UPMC for Life | Explanation of Benefits (EOB) Tutorial

UPMC for Life 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

000001
John / Jane Doe
123 Main Street
Pittsburgh, PA 15212

Statement Date:
Member:
Member ID:
Group Name:

June 30, 2007
John/Jane Doe
ID Number
Medicare HMO

This is not a bill. It explains payments made by UPMC Health Plan 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
You can also register on our website to review claims, benefits, and copayment information at any time.

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:	$256.26
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.	$35.00
Total amount denied - Denial explanation code$s$ detail listed in Claim Detail Information. See next page$s$.	$10.00

Deductible/Out-of-Pocket Status:

Network accumulations:

These payments contibuted $200.00 of your $500.00 individual out of pocket maximum for the 2007 benefit year.

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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	218.26	38.00
Deductible:	0.00	0.00	0.00
Copayment:	0.00	25.00	10.00
Coinsurance:	N/A	N/A	N/A
Member Responsibility:	2.69	25.00	10.00
Explanation Codes:	10	C0	C0

Explanation Code Descriptions:

10 - Claims must be submitted within timely filing limits.

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

IMPORTANT INFORMATION ABOUT YOUR APPEAL RIGHTS
For more information about your appeal rights, call us or see your Evidence of Coverage.

What If I Don't Agree With This Decision?
You have the right to appeal. To exercise it, file your appeal in writing within 60 calendar days after the datet of this notice. We can give you more time if you have a good reason for missing the deadline.

Who May File An Appeal?
You or someone you name to act for you (your authorized representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others also already may be authorized under State law to act for you.

You can call us at: 1-877-539-3080 to learn how to name your authorized representative. If you have a hearing or speech impairment, please call us at TTY/TTD 1-800-361-2629.

If you want someone to act for you, you and your authorized representative must sign, date and send us a statement naming that person to act for you.

How Do I File An Appeal?
You or your authorized representative should mail or deliver your written appeal to the address(es) below:

Mailing address:

UPMC for Life
P.O. Box 2939
Pittsburgh, PA 15230-2939

Physical address:

UPMC for Life
One Chatham Center
112 Washington Place
PIttsburgh, PA 15219

We must give you a decision no later than 60 calendar days after we receive your appeal.

What Do I Include With My Appeal?
You should include: your name, address, Member ID number, reasons for appealing, and any evidence you wish to attach. You may send in supporting medical records, doctors' letters, or other information that explains why we should pay for the service. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person if you wish.

What Happens Next?
If you appeal, we will review our decision. After we review our decision, if payment for any of your claims is still denied, Medicare will provide you with a new and impartial review of you case by a reviewer outside of your Medicare Health Plan. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.

Contact Information:
If you need information or help, call us at:

Toll Free: 1-877-539-3080
TTY: 1-800-361-2629

Other Resrouces To Help You:
Medicare Rights Center
Toll Free: 1-888-HMO-9050

Elder Care Locator
Toll Free: 1-800-677-1116

1-800-MEDICARE (1-800-633-4227)
TTY: 1-877-486-2048

Form No. CMS-10003

Exp. Date 8/31/2010

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0829. The time required to complete this information collection is estimated to average 6.3 to 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Office, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850,