Explanation of Benefits (EOB) Printer Friendly

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 HealthLink Participation” *
  • National Provider Identifier for the Rendering Provider (by 5/23/07)

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

Please call 800-235-0306 with any questions or email PayorRelations@HealthLink.com.