Fringe Benefits Plans for Government Contractors
Members: EOB
Explanation of Benefits
| 1. | Participant ID: The last four digits of the employee social security number/ The FCE generated identification number assigned to the claim. | |
| 2. | Employee Class: Level of benefits participant eligible for at date of service. | |
| 3. | Service Provider: The health care professional who is indicated on the claim as having provided the service. | |
| 4. | Claim Number: The FCE generated identification number assigned to the claim submitted by your provider. | |
| 5. | Network Status: Identifies whether the health care professional was a participating network provider on the date of service. | |
| 6. | Type of Service: A brief description of what services were provided on the dates listed. | |
| 7. | Service Dates: The date services were provided to patient listed. | |
| 8. | Total Billed: What the health care provider charged for the services listed. | |
| 9. | Re-Priced Amount: Amount of charge after network discount (if any) | |
| 10. | Allowed Amount: Amount of the charge that was allowed according to plan specifications and after any discount | |
| 11. | Co-pay/Deductible: A cost-sharing feature of your plan where you pay for some healthcare services up to a specified amount before the Plan begins to pay. | |
| 12. | Patient Responsibility: Total amount due from participant. | |
| 13. | Out of Pocket: The maximum amount of money you must pay during a calendar year for Covered Services that are subject to your deductible and coinsurance. | |
| 14. | Other Ins. Pay: Amount of payment from another insurance policy | |
| 15. | Co-Insurance: A cost-sharing feature of your plan where you and the Plan pay a percentage of the covered services. | |
| 16. | Co-Insurance %: The percentage of payment the Plan is responsible for. | |
| 17. | Paid: The actual dollar amount the FCE administered Plan paid to the healthcare provider, which may be less than what the healthcare provider charged. | |
| 18. | Code Explanation: The explanation of how a claim was processed if other than just paid. | |
| 19. | Member Deductible 4th Q + YTD: Identifies the deductible that has been met for the current year and the last quarter of the preceding year for the member. | |
| 20. | Family Deductible YTD: Identifies the deductible that has been met for the current year and the last quarter of the preceding year for the family participants. | |
| 21. | Out of Pocket YTD: The total out of pocket expenses (any deductible & co-insurance amounts) for the year. (see SPD for exclusions) | |
| 22. | Family Out of Pocket YTD: The total out of pocket expenses accumulated by all family participants for the year. | |
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