Explanation of Benefits.

Explanation of Benefits

  1. Participant ID: The last four digits of the employee social security number/ The FCE generated identification number assigned to the claim.
  2. Employee Class: Level of benefits participant eligible for at date of service.
  3. Service Provider: The health care professional who is indicated on the claim as having provided the service.
  4. Claim Number: The FCE generated identification number assigned to the claim submitted by your provider.
  5. Network Status: Identifies whether the health care professional was a participating network provider on the date of service.
  6. Type of Service: A brief description of what services were provided on the dates listed.
  7. Service Dates: The date services were provided to patient listed.
  8. Total Billed: What the health care provider charged for the services listed.
  9. Re-Priced Amount: Amount of charge after network discount (if any).
  10. Allowed Amount: Amount of the charge that was allowed according to plan specifications and after any discount.
  11. Co-pay/Deductible: A cost-sharing feature of your plan where you pay for some healthcare services up to a specified amount before the Plan begins to pay.
  12. Patient Responsibility: Total amount due from participant.
  13. Out of Pocket: The maximum amount of money you must pay during a calendar year for Covered Services that are subject to your deductible and coinsurance.
  14. Other Ins. Pay: Amount of payment from another insurance policy.
  15. Co-Insurance: A cost-sharing feature of your plan where you and the Plan pay a percentage of the covered services.
  16. Co-Insurance %: The percentage of payment the Plan is responsible for.
  17. Paid: The actual dollar amount the FCE administered Plan paid to the healthcare provider, which may be less than what the healthcare provider charged.
  18. Code Explanation: The explanation of how a claim was processed if other than just paid.
  19. Member Deductible 4th Q + YTD: Identifies the deductible that has been met for the current year and the last quarter of the preceding year for the member.
  20. Family Deductible YTD: Identifies the deductible that has been met for the current year and the last quarter of the preceding year for the family participants.
  21. Out of Pocket YTD: The total out of pocket expenses (any deductible & co-insurance amounts) for the year. (see SPD for exclusions)
  22. Family Out of Pocket YTD: The total out of pocket expenses accumulated by all family participants for the year.