THIS IS NOT A BILL

HOW TO READ
YOUR EXPLANATION
OF BENEFITS (EOB)
11. T
he address to which the EOB
was mailed.
22. G
roup Name—the payor of your medical
claim. If your company is a self-funded
group, their name will appear here.
33. Insured—the person who holds the
contract with the insurer.
What is an Explanation of Benefits (EOB)?
44. Patient—the person who received
An EOB is a notification from Coventry Health Care explaining
how your medical claim(s) are processed (including a payment
or denial).
55. ID Number—the identification for the
medical services. This may be a
subscriber or a dependent.
person receiving medical services.
66. C
laim Number—document control
Is an EOB a bill from the insurance company?
No, Coventry Health Care does not bill members for medical
services. Coventry Health Care processes and pays the claims
submitted from your provider or hospital.
number generated by Coventry Health
Care. If you need to call a member
service representative to discuss the
claim, this is an important number to
give them.
78. Provider—the provider of your medical
service. This could be an individual
practice or facility.
Page 1 of 2
Coventry Health Care Management Corporation
In Trust for Self Funded Group
3721 TecPort Dr
P.O. Box 67103
Harrisburg PA 17106
THIS IS NOT A BILL
EXPLANATION OF BENEFITS
Our organization processes and pays
the claims submitted from your health
care provider(s). You have received this
Explanation of Benefits (EOB) as our
notification to you explaining how your
medical claim(s), including payments or
denials, are being processed.
Member, Mrs.
630000 M RD
NOWHERE PA 15555
1
Payments made on behalf of:
2
3
4
5
GROUP NAME
Insured:
Patient:
Group Name:
ID Number:
Date:
8 Member Responsibility:
$10.00
$118.00
6 Claim Number:
18 Plan Paid:
9XXXXXX2
$751.00
8 Member Responsibility:
$0.00
Provider:
Provider Billing Address:
7 M GENTS
710 ELM STREET
ALLENTOWN, PA 18109-2732
Member’s Responsibility to Provider
Contractual
Adjustment
12
Approved
Amount
13
Copay
14
Coins
15
Deduct.
16
Other
17
Plan
Paid
18
$30.73
$87.27
$10.00
$0.00
$0.00
$0.00
$77.27
$30.73
$87.27
$10.00
$0.00
$0.00
$0.00
$77.27
Provider:
Provider Billing Address:
Cont.
Rmk
/
Other
Rmk
19
TOTALS:
Coventry agrees to pay the provider
for services rendered minus copays,
coinsurance or deductibles, if applicable.
14 Less Copay
7 WEST SLEEP MEDICINE
1260 MADISON STREET
ALLENTOWN, PA 18109-2729
15 Less Coinsurance
16 Less Deductible
8
9 01/23/08
95810/MEDICINE 10
coverage category for which the code
is classified.
13 Approved Amount—the amount
**Provider billing address may differ from physical office location**
Service Date From - To
Procedure Code/Description
10 Procedure Code/Description—the
in payment due to network savings,
coordination of benefits, or non-covered
services. For more information, see
number 19, Cont. Rmk/Other Rmk.
8
TOTALS:
were incurred.
12 Contractual Adjustment—reductions
**Provider billing address may differ from physical office location**
Service Date From - To
Billed
Procedure Code/Description Amount
11
9 01/23/08
99244/MEDICINE 10
$118.00
97. Date—the date your medical services
Coventry Health Care by your physician.
**Payments made at the time services were rendered are not reflected on this statement**
2XXXXX879
$77.27
amount the member may be responsible
to pay the provider.
11 Billed Amount—the total amount billed to
Member, Mrs.
Member, Mrs.
GROUP
85XXXXXXX01
01/23/08
6 Claim Number:
18 Plan Paid:
89. M
ember Responsibility—this is the
Member’s Responsibility to Provider
Billed
Amount
11
Contractual
Adjustment
12
Approved
Amount
13
Copay
14
Coins
15
Deduct.
16
Other
17
Plan
Paid
18
$1,200.00
$449.00
$751.00
$0.00
$0.00
$0.00
$0.00
$751.00
$1,200.00
$449.00
$751.00
$0.00
$0.00
$0.00
$0.00
$751.00
Cont.
Rmk
/
Other
Rmk
19
To ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. If you believe any
of the services were incorrectly billed, contact a customer service representative using the toll free number listed below.
17 Less Other Amounts
18 Plan Paid—the amount paid by
your plan.
19 Cont. Rmk/Other Rmk—a Coventry
Health Care code that explains why
certain amounts were not covered.
HOW TO READ YOUR MEMBER BENEFIT USAGE
A
Benefits Header
B
Benefit Period Header
• This introductory language
precedes the Benefits
Accumulation Summary.
• This identifies the period
(in date form) in which
benefits are calculated.
• This date reflects
when your claims
were processed.
• This could be by
calendar year or
contract benefit year.
A
B
• The information displayed
in the columns below is
based upon your benefit
plan.
The amounts below include claims processed as of February 23, 2008.
The information does not reflect any claims received or adjusted
after the above mentioned date.
Member Benefit Usage for Dates of Service January 1, 2008 – December 31, 2008.
Deductible Dollars
1
Out-of-Pocket Dollars
Year-to-Date
Satisfied
Maximum
$
Remaining
$
Year-to-Date
Satisfied
Maximum
$
Remaining
$
In-Network
Indiv.
$10.00
$200.00
$190.00
$0.00
$1,000.00
$1,000.00
Out of Network
Indiv.
$0.00
$400.00
$400.00
$0.00
$2,000.00
$2,000.00
1
2
3
4
5
6
7
Type
C
Benefit Accumulation
Summary
C
Type—displays the benefit coverage level where dollars
have been used or are tracked. If you have different
spending limits for different types of benefits, such as
in-network or out-of-network, they will be listed as
different types. For example, they may be listed as
individual or family.
2
Year-to-Date Satisfied—total amount spent or credited
towards the maximum amount you are required to pay
before additional benefits are available.
3
Maximum $—total amount you must spend in the
benefit year before your additional insurance benefits
are available.
4
Remaining $—total amount you have left to pay on your
deductible before the maximum limit is met and your
other insurance benefits apply (Maximum minus
Year-to-Date Satisfied).
5
Year-to-Date Satisfied—total amount spent or credited
towards the maximum amount you are required to pay in
the benefit year.
6
Maximum $—total amount you may be responsible for in
a benefit year based on your benefit plan design.
7
Remaining $—total amount you have left to pay before
the maximum limit is met (Maximum minus Year-to-Date
Satisfied).
If you have questions, call the
member services number printed
on your ID card.
0108