Values from records
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The record values this file is made from: the ones its text names with {{record.field}}, and the fields its template reads. A value here is in the file's source; whether it is readable depends on the look.
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Planted
mismatch The Evermont supplement card is in the name LORRAINE H PRUITT (her maiden name Hollis used as a middle initial). Medicare and every other document say Lorraine M. or Lorraine Mae Pruitt. The mismatch is why a $1,736 hospital bill is unpaid.
attachments.yaml
record: doc-evermont-denial
template: document
style: statement
look: scan
org:
name: Evermont Health Assurance
lines:
- PO Box 4471
- Knoxville, TN 37901
phone: '8885550114'
web: evermont.example
color: '#2e6b4f'
title: Explanation of Benefits
body: '**Date:** August 12, 2026
LORRAINE H PRUITT<br>2217 LARKMOOR LANE NW<br>CLEVELAND TN 37312
**Member ID:** {{card-lorraine-medigap.identification_number}} **Plan:** {{card-lorraine-medigap.type}}
**This is not a bill.**
| Provider | Dates of service | Billed to plan | Plan paid |
|---|---|---|---|
| Whitlow Memorial Hospital | 05/20/2026 - 05/22/2026 | $1,736.00 | $0.00 |
**Claim status: NOT PAID. Reason N-14.**
The member name on the claim sent to us by Medicare (PRUITT, LORRAINE M) does not match the member name
in our records (PRUITT, LORRAINE H). We cannot pay a claim until the name matches.
**What to do.** If the name in our records is wrong, call Member Services at (888) 555-0114 and send
us a copy of your Medicare card and a photo ID. When the record is corrected, ask the provider to submit
the claim again. You have 180 days from the date of this notice.
Amount you may be billed by the provider: $1,736.00 (Medicare Part A deductible).
'
