How to understand your Explanation of Benefits Every time you file a medical claim or a health care provider files a claim on your behalf, you will receive an Explanation of Benefits (EOB). An EOB isn’t a bill. It provides important information about how your medical claims are processed with detailed information explaining the medical treatment or services that have been rendered. This helps you understand the benefits you receive at KPS Health Plans and know your share of the cost. 1 Payment Summary – The accumulation of all total charges for this claim. Total claim charges – The total amount your provider has billed for the services rendered on this claim. Total allowed charges – The maximum amount KPS Health Plans allows for the procedure(s) billed by your provider for this claim. Total deductible – This amount reflects how much was processed towards your KPS yearly deductible. The amount of your deductible depends on the plan which you are enrolled. Total coinsurance – This amount reflects the percentage of which your benefits are covered. This applies after all applicable deductible and copays. Example: After you’ve met the deductible, KPS Health Plans pays 80% of the allowed amount. Coinsurance will reflect the remaining 20% of the allowed amount. Total copay – The amount an insured member is expected to pay for medical expenses at time of the visit. CLAIM SUMMARY Patient: Member ID: Subscriber: Group: Group Number: Provider: Provider Acct.: Claim Number: Diagnosis: 1 PAYMENT SUMMARY (This is NOT a bill) SAM SMITH 123456789 01 SAM SMITH GROUP NAME 1234567 PROVIDER ABC 99999 99999999999 847.0 SPRAIN OF NECK Details regarding the subscriber’s name and group plan. The member suffix is here. Total claim charges: Total allowed charges: Total deductible: Total coinsurance: Total copay: Other insurance paid: $80.00 $60.00 $0.00 $12.00 $0.00 $0.00 Your total responsibility: Total paid: Check No.: Check Date: Payment made to: $12.00 $48.00 2 CLAIM DETAILS Date of Service Service Description Service Code Provider Billed Plan Allowed Plan Paid Patient Responsibility Code 11/18/2012 MASSAGE THERAPY 97124 $80.00 $60.00 $48.00 $12.00 303 327 Total $80.00 Code Description A coinsurance has been applied to this service Reduced amount by max allowed $60.00 $48.00 $12.00 Code 303 327 2 Claim Details – This will provide you a brief description of how your claim was processed. Date of service – The day you received medical care from your provider. Service description – The medical service or item received from your provider. Other insurance paid – The amount the other insurer paid on behalf of your claim. Service code – A medical code that helps identify the services you received. Your total responsibility – Is an accumulation of all Patient charges you are responsible for pertaining to this claim. The total charges include deductible, coinsurance and copays. If applicable, Non- allowed services or out of network provider will reflect in this total amount. Plan allowed – The maximum amount KPS health plans allows for the procedure(s) billed by your provider for these services. NOTE: If your provider has a participating agreement with KPS Health Plans, he/she is responsible to write off the difference between the billed amount and the KPS Health Plans allowed amount. That difference would not be the patient’s responsibility. Provider billed – The amount your provider has billed for the services provided. Plan paid – The amount paid by KPS Health Plans to your provider in accordance to your plan’s benefits. Patient responsibility – The amount you are responsible paying your physician pertaining to this claim. 16KPS-2012-092012