Explanation of Benefits:

Each time you use your plan's benefits, we send you a statement like this one, called an Explanation of Benefits (EOB). This statement shows you how your benefits were applied to the healthcare service you had. 

If you have any questions about this EOB, please call our Customer Service team and they can assist you. You can also email us at cs@pacificsource.com


This is not a bill:   

This is not a bill. If you owe money to your healthcare provider, they will bill you separately.


Patient Name: 

This is the name of the person for which the service was provided.


Member ID:

This is your unique PacificSource Member ID number, which we use to identify you. This number is also shown on your PacificSource ID card.


Claim Number:  

We assign a unique identification number to each claim we receive for healthcare services sent by your provider. If you need to contact us with questions, this claim number helps us know which specific healthcare service to look at.


Provider Name:  

This is the name of the provider you saw for the services outlined in this EOB.


Patient Acct #:

Your healthcare provider may have set up a patient account for you at their office, which they use in their billing to identify you. We include that number on your statement in case you might need to coordinate with your healthcare provider's office.


Date of Service: 

This is the date you visited your provider for the services outlined in this EOB. This can help you sort out different claims, if you saw the same provider several times.


Services Provided:  

Each time you visit a health provider, they assign a service code for the service(s) they did for you. Don't be surprised to find several service codes for the same visit. A further description of each service code is shown in the next section of your EOB.


Amount Billed:  

This is the amount your provider billed PacificSource for the service they performed.


PacificSource Discount:  

This is your discount for being a PacificSource member. We arrange for you to get lower rates when you see doctors who are part of our networks. If your doctor participates in our network, this field shows the discount you received.


Reason Code:  

A reason code explains why we processed the claim the way we did. If your claim did not pay the way you expected, the reason code may help you understand it.

Here are a few examples for why your claim might not have been paid as expected.

  • We need more information from you or your provider.
  • Your provider's charge for a service may exceed our allowed amount. This is more likely if you visited a provider who does not participate in one of PacificSource's networks 
  • Your service may not be covered by your plan.
  • You may have exceeded the plan's limits for that service.

You will find an explanation for this code in the next section. If you need further information about the reason code(s) on your EOB, call Customer Service at the number shown in the top-right corner of your EOB, and we can help explain it further.


 

This field shows the amount we paid your provider for the services outlined in this EOB.


PacificSource Paid You:  

This field shows the amount we pay you if you saw a provider that required you to pay upfront for the services you received, but your plan covers some or all of those services. For example, if your provider required prepayment for a $100 service that your plan covers at 80%, we will reimburse you $80.


Deductible Amount:  

The deductible is the amount of money you pay before your plan starts to pay. Some services are subject to your plan's deductible. If so, claims will be paid in this order:

  1.  The amount charged by your provider will be applied to your deductible.
  2. Once your deductible is met, we will begin to pay your claims.

Of course, many services are not subject to deductible, so you may see $0.00 in this column.

Review the Deductible Totals section on your EOB to see exactly how much of your deductible you have met so far this year.


Copay Amount:  

A copay is a fixed-dollar amount you pay upfront for services, such as office visits or prescription drugs. If you paid your copay at the time of your visit, seeing a copay amount listed on your EOB does not mean that you need to pay it again. We are simply showing you that a copay, in that amount, was required by your plan for this type of service.


Co-insurance Amount: 

Coinsurance is the term used to describe the amount you pay, based on your plan's benefits, after you've met your deductible. For example, if your plan covers a service at 80%, then your share (co-insurance) is 20%. It does not mean that you have another insurance provider.


Amount You Owe:

This is the amount you likely owe your provider. This amount might include:

  • Deductible amounts
  • Copays
  • Coinsurance
  • Charges not covered by your plan.
  • Charges that were higher than the maximum allowed amounts, if you visited an out-of-network provider.

Remember, your EOB is not a bill. Do not pay PacificSource. Your provider will bill you separately. Their bill should show you any amounts you've already paid, such as your copay.


Service Code Explanation:  

This is the description for any service codes listed in the section, above.


Accumulator Totals: 

Your current deductible and out-of-pocket totals for the year compared to your plan's deductible and out-of-pocket maximums. Totals shown are based on claims processed through the date on this statement.


Annual Medical Deductible: 

This section shows you the amount of your plan's deductible and how much you've met so far this year. Your plan has both a per-member deductible and a per-family deductible. The family deductible may be helpful if you have three or more family members enrolled. (Don't worry, you only need to meet one deductible and we will credit you with whichever one you reach first.)

Your plan may also have a separate deductible for "Non-participating providers" (meaning providers that are not part of your plan's network.) If so, amounts you spend for covered services from non-participating providers will accumulate towards this, separate deductible.

If your plan has tiers, you may also have separate deductibles for Tier 1 providers, Tier 2 providers, and non-participating providers. If so, amounts you spend for covered services from Tier 1 providers will go towards your Tier 1 deductible; amounts you spend for covered services from Tier 2 providers will go towards your Tier 2 deductible; and amounts you spend for covered services from non-participating providers will go to your non-participating deductible.


Out-of-Pocket Individual/Family Par:

This section shows the out-of-pocket (OOP) totals you've paid to a participating or "par" provider. Participating providers are healthcare professionasl or facilities that offer discounts on services based on their relationship with your plan. Using a participating provider gives you significant discounts.

OOP is the most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. OOP might include your co-payments, deductibles, and co-insurance payments. OOP does not include your premium, balance-billed charges (the difference between the provider's charge and the allowed amount), or healthcare services your plan doesn't cover.


Out-of-Pocket Individual/Family Nonpar:

This section shows the out-of-pocket (OOP) totals you've paid to a nonparticipating or "nonpar" provider. Nonpar providers are healthcare professionals or facilities that do not belong to your network. Depending on your plan, you can use a nonparticipating provider, but you may pay more for the same services, and you might have to file a separate claim for reimbursement.

OOP is the most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. OOP might include your co-payments, deductibles, and co-insurance payments. OOP does not include your premium, balance-billed charges (the difference between the provider's charge and the allowed amount), or healthcare services your plan doesn't cover.


Reason Code Explanations:  

This is the description for any reason codes listed in the Reason Code column of the section that shows service summaries.

 

InTouch for Members

Last updated 12/14/2015