Hi Alex · Member ID PMH-447120 ·
Claims & Explanation of Benefits
This is not a bill. Your provider may bill you up to "You may owe".
Bluebonnet Regional Medical Center · Emergency room visitPaid
- Claim
- CLM-1001
- Date of service
- Sep 14, 2026
- Billed
- $2,480.00
- Plan discount
- $1,840.00
- Plan paid
- $600.00
- You may owe
- $40.00 (ER copay)
- Processed
- Oct 1, 2026
Bluebonnet Regional Medical Center · LaboratoryPaid
- Claim
- CLM-1002
- Date of service
- Sep 14, 2026
- Billed
- $180.00
- Plan discount
- $85.00
- Plan paid
- $70.00
- You may owe
- $25.00
- Processed
- Oct 1, 2026
Bluebonnet Regional Medical Center · Advanced imaging (MRI)Denied
- Claim
- CLM-1003
- Date of service
- Oct 2, 2026
- Billed
- $1,850.00
- Plan paid
- $0.00
- You may owe
- $1,850.00
- Processed
- Oct 12, 2026
- Reason
- Prior authorization not on file. You may appeal within 180 days of this notice.