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EOB
Requirements |
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| Explanation
of Benefits forms (EOBs) are sent by payors to both members
and NCPPO. These EOBs provide necessary information about claim
payment information and patient responsibility amounts. Sample
EOBs are provided initially when implementing the payor contract.
Compliance is checked periodically thereafter. Patient responsibility
amounts are needed for accurate patient balance billing. This
is an important aspect of the "Explanation of Benefits"
review process.
Both member and provider Explanation
of Benefits (EOBs) shall include the following elements:
- Name and address of payor *
- Toll-free number for payor *
- Subscriber's name/address *
- Subscriber's identification
number*
- Patient's name *
- Provider's name *
- Provider's tax identification
number (TIN) *
- Provider's participation status
(PPO, HMO)
- Claim date of service *
- Type of service
- Total billed charges *,
allowed amount * and discount amount
- Excluded charges
- Explanation of excluded charges
(code and associated key)
- Amount applied to deductible
- Co-payment/co-insurance amount
- Total patient responsibility
amount *
- Total payment made and to
whom *
- Benefit level information
(annual deductible/amount applied, annual out-of-pocket/amount
applied, lifetime maximums/amount applied)
- ERISA disclosure (if applicable)
- Discount Remarks - "Discount for NCPPO Participation" *
Required information on the
list above is indicated by an asterisk (*).
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