How to Read My Explanation of Payment (EOP) Statement

How to Read My Explanation of Payment (EOP) Statement
Delhaize America Employees
Internal Reference: B000P-01
Claim Reference Box
Date: 04/18/11
Employer: Delhaize
Subscriber: John Doe
Subscriber ID: W12345678901
Date Paid: 04/18/11
Check No: 123456
Total Paid to Provider: $79.15
Provider: NAME OF MEDICAL GROUP INC
Contact Information:
Phone Number: 1-888-709-7092
Fax Number: 1-877-733-3964
Email Address: fundservices@bcbsnc-fund.com
HRA – PAY TO PROVIDER STATEMENT – SUBSCRIBER COPY
1
Claim No.
BNC001234567890E00000001
Patient Name
Service Date
Service Type
Submitted
Paid
Pended
Denied
John Doe
03/24/11 – 03/24/11
Medical
$79.15
$79.15
$0.00
$0.00
$79.15
$79.15
$0.00
$0.00
Total
Explanation of Amount Pended or Denied
1
3
2
Employer
Contribution
Amount of funds
that Delhaize has
committed to
your HRA
account,
including rollover
funds from prior
year. These
funds may be
used to offset
your liability
under your
medical plan.
4
Submitted
The amount in the Submitted column
will match the “Amount Your Provider
May Bill You” / TOTAL amount in your
Explanation of Benefits (EOB).
5
6
7
Submitted
Paid
Pended
Denied
Available Balance
BCBSNC will
forward your
medical claim to
the BCBSNC
Fund
Administrator to
be processed
through your
HRA account.
Amount BCBSNC
paid from your
HRA account. In
most instances,
HRA
reimbursement
will be sent to
your provider.
This column is
only populated if
you have an FSA
account with
BCBSNC.
Amount of either:
the HRA
reimbursement
request that
exceeds the
available funds in
your HRA
account, or an
ineligible
expense.
Amount remaining in
your HRA account.
At the end of the
medical plan year, you
can roll over the
available balance to
next year, with a
maximum roll-over
amount of $5,000.
Paid
Pended
Denied
Available Balance
HRA Cumulative Account Balance
Employer Contribution
$625.00
2
Submitted
3
$79.15
4
$79.15
5
$0.00
6
$0.00
7
NOTE: This document gives highlights of the Delhaize America benefit programs. It is not intended to be a Summary Plan Description (SPD).
If there are differences between the document and the SPD or plan document, the terms of the SPD and plan document will control.
® Marks of the Blue Cross and Blue Shield Association. Blue Cross and Blue Shield of North Carolina is an independent licensee of
the Blue Cross and Blue Shield Association. 11/2011
$545.85