12/10/18

00276-603
MATTHEW CARLSON
11061 ISLAND CT 1-800-662-6667 TTY: 711
ALLENDALE MI 49401-9668

HANNAH Blue Care Network

2005 Attn:Member Services
MATTHEW CARLSON P.O. Box 68753
*****8131 Grand Rapids, MI 49516-8753
SALARY EXEMPT

00276-603
BLUE CARE NETWORK

___ ___
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SOLACE COUNSELING SERVIC 775.00 249.88 350.12 0.00 175.00

775.00 249.88 350.12 0.00 175.00

Because we value your membership and the confidentiality of your health information, we are very
serious about protecting the privacy and security of that data. We've always followed strict
internal procedures and are only permitted to disclose your protected health information as
specified in our Notice of Privacy Practices. A copy is available at bcbsm.com. If you'd rather call
to request a paper copy, your customer service number is in the top right corner of page 1.

*****8131 HANNAH

SOLACE COUNSELING SERVIC Total Charge ...................................... 175.00

NETWORK
10/01/18 Amount approved by BCN for this service ........... 125.12
MENTAL HEALTH CARE Minus copayment............................... - 35.00
BCN paid this provider on 11/26/18 ............... 90.12
BBB BCN discount .................................... + 49.88
10/26/18
Total Covered ..................................... $ 140.00
10500210900
35.00

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 12/10/18

*****8131 HANNAH

SOLACE COUNSELING SERVIC Total Charge ...................................... 150.00

NETWORK
10/08/18 Amount approved by BCN for this service ........... 100.00
MENTAL HEALTH CARE Minus copayment............................... - 35.00
BCN paid this provider on 11/26/18 ............... 65.00
BBB BCN discount .................................... + 50.00
10/26/18
Total Covered ..................................... $ 115.00
10500210900
35.00

SOLACE COUNSELING SERVIC Total Charge ...................................... 150.00

NETWORK
10/15/18 Amount approved by BCN for this service ........... 100.00
MENTAL HEALTH CARE Minus copayment............................... - 35.00
BCN paid this provider on 11/26/18 ............... 65.00
BBB BCN discount .................................... + 50.00
10/26/18
Total Covered ..................................... $ 115.00
___ 10500210900
35.00
___

SOLACE COUNSELING SERVIC Total Charge ...................................... 150.00

NETWORK
11/05/18 Amount approved by BCN for this service ........... 100.00
MENTAL HEALTH CARE Minus copayment............................... - 35.00
BCN paid this provider on 11/26/18 ............... 65.00
BBB BCN discount .................................... + 50.00
11/12/18
Total Covered ..................................... $ 115.00
10553155300
35.00

SOLACE COUNSELING SERVIC Total Charge ...................................... 150.00

NETWORK
11/28/18 Amount approved by BCN for this service ........... 100.00
MENTAL HEALTH CARE Minus copayment............................... - 35.00
BCN paid this provider on 12/10/18 ............... 65.00
BBB BCN discount .................................... + 50.00
12/03/18
Total Covered ..................................... $ 115.00
10617899000
35.00

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