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Explanation of Benefits and Claims Letters

When your health care claim has been processed you will receive an Explanation of Benefits (EOB) or a claims letter. An EOB is generated when HealthSelect is the primary payer and a claims letter is used when HealthSelect is the secondary or tertiary payer. These documents are provided in a print or electronic version. Print versions are mailed to your household and electronic versions are available in Blue Access for MembersSM (BAM), your secure online participant portal.

Explanation of Benefits

An EOB is a notification provided to members when BCBSTX processes a health care claim. The EOB shows how the claim was processed and how much you may owe your provider. Multiple claims may be included on a single EOB as seperate items, if processed within a similar time frame. The EOB is not a bill and does not account for how much you may have already paid your provider. Your provider may bill you separately for any amounts you may owe.

The EOB has four major sections:

Subscriber Information and Total of Claim(s)

Includes the participant’s name, address, member ID number and group name and number. The Total of Claims table shows you the amount billed by your provider, any discounts applied by the HealthSelect plan, and the amount you may owe the provider.

Service Detail for each claim includes:

  • Patient and provider information
  • Claim number(s) and when it was processed
  • Service dates and descriptions
  • Amount billed
  • Discounts or other reductions subtracted from amount billed
  • Total amount covered
  • Amount you may owe (your responsibility)

The summary shows you what the plan covers for each claim and your responsibility including:

Plan Provisions

  • The amount covered
  • Less any amounts you may owe, like deductible, copay and coinsurance

Your Responsibility

  • Deductible and copay amount
  • Your share of coinsurance
  • Amount not covered, if any
  • Amount you may owe the provider. You may have paid some of this amount, like your copay, at the time you received the service.

Sample of EOB:

  1. Participant’s name and mailing address
  2. Participant’s member ID and group number
  3. Summary box for all claims including total billed by the provider, and discounts, reductions or payments made, and the amount you may owe
  4. Detailed claim information for each claim
  5. Provider information
  6. Claim number(s) and date the claim was processed
  7. Patient name and service date
  8. Service description
  9. Amount billed for each service
  10. The amount covered (allowed) for each service and the discounts or reductions subtracted from the amount your provider billed
  11. Your share of the costs
  12. Claim summary with amount covered less your responsibility
  13. Health Care Fraud Hotline
  14. Deductible and/or out-of-pocket expense information

 

 

HealthSelect as Secondary/Tertiary payer on claim

This section only applies if HealthSelect is your secondary or tertiary insurance plan. When HealthSelect is a secondary or tertiary insurance plan, a claims letter is provided instead of a EOB. The following information is included:

  • Total Amount Billed
  • Allowable Expenses
  • Primary Insurer’s Estimated Payment
  • Blue Cross and Blue Shield Payable Amount

Sample of claim letter with HealthSelect as secondary or tertiary payer:

  1. Participant Name and Address
  2. Total Amount Billed
  3. Allowable Expenses
  4. Primary Insurer’s Estimated Payment
  5. Blue Cross and Blue Shield Payable Amount

Find your Claims Letter:

Printed versions are mailed and electronic versions are available in BAMSM.

To see your letter in BAM:

  • Log into BAM
  • Go to the message center
  • Find the claims notifications message
  • Click on the link in the message to view the letter

Sample of notification in BAM message center:

Sample BAM message

Sample of message in BAM:

Sample BAM message

If you have any questions you can call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039, Monday-Friday 7 a.m. – 7 p.m. CT and Saturday 7 a.m. – 3 p.m. CT.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

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