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Advantek Benefit Administrators Plan Administrator P.O. Box 45007 Fresno, CA 93718 Service Center 866-556-7655 Telephone Number

EXPLANATION OF BENEFITS Date: : 01/02/2008 Page: :1 EOB No: : 0801029999

Employer Name

Group ID: 99999 PETER PARKER 12345 N. MAIN ST CLOVIS, CA 93612 Dear Mr. PARKER:

Employee Name & Address

Group Division Div Desc Ident.

Claim Number

: THE DAILY BUGLE : 100A : PHOTOGRAPHY : SM9999999

Employer Assigned Identification Number

Procedure(s) Billed by the Provider

This is an explanation of benefits for the medical claim we received for Amount Paid by services rendered to PETER PARKER, DOB: 02/19/1971.

Specific Provider of Service Date Services Rendered Advantek

CLAIM 2007-12-24-9999 BREAKDOWN You paid the provider $0.00 toward these expenses.

Plan Coinsurance

Provider Otto Octavious

Date of Service 12/14/07

Procedure PHYSICAN VISITS

Charge $114.08

Inelig. $38.12

Ref 1

Deductible $50.00

Paid % 90%

Payment

Paid To

$14.36 Doctor

BENEFIT SUMMARY FOR CLAIM 2007-12-24-9999

Charges $114.08 Ineligible $0.00 References Ref # 1 Explanation Deductibles $50.00 Co Payment $10.00 Benefit Ded $0.00 PPO Disc 38.12 Balance $0.00 Plan Pays $14.36 Mbr Liability $61.60

Amount Provider Charged for Procedure(s) Billed

Amount Applied to Plan Deductible

Amount Member Owes the Provider

Services paid at the Blue Cross Prudent Buyer contracted rate. Member not liable.

If you disagree with this determination, you may file a written appeal to Advantek Benefit Administrators within 60 days of your receipt of this letter. Objective information in support of your position should accompany your appeal. Your appeal should be mailed to: Advantek Benefit Administrators P.O. Box 45007 Fresno, CA 93718 Please refer to your Summary Plan Description handbook

Description of Denial Reason(s) or Other Informational Message(s)

Information

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