Tata Consultancy Services Limited

Paid By: Cigna Health and Life Insurance Company

P.O. Box 15050
Wilmington, DE 19850 USA

Questions About Your Claims?

MEENON MUVVALA
16117 SHADOWOOD PKWY SE For questions about this document, please visit our secure website,
ATLANTA GA 30339 Cigna Envoy, at www.CignaEnvoy.com, or call the International
Service Center at the number below:

Phone 1.800.611.3082 or 302.797.3100

Fax 302.797.3150

Customer # # 700463227
Customer IDID 700463227
Account Name / Account #
TCS LIMITED (TCSL) / 03348I011
MEENON MUVVALA
16117 SHADOWOOD PKWY SE
ATLANTA GA 30339

THIS IS NOT A BILL

Your health care professional may bill you directly for any amount that
you owe.

Explanation of Benefits
Summary of claim(s) processed on June 4, 2024

U.S. Dollars
The total amount billed for all services submitted. For international claims, this
Total $606.00 amount is converted to U.S. dollars based on the foreign exchange rate for the
date of service.
Cigna Healthcare
Discount $276.27 Your total savings for the services submitted.

Cigna Healthcare
Paid $294.73 The total amount paid for the services submitted.

Amount Not The portion of the services that are not covered by the plan or the amount not
$35.00
Covered paid based on plan percentages.

The amount the patient is responsible for paying after discounts that Cigna
Patient $35.00 Healthcare has negotiated and what your plan has paid. Refer to the glossary
Responsibility
page for more information regarding patient responsibility.

PDFNAME=S7004632271663936MOMBUSD0

Reminder: A coverage determination, prior authorization, or certification that is made prior to a service being performed
is not a promise to pay for the service at any particular rate or amount. The patient's summary plan description or insurance certificate
governs amount payable, as every claim submitted is subject to all plan provisions, including, but not limited to, eligibility requirements,
exclusions, limitations and applicable state mandates.
Page Page 1 of 5
1 of
PLEASE SEE CLAIM DETAILS ON THE FOLLOWING PAGE(S)
Glossary
Amount Billed: The amount charged by the health care professional or facility (physician, hospital, etc.) for services provided to you or
your covered dependents.
Amount Not Covered: The portion of your bill that is not covered by your plan. You may or may not need to pay this amount. See the
remark codes section on the following pages for more information.
Coinsurance: A percentage of covered expenses you pay after you satisfy your deductible.
Copay or Copayment: A flat fee you pay for certain covered services such as doctor visits or prescriptions.
Deductible: The amount you may need to pay each year before your plan starts paying benefits.
Discount: Cigna Healthcare-negotiated fees for services provided by health care professionals. If applicable, the discount amount is
subtracted from the amount billed.
Exchange Rate: The rate applied to convert local currency to U.S. dollars based upon competitively published rates in effect on the date
service was provided. Plan benefits are calculated in U.S. Dollars. If services were billed in U.S. dollars and the claim is paid in U.S.
dollars, then no exchange rate applies.

Local Amount Billed: The cost of the services, expressed in the local currency where services were rendered.
Patient Responsibility: The portion of the billed amount that is the patient's responsibility to pay. This amount might include the
deductible, coinsurance, any amount over the maximum reimbursable charge, or products or services not covered by your plan.

Plan Percentages: The portion that the plan pays after any copay, deductible or coinsurance has been applied for the services submitted.
Payment Method: The U.S. or international banking system method in which a payment has been issued, for example an electronic
transfer of funds to your bank account or a check.
Remark Codes: Letter codes which indicate that a message is printed on the Explanation of Benefits. We use remark codes for various
reasons, for example, to notify you that a claim is pending. Pending means that the claim process is incomplete because additional
information is needed. Other reasons include to explain why an expense was excluded (not covered) under the plan or to suggest actions
that will simplify and possibly prevent delays in the payment of benefits.

Claim submissions tips

Please submit a separate claim form for each patient and year in which services were rendered. Please include the following information
for each claim:

1. Account name and Account #

2. Customer ID #
3. Patient name
4. Health care professional or facility name
5. Date(s) of service
6. Type of service(s) / procedure(s)
7. Reason for the treatment / diagnosis
8. The country where the services were provided
9. Payment details including the payment currency

Page 2 of 5
 Explanation of
Explanation of Benefits
Benefits THIS IS NOT A BILL

Claim Detail
DATE PROCESSED: 06/04/24 CUSTOMER NAME: NAME:
CUSTOMER MEENON MUVVALA
MEENON MUVVALA CUSTOMER ID #: 700463227 01

SERVICES
SERVICESPROVIDED
PROVIDEDBY:
BY: SIMADEHGHANY
SIMA DEHGHANYMD
MD PATIENT ACCOUNT #: P5130242210

Service Claim Local Currency Exchange USD Amount not Patient Remark
Dates Type of Service Number Total Rate Total Discount Covered Copay Deductible¹ Coinsurance² Paid Resp.³ Codes
____________________________________________________________________________________________________________________________________________________________________________________________
05/25/24 Physical Exam 131392006 0.0000000 0.0000000 309.00 82.38 0.00 0.00 0.00 0.00 226.62 0.00 BA001
05/25/24 Physician Visit O/V 131392006 0.0000000 0.0000000 297.00 193.89 0.00 35.00 0.00 0.00 68.11 35.00 BA001
____________________________________________________________________________________________________________________________________________________________________________________________
Totals for MEENON MUVVALA: 0.0000000 $606.00 $276.27 $0.00 $35.00 $0.00 $0.00 $294.73 $35.00

1 - The deductible is the amount you need to pay each year before your plan starts paying benefits.
2 - After the deductible is met, the cost of covered expenses shared by you and your health plan. The percentage of covered expenses that should be owed is called coinsurance.
3 - The portion of the billed amount that is the patient's responsibility in USD, including any amounts already paid.
* - Asterisks mean limited data
____________________________________________________________________________________________________________________________________________________________________________________________

Remark Codes
BA001-Customer: Thank you for using the Cigna Healthcare Preferred Provider Organization (PPO) Network. The discount shown is how much you saved. You do not need to pay that amount. If you already paid
your health care professional more than the "what I owe" amount, please ask for a refund.
Health Care Professional: Your Cigna Healthcare agreement does not allow you to bill the patient for the difference. If you are in Indiana, California or Tennessee, please contact Cigna Healthcare Customer
Service at 1.800.441.2668 for more information on your discounted rate.

Other important information:

Payment Method: N/A

Benefits are being paid to: WELLSTAR MEDICAL GROUP LLC

Missing a claim? If a claim has been submitted and it is not displayed above, that could mean the claim is in process. Please contact the Service Center to check the status of the claim.

KEEP THIS PAGE FOR YOUR RECORDS Page 3 of 5

Important Information about Your Appeal Rights

What if I need help understanding a denial? Contact us at the International Service Center number on your ID
card, 24 hours a day, 7 days a week, if you need assistance understanding this notice or our decision to deny you a
service or coverage.
What if I don't agree with this decision? You have a right to appeal any decision not to provide you or pay for
an item or service (in whole or in part).
How do I file an appeal? You can appeal by submitting a written request. You have at least 180 days to file an
initial appeal. Be sure to include: your name, account name and number, Customer Identification number, the
patient's name, your relationship to the patient, and any other information you want us to consider. Mail to:
Cigna Healthcare Appeals Unit, PO Box 15800, Wilmington, DE 19850.

Who may file an appeal? You or someone you name to act for you (your authorized representative) may file an
appeal.

Can I provide additional information about my claim? Yes. Send a copy of this Explanation of Benefits along
with any other information you believe shows your claim is covered under the plan, such as benefit documents
and health records.
Can I request copies of information relevant to my claim? You can receive free copies of information relevant
to your claim by calling the International Service Center.

What happens next? Your appeal will be decided by someone who was not involved in any previous decision
regarding this claim. You will be notified of the final decision in a timely manner, as described in your plan
materials. If we deny your appeal, your plan may allow you another internal appeal. If you are not satisfied with
our final internal review, you may be able to ask for an independent external review of our decision as determined
by your plan and any state or federal requirements. If your plan is governed by ERISA (Employee Retirement
Income Security Act), you may have the right to bring legal action under section 501(A) after our review.

Other resources to help you: For questions about your appeal rights, this notice, or for assistance, you can
contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.askebsa.dol.gov.
Assistance may also be available through a consumer assistance or ombudsman program (if applicable, program
information is listed below).

Georgia Office of Insurance and Safety Fire Commissioner

Consumer Services Division
2 Martin Luther King, Jr. Drive
West Tower, Suite 716
Atlanta, Georgia 30334
Telephone: (800) 656-2298
Website: http://www.oci.ga.gov/ConsumerService/Home.aspx

Page 4 of 5
If you have difficulty reading English, we offer language assistance. For help please call the Customer
Service number on your ID card.

Si tiene problemas para leer el texto en inglés, le ofrecemos asistencia de idiomas. Para obtener ayuda, por
favor, llame al número de Servicio al cliente que figura en su tarjeta de identificación.

Kung nahihirapan ka sa pagbabasa ng wikang Ingles, nag-aalok kami ng tulong sa wika. Para sa tulong
pakitawagan ang numero ng Serbisyo ng Customer sa iyong ID card.

Für den Fall, dass Sie den englischen Text nicht verstehen, bieten wir mehrsprachige Unterstützung an.
Rufen Sie in diesem Fall bitte die auf Ihrer Versicherungskarte angegebene Kundenservice-Nummer an.

Si vous avez des difficultés à lire l’anglais, nous offrons une assistance linguistique. Pour toute aide, veuillez
composer le numéro du Service à la clientèle qui se trouve sur votre carte d’identification.

Page 5 of 5