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Number assigned to your employer

Date the EOB was issued

Name of person who received care

Description of the visit (e.g., physician visit)

Identifies the claim in our system

The date you received care

Services that have been billed to your health benefit plan

The amount that has been reduced from the provider

Negotiated or ineligible amounts that are not your responsibility 

A payment made by another health plan due to coordination of benefits

Amount of submitted charges not covered by the plan

A predetermined charge that the provider can collect from you at the time of service

The amount of the covered charge that you are responsible for paying before your health plan starts sharing costs

A percentage of the covered expenses you are responsible for paying

Total amount your plan will pay for the submitted charge(s)

Percentage of the covered expense paid by your plan, after any applicable deductible

Used to explain why a portion of submitted charges is not covered by the plan. A number, or reason code, shown on the EOB corresponds with an explanation. (See page 2 of sample.)

Account number assigned by the facility or provider

Name of facility or provider

Date the claim was released and sent to processing

The total you are responsible for paying

Dollars applied toward the employee and covered dependents 

Benefit payments made during this year