Understanding Your Benefits

Your insurance card and your Explanation of Benefits (EOB) contain important information about your coverage. 

Each circled number corresponds to a detailed explanation of each below each image.

INSURANCE CARD

A. Your card will have your name as it appears on your insurance records. This section will also include your member number. Each person covered by a health insurance plan has a unique ID number, often followed by a hyphen (dash) and a number for each member of your family.  This area of the card also includes the name of the insured person and the relationship of the member to the insured.

B. The day your insurance company will begin helping to pay for your medical expenses.

C. Employers that purchase a health plan for its employees have a group number that identifies the specific benefits of the employer’s plan. Healthcare providers use the group number plus your member ID number to file claims for your care.

D. Your RX, BIN and PCN numbers provide important billing information for your providers.  The BIN number is a Bank Identification Number which tells the pharmacy database which benefit manager is to receive the claim for a particular prescription. Banks are not involved in the insurance billing process.  Not all providers use the PCN or Processor Control Number.

E. Your card also gives you and your providers quick reference information on your plan’s copays. How much for primary or specialist primary care visits?  How much of a co-payment will you make for urgent care or ER visits? 

F. The address for claims processing is where your provider or you will send claims for payment.

G. The back of your card will contain important information regarding pre-certification of coverage before you receive services as well as any penalties that will be charged without authorization.  It also contains important phone numbers and fax numbers for submitting claims or asking questions.

H. The member services phone number gives you access to experts who can help you understand your coverage and benefits.

EXPLANATION OF BENEFITS

  1. This box provides general information about your claim (such as your name and social security number, group number, patient name, name of provider rendering service, etc.).
  2. Employee’s name and address.
  3. Dates the services were rendered.
  4. This is a brief description of the services rendered and the procedure code.
  5. This is the total charge(s) billed by the provider of the service.
  6. If a preferred provider is used, this represents the negotiated discount for the service. (Preferred providers must write-off this amount.)
  7. This shows you any amounts that are allowed in your coverage.
  8. Any non-covered amounts are shown here.  (They are assigned an ineligibility code. The code(s) are explained in detail below.  See 13.)
  9. Any amounts applied towards your calendar year deductible, or any applicable co-payments are shown in this box. These amounts are to be subtracted from your adjusted charges for final benefit calculation.
  10. This represents any amounts applied towards your calendar year coinsurance or applicable co-payments.
  11. This box represents any payments made by another health plan. Any amounts shown may reduce your final benefit payment.
  12. This is the amount(s) actually being paid by the plan.
  13. This area will provide reference notes about your care and any codes assigned.
  14. This section displays any In-Network deductible and lifetime maximums paid and what’s remaining.INSURANCE CARD
  15. This section displays any Out-of-Network deductible and lifetime maximums paid and what’s remaining.
  16. The “CLAIM REMARKS’ section explains any ineligible code displayed in box #8 or on other areas of the explanation of benefits.