 |
EOB
Requirements |
| |
|
- Name and Address of Payor *
- Toll Free Number for 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 *
- Discount Amount
- Allowed Amount *
- Excluded Charges
- Explanation of Excluded Charges
(Code and Associated Key)
- Amount Applied to Deductible
- Co-Payment/Coinsurance Amount
- Total Patient Responsibility
*
- 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 HealthLink Participation" (Must Include Network
Name) *
Required information on
the list above is indicated by an asterisk (*).
|
|
|
|