An explanation of benefits (EOB) is a notification form Arkansas Blue Cross and
Blue Shield 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 NUMBER |
FIELD NAME |
FIELD DESCRIPTION |
| 1 |
Patient |
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. |
| 2 |
Member |
The name of the contract holder who meets all
applicable eligibility requirements. |
| 3 |
ID Number |
The member number of the person receiving the service. |
| 4 |
Group |
Employer name |
| 5 |
Claim Number |
The number assigned to this claim for tracking purposes |
| 6 |
Date |
Date processed. |
| 7 |
Patient's Account Number |
The number assigned to patient's account. |
| 8 |
Type of Service |
This is a description of the service or supply provided. |
| 9 |
Date of Service |
The date or dates the service was performed. |
| 10 |
Reported Charges |
Charges reported by the provider. |
| 11 |
Allowed Charges |
The customary amount for a service from which your
coinsurance, if applicable, will be determined. |
| 12 |
Non-Covered Charges |
The amount, if any, for non-covered services or the amount
that is above the allowed charge. |
| 13 |
Remarks |
A explanation of the payment determination for a particular
service. |
| 14 |
Provider of Services |
Name of physician, hospital or health-care facility that
performed the services. |
| 15 |
Non-Covered Charges |
Charges that are written off by the provider. |
| 16 |
Less Patient's Share |
Services that patients are responsible for — includes
certain non-covered charges, deductibles and encounter fees, and
coinsurance. |
| 17 |
Deductible Explanation |
In-network deductible and in-network calendar-year coinsurance
maximum status. |
| 18 |
Remarks |
This is an explanation of non-covered amounts. |
| 19 |
Disclaimer |
How to appeal a claim. |
An explanation of benefits (EOB) is a notification form the Federal Employee
Program (FEP) 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 NUMBER |
FIELD NAME |
FIELD DESCRIPTION |
| 1 |
Policyholder
|
The name of the contract holder who meets all eligibility
requirements. |
| 2 |
Patient |
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 |
Dates of Service |
The date or dates the patient received services. |
| 4 |
You owe the provider
|
This is the amount you must pay to the provider for medical
services. |
| 5 |
ID Number
|
The member number of the person receiving the service. |
| 6 |
Claim Number
|
The number assigned to this claim for tracking purposes |
| 7 |
Claim Paid
|
The date the claim was paid by your insurance plan. |
| 8 |
Claim Received |
The date the claim was received by your insurance plan. |
| 9 |
Claim Processed |
The date the claim was processed. |
| 10 |
Patient Account |
The account number of the patient. |
| 11 |
Provider |
The hospital, health care facility, physician or other health
care professional who provided services to you. |
| 12 |
Provider Type |
Each local Blue Cross and Blue Shield plan can contract with
providers in its service area. There are two type of professional contracting
providers: Preferred and Participating; and two types of contracting
facilities: Preferred and Member. If providers do not contract with the Plan,
they are considered to be non-participating or non-member providers. |
| 13 |
Type of Service
|
This is a general description of the service or supply
provided. |
| 14 |
Submitted Charges |
This is the amount the provider has billed. |
| 15 |
Plan Allowance |
The amount used to determine our payment and your coinsurance
for covered services or the amount we used to calculate our payment for covered
services. |
| 16 |
Remark Codes |
An explanation of the payment determination for a particular
service. |
| 17 |
Deductible |
The fixed amount of covered expenses you must incur each
calendar year for certain covered services and supplies before benefits are
paid by your insurance plan. |
| 18 |
Coinsurance or Copayment
|
Coinsurance — The percentage of the Plan Allowance that you
must pay for your care. Copayment — the fixed amount of money you pay to the
physician, facility, pharmacy, etc., when you receive certain services. |
| 19 |
Medicare/Other Insurance
|
The amount paid by another health insurance carrier when your
or covered family members have coverage with Medicare or another health benefit
plan. |
| 20 |
What We Paid
|
The amount paid by your health insurance plan. |
| 21 |
You Owe The Provider
|
The amount you must pay to the provider after you have paid
the copayment and insurance has paid the provider. |
| 22 |
Explanation of Remark Codes
|
This is an explanation of activity that occurred on this
claim/service and describes how the claim was processed. |
| 23 |
Summary of Out-of-Pocket Expenses for 2004
|
This is a complete summary showing your out-of-pocket expenses
for health-care services in 2004. |
| 24 |
Your Out-of-Pocket Expenses on This Claim
|
This is the amount of your out-of-pocket expenses for the
health-care services on this particular claim.
|