600002828801

Cigna Dental
Cigna Health and Life Insurance Company Page 1 of 5
P.O. BOX 188037
CHATTANOOGA, TN 37422

As administrator for ALCON VISION LLC 3342961 THIS IS NOT A BILL

To see the latest claims

and plan information on
myCigna, scan the code.

DIPEN KUMAR DAS

15323 SPECTRUM
IRVINE, CA 92618-3424

Your explanation of dental benefits ( for the claim processed on Feb 19, 2024 )

Your current account summary Your payment summary

$50 has been applied towards your $50 network individual deductible for 2024. Paid to: KAGALWALA PROFESSIONAL
$100 has been applied towards your $100 out of network individual deductible for 2024. DENTAL INC
$50 has been applied towards your $150 network family deductible for 2024. Amount: $258.60
$100 has been applied towards your $300 out of network family deductible for 2024.
$258.60 has been applied towards your $2,000 network individual maximum for 2024.
$258.60 has been applied towards your $2,000 out of network individual maximum for
2024.
$0 has been applied towards your $2,000 lifetime ortho maximum.
$0 has been applied towards your $2,000 lifetime ortho maximum.
$0 has been applied towards your $1,500 lifetime tmj maximum.
$0 has been applied towards your $1,500 lifetime tmj maximum.
01363330

The balances shown above are as of Feb 19, 2024, the day the claim was finalized.
However, the balances on the website are updated daily, so the balances shown here
may not match those listed on your participant website at myCigna.com.

* Current Dental Terminology © American Dental Association

 600002828802

Page 2 of 5

Federal rights of review and appeal If you are covered by more than one health benefit plan, you should
file all your claims with each plan.
If you have any questions about this explanation of benefits, please
call Customer Service at the toll-free number on the front of this
form.

Please follow the steps below to make sure that your appeal is
Definitions
processed in a timely manner.
· Administrative Service Only - ERISA The Employee Retirement
· If you're not satisfied with this coverage decision, you can start
Income Security Act of 1974 (ERISA) sets standards for private
the Appeal process by submitting a written request to the
sector retirement and health plans. ERISA governs most
address listed: Cigna Appeals Unit PO Box 188044 Chattanooga,
Administrative Services Only (ASO) plans.
TN 37422 within 180 days of receipt of this EOB (unless a
· Amount Your Health Care Professional Charged: Amount
longer time frame is provided by applicable state law or
charged for the services.
permitted by your plan).
· Your Health Care Professional's Contracted Amount (if
· Send a copy of this explanation of benefits along with any present): Cigna Dental has negotiated a reduced fee for
relevant additional information (e.g. benefit documents, participating dentists. The negotiated amount is printed in this
medical records) that helps to determine if your claim is column if the health care professional is a Cigna Dental
covered under the plan. Contact Customer Service if you need participating dentist, otherwise zeros will appear.
help or have further questions. · Amount Eligible for Coverage by Your Plan: Part of the
· Be sure to include: "Amount Your Health Care Professional Charged" or "Your
1) Your name, Health Care Professional's Contracted Amount" (if present)
2) Account number from the front of this form, eligible for coverage under your plan. This amount is used to
3) ID Number from the front of this form, help calculate how much will be paid by your plan.
4) Name of the patient and relationship and · Your Deductible: Portion of the "Amount Eligible for Coverage
5) "Attention: Appeals Unit" on all supporting documents by Your Plan" that is applied towards your deductible.
· Contact Customer Service at the number on the front of this · Remaining Balance: "Amount Eligible for Coverage by Your
form to request access to and copies of all documents, records, Plan" minus "Your Deductible".
and other information about your claim, free of charge. · Your Plan Covered (%,$): The amount (percentage and dollar
· You will be notified of the final decision in a timely manner, as amounts, respectively) of the "Amount Eligible for Coverage by
described in your plan materials. If your plan is governed by Your Plan" that your plan paid.
ERISA, you may also bring legal action under section 502(a) of
ERISA following our review and decision.
 600002828803
Cigna Dental
Cigna Health and Life Insurance Company Page 3 of 5
As administrator for ALCON VISION LLC 3342961

Your explanation of dental benefits ( for the claim processed on Feb 19, 2024 )
THIS IS NOT A BILL

Make the most of your dental benefits. Log on to myCigna.com

today!
Finding a dentist is easy as 1-2-3 with myCigna.com. Log on and:
1. Find providers by specialty, language, name or address.
2. Read verified patient reviews and estimate costs for a variety of procedures.
3. Schedule an appointment.
It's quick and easy to log on. First-time users will need to sign-up for an account and
provide an email address. This way we can send you important information about your
dental plan.

Availability varies by dentist and plan type. Brighter, Inc., an independent company,
provides the experience ratings, reviews, and appointment scheduling information.
Directory features should not be the sole basis for choosing a dentist and do not
guarantee quality of care. Dentists participating in the network are independent
contractors, not agents of Cigna, and are solely liable for the treatment they provide.

If you'd like information on how much the customer has met towards their accumulators
(e.g., deductibles), please visit our website at cignaforhcp.com or contact Customer
Service.

Your claim details

PATIENT NAME: DIPEN KUMAR DAS PATIENT'S RELATIONSHIP TO SUBSCRIBER: SUBSCRIBER SUBSCRIBER NAME: DIPEN KUMAR DAS PATIENT ID: U80340865
HEALTH CARE PROFESSIONAL NAME: KAGALWALA PROFESSIONAL DENTAL GROUP NAME: ALCON VISION LLC PROVIDER NETWORK STATUS:
OUT OF NETWORK GROUP #: 3342961 DOCUMENT #: D240506406450 CLAIMANT #: 01 CLAIM #: 011 PAYMENT #: 001 POLICY CODE: 01
DIVISION: 008 RECEIVED DATE: Feb 19, 2024 PROCESSED DATE: Feb 19, 2024 Administrative Services Only - ERISA
01363350

AMOUNT YOUR HEALTH CARE

YOUR HEALTH CARE PROFESSIONAL'S AMOUNT ELIGIBLE YOUR PLAN COVERED
PROFESSIONAL CONTRACTED FOR COVERAGE YOUR COPAY/ REMAINING YOUR (%) ($)
CHARGED ($) AMOUNT ($) BY YOUR PLAN ($) DEDUCTIBLE ($) BALANCE ($) COINSURANCE ($)

For service on Feb 15, 2024: First Periapical X-ray* (see note DB)
47.00 0.00 47.00 47.00 0.00 0.00 80% 0.00
For service on Feb 15, 2024: Additional Periapical X-ray* (see note DB)
42.00 0.00 40.00 40.00 0.00 0.00 80% 0.00
For service on Feb 15, 2024: Additional Periapical X-ray* (see note DB)
42.00 0.00 40.00 13.00 27.00 5.40 80% 21.60
For service on Feb 15, 2024: Additional Periapical X-ray*
42.00 0.00 40.00 0.00 40.00 8.00 80% 32.00
For service on Feb 15, 2024: Additional Periapical X-ray*
42.00 0.00 40.00 0.00 40.00 8.00 80% 32.00
For service on Feb 15, 2024: Additional Periapical X-ray*
42.00 0.00 40.00 0.00 40.00 8.00 80% 32.00
For service on Feb 15, 2024: 2 Bitewing X-rays*
65.00 0.00 65.00 0.00 65.00 0.00 100% 65.00

* Current Dental Terminology © American Dental Association

 600002828804

Page 4 of 5

Your claim details - continued

PATIENT NAME: DIPEN KUMAR DAS PATIENT'S RELATIONSHIP TO SUBSCRIBER: SUBSCRIBER SUBSCRIBER NAME: DIPEN KUMAR DAS PATIENT ID: U80340865
HEALTH CARE PROFESSIONAL NAME: KAGALWALA PROFESSIONAL DENTAL GROUP NAME: ALCON VISION LLC PROVIDER NETWORK STATUS:
OUT OF NETWORK GROUP #: 3342961 DOCUMENT #: D240506406450 CLAIMANT #: 01 CLAIM #: 011 PAYMENT #: 001 POLICY CODE: 01
DIVISION: 008 RECEIVED DATE: Feb 19, 2024 PROCESSED DATE: Feb 19, 2024 Administrative Services Only - ERISA

AMOUNT YOUR HEALTH CARE

YOUR HEALTH CARE PROFESSIONAL'S AMOUNT ELIGIBLE YOUR PLAN COVERED
PROFESSIONAL CONTRACTED FOR COVERAGE YOUR COPAY/ REMAINING YOUR (%) ($)
CHARGED ($) AMOUNT ($) BY YOUR PLAN ($) DEDUCTIBLE ($) BALANCE ($) COINSURANCE ($)

For service on Feb 15, 2024: Periodic Oral Exam*

76.00 0.00 76.00 0.00 76.00 0.00 100% 76.00

$398.00 $0.00 $388.00 $100.00 $288.00 $29.40 $258.60

Amount paid by your plan $258.60

Customer's responsibility $139.40
Notes
DB - Benefits have been applied toward the deductible.

Additional Information related to the Patient Protection and Affordable Care Act of 2010
If you would like to request information about the specific diagnosis and treatment codes submitted by your Health Care Professional, You can
contact your provider directly or you can print and fill out the request form and send it back to Cigna. Go to Cigna.com and click "Find a Form"
at the bottom of the page. Choose "Privacy Forms," then "Cigna Health Care Privacy Forms." Print the Request for Diagnosis and Treatment
Code Information form. If you have difficulty accessing the form, call Customer Service at the toll-free number listed on the back of your Cigna
ID card.
If you don't agree with our final internal review of your claim, you may be able to ask for an independent external review. Your plan and any
state or federal requirements determine whether your claim is eligible for external review. For questions about your appeal rights or for
assistance, call the Employee Benefits Security Administration at 1-866-444-EBSA(3272) or go online to www.askebsa.dol.gov
Your state may also offer a consumer assistance or an Ombudsman program to help you. Go online to mycigna.com, click on the Legal
Disclaimer link at the bottom of the page, and select "State Ombudsman/Consumer Assistance Programs" from the drop down menu. If you
have difficulty accessing the website, call Customer Service at the toll-free number listed on the back of your Cigna ID card.

* Current Dental Terminology © American Dental Association

 600002828805
Cigna Dental
Cigna Health and Life Insurance Company Page 5 of 5
As administrator for ALCON VISION LLC 3342961

Your explanation of dental benefits ( for the claim processed on Feb 19, 2024 )
THIS IS NOT A BILL

Need Help?
Login or register for myCigna.com to view claim details or chat with a representative. You can call us at 1.800.Cigna24 (1.800.244.6224)
or the number on the back of your ID Card. Please have your patient ID (U80340865S0) or the employee's social security number
available when calling Customer Service, visiting your health care professional, or writing to us.
01363370

* Current Dental Terminology © American Dental Association