The Sample Explanation of Benefits Statements Table
Part 1: The Basic Tools, Chapter 2: Understanding the Language of Health Insurance Page 4
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Table 3 - Sample Explanation of Benefits Statement
Insured: (Name of the policyholder)
Patient: (Name of patient if different from policyholder)
ID Number: (Policyholder's identification number)
Date Processed: (Date the claim was processed)
| Medical Provider | Date of Service | Type of Service | Amount of Bill |
| (Provider's Name) | (Date) | Office Visit | $100 |
| Eligible | Not Eligible | Percentage | Deductible |
| $100 | 0 | 80% | 0 |
| Amount Paid | Sent To | Balance | Notes |
| $80 | Consumer | $20 |
In this case, the check was sent to the consumer, who had presumably already paid the medical bill in full. The $20 balance refers to the co-payment, the amount that the consumer is expected to pay out-of-pocket, without reimbursement.
If treatment was provided by a network provider or a plan provider, the Explanation of Benefits Statement might also include a note about the amount of the original bill that was determined to be ineligible. Table 4 represents an Explanation of Benefits Statement in a situation that involved an office visit to a doctor where the doctor was part of the insurance company's network (See Table 4).
Although the original bill illustrated in Table 4 was $100 -- the doctor's standard charge -- only $80 was considered eligible for payment according to network rules. The deductible had been previously satisfied.
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