Message Center Account Settings Print Help Contact Us Feedback Sign Out

Home   Claims & Accounts   Physicians & Facilities   Pharmacies & Prescriptions   Benefits & Coverage   Personal Health Record   Health & Wellness

Claims & Accounts Account Balances   Medical Claim Summary Health Reimbursement Account Health Savings Account Flexible Spending Account(s) View Statements Other Claims Prescription Claims Dental Claims Vision Claims Mental Health Claims Member Actions Submit a Claim Appeal a Claim Automatic Payment Options Mailing Preferences Direct Deposit Coordination of Benefits Request ID Cards Claim Detail Back to Medical Claim Summary Patient: Pat Johnson Facility/Physician: Scott Murray Date of Service: 04/12/2006 - 04/16/2006   Claim Number: 205MR040100 Status: Processed 04/25/2006 Download Explanation of Benefits (EOB) Download HRA  Explanation of Benefits (EOB) Date Received: 04/20/2006   Services and Charges Remark Code Description Date of Services Billed Amount Network Discount Applied to Deductible Paid by Plan Patient Responsibility M3* Office visit $127.50 $0.00 Pat $0 Family $0 $76.50 Coinsurance    $51.00 Office Visit 04/12/2006 $61.20 $0.00 Pat $0 Family $0 $34.80 Coinsurance Above U&C $23.20 $3.20 $26.40 Laboratory Services 04/12/2006 $25.50 $0.00 Pat $0 Family $0 $15.30 Coinsurance $10.20 Laboratory Services 04/12/2006 $25.50 $0.00 Pat $0 Family $0 $15.30 Coinsurance $10.20 Office Visit 04/14/2006 $61.20 $0.00 Pat $0 Family $0 $34.80 Coinsurance Above U&C $23.20 $3.20 $26.40 Laboratory Services 04/14/2006 $61.20 $0.00 Pat $16.40 Family $16.40 $34.80 Copay Deductible $10.00 $16.40 $26.40 Subtotal(s) Pat $16.40 Family $16.40   Coinsurance Above U&C Copay Deductible $138.20 $6.40 $10.00 $16.40 Totals $362.10 $0.00 Pat   $16.40 Family   $16.40 $211.50 $150.60 Paid from FSA Paid from HRA Paid at Visit Already Paid $114.20 $16.40 $10.00 *$140.60 Amount You May Owe $10.00 * Does not reflect dollars paid at the time of the visit, such as copayments or coinsurance. Claim Notes *Remark Code M3: Exceeds Usual & Customary Charges in Geographic Area Network Status: Claim was processed as out-of-network Member Share: Deductible has been satisfied. Out-of-network coinsurance of 40% applied. Claim History Date Activity 04/12/2006 Date of service 04/20/2006 Claim Received 04/25/2006 Claim processed 05/01/2006 Payment #216244 sent to provider Scott Murray The Explanation of Benefits (EOB) is in PDF format. You must have Acrobat Reader® to view these files.       Also See   View personal health record Look up medical benefits     Common Questions more   What do I do if I don’t agree with the way a claim was processed? How can I see my medical history?