Sample Explanation of Benefits Statement for Providers

Part 1: The Basic Tools, Chapter 2: Understanding the Language of Health Insurance Page 5

Continued from Previous Page

Table 4 - Sample Explanation of Benefits Statement: Where the Provider Is Part of a Plan Network

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
$80	$20	80%	0
Amount Paid	Sent To	Balance	Notes
$64	Provider	$16	Network Provider

In the case illustrated by Table 4, the policy provided for payment of 80% of the eligible amount. Thus, $64 of the bill was paid by the insurer. The check was sent to the provider, since the provider is part of the insurance company's network.

The $16 balance noted in Table 4 refers to the co-payment, the amount that the consumer is expected to pay out-of- pocket. Since the provider is a part of the plan network, and agreed to follow network rules, the payment in this case repre sents 80% of the $80 eligible amount. The consumer is not generally responsible for the amount -- $20 in this case -- that was considered ineligible.

Continued on Next Page