LHMC

DELTA DENTAL OF WASHINGTON

PO BOX ***

STEVENS POINT WI 54481-0103

Inquiries: 888-***-****

www.deltadentalcoversme.com

Date: 03/15/2020

KATHERINE J CORRICK

APT B

**** * ********* ***

SPOKANE, WA 99201

Claim Number: 2-007*-***-**

Group Name: WA Individual #888-***-****

Subscriber: KATHERINE J CORRICK

Subscriber ID#: XXXXX9292

Patient: KATHERINE J CORRICK

Dentist: BRYAN L CORRELL

Other Carrier Paid: s 0.00

EXPLANATION OF BENEFITS ** THIS IS NOT A BILL **

TH SURF Service

Date

Proc.

Code

Procedure

Description

Submit

Amt

Fee

Adjust

Approved

Amt

Allowed

Amt

Deduct

Applied

Coverage

Percent

Patient

Payment

Benefit

Payment

Ref.

Code

30 B 03/11/2020 2391 Filling 213.00 74.00 139.00 139.00 100.00 80 107.80 31.20 TOTALS 213.00 74.00 139.00 139.00 100.00 107.80 31.20 Payment

To Date

Check

Number

Check

Amount

DR. BRYAN L CORRELL 202*****-******* 31.20

For Benefit Year: 09/01/2019-08/31/2020

The amount applied to this individual's benefit year deductible is: $100.00 The amount applied to this individual's annual benefit year maximum is: $145.20 The amount applied to this individual's out-of-pocket limit is: $.00 Reference Codes

Because you are seeing a Delta dentist, you are responsible to pay only the amount indicated in the patient payment column.

Payment for these services is determined in accordance with the specific terms of your dental plan or of Delta Dental's agreement with Delta Dental network dentists. You may access Delta Dental's Notice of Privacy Practices on our website at www.DeltaDentalCoversMe. com/Disclosures. You may also obtain a hard copy of these notices by contacting our compliance administrator at 888-***-****.

To submit a claim with intent to defraud an insurer is a crime. If you wish to report suspected fraud or abuse of dental care benefits please contact Delta Dental's professional services department at ad6ows@r.postjobfree.com.

RIGHTS OF REVIEW AND APPEAL

If you have questions about your claim, please contact the Dental Benefit Center at 888-***-****. Because most questions about benefits can be answered informally, we encourage you first to try resolving any problem by talking with us. If the matter cannot be resolved informally, you have the right to request that we formally review the claims decision. To file a request for review: Make your request by calling us at 888-***-****, faxing us at 800-***-****, or mailing your request to Delta Dental, P.O. Box 103, Stevens Point, WI 54481-0103. Provide the reasons why you disagree with the claims decision and include any documentation you believe supports your claim. Be sure to include the patient's name, subscriber's name and subscriber's ID number on all supporting documents. We will acknowledge your written request for review within 5 days of receiving it. Upon your request, we will provide you, free of charge, access to and copies of all documents, records and other information relevant to your claim for benefits. Within 30 days of receiving your request, we will send you our written decision and indicate any action we've taken. (Special circumstances may require 60 days.) Nondiscrimination and Language Assistance Services - Tagline WA 20170101 Nondiscrimination and Language Assistance Services Delta Dental of Washington complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Delta Dental of Washington does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Delta Dental of Washington:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language and service to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages

If you need these services, contact Delta Dental of Washington’s Customer Service at: 1-800-***-****. If you believe that Delta Dental of Washington has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Isaac Lenox, Compliance/Privacy Officer, PO Box 75983 Seattle, WA 98175, Ph: 1-800-***-****, TTY: 1-800-***-****, Fx: 206-***-**** or by email at: ad6ows@r.postjobfree.com. You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, Isaac Lenox, Compliance/Privacy Officer is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington DC 20201, 1-800-***-****, 800- 537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Amharic እርስዎ ወይም እርስዎ የሚያግዙት ግለሰብ ስለ Delta Dental of Washington ጥያቄ ካላችሁ ያለ ምንም ክፍያ በቋንቋዎ እርዳታና መረጃ የማግኘት መብት አላችሁ ከአስተርጓሚ ጋር ለመነጋገር 1-800-***-**** ይደውሉ Arabic والمعلومات المساعدة على الحصول في الحق فلدیكDelta Dental of Washington تساعده شخص لدى أو لدیك كان إن بـ اتصل مترجم مع للتحدث .تكلفة ایة دون من بلغتك الضروریة 554-1907(800)1 بخصوص أسئلة Cambodian

(Mon-Khmer)

្រសិនបរ អ្នក ឬន ណ ម្នន ក់ដ លអ្នកកំពុងដ ជួយ ម្ននសំណួ អ្្រំពី Delta Dental of Washington រប, អ្នកម្ននសិររធិរររររួលជំនួយនិងព័ដររ ម្នន រ កនុងភ ស ស់អ្នក រ យម្ិនអ្ស់ប្រ ក់ ដបររ ម្បីនិយ យជ ម្ួយអ្នក ក ្ ប សូម្ 1-800-***-****. Chinese 如果您,或是您正在協助的對象,有關於[插入項目的名稱 Delta Dental of Washington 方 面的問題,您有權利免費以您的母語得到幫助和訊息 洽詢一位翻譯員,請撥電話 [在

此插入數字 1-800-***-****.

Cushite

(Oromo)

Isin yookan namni biraa isin deeggartan Delta Dental of Washington irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabdu. Nama isiniif ibsu argachuuf, lakkoofsa bilbilaa 1(800)554- 1907 tiin bilbilaa.

German Falls Sie oder jemand, dem Sie helfen, Fragen zum Delta Dental of Washington haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-800-***-**** an. Japanese ご本人様 またはお客様の身の回りの方でも Delta Dental of Washingtonについてご質問 がございましたら ご希望の言語でサポートを受けたり 情報を入手したりすること

ができます 料金はかかりません 通訳とお話される場合 1-800-***-**** までお電話

ください

00400 041827.1

2

Nondiscrimination and Language Assistance Services - Tagline WA Korean 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Delta Dental of Washington 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는

권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1(800)554-1907로 전화하십시오. Laotian ຖາ ່ ທານ, ່ ່ ຫ ່ ນ ທ ່ ທານໍກາ ່ ລງ ່ ຊວຍເ່ ່ ຫອ, ່ ມໍຄາຖາມ ່ ກຽວ ່ ກບ Delta Dental of Washington, ່ ທານ ມິສດ ທຈະໄ ່ ດ ່ ຮບການ ່ ຊວຍເ່ ່ ຫອແລະ່ໍ່ ຂ ່ ມນ ່ ຂາວສານ ທເ່ ປນ ພາສາຂອງ ່ ທານໍ ບ ມ ່ ຄາໃ ່ ຊ ່ ຈາຍ. ການໂ ່ ອ ່ ລມ ່ ກບນາຍພາສາ, ໃ ່ ຫໂທຫາ 1-800-***-****.

Punjabi ਜੇ ਤੁਹ ਨੰ ੂ, ਜ ਂ ਤੁਸ ਜਜਸ ਦ ਮਦਦ ਕਰ ਰਹੇ ਹੋ, Delta Dental of Washington ਕੋਈ ਸਵ ਲ ਹੈ ਤ ਂ, ਤੁਹ ਨ ੰ ਜਜਨ ਜਕਸੇ ਕ ਮਤ 'ਤੇ ਆਪਣ ਭ ਸ ਜਜਵ ੱ ਚ ਮਦਦ ਅਤੇ ਜ ਣਕ ਰ ਪਰ ਪਤ ਕਰਨ ਦ ਅਜਜਕ ਰ ਹੈ . ਦੁਭ ਸ ਏ ਨ ਲ ਜ ੱ ਲ ਕਰਨ ਲਈ, 1-800-***-**** ਤੇ ਕ ਲ ਕਰ

Russian Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Delta Dental of Washington, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 1-800-***-****. Spanish Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Delta Dental of Washington, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-800-***-****. Tagalog Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Delta Dental of Washington, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-800-***-****. Ukrainian Якщо у Вас чи у когось, хто отримує Вашу допомогу, виникають питання про Delta Dental of Washington, у Вас є право отримати безкоштовну допомогу та інформацію на Вашій рідній мові. Щоб зв’язатись з перекладачем, задзвоніть на 1-800-***-****. Vietnamese Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Delta Dental of Washington, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-800-***-****. 00400 041827.1

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