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  • Sample EOB

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    Mahesh M
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    This document defines terms that may appear on an Explanation of Benefits (EOB) form from ABC Company. It provides definitions for 18 terms including: [1] Dates of Service, [2] Service Description, [3] Rate, [4] Deductible, [5] Copay/Coinsurance, [6] Not Covered, [7] Other Insurance Paid, [8] Provider Liability, [9] Remark Code, [10] Plan Pays, [11] Totals, [12] Interest, [13] Total Member Responsibility, [14] Total Plan Payment, [15] Amount Accumulated Toward Deductible, [16] Amount

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    SampleEOB

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    This document defines terms that may appear on an Explanation of Benefits (EOB) form from ABC Company. It provides definitions for 18 terms including: [1] Dates of Service, [2] Service Description, [3] Rate, [4] Deductible, [5] Copay/Coinsurance, [6] Not Covered, [7] Other Insurance Paid, [8] Provider Liability, [9] Remark Code, [10] Plan Pays, [11] Totals, [12] Interest, [13] Total Member Responsibility, [14] Total Plan Payment, [15] Amount Accumulated Toward Deductible, [16] Amount

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    Download as pdf or txt
    5 views1 page

    Sample EOB

    Uploaded by

    Mahesh M
    This document defines terms that may appear on an Explanation of Benefits (EOB) form from ABC Company. It provides definitions for 18 terms including: [1] Dates of Service, [2] Service Description, [3] Rate, [4] Deductible, [5] Copay/Coinsurance, [6] Not Covered, [7] Other Insurance Paid, [8] Provider Liability, [9] Remark Code, [10] Plan Pays, [11] Totals, [12] Interest, [13] Total Member Responsibility, [14] Total Plan Payment, [15] Amount Accumulated Toward Deductible, [16] Amount

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    © All Rights Reserved
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    of 1

    SAMPLE

    ABC C mpany

    2 3 4 5 7 9
    6 8 0

    2
    3 4

    5
    6
    7

    Definition of terms on your Explanation of Benefits (EOB)


    . Dates of Service – The actual date and or timeframe when 9. Remark Code – Used to call your attention to a specific
    you received medical services. message about the service charged. (See #18.)
    2. Service Description – The type of service(s) you received. 0. Plan Pays – The amount paid by Independent Health to your
    3. Rate – The actual amount charged to you and Independent Health. physician or provider.
    4. Deduct (deductible) – The initial out-of-pocket amount you are . Totals – The total for each respective column.
    responsible for when receiving covered services. Once you reach 2. Interest – You are not required to pay this amount. On very
    your deductible amount, copay and or coinsurance may apply. limited occasions, Independent Health is required to pay interest
    (Note: The amount remaining until you meet your plan year annual on a claim when that claim is determined to be paid beyond a
    deductible amount is determined as of the date(s) claims are specific timeframe. (The criteria to determine late payment are
    completed by us, not the date that services were provided.) defined by various regulatory agencies.)
    5. Copay/Coins (coinsurance) – The amount you are responsible 3. Total Member Responsibility – The amount you owe this
    for paying the provider once you meet your plan year annual provider for services rendered. (Note: This is not a bill; your
    deductible amount. provider will send you a bill if you owe anything.)
    6. Not Covered – Any portion of the submitted charges that are 4. Total Plan Payment – The total amount paid by Independent
    not covered by your benefit plan. Your provider may bill you for Health for all the services incurred for each claim.
    these charges. 5. The amount that you (as determined by plan) have accumulated
    7. Other Ins (Insurance) Paid – Amount paid by another insurance toward your plan year annual deductible. This amount includes
    carrier. Only applies if patient has additional health coverage previous claim activity.
    besides Independent Health. 6. Amount remaining until your plan year annual deductible
    8. Provider Liability – The amount of a claim determined to be is satisfied.
    neither Independent Health responsibility nor member responsibility. 7. Out-of-Pocket Maximum – The maximum dollar limit for
    Most often this is the difference between the provider’s billed charge deductibles, copays and coinsurance amounts that you are
    and the contracted or discounted rate (“Independent Health responsible for in a given plan year.
    allowed amount”).
    8. Remark Code Description – Specific message about the
    service charged.
    IH16212 1212

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