New PPO Medical Plan Explanation of Benefits (EOB)

March 21, 2018

Effective April 1, 2018, our Third Party Administrator, HealthScope Benefits is implementing a new Explanation of Benefits (EOB) format. An EOB outlines how HealthScope Benefits applied the Plan benefits to your claim.

We hope you find the new format easier to read and understand. If you have questions about your new EOB, contact HealthScope Benefits at: 866-995-2372.

New Explanation of Benefits (EOB)

 

  1. Your Member Information: The patient’s name, the date the EOB was issued, the patient’s ID Number, the LAFRA group ID number and group name.
  2. Contact Us: HealthScope Benefits is LAFRA’s Third Party Administrator (TPA). Contact HealthScope Benefits if you have claims, eligibility or benefits questions, including questions about your EOB.
  3. Dates of Service: Corresponds to the date(s) of treatment.
  4. Total Charge: Charges submitted by your provider for services rendered (please verify that this amount corresponds with the amount billed to you by the provider of service).
  5. Reduction Amount: The savings, from network discounts and pricing programs, that is applied to the “Total Charge”.
  6. Amount Excluded: Charges that are “not covered” such as those over usual, customary and reasonable (UCR) and other services listed under the “What is Not Covered under the Medical Plan” section of your Summary Plan Description (SPD).
  7. Co‐pay: Any applicable co‐payment(s).
  8. Deduct: The amount that applied towards your deductible.
  9. Co‐insurance: If the Plan pays a percentage of the charges and you are also responsible for a percentage, this is the percentage amount you owe.
  10. Other Payment: Any additional amount that applied to the claim such as payments from another insurance plan.
  11. Plan Pay at %: Shows the benefit percentage applied to the claim.
  12. Remark Code: HealthScope’s number code for charges that are not covered or require further explanation.
  13. Plan Pay Amount: The amount the Plan paid toward the service.
  14. Patient Responsibility: The amount to be paid to the provider, by the covered person.
  15. Reason Code Description: A description for the Remark Code in section 11.
  16. Year to Date Totals: The year‐to‐date amount accrued towards the patient’s out‐of‐pocket expense.

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