How to Read My Explanation of Benefits (EOB) Statement

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