Prior Authorization Member

Issuer (*****) 911-*****-**

Member ID: Group Number:

Member:

Co-pays May Apply

5030

Self-funded plan administered by UMR

34383944 76-415650

ANGELA DUNCAN 00 MED

INTENTIONALLY BLANK

031**-******* 000*-******* 000****-***-*-***

RUN_DATA_CLIENT_UHG N M 34383944 OC M STCPS L DATE TYP ID SEQ_SEQ_U NUMBER 589369 ID CAN KEY1 20221215 NO PD KEY 0 3 4 5 7 89 000 SHRT 343****-****** ANGELA UMR/2 / CARD 031 5 2 662 00554-4 Medical 13:0 2 01 54 0 03:~ 00123 30 CARD2,ANGELA This card must be presented each time services are requested. Printed: 12-14-2022 Call UMR CARE at 866-***-**** for plan required prior authorization. FAILURE TO CALL FOR PRIOR AUTHORIZATION MAY REDUCE BENEFITS. For Members: www.umr.com 800-***-****

Teladoc: www.Teladoc.com 800-***-****

For Providers: www.umr.com 877-***-****

Claims: EDI # 39026, UMR, PO Box 30541, Salt Lake City, UT 84130-0541 Medical: In Net Out of Net

Ded: $750 $1,000

OOPM: $5,000 No Limit

Shipper ID: 00000000 Insert #1 Insert #2

Shipping Method: DIRECT Insert #3 Insert #4

CARRIER: USPS Insert #5 Insert #6

Address: Insert #7 Insert #8

ANGELA DUNCAN Insert #9 Insert #10

1690 EL TIGRE TERR Insert #11 Insert #12

SAINT LOUIS, MO 63138

Cycle Date: 20221215

PDF Date: Thu Dec 15, 2022 @ 13:03:30

MaxMover: N

Mailing/Meter Date: UHG JOB ID: 8100 GRP: 76415650 PV: 001 RC: EMP MKT: MT: 00 SA: 90 OI: 02 FORM: K2H000 CPAY: PKG ID: L0107 DALE BROWN: N LETTER NM: LETTER2 DIVISION : CARD TYPE: TEMPLATE: TPA C30 : FAMILY T50 : 2SHRT

SORT HCN: L0107

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