An Explanation of Benefits (EOB) is a notification form USAble Life group health insurance division
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 provider of medical 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
||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 provider.
||DATE OF SERVICE
||The date the patient received services.
||TYPE OF SERVICE
||A description of the type of service provided.
||The amount the provider 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 seeing an out-of-network provider.
||The amount, if applicable, you pay to providers for services each
benefit period before your health plan starts paying their share.
||The amount you pay to the provider each time you receive a certain
||The percentage of the Allowed Amount you pay to the provider for covered
services for which the member is responsible. The Allowed Amount includes
amounts withheld from provider payment, which are subject to the terms and
conditions of the contractual agreement with the provider.
||PRIMARY PAYER AMOUNT
||The amount paid by another insurance carrier.
||PROVIDER ADJUSTMENT AMOUNT
||The amount the provider must write off and/or the amount that has been withheld
from the provider payment subject to the terms and conditions of the
contractural agreement with the provider. The provider cannot bill you for this
||The amount your health plan paid, based on your coverage and the contractual
agreement with the provider.
||YOUR MINIMUM RESPONSIBILITY
||The amount you pay to the provider for this claim. This includes any copayment,
coinsurance, deductible, non-covered services, and the amount above the
allowable for the out-of-network providers.
||This is an explanation of activity that occurred on this
claim/service and describes how the claim was processed.