Employee: JOHN SAMPLE

Emp ID.:
Customer
Group#:Service
0712
Date: 02/15/13
Group: GROUP NAME
EOB#:
Check #: 1168
Questions?
Employee: Please contact us at
JOHN SAMPLE
Emp{cTollFreePhone}
ID.: or {cLocalPhone}
Please visit0712
Group#: us at our web-site: {cWebAddress}
Group: GROUP NAME

How to Read an EOB (Explanation of Benefits) Questions? Please contact us at

How to read an explanation of benefits (EOB)
EXPLANATION OF BENEFITS
While an Explanation of is
***This Benefits
NOT aletter looks a lot like a bill, the purpose of these
Bill***
{cTollFreePhone}
letters is to shed
Please visit us atPage
or {cLocalPhone}
light
of 2 on how
our 1web-site: {cWebAddress}
your medical plan processed a healthcare claim. You can see a copy of your EOBs by loggingPage in to 1the
of 2ABS member
portal. This is done in the form of a chart, which will include some key factors to review such as:
AnClaim:
EOB is a great way to keep track of your health care Patient:
1315738593
benefitsJANE SAMPLE
and how your medical plan processes a healthcare
1. Patient
claim. You name: The recipient of the service provided. Provider: PROVIDER GROUP INC Patient Acct: 765472V3122
Dates of will receive one
EXPLANATION
Service Totalof
OFthese
PPO forAllowed
BENEFITS every service
Ineligible orCo-Pay
claimDeductible
billed to SmartHealth.
Co-Insur Paid They
Other look similar
Payment Paid to a bill, but they
Patient Ref
Servicea ID Charge Disc will
Amount Amount Amount Amount Amount % This Ins Amount Responsibility No.
To IDprocessed.
function
2. Insured little differently.
number: Your The EOB
identification
***This is NOT a Bill*** be
numbera letter
with that
your includes
SmartHealth a chart, outlining
medical plan. how your
should claim
match was
the number on You
your
01/23-01/01/01 99214 $192.00 $26.50 $165.50 $0.00 $25.00 $0.00 $0.00 100% $0.00 $140.50 $0.00 S10
should make
insurance card. sure your EOB and bill from your provider match. Customer Service
Column Totals $192.00 $26.50 $165.50 $0.00 $25.00 $0.00 $0.00 $0.00 $140.50 $25.00

3. Claim medical Customer

Patient: JANE SAMPLE
number: The number by which you and your SmartHealth Date:Service
plan will 02/15/13
be able to refer to this$25.00
claim should you have
1. Patient name: The recipient of the service provided.
Claim: 1315738593 Patient's Responsibility........
Provider: PROVIDER GROUP EOB#:
Date:
INC 02/15/13 Patient Acct: 765472V3122
2. any
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Patient
Service
of or concerns.
account
Service number:
Total
Charge
Your
PPOidentification
Disc
number
Allowed Ineligible
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with
Co-Pay
Amount
your
Deductible
Amount
Check
doctor's
Co-Insur
EOB#:
Amount
#: 1168 Other Payment Paid
office.
Paid
% Ins Amount To
Patient Ref
Responsibility No.
Patient: JANE SAMPLEEmployee:
Check #: JOHN SAMPLE
1168
3. Claim
4. 01/23-01/01/01
Provider:
Claim: number:
The
1315739006 name
99214 Theof number
the
$192.00 by which
healthcare
$26.50 youwho
provider
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rendered
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thisPROVIDER
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to this claimS10
$0.00
768726V3122
Emp
Employee: JOHN SAMPLE
should
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Column Totals have
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Total
$192.00 PPO
$26.50 or concerns.
Allowed
$165.50 Ineligible
$0.00 Co-Pay
$25.00 Deductible
$0.00 Co-Insur
$0.00
Group#:
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Paid Other
$0.00
ID.:% 0712 Ins
Payment
$140.50 Paid $25.00 Ref
Patient
5. Date of service: The start
Service Chargeand end dateAmount
Disc of the referenced
Amount service. Amount Amount
Amount Amount To Responsibility No.
4. 01/23-01/01/01
Provider: The name of the $66.84
healthcare provider or facility that$0.00
rendered the services.
Group:
Group#: GROUP NAME
0712
76816 $235.00 $168.16 $0.00 Patient's
$0.00 Responsibility........
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6. Type
5. Date ofofservice:
01/23-01/01/01 service:
76819
A description
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of
andthe
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$0.00 $195.48 $0.00
6. Type
7. Healthcare
Columnof service:
providerA$480.00
Totals standard
charge: The numerical
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your insurance
$0.00
Patient: service
by$0.00
the received.
provider.
SAMPLE $0.00 Questions? $0.00Please contact us at $0.00
$363.64
7. Claim:
Total1315739006
charge: The amount billed to your insuranceProvider: by the PROVIDER
provider GROUP {cTollFreePhone}
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INC
Questions? or contact
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Patient Acct: 768726V3122
us at
8. Cost
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by insurance: sum your health
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Ineligible for your
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8. Allowed
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Amount Amount Amount % Ins Amount To Responsibility No.
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9. What
9. Ref no.:you owe:
01/23-01/01/01 This
76816codebalance
$235.00 the
will provide provider
$66.84a brief billed
$168.16 that
description was of
$0.00 not covered
service
$0.00
Patient: JANEinby your
the
$0.00
SAMPLE
insurance.
“Reference
$0.00 100% Code $0.00Explanation”
$168.16 section.$0.00
Claim: 1315741664
10. Patient responsibility:
01/23-01/01/01 76819 $245.00 Any balance
$49.52 the provider
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Provider: was
$0.00 not
PROVIDER covered
$0.00
GROUP 100%by your
INC $0.00 insurance.
$195.48 $0.00
Patient Acct: 123456789
Dates of
Column Service
Totals Total
$480.00 PPO
$116.36 Allowed
$363.64 Ineligible
$0.00 Co-Pay
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Service EXPLANATION
Charge OF BENEFITS
Disc Amount Amount Amount Amount Amount % Ins Amount To Responsibility No.
01/30-01/01/01 ***This
EXPLANATION
76815 is NOT
$211.00 a Bill***$168.81
OF BENEFITS
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01/30-01/01/01
***This$245.00
76819
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1
$0.00 $0.00 100% $0.00 $195.48 $0.00
Column Totals $456.00 $91.71 $364.29 $0.00 $0.00 JANE
Patient: $0.00
SAMPLE$0.00 $0.00 $364.29 $0.00
Patient: JANE SAMPLE
Claim:31315741664 1Provider: PROVIDER GROUP INC
2
Patient Acct: 123456789
Claim: 1315738593
Dates of Service Total PPO Patient's
Provider:
Allowed Ineligible 4 Co-Pay Responsibility........
PROVIDER
Patient:Deductible
JANE GROUP INC
SAMPLE
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Patient Acct: 765472V3122
Patient Ref
Dates1315738593
of Service Total PPO Allowed Amount
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Patient No.
3 Service
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Patient 765472V3122
Reference
Service Code Explanation
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76815
8 8$168.81 $0.00 $0.00 Deductible
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01/30-01/01/01
Dates of Service Total PPO Allowed Ineligible Co-Pay Co-Insur Paid Other Payment Patient
55Code 6Explanation
01/23-01/01/01
Service 6 99214 77 Charge
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*** Column Totals
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Code Explanation Code Explanation
Download the
Reference CodeSmartHealth
Explanation app to access your EOBs, deductibles, Service ID cards and more.
Explanation
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