How to Read My Explanation of Benefits (EOB) Statement Delhaize America Employees Year 1 Benefit Summary Explanation of Benefits Shows your year-todate Benefit Summary for every member of your plan. September 03, 2011 Subscriber information First: John Last: Doe ID: W12345678901 Blue Options HRA Plan Claim 2 Patient Shows the most recent claim for the member identified. You’ll see: • How much the service cost • Negotiated BCBSNC discount • How much your plan paid • How much you owe your provider for the service 3 Additional Information Please save this form for your tax records. Your balance may not reflect any prior payments made by you or another insurance company. BCBSNC provides administrative services only for this plan. Your plan sponsor retains sole responsibility for funding the claim payments. The information listed in the “Benefit Year Summary” section indicates the most current benefit period information on your plan as of the date of this notice. The “Amount Satisfied” will reflect the total amount applied throughout the benefit period on the plan, which may include all applied before and after any changes in benefits or dependents covered throughout the current benefit period. Para obtener asistencia en español, comuníquese con el departamento de servicio al cliente al número que aparece al respaldo de su tarjeta del seguro. Find answers online at mybcbsnc.com Customer service (Monday – Friday 8 a.m.-9 p.m. EST) 1-877-272-9787 Servicio al Cliente (Lunes – Viernes, 8 a.m.-6 p.m. EST) 1-877-275-9787 Benefit Year Summary 1 For policy starting 10/01/2010 In-Network Deductible Blue Options HRA Plan Plan’s Maximum Plan Information Out-of-Network Deductible Amount Satisfied Plan’s Maximum In-Network Out-of-Pocket Amount Satisfied Plan’s Maximum Amount Satisfied Out-of-Network Out-of-Pocket Plan’s Maximum Amount Satisfied John $2,500 $79.15 $5,000 $79.15 $7,000 $79.15 $14,000 $79.15 Sarah $2,500 $0.00 $5,000 $0.00 $7,000 $0.00 $14,000 $0.00 Robert Family $2,500 $0.00 $5,000 $0.00 $7,000 $0.00 $14,000 $0.00 $2,500 $79.15 $5,000 $79.15 $7,000 $79.15 $14,000 $79.15 4 TOTAL The TOTAL amount is also represented on your Explanation of Payment (EOP), in the Submitted column. These benefits require you and/or your family to reach payment maximums, labeled “Plan’s Maximum”, before your plan pays a greater share of the cost. These maximums can be reached in two ways: when you’ve satisfied your individual maximums, or when your family has met its maximums. Payments made by members are credited both to their individual “Amount Satisfied” and to the family’s, up to the individual maximum amount. Individual maximum requirements are waived when your family maximum is reached. The amount satisfied column will read “Met” if an individual or family maximum has been satisfied. Look here to learn more about how your plan claims are administrated. Patient: SARAH DOE NOTE: This document gives highlights of the Delhaize America benefit programs. It is not intended to be a Summary Plan Description (SPD). If there are differences between the document and the SPD or plan document, the terms of the SPD and plan document will control. ® Marks of the Blue Cross and Blue Shield Association. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association. 11/2011 Need more information? Medical Service Detail 2 Claim #: BNC001234567890E00000001 Provider: Novant Medical Group Dates(s): 03/24/11 – 03/24/11 Total for Claim: BNC001234567890E00000001 3 This is not a bill. #: W12345678902 Your Provider Billed $95.00 Service: HDHP $95.00 Member Benefit Allowed Amount Member Savings Your Plan Paid Other Insurance Paid Amount Your Provider May Bill You Copayment Deductible Coinsurance Other Liability 4 TOTAL $79.15 $15.85 $0.00 $0.00 $0.00 $79.15 $0.00 $0.00 $79.15 $79.15 $15.85 $0.00 $0.00 $0.00 $79.15 $0.00 $0.00 $79.15 Reason Code (See below) What our codes mean HRA Your Claim Total Balance reported in “Amount Provider May Bill You” will be sent to your HRA/FSA for payment of eligible medical expenses. You will be responsible for any remaining member liability that is not paid from your HRA/FSA. HRA