UNDERSTANDING YOUR EOB
An Explanation of Benefits (EOB) Statement is a notification form provided to members when a health care benefits claim is processed by PAI. The EOB displays the expenses submitted by the provider and shows how the claim was processed.
A GUIDE TO UNDERSTANDING YOUR BENEFITS
The numbers 1-21 appearing on the statement example are for reference purposes only and correspond to further details, definitions and terminology.
Customer Service: This section provides PAI’s website and customer service telephone number, as well as generalinformation identifying the enrolled member and the employer group. Refer to the Messages section (#21) for additional details on customer service assistance information.
Dates of Service: The date(s) the patient received services.
Service Code: This code represents the type of service(s) billed on the claim. Refer to the Service Code Description section(#19) for additional details.
Total Charges: The amount(s) the provider charged for the service.
Ineligible: The portion of charges ineligible under your health plan.
Reason Code: This code represents the reason for the ineligible amount(s). Refer to the Reason Code Description section(#18) for additional details.
Provider Discount: If a preferred provider is used, this amount represents the negotiated discount for the service. (Preferredproviders must write off this amount.)
Covered Amount: Amount covered by your plan after subtracting any ineligible amounts or provider discounts.
Deductible Amount: The amount, if any, that you are responsible for paying to the health care provider before we startpaying contract benefits. You do not send this amount to us. We subtract this amount from the covered charges on the claim(s) you and health care professionals send to us.
Co-Pay Amount: The set fee you pay each time you receive a certain service.
Co-Insurance: The percentage of the Allowed Amount you pay as your share of charges. If your plan pays 80 percent ofeligible charges, then 20 percent of eligible charges would be your Co- Insurance amount.
Balance: Remainder of the charges after the Deductible, Co-Pay and/or Co-Insurance have been subtracted from theAllowed Amount.
Paid At: The percentage of the balance paid by your plan for each service.
Payment Amount: The amount to be paid by your plan for each service, based on your coverage.
Amount You May Owe or Have Paid Provider: The amount, if any, you owe the provider for this claim.
Other Insurance Credits or Adjustments: Amounts on this line represent any other insurance or adjustments to be applied.
Total Net Payment: The actual amount paid by your plan after taking into consideration Other Insurance Credits orAdjustments.
Reason Code Description: This section describes the Reason Code(s) referenced in section #6.
Service Code: This section describes the Service Code(s) referenced in section #3.
Accumulators: This section shows the total amount you have accumulated toward your deductible(s) and/or out-of-pocketmaximum(s) during this benefit period.
Messages: This section provides additional detail for customer service assistance.
Note: Additional pages following the EOB include definitions to help you better understand your benefits, provide importantinformation about your appeal rights, and the process for filing an appeal if you disagree with how your claim was paid.
