Sample Explanation of Benefits Statement for Providers
Part 1: The Basic Tools, Chapter 2: Understanding the Language of Health Insurance Page 5
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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.
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