EXHIBIT B

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I IIHIHXH saMuTuid 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 22 of 128
2017 Summary of 

UnitedHealthcare Dual Complete® (HMO SNP) 

H0321-002 

Our service area includes the following counties in: 

Arizona: Apache, Cochise, Coconino, Graham, Greenlee, La Paz, Maricopa, 

Mohave, Navajo, Pima, Pinal, Santa Cruz, Yavapai, Yuma. 

This is a summary of drug coverages and health services provided by 

UnitedHealthcare Dual Complete® (HMO SNP) 

January 1st, 2017 - December 31st, 2017. 

For more information, please contact Customer Service at: 

) Toll-Free 1-888-834-3721, TTY 711 

8 a.m. - 8 p.m. local time, 7 days a week 

www.UHCCommunityPlan.com 

UnitedHealthcare 

Community Plan 

Y0066_SB_H0321_002_2017 CMS Accepted 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 23 of 128
Summary of Benefits 

January 1st, 2017 - December 31st, 2017 

We're dedicated to providing clear and simple information about your plan so you always stay fully 

informed. The following information is a breakdown of what we cover and what you pay. This is 

called "cost-sharing" or "out-of-pocket" costs. Cost-sharing includes co-pays, co-insurance and 

deductibles. This will help you control your health care costs throughout the plan year. 

Keep in mind that this isn't a full list of benefits we provide, it's just an overview. To get a complete 

list, visit our website at www.UHCCommunityPlan.com to see the "Evidence of Coverage" or call 

customer service with any questions. 

About this plan. 

UnitedHealthcare Dual Complete® (HMO SNP) is a Medicare Advantage HMO plan with a Medicare 

contract. 

To join UnitedHealthcare Dual Complete® (HMO SNP), you must be entitled to Medicare Part A, be 

enrolled in Medicare Part B, live in our service area as listed on the cover, and be a United States 

citizen or lawfully present in the United States. 

UnitedHealthcare Dual Complete® (HMO SNP) is a Full Dual Eligible Special Needs Plan (D-SNP). It 

is designed for people entitled to both Medicare and Medicaid. If you have both Medicare and 

Medicaid, your services are paid first by Medicare and then by Medicaid. Your Medicaid coverage 

depends on your income, resources and other factors. For an explanation of the categories of 

people who can enroll please see the Medicaid section after the benefits chart. 

What's inside? 

Plan Premiums, Annual Deductibles, and Benefits 

See plan costs including the monthly plan premium, deductible and maximum out-of-pocket limit. 

UnitedHealthcare Dual Complete® (HMO SNP) has a network of doctors, hospitals, pharmacies, 

and other providers. If you use the providers or pharmacies that are not in our network, the plan 

may not pay for these services or drugs, or you may pay more than you pay at an in-network 

pharmacy. 

You can search for a network Provider and pharmacy in the online directories at 

www.UHCCommunityPlan.com. 

Drug Coverage 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 24 of 128
Look to see what drugs are covered along with any restrictions in our plan formulary (list of Part D 

prescription drugs) found at www.UHCCommunityPlan.com. 

Medicaid Benefits 

If you qualify for Medicaid and Medicare there are programs that can help pay premiums, 

deductibles, co-pays and co-insurance. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 25 of 128
Monthly Plan Premium There is no monthly premium for this plan. 

Annual Medical Deductible $166 for Outpatient services from in-network providers. 

These amounts may change for 2017. 

Maximum Out-of-Pocket Amount 

(does not include prescription drugs) 

$6,700 annually for services you receive from 

in-network providers. 

If you reach the limit on out-of-pocket costs, you keep 

getting covered hospital and medical services and we 

will pay the full cost for the rest of the year. 

Please note that you will still need to pay your monthly 

premiums and cost-sharing for your Part D 

prescription drugs. 

Premiums and Benefits 

UnitedHealthcare Dual Complete® (HMO SNP) 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 26 of 128
UnitedHealthcare Dual Complete® (HMO SNP) 

Benefits In-Network 

Inpatient Hospital Coverage $1,238 upon admission: for days 1-60 

$322 co-pay per day: for days 61-90 

$644 co-pay per day: for days 91-150 (lifetime reserve 

days) 

Our plan covers 90 days for an inpatient hospital stay. 

These are the 2016 amounts and may change for 

2017. 

Doctor Visits Primary 20% of the cost 

Specialists 20% of the cost 

Preventive Care Medicare-covered $0 co-pay 

Emergency Care $75 co-pay ($0 co-pay for worldwide coverage) per 

visit 

If you are admitted to the hospital within 24 hours, you 

pay the inpatient hospital co-pay instead of the 

Emergency co-pay. See the "Inpatient Hospital Care" 

section of this booklet for other costs. 

Urgently Needed Services $65 co-pay 

Diagnostic 

Tests, Lab 

and Radiology 

Services, 

and X-Rays 

Diagnostic 

radiology services 

(e.g. MRI) 

20% of the cost 

Lab services $0 co-pay 

Diagnostic tests 

and procedures 

20% of the cost 

Therapeutic 

Radiology 

20% of the cost 

Outpatient X-rays 20% of the cost 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 27 of 128
Benefits In-Network 

Hearing Services Exam to 20% of the cost 

diagnose and 

treat hearing and 

balance issues 

Routine 

hearing exam 

$0 co-pay; 1 per year 

Hearing aid $1,500 allowance every 2 years 

Dental Services Preventive $0 co-pay for covered services (exam, cleaning, x-rays) 

Comprehensive $0 co-pay for covered services 

Benefit limit $2,500 limit on all covered dental services 

Vision Services Exam to 

diagnose and 

treat diseases 

and conditions 

of the eye 

20% of the cost 

Eyewear after 

cataract surgery 

$0 co-pay 

Routine eye exam $0 co-pay 

Lip to 1 every year 

Eyewear $0 co-pay every 2 years; up to $150 for lenses/frames 

or contact3 

Mental 

Health Care 

Inpatient visit $1,288 upon admission; 

$322 co-pay per day: for days 61-90; 

$644 co-pay per day: for days 91-150 (lifetime reserve 

days). 

Our plan covers 90 days for an inpatient hospital stay. 

These are the 2016 amounts and may change for 

2017. 

Outpatient group 

therapy visit 

20% of the cost 

Outpatient 

individual 

therapy visit 

20% of the cost 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 28 of 128
Benefits , 

Skilled Nursing Facility (SNF) 

(Stay must meet Medicare 

coverage criteria) 

In-Network 

$0 co-pay per day: for days 1-20 

$161 co-pay per day: for days 21-100 

Our plan covers up to 1UU' days in a SNF. 

These are the 2016 amounts and may change for 

2017. 

Rehabilitation 

Services 

Occupational 

therapy visit 

$0 co-pay 

Physical therapy 

and speech 

and language 

therapy visit 

20% of the cost 

. 

Ambulance 20% of the cost 

Routine Transportation $0 co-pay; 24 one-way trips per year to or from 

approved locations; limited to routine dental, vision, 

podiatry Or hearing services not covered by Original 

Medicare 

Foot Care 

(podiatry 

services) 

Foot exams 

and treatment 

20% of the cost 

Routine 

foot care 

$0 co-pay; for each visit up to 4 visits every year 

Medical 

Equipment / 

Supplies 

Durable Medical 

Equipment (e.g., 

wheelchairs, 

oxygen) 

20% of the cost 

Prosthetics 

(e.g., braces, 

artificial limbs) 

20% of the cost 

Wellness 

Programs 

Fitness program 

through 

SilverSneakers® 

Fitness program 

Basic membership in a fitness program at a network 

location. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 29 of 128
Chemotherapy 20% of the cost 

drugs 

Benefits 

Medicare 

Part B Drugs 

Other Part B 

drugs 

20% of the cost 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 30 of 128
Prescription Drugs 

• 

If you don't qualify for Low-Income Subsidy (LIS), you pay the Medicare Part D cost share outlined 

in the Evidence of Coverage. If you do qualify for Low-Income Subsidy (LIS) you pay: 

rAnnual .,„ , . 

rr-,...1..._;-4,6.,t.. • „ .-',;. 

rPrescription, , . 

siDeductible • 4 

!.- .: rTt.744-il.45'Ine ... 

Your deductible amount is either $0 or $82, depending on the level of 

"Extra Help" you receive. 

. 

• 

. • 

-......'4•,-7irr.4;' 7fiff '4.frkil,17.r.' *.'1..--4AW'rW-‘trtiV.1.7-'''liSF-"e'4'&' ..- • ' N ',' - 

1.30,-day supfily,fitimivtairmetworkpharmiey. - ' . 

°"2,, .•7'...,1".t. ..:. 4109 ii--- - NI,c'...',-:.* 'a -"t 4" It .e..: . 4N'Ar'...Ce't AZ...SO; .....,.......V., ter '1... . t" 4.i.' r Vdn .., . . i 

'..penerici4-, i

i...• --,,,,,--5

dinglb

.., .. 

(incluran ' 

,,..,.

.,ru

LA..-_-,y.1.,v 

-‘reat

,..1- ed,..

a gs t , 1.,,,,-. 

aS 1 gen

4,

eric),...,,, 

:;,, ,..1A4. -.:,.. 4s,--,N.:.• --r 

E, c 

P .-. -'•47":414?,...,q.., 1:.",-:: 

$0, $1.20, $3.30 co-pay, or 15% of the total cost 

3A11 Other DrUgsk- $0, $3.70, $8.25 co pay, or 15% of the total cost 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 31 of 128
Additional Benefits 

Chiropractic 

Care 

Manual 

manipulation 

of the spine 

to correct 

subluxation 

In-Network 

$0 co-pay 

Routine 

chiropractic care 

$10 co-pay; 18 visits per year 

Diabetes 

Management 

Diabetes 

monitoring 

supplies 

$0 co-pay 

We only cover blood glucose monitors and test strips 

from the following brands: OneTouch Ultra®2 System, 

OneTouch UltraMini®, OneTouch Verio®, OneTouch 

Verio® Sync, OneTouch Verio® IQ, OneTouch Verio® 

Flex System Kit, ACCU-CHEK® Nano SmartView, and 

ACCU-CHEK® Aviva Plus. 

Diabetes 

Self-management 

training 

$0 co-pay 

Therapeutic 

shoes or inserts 

20% of the cost 

Home Health Care $0 co-pay 

Hospice You pay nothing for hospice care from any Medicareapproved hospice. You may have to pay part of the 

costs for drugs and respite care. Hospice is covered 

by Original Medicare, outside of our plan. 

NurseLinesm Speak with a registered nurse (RN) 24 hours a day, 7 

days a week 

Outpatient Surgery 20% of the cost 

Outpatient 

Substance 

Abuse 

Outpatient group 

therapy visit 

20% of the cost 

Outpatient 

individual 

therapy visit 

20% of the cost 

Health Products Benefit $130 credit per quarter to use on approved health 

products 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 32 of 128
Additional Benefits In-Network 

r

Renal Dialysis 20% of the cost 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 33 of 128
Medicaid Benefits 

Information for People with Medicare and Medicaid 

UnitedHealthcare Dual Complete (HMO SNP) is a Full Dual Eligible Special Needs Plan (D-SNP). It 

is designed for persons entitled to both Medicare and Medicaid. If you have both Medicare and 

Medicaid, your services are paid first by Medicare and then by Medicaid. Your Medicaid coverage 

depends on your income, resources and other factors. 

Below are the categories of people who can enroll in UnitedHealthcare Dual Complete (HMO SNP): 

• Qualified Medicare Beneficiary Plus (QMB+). You get Medicaid coverage of Medicare 

cost-share and are also eligible for full Medicaid benefits. Medicaid pays your Part A and Part B 

premiums, deductibles, coinsurance and copayment amounts. 

• Specified Low-Income Medicare Beneficiary Plus (SLMB+). Medicaid pays your Part B 

premium and provides full Medicaid benefits. 

• Full Benefits Dual Eligible (FBDE). Medicaid may provide limited assistance with Medicare 

cost-sharing. Medicaid also provides full Medicaid benefits. 

If you are a QMB+ Beneficiary: 

You have 0% cost-share, except for Part D prescription drug copays. 

If you are a SLMB+ or FBDE: 

You are eligible for full Medicaid benefits. At times you may also be eligible for limited assistance 

from the Arizona Health Care Cost Containment System (AHCCCS) in paying your Medicare cost 

share amounts. Generally your cost share is 0% when the service is covered by both Medicare and 

Medicaid. There may be cases where you have to pay cost sharing when a service or benefit is not 

covered by Medicaid. 

If your category of Medicaid eligibility changes, your cost share may also increase or decrease. You 

must recertify your Medicaid enrollment to continue to receive your Medicare coverage 

How to Read the Medicaid Benefit Chart: 

The benefits described below are covered by Medicaid. The benefits described in the Covered 

Medical and Hospital Benefits section of the Summary of Benefits are covered by Medicare. For 

each benefit listed below, you can see what Arizona Health Care Cost Containment System 

(AHCCCS) covers and what our plan covers. If a benefit is used up or not covered by Medicare, 

then Medicaid may provide coverage. This depends on your type of Medicaid coverage. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 34 of 128
Benefit 

UnitedHealthcare 

Dual Complete® 

(HMO SNP) 

Arizona 0126a Care Cost 

(4560Th (AFICCCS) 

OMB CiniMB+ 

%km Gee) 

Containment 

SLMB+ cuFBDE 

%tmcev 

Nursing Facility Member contribution 

determined by 

Medicaid Agency 

Member contribution 

determined by 

Medicaid Agency 

Not Covered 

Home and 

Community Based 

Services 

Member contribution 

determined by 

Medicaid Agency 

Member contribution 

determined by 

Medicaid Agency 

Not Covered 

Medicare-covered apizttaGa 

Ambulance $0 $0 Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Chiropractic Care $0 $0 for age 20 and 

under. 

Not covered for 

people age 21 and 

over. 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 35 of 128
Arizona Health Care Cost Containment 

System (AHCCCS) 

Benefit 

Dental Services 

QMB or OMB+ 

You Pay 

Depending on your 

level of Medicaid 

eligibility, Medicaid 

may pay your 

Medicare cost 

sharing amount. 

SLMB+ or FBDE 

You pay 

Depending on your 

level of Medicaid 

eligibility, Medicaid 

may pay your 

Medicare cost 

sharing amount. 

UnitedHealthcare 

Dual Complete® 

(HMO SNP) 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

For services not 

covered by Medicare 

or if the benefit is 

exhausted, Medicaid 

may provide 

additional coverage 

subject to the 

following cost share 

amounts: 

$0 co-pay for 

Medicaid services 

For services not 

covered by Medicare 

or if the benefit is 

exhausted, Medicaid 

may provide 

additional coverage 

subject to the 

following cost share 

amounts: 

$0 co-pay for 

Medicaid services 

$0 $0 Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Diabetes Supplies 

and Services 

Diagnostic Tests, $o 

Lab and Radiology 

Services, 

and X-Rays 

(Costs for these 

services may be 

different if received in 

an outpatient surgery 

setting) 

$o Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 36 of 128
Arizona Health Care Cost Containment 

System (AHCCCS) 

Benefit 

QMB or QMB+ 

You Pay 

SLMB+ or FBDE 

You pay 

Un itedHealthcare 

Dual Complete® 

(HMO SNP) 

Doctor Office Visits $o $0 to $5 depending 

on eligibility* for age 

19 and over. 

$0 for age 18 and 

under. 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Durable Medical $0 $0 

Equipment 

(wheelchairs, 

oxygen, etc.) 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Emergency Care $o $30 for NonEmergency use of the 

ER depending on 

eligibility* for age 19 

and over. 

$0 for all others. 

Emergency Room 

visits for which 

presen4ify 

problem(s) are 

usually minor or selflimited - indicated by 

procedure 99281 are 

not covered for 

people age 21 and 

QV II 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Foot Care $0 

(podiatry services) 

$0 for people age 20 

and under, if 

furnished by a 

Podiatrist 

Not covered for 

people age 21 and 

over. 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier In this booklet. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 37 of 128
Arizona Health Care Cost Containment 

System (AHCCCS) 

Benefit 

Hearing Services 

QMB or QMB+ 

You Pay 

$0 for people age 20 

and under. 

Not covered for 

people age 21 and 

over. 

SLMB+ or FBDE 

You pay 

$0 for people age 20 

and under. 

Not covered for 

people age 21 and 

over. 

UnitedHealthcare 

Dual Complete® 

(HMO SNP) 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Home Health Care $0 $0 Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Mental Health Care $0 $o Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Outpatient 

Rehabilitation 

Depending on your 

level of Medicaid 

eligibility, Medicaid 

may pay your 

Medicare cost 

sharing amount. 

Depending on your 

level of Medicaid 

eligibility, Medicaid 

may pay your 

Medicare cost 

sharing amount. 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

For services not 

covered by Medicare 

or if the benefit is 

exhausted, Medicaid 

may provide 

additional coverage 

subject to the 

following cost share 

amounts: 

$0 co-pay for 

Medicaid services 

For services not 

covered by Medicare 

or if the benefit is 

exhausted, Medicaid 

may provide 

additional coverage 

subject to the 

following cost share 

amounts: 

$0 co-pay for 

Medicaid services 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 38 of 128
SLMB+ or FBDE 

You pay 

So 

OMB or OMB+ 

You Pay 

So 

UnitedHealthcare 

Dual Complete® 

(HMO SNP) 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Arizona Health Care Cost Containment 

System (AHCCCS) 

Benefit 

Outpatient 

Substance Abuse 

Outpatient Surgery Depending on your 

level of Medicaid 

eligibility, Medicaid 

may pay your 

Medicare cost 

sharing amount. 

For services not 

covered by Medicare 

or if the benefit is 

exhausted, Medicaid 

may provide 

additional coverage 

subject to the 

following cost share 

amounts: 

$0 co-pay for 

Medicaid services 

Depending on your 

level of Medicaid 

eligibility, Medicaid 

may pay your 

Medicare cost 

sharing amount. 

For services not 

covered by Medicare 

or if the benefit is 

exhausted, Medicaid 

may provide 

additional coverage 

subject to the 

following cost share 

amounts: 

$0 co-pay for 

Medicaid services 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Prosthetic Devices So 

(braces, artificial 

limbs, etc.) 

$o 

Lower Limb 

microprocessor 

controlled limb or 

joint not covered for 

adults age 21 and 

over. 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Renal Dialysis $0 $0 Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 39 of 128
Arizona Health Care Cost 

System (AHCCCS) 

Containment 

UnitedHealthcare 

OMB or OMB+ SLMB+ or FBDE Dual Complete® 

Benefit You Pay You pay (HMO SNP) 

Urgently Needed $0 $0 to $5 depending Covered. See the 

Services on eligibility* for age 

19 and over, 

$0 for age 18 and 

under. 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Vision Services Depending on your Depending on your Covered. See the 

level of Medicaid level of Medicaid benefits charts for 

eligibility, Medicaid eligibility, Medicaid applicable cost 

may pay your may pay your sharing amount 

Medicare cost 

sharing amount. 

Medicare cost 

sharing amount. 

earlier in this booklet. 

For services not For services not 

covered by Medicare 

or if the benefit is 

exhausted, Medicaid 

may provide 

additional coverage 

covered by Medicare 

or if the benefit is 

exhausted, Medicaid 

may provide 

additional coverage 

. 

subject to the subject to the . 

following cost share 

amounts: 

following cost share 

amounts: 

, , - 

. 

.... 

• , 

. 

$0 co-pay for $0 co-pay for . 

Medicaid services Medicaid services 

Preventive Care $0 $0 Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 40 of 128
Arizona Health Care Cost Containment 

System (AHCCCS) 

Benefit 

Hospice 

OMB or C2MB+ 

You Pay 

Depending on your 

level of Medicaid 

eligibility, Medicaid 

may pay your 

Medicare cost 

sharing amount. 

SLMB+ or FBDE 

You pay 

Depending on your 

level of Medicaid 

eligibility, Medicaid 

may pay your 

Medicare cost 

sharing amount. 

UnitedHealthcare 

Dual Complete® 

(HMO SNP) 

Covered. See the • 

benefits charts for 

'applicable cost 

sharing amount 

earlier in this booklet. 

For services not 

covered by Medicare 

or if the benefit is 

exhausted, Medicaid 

may provide 

additional coverage 

subject to the 

following cost share 

amounts: 

$0 co-pay for 

Medicaid services 

For services not 

covered by Medicare 

or if the benefit is 

exhausted, Medicaid 

may provide 

additional coverage 

subject to the 

following cost share 

amounts: 

$0 co-pay for 

Medicaid services 

Inpatient Hospital $0 

Care 

$0 

For age 21 and over 

limited to 25 days per 

1 year period 

beginning October 

1st of each year 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Inpatient Mental $0 $0 

Health Care 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Skilled Nursing $0 

Facility (SNF) 

$0 Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 41 of 128
Benefit 

Prescription Drug 

Benefits 

OMB or OMB+ 

You Pay 

$o 

Arizona Health Care Cost Containment 

System (AHCCCS) 

SLMB+ or FBDE 

You pay 

Generic 

$0 to $4 depending 

on eligibility* for age 

19 and over 

Un ited Healthcare 

Dual Complete® 

(HMO SNP) 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

$0 for age 18 and 

under 

Brand 

$0 to $10 depending 

on eligibility* for age 

19 and over 

$0 for age 18 and 

under 

Additional services available through UnitedHealthcare Dual Complete® (HMO SNP) 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Additional Dental Not Covered Not Covered 

Services 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Additional Foot Care Not Covered Not Covered 

Additional Hearing Not Covered Not Covered 

Services 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 42 of 128
OMB or OMB+ 

You Pay 

Not Covered 

SLMB+ or FBDE 

You pay 

Not Covered 

UnitedHealthcare 

Dual Complete® 

(HMO SNP) 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Arizona Health Care Cost Containment 

System (AHCCCS) 

Benefit 

Over-the-Counter 

Items 

Transportation 

(routine) 

Not Covered Not Covered Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Covered. See the 

benefits charts for 

applicable cost 

sharing amount 

earlier in this booklet. 

Additional Vision 

Services 

Not Covered Not Covered 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 43 of 128
This information is not a complete description of benefits. Contact the plan for more information. 

Limitations, co-payments, and restrictions may apply. 

The Formulary, pharmacy network, and/or provider network may change at any time. You will 

receive notice when necessary. 

Benefits, premium and/or co-payments/co-insurance may change on January 1 of each year. 

Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you 

receive. Please contact the plan for further details. 

You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid 

or by another third party. 

You are not required to use OptumRx home delivery for a 90 day supply of your maintenance 

medication. If you have not used OptumRx home delivery, you must approve the first prescription 

order sent directly from your doctor to OptumRx before it can be filled. New prescriptions from 

OptumRx should arrive within ten business days from the date the completed order is received, 

and refill orders should arrive in about seven business days. Contact OptumRx anytime at 1-877-

889-5802, TTY 711. OptumRx is an affiliate of UnitedHealthcare Insurance Company. 

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, 

a Medicare Advantage organization with a Medicare contract and a contract with the State 

Medicaid Program. This plan is available to anyone who has both Medical Assistance from the 

State and Medicare. Enrollment in the plan depends on contract renewal with Medicare. 

If you want to know more about the coverage and costs of Original Medicare, look in your current 

"Medicare & You" handbook. View it online at http://www.medicare.govor get a copy by calling 

1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 

1-877-486-2048. 

This document is available in other formats such as Braille and large print. This document may be 

available in a non-English language. For additional information, call us at 1-888-834-3721. 

This information is available for free in other languages. Please call our customer service number at 

1-888-834-3721, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. 

Esta informaciOn esta disponible sin costo en otros idiomas. Comuniquese con nuestro Servicio al 

Cliente al numero 1-888-834-3721, TTY 711, 8 a.m. a 8 p.m. hora local, los 7 dias de la semana. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 44 of 128
The company does not discriminate on the basis of race, color, national origin, sex, age, or 

disability in health programs and activities. 

We provide free services to help you communicate with us. Such as, letters in other languages or 

large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone 

number listed on your ID card TTY 711, Monday through Friday, 8 a.m. to 8 p.m. 

ATENCION: Si habla espanol (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su 

disposici6n. Llame al numero de telefono gratuito que aparece en su tarjeta de identificacion. 

liaA2E'4li (Chinese) , VARS. StIRITS'A-K*M9L142* 

MJo 

Multi-language Interpreter Services 

English: We have free interpreter services to answer any questions you may have about our health 

or drug plan. To get an interpreter, just call us at 1-888-834-3721. Someone who speaks English/ 

Language can help you. This is a free service 

Spanish: Tenemos servicios de interprete sin costo alguno para responder cualquier pregunta que 

pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un interprete, por favor 

Ilame al 1-888-834-3721. Alguien que hable espanol le podra ayudar. Este es un servicio gratuito. 

Chinese Mandarin: RC tt R0/9 afg* , mmiglimATtimageigffiregfigka 

MRIth a/JR* ,ikEg 1-888-834-3721. It 4f10/91I*AR1EMIltiiniriP.A'. -IktRAE 

Chinese Cantonese: resraffIntisAmeigommmr.io , Aittairamtnnin pu 

MEM-888-834-37210 fiff1M413MARIX*IhiniTt*M. t NEC 

Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga 

katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng 

tagasaling-wika, tawagan lamang kami sa 1-888-834-3721. Maaari kayong tulungan ng isang 

nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. 

French: Nous proposons des services gratuits d'interpretation pour repondre a toutes vos 

questions relatives a notre regime de sante ou d'assurance-medicaments. Pour acceder au service 

d'interpretation, ii vous suffit de nous appeler au 1-888-834-3721. Un interlocuteur parlant Francais 

pourra vous aider. Ce service est gratuit. 

Vietnamese: Chung toi c6 dich vii th6ng dich min phi de tre 16i cac cau hoi ve chuVng st:ec khoe va 

chu'ong trinh thu5c men. Neu qui vi can thong dich vien xin g9i 1-888-834-3721 se co nhan vier) n6i 

tieng Viet giup do qui vi. Day la dich vy mien phi. 

German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem 

Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-888-834-3721. Man 

wird lhnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 45 of 128
Korean: gAl-t2 011 RI-1F NE 011 U-aH gc24 A-11:11.2 

?,,!0 LIEF. ,,,c4MUk 0lgt1- 219J 

ko+ tl- agX1- 71. £21- 7.;2.4--IEF. 01 A-II:11 1-t• /4 -T-Rf. E.9=1 LIEF. 

Russian: EMI/1y Bac BO3HOKHyT Bonpocbi OTHOCOTellbH0 cTpaxoBoro Him megnameHTHoro nnaHa, 

Bbl moweTe BOC110/1630BaTbCfl Hawvimm 6ecnnambimw ycnyramm nepeBo,qHmKoB. LITO6b1 

BOCII0f1b30BaTbCA ycnyramm nepeeopHma, 1103BOHMTB Ham no TenecPoHy 1-888-834-3721. Bam 

oxamT nomouAb coTpyrtHwK, KOTOpbIA 10BOINIT no-pyccm. rtaHHaR ycnyra 6ecnnaTHas. 

Arabic: 

J31---11 .1:14 Z.4.3.11 J34.il L31,61 klij 41 (Dr. Z.1.3.1...111 j 1.1i) 

1273-438-888-1 Lsic• LL.) 4.1c. e÷..514Ls-1 

Date 

Hindi: TaTT.Tzr TfT TdT 41-417-9T Gil 4 31111* 141-VR19' ,31.411 t" ciR Ti:rft 1:MT IVO 

sii1i TI urr9-‘4- t..crT swruriirr 777 cp& 1 * clf, Tfr 1-888-834-3721 tR41-1,-1 Tt.c cc çifl 

3111r+rt 4-1 ti cbd I t. 1V.),c1 

Italian: E disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul 

nostro piano sanitario e farmaceutico. Per un interprete, contattare ii numero 1-888-834-3721. Un 

nostro incaricato che parla ltalianovi fornira l'assistenza necessaria. E un servizio gratuito. 

Portugues: Dispomos de servicos de interpretacao gratuitos para responder a qualquer questa° 

que ten ha acerca do nosso piano de saude ou de medicacao. Para obter urn interprete, 

contacte-nos atraves do numero 1-888-834-3721. Ira encontrar alguern que tale o idioma Portugues 

para o ajudar. Este servico e gratuito. 

French Creole: Nou genyen sevis entepret gratis pou reponn tout kesyon ou ta genyen konsenan 

plan medikal oswa dw6g nou an. Pou jwenn yon entepret, jis rele nou nan 1-888-834-3721. Yon 

moun ki pale Kreyol kapab ede w. Sa a se yon sevis ki gratis. 

Polish: Umo2liwiamy bezpfatne skorzystanie z uslug tfumacza ustnego, ktOry pomo2e w uzyskaniu 

odpowiedzi na temat planu zdrowotnego lub dawkowania lekOw. Aby skorzystao z pomocy 

tfumacza znajacego jQzyk polski, nale2y zadzwoniO pod numer 1-888-834-3721. Ta usfuga jest 

bezpfatna. 

Japanese: .01111* lz, Agit® 

3iTaRa'fii-aftztxr_1s 1-888-834-3721 L</ 

1E121K7AM-4•A ti'Int,Ntzt,1-0 attictIR:P0-it— 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 46 of 128
Vendor Information 

Before contacting any of the providers below you must be fully enrolled in UnitedHealthcare Dual 

Complete® (HMO SNP). 

Benefit Type 

Hearing Exams 

Vendor Name 

EPIC Hearing Health 

Care 

Contact Information 

1-866-956-5400, TTY 711 

6 a.m. - 6 p.m. Pacific Standard Time, Monday 

- Friday 

www.epichearing.com 

Hearing Aids EPIC Hearing Health 

Care 

1-866-956-5400, TTY 711 

6 a.m. - 6 p.m. Pacific Standard Time, Monday 

- Friday 

www.epichearing.com 

Vision Care NationwideTM Vision 1-877-614-0623, TTY 711 

8 a.m. - 8 p.m. local time, 7 days a week 

www.UHCCommunityPlan.com 

Dental Services UnitedHealthcare Dental 1-877-614-0623, TTY 711 

8 a.m. - 8 p.m. local time, 7 days a week 

www.UHCCommunityPlan.com 

Chiropractic ' 

Services 

OptumHealthTM Physical 

Health 

1-866-785-1654, TTY 1-888-877-5378 

8 a.m. - 8 p.m. Eastern Standard Time, 

Monday - Friday 

www.myoptumhealth.com 

NurseLine NurseLinesm 1-877-440-9407, TTY 711 

24 hours a day, 7 days a week 

Routine 

Transportation 

(Limited to 

ground 

transportation 

only) 

Medical Transportation 

Brokerage of Arizona® 

(MTBA) 

1-888-700-6822, TTY 711 

6 a.m. - 7 p.m. local time, Monday - Friday 

Health Products 

Benefit Catalog 

FirstLine Medical® 1-800-933-2914, TTY 711 

7 a.m. - 7 p.m. Central Standard Time, Monday 

- Friday; 7 a.m. - 4 p.m. Central Standard Time, 

Saturday 

www.HealthProductsBenefit.com 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 47 of 128
Benefit Type • Vendor Name Contact Information 

Fitness 

Membership 

SilverSneakers® Fitness 

program 

1-888-423-4632, TTY 711 

8 a.m. - 8 p.m. Eastern Standard Time, 

Monday - Friday 

silversneakers,com 

UHAZ17HM3865217_001 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 48 of 128
-October 17; 2017 

251STAN0ARDBM31305001.01735. 

GUN-I- SCHULER 

7907 E PORTOBELLO A 

MESA AZ85212-154? 

Unitedilealthcare 

GREE&CRAPT INTERIORS 

4675 E COTTON CENTER BLVD 

PHOENfXZ aqp4c) 

4611682, 456 

Dear CLINT SCHU LER, 

Thank you for being a valued member, We_ have been happy. to serve you. 

We are Sending this notice, 

health insurance. coverage 

ended, Below is a surnmecause either you or your employer has notified us that your 

ith UnitedHealtheare Or one of its affiliated companies haS 

of how long you have had coverage with us, 

Group: 

Group #: 

Erriployee Name: 

Employee ID: 

GREEN RAFT INTERIORS 

05U894 

• CUNT PHULER 

976771 05-00 

Member/Dependent Nami Date of Birth 

Coverage Period 

Begin Date to End Date 

GLINT SCHULER 

976771105-00 

10-13-1970 05-01-2016 12-01-2017* 

PLEZANA SCHULER 

976771105-01 

01-11-1969 05-01-2016 12-01-2017' 

JARIEK SCHULER , 

976771105-02 

03-06-1993 05-01-2016 12-01-2017' 

RAND] SCHULER . 

976771105-03 

02-14-1994 05-01-2016 12-01-2017* 

BREOAN SCHULER 

976771105-04 

07-12.1996 05-0-2016 12-01-2017° 

RIVER SCHULER I 

976771105-05 

06-05-1999 05.01-2016 12-01:2017* 

*Coverage ends at 12:01 am Egron the End Date 

.PRINIeFEDLE. .53,12P91G-F:Ept '• 

tle.'4615 

171219 

RriA5.1.420.1,`IrN. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 49 of 128
UnitedHealthcare 

Division: Benefit Services' 

P.O. Box 740221, Atlanta, GA30374-0221 

Ph: (860 747-0048 

CONTINUATION COVERAGE TERMINATION 

1 

1 

1 

CLINT SCHULER 

7907 E,PORTOBELILO AVE 

MESA; AZ66212 

dontinuation coverage has ended pti the tennirlatiohdate. ShoWn batik PleaSe;reView the terminatiOn dataand, if 

_ , .,„ . . _ , 

applicable, the list øf persons who have had their coverage' terminated 

'.0lient!,GYeiihaiaft. lriterlore 

)00C40(-)000C 

iSCHULER, CLINTTermination Date: 11/30/20:1 

Reesonior Termination:. EndotEligibility' 

- 

Cayaraga jf 

(se11).' 

,Spo-use: 

'Child 

ChUci 

tChild 

,Spousei 

, Child 

iChild 

'Child 

Child 

, 

Dental P9634' Participant 

MEMBERS WHOSE COVERAGE WILL BE TERMlNATEO: 

SCHULER, CLINT' 

'SCHULER PLEZANA 

SCHULER, JARIEK 

SCHULER, RANDI 

SCHULER, BREOAN 

SCHULER, RIVER 

',CarrieL,Name rage 1 

. . 

1,y10ife Melon , Participant Ear* 

MEMBERS VVHOSE COVERAGE WILL BE TERMINATED:. 

SCHULER, CLINT 

SCHULER, PLEZANA 

SCHULER,-JARIEK 

SCHULER,,RANDI 

SCHULER: BREOAN, 

SCHULER, RIVER' 

•"" 

rila 

XXx=XX-XXX 

XXXixX1XxXx , 

XXX-xX7XXXX. 

xXx-XX.W2.0( 

),(XX-XX-4290( 

it* 

.n/a 

XXX-Xx7xxXX 

)O()0(X,xxXx' 

XXX-XXAXXX' 

XXX-XkXXXX: 

XXXAX-XxXx: 

17— 

&rib: 

10/i ?/1970 

01/1i/196C 

b3to8t1993: 

02/14/1 994:: 

07/12/1998' 

08/05/1999 

Birth , 

103119m 

h11196§': 

03/00 991 

02/14/1 904 

07(1.2ii 996' 

08/05/1999 

Parnethame 3 ,coverAge - 1 

. . . 

Charter' Wine` 3F5 4000, PaiticiParit ':1 Family 

MEMBERS WHOSE COVEFIAGEWILL• BE TERN/NATO:X.: . 

SCHULER-CLINT (sell) 

'SCHULER; PLEZANA Spouse 

fl/a. 10/13/1970 

XXX-XX-XXX* 01/1-1/1959 

;1,1*1;e1q..41.1V20:9 

- 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 50 of 128
Z IIHIHXJ siiMuIEId 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 51 of 128
Claim Numb( Patient Nai Date Visited Visited Claim Type Claim St Date Processed Amount Billec Deductible Your Plan Plan Discour Your Responsibility You Owe 

1.71E+11 Clint Schul 3/1/2017 Lior Berger Dental Processe 3/3/2017 3365 0 25-9-7721 

1.70E+11 Clint Schul 2/7/2017 Ryan Baker Dental Processe 2/8/2017 1978 0 

33.6 Not Available 2597.41 

946.8 Not Available 249.2 _249.2 

1.71E+11 Clint Schul 2/1/2017 Lior Berger Dental Processe 3/1/2017 273 0 0 Not Available 0 

1.71E+11 Clint Schul 2/1/2017 Lior Berger Dental Processe 3/1/2017 ' 273 0 123 Not Available 0 

1.72E+11 Clint Schul 1/25/2017 Lior Berger Dental Processe 7/10/2017 1918 0 0 Not Available 1918 ' 1918] 

1.71E+11 Clint Schul 

1.71E+11 Clint Schul 

1/25/2017 Lior Berger Dental 

1/25/2017 Lior Berger Dental 

Processe 

Processe 

3/1/2017 

3/1/2017 ! 

93 

521 

0 

0 

0 Not Available 

146.6 Not Available 

0 

25.41 

0 

254J 

6866962834 Clint Schul 11/29/2017 Brian Lilien Not Available In Proce Not Available 5559 0 0 0 Not Available 0 

6683914020 Clint Schul 3/10/2017 Brian Lilien Not Available In Proce: Not Available 4188.88 0 0 0 Not Available 0 

8209348065 Clint Schul 11/29/2017 PHARMACY Pharmacy Processe 11/29/2017 0 0 4.01 0 

8209342865 Clint Schul 11/29/2017 PHARMACY Pharmacy Processe 11/29/2017 0 0 4 0 

6711894248 Clint Schul 9/6/2017 B Lilien Medical Processe 10/24/2017 -2546 0 0 0 -2546 0 

6711894248 Clint Schul 9/6/2017 B Lilien Medical Processe 10/24/2017 2546 0 1172.94 1242.74 130.32 130.32 

6711894248 Clint Schul 9/6/2017 B Lilien Medical Processe 9/9/2017 2546 0 0 0 2546 2546 

6553947109 Clint Schul 6/5/2017 B Lilien Medical Processe 6/8/2017 I 138 83.49 0 54.51 83.49 83.49 

3308696789 Clint Schul 03/15/2017 to 04/ B Lilien Medical Processe 10/16/2017 ; -1001 0 0 -60 -941 0 

3308696789 Clint Schul 03/15/2017 to 04/' B Lilien Medical Processe 10/16/2017 ; 3.07 0 3.07 0 0 0 

3308696789 Clint Schul 03/15/2017 to 04/' B Lilieb Medical Processe 10/16/2017 I 1001 0 421.25 532.95 46.8 4-6131 

3308696789 Clint Schul 03/15/2017 to 04/' B Lilien Medical Processe 7/11/2017 1001 0 0 60 941 9411 

8213516362 Clint Schul 3/10/2017 B Lilien Medical Processe 12/8/2017 4188.88 0 0 4188.88 0 0 

3318939511 Clint Schul 3/10/2017 B Lilien Medical Processe 10/12/2017 3227.88 965.36 2036.26 0 1191.621 1191.621 

3318939511 Clint Schul 3/10/2017 B Lilien Medical Processe 10/12/2017 ; 961 0 0 961 0 0 

3318939511 Clint Schul 3/10/2017 B Lilien Medical Processe 10/5/2017 4188.88 965.36 2036.28 961 1191.61 •

1191.6] 

3318939511 Clint Schul 3/10/2017 B Lilien Medical Processe 10/5/2017 . 0 0 0 511 0 0 

6407657513 Clint Schul 3/10/2017 B Lilien Medical Processe 10/4/2017 -654.14 0 0 -1919.6 -654.14 0 

3304566361 Clint Schul 3/10/2017 B Lilien Medical Processe 10/4/2017 -3084.74 -959.88 0 -2288.4 -959.88 0 

8084700591 Clint Schul 3/10/2017 B Lilien Medical Processe 6/25/2017 1165.14 0 0 3084.74 0 0 

3304566361 Clint Schul 3/10/2017 B Lilien Medical Processe 6/9/2017 1165.14 959.88 0 2124.86 959.88 959 . 6 61 

6407657513 Clint Schul 3/10/2017 B Lilien Medical Processe 3/21/2017 2573.74 0 0 0 654.14 - 654.14 

9927909432 Clint Schul 3/10/2017 PHARMACY Pharmacy Processe 3/10/2017 4 0 4 0 

9927850873 Clint Schul 3/10/2017 PHARMACY Pharmacy Processe 3/10/2017 15.63 0 15.63 0 

9924360849 Clint Schul 3/7/2017 PHARMACY Pharmacy Processe 3/7/2017 4 0 4 0 

9920738873 Clint Schul 3/2/2017 PHARMACY Pharmacy Processe 3/3/2017 4 0 4 0 

6553947110 Clint Schul 3/1/2017 B Lilien Medical Processe 6/30/2017 -1571 0 0 -1571 0 0 

6553947110 Clint Schul 3/1/2017 B Lilien Medical Processe 6/30/2017 • 1571 0 0 0 1571 1571] 

6553947110 Clint Schul 3/1/2017 B Lilien Medical Processe 6/8/2017 , 1571 .0 0 1571 0 0 

6392985894 Clint Schul 2/23/2017 Ati Physical 1 Medical Processe 3/10/2017 323.35 65 0 258.35 65 65 

6376110897 Clint Schul 2/16/2017 Ati Physical 1 Medical Processe 2/26/2017 277.92 65 0 212.92 65 65 

6362360600 Clint Schul 2/9/2017 Ati Physical 1 Medical Processe 2/17/2017 252.78 65 0 187.78 65 65 

9896510888 Clint Schul 2/8/2017 PHARMACY Pharmacy Processe 2/9/2017 5.33 0 5.33 0 

9896507750 Clint Schul 2/7/2017 PHARMACY Pharmacy Processe 2/9/2017 5.33 0 5.33 0 

9895103894 Clint Schul 2/7/2017 PHARMACY Pharmacy Processe 2/7/2017 5.33 0 5.33 0 

9895102227 Clint Schul 2/7/2017 PHARMACY Pharmacy Processe 2/7/2017 9.01 0 9.01 0 

9895101306 Clint Schul 2/7/2017 PHARMACY Pharmacy Processe 2/7/2017 1 12.24 0 12.24 0 

3308696789 Clint Schul 02/01/2017 to 03/' B Lilien Medical Processe 10/16/2017 ; 6.02 0 6.02 0 0 0 

3308696789 Clint Schul 02/01/2017 to 03/' B Lilien Medical Processe 10/16/2017 -1769 -5 0 -1764 -35 0 

3308696789 Clint Schul 02/01/2017 to 03/' B Lilien Medical Processe 10/16/2017 1734 5 825.29 795.29 113.42 113742 

3308696789 Clint Schul 02/01/2017 to 03/' B Lilien Medical Processe 7/11/2017 1734 0 0 35 1734 • 1734 

6344402905 Clint Schul 1/31/2017 Ati Physical 1 Medical Processe 2/6/2017 292.94 65 0 227.94 65 65 

6337741530 Clint Schul 1/27/2017 Ati Physical 1 Medical Processe 2/3/2017 292.94 65 0 227.94 65 65 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 52 of 128
6465691996 Clint Schul 1/25/2017 B Lilien Medical Processe 4/25/2017 994 0 0 0 

6465691996 Clint Schul 1/25/2017 B Lilien Medical Processe 4/18/2017 428 339.88 0 88.12 

9880028746 Clint Schul 1/25/2017 PHARMACY Pharmacy Processe 1/26/2017 4.54 0 

6333716851 Clint Schul 1/24/2017 Ati Physical 1 Medical Processe 1/30/2017292.94 65 0 227.94 

6330122258 Clint Schul 1/20/2017 Ati Physical 1 Medical Processe 1/27/2017 292.94 65 0 227.94 

6327627813 Clint Schul 1/17/2017 Ati Physical 1 Medical Processe 1/26/2017 363.51 65 0 298.51 

6316893839 Clint Schul 1/12/2017 Ati Physical 1 Medical Processe 1/19/2017 363.51 65 0 298.51 

6357063363 Clint Schul 1/10/2017 Ati Physical 1 Medical Processe 2/18/2017 348.49 65 0 283.49 

6308518352 Clint Schul 1/5/2017 Ati Physical 1 Medical Processe 1/12/2017 348.49 65 0 283.49 

6311576783 Clint Schul 1/3/2017 Ati Physical 1 Medical Processe 1/13/2017 348.49 65 0 283.49 

6465691996 Clint Schul 01/02/2017 to 01/; B Lilien Medical Processe 4/25/2017 372 0 0 372 

6299236995 Clint Schul 12/29/2016 Ati Physical 1 Medical Processe 1/5/2017 334.9 0 65 269.9 

6299236994 Clint Schul 12/27/2016 Ati Physical 1 Medical Processe 1/5/2017 220 0 65 155 

6299236993 Clint Schul 12/22/2016 Ati Physical 1 Medical Processe 1/5/2017 279.9 0 65 214.9 

6299236992 Clint Schul 12/20/2016 Ati Physical 1 Medical Processe 1/5/2017 224.9 0 65 159.9 

6756852721 Clint Schul 12/19/2016 B Lilien Medical Processe 1/2/2018 , 0.53 0 0.53 0 

6756852721 Clint Schul 12/19/2016 B Lilien Medical Processe 1/2/2018 -2073.28 0 0 -2373.28 

6756852721 Clint Schul 12/19/2016 B Lilien Medical Processe 1/2/2018 1578.56 0 90 1074.28 

6756852721 Clint Schul 12/19/2016 B Lilien Medical Processe 1/2/2018 375 0 0 375 

6756852721 Clint Schul 12/19/2016 B Lilien Medical Processe 1/2/2018 2.16 0 2.16 

6756852721 Clint Schul 12/19/2016 B Lilien Medical Processe 1/2/2018 1209 0 363.6 545.4 0

6756852721 Clint Schul 12/19/2016 B Lilien Medical Processe 10/9/2017 2073.28 0 0 2073.28 

6756852721 Clint Schul 12/19/2016 B Lilien Medical Processe 10/8/2017 375 0 0 0 

3309367282 Clint Schul 12/19/2016 B Lilien Medical Processe 8/7/2017 2.51 0 2.51 0 

3309367282 Clint Schul 12/19/2016 B Lilien Medical Processe 8/7/2017 92064.28 0 714.28 91350 

3309367282 Clint Schul 12/19/2016 B Lilien Medical Processe 8/7/2017 375 0 0 375 

6287945873 Clint Schul 12/15/2016 Southwest Di. Medical Processe 12/23/2016 129 0 41.36 87.64 

6280099823 Clint Schul 12/15/2016 Ati Physical 1 Medical Processe 12/22/2016 224.9 0 65 159.9 

6282378083 Clint Schul 12/13/2016 Ati Physical 1 Medical Processe 12/23/2016 359.9 0 65 294.9 

6708450253 Clint Schul 12/9/2016 B Lilien Medical Processe 9/13/2017 375 0 0 0 

6388253389 Clint Schul 12/07/2016 to 12/C B Lilien Medical Processe 3/2/2017 357 0 151.06205.94 

6281108752 Clint Schul 12/7/2016 A Sharma Medical Processe 12/20/2016 868 0 94.86 773.14 

3300922913 Clint Schul 11/29/2016 P Prichard Medical Processe 5/13/2017 3657.96 474.76 0 0 

8030128551 Clint Schul 11/29/2016 P Prichard Medical Processe 4/4/2017 3657.96 0 0 3657.96 

6277422127 Clint Schul 11/29/2016 T Harrison Medical Processe 2/21/2017 1.69 0 1.69 0 

6277422127 Clint Schul 11/29/2016 T Harrison Medical Processe 2/16/2017 1224 0 9 0 

6295740937 Clint Schul 11/29/2016 John C Lincol Medical Processe 12/30/2016 11562.8 0 

16204.80 0 

9162.8 

6277422127 Clint Schul 11/29/2016 T Harrison Medical Processe 12/23/2016 1224 160.89 0 0 

6268533440 Clint Schul 11/08/2016 to 12/( Preferred Hot Medical Processe 12/10/2016 2759.4 0 0 2759.4 

6268533439 Clint Schul 11/08/2016 to 12/C Preferred Hot Medical Processe 12/10/2016 750 0 90 660 

6239829856 Clint Schul 11/8/2016 Preferred Hor Medical Processe 11/29/2016 300.92 0 76.16 224.76 

6239829856 Clint Schul 11/8/2016 Preferred Hor Medical Processe 11/19/2016 24.04 0 8.12 15.92 

6239829855 Clint Schul 11/8/2016 Preferred Nor Medical Processe 11/19/2016 239 0 78.02 160.98 

6229660330 Clint Schul 11/8/2016 Scottsdale Medical Processe 11/14/2016 262 0 75.6 186.4 

6226975414 Clint Schul 11/8/2016 Preferred Hor Medical Processe 11/10/2016 1308.57 0 321.73 713 

6224008314 Clint Schul 11/3/2016 Scottsdale Medical Processe 11/9/2016 337 0 118.44 218.56 

6244044287 Clint Schul 11/2/2016 G Carr Medical Processe 11/23/2016 140 0 80 60 

6258106489 Clint Schul 11/1/2016 American Me Medical Processe 3/1/2017 1517.2 0 1517.2 0 

6258106489 Clint Schul 11/1/2016 American Me Medical Processe 12/15/2016 1517.2 0 0 0 

6226129668 Clint Schul 11/01/2016 to 11/( Plaza Health( Medical Processe 11/22/2016 3325 0 3325 0 

6221971254 Clint Schul 10/31/2016 Scottsdale Medical Processe 11/8/2016 337 0 118.44 218.56 

9941 9941 

1 339.88 339.881 

4.54 0 

65 65 

65 65 

65 65 

65 65 

65 65 

65 65 

65 65 

0 0 

0 0 

0 0 

0 0 

0 0 

0 0 

0 0 

0 0 

0 0 

0 0 

0 0 

0 0 

375 r--- 3751 

0 0 

0 0 

0 0 

0 0 

0 0 

0 0 

3751 3151 

0 0 

0 0 

3657.961 -, 3657.961 

0 0 

0 0 

1063.11 1063.11 

0 

1224 12240 

0 0 

0 0 

0 0 

0 0 

0 0 

0 0 

273.84 273.84 

0 0 

0 0 

0 0 

1517.2 1517.2 

0 0 

0 0 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 53 of 128
6221971253 Clint Schul 10/28/2016 Scottsdale Medical Processe 11/8/2016 337 0 118.44 218.56 0 0 

6221971252 Clint Schul 10/27/2016 Scottsdale Medical Processe 11/8/2016 337 0 118.44 218.56 0 0 

6221971251 Clint Schul 10/25/2016 Scottsdale Medical Processe 11/8/2016 410.01 0 143.28 266.73 0 0 

6205880178 Clint Schul 10/24/2016 N Usmani. Medical Processe 10/28/2016 185 139.31 0 45.69 139.31 139.31 

6213080993 Clint Schul 10/23/2016 Diagnostic Medical Processe 11/13/2016 23.18 0 11.64 11.54 0 0 

6242137789 Clint Schul 10/22/2016 American Me Medical Processe 11/30/2016 1106.4 0 1106.4 0 0 0 

6242137789 Clint Schul 10/22/2016 American Me Medical Processe 11/23/2016 1106.4 0 421.24 0 685.16 685.16 

6213370541 Clint Schul 10/22/2016 to 10K Plaza Health( Medical Processe 11/18/2016 4750 0 4750 0 0 0 

6209548247 Clint Schul 10/21/2016 V Johnson Jr Medical Processe 5/11/2017 0.14 0 0.14 0 0 0 

6209548247 Clint Schul 10/21/2016 V Johnson Jr Medical Processe 5/5/2017 275 79.52 3.29 0 271.71 271.71 

6209548247 Clint Schul 10/21/2016 V Johnson Jr Medical Processe 11/2/2016 275 79.52 0 0 275 275 

6221816829 Clint Schul 10/20/2016 F Ali-osman Medical Processe 11/9/2016 796 0 246.63 0 549.37 549.37 

6229575765 Clint Schul 10/19/2016 A Hollingwort Medical Processe 11/22/2016 796 0 246.63 0 549.37 549.37 

6208024292 Clint Schul 10/19/2016 Medical Diagi Medical Processe 10/29/2016 36 16.51 0 19.49 16.51 16.51 

6229575764 Clint Schul 10/18/2016 A Hollingwort Medical Processe 11/22/2016 1111 0 364.99 0 746.01 746.01 

6204107858 Clint Schul 10/18/2016 Medical Diagi Medical Processe 10/27/2016 36 16.51 0 19.49 16.51 16.51 

3287366394 Clint Schul 10/17/2016 A Hollingwort Medical Processe 2/17/2017 0.1 0 0.1 0 0 0 

3287366394 Clint Schul 10/17/2016 A Hollingwort Medical Processe 2/14/2017 1153 0 123.53 0 782.84 782.84 

3287366394 Clint Schul 10/17/2016 A Hollingwort Medical Processe 1/20/2017 1153 0 246.63 357 549.37 549.37 

3287366394 Clint Schul 10/17/2016 A Hollingwort Medical Processe 1/12/2017 1153 0 246.63 357 549.37 549.37 

6259307105 Clint Schul 10/17/2016 A Hollingwort Medical Processe 12/6/2016 1153 0 0 0 1153 1153 

6259307105 Clint Schul 10/17/2016 A Hollingwort Medical Processe 12/5/2016 1153 0 0 0 1153 1153 

3281813416 Clint Schul 10/17/2016 A Hollingwort Medical Processe 11/30/2016 1153 0 0 357 796 796 

3281813416 Clint Schul 10/17/2016 A Hollingwort Medical Processe 11/26/2016 1153 0 246.63 357 549.37 549.37 

6204107859 Clint Schul 10/17/2016 Medical Diagi Medical Processe 10/27/2016 36 16.51 0 19.49 16.51 16.51 

6202333017 Clint Schul 10/17/2016 Medical Diagi Medical Processe 10/26/2016 36 16.51 0 19.49 16.51 16.51 

6503575889 Clint Schul 10/16/2016 0 Tylor Medical Processe 5/18/2017 3024 0 0 0 3024 3024 

3290527281 Clint Schul 10/16/2016 P Prichard Medical Processe 2/9/2017 13237.14 0 1361.32 0 11875.82 r 11875.82 

6327740575 Clint Schul 10/16/2016 J Mussman Medical Processe 2/7/2017 13237.14 0 91.48 0 13145.661 13145.66 

6214634755 Clint Schul 10/16/2016 0 Tylor Medical Processe 11/16/2016 3384 0 401.02 0 2982.98 2982.98 

6198175376 Clint Schul 10/16/2016 V Johnson Jr Medical Processe 11/11/2016 2866 0 1032.76 0 1833.24 1833.24 

6202333021 Clint Schul 10/16/2016 Medical Diagi Medical Processe 10/26/2016 137 64.03 0 72.97 64.03 64.03 

6305946656 Clint Schul 10/15/2016 V Johnson Jr Medical Processe 2/27/2017 1153 0 370.16 0 782.84 782.84 

6289038038 Clint Schul 10/15/2016 V Johnson Jr Medical Processe 12/27/2016 1153 0 0 0 1153 1153 

6289038038 Clint Schul 10/15/2016 V Johnson Jr Medical Processe 12/26/2016 1153 0 0 0 1153 1153 

3281813051 Clint Schul 10/15/2016 V Johnson Jr Medical Processe 11/26/2016 1153 0 0 1153 0 0 

6202333020 Clint Schul 10/15/2016 Medical Diagi Medical Processe 10/26/2016 36 16.51 0 19.49 16.51 16.51 

6202333018 Clint Schul 10/15/2016 Medical Diagi Medical Processe 10/26/2016 36 16.51 0 19.49 16.51 16.51 

6192391486 Clint Schul 10/14/2016 A Mangram Medical Processe 10/28/2016 796 246.63 0 0 796 r 796 

6202333022 Clint Schul 10/14/2016 to 10/' Medical Diagi Medical Processe 10/26/2016 72 33.02 0 38.98 33.02 33.02 

6202333019 Clint Schul 10/14/2016 Medical Diagl Medical Processe 10/26/2016 47 20.46 0 26.54 20.46 20.46 

6218601692 Clint Schul 10/13/2016 Medical Diagi Medical Processe 11/5/2016 36 0 16.51 19.49 0 

6192391487 Clint Schul 10/13/2016 A Mangram Medical Processe 10/20/2016 1153 370.16 0 0 1153 1153 

3293620626 Clint Schul 10/12/2016 C Beneduce Medical Processe 4/5/2017 0.43 0 0.43 0 0 0 

3293620626 Clint Schul 10/12/2016 C Beneduce Medical Processe 4/5/2017 2100 0 319.37 0 1780.63 1780.63 

3291705390 Clint Schul 10/12/2016 P Prichard Medical Processe 3/20/2017 0 0 438.87 0 6075.29 6075.29 

3291705390 Clint Schul 10/12/2016 P Prichard Medical Processe 3/20/2017 1218.18 0 0 0 1218.18 1218.18 

3291705390 Clint Schul 10/12/2016 P Prichard Medical Processe 3/20/2017 0.24 0 0.24 0 0 0 

3291705390 Clint Schul 10/12/2016 P Prichard Medical Processe 3/20/2017 1.83 0 1.83 0 0 0 

3291705390 Clint Schul 10/12/2016 P Prichard Medical Processe 3/20/2017 67452.38 0 3394.87 0 77294.65 77294.651 

3293620626 Clint Schul 10/12/2016 C Beneduce Medical Processe 3/10/2017 2100 319.37 0 0 2100 2100 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 54 of 128
3292906553 Clint Schul 10/12/2016 J Mussman Medical Processe 2/28/2017 1.04 0 1.04 o 0 

3292906553 Clint Schul 10/12/2016 J Mussman Medical Processe 2/28/2017 39502.6 0 274.71 0 39227.89 3927.89 

3291705390 Clint Schul 10/12/2016 P Prichard Medical Processe 2/18/2017 68670.56 3203.76 0 0 88421.86 88421.86 

6217258596 Clint Schul 10/12/2016 G lzuegbunar Medical Processe 1/31/2017 2210 0 505.09 0 1313.5 1313.5 

6217258596 Clint Schul 10/12/2016 G lzuegbunar Medical Processe 1/31/2017 8.32 0 8.32 0 

6251632398 Clint Schul 10/12/2016 City Of Phoer Medical Processe 12/7/2016 1189.78 0 1189.78 0 

6251632398 Clint Schul 10/12/2016 City Of Phoer Medical Processe 11/30/2016 1189.78 0 582.77 0 607.01 607.01 

6235441488 Clint Schul 10/12J2016 Emcare-pnx I Medical Processe 11/19/2016 1886 0 1225.9 660.1 0 

6217258596 Clint Schul 10/12/2016 G lzuegbunar Medical Processe 11/17/2016 2210 0 391.41 0 1818.59 1818.59 

6214890237 Clint Schul 10/12/2016 Medical DOD Medical Processe 11/11/2016 36 0 16.51 19.49 

6214011094 Clint Schul 10/12/2016 to 10/; John C Lincol Medical Processe 11/4/2016 19350 0 o 19350 

6214011094 Clint Schul 10/12/2016 to 10/; John C Lincol Medical Processe 11/4/2016 24E920.4 675.7 82904.3 159970.4 3045.7 3045.7 

6214890238 Clint Schul 10/12/2016 Medical Dag Medical Processe 11/3/2016 36 16.51 o 19.49 16.51 16.51 

6208024293 Clint Schul 10/12/2016 Medical Diagi Medical Processe 10/29/2016 924 344.54 0 579.46 344.54 344.54 

6208024291 Clint Schul 10/12/2016 Medical Diagi Medical Processe 10/29/2016 1101 469.76 0 631.24 469.76 469.76 

6205761392 Clint Schul 10/12/2016 A Sharma Medical Processe 10/27/2016 1795 197.78 0 1597.22 197.78 197.78 

6192391488 Clint Schul 10/12/2016 F Ali-osman Medical Processe 10/20/2016. 2371 710.02 o 0 2371 2371 

Patient Nal Date Visited Visited Claim Type Claim St Date Processed Amount Billet Deductible Your Plan Plan Discour Your Responsibility You Owe 

$659,902.70 $10,908.30 $289,872.54 $299,721.14 

Dr. Prichard Surgery Related Total $ 245,998.40 Dental Specialty Assoc Total $18,037.15 UHC/Not Paid Per Plan FS 264,035.-iii 

Schuler's OUT OF POCKET pd to Dental Specialty Associates/Apex Endo $ 9,117.26 

TOTAL UNPAID BY UHC HEALTH INS. PLAN $ 254,918.29 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 55 of 128
E immxa sB9u!uid 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 56 of 128
Gmail - UnitedHealthcare Insurance Company https://mail.google.com/mail/u/0/?ui=2&ilc=0d8bf3efd4&jsver=eqR4N... 

M Grnail Clint Schuler <schulerclint@gmail.com> 

UnitedHealthcare Insurance Company 

6 messages 

Dawn Lucero <DLucero@azinsurance.gov> Wed, Oct 18, 2017 at 12:20 PM 

To: "schulerclint@gmail.com" <schulerclint@gmail.com> 

This note is a follow up to our conversation today. You may provide all bills submitted to you by the provider. If you 

have any further questions regarding this matter you may contact me at the number below. 

12aval Zucero, Caasuzzior ,S:poatilc-c 

reirialaa Ovaranazg a Insuz072,0 

2910 North 4446,..Covoc, Stzico 2/0 

Pkoaair, AZ 85018 

Phozzo 602-364-2492 

dlucero@azinsurance.gov 

NOTICE: This communication may contain privileged or other confidential information. If you have received it in error, 

please advise the sender by reply e-mail and immediately delete the message and any attachments 'without copying 

or disclosing the contents. Thank you. 

Clint Schuler <schulerclint@gmail.com> Wed, Oct 18, 2017 at 12:49 PM 

To: Dawn Lucero <DLucero@azinsurance.gov>, Marie Sessions <mariedsaofaz@gmail.com> 

Cc: clint@gentryestates.com 

I just sent you an email also and included my Provider Office Manager — Marie Sessions. I 

have also left a message with Gloria. Please let u know of anything else you may need. 

Sincerely, 

Clint Schuler 

480-721-9023 

1 of 12 2/16/2018, 11:14 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 57 of 128
Gmail - UnitedHealthcare Insurance Company https://mail.google.com/mail/u/0/?ui=2&ilc=0d8bf3efd4&jsver=eqR4N... 

From: Dawn Lucero [mailto:DLucero@azinsurance.gov] 

Sent: Wednesday, October 18, 2017 12:20 PM 

To: schulerclint@gmail.com 

Subject: UnitedHealthcare Insurance Company 

[Quoted text hidden] 

Forwarded message 

From: Clint Schuler <schulerclint@gmail.com> 

To: Marie Sessions <mariedsaofaz@gmail.com>, Clint Schuler <schulerclint@gmail.com>, Dawn Lucero 

<dlucero@azinsurance.gov> 

Cc: 

Bcc: 

Date: Wed, 18 Oct 2017 12:42:26 -0700 

Subject: Insurance and complaint 

Hey Marie. 

I just received a call from the state of AZ department of insurance. Apparently, UHC states they have paid Dr. Lilien 

and Dr. Berger for any and all of the Billings related to my treatment. Would you please verify for me!? 

I know I just received a bill yesterday and I know the statements of amounts due and owing which you have provided 

to me prior of over $100k. 

So please confirm to me and the state whether or not you have received payment and we can begin treatment again. 

I am cc'ing the contact at the State of AZ as well. Please reply all. 

_ 

I am also attaching the bill and please confirm I have paid these amounts out of pocket. 

2 of12 2/16/2018, 11:14 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 58 of 128
. Dataai sz4polo1df,ls A.c6.0414 4; 4.. 

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f.i...a.R041 1,71 

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Gmail - UnitedHealthcare Insurance Company 

https://mail.google.com/mail/u/0/?ui=2&ilc=0d8bf3efd4&jsver=eqR4N.. 

woe '2,3 rtyt VA: *4 Cfn 04-0 r,hlra-tii /TA? exPirL 

142 M17 ,, ilii4 2Stili CA) 314(00 U1-4a7S 

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$3115.79 it 

ICAork; PeoastAws.i, 77$4 Ytt.'1404 t i 5.M 1134t Eiô. ii *ra %f4Wbgn tr2r0E4T"133-=;14PZ 

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r.-.'4 LL It&tV4f1 N4F7 P PtVE)47 OteAde CALL leo 6.33-ove 

' 

2/1 6/2018,11:14 AM 

of 12 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 59 of 128
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t 

Gmail - UnitedHealthcare Insurance Company https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

moinnimmowairrumwsiclowsminalso 

r41,, NUL 5PECIALI1f.6 nsnoroe,, 

nqyM VIt..;T% tlft.C1.0ti iipuci SI1f4 

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ft ow ptO*11. 10,4 

STATEMENT 

D‘JE riair• 30 Pa?* 0 i.;.-11y4 XI 03,0 cutaK tit 

EALANCE 

1011(2(J)7 -2544,00 2690 00 $115.75 3003,79 

AMOUNT DUE 

$3115.19 

OvkAGES I:31E1M 

SO8179 

mscrolitoti 

9111,(2017 

94)5/2017. Ciltit 

$005,2017 Cimt 

10(0647017 Clint 

iBC06i2017 Ciint 

p'06)2017 CFht 

9061017 C6:tt 

1'0E1017 Grim 

1062017 Ctinl 

1001017 ChM 

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i. 3152017 Vial 

.;0&2017 Vint 

.014011 CFA 

_...-------"--------

, Tf: 

P)N AM. PA 0:tit:PA:Si 4I•A'i Af4aPAYMF.NTS PLEASE CALL 002,631cr272. 

r 3,iyi,,, 443- .c.;3! l

ie:. ise.,=ilivz, V;i11,5; VAltil:ia Dr 0140 11 STE 164, Biog.., s 57E164, Gilbert Az 85225 tom 533977 

Please reply with the previous Billings as well-back to December 2016 - unless this is the total amount owed and the 

insurance co has in fact paid you. 

Thanks. 

Clint Schuler 

Si1niz Forward -

Prophyfakis-aduit 

Custom abeimonlincl placeinefit 

Custom ibuneanyinct placement 

l

.Abuutorn soppeneu P0rOl0er Cm 

Arauunen1 supported pi:nicer ern 

Carecrodd - Thank YOU Oh # 7858 

Spnngstone Admin: e41,, 

f ilad tiA0c3/0al.tP*00,4-Atii 

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52.00 

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4 of 12 

2/16/2018, 11:14 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 60 of 128
Gmail - UnitedHealthcare Insurance Company https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

13 attachments 

Dental Specialty assoc bill 102017 2.jpg 

1072K 

Dental Specialty assoc bill 102017.jpg 

955K 

t Claim Detail UnitedHealthcare_Dr Lilien_Dental Specialty Assoc_09092017.pdf 

163K 

in Claim Detail UnitedHealthcare_Dr Lilien_DSA_06062017.pdf 

151K 

v2 I - Claim Detail UnitedHealthcare_Dr Lilien_DSA_06082017.pdf 

151K 

in Claim Detail UnitedHealthcare_Dr Lilien_DSA_06092017.pdf 

195K 

t Claim Detail UnitedHealthcare_Dr Lilien_DSA_07082017.pdf 

183K 

t Claim Detail UnitedHealthcare_Dr Lilien_DSA_07112017.pdf 

162K 

t Claim Detail UnitedHealthcare_Dr Lilien_DSA_08072017.pdf 

145K 

t Clint Schuler Claims_Dental Specialty Assoc_UNPAID BY UHC.pdf 

5868K 

t Clint Schuler EOB_UHC_DENTALSPECIALTY ASSOC.pdf 

957K 

t noname.eml 

2777K 

in Preauthroization Requests_Dental Specialty Assoc.Schuler.pdf 

9596K 

Clint Schuler <schulerclint@gmail.com> Wed, Oct 18, 2017 at 12:49 PM 

5 of 12 2/16/2018, 11:14 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 61 of 128
Gmail - UnitedHealthcare Insurance Company https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

To: Dawn Lucero <DLucero@azinsurance.gov>, Marie Sessions <mariedsaofaz@gmail.com> 

Cc: clint@gentryestates.com 

I just sent you an email also and included my Provider Office Manager — Marie Sessions. I 

have also left a message with Gloria. Please let u know of anything else you may need. 

Sincerely, 

Clint Schuler 

480-721-9023 

From: Dawn Lucero [mailto:DLucero@azinsurance.gov] 

Sent: Wednesday, October 18, 2017 12:20 PM 

To: schulerclint@gmail.com 

Subject: UnitedHeaIthcare Insurance Company 

This note is a follow up to our conversation today. You may provide all bills submitted to you by the provider. If you 

have any further questions regarding this matter you may contact me at the number below. 

[Quoted text hidden] 

Forwarded message 

From: Clint Schuler <schulerclint@gmail.com> 

To: Marie Sessions <mariedsaofaz@gmail.com>, Clint Schuler <schulerclint@gmail.com>, Dawn Lucero 

<dlucero@azinsurance.gov> 

Cc: 

Bcc: 

Date: Wed, 18 Oct 2017 12:42:26 -0700 

Subject: Insurance and complaint 

Hey Marie. 

I just received a call from the state of AZ department of insurance. Apparently, UHC states they have paid Dr. Lilien 

and Dr. Berger for any and all of the Billings related to my treatment. Would you please verify for me!? 

I know I just received a bill yesterday and I know the statements of amounts due and owing which you have provided 

to me prior of over $100k. 

So please confirm to me and the state whether or not you have received payment and we can begin treatment again. 

I am cc'ing the contact at the State of AZ as well. Please reply all. 

I am also attaching the bill and please confirm I have paid these amounts out of pocket. 

6 of 12 2/16/2018, 11:14 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 62 of 128
Gmail - UnitedHealthcare Insurance Company https://mail.google.corn/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

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$3115,79 

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Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 63 of 128
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Gmail - UnitedHealthcare Insurance Company https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsyer=eqR4N... 

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Please reply with the previous Billings as well-back to December 2016 - unless this is the total amount owed and the insurance co has in fact paid you. 

Thanks. 

Clint Schuler 

2/16/2018, 11:14 AM 

of 12 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 64 of 128
Gmail - UnitedHealthcare Insurance Company https://mail.google.com/mail/u/0/?ui=2&ilc=0d8bf3efd4&jsver=eqR4N... 

13 attachments 

Dental Specialty assoc bill 102017 2.jpg 

1072K 

Dental Specialty assoc bill 102017.jpg 

955K 

18 Claim Detail Uni- te- dHealthcare_Dr Lilien_Dental Specialty Assoc_09092017.pdf 

163K 

in Claim Detail UnitedHealthcare_Dr Lilien_DSA_06062017.pdf 

151K 

fa Claim Detail UnitedHealthcare_Dr Lilien_DSA_06082017.pdf 

151K 

t Claim Detail UnitedHealthcare_Dr Lilien_DSA_06092017.pdf 

195K 

Is Claim Detail UnitedHealthcare_Dr Lilien_DSA_07082017.pdf 

183K 

t Claim Detail UnitedHealthcare_Dr Lilien_DSA_07112017.pdf 

162K 

• 1 Claim Detail UnitedHealthcare_Dr Lilien_DSA_08072017.pdf 

145K 

t Clint Schuler Claims_Dental Specialty Assoc_UNPAID BY UHC.pdf 

5868K 

t Clint Schuler EOB_UHC_DENTALSPECIALTY ASSOC.pdf 

957K 

t noname.eml 

2777K 

18 Preauthroization Requests_Dental Specialty Assoc.Schuler.pdf 

9596K 

Mail Delivery Subsystem <mailer-daemon@googlemail.com> Wed, Oct 18, 2017 at 12:50 PM 

To: schulerclint@gmail.com 

9 of 12 2/16/2018, 11:14 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 65 of 128
Gmail - UnitedHealthcare Insurance Company https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

Recipient inbox full 

Your message couldn't be delivered to 

DLucero@azinsurance.gov. Their inbox is full, or it's getting 

too much mail right now. 

The response was: 

552 size limit exceeded 

Final-Recipient: rfc822; DLucero@azinsurance.gov 

Action: failed 

Status: 5.0.0 

Rernote-M IA: dns; cybele.azinsurance.gov. (159.87.65.24, the server for the 

domain azinsurance.gov.) 

Diagnostic-Code: smtp; 552 size limit exceeded 

Last-Attempt-Date: Wed, 18 Oct 2017 12:50:29 -0700 (PDT) 

Forwarded message 

From: Clint Schuler <schulerclint@gmail.com> 

To: "'Dawn Lucero" <DLucero@azinsurance.gov>, "Marie Sessions" <mariedsaofaz@gmail.com> 

Cc: <clint@gentryestates.com> 

Bcc: 

Date: Wed, 18 Oct 2017 12:49:02 -0700 

Subject: RE: UnitedHealthcare Insurance Company 

I just sent you an email also and included my Provider Office Manager — Marie Sessions. I 

have also left a message with Gloria. Please let u know of anything else you may need. 

<span style='font-size:12.0pt;color:#1F497D' ---- Message truncated 

Clint Schuler <schulerclint@gmail.com> Wed, Oct 18, 2017 at 12:52 PM 

To: Dawn Lucero <DLucero@azinsurance.gov> 

I just tried to send you more of the info and the docs you requested and it states you inbox is 

full.??? 

10 of 12 2/16/2018, 11:14 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 66 of 128
Gmail - UnitedHealthcare Insurance Company https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

Please let me know.... 

THANKS, 

Clint Schuler 

480-721-9023 

From: Dawn Lucero [mailto:DLucero@azinsurance.gov] 

Sent: Wednesday, October 18, 2017 12:20 PM 

To: schulerclint@gmail.com 

Subject: UnitedHealthcare Insurance Company 

This note is a follow up to our conversation today. You may provide all bills submitted to you by the provider. If you 

have any further questions regarding this matter you may contact me at the number below. 

. _ . _ 

[Quoted text hidden] 

Clint Schuler <schulerclint@gmail.com> Wed, Oct 18, 2017 at 12:52 PM 

To: Dawn Lucero <DLucero@azinsurance.gov> 

I just tried to send you more of the info and the docs you requested and it states you inbox is 

full.??? 

Please let me know.... 

THANKS, 

Clint Schuler 

480-721-9023 

From: Dawn Lucero [mailto:DLucero@azinsurance.gov] 

Sent: Wednesday, October 18, 2017 12:20 PM 

11 of 12 2/16/2018, 11:14 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 67 of 128
Gmail - UnitedHealthcare Insurance Company https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

To: schulerclint@gmail.com 

Subject: UnitedHealthcare Insurance Company 

This note is a follow up to our conversation today. You may provide all bills submitted to you by the provider. If you 

have any further questions regarding this matter you may contact me at the number below. 

[Quoted text hidden] 

12 of 12 2/16/2018, 11:14 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 68 of 128
Gmail - Link to Files - since you cannot access dropbox and your email ... https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver--eqR4N... 

M Gmail Clint Schuler <schulerclint@gmail.com> 

Link to Files - since you cannot access dropbox and your email box is full 

2 messages 

Clint Schuler <schulerclint@gmail.com> Wed, Oct 18, 2017 at 2:14 PM 

To: Dawn Lucero <DLucero@azinsurance.gov>, Clint Schuler <schulerclint@gmail.com> 

Cc: Marie Sessions <mariedsaofaz@gmail.com>, clint@gentryestates.com 

Ms. Lucero...I already emailed you.. .1 previously tried to send you this information as 

attachments and your email box is full and the email and all attachments bounced back to me. 

Here is a link to the files, they are extensive as there are a lot of billing since Dec 2016 that to 

date remain unpaid by UHC. You can print them or forward the link to UHC for review. 

I have included my most recent billing from Dental Specialty Assoc which is the provider 

including Dr. Lilien and Dr. Berger. All of the provider amounts I have paid to Dr. Lilien and Dr 

Berger should have been paid by UHC as they were all services related to the plane crash last 

October 2016. There has been a peer to peer review and this fact has been confirmed, yet 

many many bills to both Dr Berger and Dr Lilien remain unpaid. 

The only bills having been paid were either paid by me or paid via my dental insurance in error 

of UHC. These are medical claims, all of them, not dental claims. 

As we spoke on the phone today, I do not believe you have confirmation of payment to Dental 

Specialty Assoc for the amounts due related to all of these services. They are numerous! 

Please let me know if you can confirm payment for all of the related amounts and I am CC'ing 

my provder to confirm as well. Please have your supervisor call me. 

Please access all of the complaint related docs and billing from Dental Specialty Assoc via this 

link. https://www.dropbox.com/sh/f8gq6iu4tubs42d/AAApfQVCNLxPZxKzgO7Lorcia?d1=0 

Respectfully, 

Clint Schuler 

480-721-9023 

1 of 2 . 2/16/2018, 11:13 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 69 of 128
Gmail - Link to Files - since you cannot access dropbox and your email ... https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

From: Dawn Lucero [mailto:DLucero@azinsurance.gov] 

Sent: Wednesday, October 18, 2017 1:38 PM 

To: schulerclint@gmail.com 

Subject: Dropbox 

Mr. Schluer: 

The Department has received your invitation to the Drop Box, however the Department is unable to access the 

information. If you would attach the bills your receiving to this email, the Department will forward the information to 

UnitedHealthcare for review. Thank you for your assistance in this matter. 

Daw22 Zucaro, 6o2s-T=4z Sp' oeiab;sr 

4.224-0124 apar=021C .63474ra-12CW 

29/0 ArorCh 440SCroo, StziCo 210 

acorn:1e; AZ 8,501g 

'60130 602-364-2492 

dlucero@azinsurance.gov 

NOTICE: This communication may contain privileged or other confidential information. If you have received it in error, 

please advise the sender by reply e-mail and immediately delete the message and any attachments without copying 

or disclosing the contents. Thank you. 

Clint Schuler <schulerclint@gmail.com> 

To: Dawn Lucero <DLucero@azinsurance.gov>, Clint Schuler <schulerclint@gmail.com> 

Cc: Marie Sessions <mariedsaofaz@gmail.com>, clint@gentryestates.com 

[Quoted text hidden) 

Wed, Oct 18, 2017 at 2:14 PM 

2 of 2 2/16/2018, 11:13 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 70 of 128
Gmail - UnitedHealthcare Insurance Company https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

M Gma I Clint Schuler <schulerclint@gmailcom> 

UnitedHealthcare Insurance Company 

1 message 

Dawn Lucero <fiquidfiles@azinsurance.gov> Fri, Oct 20, 2017 at 6:41 AM 

Reply-To: DLucero@azinsurance.gov 

To: schulerclint@gmail.com 

File Request 

Mr. Schuler: 

The Arizona Department of Insurance (Department) is in receipt of your emails regarding your concerns with 

UnitedHealthcare. However, the Department is unable to download the programming for the Dropbox and is 

unable to view the attachments. Please provide your attachments via this secure email link. Upon receipt of the 

information, the Department will forward it to UnitedHealthcare for response. Thank you for your assistance in this 

matter. 

Dawn Lucero 

Consumer Specialist 

Please visit.the following.URL to-send the files: 

https://soter.azinsurance.gov/requests/Sp2BomI1ms4gkkadVazOTt 

This link expires: Saturday, 4 November. 

LiquidFiles Appliance: https://soter.azinsurance.gov 

NOTICE: This communication may contain privileged or other confidential information. If you have received it in error, 

please advise the sender by reply e-mail and immediately delete the message and any attachments without copying 

or disclosing the contents. Thank you. 

1 of 1 2/16/2018, 11:12 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 71 of 128
Gmail - Fwd: UnitedHealthcare https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

M Grnail Clint Schuler <schulerclint@gmail.com> 

Fwd: UnitedHealthcare 

2 messages 

Clint Schuler <schulerclint@gmail.com> Fri, Oct 27, 2017 at 1:17 PM 

To: Marie Sessions <mariedsaofaz@gmail.com> 

Clint Schuler 

Begin forwarded message: 

I From: Dawn Lucero <dlucero@azinsurance.gov> 

I Date: Oct 27, 2017 at 12:46 PM 

I To: Clint Schuler <schulerclint@gmail.com> 

I Subject: UnitedHealthcare 

Ms. Schuler: 

I This note is to inform you that we have forwarded the additional information we received from you to 

UnitedHealthcare. The Department will contact you once we have received a final response from UnitedHealthcare. 

I I apologize for the inconvenience this may have paused you, but wanted to provide you an update. Thank you for 

your patience in the interim. 

I 9ar4a2 .4=oz-0, Cozumzuor Spociaas'C 

1 

1372740114 9op4rano.ziC Asur4z:co 

129/0 Nara 44° Strooc, Salo 210 

lawonir, AZ 45'018 

lawno 602-364-2492 

Idlucero@azinsurance.gov 

NOTICE: This communication may contain privileged or other confidential information. If you have received it in error, 

please advise the sender by reply e-mail and immediately delete the message and any attachments without copying 

I or disclosing the contents. Thank you. 

Marie Sessions <mariedsaofaz@gmail.com> Fri, Oct 27, 2017 at 1:22 PM 

To: Clint Schuler <schulerclint@gmail.com> 

1 of 2 2/16/2018, 11:11.AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 72 of 128
Gmail - Fwd: UnitedHealthcare https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

That is good news! 

[Quoted text hidden) 

Marie Sessions 

Office Manager 

Dental Specialty Associates 

480-633-9977-Office 

480-201-7937-Cell 

2 of 2 2/16/2018, 11:11 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 73 of 128
Gmail - UnitedHealthcare https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

NI Gmail Clint Schuler <schulerclint@gmail.com> 

UnitedHealthcare 

3 messages 

Dawn Lucero <DLucero@azinsurance.gov> Fri, Oct 27, 2017 at 12:46 PM 

To: Clint Schuler <schulerclint@gmail.com> 

Ms. Schuler: 

This note is to inform you that we have forwarded the additional information we received from you to 

UnitedHealthcare. The Department will contact you once we have received a final response from UnitedHealthcare. I 

apologize for the inconvenience this may have caused you, but wanted to provide you an update. Thank you for your 

patience in the interim. 

124vtaz Lamm, Caasurnar Spocialt;s•C 

Ariava Ooparoszozic Ensurazzco 

2910 North 4446Sowc, Stzio 210 

Phoozu:1-, AZ 65018 

Phozo 602-364-2492 

dlucero@azinsurance.gov 

NOTICE: This communication may contain privileged or other confidential information. If you have received it in error, 

please advise the sender by reply e-mail and immediately delete the message and any attachments without copying 

or disclosing the contents. Thank you. 

Clint Schuler <schulerclint@gmail.com> Tue, Nov 14, 2017 at 11:08 AM 

To: Dawn Lucero <DLucero@azinsurance.gov> 

Cc: Marie Sessions <mariedsaofaz@gmail.com> 

Ms. Lucero...thank you again for your help! Please let me know what you hear back from UHC 

and my provider Dental Specialty Assoc regarding making me pay upfront for my next level of 

care on November 29th. I have already paid them upfront fo my last care, last month. I did not 

know they couldn't require me to pay upfront!! 

Please find attached herein the contact info for both of my dentists prior to the plane crash. 

1 of 4 2/16/2018, 11:04 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 74 of 128
Gmail - UnitedHealthcare https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

TO ALL CONCERNED: 

Please release any and all medical and dental records related to my care at your offices for all 

timeframes and procedures as necessary and requested by my health insurer, United 

Healthcare. United Healthcare is in need of my previous conditions for teeth and jaw in order to 

approve billings by my current provider for teeth reconstruction and jaw reconstruction after our 

plane crash which occurred on October 12th, 2016. 

If you have questions or concerns before responding to UHC please contact them or me. 

Sincerely, 

Clint Schuler 

480-721-9023 

TO: Dr. John C. Logan, DDS 

-Dentist in Casper, Wyoming 

Address: 264 S Wilson St, Casper, WY 82601 

Phone: (307) 234-3259 

TO: Linda 

Office Manager for David P Lindstrom, DDS, PC 

2204 S Dobson Rd #202, Mesa, AZ 85202 

smile@davidlindstromdds.com 

www.davidlindstromdds.com 

From: Dawn Lucero [mailto:DLucero@azinsurance.gov] 

Sent: Friday, October 27, 2017 12:47 PM 

To: Clint Schuler 

Subject: UnitedHealthcare 

2 of 4 2/16/2018, 11:04 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 75 of 128
Gmail - UnitedHealthcare https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

[Quoted text hidden] 

Clint Schuler <schulerclint@gmail.com> Tue, Nov 14, 2017 at 11:08 AM 

To: Dawn Lucero <DLucero@azinsurance.gov> 

Cc: Marie Sessions <mariedsaofaz@gnnail.com> 

Ms. Lucero...thank you again for your help! Please let me know what you hear back from UHC 

and my provider Dental Specialty Assoc regarding making me pay upfront for my next level of 

care on November 29th. I have already paid them upfront fo my last care, last month. I did not 

know they couldn't require me to pay upfront!! 

Please find attached herein the contact info for both of my dentists prior to the plane crash. 

TO ALL CONCERNED: 

Please release any and all medical and dental records related to my care at your offices for all 

timeframes and procedures as necessary and requested by my health insurer, United 

Healthcare. United Healthcare is in need of my previous conditions for teeth and jaw in-order-to-- ---

_----approve billings-by my curre-it proVider for teeth reconstruction and jaw reconstruction after our 

plane crash which occurred on October 12th, 2016. 

If you have questions or concerns before responding to UHC please contact them or me. 

Sincerely, 

Clint Schuler 

480-721-9023 

TO: Dr. John C. Logan, DDS 

Dentist in Casper, Wyoming 

Address: 264 S Wilson St, Casper, WY 82601 

Phone: (307) 234-3259 

TO: Linda 

3 of 4 2/16/2018, 11:04 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 76 of 128
Gmail - UnitedHealthcare https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4ksver=eqR4N... 

Office Manager for David P Lindstrom, DDS, PC 

2204 S Dobson Rd #202, Mesa, AZ 85202 

smile©davidlindstromdds.com 

www.davidlindstromdds.com 

From: Dawn Lucero [mailto:DLucero@azinsurance.gov] 

Sent: Friday, October 27, 2017 12:47 PM 

To: Clint Schuler 

Subject: UnitedHealthcare 

Ms. Schuler: 

[Quoted text hidden] 

4 of 4 2/16/2018, 11:04 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 77 of 128
Gmail - RE: Clint Schuler Additional payments - UHC-Missing Payment... https://mail.google.com/mail/u/0/?ui-284ik=0d8bf3efd4&jsyer=eqR4N... 

M Grnall Clint Schuler <schulerclint@gmail.com> 

RE: Clint Schuler Additional payments - UHC-Missing Payments Still Outstanding 

2 messages 

Clint Schuler <schulerclint@gmail.com> Tue, Oct 31, 2017 at 10:04 AM 

To: Marie Sessions <mariedsaofaz@gmail.com>, Clint Schuler <clint@gentryestates.com>, 

kami@insurancebillingoutsourcing.com, Dawn Lucero <DLucero@azinsurance.gov> 

Marie...I printed my ledger and compared. For the record: 

The payment which Kami references "DOS 02/01-03/13/17 $831.31", seems to be correct...it is the $825.29 billed and 

the interest due of 6.02 which totals the $831.31 for this DOS. 

The payment which Kami references "03/15-04/10/17 $442.32" is probably a misspelling and should be $424.32 which 

is the $421.25 and the interest due of $3.07 for this DOS. 

So you are still waiting on the amount for DOS 03/10/2017 which UHC states they paid $2036.26 AND the amount for DOS 

09/06/2017 of $1172.94 AND the amount for DOS 12/19/2017 of $716.79. 

_ But this still doesn't account for the billings of Dr. Berger, much of which I have also paid out of pocket which I have complained 

of to the insurance commission also. 

Please let me know if anything else comes in. 

THANKS, 

Clint Schuler 

480-721-9023 

From: Marie Sessions [rnailto:mariedsaofaz@gmail.com] 

Sent: Tuesday, October 31, 2017 7:50 AM 

To: Clint Schuler 

Subject: Fwd: Clint Schuler Additional payment 

1 of 3 2/16/2018, 11:10 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 78 of 128
Gmail - RE: Clint Schuler Additional payments - UHC-Missing Payment... https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

This came in this morning. 

Looks like we got a few more payments. But we are still waiting 

on a few. 

Just wanted to update you. 

And Kayla will be emailing you today. 

Forwarded message 

From: Kami Bertram <kami@insurancebillingoutsourcing.com> 

Date: Tue, Oct 31, 2017 at 6:03 AM 

Subject: Clint Schuler Additional payment 

To: Marie Sessions <mariedsaofaz@gmail.com> 

Per EOB for DOS 02/01-03/13/17, 03/10/17, 03/15-04/10/17, An additional amount has been paid for DOS 02/01-03 

/13/17 $831.31, 03/10/17 NO ADDITIONAL PAYMENT, 03/15-04/10/17 $442.32, Pt's Resp $160.22 We are still _ _ _ _ . 

waiting-on-paymentirbniDOS-12/1911-6-and 09/06/17. 

Kami Bertram 

Medical Billing / Claims 

ph. 317-565-4988 

fax 765-374-0806 

This transmission may contain information that is personal and confidential or legally prohibited from disclosure. The email and any 

attached documents are intended solely for the above-named individual. Information contained herewith may not be shared with any 

other party. Disclosure is strictly prohibited to protect the confidentiality of these documents, and in compliance with the HIPAA 

privacy act, effective April 14, 2003. If you are not the intended recipient, be aware that duplication, distribution, retention, 

disclosure, or any other action resulting in a breach of the confidential nature of these documents is prohibited by law. If you have 

received this email in error, please immediately notify Insurance Billing Outsourcing at 317-565-4988 to return and/or destroy all 

copies of the documents. 

2 of 3 2/16/2018, 11:10 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 79 of 128
Gmail - RE: Clint Schuler Additional payments - UHC-Missing Payment... https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

Marie Sessions 

Office Manager 

• Dental Specialty Associates 

480-633-9977-Office 

480-201-7937-Cell 

Clint Schuler <schulerclint@gmail.com> Tue, Oct 31, 2017 at 10:04 AM 

To: Marie Sessions <mariedsaofaz@gmail.com>, Clint Schuler <clint@gentryestates.com>, 

kami@insurancebillingoutsourcing.com, Dawn Lucero <DLucero@azinsurance.gov> 

[Quoted text hidden] 

3 of 3 2/16/2018, 11:10 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 80 of 128
Gmail - RE: Clint Schuler - COMPLAINT STATE FILE #20423_UHC https://mail.google.com/mail/u/0/?ui=2&ilc=0d8bf3efd4&jsyer=eqR4N... 

M Gmail Clint Schuler <schulerclint@gmail.com> 

RE: Clint Schuler - COMPLAINT STATE FILE #20423 UHC 

1 message 

Clint Schuler <clint@gentryestates.com> Wed, Nov 1, 2017 at 10:56 AM 

To: smile@davidlindstronndds.com, central_consumer_affairs@uhc.com, Dawn Lucero <DLucero@azinsurance.gov>, 

Marie Sessions <mariedsaofaz@gmail.com> 

Cc: Clint Schuler <schulerclint@gmail.com> 

Ms. Lucero and Ms. Ewald with UHC: 

I received a very large file today in the UPS mail of all communications which UHC alleges they had with ME and my dentists and 

oral surgeons, with what seems to be at first glance all related billings, medical records and preauth's, etc. In the package today 

however, there are no proof of payments by UHC. 

First of all, THIS IS THE FIRST TIME I HAVE EVER BEEN CONTACTED DIRECTLY BY UHC or any UHC Rep with regard to this matter. 

I see in UHC's, Ms. Ewald's response, the reason for denial of my claims was they needed to see my teeth prior to the plane 

crash? This is the first I have heard of this ridiculous request. I had a different dentist prior to the plane crash as you can confirm 

in the email thread below - so if UHC requested this info of my dentist and oral surgeon at Dental Specialty Assoc, this 

information would not have been in their possession. UHC should have immediately contacted me in this regard and not waited 

approx. 1 year and several grievances and complaint, filed later. 

My previous dentist, today, has supplied the bite wing X-rays to UHC, Ms Ewald, and I am attaching them also. If UHC wishes to 

confirm anything else in regard to my teeth prior to the accident, they may contact Dr. Lindstrom or his assistant, as below. 

This is all simply an excuse by UHC, once again. When a patient (me) suffers a jaw that was literally broken in two and wired and 

plated back together, as in my case...it is complete common sense that TEETH were removed (broken out!) and would need to be 

replaced and repaired. Does UHC really believe a broken jaw as repaired by Dr. Prichard for whom has billed and been paid in 

part by UHC under my insurance contract, was able to keep all of my teeth in the process? Maybe Dr. Prichard went to the scene 

of the plane crash and picked up my teeth, to replace them in emergency surgery? This idea and excuse by UHC is absolutely 

absurd! I can assure you I never had one crown or any partials or missing teeth in my mouth prior to the accident and Dr. 

Lindstrom can attest to this. 

UHC claims and has apparently finally begun to pay some of the claims related to my broken jaw and repair and dental 

surgery(s). However, they still are not giving me credit proper for my deductible paid in 2016 and 2017 and amounts I have paid 

which should have been paid by UHC to Dr. BERGER and Dr. LILIEN at Dental Specialty Assoc. In fact the documents delivered to 

my door today by UPS from UHC further reiterate that my doctors have supplied the proper information and made proper 

preauthorization's. In any event, this is all related to the emergency medical treatment required from the plane crash. Preauth's 

should not be a question. 

1 of 3 2/16/2018, 11:09 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 81 of 128
Gmail - RE: Clint Schuler - COMPLAINT STATE FILE #20423_UHC https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

Also, since UHC has been so defiant and obstinate in all of this, I would like to supplement my complaint and complain to the 

Commission with regard to amounts NOT paid to Dr. Prichard by UHC, last year. Dr. Prichard billed multiple times as well (like 

DSA) and I believe he has never been paid in full by UHC. Again, Dr. Prichard was the surgeon who repaired my jaw. I also want 

to add a complaint for amounts I paid out of pocket to the dental surgeon who completed two root canals for me, for which UHC 

only paid as a dental claim even though it was trauma related to the medical (not dental) plane accident. UHC owes me approx., 

$295 I believe for amounts I paid out of pocket for the root canals earlier this year. 

I am losing coverage with UHC at the end of this month, - COBRA plan expires. I absolutely must finish my treatment with Dental 

Specialty Assoc's this month under my current insurance contract with UHC or I will be forced to pay yet ANOTHER deductible for 

new insurance coverage. I also MUST see to it that my doctors are paid and NOT billing me for amounts to be paid under 

contract with UHC. 

Ms. Lucero and Ms. Ewald — please finish this investigation and close the complaint in this matter with FULL payment to Dental 

Specialty Assoc (DSA) and Dr. Prichard immediately! 

Please immediately CC contact with ME and my Doctor's for any further information you may need to complete this matter so I 

can schedule my final implant surgery with DSA prior to the end of November, 2017. 

Please confirm receipt of this email. 

Sincerely, 

Clint Schuler 

480-721-9023 

From: smile@davidlindstromdds.com[mailto:smile@davidlindstromdds.com] 

Sent: Wednesday, November 01, 2017 10:12 AM 

To: central_consumer_affairs@uhc.com 

Cc: clint@gentryestates.com 

Subject: Clint Schuler 

Dear Dawn, 

Please see the attached x-rays for Clint Schuler from last year. If you have any further questions or 

require any addition information, please contact us. 

2 of 3 2/16/2018, 11:09 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 82 of 128
Gmail - RE: Clint Schuler - COMPLAINT STATE FILE #20423_UHC https://mail.google.com/mai1/u/0/?ui=2&ik=0d8bnefd4&jsver=eqR4N... 

Linda 

Office Manager for David P Lindstrom, DDS, PC 

smile@davidlindstromdds.com 

www.davidlindstromdds.com 

C"r:Intffjoitlrhr 

X09483.J PG 

74K 

3 of 3 2/16/2018, 11:09 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 83 of 128
9700 Health Care Lane 

MN017-E300 

Minnetonka, MN 55343 

UnitedHealthcar6 

November 27, 2017 

Arizona Department of Insurance 

Dawn Lucero 

2910 North 44thStreet, Suite 210 

Phoenix, AZ 85018 

Re: State File Number: DLL-20423 

Complainant Name: Clint Schuler 

Dear Dawn Lucero: 

I am writing in response to the above-referenced verbal follow-up complaint from November 17, 2017. 

On the call you stated that Clint Schuler stated he has been unable to receive services from Brian Lilien, 

D.D.S., because they are requiring him to pay $7,000.00 upfront prior to services being rendered on 

November 29, 2017. 

On November 27, 2017, we were able to speak with Marie at Dr. Lilien's office. She stated that Mr. 

Schuler has an appointment on Wednesday; however, the appointment is not contingent on payment. She 

stated that they are not requiring Mr. Schuler to pay upfront for the services. 

Marie stated that she would call Mr. Schuler today, and notify him he is not required to pay upfront for 

Wednesday's services. 

It is our goal to thoroughly review complaints and provide you with a complete response. If you have any 

questions, please call me at 800-842-2656, or directly at 715-363-2787, Monday through Friday from 

8:00 a.m. to 4:30 p.m. Central time or by email at central_consumer affairs@uhc.com.My fax number is 

877-507-0889. 

Sincerely, 

c 

Michelle Ewald 

Regulatory Consumer Advocate 

NOTICE: This communication may contain PERSONAL and CONFIDENTIAL information and is intended only for the use of the 

specific individual(s) to which it is addressed. It may contain Protected Health Information that is personal and confidential. 

Protected Health Information may be used or disclosed in accordance with law and you may be subject to penalties under law for 

improper use or further disclosure of the Protected Health Information in this communication. If you are not an intended recipient, 

you are hereby notified that any unauthorized use, dissemination or copying of the information contained in it or attached to it is 

strictly prohibited. If you have received this in error, please securely destroy it and immediately notify the sender. Thank you. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 84 of 128
From: Dawn Lucero 

Sent: Tuesday, November 28, 2017 7:22 AM 

To: Clint Schuler 

Subject: RE: Update? 

Mr. Schuler: 

This note is in response to your email below. Attached is the latest response the Arizona Department of 

Insurance (Department) received from UnitedHealthcare. As you will note, UnitedHealthcare has 

confirmed with your providers office that your appointment Wednesday, November 29, 2017, is not 

contingent on payment up front. If you have any further questions regarding this matter, you may 

contact me at the number listed below. 

We hope the information provided will be of assistance to you. 

Dastaz Zerearo,Asuraar Spociaioc 

Deparztvaone Zraurazaeo 

2910 Nora 4406SCroot, Surro 210 

Phoozzir, AZ 45018 

Ellozto _ 

a7uceoro@aZziastzra22cog-gr 

From: Clint Schuler [mailto:schulerclintegmail.com] 

Sent: Monday, November 27, 2017 10:00 AM 

To: Dawn Lucero <DLucero@azinsurance.gpv> 

Subject: Update? 

Ms Lucero...i hope you had a good holiday. 

I have a scheduled implant surgery for Wednesday. I know last time we talked you had indicated 

you talked with my Provider Dental Specialty Assoc and advised them they cannot charge me up 

front for the implants. Did they agree with you or do you have other info for me before I go in on 

Wednesday. Please let me know. Thank you! 

Clint Schuler 

Scanned on receipt by Cisco IronPort at 11/27/17 09:59:54 

NOTICE: This communication may contain privileged or other confidential information. If you 

have received it in error, please advise the sender by reply e-mail and immediately delete the 

message and any attachments without copying or disclosing the contents. Thank you. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 85 of 128
Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 86 of 128
Gmail - UnitedHealthcare https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

M Gala I Clint Schuler <schulerclint@gmail.com> 

UnitedHealthcare 

1 message 

Dawn Lucero <liquidfiles@azinsurance.gov> Wed, Nov 29, 2017 at 2:46 PM 

Reply-To: DLucero@azinsurance.gov 

To: schulerclint@gmail.com 

File Request 

Please provide your Medical Records via this secured link. In addition, to providing the Department with the 

documentation you may want to forward the information to UnitedHealthcare. 

Please visit the following URL to send the files: 

https://soter.azinsurance.gov/requests/zn2CNIEUFL4PluaYuMP21h 

This link expires: Thursday, 14 December. 

LiquidFiles Appliance: https://soter.azinsurance.gov 

• NOTICE: This communication may contain privileged or other confidential information. If you have received it in error, 

please advise the sender by reply e-mail and immediately delete the message and any attachments without copying 

or disclosing the contents. Thank you. 

1 of! 2/16/2018, 11:07 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 87 of 128
From: Clint Schuler 

Sent: Wednesday, November 29, 2017 2:43 PM 

To: 'Dawn Lucero' 

Subject: RE: Update? 

Ms. Lucerro...I have received my medical records from the hospital related to the plane crash. I 

would like to send these to you so you can forward to your contact at UHC? Please provide me 

with an link to upload? The file is large, nearly 35 Megabytes. 

Thank you, 

Clint Schuler 

From: Clint Schuler [mailto:schulerclint©gmail.com] 

Sent: Tuesday, November 28, 2017 8:01 AM 

To: Dawn Lucero 

Subject: Re: Update? 

Thanks again! Good news. Thanks so much for helping me! 

Have a blessed day! 

Clint Schuler 

On Nov 28, 2017 at 7:22 AM, <Dawn Lucero> wrote: 

Mr. Schuler: 

This note is in response to your email below. Attached is the latest response the Arizona Department of 

Insurance (Department) received from UnitedHealthcare. As you will note, UnitedHealthcare has 

confirmed with your providers office that your appointment Wednesday, November 29, 2017, is not 

contingent on payment up front. If you have any further questions regarding this matter, you may 

contact me at the number listed below. 

We hope the information provided will be of assistance to you. 

12V4,21 Z1Cia20, ansuznar Spocja4sr 

Arizava OvarO2zo21Coffzgarai3co 

2,910 Arortra 4.4P Sfroot; Stri0 210 

Rizoozu:zr, AZ 45018 

Phozo 602-,364-2492 

ellueoroA2424suraveo.gar 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 88 of 128
From: Clint Schuler [mailto:schulerclint@gmail.com] 

Sent: Monday, November 27, 2017 10:00 AM 

To: Dawn Lucero <DLucero©azinsurance.gov> 

Subject: Update? 

Ms Lucero...i hope you had a good holiday. 

I have a scheduled implant surgery for Wednesday. I know last time we talked you had indicated 

you talked with my Provider Dental Specialty Assoc and advised them they cannot charge me up 

front for the implants. Did they agree with you or do you have other info for me before I go in on 

Wednesday. Please let me know. Thank you! 

Clint Schuler 

Scanned on receipt by Cisco IronPort at 11/27/17 09:59:54 

NOTICE: This communication may contain privileged or other confidential information. If you 

have received it in error, please advise the sender by reply e-mail and immediately delete the 

message and any attachments without copying or disclosing the contents. Thank you. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 89 of 128
From: Dawn Lucero 

Sent: Wednesday, November 29, 2017 2:46 PM 

To: schulerclint@gmail.com 

Subject: UnitedHealthcare 

File Request 

Please provide your Medical Records via this secured link. In addition, to providing the Department with 

the documentation you may want to forward the information to UnitedHealthcare. 

Please visit the following URL to send the files: 

https://soter.azinsurance.govirequestshn2CNIEUFL4PluaYuMP21h 

This link expires: Thursday, 14 December. 

LiquidFiles Appliance: https://soter.azinsurance.eov 

_ _ 

- NOTICE: This communication may contain privileged or other Confidential information. If you have 

received it in error, please advise the sender by reply e-mail and immediately delete the message and 

any attachments without copying or disclosing the contents. Thank you. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 90 of 128
Gmail - medical documents https://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

Grnail Clint Schuler <schulerclint@gmail.com> 

medical documents 

1 message 

Clint Schuler <schulerclint@gmail.com> Thu, Nov 30, 2017 at 7:49 AM 

To: Dawn Lucero <dlucero@azinsurance.gov>, Marie Sessions <mariedsaofaz@gmail.com> 

It was supplied to me with password protection. I apologize. The password is my birthdate. 10131970. My birthdate is 

not confidential information. Please forward to the parties. Thank you. 

Clint Schuler 

480-721-9023 

I On Nov 29, 2017 at 3:36 PM, <Dawn Lucero> wrote: 

Mr. Schuler: 

The Department received your documentation however it is password protected. Please provide a copy without the 

password protection. 

_ 

i 

I Davi/2a Zuc'oro, atisutuar Spocia.14.4- 

I Ariozla - 12epa21J22a2zc ofZasuracco 

1 

12910 Ararch *06 Scroo; SeziCo 210 

iRioaair,4Z 45016' 

1.e6,2,0 602-364-2492 

Idlucero@azinsurance.gov 

--- i NOTICE: This communication may contain privileged or other confidential information. If you have received it in error, 

please advise the sender by reply e-mail and immediately delete the message and any attachments without copying 

or disclosing the contents. Thank you. 

1 of 1 2/16/2018, 11:05 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 91 of 128
Secure Message: Secure Message from michelle_l_ewald@uhc.com file:///C:/Users/Clint Schuler/AppData/Local/Packages/microsoft.windo... 

Hell) I Forget me on this computer (Loa Out) 

Secured Message [XIV 

From: Ewald, Michelle L <michelle_l_ewald®uhc.com> 

To: "schulerclint@gmail.com" <schulerclint@gmail.com> 

Date: 12/06/2017 04:12:41 PM MST 

Subject: Secure Message from michelle_l_ewald@uhc.com 

Hello Clint; 

We just spoke on the phone, and I let you know I was unable to open your attachment. If you could 

please attach the records to this email I would greatly appreciate it. 

Thank you! 

Michelle L. Ewald 

Regulatory Consumer Affairs Advocate 

Regulatory Consumer Affairs 

UnitedHealthcare 

4316 Rice Lake Rd. Duluth, MN 55811 

Phone: 715-363-2787 Fax: 855-710-2187 E-mail: michelle 1 ewaldPuhc.com 

NOTICE: This email may contain PERSONAL and CONFIDENTIAL information and is intended only for the use of the specific 

individual(s) to which it is addressed. It may contain Protected Health Information that is personal and confidential. Protected Health 

Information may be used or disclosed in accordance with law and you may be subject to penalties under law for improper use or 

further disclosure of the Protected Health Information in this email. If you are not an intended recipient of this email, you are hereby 

notified that any unauthorized use, dissemination or copying of this email or the information contained in it or attached to it is strictly 

prohibited. If you have received this email in error, please delete it and immediately notify the person named above by reply email. 

Thank you. 

*--SecureDelivery-- 

This e-mail, including attachments, may include confidential and/or 

proprietary information, and may be used only by the person or entity 

to which it is addressed. If the reader of this e-mail is not the intended 

recipient or his or her authorized agent, the reader is hereby notified 

that any dissemination, distribution or copying of this e-mail is 

prohibited. If you have received this e-mail in error, please notify the 

sender by replying to this message and delete this e-mail immediately. 

(220/7 

Copyright © 2011-2017 Cisco Systems, Inc. and/or its affiliates. All rights reserved. 

1 of 1 2/16/2018, 10:55 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 92 of 128
From: Clint Schuler 

Sent: Thursday, December 7, 2017 11:11 AM 

To: 'Ewald, Michelle L' 

Cc: 'Clint Schuler'; 'Dawn Lucero' 

Subject: RE: Secure Message from michelle_l_ewald@uhc.com 

Michelle...please open this drop box link to the files. I was not able to send upload the files 

through the secure system email link you sent to me yesterday. The files bounced back to me 

yesterday. Ms. Lucero at the state of AZ called me this morning. 

https://www.dropbox.com/shiewneyzieizrxiOr/AACxsTMvcgg0q5ORSKviKkCa?d1=0 

Thanks, 

Clint Schuler 

From: Ewald, Michelle L [mailto:michelle I ewald@uhc corn] 

Sent: Wednesday, December 06, 2017 4:13 PM 

To: schulerclint@gmail.com Subject: Secure Message from michelle I ewald@uhc.coni 

You have received a secure message 

If you have concerns about the validity of this message, contact the sender directly. 

To retrieve your encrypted message, follow these steps: 

1. Click the attachment, securedoc.html. 

You will be prompted to open (view) the file or save (download) it to your computer. For best 

results, save the file first, then open it in a Web browser. 

2. Enter your password. 

If you are a first time user, you will be asked to register first. 

Mobile device users: forward this message to mobilePres.cisco.com. You will be emailed a link 

where you can enter your password and view the secure email message. 

For help opening securedoc.html, see https://res.cisco.com/websafe/help?topic=ReuEnvelobe. 

To initiate a new email message https://res.cisco.com/websafe. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 93 of 128
Gmail - Michelle Ewald hqs://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

M Grnail Clint Schuler <schulerclint@gmail.com> 

Michelle Ewald 

1 message 

Clint Schuler <schulerclint@gmail.com> Fri, Dec 15, 2017 at 3:37 PM 

To: Central Affairs <central_consumer_affairs@uhc.com>, Dawn Lucero <dlucero@azinsurance.gov> 

Per your request. I mailed first class postage paid my medical records on USB drive along with the grievance form you 

once again requested from me. This is unbelievable. This information has been sent multiple times. I ha w called you 

multiple times. I have called my state agent multiple times. I also emailed my records to you again today in smaller 

files sizes as your system is antiquated. 

Please call me immediately next week if you do not receive the USB DRIVE and forms. 

Clint Schuler 

480-721-9023 

1 of! 2/16/2018, 11:16 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 94 of 128
Gmail - Michelle Ewald hqs://mail.google.com/mail/u/0/?ui=2&ik=0d8bf3efd4&jsver=eqR4N... 

M Grnail Clint Schuler <schulerclint@gmail.com> 

Michelle Ewald 

1 message 

Clint Schuler <schulerclint@gmail.com> Fri, Dec 15, 2017 at 3:37 PM 

To: Central Affairs <central_consumer_affairs@uhc.com>, Dawn Lucero <dlucero@azinsurance.gov> 

Per your request. I mailed first class postage paid my medical records on USB drive along with the grievance form you 

once again requested from me. This is unbelievable. This information has been sent multiple times. I ha w called you 

multiple times. I have called my state agent multiple times. I also emailed my records to you again today in smaller 

files sizes as your system is antiquated. 

Please call me immediately next week if you do not receive the USB DRIVE and forms. 

Clint Schuler 

480-721-9023 

1 of! 2/16/2018, 11:16 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 95 of 128
Plaintiffs EXHIBIT 4 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 96 of 128
9700 Health Care Lane 

MN017-E300 

Minnetonka, MN 55343 

UnitedHealthcar6 

December 15, 2017 

Arizona Department of Insurance 

Dawn Lucero 

2910 North 44thStreet, Suite 210 

Phoenix, AZ 85018 

Re: State File Number: DLL-20423 

Complainant Name: Clint Schuler 

Dear Dawn Lucero: 

I am writing in response to the above-referenced follow-up status inquiry dated December 14, 2017, 

received in our office on the same day. 

As stated previously Mr. Schuler's claim has denied as provider liability, the provider is unable to balance 

bill the member for any not covered amounts. We are unable to open the electronic correspondence Mr. 

Schuler sent. Mr. Schuler can provide the records to the provider and the provider is able to submit an 

appeal requesting reconsideration of the claim, or Mr. Schuler can mail or fax his records to myself. Until 

a hard copy of the records are received, or the provider submits the appeal we are upholding our original 

determination and consider this case closed. We have reached out to the provider multiple times to ensure 

they are not balance billing Mr. Schuler and are not making Mr. Schuler pre-pay for future services. 

It is our goal to thoroughly review complaints and provide you with a complete response. If you have any 

questions, please call me at 800-842-2656, or directly at 715-363-2787, Monday through Friday from 

8:00 a.m. to 4:30 p.m. Central time or by email at central consumer affairsuhc.com. My fax number is 

877-507-0889. 

Sincerely, 

4Iul1t 6,214_ 

Michelle Ewald 

Regulatory Consumer Advocate 

NOTICE: This communication may contain PERSONAL and CONFIDENTIAL information and is intended only for the use of the 

specific individual(s) to which it is addressed. It may contain Protected Health Information that is personal and confidential. 

Protected Health Information may be used or disclosed in accordance with law and you may be subject to penalties under law for 

improper use or further disclosure of the Protected Health Information in this communication. If you are not an intended recipient, 

you are hereby notified that any unauthorized use, dissemination or copying of the information contained in it or attached to it is 

strictly prohibited. If you have received this in error, please securely destroy it and immediately notify the sender. Thank you. 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 97 of 128
Secure Message: UnitedHealthcare Insurance Company - secure https://res.cisco.com/envelopeopener/postxeo/oo/fDFfX2FmMDJkMT... 

Help I Forget me on this computer (Log Out) 

Secured Message 

From: Dawn Lucero <DLucero@azinsurance.gov> 

To: Clint Schuler <schulerclint@gmail.com > 

Date: 12/15/2017 02:19:32 PM MST 

Subject: UnitedHealthcare Insurance Company - secure 

Attachments: 12.15.2017 Resolution letter - Schuler.Ddf 

Mr. Schuler: 

In an effort to assist you, the Department reached out to UnitedHealthcare to request a status. Attached is 

UnitedHealthcare's response for your review. As you will note, 

UnitedHealthcare is unable to open the electronic correspondence you sent. UnitedHealthcare has requested that you 

provide the records to your provider and the provider can submit an appeal requesting reconsideration of the claim, or 

you can mail or fax your records to Ms. Ewald. Until a hard copy of the records are received, or the provider submits 

the appeal UnitedHealthcare is upholding their original determination and consider this case closed. Ms. Ewald 

indicates that UnitedHealthcare has reached out to the provider multiple times to ensure they are not balance billing 

you and are not making you pre-pay for future services. If you have any questions regarding this matter you may 

contact me at the number listed below. 

1.2awz4tzcwro„ Consumer 

4rirzo.2 Dvaranozie fasuralacw 

2910 Kora .040 Serowe, Stueo 210 -

Phoo.zzi2r, AZ 45018 

Pizaz2o 602-,364-24,92 

aucwro@wziasurazzc000v 

NOTICE: This communication may contain privileged or other confidential information. If you have received 

it in error, please advise the sender by reply e-mail and immediately delete the message and any attachments 

without copying or disclosing the contents. Thank you. 

Reply 

Reply 

Copyright @ 2011-2018 Cisco Systems, Inc. and/or its affiliates. All rights reserved. 

1 of 1 2/16/2018, 10:46 AM 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 98 of 128
Plaintiffs EXHIBIT 5 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 99 of 128
Dental Specialties Associates 

2730 S Val Vista Dr.BIdg. 11 STE 164 

Bldg. 11 STE 164 

Gilbert AZ 85295 

IF PAYING BY CREDIT CARD, FILL OUT BELOW. 

I= e'llA _.

CARD NUMBER EXP. DATE 

'FULL NAME (Please Print) CCV CODE 

SIGNATURE 

STATEMENT DATE 

02/05/2018 

PAY THIS AMOUNT 

3745.34 

ACCOUNT NUMBER 

024522 

ilpir tar,- $ 

RETURN SERVICE REQUESTED 

ADDRESSEE MAKE CHECK PAYABLE TO 

CLINT SCHULER 

7907 E PORTOBELLO AVE 

MESA AZ 85212-1542 

El Please check box It address Is incorrect or Insurance information 

has changed end indicate change(s) on reverse side. 

IIHJHIIIUIIIIIIlIUhIIIItuIII 

DENTAL SPECIALTIES ASSOCIATES 

27305 VAL VISTA DR.BLDG 11 STE 164 

BLDG 11 STE 164 

GILBERT AZ 85295 

Please detach and return this portion with payment. 

STATEMENT 

DUE DATE 30 Days 60 Days 90 Days CURRENT 

BALANCE 

02/20/2018 0.00 3671.34 0.00 74.00 

AMOUNT DUE 

$3745.34 

DATE PATIENT NAME DESCRIPTION CHARGES CREDITS 

01/01/2018 Balance Forward 4127.63 

01/12/2018 Clint Medical Insurance Payment Ch # QC65926744 -456.29 

01/12/2018 Clint Medical claim note 0.00 

01/19/2018 Clint Limited re-evaluation estab pat 74.00 

01/26/2018 Clint 

PleasE 

Medical claim note 

pay balance within 30 days to avoid 2% finance charge. 

0.00 

NOTE: FOR ALL BILLING QUESTIONS AND PAYMENTS PLEASE CALL 602-633-0272. 

Dental Specialties Associates, 2730 S Val Vista Dr.131dg. 11 STE 164, Bldg. 11 STE 1641Gilbert AZ 85295 (480) 633-9977 

11mns ann11dR-9t14/01705147014.2.411017717 \Mrs Fah c 10.1/1•07 51115 mnr• .1 / A 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 100 of 128
Plaintiffs EXHIBIT 6 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 101 of 128
S WU-16173'01091505-M0-17048-85499-AFJ 11SYMS 

UnitedHealthc,are' 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA, GA 30374-0800 

DPS$$$PKG 

CLINT SCHULER 

7907 E PORTOBELLO AVE 

MESA AZ 85212-1542 

February 17, 2017 

Member/Patient Information 

Member/Patient: CLINT SCHULER 

Member ID: A976771105 

Relationship: EE 

Group Name: GREENCRAFT 

INTERIORS 

Group* 05U8947 

Explanation of Benefits Statement 

This is not a bill. Do not pay. This is to notify you that we processed your claim. 

Claims Summary 

Detailed claim information is located on the following page(s). 

Dollar Amount Description 

Amount Billed 

$1,224.00 This is the total amount that your provider billed for the services that were provided to you. 

Plan Discounts 

Your plan negotiates discounts with providers to save you money. This amount may also include . 

services that you are riot responsible to pay. 

Your Plan Paid 

$160.89 This is the portion of the amount billed that was paid by your plan. 

Total amount you owe the proviciens) 

The portion of the Amount Billed you owe the provider(s). This amount does not reflect any 

$1,063.11) payment you may have already made at the time you received care. This amount may include your • 

deductible, co-pay, coinsurance and/or non covered charges. This amount does not include any 

payments made to the subscriber*. If a payment was made directly to the subscriber, you/the 

subscriber is responsible for paying the physician, facility or other health care professional. 

•* When coordination of benefits applies, this amount will include payments made to the subscriber.— • / 

STD-EOB Use this EOB statement as a reference or retain as needed Page 1 of 7 

000001193153385 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 102 of 128
UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA GA 30374-0800 

Phone: 1-800-782-3740 

S VV1J-16173•01`091506410-170,18-85499-AFJ 12SYMS 

g Unitedikalthcare 

February 17, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

Claim Detail for CLINT SCHULER 

Provider: T HARRISON Claim Number: 627742212701 Patient Account Number: 528082 

Date(s) of 

Service 

Type of Service Notes* Amount 

Billed 

Plan 

(-) Discounts (-) (=) Deductible 

Your Itemized Responsibilit to Provider** 

(+) Copay (+) Coinsurance (+) Non Covered (=) 

Amount You 

Owe 

Your Plant. 

Paid 

11/29/2016 ANESTHESIA CK $1,224.00 $0.00 $160.89 $0.00 $0.00 $0.00 91,063.11 $1,063.11 

Claim Total: $1,224.00 90.00 9160.89 $0.00 $0.00 90.00 91,063.11 $1,063.11 

**This total does not reflect any payments / copays you made at the time of service. 

Please wait for a provider bill before making a payment. 

Notes* 

CK - A NON NETWORK HEALTH CARE PROVIDER OR FACILITY PROVIDED THESE SERVICES. YOUR CLAIM HAS BEEN PAID BASED ON YOUR BENEFIT 

PLAN, WHICH USES RATES ESTABLISHED BY THE FEDERAL GOVERNMENT FOR THE MEDICARE PROGRAM. THIS SERVICE WAS PAID BASED ON AMOUNTS 

SET BY MEDICARE OR OTHER SOURCES IF NO MEDICARE AMOUNT IS AVAILABLE. THE MEMBER IS RESPONSIBLE FOR THE TOTAL AMOUNT INDICATED IN 

THE AREA OF THIS STATEMENT SHOWING WHAT THE PATIENT OWES. 

Because your family deductible has been satisfied, your remaining individual deductible has been adjusted to $0. The coinsurance period of your plan has begun for all 

covered members of your family. 

Because your family's out-of-pocket maximum has been satisfied, your remaining individual out-of-pocket maximum has been adjusted to $0. 

You have a right to request an appeal of the claim determination outlined in this statement. This appeal must be submitted within 2 years from the date you receive this 

statement. 

You may submit a written appeal, along with the copies of any relevant documents, to: 

UnitedHealthcare Appeals, P.O. Box 30573, Salt Lake City, UT 84130-0573. 

If you request a review of your claim determination, we will complete our review no later than 30 days after we receive your appeal. 

If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 7 

000001193153385 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 103 of 128
UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA GA 30374-0800 

Phone: 1-800-782-3740 

S WU-16173`02091507-M0-17048-85499-AFJ 12SYMS 

g Unitedflealthc,ar4 

February 17, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to 

the appeal address referenced above. 

You may request copies (free of charge) of information relevant to your claim by contacting us at the above address. 

Availability of Consumer Assistance/Ombudsman Services 

There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security 

Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance 

Assistance Team at 1-888-393-2789. 

If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by 

an independent third party, who will review the denial and issue a final decision. 

Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-782-3740. 

Meet Your Needs Online 

At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information 

on EOB content and more! For immediate, secure self-service visit www.myuhc.com. 

Myuhc Registration 

You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID 

card (first name, last name, member ID, group number and date of birth). 

Maintaining the privacy and security of individuals' personal information is very important to us at UnitedHealthcare. To protect your privacy, we implemented strict 

confidentiality practices. These practices include the ability to use a unique individual identifier. You may see the unique individual identifier on UnitedHealthcare 

correspondence, including medical ID cards (if applicable), letters, explanation of benefits (E0B5), and provider remittance advices (PRAs). If you have any questions about 

the unique individual identifier or its use, please contact your customer care professional at the number shown at the top of this Statement. 

Please call the number included in this document or on the back of your ID card if you need diagnosis and/or treatment code information regarding the services referenced in 

this communication. 

Para obtener asistencia en espaiiol, llame al niunero de telefono que se incluye en este 

document° o al dorso de su tarjeta de identificacion. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 3 of 7 

000001193153385 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 104 of 128
UnitedHealthcare Insurance Company_ 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA, GA 30374-0800 

Phone: 1-800-782-3740 

S VVU-16173•02`091508-M0-17048-85499-AFJ 12SYMS 

g Unitedilealthcare 

February 17, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your daim and benefit information. 

We do not treat members differently because of sex, age, race, color, disability or national origin. 

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator. 

Online: UHC_Civil_Rights@uhc.com 

Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130 

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. 

If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, 

please call the toll-free number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m. 

You can also file a complaint with the U.S. Dept. of Health and Human Services. 

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf 

Complaint forms are available at http://www.hhs.gov/ocr/officeffile/index.html. 

Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) 

Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call 

the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m. 

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. 

Please call the toll-free phone number listed on your identification card. 

ATENCION: Si habla espaiiol (Spanish), hay servicios de asistencia de idioms, sin cargo, a su 

disposicion. Llame al numero de telefono gratuito que aparece en su tarjeta de identificaci6n. 

: talAtfaartISC (Chinese) , RifiklithtatteNtilin S. NIVT*M-PROU911-4 

XIN LU1J lir: Neu quk vj n6i tieng Vi4 (Vietnamese), qu vi se dugc ctmg cp dich vu trg giup ye 

nen ngfr mien phi. Vui long goi s6 din thoai mien phi er mat sau the hi vien cáa quk vi. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 7 

000001193153385 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 105 of 128
UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA, GA 30374-0800 

Phone: 1-800-782-3740 

S VV1J-16173•03091509-M0-17048-85499-AFJ 12SYMS 

Phi UnitedHealthcare 

February 17, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

'4E1: E01(Korean)2AIFAl 201.l!! A-11:11L,1/4.0 01g814 51-6-LI c4. 

W8121 ,A21,12g- 31E011 31X11 

PAALALA: Kong nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng 

tulong sa wika. Pakitawagan ang toll-free na numero ng telepono na nasa iyong identification card. 

BIMMAHHE: fiecnnailme ycnym nepeooaa Aocrylmbr AJIA .1110/Wri, Reit pogaoil sum SIEJDIeTC1 

pyecicom (Russian). Hosoomrre no fiecnnaruomy rtomepy renertarm, yrrastuncomy ma Bruner' 

Krtetrnulutkauttommii xapre. 

‘,114-41,-11431efii (1.01 .745;11 ,(Arabic) 

ATANSYON: Si w pale Kreyol ayisyen (Haitian Creole), ou kapab benefisye sevis Id gratis pou ede w 

nan lang paw. Tanpri rele nimewo gratis ki sou kat idantifikasyon w. 

ATTENTION: Si vous parlez francais (French), des services d'aide linguistique vous sont proposes 

gramitement. Veuillez appeler le numero de telephone gratuit figurant $111" votre carte d'identification. 

UWAGA: JeZeli mciwisz po polsku (Polish), udostepniliimy darmowe uslugi tiumacza. Prosimy 

zadzwoniC pod bezplatny runner telefonu podany na karcie identyfikacyjnej. 

ATEKAO: Se vote fala portugues (Portuguese), contate o servico de assistencia de idiomas gratuito. 

Ligue gratuitamente para o tnimero encontrado no sett card° de identificach-o. 

ATTENZIONE: in caso la lingua parlata sia Pitaliano (Italian), sono disponibili servizi di assistenza 

linguistica gratuiti. Per favore chiamate ii numero di telefcmo verde indicato sulla vostra tessera 

identificativa. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 5 of 7 

00000119316n:1AS 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 106 of 128
UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTAxGA 30374-0800 

Phone: 1-800-782-3740 

S WU-161731)3•091510-M0-17048-85499-AFJ 12SYMS 

g UnitedHealthcare' 

February 17, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Buten kostenlos sprachliche 

Hilfsdienstleistungen zur Verrugung. Bitte rufen Sie die gebiihrenfreie Rufnummer auf der Rfickseite 

Mires Mitgliedsausweises an. 

: 8 *11§(Japanese)tg Mt' 141,140/:: flit *1- 

2111gRal•=2112 06 '1 —14 t)1,tztVen < 

,..,5(.11.) j...4 LW ;1.11L a1 j.jib 44„:314.) ,Cual (Farsi) veruti L014.) fl l :444 

• 4.44 0" "4 1-°:° 

yrr tziW a: zrfa 3/P:1 It (Hindi) art t HY 3111* W" 31N1 Iqc1u W ¶j 344(44 

¶-trr 3Tr1* crow cm'q ftv ETF-5.8t *4-4- wrg 441 

CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj key pab tahais [us pub dawb rau koj. Thov hu 

rau ins xov tooj hu deb dawb nas teev muaj nyob ran ntawm koj daim yuaj cim qhia tus kheej. 

Aarnirsturii: dialultil noun* (Khmer) stanalearnmenamiciti &native:Rini aisirciirtiwetssatt ttscutnesaisdiapruatintigni 

PAKDAAR: Nu saritaem ti Doran° (Docano), ti serbisyo para ti baddang ti lengguahe nga awanan 

bayadna, ket sidadaan para kenyam. Maidawat nga awagan iti toll-free a numero ti telepono nga 

nakalista ayan iti identification card mo. 

Dii BANAKONiNiZIN: Dine (Navajo) bizaad bee yanilti'go, saad bee alca'anida'aweigii, jiileeh, 

bee nalah66fi'. Tfiá shwdi ninaaltsoos nitlizi bee neehozinigli bine.** Via Wag() beesh bee hane'i 

bikalgii bee hodiilnih. 

OGOW: Haddii and ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, 

ayaad heli kartaa. Full= wan lambarka telefonlca khadlca bilaashIca ee ku yaalla kaarkaaga agoonsiga. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 6 of 7 

GII00011931CaagS 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 107 of 128
S WU-16173•04091511-M0-17048-85499-AFJ 12SYMS 

F UnitedHealthcare' 

UnitedHealthcare Insurance Company_ 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA GA 30374-0800 

Phone: 1-800-782-3740 

February 17, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

Summary of Deductible and Out of Pocket 

Plan Year: 2016 

Account Summary 

1 

CLINT 

Relationship: EE 

Annual 

Amount 

(-)Applied to (=)Remaining 

Date Balance FAMILY Annual (-)Applied to 

Amount Date 

(=)Remaining 

Balance 

'0..?1E11MEDICIJR.X(Pqrv,TINFP.:4::ni,' 71;q11,_ 2i5g7, - 11:145Kii 

IN, NETiMEDICAII/RX'COMBINEDI, .S1 , 1124:gar,i, , m,..454 , :01 Deductible $8,000.00 $8,000.00 Met 

Deductible $4,000.00 $3,466.50 Met Out of Pocket $12,500.00 $12,500.00 Met 

Out of Pocket $6,250.00 $5,716.50 Met bUT OF'NETWORW 17410YS"Mv:d4.-^k 1.1%.7"?,57r.-AM ,

Deductible $16,000.00 $246.63 $15,753.37 

Deductible $8,000.00 $0.00 $8,000.00 Out of Pocket $48,000.00 $246.63 $47,753.37 

Out of Pocket $24,000.00 $0.00 $24,000.00 

I 

Definitions of_Key Terms 

Applied to Date: The total amount of money applied to your deductible or out of pocket as of 

this EOB statement. 

Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for 

eligible health care services. Please refer to your plan documents for more information. 

Plan Year The dates your plan benefit maximums are applicable. 

Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 

health care services before your plan benefits are payable. Once the deductible has been 

met, the co-payment and/or coinsurance period of your plan may begin. Please refer to your 

plan documents for specific information regarding what services apply to the deductible. 

Patient Non Covered The amount of money you pay for services that are not covered 

under your plan. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 7 of 7 

000001193153385 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 108 of 128
Claims Summary 

Detailed claim information is located on the following page(s). 

r Dollar Amount Description 

Amount Billed 

$68,672.63 This is the total amount that your provider billed for the services that were provided to you. 

Plan Discounts 

$0.00 Your plan negotiates discounts with providers to save you money .--This amount may also include 

services that you are not responsible to pay. 

Your Plan Paid 

$3,835.81 This is the portion of the amount billed that was paid by your plan. 

Total amount you owe the provider(s) 

The portion of the Amount Billed you owe the provider(s). This amount does not reflect any 

payment you may have already made at the time you received care: This amount may include your 

deductible, co-pay, coinsurance and/or non covered charges. This amount does not include any 

payments made to the subscriber*. If a payment was made directly to the subscriber, you/the 

subscriber is responsible for paying the physician, facility or other health care professional. 

* When coordination of benefits applies, this amount will include payments made to the subscriber. 

S 01433912•01`031651-M0•17080-85499-AFJ 31SYCP 

Unitedilealthc,are 

UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA, GA 30374-0800 Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

March 21, 2017 

DPS$$$PKG 

CLINT SCHULER 

7907 E PORTOBELLO AVE 

MESA AZ 85212-1542 

Member/Patient Information 

Member/Patient: CLINT SCHULER 

Member ID: A976771105 

Relationship: EE 

Group Name: GREENCRAFT 

INTERIORS 

Group #: 05U8947 

Explanation of Benefits Statement 

This is not a bill. Do not pay. This is to notify you that we processed your claim. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 1 of 9 

000001219033565 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 109 of 128
UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA GA 30374-0800 

Phone: 1-800-782-3740 

S VN-03912131•031652-M0-17080-85499-AFJ 32SYCP 

Ii Unitedlealthcare 

March 21, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

Claim Detail for CLINT SCHULER 

Provider: P PRICHARD Claim Number: 329170539001 Patient Account Number: 11212 

Date(s) of Type of Service Notes* Amount Plan 

I 

Your Itemized Responsibility to Provider** I 

' Your. Plan Amount You 

Service Billed (-) Discounts (-) Paid (=) Deductible (+) Copay (+) Coinsurance (+) Non Covered (=) Owe i 

1 10/12/2016 SURGERY CK $13,237.14 $0.00 $1,680.01 $0.00 $0.00 $0.00 $11,557.13 $11,557.13 

10/12/2016 SURGERY CK $6,514.16 $0.00 $438.87 $0.00 $0.00 $0.00 $6,075.29 $6,075.29 

10/12/2016 SURGERY CK $6,451.08 $0.00 $283.89 $0.00 $0.00 $0.00 $6,167.19 $6,167.19 

10/12/2016 SURGERY CK $41,250.00 $0.00 $152.09 $0.00 $0.00 $0.00 $41,097.91 $41,097.91 

10/12/2016 SURGERY CK $0.00 $0.00 $840.01 $0.00 $0.00 $0.00 $12,397.13 $12,397.13 

Claim Total: $67,452.38 $0.00 $3,394.87 $0.00 $0.00 $0.00 $77,294.65 $77,294.65 

**This total does not reflect any payments / copays you made at the time of service. 

Please wait for a provider bill before making a payment. 

Claim Detail for CLINT SCHULER 

Provider: P PRICHARD Claim Number: 329170539001 Patient Account Number: 11212 

Date(s) of 

Service 

Type of Service Notes* Amount 

Billed 

Plan 

(-) Discounts (-) (=) Deductible 

Your Itemized Responsibility to Provider** 

Amount You 

(+) Copay (+) Coinsurance (+) Non Covered (=) Owe 

[Your Plail 

Paid 

10/12/2016 CLM EXPENSE 

INTEREST 

5U $1.83 $0.00 $1.83 $0.00 $0.00 $0.00 $0.00 $0.0 • 

Claim Total: $1.83 $0.00 $1.83 $0.00 $0.00 $0.00 $0.00 $0.00 

**This total does not reflect any payments / copays you made at the time of service. 

Please wait for a provider bill before making a payment 

STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 9 

000301219033566 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 110 of 128
S VN-03912•02•031653-M0-17080-85499-AFJ 32SYCP 

Unitedilealthcare 

UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA GA 30374-0800 

Phone: 1-800-782-3740 

March 21, 2017 

Have more questions about your claim? 

Visit www.myuhC.com 

for all your claim and benefit information. 

Claim Detail for CLINT SCHULER 

Provider: P PRICHARD Claim Number: 329170539001 Patient Account Number: 11212 

Date(s) of Type of Service 

Service 

Notes* Amount 

Billed 

Plan 

(-) Discounts (-) (=) Deductible 

Your Itemized Responsibilit to Provider** 

Amount You 

(+) Copay (+) Coinsurance (+) Non Covered (=) Owe 

YoLif Plan 

Paid 

10/12/2016 SURGERY CK $0.00 $0.00 $438.87 $0.00 $0.00 $0.00 $6,075.29 $6,075.2 • 

Claim Total: $0.00 $0.00 $438.87 $0.00 $0.00 $0.00 $6,075.29 $6,075.29 

**This total does not reflect any payments / copays you made at the time of service. 

Please wait for a provider bill before making a payment 

Claim Detail for CLINT SCHULER 

Provider: P PRICHARD Claim Number: 329170539001 Patient Account Number: 11212 

Date(s) of 

Service 

Type of Service Notes* Amount 

Billed 

Plan 

(-) Discounts (-) (=) Deductible 

Your Itemized Responsibility to Provider** 

Amount You 

(+) Copay (+) Coinsurance (+) Non Covered (=) Owe 

Your Plan 

Paid 

10/12/2016 CLM EXPENSE 

INTEREST 

5U $0.24 $0.00 $0.24 $0.00 $0.00 $0.00 $0.00 $0.0 • 

Claim Total: $0.24 $0.00 $0.24 $0.00 $0.00 $0.00 $0.00 $0.00 

**This total does not reflect any payments / copays you made at the time of service. 

Please wait for a provider bill before making a payment. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 3 of 9 

00000121GMIS65 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 111 of 128
UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA GA 30374-0800 

Phone: 1-800-782-3740 

S VN-03912'021331654-M0-17080-85499-AFJ 32SYCP 

g UnitedHealtitcare 

March 21, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your daim and benefit information. 

Claim Detail for CLINT SCHULER 

Provider: P PRICHARD Claim Number: 329170539001 Patient Account Number: 11212 

Date(s) of 

Service 

Type of Service Notes* Amount 

Billed 

Plan 

(-) Discounts (-) (=) Deductible 

Your Itemized Responsibility to Provider** 

Amount You 

(+) Copay (+) Coinsurance (+) Non Covered (=) Owe 

Your Plãiil 

Paid 

10/12/2016 III MEDICAL VISIT AD $1,218.18 $0.00 $0.00 $0.00 $0.00 $0.00 $1,218.18 $1,218.1 

Claim Total: HR $1,218.18 $0.00 $0.00 $0.00 $0.00 $0.00 $1,218.18 $1,218.1 

**This total does not reflect any payments / copays you made at the time of service. 

Please wait for a provider bill before making a payment. 

Notes* 

5U - THIS AMOUNT REPRESENTS INTEREST PAID. 

AD - CHARGES ARE NOT ELIGIBLE AS THEY FALL VV1THIN THE GLOBAL DAYS TIME FRAME OR ARE INCLUDED AS PART OF THE GLOBAL CHARGE. 

CK - AN OUT-OF-NETWORK PROVIDER OR FACILITY PROVIDED THESE SERVICES. THE AMOUNT PAID FOR THIS SERVICE WAS DETERMINED USING 

MEDICARE RATES (OR OTHER SOURCES IF NO MEDICARE RATE WAS AVAILABLE), EVEN IF THE PATIENT DOES NOT HAVE MEDICARE. YOU MAY BE 

RESPONSIBLE FOR PAYING THE DIFFERENCE BETWEEN WHAT THE FACILITY OR PROVIDER BILLED AND WHAT WAS PAID.THE NOT COVERED AMOUNT 

MAY NOT APPLY TO YOUR ANNUAL OUT- OF-POCKET MAXIMUM. 

HR - CHARGES WERE RECONSIDERED AND THE CLAIM WAS PROCESSED PER MEMBER BENEFITS, AS A RESULT OF THE ADDITIONAL INFORMATION 

PROVIDED. 

Because your family deductible has been satisfied, your remaining individual deductible has been adjusted to $0. The coinsurance period of your plan has begun for all 

covered members of your family. 

Because your family's out-of-pocket maximum has been satisfied, your remaining individual out-of-pocket maximum has been adjusted to $0. 

You have a right to request an appeal of the daim determination outlined in this statement. This appeal must be submitted within 2 years from the date you receive this 

statement. 

You may submit a written appeal, along with the copies of any relevant documents, to: 

STD-EOB • Use this EOB statement as a reference or retain as needed Page 4 of 9 

0000012190335E6 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 112 of 128
UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA GA 30374-0800 

Phone: 1-800-782-3740 

S VN-03912133•031655-M0-17080-85499-AFJ 32SYCP 

g UnitedHealthcare' 

March 21, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

UnitedHealthcare Appeals, P.O. Box 30573, Salt Lake City, UT 84130-0573. 

If you request a review of your daim determination, we will complete our review no later than 30 days after we receive your appeal. 

If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your daim have been completed. 

You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to 

the appeal address referenced above. 

You may request copies (free of charge) of information relevant to your daim by contacting us at the above address. 

Availability of Consumer Assistance/Ombudsman Services 

There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security 

Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance 

Assistance Team at 1-888-393-2789. 

If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by 

an independent third party, who will review the denial and issue a final decision. 

Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-782-3740. 

Meet Your Needs Online 

At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information 

on EOB content and more! For immediate, secure self-service visit www.myuhc.com. 

Myuhc Registration 

You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID 

card (first name, last name, member ID, group number and date of birth). 

Maintaining the privacy and security of individuals' personal information is very important to us at UnitedHealthcare. To protect your privacy, we implemented strict 

confidentiality practices. These practices include the ability to use a unique individual identifier. You may see the unique individual identifier on UnitedHealthcare 

correspondence, induding medical ID cards (if applicable), letters, explanation of benefits (E0Bs), and provider remittance advices (PRAs). If you have any questions about 

the unique individual identifier or its use, please contact your customer care professional at the number shown at the top of this Statement. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 5 of 9 

000001219033565 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 113 of 128
UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA, GA 30374-0800 

Phone: 1-800-782-3740 

S VN-03912113•031656-M0-17030-85499-AFJ 32SYCP 

g UnitedReethcare 

March 21, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

Please call the number included in this document or on the back of your ID card if you need diagnosis and/or treatment code information regarding the services referenced in 

this communication. 

Para obtener asistencia en espadol, flame al reamer° de telefono que se incluye en este 

document° o at dorso de su tarjeta de identificacion. 

We do not treat members differently because of sex, age, race, color, disability or national origin. 

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator. 

Online: UHC_Civil_Rights@uhc.com 

Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130 

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. 

If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, 

please call the toll-free number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m. 

You can also file a complaint with the U.S. Dept. of Health and Human Services. 

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) 

Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call 

the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m. 

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. 

Please call the toll-free phone number listed on your identification card. 

ATENCION: Si habla espariol (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su 

disposicion. Llame al numero de telefono gratuito que aparece en su tarjeta de identificaci6n. 

(Chinese) , 14491tOtAZIZAEMSIMES. astn*A-M374119111 

STD-EOB Use this EOB statement as a reference or retain as needed Page 6 of 9 

000001219033565 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 114 of 128
S VN-03912•04031657-M0-17060-85499-AFJ 32SYCP 

UnitedHealthcanS 

UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA, GA 30374-0800 

Phone: 1-800-782-3740 

March 21, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

XIN LIYU 1.1: Neu quk vi n6i tieng Viet (Vietnamese), quY vi sê duqc cung c.lp dich vu trq giap ye 

nein ng r mien phi. Viii long gni sti din thoai mien phi 6 mat sau the hi vien cila quk vi. 

01(Korean)2 1%1g61-Alt- 17:- (.11 01 X12.4 Aldi-AP FIRM 01g614 

181. 2.1 áJ 4 31.E011 -71 1.R §Th' tl-'9-131.41Al2. 

PAALALA: Kung nagsasalita Ica ng Tagalog (Tagalog), may makulcuha kang mga libreng serbisyo ng 

tulong sa wika_ Pakitawagan ang toll-fie na numero ng telepono na nasa iyong identification card. 

BHHMAHHE: fiecn.irartme yaryru nepeBoAa Aocrynabr Ans momil, gen pomori 513161K miasma 

pyCCKOM (Russian). Ilosaontre no 6eennaruomy nomepy reneritona, ykaaaintomy HB Baineii 

Kaermujuntaimonnoil kapre. 

01*_)11 UlI iX.L U c(Arabic) &Nix!, 1:3) 

ATANSYON: Si w pale Kreyol ayisyen (Haitian Creole), ou kapab benefisye sevis Id gratis pou ede w 

nan lang paw. Tanpri rele nimewo gratis ki sou kat idantifikasyon w. 

ATTENTION: Si vous parlez francais (French), des services d'aide linguistique vous sont proposes 

gratuitement. Veuillez appeler le numero de telephone gratuit figurant sur vote carte d'identification. 

UWAGA: Jeieli mowisz po polsku (Polish), udostepniliimy darmowe uslugi tlumacza. Prosimy 

zadzwonie pod bezplatny 'turner telefonu podany na karcie identyfikacyjnej. 

ATEKAO: Se voce fala porttigues (Portuguese), contate o servico de assistencia de idiomas gratuito. 

Ligue gratuitamente para o mimero encontrado no seu carte° de identificacAo. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 7 of 9 

000001219033565 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 115 of 128
UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA GA 30374-0800 

Phone: 1-800-782-3740 

S VN-03912134•031658-M0-17080-85499-AFJ 32SYCP 

g Unitedlisaithcare 

March 21, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

ATTENZIONE: in caso la lingua parlata sia l'italiano (Italian), sono disponibili servizi di assistenza 

linguistica gratuiti. Per favore chiamate ii numero di telefono verde indicato sulla vostra tessera 

identificativa. 

ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche 

Hilfsdienstleistungen zur Verfiigung. Bitte rufen Sie die gebiihrenfreie Rufmmuner auf der Rtickseite 

Dues Mitgliedsausweises an. 

aitVA : e*E5 (Japanese) t.a *1- eAt..-_10110tztlt-t -4- 

ttvc 06 7 — -NW:4MM < 

LAI) LIlib tUb3 :1•114 1-4 J.J CAI.) J.A. ki aaa:, .ca-A (Fars) ceuti 34.3 _SI :4,V 

41-1LrILAII,:i_Asaii 

TIT Ma' t: zit 31FT tra (Hindi) PI* fr 3117k itV SINT I14c11 (c3I tJi.34ei 

tl Tcir 3F14 crow trT Err ittr zir- r441- . wrg 47ti 

CEEB TOOM: Yog koj hais Lus Ilmoob (among), muaj key pab txhais [us pub dawb rau koj. Thov hu 

mu tus xov tooj hu deb dawb nas teev muaj nyob mu ntawm koj claim yuaj cim qhia tus kheej. 

oamfiwatrui: Athinlanesertanisr (Khmer) itaftevamantenenadairg knoainktem trottirrtunestenialg hanneriatutiuganzanitymaril 

PAKDAAR: Nu saritaem ti Docano (Ilocano), ti serbisyo para ti badriang ti lengguahe nga awanan 

bayarina, ket sidadaan para kenyam. Maidawat nga awagan iti toll-free a minter° ti telepono nga 

nakalista ayan iti identification card mo. 

Dff BANAKONINIZIN: Dine (Navajo) bizaad bee ylanitti'go, saad bee akdanida'aweigii, jiik'eh, 

bee na'ahetit'i'. TM shcodi ninaaltsoos nitlizi bee neehozinigii bine'dee' t'áá jilleehgo beesh bee hane'i 

bilcalgii bee hodfilnih. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 8 of 9 

000001219033565 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 116 of 128
1 

S VN-03912•05031659-M0-17080-85499-AFJ 32SYCP 

F Unitedlealthcare 

UnitedHealthcare Insurance Company_ 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA GA 30374-0800 

Phone: 1-800-782-3740 

March 21,2017 

Have more questions about your claim? 

Visit wviw.myuhc.com 

for all your claim and benefit information. 

OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, 

ayaad heli kartaa. Fadlan wac lambarka telefonka khadlca bilaashica ee ku yaalla kaarkaaga aqoonsig;a. 

.Account Summary 

Summary of Deductible and Out of Pocket 

Plan Year: 2016 

CLINT Annual 

Amount 

Relationship: EE 

IIKNETtMEDICAr4Fp9pmqiNEDArt,t0Vf iii0SWIWkM, 

Deductible $4,000.00 $3,466.50 Met 

Out of Pocket $6,250.00 $5,716.50 Met 

rOUT-OFJNETWORKm"7-44- 1:%„t ftrirrLagaZliltega z

Deductible $8,000.00 $0.00 $8,000.00 

Out of Pocket $24,000.00 $319.37 $23,680.63 

(-)Applied to (=)Remaining 

Date Balance 

N,EV/ItpiCAti/R2CCOMBINED.,4. 17:1,:p5,474:1: 4FIA 

Deductible $8,000.00 

Out of Pocket $12,500.00 

LOIFFENE_TyyORKigkiMMilip7jty 

Deductible $16,000.00 

Out of Pocket $48,000.00 

(-)Applied to 

Date 

(=)Remaining 

, Balance 

Annual 

Amount 

$8,000.00 Met 

$12,500.00 Met 

f7. 411 -

$566.00 $15,434.00 

$566.00 $47,434.00 

Definitions of Key Terms 

Applied to Date: The total amount of money applied to your deductible or out of pocket as of 

this EOB statement. 

Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for 

eligible health care services. Please refer to your plan documents for more information. 

Plan Year The dates your plan benefit maximums are applicable. 

Deductible The deductible is the fixed dollar amount that you pay each year toward eligible 

health Care services before your plan benefits are payable. Once the deductible has been 

met, the co-payment and/or coinsurance period of your plan may begin. Please refer to your 

plan dobuments for specific information regarding what services apply to the deductible. 

Patient Non Covered The amount of money you pay for services that are not covered 

under your plan. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 9 of 9 

000001219333565 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 117 of 128
Claims Summary 

Detailed claim information is located on the following page(s). 

1 Dollar Amount Description 

Amount Billed 

$13,237.14 This is the total amount that your provider billed for the services that were provided to you. 

Plan Discounts 

$0.00 Your plan negotiates discounts with providers to save you money. This amount may also include 

services that you are not responsible to pay. 

Your Plan Paid 

$1,361.32 This is the portion of the amount billed that was paid by your plan. 

Total amount you owe the provider(s) 

The portion of the Amount Billed you owe the provider(s). This amount does not reflect any 

payment you may have already made at the time you received care. This amount may include your.'.1 

deductible, co-pay, coinsurance and/or non covered charges. This amount does not include any 

payments made to the subscriber*. If a payment was made directly to the subscriber, you/the 

subscriber is responsible for paying the physician, facility or other health care professional. 

* When coordination of benefits applies, this amount will include payments made to the subscriber. 

S VN•08756'01'04323740-17044-85499-AFJ 41SYMS 

Unitedilealthcare' 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA, GA 30374-0800 

DPS$$$PKG 

CLINT SCHULER 

7907 E PORTOBELLO AVE 

MESA AZ 85212-1542 

1"111111111+1111111111"1111111111111111111""11111111111111 

February 13, 2017 

Member/Patient Information 

Member/Patient: CLINT SCHULER 

Member ID: A976771105 

Relationship: EE 

Group Name: GREENCRAFT 

INTERIORS 

Group #: 05U8947 

Explanation of Benefits Statement 

This is not a bill. Do not pay. This is to notify you that we processed your claim. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 1 of 4 

000001188846321 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 118 of 128
UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA GA 30374-0800 

Phone: 1-800-782-3740 

S VN-08756131'043238-M0-17044-85499-AFJ 42SYMS 

g Unite:ilk:Abeam' 

February 13, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

Claim Detail for CLINT SCHULER 

Provider: P PRICHARD Claim Number: 329052728101 Patient Account Number: 11212 

Date(s) of 

Service 

Type of Service Notes* Amount 

Billed 

Plan 

(-) Discounts (-)I Deductible 

Your Itemized Responsibility to Provider** 

Amount You 

(+) Copay (+) Coinsurance (+) Non Covered (=) Owe 

Yo—u7Plan 

Paid 

10/16/2016 SURGERY CK $13,237.14 $0.00 $1,361.32 $0.00 $0.00 $0.00 $11,875.82 $11,875.8 

Claim Total: HR $13,237.14 $0.00 $1,361.32 $0.00 $0.00 $0.00 $11,875.82 $11,875.82 

**This total does not reflect any payments / copays you made at the time of service. 

Please wait for a provider bill before making a payment. 

We received the requested information on 02/09/17 and have processed claim number 6327745038001. 

Notes* 

CK - A NON NETWORK HEALTH CARE PROVIDER OR FACILITY PROVIDED THESE SERVICES. YOUR CLAIM HAS BEEN PAID BASED ON YOUR BENEFIT 

PLAN, WHICH USES RATES ESTABLISHED BY THE FEDERAL GOVERNMENT FOR THE MEDICARE PROGRAM. THIS SERVICE WAS PAID BASED ON AMOUNTS 

SET BY MEDICARE OR OTHER SOURCES IF NO MEDICARE AMOUNT IS AVAILABLE. THE MEMBER IS RESPONSIBLE FOR THE TOTAL AMOUNT INDICATED IN 

THE AREA OF THIS STATEMENT SHOVVING WHAT THE PATIENT OWES. 

HR - CHARGES WERE RECONSIDERED AND THE CLAIM WAS PROCESSED PER MEMBER BENEFITS, AS A RESULT OF THE ADDITIONAL INFORMATION 

PROVIDED. 

Because your family deductible has been satisfied, your remaining individual deductible has been adjusted to $0. The coinsurance period of your plan has begun for all 

covered members of your family. 

Because your family's out-of-pocket maximum has been satisfied, your remaining individual out-of-pocket maximum has been adjusted to $0. 

You have a right to request an appeal of the claim determination outlined in this statement. This appeal must be submitted within 2 years from the date you receive this 

statement. 

You may submit a written appeal, along with the copies of any relevant documents, to: 

UnitedHealthcare Appeals, P.O. Box 30573, Salt Lake City, UT 84130-0573. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 4 

000001188846321 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 119 of 128
UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA GA 30374-0800 

Phone: 1-800-782-3740 

S VN-08756.02'043239-M0-17044-85499-AFJ 42SYMS 

Iii Unitedlioalthcare 

February 13, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

If you request a review of your claim determination, we will complete our review no later than 30 days after we receive your appeal. 

If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. 

You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to 

the appeal address referenced above. 

You may request copies (free of charge) of information relevant to your daim by contacting us at the above address. 

Availability of Consumer Assistance/Ombudsman Services 

There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security 

Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance 

Assistance Team at 1-888-393-2789. 

If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by 

an independent third party, who will review the denial and issue a final decision. 

Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-782-3740. 

Meet Your Needs Online 

At almost anytime day or night, you can review claims, check eligibility, locate a network physician, request an ID card, refill prescriptions if eligible, obtain more information 

on EOB content and more! For immediate, secure self-service visit www.myuhc.com. 

Myuhc Registration 

You can register and begin using myuhc in the same session. Navigate to www.myuhc.com to register. The information required for registration is on your insurance ID 

card (first name, last name, member ID, group number and date of birth). 

Maintaining the privacy and security of individuals' personal information is very important to us at UnitedHealthcare. To protect your privacy, we implemented strict 

confidentiality practices. These practices include the ability to use a unique individual identifier. You may see the unique individual identifier on UnitedHealthcare 

correspondence, including medical ID cards (if applicable), letters, explanation of benefits (E0Bs), and provider remittance advices (PRAs). If you have any questions about 

the unique individual identifier or its use, please contact your customer care professional at the number shown at the top of this Statement. 

Please call the number included in this document or on the back of your ID card if you need diagnosis and/or treatment code information regarding the services referenced in 

this communication. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 3 of 4 

000001188846321 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 120 of 128
(-)Applied to 

Date 

(=)Remaining 

Balance FAMILY Annual (-)Applied to (=)Remaining 

. Amount Date Balance 

Deductible $8,000.00 $8,000.00 Met 

Out of Pocket $12,500.00 $12,500.00 Met 

pUT OF, NETWORKrv JAMMA 

Deductible $16,000.00 $452.62 $15,547.38 

Out of Pocket $48,000.00 $452.62 $47,547.38 

InI.NETpMEDICAL/R?C4COMBI.NEcoow 

S VN-08756•02.043240-M0-17044135499-AFJ 

g UnitedHealthcarei 

42SYMS 

UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA GA 30374-0800 

Phone: 1-800-782-3740 

February 13, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

Para obtener asistencia en espaiiol, !lame al numero de telefono que se incluye en este 

document° o al dors° de su tadeta de identificacian • 

Account Summary 

Summary of Deductible and Out of Pocket 

Plan Year: 2016 

CLINT - Annual 

, Amount 

Relationship: EE 

1‘,1EVMEDIOA11/ . , RX.001y1BINED 

Deductible $4,000.00 $3,466.50 

Out of Pocket $6,250.00 $5,716.50 

pUTtp F11 ETWORK ItutartfaZN 

Deductible $8,000.00 $0.00 

Out of Pocket $24,000.00 $160.89 

• r 

Met 

Met 

.1 

. $8,000.00 

$23,839.11 

Definitions of Key Terms 

Applied to Date: The total amount of money applied to yourileductible or out of pocket as 

this EOB statement. 

Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for 

eligible health care services. Please refer to your plan documents for more information. 

Plan Year The dates your plan benefit maximums are applicable. 

of Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 

health Care services before your plan benefits are payable. Once the deductible has been 

met, the co-payment and/or coinsurance period of your plan may begin. Please refer to your 

plan do'cuments for specific information regarding what services apply to the deductible. 

Patient Non Covered The amount of money you pay for services that are not covered 

under your plan. 

STD-EOB Page 4 of 4 

000001188846321 

Use this EOB statement as a reference or retain as needed 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 121 of 128
Plan Discounts 

$0.00 Your plan negotiates discounts with providers to save you money. This amount may also include 

services that you are not responsible to pay. 

Your Plan Paid 

$0.00 This is the portion of the amount billed that was paid by your plan. 

S WS-04383'01'029163-M0-17139-85499-AFJ 21SYMS 

UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA, GA 30374-0800 

g UnitedHealthc,are° 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

DPS$$$PKG 

CLINT SCHULER 

7907 E PORTOBELLO AVE 

MESA AZ 85212-1542 

May 19, 2017 

Member/Patient Information 

Member/Patient: CLINT SCHULER 

Member ID: A976771105 

Relationship: EE 

Group Name: GREENCRAFT 

INTERIORS 

Group* 05U8947 

Explanation of Benefits Statement 

This is not a bill. Do not pay. This is to notify you that we processed your claim. 

Claims Summary 

Detailed claim information is located on the following page(s). 

Dollar Amount Description 

Amount Billed 

$6,681.96 This is the total amount that your provider billed for the services that were provided to you. 

\. 

Total amount you owe the provider(s) 

The portion of the Amount Billed you owe the provider(s). This amount does not reflect any 

payment you may have already made at the time you received care. This amount may include your 

deductible, co-pay, coinsurance and/or non covered charges. This amount does not include any 

payments made to the subscriber". If a payment was made directly to the subscriber, you/the 

subscriber is responsible for paying the physician, facility or other health care professional. 

* When coordination of benefits applies, this amount will include payments made to the subscriber,. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 1 of 7 

000001287289733 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 122 of 128
UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA GA 30374-0800 

Phone: 1-800-782-3740 

S WS-04363•01•029164-M0-17139-85499-AFJ 22SY MS 

Ii UniteclHealthcare 

May 19, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

Claim Detail for CLINT SCHULER 

Provider: P PRICHARD Claim Number: 330092291301 Patient Account Number: 11212 

Date(s) of Type of Service 

Service 

Notes* Amount 

Billed 

Plan 

(-) Discounts (-) (=) Deductible 

Your Itemized Responsibility to Provider** 

Amount You 

(+) Copay (+) Coinsurance (+) Non Covered (=) Owe 

[Your PIfl 

Paid 

11/29/2016 SURGERY ND $3,657.96 $0.00 $0.00 $474.76 $0.00 $0.00 $3,183.20 $3,657.9 

Claim Total: HR $3,657.96 $0.00 $0.00 $474.76 $0.00 $0.00 $3,183.20 $3,657.9 

**This total does not reflect any payments / copays you made at the time of service. 

Please wait for a provider bill before making a payment 

We received the requested information on 05/09/17 and have processed claim number 636U130373001. 

Claim Detail for CLINT SCHULER 

Provider: 0 TYLOR Claim Number: 650357588901 Patient Account Number: 535101 

Date(s) of Type of Service 

Service 

Notes* Amount 

Billed 

Plan 

(-) Discounts (-) (=) Deductible 

Your Itemized Res onsibilit to Provider* 

(+) Copay (+) Coinsurance (+) 

Amount You 

Non Covered (=) Owe 

Your Plan, 

Paid10/16/2016 ANESTHESIA Q9 $3,024.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3,024.00 $3,024.0 

Claim Total: $3,024.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3,024.00 $3,024.0 

**This total does not reflect any payments / copays you made at the time of service. 

Please wait for a provider bill before making a payment 

We received the requested information on 04/04/17 and have processed claim number 64.54196191001. 

Notes* 

HR - CHARGES WERE RECONSIDERED AND THE CLAIM WAS PROCESSED PER MEMBER BENEFITS, AS A RESULT OF THE ADDITIONAL INFORMATION 

PROVIDED. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 2 of 7 

000001267289733 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 123 of 128
UnitedHealthcare Insurance Company_ 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA GA 30374-0800 

Phone: 1-800-782-3740 

S WS-0436302029165-M0-17139-85499-AFJ 22SYMS 

Ii Unitedilealtircare 

May 19, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

ND - THIS PHYSICIAN OR HEALTH CARE PROVIDER IS OUT-OF-NETWORK. THIS SERVICE WAS PAID BASED ON AMOUNTS SET BY MEDICARE OR OTHER 

SOURCES IF NO MEDICARE AMOUNT IS AVAILABLE. MEDICARE AMOUNTS ARE APPLIED TO THESE SERVICES EVEN IF THE PATIENT DOESNT HAVE 

MEDICARE. YOU ARE RESPONSIBLE FOR ANY AMOUNT LEFT AFTER OUR PAYMENT. IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE 

GO TO YOUR MEMBER VVEBSITE OR PLAN DOCUMENTS. 

Q9 - THIS PROCEDURE CODE AND MODIFIER ARE THE SAME AS OR EQUIVALENT TO ANOTHER PROCEDURE CODE AND MODIFIER SHOWN ON THIS 

SAME CLAIM SUBMISSION OR A PRIOR CLAIM SUBMISSION. NO FURTHER BENEFITS ARE AVAILABLE FOR THIS SERVICE. 

Because your family deductible has been satisfied, your remaining individual deductible has been adjusted to $0. The coinsurance period of your plan has begun for all 

covered members of your family. 

Because your family's out-of-pocket maximum has been satisfied, your remaining individual out-of-pocket maximum has been adjusted to $0. 

You have a right to request an appeal of the claim determination outlined in this statement. This appeal must be submitted within 2 years from the date you receive this 

statement. 

You may submit a written appeal, along with the copies of any relevant documents, to: 

UnitedHealthcare Appeals, P.O. Box 30573, Salt Lake City, UT 84130-0573. 

If you request a review of your claim determination, we will complete our review no later than 30 days after we receive your appeal. 

If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed. 

You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents or other relevant information to 

the appeal address referenced above. 

You may request copies (free of charge) of information relevant to your claim by contacting us at the above address. 

Availability of Consumer Assistance/Ombudsman Services 

There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security 

Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance 

Assistance Team at 1-888-393-2789. 

If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your daim by 

an independent third party, who will review the denial and issue a final decision. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 3 of 7 

000001267289733 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 124 of 128
UnitedHealthcare Insurance Company_ 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA, GA 30374-0800 

Phone: 1-800-782-3740 

S WS-04363•02•029166-M0-17139-85499-AFJ 22SYMS 

g Unitedllea1thcar1 

May 19, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

Insurance fraud adds millions to the cost of health care. If services are listed which you did not receive or service you were told would be free, call 1-800-782-3740. 

Rather view this online? 

Sign up for myuhc.com to easily view claims and account balances, see where you're at against your deductible, locate a network doctor, compare costs, select paperless 

delivery of your important plan documents and more. 

Rather view this on your mobile device? 

Download the free UnitedHealthcare Health4Me app, then sign up to easily find and map care,,compare costs, view daims and account balances and more. Get access to 

the same personalized health plan information while you're on the go. 

Maintaining the privacy and security of individuals' personal information is very important to us at UnitedHealthcare. To protect your privacy, we implemented strict 

confidentiality practices. These practices include the ability to use a unique individual identifier. You may see the unique individual identifier on UnitedHealthcare 

correspondence, including medical ID cards (if applicable), letters, explanation of benefits (E0Bs), and provider remittance advices (PRAs). If you have any questions about 

the unique individual identifier or its use, please contact your customer care professional at the number shown at the top of this Statement. 

Please call the number induded in this document or on the back of your ID card if you need diagnosis and/or treatment code information regarding theservices referenced in 

this communication. 

Para obtener asistencia en espafiol, name al minter° de telefono que se incluye en este 

document° o al dorso de su tarjeta de identificacion. 

We do not treat members differently because of sex, age, race, color, disability or national origin. If you think you weren't treated fairly you can send a complaint to: Civil 

Rights Coordinator, United HealthCare Civil Rights Grievance, P.O. Box 30608, Salt Lake City, UTAH 84130, UHC_Civil_Rights©uhc.com. You must send the complaint 

within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If 

you need help with your complaint, please call the toll-free member number listed on your health plan ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m. 

You can also file a complaint with the U.S. Dept. of Health and Human Services. 

Online: https://ocrportal.hhs.gov/ocr/portaVlobby.jsf 

Complaint forms are available at http://www.hhs.gov/ocr/officeffile/index.html. 

Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) 

Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 

STD-EOB Use this EOB statement as a reference or retain as needed Page 4 of 7 

000001267259733 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 125 of 128
UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA, GA 30374-0800 

Phone: 1-800-782-3740 

S WS-04363133`029167-M0-17139-85499-AFJ 22SYMS 

g Unitedilealthcare 

May 19, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call 

the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m. 

ATENCION: Si habla espatiol (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su 

disposicion. Llame al numero de telefono gratuito que aparece en su tarjeta de identificacion. 

FVWX : 44 3Z (Chinese) , tialtS4AMSItb Se MilafT*A+Mililtil 

XIN LUIJ Nu quY vj n6i tieng Vi'81 (Vietnamese), quY vi se &roc cung cAp dich v tro giitp ye 

nglin ngii mien phi. Vui long goi se din thoni mien phi 6 mat sau th8 hied via cüa qujr vi. 

fl- GI(Korean)M 5?- al01 xi Ai 1:11.?.'_• -TIMM 01 g 8144 1-6-L10E 

16121 . 3lE011 3IXH9 §11' E22181-41Al2. 

PAALALA: Kung nagsasalita ka ng Tagalog (T'ag,alog), may makukuha kang mga libreng serbisyo ng 

tulong sa wika. Pakitawagan ang toll-free na numero ng telepcmo na nasa iyong identification card. 

BHHMAHHE: 6ecnuarttme ycnyrn rrepesona Aocrynnta nns mortar, gat pomtort 31:3111K numercx 

pyCCICOItt (Russian). TIo3aokin.reno 6ecanar8omy Homepy Te3e4mHa, yrcasatrnomy Ha aaineii 

HateartulmucamionHon Kapre. 

val÷.11 egiuSa .14.) 4. 4_0111 (Arabic) Jt Z t :atias 

,lc. 

ATANSYON: Si w pale Kreyol ayisyen (Haitian Creole), ou kapab benefisye sevis Id gratis pou ecle w 

nan lung paw. Tanpri rele nimewo gratis Id sou kat idantifikasyon w. 

ATTENTION: Si vous parlez francais (French), des services d'aide linguistique vous sont proposes 

gratuitement. Veuillez appeler le numero de telephone gratuit figurant sur votre carte d'identification. 

000001267289733 

STD-EOB Use this EOB statement as a reference or retain as needed Page 5 of 7 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 126 of 128
UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC. CNTR 

P.O. BOX 740800 

ATLANTA GA 30374-0800 

Phone: 1-800-782-3740 

S WS-04363133•029168-M0-17139-85499-AFJ 22SY MS 

Ii Unitedllealthcarq 

May 19, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

UWAGA: JeZeli mowisz po polsku (Polish), udostepnilihmy dannowe uslugi tlumacza. Prosimy 

zadzwonie pod bezplatny numer telefonu podany na karcie identyfilracyjnej. 

ATEKAO: Se voce' fala portugues (Portuguese), c,ontate o servico de assistencia de idiomas gratuito. 

Ligue gratuitamente para o nnmero encontrado no seu cardo de identificacao. 

ACHT1UNG: Falls Sie Deutsch (German) sprechen, stehen Buten kostenlos sprachliche 

Hilfsdienstleistungen zur VerMgung_ Bite rufen Sie die gebithrenfreie Rufnummer auf der Rtickseite 

Mres Mitgliedsausweises an. 

1410=1 .A ate ta'tJJCAIJ _1,1.4acs-,14.) ala.1 (Fars) ce.,..4 L.%d.j ft 

MJ Lø ca.% L..% 0,11-aal c-utsLCJJ AS 

yfr MIR t i1 311w fit (Hindi) srpft it 3frErk f1Lr 31r5r1 c3JL ft:vj 

fl TErr 3itt* Erom trT Er4" ittr zra-01T*c{ wrg 441 

Dil BAA'ARONiNiZIN: Dine (Navajo) bizaad bee yeanilti'go, saad bee alca'anida'awolgii, jiik'eh, 

bee nit'ah6ore. rM shdi ninaaltsoos nitrizi bee neehozinigii bine'deel t'áá jitleehgo beesh bee hanel 

bee hodiilnik 

STD-EOB Use this EOB statement as a reference or retain as needed Page 6 of 7 

000001267289733 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 127 of 128
S WS-04363•60029169-M0-17139-85499-AFJ 22SYMS 

ijJ UnitedHealthcare 

UnitedHealthcare Insurance Company 

RICHARDSON/SPRGFLD SRVC CNTR 

P.O. BOX 740800 

ATLANTA GA 30374-0800 

Phone: 1-800-782-3740 

May 19, 2017 

Have more questions about your claim? 

Visit www.myuhc.com 

for all your claim and benefit information. 

Account Summary 

FAMILY 

Summary of Deductible and Out of Pocket 

Plan Year: 2016 

CLINT Annual 

Amount 

Relationship: EE 

[!Nj ,IMS-C....MP I 414:0AF,V22-tg1 /4

Deductible $4,000.00 $3,466.50 Met 

Out of Pocket $6,250.00 $5,716.86 Met 

Deductible $8,000.00 $0.00 $8,000.90 

Out of Pocket $24,000.00 $474.76 $23,525.24 

Annual (-)Applied to HRemaining 

Amount Date Balance 

4 11N NET MEDICAL:MX.COMBINEDA,F>7'7 •;171; '?: 147'- 

Deductible $8,000.00 $8,000.00 Met 

Out of Pocket $12,500.00 $12,500.00 Met 

pUT.A...1\1B1WORiltV64DT79-W 

Deductible $16,000.00 $474.76 $15,525.24 

Out of Pocket $48,000.00 $474.76 $47,525.24 

(-)Applied to 

Date 

(=)Remaining 

Balance 

Definitions of Key Terms 

Applied to Date: The total ambunt of money applied to your deductible or out of pocket as of 

this EOB statement. 

Out of Pocket This is the amount you pay before your plan benefit starts paying 100% for 

eligible health care services. Please refer to your plan documents for more information. 

Plan Year The dates your plan benefit maximums are applicable. 

Deductible: The deductible is the fixed dollar amount that you pay each year toward eligible 

health care services before your plan benefits are payable. Once the deductible has been 

met, the co-payment and/or coinsurance period of your plan may begin. Please refer to your 

plan documents for specific information regarding what services apply to the deductible: 

Patient Non Covered The amount of money you pay for services that are not covered 

under your plan. 

STD-EOB Use this EOB statement as a reference or retain as needed Page 7 of 7 

000001267289733 

Case 2:18-cv-00920-DJH Document 1-2 Filed 03/23/18 Page 128 of 128