An Explanation of Benefits (EOB) is a notification form USAble Mutual Insurance Company
sends to 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 doctor or hospital services to compare to your
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 21 is probably the most important to you. It
shows the total amount you, as the patient, are responsible for paying.
||The name of the contract holder who meets all applicable eligibility requirements.
||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.
||This is the patient's relationship to the subscriber.
||The member number of the person receiving the service.
||The number assigned to your employer for tracking purposes.
||The number assigned to this claim for tracking purposes.
||PROVIDER OF SERVICE
||The health-care professional or facility that provided services to the patient.
||The number assigned to the doctor or hospital.
||DATE OF SERVICE
||The date the patient received services.
||TYPE OF SERVICE
||A description of the type of service provided.
||The amount the doctor or hospital charged for the service.
||The customary amount for a service from which your coinsurance, if applicable, will be determined.
||The amount, if any, for non-covered services or the amount that is above the allowed charge when visiting an out-of-network doctor or hospital.
||The amount, if applicable, you pay to doctors or hospitals for services each benefit period before your health plan starts paying their share.
||The amount you pay to the doctor or hospital each time you receive a certain service.
||The percentage of the Allowed Amount you pay to the doctor or hospital for covered services for which the member is responsible. The Allowed Amount includes amounts withheld from the doctor or hospital payment, which are subject to the terms and conditions of the contractual agreement with the doctor or hospital.
||PRIMARY PAYER AMOUNT
||The amount paid by another insurance carrier.
||PROVIDER ADJUSTMENT AMOUNT
||The amount the doctor or hospital must write off and/or the amount that has been withheld from the doctor or hospital payment subject to the terms and conditions of the contractual agreement with the doctor or hospital. The doctor or hospital cannot bill you for this amount.
||The amount your health plan paid, based on your coverage and the contractual agreement with the doctor or hospital.
||YOUR MINIMUM RESPONSIBILITY
||The amount you pay to the doctor or hospital for this claim. This includes any copayment, coinsurance, deductible, non-covered services, and the amount above the allowable for the out-of-network doctors & hospitals.
||This is an explanation of activity that occurred on this claim/service and describes how the claim was processed.