Explanation of Benefits
Explanation of Benefits or EOB is the detailed statement of the carrier’s determination of the claims processed. The determination can result in a payment or a denial.
The Explanation of Benefits contains the following information:
Name of the payer, Name of the provider, Pay-to address, Name of the patient, Name of the member, his id #, date of service, procedure code, amount billed by the provider, amount allowed by the payer, co-insurance, deductible, amount paid by the payer. The amount paid by the payer is equal to the amount shown by the check.
Serv Date: This field provides the service from and to dates as well as the patient’s responsibility.
POS: The place of service field contains a two digit number that references where the services were rendered.
NOS: The number of service field shows how many services were billed per procedure code.
Proc: The procedure code is located in this column as well as the patients Health Insurance Claim number (HIC) or the Medicare number.
MODS: If any modifiers were billed, they will be located in this field.
Claim Total Fields:
Billed: This field also contains the billed amount per procedure. If the patient account number is reported on the claim, Medicare will display that number in this field.
Allowed: This column displays the allowed amounts per procedure. This amount is based on the Medicare Fee Schedule.
Deduct: If any deductible is applied the amount will show in this field. The Internal Control Number (ICN) will also appear in this column.
Coins: This is the coinsurance field. The amount of the beneficiary’s coinsurance, 20% of the allowed amount, will be displayed here.
Group Reason Code (GRP/RC): Group codes represent the financially responsible party. Reason codes explain denials and payments. These combinations of codes are defined in the glossary at the bottom of the Standard Provider Remittance.
Grp/RC-Amt: This column contains the type of assignment (ASG). A “Y” indicator shows the provider accepted assignment. A “N” indicator shows a non-assigned claim. Under the assignment indicator are the non-covered service amounts. These amounts will equal the difference between the billed amount and allowed amount. The last field in this column is a total of the non-covered amounts.
Prov. Pd: The amount paid per procedure is displayed in this field. Also the total amount paid on this claim is shown in this column. The claim total reported is the net payment. The MOA (Medicare outpatient adjudication remarks) code is the heading. This code does not display any adjustments or reasons. The codes following this heading explain the outcome of the claim, and also need to be defined in the glossary.
Adj. To Totals: Adjustments are printed on the ADJs line.
Prev Pd: For full claim adjustments, the Prev Pd field represents the previous accumulative payment to the provider, on an original claim, and has the GRP/RC-AMT value OA-B13
INT: This field represents the difference between the current interest on the adjustment claim and the previous interest from the original claim.
Late Filing Charge: This field represents the reduction taken when the claim was submitted more than 1 year after the date of service.
Claim Information Forwarded To: This represents the patient’s secondary insurance carrier.
Net: This field represents the net amount for a given claim, which should be the actual amount being paid for that claim to the provider. This field does include interest.
Summary (Totals) fields: # Of Claims: Number of claims displayed on the SPR.
Billed Amt: Total amount billed on the SPR.
Allowed Amt: Total allowed amount on the SPR. This amount is based on Medicare’s Fee Schedule.
Deduct Amt: The total amount of the deductible applied on the SPR.
Coins Amt: Total amount of coinsurance on the SPR.
Total RC-Amt: Total amount of non-covered services. This is the difference between the total billed amount and the total allowed amount.
Prov. Pd Amt: The total amount paid on the SPR. This should be the check amount if no adjustments were made.
ADJS Fields:Prov Adj. Amt: The amount the check has been adjusted from the provider’s aid amount.
Check Amt: The amount of the check.
Offset Fields Offsets to payments are shown as an adjustment from the provider’s payment at the summary level rather than as an adjustment against an individual claim in that remittance notice.
Offset Details: This field displays the reason for the offset. A two letter code is shown. The codes need to be defined in the glossary. AP = Advanced Payment.FB = Balance Forward. This can represent an amount under $1.00 which will be paid in the future. L6 = Interest applied. The difference between the original interest amount and the adjusted interested amount. 50 = Late filing reduction WO = Withholding Offset as a result of a previous payment CS = Adjustment – The amount paid on an original claim for full adjustments. B2 = Refund
FCN: The financial control numbers that associate the offset with those claims and payments that led to the withholding. FCN information is not applicable for IN and LF.
HIC: The field displays the health insurance claim number of the patient who caused the offset. Multiple HIC numbers will not be printed. HIC information is not applicable for IN and LF.
Amount: The amount being withheld or added
Glossary: This is a guide to all the reason codes. Use remarks and codes in the claim detail and summary portions of SPR to determine the outcome of the claim.For complete details regarding the new Standard Paper Remittance, please check your MCS Transition News.