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000485 01 01 51 000010040179.4 <br />Filijtrkr�r�20t*WAjggWM - Kittitas County, WA Auditor - 20171229 16 Page F of 16 <br />E � IIJJ rr �i��uuVV'' GGA °explanation of Benefits <br />Kaiser Foundation Health Plan <br />of Washington <br />Member Services PLEASE SAVE THIS DOCUMENT FOR <br />P.O. Bos 34590 Seattle, WA 98124-1590 YOUR RECORDS AND TAX PURPOSES. <br />Important Plan Information Page No.: 1 of 1 Dear Subscriber: <br />Print Date: 11/18/2017 <br />19 SUZANNE H. RECTOR <br />442 BUCKBOARD LN <br />ELLENSBURG WA 98926 <br />Pati en t : - - - <br />Member ID: <br />Subscriber: <br />Group: <br />Group Number: <br />Provider: <br />Provider Acct. No.: <br />Claim Number: <br />Diagnosis Code: <br />SUZANNE--H-.-RECTOR- - -- <br />01226189 <br />SUZANNE H. RECTOR <br />PEBB VALUE PLAN EAST <br />4090000 <br />KITTITAS COUNTY FIRE PROTECTIC <br />198-2017-2880-1 <br />1729928864000 <br />M79606 Leg pain <br />THIS IS NOT A BILL. This is an itemized <br />slunmary of services that outlines provider <br />charges, payments, and claims decisions <br />based on your coverage contract. <br />If you are responsible for any amount as <br />noted in the Payment Slmmary, you may <br />receive a separate statement. Thank you. <br />09/03/17 Ambulance transport A0427 SH $ 875.00 $ 875.00 $ 700.00 $ 175.00 3005 <br />09/03/17 Ambulance mileage A0425 SH $ 9.50 $ 9.50 $ 7.60 $ 1.90 3005 <br />TOTALS $ 884.50 $ 884.50 $ 707.60 $ 176.90 <br />Notes: <br />3005 - SEE "AMBULANCE" IN THE BENEFITS DETAILS SECTION OF YOUR BENEFITS BOOKLET. <br />In Network: Annual Deductible <br />$ 250.00 <br />$. <br />750.00 <br />$ <br />0.00 <br />$ 0.00 <br />$ <br />250.00 <br />$ <br />250.00 <br />Out -of -Pocket Limit <br />$ 3000.00 <br />$ <br />6000.00 <br />$ <br />176.90 <br />$ 176.90 <br />$ <br />1022.18 <br />$ <br />1022.18 <br />Out of Network: Annual Deductible <br />$ 0.00 <br />$ <br />0.00 <br />$ <br />0.00 <br />$ 0.00 <br />$ <br />0.00 <br />$ <br />0.00 <br />Out -of -Pocket Limit <br />$ 0.00 <br />$ <br />0.00 <br />$ <br />0.00 <br />$ 0.00 <br />$ <br />0.00 <br />$ <br />0.00 <br />Pharmacy: Out -of -Pocket Limit <br />$ 0.00 <br />$ <br />0.00 <br />$ <br />0.00 <br />Life Time Maximum: <br />$ 0.00 <br />$ <br />0.00 <br />$ <br />0.00 <br />Questions? Please call 206-630-4636, or 1-888-901-4636 (TTY/TDD: 1-800-833-6384), or you may submit your questions <br />to the E-mail link at www.lcp.org/wa/membersel-vices. Please see back of page for appeals information. <br />CLKGSY <br />