Expand to see definitions and a sample Explanation of Benefits (EOB). See complete EOB. (Full Website)
This section shows a summary of the amounts your plan has applied to the deductible, coinsurance, and/or out of pocket maximums based on the covered services you received. The summary provided is that of the benefit period applicable to the service date of your claim because we process claims against the benefits at the time of the service. If the EOB details a claim from several months prior, and you transitioned to a new benefit period since you received the service, the summary on that EOB will reflect the benefits at that time and not be reflective of your current benefit period.
Doctors, hospitals, clinics, and other health care providers who have a contract with your plan to provide services to you at a discount.
Services from health care providers who don't have a contract with your plan will usually cost you more than those received from an in-network provider.
The amount you pay for eligible services during a benefit period before your plan begins to pay. For example, if your deductible is $1000, your plan won't pay anything until you've met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. This means you may be able to pay a copayment rather than the full amount. (Check your policy for details) Copayments, coinsurance, noncovered services, or any charges in excess of any maximum or allowed amount are never applied to your deductible amount. Note: Your plan may have different deductible amounts for services in and out of the BCBSNC provider network.
Deductible types include:
Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if your plan's allowed amount for an office visit is $100 and you've met your deductible, your co-insurance payment of 20% would be $20. Your plan pays the rest of the allowed amount. Also, once you reach your coinsurance maximum, your plan will pay 100% for covered services for the rest of the benefit period.
This is the specific deductible, coinsurance, or out-of-pocket amount for your plan, and what you may owe cannot exceed these amounts. This does not include copayments or non-covered services.
The total amount of coinsurance that you will pay during a policy period before your plan begins to pay at 100% of the allowed amount. This limit typically does not include your premium, copayments, deductibles, charges over allowed amounts, or services that are non-covered. Charges that are applied to your out-of-network coinsurance are credited to your in-network out-of-pocket maximum. However, charges applied to your in-network coinsurance are not credited to your out-of-network out-of-pocket maximum.
The total amount of the deductible, coinsurance, and/or out-of-pocket expenses you and/or your family has met for the benefit period as of the date of the EOB. Remember, copayments, if applicable, are not applied to the deductible, coinsurance or out-of-pocket amounts. Note: If you have met the required amount, this field will simply show "Met" on the EOB.
Identifies specific services received during a health care visit through a uniquely assigned number. No two claim numbers are alike.
A summary description of the type of medical service provided. If you need more information about a particular service, contact your health care provider to discuss the details of how they filed the claim with your plan. Alternatively, you may call customer service at the number listed on your EOB or ID card.
The amount your health care provider submitted for the services you received. You may notice this amount is often higher than the allowed amount. The advantage of being a member of your plan is that the provider has agreed to accept a reduced amount (allowed amount) for the services you received and your liability is based on the allowed amount and not the billed amount.
The discounted rate your plan has negotiated with in-network providers and facilities for covered services. These rates save you money when you receive in-network care.
The amount you saved by visiting an in-network provider or facility and being a member of your plan, entitling you to receive these negotiated discounts.
The amount your plan paid for the services you received.
The fixed dollar amount, (for example, $15) you pay upfront to a health care provider for a covered service. Copayment amounts can vary depending on the service, the type of health care provider, and whether the provider is in or out of network. Copayments do not count toward your deductible or out-of-pocket maximum.
Out-of-network providers do not have contracts with us to agree to lower negotiated rates, thus, they can bill you for more than your plan's allowed amount. Also, if you or the out-of-network provider does not get prior review or prior authorization for services that require such approval in advance, the out-of-network provider can bill you for the entire charge. If you have any excluded services, (services your plan does not cover) they will appear in this column as well.
The amount you owe the provider, including any applicable copayment, deductible, coinsurance, or other liability. If you have already paid a copayment or any other upfront payment to the provider, it will not be reflected here. This information will help you confirm that anything you paid to the health care provider at the time of service was the correct amount per your plan. For instance, you may have paid a copayment amount of $15 at the time of service. You will note that the copayment amount on your EOB correctly shows $15, but the $15 is not subtracted from the TOTAL amount that appears on the EOB. Your plan is not notified by your provider when you have made any payments to them.
Indicates an explanation is available in the "What Our Codes Mean" section at the end of the EOB. These reasons are used to explain how a service was processed and gives additional information to help you understand how the plan determined what it will pay for the services you received.