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Ball, Lucille - 2/5/1968 MRN 1234-5678
Eligiblity History
Submitted DOS Service Types Result
3/2/2022 3/2/2022 - Active
11/19/2021 11/1/2021 Mental Health
Vision		 Active
6/13/2021 6/13/2021 Physical Therapy Inactive
View Full History

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Services Restricted to Following Provider
Party Service Type Provider NPI
Individual Medical Care CARREY, ZEV 1618971687
Deductible / Max Out of Pocket
Party Service Type In Network Out of Network
Remaining Deductible Remaining OOP Remaining Deductible Remaining OOP
Individual Health Plan Benefit Coverage $1,388 $6,188
Family Health Plan Benefit Coverage $2,950 $11,146
Flags / Exceptions
  • No Therapy
  • Emergency Services Only
  • RE Code 95
Coverage
Party Service Type In Network Out of Network
Active Co-pay Auth Limit Active Co-pay Auth Limit
  Open Access Plus (Commercial)
Individual Physician Visit - Office $20 No
$40 Yes
Individual Health Plan Benefit Coverage $40 No
Individual Urgent Care $50 No $75 Yes
Individual Physical Therapy $25 No Unlimited
Individual Vision (Optometry)
Other Service Types
Insured
Name Desi Arnaz
DOB 8/14/1961
Gender Male
Dependent
Relationship Spouse
Name Lucy Ball
DOB 2/5/1968
Gender Female
Address 123 Main St
Brooklyn, NY 12345
Primary Care Provider
Name Carrey, Zev
Specialty Physician/Internal Medicine
NPI 1992078454
Address 270 Doughty Blvd #2
Inwood, NY 110961367
Deductible
Party Service Type In Network Out of Network
Deductible Remaining OOP Max Remaining Deductible Remaining OOP Max Remaining
Individual Health Plan Benefit Coverage $1,500 $1,500 $6,350 $6,346
Family Health Plan Benefit Coverage $3,000 $2,516 $12,700 $12,022
Individual Urgent Care $6,350 $6,346
Family Urgent Care $12,700 $12,022 
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