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Tidewell letter Aug 2021

personas/two-country-family/files/documents/tidewell-letter-2021.pdf
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                                                                                     Member Appeals
                                                                                          PO Box 9180
                                                                                      Iselin, NJ 08830

Tidewell Health Plan                                                                    (866) 555-0108
                                                                                tidewellhealth.example




Re: Claim 21-0481-77315 - reprocessed
August 12, 2021

IULIIA ZARETCKAIA

8-17 Larkmoor Terrace, Fair Lawn, NJ 07410

Member ID TWH71502936, group CCR-11562

Dear Member,

We reviewed the appeal we received on June 21, 2021. The claim below was first processed as
out of network. The provider was in the Tidewell network on the date of service. The claim has
been processed again.


 Patient                                Vera Zaretskaya, dependent

 Date of service                        02/16/2021

 Provider                               Bergen Highlands Medical Center, urgent care

 Diagnosis reported                     L50.0 allergic urticaria

 Amount billed                          $1,146.00

 Network discount                       -$389.80

 Paid by the plan                       -$606.20

 Your share: urgent care copay          $150.00

The provider has been told that it may bill you no more than $150.00 for this visit. If you have
paid more, the provider must refund the difference. Disregard the statement for $1,146.00
dated April 2, 2021.

You do not need to do anything else. If you disagree with this decision you may ask for an
external review within four months of the date of this letter.

Member Appeals Unit

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Tidewell letter Aug 2021 Document · saved Aug 19, 2021

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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.

ValueNow
insurance-card-tidewell-old.identification_number TWH71502936
insurance-card-tidewell-old.group_number CCR-11562

The values at render time were not recorded: the file was rendered before files/rendered.json existed. Rendering it again records them.

Planted

spelled_differently Yulia is Юлия Зарецкая, Yulia Zaretskaya, ZARETSKAIA IULIIA, ZARETCKAIA IULIIA, ZARETSKAYA YULIYA and, on the diploma evaluation, Yuliya Lapteva. Pavel is Zaretsky, ZARETSKII and ZARETCKII. Tim is Timofey Zaretsky, ZARETSKII TIMOFEI, ZARETCKII TIMOFEI and Tim. Her mother is Мама, Галина Петровна Лаптева and LAPTEVA GALINA. Husband and son are Zaretsky, wife and daughter are Zaretskaya. Vera's birth certificate names her parents as Pavel Zaretckii and Iuliia Lapteva. Pavel's records show their owner as Паша, Tim's as Tim, the mother's as Мама. The closing statement, the payoff letter, the 1098, the mortgage statement, the car order and the old insurer's letter are all in the names they had before November 2022.

attachments.yaml 
record: doc-tidewell-dispute
template: document
style: letter
org:
  name: Tidewell Health Plan
  lines:
  - Member Appeals
  - PO Box 9180
  - Iselin, NJ 08830
  phone: '8665550108'
  web: tidewellhealth.example
  color: '#2a5d8a'
title: 'Re: Claim 21-0481-77315 - reprocessed'
body: 'August 12, 2021


  IULIIA ZARETCKAIA


  8-17 Larkmoor Terrace, Fair Lawn, NJ 07410


  Member ID {{insurance-card-tidewell-old.identification_number}}, group {{insurance-card-tidewell-old.group_number}}


  Dear Member,


  We reviewed the appeal we received on June 21, 2021. The claim below was first processed as out of network.
  The provider was in the Tidewell network on the date of service. The claim has been processed again.


  | | |

  |---|---|

  | Patient | Vera Zaretskaya, dependent |

  | Date of service | 02/16/2021 |

  | Provider | Bergen Highlands Medical Center, urgent care |

  | Diagnosis reported | L50.0 allergic urticaria |

  | Amount billed | $1,146.00 |

  | Network discount | -$389.80 |

  | Paid by the plan | -$606.20 |

  | Your share: urgent care copay | $150.00 |


  The provider has been told that it may bill you no more than $150.00 for this visit. If you have paid
  more, the provider must refund the difference. Disregard the statement for $1,146.00 dated April 2,
  2021.


  You do not need to do anything else. If you disagree with this decision you may ask for an external
  review within four months of the date of this letter.


  Member Appeals Unit

  '