Your card. Your dental health. - Premera Blue Cross

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Meet the Explanation of Benefits(EOB) StatementUnderstand your claims and billing1 2 3 4 5 6 7 8 9 10 11An Independent Licensee of the Blue Cross Blue Shield AssociationThe EOB breaks down the charges submitted to Premera by your dentist, andit shows what benefits we pay for, how much we pay, and how much you areresponsible for.8
When you use an in-network dentist, he or she sends the dental claim directlyto us for payment. You may be responsible to pay a portion of the dental claimdepending on the amount paid by your dental plan.Definition of EOB Terms12345Service/product description—typeof service/product you received fromyour provider.Dates you received service/product—when you saw your provider (month/day/yearto month/day/year).Charges billed by provider —amount billedto you and your dental plan(s).Provider’s fee adjustment—differencebetween “charges billed by provider” and theamount network providers have agreed toaccept as full payment; see “Message Codes”at the bottom of your EOB for details.Your copay, deductible or amount notcovered—“copay” is a set fee you pay aprovider for a given service; “deductible” ishow much you pay each year before thedental plan pays; “amount not covered”applies to services/products not coveredby your plan; see “Message Codes” at thebottom of your EOB for details.67891011Total amount eligible for benefits—“charges billed by provider” minus “providerfee adjustment” minus “your copay,deductible or amount not covered.”%—the percentage your plan pays forcovered services.Your coinsurance amount—what youmust pay the provider after we pay thecovered percentage.Adjustment—see explanation(s) at thebottom of your EOB for details.Total benefits from your plan—“totalamount eligible for benefits” minus“your coinsurance amount.”Amount you’re responsible for—whatyou must pay of the billed charges afterplan benefits are paid.Paperless EOBSign up to see your EOB online instead of receiving it by mailwhen you register and log in to premera.com…that’s one lesspiece of paper you’ll have to file away.9
Page 1 and 2: Your card. Your dental health.
Page 3 and 4: Know how your dental plan works.Sav
Page 5 and 6: Access our dental providernetwork a
Page 7: Free online member tools.Inform and
Page 11 and 12: Thank youWe are proud to have serve

Your card. Your dental health. - Premera Blue Cross

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