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CMS 2022 C2C RTBC EOB English 8 5X11 V4

The document is an example of an Explanation of Benefits (EOB) from a health insurance plan. An EOB provides the total charges for a medical visit, how much the health plan and patient will pay, and is not a bill from the provider. It includes details of services received, charges billed by the provider, allowed costs under the plan, amounts paid by the insurer and patient responsibilities. The EOB also includes contact numbers for customer service and codes to explain payment amounts.

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krishna Enagaluru
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64 views1 page

CMS 2022 C2C RTBC EOB English 8 5X11 V4

The document is an example of an Explanation of Benefits (EOB) from a health insurance plan. An EOB provides the total charges for a medical visit, how much the health plan and patient will pay, and is not a bill from the provider. It includes details of services received, charges billed by the provider, allowed costs under the plan, amounts paid by the insurer and patient responsibilities. The EOB also includes contact numbers for customer service and codes to explain payment amounts.

Uploaded by

krishna Enagaluru
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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READING YOUR EXPLANATION

OF BENEFITS (EOB)

You may receive an EOB from your health plan after your visit with the provider. It will show you the total charges for your visit and how
much you and your health plan owe. An EOB is NOT A BILL. You can also use it to track how you and your family use your coverage.
You may get a separate bill from the provider.

Here’s an example of an Explanation of Benefits.


Your health plan’s Customer Service Number may be near the plan’s logo or on the back of your EOB.

1. Phone Numbers
You can call your health plan if you have questions about
2. Payee is the person who will receive any
finding a provider or what your coverage includes.
reimbursement for over-paying the claim.

EXPLANATION OF BENEFITS 1 Customer Service Number: 1-800-123-4567

Statement Date: XXXXXX Member Name:


Document Number: XXXXXXXXXX Address:
City, State, Zip:
THIS IS NOT A BILL
Subscriber Number: XXXXXXXXXX ID: XXXXXXX Group: ABCDE Group Number: XXXXX

Patient Name: XXXXXX Provider: Claim Number: XXXXXXXX


Date Received: XXXXXXXXXX Payee: 2 Date Paid: XXXXXXXX

3. Service Description 4. Provider Charges 5. Allowed Charges


shows the health services you received, is the amount your provider is the amount your provider will
like a medical visit, lab test, or screening. bills for your visit. be paid; this may not be the
same as the Provider Charges.

What your
Claim Detail Provider Can Your Responsibility Total Claim Cost
Charge You

3 4 5 6 7 8
Service What
Line Date of Descrip- Claim Provider Allowed Co Deduct- Paid by You Remark
No. Service tion Status Charges Charges Pay ible Coinsurance Insurer Owe Code

1 3/20/22- Medical Paid $31.60 $2.15 $0.00 $0.00 $0.00 $2.15 $0.00 PDC
3/20/22 care

2 3/20/22- Medical Paid $375.00 $118.12 $35.00 $0.00 $0.00 $83.12 $35.00 PDC
3/20/22 care

Total $406.60 $120.27 $35.00 $0.00 $0.00 $85.27 $35.00 PDC

Remark Code: PDC—Billed amount is higher than the maximum payment insurance allows. The payment is for the allowed amount.

6. Paid by Insurer 7. What You Owe is the amount you owe after 8. Remark Code
is the amount your your insurer has paid everything else. You may have is a note from the health
health plan will pay already paid part of this amount. Payments made plan that explains more about
to your provider. directly to your provider may not be subtracted from the costs, charges, and paid
this amount. amounts for your visit.

Pay your bills Appeals


Pay your bills and keep all paperwork in a safe place. Some If you disagree with a coverage or payment decision by your health
providers will not see you if you have unpaid bills. You may be plan, you may be able to appeal. If you think you were charged for tests
able to pay your bills online or over the phone. This can vary or services your coverage should pay for, keep the bill. Call your health
depending on your health plan and coverage. plan right away. Health plans have call and support centers to help.

go.cms.gov/c2c
Paid for by the US Department of Health and Human Services.
Revision Date: May 2022 Publication #11819

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