Explanation
of Benefits forms (EOBs) are sent by payors to both members
and NCPPO and HealthLink. 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)
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