UPMC Health Plan

One Chatham Center
112 Washington Place
Pittsburgh, PA 15219

Explanation of Benefits (EOB)
This is not a bill

000001
John Doe
123 Main Street
Pittsburgh, PA 15212

Statement Date:
Member:
Member ID:
Group Name:

June 30, 2007
John/Jane Doe
000029567-02
Acme

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:	$286.56
Total Network Discount:	$74.05
Total Amount you owe: Each provider can bill you for the amount listed in the Member Responsibility Detail Information section, if you have not already paid these individual amounts 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	$0.00
Total amount denied — Denial explanation code(s) detail listed in Claim Detail Information. See next page(s).	$0.00

Deductible/Out-of-Pocket Status:

Non-Contractual accumulations:

You have satisfied $100.00 of your $200.00 individual deductible for the 2007 benefit year.

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

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