Explanation of Benefits (EOB)

Explanation of Benefits forms (EOBs) are sent by payors to both enrollees and providers. These EOBs provide necessary information about claim payment information and patient responsibility amounts. Sample EOBs are provided initially when implementing the payor business. Compliance is checked periodically thereafter. Patient responsibility amounts are needed for accurate patient balance billing. EOB remarks must clearly identify the network name associated with the discount. This is an important aspect of the ?Explanation of Benefits? review process.

Both enrollee and provider Explanation of Benefits (EOBs) shall include the following elements:

• Name and address of payor *
• Toll-free number of payor *
• Subscriber's name/address *
• Subscriber's identification number *
• Patient's name *
• Provider name *
• Provider 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 Remark ? ?Discount For NCPPO/HealthLink Participation? *
• National Provider Identifier for the Rendering Provider

Required information on the list above is indicated by an asterisk (*).

Please contact your Payor Relations Specialist with any questions at 877-284-0101, extension 6132 or email PayorRelations@HealthLink.com.

National Capital Preferred Provider Organization, Inc. ("NCPPO") is a Maryland corporation. HealthLink®, Inc., is an Illinois corporation. Both are organizers of independently contracted provider networks, which are made available by contract to a variety of payors of health benefits, including insurers, third party administrators or employers. Neither has control nor right of control over the professional, medical judgment of contracted providers, nor are they liable for any acts or failures to act, by contracted providers. Neither is an insurance company and neither has liability for benefits under benefit plans offered or administered by payors. HealthLink® is a registered trademark of HealthLink, Inc. Both companies are subsidiaries of WellPoint, Inc.