PLAN ADMINISTERED BY:STAR MARKETING AND ADMIN.

INC
PO BOX 2942
CLINTON, IA 52733-2942
Questions? Contact us:
Toll-Free: (800) 522-1246
Website: TRUSTMARKSB.COM

Group Number: SM90630C

Employer: GENERAL REVENUE CORPORATION
Print Date: May 11, 2025
NAMIKI ELAM
620 MOONLIGHT STROLL ST
HENDERSON NV 89002

Consolidated Explanation of Benefits

This is not a Bill

Page 1 of 6
NAMIKI ELAM
Patient's Name Other Other Patient Responsibility After Payments
Code & Description Service Charged Discount Allowed Explanation
Plan Adjust- Copay/Enc
Benefit
Provider Date(s) Amount Amount Amount Ineligible Fee/Access Deductible Coinsurance Code
Payment ments Fee

NAMIKI ELAM
Claim #: A35096542-00 Pat. Acct. #: 5006684541VSD Issued: 5/4/25

99283 - PHYSICIAN 04/07/2025 853.00 0.00 90.16 0.00 762.84 0.00 0.00 90.16 0.00 0.00 QPA
MEDICAL FEES -
SHADOW EMERGENCY
PHY
Totals: 853.00 0.00 90.16 0.00 762.84 0.00 0.00 90.16 0.00 $0.00

Patient Responsibility 90.16

Claim #: A35115705-01 Pat. Acct. #: 5006684541 Issued: 5/9/25

509 - HOSPITAL 04/07/2025 1,503.00 0.00 1,503.00 0.00 1,271.59 0.00 0.00 231.41 0.00 0.00 QPA
OUTPATIENT -
HENDERSON HOSPITAL
Totals: 1,503.00 0.00 1,503.00 0.00 1,271.59 0.00 0.00 231.41 0.00 $0.00

Patient Responsibility 1,503.00

Explanation Code Descriptions:

QPA ALLOWED AMOUNT PAID IN ACCORDANCE WITH THE NO SURPRISES ACT.

2025
Family Medical Deductible Remaining $5,278.43
Medical Out of Pocket Remaining $9,678.43

NAMIKI ELAM Medical Deductible Remaining $5,278.43

Medical Out of Pocket Remaining $8,778.43

Accumulator information available upon request for any blank fields

Conveniently access your EOB(s) online and opt-in to go paperless by logging in at

TrustmarkSB.com/login
Please see your Plan Document for a more detailed explanation of your plan benefits, exclusions, and maximums. The dollars
displayed on this statement are as of the Print Date and are subject to change. Your next Consolidated Explanation of
Benefits, if any claims are processed, will be issued no later than the week of: 05/12/2025
EMPLOYEE RETIREMENT INCOME SECURITY ACT (ERISA)
If your Plan is subject to ERISA and you receive an adverse benefit determination you or your authorized representative are
entitled to appeal that determination. All information submitted on appeal will be reviewed, including any additional documentation
submitted. The appeal must be submitted within 180 days following receipt of the adverse benefit determination and in writing
to:Grievance Review – Dept. 1146, 400 Field Drive, Lake Forest, IL 60045. A decision regarding the appeal will be provided within
30 days of receipt of all relevant information. Your plan provides two levels of internal appeal . You have the right to request from
us, free of charge: information regarding any voluntary appeals available; copies of any relevant documents that were used to
make a claim decision; copies of internal rules, guidelines, protocols, or similar criteria used to make a claim decision; and an
explanation of any scientific or clinical judgment used to make a claim decision. If, after your internal levels of appeal have been
exhausted, you still disagree with the determination you have the right to bring civil action under section 502(A) of ERISA. Legal
action must be filed within one year from the date all claim review procedures provided for in your Plan Document have been
exhausted. Please see your Plan Document for additional information about your appeal process or contact this office for further
information. Plans not subject to ERISA may not have the same rights and may be subject to different state and /or federal laws.

Non-Erisa
If you receive an adverse benefit determination, you are entitled to appeal that determination. All information submitted on appeal
will be reviewed, including any additional documentation submitted. The appeal must be submitted in a timely manner and in
writing to Grievance Review – Dept. 1146, 400 Field Drive, Lake Forest, IL 60045 . Please see your Plan Document for additional
information about your state’s appeals process or contact this office for further information . Plans not subject to ERISA may not
have the same rights and may be subject to different state and/or federal laws. Legal action must be filed within one year from
the date all claim review procedures provided for in your Plan Document have been exhausted.

If state internal appeal rights differ from federal rights as set forth on the attached notice, the rights that are more favorable shall apply.

If you are covered by more than one health benefit plan, you should file all your claims with each plan.

Para obtener asistencia en Español, llame al (800) 522-1246

 Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an
in-network hospital or ambulatory surgical center, you are protected from surprise
billing or balance billing.

What is "balance billing" (sometimes called "surprise billing")?

When you see a doctor or other health care provider, you may owe certain out -of-pocket costs, such
as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the
entire bill if you see a provider or visit a health care facility that isn't in your health plan's network.

"Out-of-network" describes providers and facilities that haven't signed a contract with your
health plan. Out-of-network providers may be permitted to bill you for the difference between
what your plan agreed to pay and the full amount charged for a service. This is called
"balance billing." This amount is likely more than in-network costs for the same service and
might not count toward your annual out-of-pocket limit.

"Surprise billing" is an unexpected balance bill. This can happen when you can 't control who
is involved in your care-like when you have an emergency or when you schedule a visit at an
in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services
If you have an emergency medical condition and get emergency services from an out -of-network
provider or facility, the most the provider or facility may bill you is your plan 's in-network
cost-sharing amount (such as copayments and coinsurance). You can't be balance billed for
these emergency services. This includes services you may get after you 're in stable condition,
unless you give written consent and give up your protections not to be balanced billed for these
post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers
there may be out-of-network. In these cases, the most those providers may bill you is your plan 's
in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology,
radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These
providers can't balance bill you and may not ask you to give up your protections not to be balance
billed.
If you get other services at these in-network facilities, out-of-network providers can't balance bill
you, unless you give written consent and give up your protections.

You're never required to give up your protections from balance billing. You also aren't
required to get care out-of-network. You can choose a provider or facility in your
plan's network.

When balance billing isn't allowed, you also have the following protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance,
and deductibles that you would pay if the provider or facility was in-network). Your health plan
will pay out-of-network providers and facilities directly.
• Your health plan generally must:
○ Cover emergency services without requiring you to get approval for services in advance
(prior authorization)
○ Cover emergency services by out-of-network providers.
○ Base what you owe the provider or facility (cost-sharing) on what it would pay an
in-network provider or facility and show that amount in your explanation of benefits.
○ Count any amount you pay for emergency services or out-of-network services toward your
deductible and out-of-pocket limit.

If you believe you've been wrongly billed, you may contact:

Federal No Surprises Help Desk Contact Information:

1-800-985-3059
www.cms.gov/nosurprises website for more information about your rights under federal
law.
This document contains important information including your Appeal Rights that you should retain for your records.
This document serves as notice of any adverse benefit determination. Benefits under your benefit plan, which are denied in
whole or in part for the requested treatment or service, are described in the attached Explanation of Benefits (EOB). If you
think this determination was made in error, you have the right to appeal.
What if I need help understanding this denial? Contact Customer Service at the phone number provided on the attached
EOB if you need assistance understanding this notice or the decision to deny you coverage under your benefit plan.

What if I don’t agree with this decision? You have a right to appeal any decision not to provide or pay for an item or service (in
whole or in part).

How do I file an appeal? Complete, detach, copy and send in the form below within one hundred eighty (180) calendar days
from receipt of notification of the denial. See also the “Other resources to help you” section below for assistance filing a request
for an appeal.

What if my situation is urgent? If your situation meets the definition of urgent under the law, your review will generally be
conducted within 72 hours. Generally, an urgent situation is one in which your health may be in serious jeopardy or, in the
opinion of your physician, you may experience severe pain that cannot be adequately controlled without immediate treatment. If
you believe your situation is urgent, you may request an expedited appeal when filing your appeal request (see form below), or
by filing a request for simultaneous external review, or by contacting Customer Service at the telephone number or website
provided on the attached Explanation of Benefits.

Who may file an appeal? You or someone you name in writing to act for you (your authorized representative) may file an
appeal.

Can I provide additional information about my claim? Yes, you may supply additional information in support of your claim to
the address provided on the attached Explanation of Benefits.

Can I request copies of information relevant to my claim? Yes, you may request copies (free of charge). If you think a
coding error may have caused this claim to be denied, you have the right to have billing and diagnosis codes sent to you, as well.
You can request copies of this information by contacting Customer Service at the telephone number or website provided on the
attached Explanation of Benefits.

What happens next? If you appeal, we will review the decision and provide you with a written determination. If we continue to
deny the payment or coverage requested, on behalf of your benefit plan, or you do not receive a timely decision, you may be
able to request an external review of certain claims by an independent third party, who will review the denial and issue a final
decision. External review applies to a rescission of coverage and an adverse benefit determination involving medical judgment,
including but not limited to, to those plan requirements involving medical necessity, appropriateness, health care setting, level of
care or effectiveness of a covered benefit, or experimental or investigational treatments or services.

Appeal Filing Form

Detach this form and send to Grievance Review – Dept. 1146, 400 Field Drive, Lake Forest, IL 60045. Be certain to keep copies
of this form, your denial notice, and all documents related to this claim.
Covered Person’s Name: Patient Name:

Covered Person’s ID #: Claim Number:

Name of Person Filing Appeal: Today’s Date:

Check One: Covered person Patient Authorized Representative
Contact information of person filing appeal ( if different from patient)

Address: Phone: Email:

If the person filing the appeal is other than the patient, the patient must indicate authorization by signing here :

Are you requesting an urgent appeal? Yes No

Briefly describe why you disagree with this decision (you may use the back of this form, or attach additional information, such as a
physician’s letter, bills, medical records, or other documents to support your claim) :