HOW TO READ YOUR EXPLANATION OF BENEFITS (EOB) 11. T he address to which the EOB was mailed. 22. G roup Name—the payor of your medical claim. If your company is a self-funded group, their name will appear here. 33. Insured—the person who holds the contract with the insurer. What is an Explanation of Benefits (EOB)? 44. Patient—the person who received An EOB is a notification from Coventry Health Care explaining how your medical claim(s) are processed (including a payment or denial). 55. ID Number—the identification for the medical services. This may be a subscriber or a dependent. person receiving medical services. 66. C laim Number—document control Is an EOB a bill from the insurance company? No, Coventry Health Care does not bill members for medical services. Coventry Health Care processes and pays the claims submitted from your provider or hospital. number generated by Coventry Health Care. If you need to call a member service representative to discuss the claim, this is an important number to give them. 78. Provider—the provider of your medical service. This could be an individual practice or facility. Page 1 of 2 Coventry Health Care Management Corporation In Trust for Self Funded Group 3721 TecPort Dr P.O. Box 67103 Harrisburg PA 17106 THIS IS NOT A BILL EXPLANATION OF BENEFITS Our organization processes and pays the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your medical claim(s), including payments or denials, are being processed. Member, Mrs. 630000 M RD NOWHERE PA 15555 1 Payments made on behalf of: 2 3 4 5 GROUP NAME Insured: Patient: Group Name: ID Number: Date: 8 Member Responsibility: $10.00 $118.00 6 Claim Number: 18 Plan Paid: 9XXXXXX2 $751.00 8 Member Responsibility: $0.00 Provider: Provider Billing Address: 7 M GENTS 710 ELM STREET ALLENTOWN, PA 18109-2732 Member’s Responsibility to Provider Contractual Adjustment 12 Approved Amount 13 Copay 14 Coins 15 Deduct. 16 Other 17 Plan Paid 18 $30.73 $87.27 $10.00 $0.00 $0.00 $0.00 $77.27 $30.73 $87.27 $10.00 $0.00 $0.00 $0.00 $77.27 Provider: Provider Billing Address: Cont. Rmk / Other Rmk 19 TOTALS: Coventry agrees to pay the provider for services rendered minus copays, coinsurance or deductibles, if applicable. 14 Less Copay 7 WEST SLEEP MEDICINE 1260 MADISON STREET ALLENTOWN, PA 18109-2729 15 Less Coinsurance 16 Less Deductible 8 9 01/23/08 95810/MEDICINE 10 coverage category for which the code is classified. 13 Approved Amount—the amount **Provider billing address may differ from physical office location** Service Date From - To Procedure Code/Description 10 Procedure Code/Description—the in payment due to network savings, coordination of benefits, or non-covered services. For more information, see number 19, Cont. Rmk/Other Rmk. 8 TOTALS: were incurred. 12 Contractual Adjustment—reductions **Provider billing address may differ from physical office location** Service Date From - To Billed Procedure Code/Description Amount 11 9 01/23/08 99244/MEDICINE 10 $118.00 97. Date—the date your medical services Coventry Health Care by your physician. **Payments made at the time services were rendered are not reflected on this statement** 2XXXXX879 $77.27 amount the member may be responsible to pay the provider. 11 Billed Amount—the total amount billed to Member, Mrs. Member, Mrs. GROUP 85XXXXXXX01 01/23/08 6 Claim Number: 18 Plan Paid: 89. M ember Responsibility—this is the Member’s Responsibility to Provider Billed Amount 11 Contractual Adjustment 12 Approved Amount 13 Copay 14 Coins 15 Deduct. 16 Other 17 Plan Paid 18 $1,200.00 $449.00 $751.00 $0.00 $0.00 $0.00 $0.00 $751.00 $1,200.00 $449.00 $751.00 $0.00 $0.00 $0.00 $0.00 $751.00 Cont. Rmk / Other Rmk 19 To ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. If you believe any of the services were incorrectly billed, contact a customer service representative using the toll free number listed below. 17 Less Other Amounts 18 Plan Paid—the amount paid by your plan. 19 Cont. Rmk/Other Rmk—a Coventry Health Care code that explains why certain amounts were not covered. HOW TO READ YOUR MEMBER BENEFIT USAGE A Benefits Header B Benefit Period Header • This introductory language precedes the Benefits Accumulation Summary. • This identifies the period (in date form) in which benefits are calculated. • This date reflects when your claims were processed. • This could be by calendar year or contract benefit year. A B • The information displayed in the columns below is based upon your benefit plan. The amounts below include claims processed as of February 23, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member Benefit Usage for Dates of Service January 1, 2008 – December 31, 2008. Deductible Dollars 1 Out-of-Pocket Dollars Year-to-Date Satisfied Maximum $ Remaining $ Year-to-Date Satisfied Maximum $ Remaining $ In-Network Indiv. $10.00 $200.00 $190.00 $0.00 $1,000.00 $1,000.00 Out of Network Indiv. $0.00 $400.00 $400.00 $0.00 $2,000.00 $2,000.00 1 2 3 4 5 6 7 Type C Benefit Accumulation Summary C Type—displays the benefit coverage level where dollars have been used or are tracked. If you have different spending limits for different types of benefits, such as in-network or out-of-network, they will be listed as different types. For example, they may be listed as individual or family. 2 Year-to-Date Satisfied—total amount spent or credited towards the maximum amount you are required to pay before additional benefits are available. 3 Maximum $—total amount you must spend in the benefit year before your additional insurance benefits are available. 4 Remaining $—total amount you have left to pay on your deductible before the maximum limit is met and your other insurance benefits apply (Maximum minus Year-to-Date Satisfied). 5 Year-to-Date Satisfied—total amount spent or credited towards the maximum amount you are required to pay in the benefit year. 6 Maximum $—total amount you may be responsible for in a benefit year based on your benefit plan design. 7 Remaining $—total amount you have left to pay before the maximum limit is met (Maximum minus Year-to-Date Satisfied). If you have questions, call the member services number printed on your ID card. 0108