UMR How To Read Your EOB SAMPLE T

000001
PO BOX 30541
Salt Lake City, UT 84130-0541
UMR How To
Read Your EOB
SAMPLE
00001 001
JOE PATIENT
123 ABC LANE
ANYTOWN USA 99999-9999
CONCERNS?
T QUESTIONS?
Contact your Customer Service Representative at 1-866-684-8090.
U INTERNET:
Online services are available 24 hours a day at www.umr.com.
.
Claim payment detail
Claim status
Benefit information
Eligibility
Order an ID card
Many other services!
V APPEAL:
You may file an appeal of the claim decision by sending a written request and pertinent
information within 180 days from the date of this Notice to "Claims Appeal Unit, P.O.
Box 30546, Salt Lake City, UT 84130-0546.” Refer to your current benefit booklet for
information on the appeal process. After you have exhausted the mandatory appeal
levels that are described in your benefit booklet, you have the right to bring a civil
action under section 502(a) of the Employee Retirement Income Security Act (ERISA).
STOP FRAUD!
W HELP
If you know or suspect any illegal activity concerning claims, contact our anti-fraud unit
by calling our toll-free number 1-800-356-5803. You do not need to identify yourself.
Refer to your benefit booklet for more details on Claim determination.
© 2010 United HealthCare Services, Inc. UM0088-CPS 07-10
No part of this document may be reproduced without permission.
Please retain this statement for future reference.
C
Provider: Physician,Joe,MD
PO Box 30541 Salt Lake City, UT 84130-0541
1-866-684-8090
www.umr.com
Service Description
Amount
Not Payable
908
See Note
Section
$50.00
SAMPLE
Amount
Billed
$25.00
Less
Deductible
B
Allowable
Amount
$25.00
D Patient Account: 05050505aa
$100.00
EXPLANATION OF BENEFITS NOTICE - THIS IS NOT A BILL
01-01-08
Dates of Service
From:
To:
Plan
Benefit Amount
Employee
Member Number
Patient
Notice Date
Employer Name
Employer Number
%
$20.00
Amount
Paid
$20.00
Page
Dist Code
Joe Patient
999999999
Joe Patient
02-01-08
Customer Inc.
7670-00-999999
Provider May
Bill You
$55.00
E Claim Control Number: 08171769999
80
P
members to call if they suspect illegal activity
regarding claims.
01-01-08
WIndicates the toll-free telephone number for
O
to file appeals. This information is provided
in the members’ SPD (Summary Plan
Description). Also indicates the members’
right to file civil action.
99283 - Emergency Care
VIndicates the specific time frame for members
$55.00
paid.
regarding eligibility and claim information.
N
MPercentage at which the Allowable charges are
U Web Site address for members to access
$20.00
difference between the “Amount Billed” and
the “Amount Not Payable” and/or “Less
Deductible” columns.
members to call with questions regarding the
Explanation of Benefits.
UM0088-CPS 08-08
L C
harges allowed for payment – this is the
TUMR toll-free telephone number for
L M
K Amount applied to the deductible.
(see back page of this flyer)
K
were not allowed – see Notes Section.
Cover Page Explanations:
$20.00
J R
efers to codes used to explain charges that
amounts applied to individual/family
deductibles, out-of-pocket and lifetime
maximums, if applicable.
Payment Amount: $20.00
see comment code.
SProvides benefit period and benefit levels,
J
ICharges not allowed according to the Plan –
checks were issued.
I
hospital, physician or other health care
provider.
RList of individuals or organizations to whom
H
H Amount charged for the services by the
Section” column. Lists the specific code and its
definition.
$25.00
hospital, physician or other health care
provider.
G
G D
ates(s) services were performed by the
QExplains codes provided in the “See Notes
$50.00
Service description T9999 will print if dollars
are available to be reimbursed from HRA.
the hospital, physician or other health care
provider, if applicable.
Payment Date: 09-01-08
performed by the hospital, physician or other
health care provider.
F
F Services and/or procedures that were
POnly amount you are responsible to pay to
$100.00
to each claim received.
TOTALS
E UMR assigns a unique claim control number
Q
physician or other health care provider.
OAmount that UMR paid to the provider.
Applied To Date
$1,500.00
$200.00 Met
$300.00
$205.00
$305.00
D A
ccount number assigned by the hospital,
Charge reduced due to provider’s discount.
provider that performed the services.
Note Section
CHospital, physician or other health care
NAmount actually payable by the Plan.
908
which the claim was processed.
R
BFields include member information under
Payment To: XYZ Clinic
S
EOB Field Explanations:
Benefit Period Benefit Level
$1,000,000 Lifetime Maximum
$200 Ind Cal Yr Deductible
$400 Fam Cal Yr Deductible
$400 Ind Out-Of-Pocket
$800 Fam Out-Of-Pocket
01-01-08
01-01-08
01-01-08
01-01-08
How To Read
Your EOB
000001
PO BOX 30541
Salt Lake City, UT 84130-0541
UMR How To
Read Your EOB
SAMPLE
00001 001
JOE PATIENT
123 ABC LANE
ANYTOWN USA 99999-9999
CONCERNS?
T QUESTIONS?
Contact your Customer Service Representative at 1-866-684-8090.
U INTERNET:
Online services are available 24 hours a day at www.umr.com.
.
Claim payment detail
Claim status
Benefit information
Eligibility
Order an ID card
Many other services!
V APPEAL:
You may file an appeal of the claim decision by sending a written request and pertinent
information within 180 days from the date of this Notice to "Claims Appeal Unit, P.O.
Box 30546, Salt Lake City, UT 84130-0546.” Refer to your current benefit booklet for
information on the appeal process. After you have exhausted the mandatory appeal
levels that are described in your benefit booklet, you have the right to bring a civil
action under section 502(a) of the Employee Retirement Income Security Act (ERISA).
STOP FRAUD!
W HELP
If you know or suspect any illegal activity concerning claims, contact our anti-fraud unit
by calling our toll-free number 1-800-356-5803. You do not need to identify yourself.
Refer to your benefit booklet for more details on Claim determination.
© 2010 United HealthCare Services, Inc. UM0088-CPS 07-10
No part of this document may be reproduced without permission.
Please retain this statement for future reference.