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MedITLive - Real-Time Patient Elig
ibility Response (www.meditlive.com) Page 1 o
f 5 Transaction Summary COLL
APSE As O
f
: 4/
2/
2
0
0
9
Payer: CM
S
Member ID: D
E
MO_ID
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bscriber Name: Sm
ith
,
Joh
n
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bscriber DOB: 8/
7/
1
9
2
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Subscriber Addr
ess: 5
10 Vonderburg Dr, Brand
o
n, FL 335
1
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show
deta
i
l
ed infor
m
ation Health Benefit Plan Coverage COLL
APSE Coverage Statu
s
: E
l
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ibi
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i
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y Da
tes: Co-
Payment: Co-
In
s
u
r
a
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c
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: Ded
u
ctibl
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: Ded
u
ctibl
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ing: Lim
i
tation
s: Lim
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ing: Ou
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N
e
t Co-
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u
r
a
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c
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t o
f
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t o
f N
e
t Ded
u
ctibl
e Remain
ing: A
C
TIVE
COVER
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GE 7/1/2007
- 12
/31
/
200
9 N/A N/A $38.60 Ins Type
:
Me
dicare
P
a
rt B $38.60 Ins Type
:
Me
dicare
P
a
rt B $1,840.00 Cov
e
r
a
ge
:
Indi
vidual, Ins Type
:
Me
dicare
P
a
rt
B
, No
tes
:
PH
YSICAL AND SPEECH TH
E
R
A
P
Y $1,840.00 Cov
e
r
a
ge
:
Indi
vidual, Ins Type
:
Me
dicare
P
a
rt
B
, No
tes
:
PH
YSICAL AND SPEECH TH
E
R
A
P
Y N/A N/A N/A Primary UNITEDHEALT
H
CARE INSURANCE COMPANY Payer htt
p
://localhost:8081/eli
g
ibilit
y
/PatientEli
g
ib
ilit
y
.as
p
x 4/2/2009 MedITLive - Real-Time Patient Elig
ibility Response (www.meditlive.com) Page 2 o
f 5 4
350 W CYPRESS ST STE 100
0, TAMPA, FL
3360
74164 Phone: (888) 861
-5
518 Blood Charges COLL
APSE Coverage
Status: STATUS NOT SPEC
IFIED BY PAYER E
l
ig
ibi
l
i
t
y Dates: 1/1/2009
- 12
/31
/
200
9 Co-Payment: N/A Co-I
nsura
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ce: N/A Ded
u
ctibl
e
: N/A Dedu
ctibl
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maini
n
g: N/A O
u
t of
Net Co-I
nsura
n
ce: O
u
t of Net Deductible
: O
u
t of Net Deductible Remain
ing: N/A N/A N/A Hospital COLL
APSE Coverage
Status: E
l
ig
ibi
l
i
t
y Dates: Co-Payment: Co-I
nsura
n
ce: Ded
u
ctibl
e
: Dedu
ctibl
e
R
e
maini
n
g: STATUS NOT SPEC
IFIED BY PAYER N/A N/A $267.00 Ins Type
:
Me
dicare
P
a
rt A $1,068.00 Ins Type
:
Me
dicare
P
a
rt A $1,068.00 Ins Type
:
Me
dicare
P
a
rt A O
u
t of
Net Co-I
nsura
n
ce: O
u
t of Net Deductible
: O
u
t of Net Deductible Remain
ing: N/A N/A N/A Occupational Therapy COLL
APSE Coverage
Status: E
l
ig
ibi
l
i
t
y Dates: STATUS NOT SPEC
IFIED BY PAYER 1/1/2009
- 12
/31
/
200
9 htt
p
://localhost:8081/eli
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ibilit
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/PatientEli
g
ib
ilit
y
.as
p
x 4/2/2009 MedITLive - Real-Time Patient Elig
ibility Response (www.meditlive.com
)
Page 3 o
f 5 Co-Payment: N/A Co-I
nsura
n
ce: N/A Ded
u
ctibl
e
: N/A Dedu
ctibl
e
R
e
maini
n
g: N/A Lim
i
tation
s: $1,840.00 Cov
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ge
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vidual, Ins Type
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Me
dicare
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i
mitations R
e
mainin
g: $1,840.00 Cov
e
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a
ge
:
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vidual, Ins Type
:
Me
dicare
P
a
rt B O
u
t of
Net Co-I
nsura
n
ce: O
u
t of Net Deductible
: O
u
t of Net Deductible Remain
ing: N/A N/A N/A Ph
arm
a
cy COLL
APSE Coverage
Status: E
l
ig
ibi
l
i
t
y Dates: Co-Payment: Co-I
nsura
n
ce: Ded
u
ctibl
e
: Dedu
ctibl
e
R
e
maini
n
g: STATUS NOT SPEC
IFIED BY PAYER 1/1/2008
- no end date N/A N/A N/A N/A O
u
t of
Net Co-I
nsura
n
ce: N/A O
u
t of Net Deductible
: N/A O
u
t of Net Deductible N/A Remain
ing: Paye
r
UNITEDHEALT
H
CARE INSURANCE COMPAN
Y
4
350 W CYPRESS ST STE 100
0, TAMPA, FL
3360
7416
4
Phone: (888) 861
-5
51
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COLL
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COVER
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Statu
s
:
E
l
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ibi
l
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t
y 7/1/2007
- 12
/31
/
200
9 htt
p
://localhost:8081/eli
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ibilit
y
/PatientEli
g
ib
ilit
y
.as
p
x 4/2/2009 MedITLive - Real-Time Patient Elig
ibility Response (www.meditlive.com) Page 4 o
f 5 Da
tes: Co-
Payment: Co-
In
s
u
r
a
n
c
e
: Ded
u
ctibl
e
: Ded
u
ctibl
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ing: Lim
i
tation
s: Lim
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tation
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ing: Ou
t o
f
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t Co-
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r
a
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t o
f
N
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: Ou
t o
f N
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u
ctibl
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ing: Primary Payer N/A N/A $38.60 Ins Type
:
Me
dicare
P
a
rt B $38.60 Ins Type
:
Me
dicare
P
a
rt B $1,840.00 Cov
e
r
a
ge
:
Indi
vidual, Ins Type
:
Me
dicare
P
a
rt
B
, No
tes
:
PH
YSICAL AND SPEECH TH
E
R
A
P
Y $1,840.00 Cov
e
r
a
ge
:
Indi
vidual, Ins Type
:
Me
dicare
P
a
rt
B
, No
tes
:
PH
YSICAL AND SPEECH TH
E
R
A
P
Y N/A N/A N/A UNITEDHEALT
H
CARE INSURANCE COMPANY 4
350 W CYPRESS ST STE 100
0, TAMPA, FL
3360
74164 Phone: (888) 861
-5
518 Skilled Nursing Care COLL
APSE Coverage
Status: STATUS NOT SPEC
IFIED BY PAYER E
l
ig
ibi
l
i
t
y Dates: N/A Co-Payment: N/A Co-I
nsura
n
ce: $133.50 Ins Type
:
Me
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u
ctibl
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: N/A Dedu
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maini
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u
t of
Net Co-I
nsura
n
ce: N/
A
O
u
t of Net Deductible
: N/
A
htt
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ibilit
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x 4/2/2009 MedITLive - Real-Time Patient Elig
ibility Response (www.meditlive.com) Page 5 o
f 5 O
u
t of Net Deductible N/
A
Remain
ing
:
Smoking Cessation COLL
APSE Coverage
Status: STATUS NOT SPEC
IFIED BY PAYER E
l
ig
ibi
l
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t
y Dates: N/A Co-Payment: N/A Co-I
nsura
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maini
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u
t of
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A
O
u
t of Net Deductible
: N/
A
O
u
t of Net Deductible N/
A
Remain
ing: N/A
- i
n
f
o
rm
at
i
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n not r
e
tu
rn
ed b
y th
e pay
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s
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xt htt
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g
ib
ilit
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p
x 4/2/2009 
Автор
pavl.alexandr
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