02/28/2019

Member: RAYMOND L. NICOL

ID Number: NHP0970517926
Authorization Number: 50518NMT00
Facility:
Provider: RECESSO PHYSICAL THERAPY LLC
RAYMOND L. NICOL Date(s) of Service: 02/27/19 - 02/27/20
24 BANCROFT RD
NEWTON, NH 03858

Dear Member:

Your doctor or other health care provider asked us to review the service below to confirm that
it meets our medical necessity guidelines. We authorized this service for you up to 16 day(s) or
service(s) based on the specific services your health care provider requested and the information
submitted.

Type of Service: Physical Therapy

Place of Service: Outpatient Department

Payment for these services will be based on your plan benefits

Any payment from us toward these services is based on your health insurance plan benefits,
as described in your subscriber certificate/benefits description. (For a copy of your subscriber
certificate/benefits description, log in to your account at www.bluecrossma.com/membercentral,
or call us at the number on the front of your ID card.) We pay claims based on:
What your health insurance plan covers
If you haven't reached certain benefit limits
Whether you are a member at the time of service
Whether the information submitted and the services actually provided match those
we authorized (we may review the services after you receive them)

If you are a PPO or POS plan member, your costs will vary depending on the health care
provider you choose. Please see the back of this page for important plan information.

What if I need these services beyond the time authorized in this letter?
If it is medically necessary for you to receive services beyond 02/27/20,
your doctor or other health care provider can request an extension of this authorization.

Questions?
For questions about your benefits, please review your subscriber certificate/benefits description,
or contact Member Service at the number on the front of your ID card.
Sincerely,

Fred Dekow, M.D.

Vice President, Physician Review and Appeals
Blue Cross Blue Shield of Massachusetts
101 Huntington Avenue Suite 1300 Boston, MA 02199-7611 www.bluecrossma.com
MRP61 Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association
121517
 For PPO and POS plan members
Your expenses are lowest when you use doctors, hospitals, and other health care providers in
the Blue Cross network. If you choose an out-of-network health care provider, you will pay
significantly more for your care. This can include:
Deductibles and co-insurance
Services that we do not consider medically necessary
Any charges greater than those your plan covers

PPO and POS plans with out-of-network "usual and customary" fees
If your PPO or POS plan pays out-of-network providers a usual and customary fee, we only
cover a set amount when you get care out-of-network. Our usual and customary fees are
based on the average fees charged by health care providers in a specific area. You pay any
difference between the health care provider's actual fee and our usual and customary fee.

This is in addition to any copayments, deductibles, and co-insurance you already must
pay and could be a large amount of money. In many cases, out-of-network health care
providers charge as much as three to five times more than in-network health care providers.

Below is an example
Please note: All amounts are not actual charges and are for illustrative purposes only.
Your actual out-of-pocket costs may vary depending on the service and health care provider.

Surgery from Surgery from

an In-Network an Out-of-Network
Provider Provider
The Amount Charged by the
$90,000 $90,000
Health Care Provider
Blue Cross Pays Negotiated rate Usual and customary fee = $40,500

Member's Copayment $500 $0

Member's Co-insurance $0 20% of $40,500 = $8,100
(20% after deductible, out-of-
network only)
Member Pays Balance $0 $90,000 - $40,500 = $49,500

Member's Total Out-of-Pocket $500 $8,100 + $49,500 = $57,600

Cost (after deductible)

To save money, use in-network health care providers

Your plan gives you access to a large network of doctors and hospitals in Massachusetts and across
the country. To find an in-network health care provider, visit www.bluecrossma.com/findadoctor.
If you have any questions, please call Member Service at the number on the front
of your ID card.

Registered Marks of the Blue Cross and Blue Shield Association.

2013 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

MR61A
071913