Your Explanation of Benefits Form


Below is an example of an Explanation of Benefits form. If you have any questions about what these terms mean, click the link for further explanation.



Medical Explanation of Benefits

 
Direct Inquiries To:
Your Insurance Carrier
Insurance Carrier's Service Center
P.O. Box 123456
Hometown NE 12345-6789

  For Questions Call:
  Toll Free: 1-800-123-4567
Claim No:  05400566700
Group ID:  G00079W8
Subscriber ID:  800858446
Subscriber Name:  John A. Doe
Amount You Owe Provider:  $25.00

 
Member Name:  Jane B. Doe
 		   Account No:  70053269ACB
 		  
Provider:  John Smith, MD
Provider Group:  Alegent Health		   Reference No:  2004110110800472 Date:  02/16/2005
Page:  1
 
Please Review The Reverse Side Of This Form - You May Review Or Print This Statement Online Through Customer Access At chcne-m.com
Date(s) of Service Service Type Submitted Charge *Negotiated Savings/ Write-Off Note Charges Non-Covered Note(s) Co-Pay Deductible Co-Insurance Amount % Benefit Amount **Patient Liability
01/18/05  01/18/05 Office Visit 200.00 50.00 PEX 0.00   10.00 0.00 0.00 140.00 10.00
01/18/05  01/18/05 Laboratory 50.00 25.00 PEX 0.00   0.00 0.00 0.00 25.00 0.00
01/18/05  01/18/05 Immunization 50.00 25.00 PEX 25.00 ZNA 0.00 0.00 0.00 0.00 25.00
CLAIM TOTALS   300.00 100.00   25.00   10.00 0.00 0.00 165.00 35.00
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Other Carrier Allowed Other Carrier Paid Other Carrier Allowed
minus Other Carrier Paid
 Coordinated Benefit Patient Liability after
Coordination of Benefits
9999999.99 9999999.99 9999999.99 9999999.99 9999999.99
 
Provider: John Smith   is being paid: 165.00   Provider previously paid 0.00
Subscriber: John A Doe   is being paid: 0.00   Subscriber previously paid: 0.00


2005 deductible yet to be satisfied is    if you use a participating provider and    if you use a non-participating provider.
2005 Family deductible yet to be satisfied is    if you use a participating provider and    if you use a non-participating provider.

PEX The charge exceeds the allowable rate for this service
ZNA This service is specifically excluded by the plan. Please refer to the plan's General Exclusions

*Savings negotiated by your insurance carrier with your provider of service. The patient is not liable for this amount.

**PATIENT LIABILITY: Includes charges non-covered, co-payment, deductible and co-insurance amounts. Patient Liability may be reduced by Coordination of Benefits with a Primary Carrier.