Document 6509295

How to understand your Explanation of Benefits
Every time you file a medical claim or a health care provider files a claim on your behalf, you will receive an Explanation of Benefits (EOB).
An EOB isn’t a bill. It provides important information about how your medical claims are processed with detailed information explaining the medical
treatment or services that have been rendered. This helps you understand the benefits you receive at KPS Health Plans and know your share of the cost.
1
Payment Summary – The accumulation
of all total charges for this claim.
Total claim charges – The total amount
your provider has billed for the services
rendered on this claim.
Total allowed charges – The maximum
amount KPS Health Plans allows for the
procedure(s) billed by your provider for
this claim.
Total deductible – This amount reflects
how much was processed towards your
KPS yearly deductible. The amount of your
deductible depends on the plan which you
are enrolled.
Total coinsurance – This amount reflects
the percentage of which your benefits are
covered. This applies after all applicable
deductible and copays. Example: After
you’ve met the deductible, KPS Health
Plans pays 80% of the allowed amount.
Coinsurance will reflect the remaining
20% of the allowed amount.
Total copay – The amount an insured
member is expected to pay for medical
expenses at time of the visit.
CLAIM SUMMARY
Patient:
Member ID:
Subscriber:
Group:
Group Number:
Provider:
Provider Acct.:
Claim Number:
Diagnosis:
1
PAYMENT SUMMARY (This is NOT a bill)
SAM SMITH
123456789 01
SAM SMITH
GROUP NAME
1234567
PROVIDER ABC
99999
99999999999
847.0 SPRAIN OF NECK
Details regarding the
subscriber’s name and
group plan.
The member suffix is here.
Total claim charges:
Total allowed charges:
Total deductible:
Total coinsurance:
Total copay:
Other insurance paid:
$80.00
$60.00
$0.00
$12.00
$0.00
$0.00
Your total responsibility:
Total paid:
Check No.:
Check Date:
Payment made to:
$12.00
$48.00
2
CLAIM DETAILS
Date of
Service
Service
Description
Service
Code
Provider
Billed
Plan
Allowed
Plan
Paid
Patient
Responsibility
Code
11/18/2012
MASSAGE THERAPY
97124
$80.00
$60.00
$48.00
$12.00
303 327
Total
$80.00
Code Description
A coinsurance has been applied to this service
Reduced amount by max allowed
$60.00
$48.00
$12.00
Code
303
327
2
Claim Details – This will provide you a brief description of how your claim was processed.
Date of service – The day you received medical care from your provider.
Service description – The medical service or item received from your provider.
Other insurance paid – The amount the
other insurer paid on behalf of your claim.
Service code – A medical code that helps identify the services you received.
Your total responsibility – Is an
accumulation of all Patient charges
you are responsible for pertaining to
this claim. The total charges include
deductible, coinsurance and copays. If
applicable, Non- allowed services or out
of network provider will reflect in this
total amount.
Plan allowed – The maximum amount KPS health plans allows for the procedure(s) billed by your provider for these services. NOTE: If your
provider has a participating agreement with KPS Health Plans, he/she is responsible to write off the difference between the billed amount and
the KPS Health Plans allowed amount. That difference would not be the patient’s responsibility.
Provider billed – The amount your provider has billed for the services provided.
Plan paid – The amount paid by KPS Health Plans to your provider in accordance to your plan’s benefits.
Patient responsibility – The amount you are responsible paying your physician pertaining to this claim.
16KPS-2012-092012