Currency: (USD)
International Claims Services
26000 Towne Centre Drive Suite 130
Foothill Ranch, CA 92610
Explanation of Benefits
Plan Year:
2006
Check Number:
Group #:
21
Group Name:
A Group
Claim Number:
123456
Pay To:
Provider
Policy Number:
W123-4567-8900
Claim Date:
Aug 01 2007
Employer
Claimant
Provider
123-45-6789
John Doe
123 Main St.
Hometown, CA USA
123-45-6789-00
Doe, John
123 Main St.
Hometown, CA USA
Health America
456 West Ave.
Othertown FL 33123,USA
Line Item
Procedure
Reason Code
Treatment Date
Claim Amount
Re-Priced(In-network)
Allowed
Co-Pay
Other Coverage
Deductible
Balance
Plan Co-pay
Payable Benefit
1
45123
"DUPLEX SCAN"
Jun 11 2007
255.00
144.95
144.95
0.00
0.00
0.00
144.95
0.00
144.95
Reason Codes:
Totals:
255.0
144.95
144.95
0.00
0.00
0.00
144.95
0.00
144.95
Explanation:
Benefits YTD**:
11,011.11
Family Benefits YTD**:
11,011.11
Individual Deductible YTD**:
500.00
Family Deductible YTD**:
500.00
Total Claim Amount:
255.00
Total Re-Priced Amount:
144.95
Less Other Coverage:
0.00
Less Co-pay:
0.00
Less Deductible:
0.00
Claim Amount Subject to Benefit:
144.95
MEMBER RESPONSIBILITY:
0.00
Account # A12345JD. - Ntwk (FH_P) - (CMN INVOICE # 45123-102001) -Thank you for using a Preferred Providers Network. This claim has been priced at the network contracted amount. If there is a difference between the Charged amount and the Re-Priced amount, the patient is not responsible for that amount. Patients are responsible for any deductibles or co-pays that may have been applied. Please refer to the "Member Responsibility" field below.
Currency: (USD)
International Claims Services
26000 Towne Centre Drive Suite 130
Foothill Ranch, CA 92610
John Doe
123 Main St.
Hometown, CA USA
Health America
456 West Ave.
Othertown FL 33123 UNITED STATES
**Please note: the amount shown in these fields is “to date”. If a duplicate EOB needs to be reprinted at a later time, the amount in these fields will be current with the date of the reprinting. It will not reflect the amount that was provided on the original printing of the EOB>
The primary insured on the account
The patient who received medical service
Provides the policy year in which the services were performed
This is mainly an internal number. It is the Group number of the company's client
The party to whom the payment has been issued
Name of the client in which the Insured is employed
Number assigned to the Group Policy
The number of the check issued
The number assigned in our system and the number to reference if members have questions on their claim
the date in which the claim was processed in the system
The physician or facility that provided medical services. If outside the U.S., will state "medical providers in (name of country)"
The number of charge line entries on the claim
The type of procedures performed
Reason provided if denied. There is another area under the Charge Line Items that will provide the description. Or refer to the Explanation field to read full explanation
The date of service. If the claim is an In-Patient stay, only the admit date will be shown
The amount of the services being billed. This amount has been converted to USD
If the claim is for services within the U.S.A., the discount rate will be shown in this field. The member is not responsible for any differences between the Claim Amount and the Re-priced Amount. The provider needs to write that amount off
The amount that is being considered for payment prior to any deductibles and/or copays
Any miscellaneous copays due to use of non-network providers, non-authorization, etc
If there is primary coverage with another insurance carrier, their payment is applied here. Or if the claim is being adjusted to allow additional benefits, the amount previously paid will be shown here
The amount that needs to be met before benefits are payable (if the plan has a deductible)
The amount remaining after miscellaneous copays and/or deductibles have been applied
If applicable, this is the copay that the employer opted to purchase at the time the Group enrolled
The amount to be paid after all deductibles and/or copays have been applied
This is the amount that has been paid to date on the claimant for the current policy year
This is the amount that has been paid to date on the family for the current policy year
The amount of the deductible in which the claimant has met to date for the current policy year
The amount of the deductible in which the family has met to date for the current policy year
The amount that the claimant is responsible for
This is the currency in which the claim was paid
This is the provider of service. To see to whom this payment was made, please refer to the “Pay To” field above.
This is the insured’s name and address. Whether the "Pay To" field above lists the member or the provider, the insured will receive a copy of this explanation of benefits
The field in which any explanation is required will be provided here. If additional information is requested, please refer to the "Pay To" section at the top left hand side of the form. If it states "Pay to: Provider" the company is requesting this information from the Provider. If it states "Pay to: Member" the company is requesting the information from the Claimant. This information is required within 60-days of the date the EOB has been received by the Claimant. Failure to provide requested information may result in denial of the claim