An explanation of benefits can be tricky to read if you are unfamiliar with the layout or terms used:
Claim #: The claim number in the CareFactor system. This will also match up with the list of claims on your online portal.
Patient: The name of the patient the service was for, either the cardholder or one of their dependents on the account.
Service Provided: The type of service the claim is for.
Dates of Service: The dates of service the claim was billed for. This will be a date range for services over an extended period of time, such as an inpatient stay at a hospital.
Billed Charge: The total amount charged for the service. Each line is the charge amount for each item or service, with the last line being the sum total of all charges.
Write Off: The contractual write off of the total charge. This occurs when the provider has a contract with your network, with some exceptions.
Provider Number: The provider's tax ID number.
Provider: The name of the doctor or facility that billed the claim.
Employee: The policy holder. This will always be the name of the cardholder, regardless of who the patient was.
Non-Covered / Codes: If there is an amount in the left column, this is the dollar amount for that service or line item that is not covered. The last line will be the sum total of non-covered charges. Codes are often seen in conjunction with non-covered charges, as they are used to explain why they are not covered, though codes can be present to explain other details as well.
Other Insurance: If you have a different primary provider of benefits or insurance, this lists how much they paid.
Deductible Applied: If you have a deductible that has not yet been met, this shows how much applied to it.
Copay Amount: If a copay applies to the service billed, the amount will be listed here.
Covered Amount: The amount considered for coinsurance/payment.
Paid Amount: The amount paid by CareFactor. Each line will list the amount paid for each line item or service, with the last line being the sum total of all paid amounts.
Member Portion: The amount that is your responsibility or the responsibility of the patient.
Paid Amount: The final paid amount line that reiterates the sum total paid by CareFactor for the claim.
Patient's Responsibility: The sum total of charges that the patient is responsible for.
Claim Remarks: If there are any codes on the EOB where item 10 indicates, they will be explained here.
Appeal Language: An explanation of your patient rights as it pertains to the claim.
*: Your EOB is not a bill or an exact replication of your bill from your provider, but simply an explanation of how your claim was processed by CareFactor. Keep in mind if you have paid anything to the provider, this is information is not submitted to CareFactor by your provider and is not reflected in processing.
If you still opt to receive paper copies of your explanation of benefits, they are not mailed one at a time; multiple EOBs for the cardholder and all dependents are collected over a period of time and then mailed out as a group. At the top of your EOB, you will see something similar to the following:
For the Service Period: 01/01/2000 through 02/01/2000
Dear (Member's name),
The information below is a summary of your healthcare claims for the period. This information is commonly referred to as
an “Explanation of Benefits” (EOB). This document shows how your recent claims were processed. It includes any co-pay,
deductible, coinsurance (%), or non-covered amounts that you may owe to the provider(s) of service. Use this EOB to
verify the accuracy and validity of any bill you may receive from the provider(s) listed below. If you did not receive service
from the provider(s) listed in this summary or suspect fraudulent charges, please contact CareFactor at 877-304-0761.
As part of CareFactor's “Going Green” initiative, instead of receiving a paper EOB, you can sign up to
receive an email notification when an EOB is available. If you are interested in going paperless but have not signed in to
the portal through to provide your email address, please do so now.
This provides a brief description of what the EOB is, and tells you the time period for the included claims. As such, instead of a single section of claim information, you will see multiple. These claims are still available online individually and, as the last section suggests, you can also sign up to receive EOBs on your online portal only and no longer have EOBs mailed to you.
For a closer look at the EOB, please see the desktop site.