Understanding Your Explanation of Benefits - WPS Health Insurance ...

Understanding Your
Explanation of Benefits
Redesigned with You in Mind.
Your Explanation of Benefits (EOB) is a statement showing how WPS processed the claims for medical services received by
you (or a covered family member). This document is designed to help you better understand your EOB when you receive one
in the mail. Below you’ll find a sample EOB with letters and numbers labeling various important sections. You’ll also find a
coded key providing a description of each lettered or numbered item.
Summary Information:
Lists the person(s) who received
health care services, the total
amount of health care costs
billed, negotiated provider
discounts, amounts not covered,
what we paid, and what you owe.
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Total
Billed
Provider
Responsibility
EXPLANATION OF BENEFITS
THIS IS NOT A BILL - SAVE FOR YOUR RECORDS
Printed on 05/07/2013 Page 2 of 3
DETAIL INFORMATION
(See Remarks for Definitions)
Amount
Not
Covered
Questions
Call (800) 798-8914
TTY/TTD Call 800-351-9945 or 608-222-1879
Claim #: 9239311890 Member #: 000000000 Member Name: SMITH, WILLIAM Patient Name: SMITH, JOHN
Process Date: 05/07/13
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Group #: 123456-00001
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Group Name: ABC SUPPY COMPANY Patient Account: A1111111111
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Services Provided By Service Dates Total Provider Amount Your Your Your Plan Other See
Type of Service
From To Billed Responsibility Not Copay Deductible Coinsurance Paid Insurance Remarks
Servicing Provider
Covered
HYZER, THOMAS S.
80048 - Lab
20130503 20130503 85.00
40.14 0.00 0.00 0.00 0.00 44.86 0.00
HYZER, THOMAS S.
36415 - Surgery
20130503 20130503 29.00
24.92 0.00 0.00 0.00 0.00
4.08 0.00
HYZER, THOMAS S.
84484 - Lab
20130503 20130503 99.00
58.22 0.00 0.00 0.00 0.00 40.78 0.00
HYZER, THOMAS S.
Payment To Provider on 5/8/2013
CLAIM TOTALS: $213.00 $123.28 $0.00 $0.00 $0.00 $0.00 $89.72 $0.00
Claim #: 9239311890 Member #: 000000000 Member Name: SMITH, WILLIAM Patient Name: SMITH, JOHN
Process Date: 05/07/2013 Group #: 123456-00001 Group Name: ABC SUPPY COMPANY - Patient Account: A1111111111
Services Provided By Service Dates Total Provider Amount Your Your Your Plan Other See
Type of Service
Servicing Provider
From To Billed Responsibility Not
Covered
Your
Copay
Your
Deductible
Your
Coinsurance
Plan
Paid
Other
Insurance
R032 R32
R032 R32
R032 R32
Copay Deductible Coinsurance Paid Insurance Remarks
HYZER, THOMAS S.
71020 - Xray
20130503 20130503 130.00 54.00 0.00 0.00 0.00 0.00 76.00 0.00 R032 R32
HYZER, THOMAS S.
Payment To Provider on 5/8/13
CLAIM TOTALS: $130.00 $54.00 $0.00 $0.00 $0.00 $0.00 $76.00 $0.00
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Wisconsin Physicians Service Insurance Corporation
1717 W. Broadway - Box 8190 - Madison, WI 53708
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STATEMENT TOTALS:
REMARKS:
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A
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What
You Owe
$343.00 $177.28 $0.00 $0.00 $0.00 $0.00 $165.72 $0.00 $0.00
R32 - ANSI Code - 45 : Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
Reimbursement according to provider contracted rate.
R032 - WPS PPO preferred provider agreement
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DID YOU KNOW
The Member Health Center at www.wpsic.com provides action-oriented tools and information that you can use in the day-to-day management of chronic
conditions like asthma and diabetes. Visit the WPS website today to learn more!
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Our Phone System Gives You 24/7 Access to Your Health Plan and Benefit Info.
Convenience is key when you need to access your health plan and benefit information. Sometimes the easiest thing is to look it up online at
www.wpsic.com. Other times (like when you're standing at the Clinic Registration counter) it's easier to call. Our 24/7 phone system, combined with our 24/7
website, means you have the flexibility you need to check your information anytime, from anywhere.
Depending on your policy,
not all lettered and numbered
sections shown above may appear
on your Explanation of Benefits.
Call our phone system - anytime, day or night - to find information about:
- Medical claim status
- Eligibility
- Prescription drug information
- Hospitalization precertification requirements
- Out of Pocket remaining
- And much more

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Detail Information
Provides details on each medical service provided.
Member Name: The person insured by WPS
(policyholder).
Member Number: Number associated with each
member, shown on your WPS ID card.
Group Name: Employer Name (if covered under
a group plan) or Individual Plan Name (if covered
under an individual plan).
Group-Division Number: Unique code identifying
your health plan in our claims system.
Process Date: The date WPS processed this claim.
Claim Number: Unique code identifying the claim
submitted.
Patient Name: Lists the person(s) who received
health care services.
Patient Account: Unique health care provider code
identifying the patient treated.
Services Provided By: The provider that performed
the procedure, plus the code and general category of
the procedure performed.
Service Dates: The start and end date during which
the listed procedure was performed.
Total Billed: The total cost of the procedure, as
billed by the provider.
Provider Responsibilityt: The discount WPS negotiated
with your provider, which will be subtracted from the
total cost. Usually based on contractual agreements
between WPS and providers in your WPS network.
Amount Not Covered: The portion of the total cost
not covered under your health plan. This portion is
your responsibility. See Remarks codes in the last
column and the Remarks box for explanation.
Your Copay: The portion of the total cost you
are responsible to pay before any deductible or
coinsurance is applied for certain covered services
(e.g., office visits).
Your Deductible: The portion of total cost applied
to your deductible. (Your deductible is the amount
of covered charges you must pay each calendar year
before WPS pays benefits).(e.g., office visits).
Your Coinsurance: The balance of total cost after
subtracting provider discount, ineligible amount,
copay, and deductible.
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Plan Plaid: The percentage of the coinsurance
amount paid by WPS.
Other Insurance: The portion of the coinsurance
paid by another insurance plan (e.g., auto
insurance).
See Remarks: The procedure performed may have
triggered additional comments that do not fit in
the chart. Match the Remarks code to those in the
Remarks box under the chart to view the specific
comment.
Statement Totals
A summary of total charges billed by health care
providers, negotiated provider discounts, WPS’
financial responsibility and yours. What you owe
is the portion of coinsurance you are responsible
to pay. Includes copay, deductible, coinsurance,
and any amount not covered. Paid directly to your
provider, who will send you a bill.
Remarks
Includes explanations of any Remarks codes listed
in the See Remarks column.
Did You Know
Tips and announcements to help you get the most
out of your benefit plan.
Please consult your Member Guide for more
detailed definitions of these terms. If you have any
questions, please contact Member Services at the
number listed on the back of your WPS ID card.
©2013 Wisconsin Physicians Service Insurance Corporation. All rights reserved. 18502-021- 1008