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Description	Total billed charges	Amount Humana paid	Your share	Payment status
Medical Services and Procedures	$350.00	$0.00	$0.00	Denied
Service date Jan 04, 2022 Service code 90792 Humana discounts $0.00 Plan exclusion $350.00 Benefit exclusions $0.00 Deductible $0.00 Copay $0.00 Coinsurance $0.00
Total billed charges	$350.00
Amount Humana paid	$0.00
Your share	$0.00
Payment status	Denied
Medical Services and Procedures	$30.00	$0.00	$0.00	Denied
Service date Jan 04, 2022 Service code 96127 Humana discounts $0.00 Plan exclusion $30.00 Benefit exclusions $0.00 Deductible $0.00 Copay $0.00 Coinsurance $0.00
Total billed charges	$30.00
Amount Humana paid	$0.00
Your share	$0.00
Payment status	Denied
Current tobacco non-user (cad, cap, copd, pv) (dm) (ibd)	$75.00	$0.00	$0.00	Denied
Service date Jan 04, 2022 Service code 1036F Humana discounts $0.00 Plan exclusion $75.00 Benefit exclusions $0.00 Deductible $0.00 Copay $0.00 Coinsurance $0.00
Total billed charges	$75.00
Amount Humana paid	$0.00
Your share	$0.00
Payment status	Denied
or drug screening	$75.00	$0.00	$0.00	Denied
Service date Jan 04, 2022 Service code H0049 Humana discounts $0.00 Plan exclusion $75.00 Benefit exclusions $0.00 Deductible $0.00 Copay $0.00 Coinsurance $0.00
Total billed charges	$75.00
Amount Humana paid	$0.00
Your share	$0.00
Payment status	Denied

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Claim 820220130515734

Your appeal rights

Help

Out of network

Your share

Humana discounts

Plan exclusion

Benefit exclusions

Amount Humana paid

Maximum out-of-pocket

Plan paid

Part B

Part D

DDW (Drug Discount Wrap)

Centers for Medicare and Medicaid Services (CMS) excluded

DMR (Direct Member Reimbursement)

OTC (Over the Counter)

PA (Prior Authorization)

Claim details

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Exclusions

Service code

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Exclusions

Service code

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Exclusions

Service code

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Exclusions

Service code

Questions or comments about this claim?

How are you covered?

What about discounts?

Claim 820220130515734

Your appeal rights

Help

Out of network

Your share

Humana discounts

Plan exclusion

Benefit exclusions

Amount Humana paid

Maximum out-of-pocket

Plan paid

Part B

Part D

DDW (Drug Discount Wrap)

Centers for Medicare and Medicaid Services (CMS) excluded

DMR (Direct Member Reimbursement)

OTC (Over the Counter)

PA (Prior Authorization)

Claim details

Help

Exclusions

Service code

Help

Exclusions

Service code

Help

Exclusions

Service code

Help

Exclusions

Service code

Questions or comments about this claim?

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