Statement of Benefits

Explanation of Benefits (EOB)

UNDERSTANDING YOUR STATEMENT

PRINT DATE Date the EOB was sent to print

PATIENT NAME Services and procedures broken out by family member

PROVIDER The healthcare physician, office, hospital, or facility that provided the service or procedure

CODE AND DESCRIPTION Procedure code and explanation of service provided SERVICE DATE Date the services were provided

BILLED AMOUNT Fee charged by provider for treatment or service

DISCOUNT Negotiated reduced rate with networks, facilities, hospitals, or providers

ALLOWED Charges to be considered after discounts and ineligible amounts have been deducted COB CREDIT Credit due to other entity paying as primary carrier OTHER ADJUSTMENTS Negotiated or ineligible amounts that are not the member’s responsibility.

INELIGIBLE CHARGES Charges that were previously considered or not covered by your plan. Refer to Remark Codes

COPAY The amount paid by you per visit or treatment DEDUCTIBLE The amount of covered charges that must be incurred by you before benefits are applied

AMOUNT SUBJECT TO COINS Calculated total after discounts, ineligible charges, and COB credits

PATIENT COINS % Percentage of coninsurance to be applied to allowed charges

COINS AMOUNT Coinsurance dollar amount for which you are responsible

AMOUNT PAID The amount paid to a provider and/or to you by Nippon Life Benefits

REMARK CODE/DESCRIPTION Explains why a portion was not paid by the plan

ISSUE DATE Date the claim was processed

PATIENT RESPONSIBILITY Portion of Billed Amount which is your responsibility

PAYMENT INFORMATION This shows if we paid the provider or if a check is attached to pay you directly ACCUMULATORS Deductible and out-of-pocket amounts remaining for you or a family member