Explanation of Benefits

You will receive an Explanation of Benefits (EOB) Statement for each claim submitted. The EOB explains how your claim was handled. This information is provided to help you understand your Explanation of Benefits.
View each circled number and the detailed explanations of each section at the bottom of this page. 

 

  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. The “YOU PAY” box tells you how much of the total amount you are responsible for paying. (You are not responsible for any non-covered charges denied as a result of a network discount.)
  3. Employee’s name and address.
  4. Dates the services were rendered.
  5. This is a brief description of the services rendered and the procedure code.
  6. This is the total charge(s) billed by the provider of the service.
  7. If a preferred provider is used, this represents the negotiated discount for the service. (Preferred providers must write-off this amount.)
  8. This shows you any amounts that are not covered for benefits under your plan.
  9. Any non-covered amounts are assigned an ineligibility code. The code(s) are explained in detail (see box #18).
  10. 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.
  11. This represents any amounts applied towards your calendar year coinsurance or applicable co-payments.
  12. This box represents any payments made by another health plan. Any amounts shown may reduce your final benefit payment.
  13. This is the percentage your plan paid for these charges.
  14. This is the amount(s) actually being paid by the plan.
  15. This area displays the network information, if applicable.
  16. Depending on your plan the “ACCUMULATORS” section displays any deductible and lifetime maximums remaining.
  17. “PAYMENT TO” area will display to whom benefits are payable and corresponding check information.
  18. “CLAIM REMARKS’ explains any ineligible code displayed in box #9 or comments requesting information.
  19. Sample of a Check