#3 Traditional HMO
(No deductible/coinsurance)
Explanation of Benefits-Summary
This Is Not A Bill
Your Provider will bill you for any amounts due.
Medical Payment Summary
Forwarding Services Requested
1. Member name and address
BAR CODE
FirstName LastName
Address
City, State Zip
Total Allowed Charges
HealthPlus of Michigan Paid
Your Other Insurance Paid
Your Copay Amount
Denied or not Covered Amount
$999,999.99
$999,999.99
$999,999.99
$999,999.99
$999,999.99
Your Total Responsibility
$999,999.99
2. Date this EOB was printed by HealthPlus
Statement Date:
MM/DD/YYYY
Name:
Sally Jones
Date of Birth:
12/23/1987
Member ID:
xxxxxxx3201
Claim Number: 123456789012
Plan Type and Code: HMO ME
Date Paid:
mm/dd/yyyy
Employer:
Just in time Inventory
Benefit Year:
07/01/2013-06/30/2014
4. Summary of Charges shown on the following Detail page
Claim Number:
Date Paid:
123456789012
mm/dd/yyyy
5. Claim number indicates a specific provider claim. You
should always have this number if you call HealthPlus
Customer Service with questions about your claim and EOB
3. Member specific and benefit plan information
Out of Pocket Expense Summary
Benefit Year Expenses To-Date (Including Those On This EOB) & Maximum Requirement
In-Network
Total Out-of-Pocket
Out-of-Pocket Maximum
Individual
$1,012.50
$6,350.00
Family
$4,830.82
$12,700.00
6. The Out- of -Pocket Expense Summary shows two items:
a) Total Out- of- Pocket: . This shows the dollar amount of all copays you have paid for covered services to date.
b) The Out –of- Pocket Maximum: This is the maximum dollar amount you must pay for all covered
services during your benefit year.