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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: Madison Johnson Facility/Physician: Julien Osborne Date of Service: 04/04/2006   Claim Number: 205MR064501 Status: Processed 04/15/2006 Download Explanation of Benefits (EOB) Download HRA   Explanation of Benefits (EOB) Date Received: 04/10/2006   Services and Charges Remark Code Description Date of Services Billed Amount Network Discount Applied to Deductible Paid by Plan Patient Responsibility DO* Office Visit $193.00 $96.99 Madison $96.01 Family $96.01 $0.00 $96.01 Subtotal(s) $96.01 Totals $193.00 $96.99 Madison $96.01 Family $96.01 $0.00 $96.01 Paid from HRA Paid at Visit Already Paid $96.01 $0.00 *$96.01 Amount You May Owe $0.00 * Does not reflect dollars paid at the time of the visit, such as copayments or coinsurance. Claim Notes *Remark Code DO: Options PPO Network Discount Applied Network Status: Claim was processed as In Network Member Responsibility: Deductible has not been satisfied. Claim History Date Activity 04/04/2006 Date of service 04/10/2006 Claim Received 04/15/2006 Claim processed 04/20/2006 Payment #216944 sent to provider Julien Osborne 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?