UPMC for Kids | Explanation of Benefits (EOB) Tutorial

UPMC for Kids Explanation of Benefits (EOB) Tutorial

How to use this online tutorial:
Use your mouse to roll over the different sections of the EOB for a more detailed explanation.

PAGE 1

One Chatham Center
112 Washington Place
Pittsburgh, PA 15219

Explanation of Benefits (EOB)
This is not a bill

John / Jane Doe
123 Main Street
Pittsburgh, PA 15212

Statement Date:
Member:
Member ID:

June 30, 2007
John/Jane Doe
ID Number

This is not a bill. It explains payments made by UPMC for Kids to health care providers for claims they submitted for health care services you recently received.

Any additional payments that are your responsibility are listed.
You can access our "Beginners's Guide to EOB's" on our website: www.upmchealthplan.com

In some cases, services that you have received may NOT be covered, either because they are not part of your health benefits package or because you have exceeded the maximum allowable benefit for those services. A provider has the right to bill you for any portion of the submitted charges that has not been covered under your benefit plan.

Claims Summary at a Glance:
Total amount billed by providers:	$368.00
Total amount paid by UPMC Health Plan directly to your providers:	$281.26
Total Network Discount:	$66.74
Total Amount you owe: If you have not already paid these individual amounts, each provider can bill you for the amount listed in the Member Responsibility Detail Information section. If a provider bills you for more than the amount listed, ask the provider for an explanation or contact your health plan for additional information.	$10.00
Total amount denied — Denial explanation code(s) detail listed in Claim Detail Information. See next page(s).	$10.00

PAGE 2

One Chatham Center
112 Washington Place
Pittsburgh, PA 15219

Explanation of Benefits (EOB)
This is not a bill

Claim Detail Information
Claim Number:	0123456789E200700630	02468013579E200700630	01357902468E200700630
Provider:	ABC Provider	ABC Provider	ABC Provider
Network Participation:	Yes	Yes	Yes
Dates of Service:	4/19/2005	4/25/2007	3/10/2006
Description of Service:	Allergen immunotherapy	Ambulance	Office/Outpatient Visit, ES
Billed Amount:	10.00	310.00	48.00
Network Discount:	7.31	66.74	0.00
Other Insurance Payment:	0.00	0.00	0.00
Health Plan Payment:	0.00	243.26	38.00
Deductible:	N/A	N/A	N/A
Copayment:	0.00	0.00	10.00
Coinsurance:	N/A	N/A	N/A
Member Responsibility:	0.00	0.00	0.00
Explanation Codes:	DH	0A	C0

Explanation Code Descriptions:

DH — Our records indicate this claim has been previously processed
0A — Paid at contracted rate - do not bill member
C0 — A copay has been applied to this service

IMPORTANT INFORMATION FOR YOU FROM UPMC HEALTH PLAN

This Explanation of Benefits (EOB) gives you important information about health benefits that have been provided to you and billed to UPMC Health Plan. If any additional materials or information may be necessary to consider your claim and to learn why such materials or information are necessary, please contact your plan administrator, UPMC Health Plan, 112 Washington Place, Pittsburgh, PA 15219, or visit our website: www.upmchealthplan.com

DO NOT SEND PAYMENT UNLESS YOU RECEIVE A BILL DIRECTLY FROM YOUR PROVIDER. If you are billed for more than the amount listed in the Member Responsibility section of this EOB, ask your provider for a detailed explanation before paying.

Please refer to the information in your Schedule of Benefits in your member materials concerning benefit exclusions and member cost-sharing responsibilities, if you wish to have any further details in regard to the benefit determination in this EOB.

Should you have any questions concerning this benefit determination, please call the Member Services Department at 1-877-381-3764, or write to us at UPMC Health Plan, PO Box 2999, Pittsburgh, PA 15230-2999. Please reference the corresponding claim number and provider name when inquiring about a benefit determination.

If you suspect fraud or abuse involving your health insurance, please call the toll-free UPMC Health Plan Fraud and Abuse Hotline at 1-866-FRAUD-01 (1866-372-8301). Thank you.

PAGE 3

Process to Request a Review of this Benefit Determination

If you disagree with the benefit determination that UPMC for Kids made for the claim(s) covered on this Explanation of Benefits (EOB), you may request that the decision be reviewed. UPMC for Kids has established a two-level internal process to review all member complaints and grievances.

The complete description of the complaint and grievance process is in the UPMC for Kids Member Handbook. A brief description of the process is listed below:

For a full description fo the UPMC for Kids Complaint and Grievance Process, please refer to the UPMC for Kids Member Handbook and the Exclusions booklet.

If you have any questions concerning the complaint and grievance process, please call the Member Services Department at 1-800-650-8762. TTY users should call 1-800-361-2629. Member Services staff are available to answer you calls Monday through Friday from 8 a.m. to 8 p.m. and on Saturday from 8 a.m. to 3 p.m. You can also send a complaint or grievance to:

UPMC for Kids
Complaints and Grievances Department
P.O. Box 2939
Pittsburgh, PA 15230-2939