An Explanation of Benefits (EOB) is a notification form Health Advantage sends you
after processing a claim. This form explains the total amount billed, the amount
paid, and who was paid. It's a good idea to keep a copy of any bill you receive
from a provider of medical services to compare to your EOB.
The following is a description of the items listed on the EOB. The field numbers
referenced within the sample EOB correspond with the field names and descriptions
provided below. Field 23 is probably the most important to you. It shows the total
amount you, as the patient, are responsible for paying.
|
FIELD NUMBER |
FIELD NAME |
FIELD DESCRIPTION |
|
1 |
SUBSCRIBER NAME |
The name of the contract holder who meets all applicable eligibility requirements. |
|
2 |
PATIENT NAME |
The name of the person who received the service. This could be you, your spouse,
or a dependent child who has coverage under your health plan. |
|
3 |
RELATIONSHIP |
This is the patient's relationship to the subscriber. |
|
4 |
ID NUMBER |
The member number of the person receiving the service. |
|
5 |
GROUP NAME |
Employer name. |
|
6 |
GROUP NUMBER |
The number assigned to your employer for tracking purposes.
|
|
7 |
DATE RECEIVED |
The date the claim was received by Health Advantage.
|
|
8 |
DATE PROCESSED |
The date the claim was paid or denied by Health Advantage.
|
|
9 |
CLAIM NUMBER |
The number assigned to this claim for tracking purposes. |
|
10 |
PROVIDER OF SERVICE |
The health care professional or facility that provided services to the patient. |
|
11 |
PROVIDER NUMBER |
The number assigned to the provider. |
|
12 |
DATE OF SERVICE |
The date the patient received services. |
|
13 |
TYPE OF SERVICE |
A description of the type of service provided. |
|
14 |
BILLED AMOUNT |
The amount the provider charged for the service. |
|
15 |
ALLOWED AMOUNT |
The customary amount for a service from which your coinsurance, if applicable, will
be determined. |
|
16 |
NON-COVERED AMOUNT |
The amount, if any, for non-covered services or the amount that is above the allowed
charge when seeing an out-of-network provider. |
|
17 |
DEDUCTIBLE AMOUNT |
The amount, if applicable, you pay to providers for services each benefit
period before your health plan starts paying its share. |
|
18 |
COPAYMENT AMOUNT |
The amount you pay to the provider each time you receive a certain service. |
|
19 |
COINSURANCE AMOUNT |
The percentage of the Allowed Amount you pay to the provider for covered
services for which the member is responsible. The Allowed Amount includes amounts
withheld from provider payment, which are subject to the terms and conditions of
the contractual agreement with the provider. |
|
20 |
PRIMARY PAYER AMOUNT |
The amount paid by another insurance carrier. |
|
21 |
PROVIDER ADJUSTMENT AMOUNT |
The amount the provider must write off and/or the amount that has been withheld
from the provider payment subject to the terms and conditions of the contractural
agreement with the provider. The provider cannot bill you for this amount. |
|
22 |
PROVIDER PAYMENT |
The amount your health plan paid, based on your coverage and the contractual agreement
with the provider. |
|
23 |
YOUR MINIMUM RESPONSIBILITY |
The amount you pay to the provider for this claim. This includes any copayment,
coinsurance, deductible, non-covered services, or the amount above the allowable. |
|
24 |
CONTRACT YEAR OUT-OF-POCKET MAXIMUM |
If applicable, this area shows how much of this claim went toward your maximum out-of-pocket
expenses and how much you have left before you meet your maximum. This excludes
any copayments and Mental Health coinsurance. |
|
25 |
EXPLANATION CODES |
This is an explanation of activity that occurred on this claim/service, describing
the disposition of the claim. |