EXPLANATION OF BENEFITS FOR INSUREDS.
The explanation of benefits form for
insureds shall include, at a minimum, all of the following:
1. The insurer's name and address and the
telephone number of the section of the insurer designated to handle questions
and appeals from insureds relating to payments.
2. The insured's name, address and policy
number, certificate number or both.
3. A statement as to whether payment
accompanies the form, payment has been made to the health care provider or
payment has been denied.
last name followed by the first name and middle initial of each patient insured
under the policy or certificate for whom claim information is being reported,
and the patient account number, if it has been supplied by the health care
For each patient
listed, all of the following that are applicable, using a single line for each
procedure or service:
a. The health care
provider as indicated on the claim form.
b. The date the service was provided or
c. The CPT-4,
HCPCS or CDT-1 code.
d. The amount
charged by the health care provider if the insured may be liable for any of the
difference between the amount charged and the amount allowed by the
e. The amount allowed by
the insurer. An insurer may modify this requirement if necessary to provide
information relating to supplemental insurance.
f. Each claim adjustment reason code, unless
the claim is for a dental procedure for which there is no applicable code, in
which case the insurer shall provide an appropriate narrative explanation as a
replacement for the information required under subd. 7.
g. The applicable deductible amount, if
h. The applicable copayment
amount, if any.
i. The amount paid
by the insurer toward the charge.
6. A general description of each procedure
performed or service provided.
narrative explanation of each claim adjustment reason code. An insurer may
provide information in addition to the narrative accompanying the code on form
Any of the following
a. The total deductible amount
remaining for the policy period.
The total out-of-pocket amount remaining for the policy period.
c. The remaining amount of the policy's
d. The annual