WellPoint Plan P.o. BOX 600 ANYTOWN, ANY STATE 00010 (888)555-5551 CASEY M PATIENT 123 MAIN ST ANYTOWN, ANY STATE 12345 DATE: ENROLLEE: CONTRACT: BENEFIT PLAN: 11/16/2015 FEP123456789 CASEY M PATIENT 2489 ANY STATE PLAN EXPLANATION OF BENEFITS SERVICE DETAIL COPAY/ AMOUNT PATIENT/ NUMBER ENROLLEE 567892 PROVIDER/ SERVICE D SMITH DATE OF SERVICE AMOUNT CHARGED 92.75 NOT COVERED ALLOWED DEDUCTIBLE 0 PLAN BENEFITS 00 REMARK CODE OFFICE VISITS 10/20/2015 A COPY OF INFORMATION SENT TO THE PROVIDER WITH THE PAYMENT/DENIAL AS APPROPRIATE PRI WE ARE UNABLE TO IDENTIFY THE ABOVE RECIPIENT AS A MEMBER AS A POLICYHOLDER. THE PATIENT IS RESPONSIBLE FOR THE BILLED AMOUNT OF THIS CLAIM. (Note: This explanation of benefits indicates this patient is not a member of the WellPoint Plan insurance.)