ADDITIONAL ITEMS                                                   
                         Additional Item Description/Incurred Date/Product/Sub Group-8 Digit                         

INVOICE NUMBER:     230801581733                                           PAGE:               1 of 2            
BILL ACCOUNT NUMBER:CN02401002                                             PAID CLAIMS MONTH:  July 2023         
BILL ACCOUNT NAME:  Admiral Peary                                          CLAIMS PAID THRU:   07/28/2023        
CLIENT NUMBER:      0240                                                   BILL CYCLE:         4 of 4            
CLIENT NAME:        Admiral Peary                                          PREPARED DATE:      08/01/2023        

                                        Adjustment Description                                            Adjustment Amount                              
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
Other Claims Related Expense
  08/22
    HDHP PPO
      104272-09                                                                                                        $14.70
      104272- Total                                                                                                    $14.70
    HDHP PPO Total                                                                                                     $14.70
  08/22 Total                                                                                                          $14.70
  11/22
    PPO
      014267-03                                                                                                     $1,145.76
      014267- Total                                                                                                 $1,145.76
    PPO Total                                                                                                       $1,145.76
  11/22 Total                                                                                                       $1,145.76
Other Claims Related Expense Total                                                                                  $1,160.46
                                                                                                                                                            
Payment Integrity Pre Pay Review
  05/20
    HDHP PPO
      104272-02                                                                                                        $37.45
      104272- Total                                                                                                    $37.45
    HDHP PPO Total                                                                                                     $37.45
  05/20 Total                                                                                                          $37.45
  02/21
    PPO
      014267-05                                                                                                        $50.87
      014267- Total                                                                                                    $50.87
    PPO Total                                                                                                          $50.87

                                                                                                                                                PAGE:2 of 2
                                                                                                                                                            
                                        Adjustment Description                                            Adjustment Amount                              
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
  02/21 Total                                                                                                          $50.87
Payment Integrity Pre Pay Review Total                                                                                 $88.32
                                                                                                                                                            
Retroactive Administrative Expense - Enrollment
  06/23
    HDHP PPO
      014267-54                                                                                                     $3,712.00
      014267- Total                                                                                                 $3,712.00
      017697-00                                                                                                     $3,480.00
      017697-01                                                                                                     $1,218.00
      017697-10                                                                                                       $232.00
      017697-70                                                                                                        $58.00
      017697- Total                                                                                                 $4,988.00
      017728-00                                                                                                       $638.00
      017728- Total                                                                                                   $638.00
      104272-02                                                                                                     $8,410.00
      104272-09                                                                                                       $348.00
      104272-12                                                                                                       $580.00
      104272-19                                                                                                        $58.00
      104272- Total                                                                                                 $9,396.00
    HDHP PPO Total                                                                                                 $18,734.00
  06/23 Total                                                                                                      $18,734.00
Retroactive Administrative Expense - Enrollment Tota                                                               $18,734.00
                                                                                                                                                            
Additional Items Total                                                                                             $19,982.78