Your health care [plans may add the following phrase, if preferred: and long-term services and supports] claims for [insert month and year or date range] [Insert information for all claims processed during the reporting period.] [If the EOB is being sent to a member who did not have any health care claims or long-term services and supports claims during the reporting period, (1) insert the following note in the first column: No health care claims or long-term services and supports claims for <insert month and year or date range>; and (2) insert amounts of for the columns labeled “$0.00” “Plan’s and share” “Your share.”] NOTE: To describe the services you got, this report uses billing codes and descriptions that were developed and copyrighted by the American Medical Association (all rights reserved). If you do not understand any of the services listed below, call us at <toll-free number> and we can explain the services. <Provider name> Date(s) of service Your share Plan’s share [Insert as applicable: In-network or Out-of-network] provider The date(s) you got The amount <plan The amount you may Claim Number: <Claim number> the services name> pays for the need to pay for the services services [Show each service or item in a separate row.] [Insert date(s) of $[Insert plan share $[Insert member service, using amount for this liability amount for [Insert description of the service or item that was provided, mm/dd/yy format.] service or item.] this service or item.] using the American Medical Association (AMA)'s HCPCS code descriptors and CPT consumer descriptors, followed [Note: If service or by the HCPCS or CPT billing code shown in parentheses. item has been For example: Air and bone conduction assessment of denied, use either hearing loss and speech recognition (billing code 92557).] the maximum When HCPCS or CPT codes are not available, health care potential liability or information in the EOB may include NOC codes and for the “$0.00”
Your health care [plans may add the following phrase, if preferred: and long-term services and supports] claims for [insert month and year or date range] [Insert information for all claims processed during the reporting period.] [If the EOB is being sent to a member who did not have any health care claims or long-term services and supports claims during the reporting period, (1) insert the following note in the first column: No health care claims or long-term services and supports claims for <insert month and year or date range>; and (2) insert amounts of “$0.00” for the columns labeled “Plan’s share” and “Your share.”] NOTE: To describe the services you got, this report uses billing codes and descriptions that were developed and copyrighted by the American Medical Association (all rights reserved). If you do not understand any of the services listed below, call us at <toll-free number> and we can explain the services. <Provider name> [Insert as applicable: In-network or Out-of-network] provider Claim Number: <Claim number> Date(s) of service The date(s) you got the services Plan’s share The amount <plan name> pays for the services Your share The amount you may need to pay for the services [Show each service or item in a separate row.] [Insert description of the service or item that was provided, using the American Medical Association (AMA)'s HCPCS code descriptors and CPT consumer descriptors, followed by the HCPCS or CPT billing code shown in parentheses. For example: Air and bone conduction assessment of hearing loss and speech recognition (billing code 92557).] When HCPCS or CPT codes are not available, health care information in the EOB may include NOC codes and [Insert date(s) of service, using mm/dd/yy format.] $[Insert plan share amount for this service or item.] $[Insert member liability amount for this service or item.] [Note: If service or item has been denied, use either the maximum potential liability or “$0.00” for the
EOBIntegrated_CY2018.docx