How to read your Explanation of Benefits (EOB)
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Your visit BCBSKS' responsibility Additional details Your responsibility Deductible & coinsurance In this first section of your Explanation of Benefits (EOB), you will be able to identify if the EOB is for you or one of your dependents. You will also be able to identify which doctor's office and the date of the visit this EOB pertains to, as well as when the claim was paid by us. In the second section of your EOB, you can see how much the total charge was for your doctor's visit or prescription drug purchase, how much we paid, how much you saved as a result of our contract with your doctor (Provider Contractual Write-off), and if there is any amount that will be paid to you. In this next section of your EOB, you will find details about what charges were not covered by us, what amount will be applied to your deductible and/or coinsurance, and what the total amount will be that you will have to pay. If there are additional details to help us explain your EOB and how it is processed, this is the section where you will find that information. Your deductible is the amount you owe for covered health care services before your health insurance or plan begins to pay. Your coinsurance is your share of the costs of a covered healthcare service, calculated as a percentage of the allowed amount for the service. You pay this amount after you’ve met your deductible. This section will list the amounts that have been applied to individual and/or family deductibles, as well as individual and/or family coinsurance limits. 1 2 3 4 5 1 2 3 4 5 PW00000001 Page # 01 of 01 05/18/21 JOHN SMITH 1234 Main Street Anytown, KS 66666-0000 NOTE H -Our contracting provider has agreed to accept our payment allowance and should not bill the patient for the provider write-off. Refer to the allowable charge section of the patient’s contract. NOTE BG -This claim was processed according to the payment provisions of your medical contract because the laboratory and x ray Patient Name: John Claim Number: 123456789012 Paid To: Place of Service: Outpatient Type of Service: Laboratory Performing Provider: Provider Name Provider Date Received: 05/13/21 Date Processed: 05/13/21 Billing Provider: Provider Name Member ID: XXX123456789 Group Name: YOUR GROUP NAME Group Number: 12345 EXPLANATION OF BENEFITS THIS IS NOT A BILL PLEASE KEEP FOR INCOME TAX PURPOSES 1133 SW TOPEKA BLVD TOPEKA KS 66629-0001 YOUR RESPONSIBILITY Date of Service Total Charges Other Insurance Payment Provider Contractual Write-off Amount Paid To You See Note Below Non-covered Charges Applied to Deductible Patient’s Share (Co-ins) Copay Total Patient Responsibility 05/12/21 42.40 21.26 21.14 H BG 05/12/21 42.40 21.26 21.14 H BG 05/12/21 50.28 8.96 41.32 H BG 05/12/21 45.25 3.93 41.32 H BG 05/12/21 49.74 8.42 41.32 H BG 05/12/21 26.90 16.14 10.76 H BG Claim Total 256.97 79.97 177.00 YOUR RESPONSIBILITY Date of Service Total Charges Other Insurance Payment Provider Contractual Write-off Amount Paid To You See Note Below Non-covered Charges Applied to Deductible Patient’s Share (Co-ins) Copay Total Patient Responsibility 05/12/21 200.00 75.00 H 125.00 125.00 Claim Total 200.00 75.00 125.00 125.00 Patient Name: John Claim Number: 123456789012 Paid To: Place of Service: Outpatient Type of Service: Laboratory Performing Provider: Provider Name Provider Date Received: 05/13/21 Date Processed: 05/13/21 Billing Provider: Provider Name Credited to Deductible: $210.49 Time Period 05-01-21-John Credited to Family Deductible: $210.49 Time Period 05-01-21 * Any amount shown in these columns are your responsibility according to your contractual provisions when we are your primary insurance carrier. For claims information For customer service call 1-800-432-3990 or (785) 291-4180 To report suspected fraud www.bcbsks.com 1-800-498-0216 Please see the appeal procedure and notice of rights form Learn more about Health Care Reform and access your Explanation of Benefits on our website. Visit www.bcbsks.com An independent licensee of the Blue Cross Blue Shield Association. 34-731 06/21 An independent licensee of the Blue Cross Blue Shield Association. Visit us at bcbsks.com 1133 SW Topeka Blvd, Topeka, KS 66629 How to read your Explanation of Benefits
Transcript of How to read your Explanation of Benefits (EOB)
Your visit
BCBSKS'responsibility
Additionaldetails
Yourresponsibility
Deductible & coinsurance
In this �rst section of your Explanation of Bene�ts (EOB), you will be able to identify if the EOB is for you or one of your dependents. You will also be able to identify which doctor's of�ce and the date of the visit this EOB pertains to, as well as when the claim was paid by us.
In the second section of your EOB, you can see how much the total charge was for your doctor's visit or prescription drug purchase, how much we paid, how much you saved as a result of our contract with your doctor (Provider Contractual Write-off), and if there is any amount that will be paid to you.
In this next section of your EOB, you will �nd details about what charges were not covered by us, what amount will be applied to your deductible and/or coinsurance, and what the total amount will be that you will have to pay.
If there are additional details to help us explain your EOB and how it is processed, this is the section where you will �nd that information.
Your deductible is the amount you owe for covered health care services before your health insurance or plan begins to pay. Your coinsurance is your share of the costs of a covered healthcare service, calculated as a percentage of the allowed amount for the service. You pay this amount after you’ve met your deductible. This section will list the amounts that have been applied to individual and/or family deductibles, as well as individual and/or family coinsurance limits.
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PW00000001Page # 01 of 01
05/18/21JOHN SMITH1234 Main Street
Anytown, KS 66666-0000
NOTE H -Our contracting provider has agreed to accept our payment allowance and should not bill the patient for the provider write-off.
Refer to the allowable charge section of the patient’s contract.
NOTE BG -This claim was processed according to the payment provisions of your medical contract because the laboratory and x ray
Patient Name: John Claim Number: 123456789012 Paid To:
Place of Service: Outpatient Type of Service: Laboratory Performing Provider: Provider NameProvider
Date Received: 05/13/21Date Processed: 05/13/21
Billing Provider: Provider Name
Member ID: XXX123456789
Group Name: YOUR GROUP NAME
Group Number: 12345
EXPLANATION OF BENEFITS
THIS IS NOT A BILL
PLEASE KEEP FOR INCOME TAX PURPOSES 1133 SW TOPEKA BLVD
TOPEKA KS 66629-0001
YOUR RESPONSIBILITY
Date of Service
Total Charges
Other InsurancePayment
Provider Contractual
Write-off
Amount Paid To You
See Note BelowNon-covered
ChargesApplied to Deductible
Patient’s Share
(Co-ins)Copay
Total Patient
Responsibility
05/12/21 42.4021.26 21.14 H BG
05/12/21 42.4021.26 21.14 H BG
05/12/21 50.288.96 41.32 H BG
05/12/21 45.253.93 41.32 H BG
05/12/21 49.748.42 41.32 H BG
05/12/21 26.9016.14 10.76 H BG
Claim Total 256.9779.97 177.00
YOUR RESPONSIBILITY
Date of Service
Total Charges
Other InsurancePayment
Provider Contractual
Write-off
Amount Paid To You
See Note BelowNon-covered
ChargesApplied to Deductible
Patient’s Share
(Co-ins)Copay
Total Patient
Responsibility
05/12/21 200.0075.00 H
125.00 125.00
Claim Total 200.0075.00
125.00125.00
Patient Name: JohnClaim Number: 123456789012 Paid To:
Place of Service: Outpatient Type of Service: LaboratoryPerforming Provider: Provider NameProvider
Date Received: 05/13/21Date Processed: 05/13/21
Billing Provider: Provider Name
Credited to Deductible:
$210.49
Time Period 05-01-21-John
Credited to Family Deductibl
e: $210.49
Time Period 05-01-21
* Any amount shown in these columns are your responsibility according to your contractual provisions when we are your primary insurance carrier.
For claims informationFor customer service call 1-800-432-3990 or (785) 291-4180 To report suspected fraud
www.bcbsks.com
1-800-498-0216
Please see the appeal procedure and notice of rights formLearn more about Health Care Reform and access your Explanation of Benefits on our website. Visit www.bcbsks.com
An independent licensee of the Blue Cross Blue Shield Association.
34-731 06/21 An independent licensee of the Blue Cross Blue Shield Association.
Visit us at bcbsks.com
1133 SW Topeka Blvd, Topeka, KS 66629
How to read your Explanation of Benefits
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