Understanding your Explanation of Benefits (EOB)

The Explanation of Benefits (EOB) screen displays a summary of the entered claim information. You can view an EOB by using the Activity Log or the Search function to locate the claim and click on the claim number.

Patient Information

Patient Account Number — the patient account number is required on electronic formats whenever the patient account number is provided. (HIPAA Requirement)
Patient Name — the first and last name of the person who received the dental treatment.
Date of Birth — the month, day and year of the patient’s birth.
Relationship Code — identifies the relationship of the patient to the subscriber.
Subscriber Name — The person who has obtained the health insurance. In the case of employer-sponsored health insurance, this is the employee.

Dentist Information

Dentist —the treating business or dentist name.
License Number — the treating dentist’s state-assigned license number. National Provider Identifier (NPI), if available, will go on the end of the license number.
Dentist TIN — tax identification number
Speciality —
General Practitioner
Endodontics
Oral Surgery
Orthodontics
Prosthodontics
Pediatric Dentistry
Periodontics

Other Carrier

Other Carrier — name of the other carrier when coordination of benefits exist.

Claim Information

Receipt Date — the date the claim was received.
Process Date — the date the claim was processed.
Claim Number — the number assigned to the claim that corresponds to the EOB.
Claim Type —
In For Pay — the claim that has been submitted for payment .
Pre-treatment estimate — the claim that has been submitted for an estimate (not a guarantee) of expected payment.
Pre-treatment estimate In For Pay — a pre-treatment estimate (with actual dates of service added) submitted for payment
Prior Carrier — a claim received from a previous carrier. Entered manually or electronically.
Claim Status — the current status and process stage of a claim, reflecting the claim's progress through the system.
Processed Paid — claim has been:
Adjudicated to completion. View payment field to determine if truly "paid."
Processed and issued payment.
Processed Denied — claim has been processed and payment denied.
Processed Reversed — the claim was reversed by an adjustment, and EOB were sent.
Canceled — the claim was canceled in-house. No paperwork was issued.
Active — this status is applied to Prior Carrier claims. The information on the claim will be used by the system for history purposes.
Primary Payment— the amount paid by the primary carrier for the services listed.
Print Preview — the Print Preview button allows you to view, print and save the EOB in a pdf format.
Cancel Claim — If a claim is submitted with incorrect information, you can cancel the claim by way of the Cancel Claim button. The Select a Cancel Claim Reason drop down will list the following reasons:

Claim submitted in error.
Claim submitted with incorrect information
Other

Once a claim is canceled, it cannot be un-canceled. However, a new claim can be submitted with the correct information. The cancel function will only be available for those claims that have not been paid.

Client Information

Client Number — the number assigned to the main group under which the subscriber has dental coverage.
SubClient Number — the subnumber of the particular category, branch or location under which the subscriber has dental coverage.

Detailed Explanation

Tooth Code — the tooth number of the tooth on which the procedure was performed. For orthodontic EOBs, this column is used to identify the stage of orthodontic treatment:
T = Total; total orthodontic treatment plan
RT = Revised Total; revised total orthodontic treatment plan
I = Initial; initial banding or placement of orthodontic appliances
Numeric Value (s) (01-99) = The month of the treatment plan processed (for example: “01” would be the 1st month of treatment after banding, “02” would be the 2nd month of treatment after banding...)
L = Last; completion of or last payment for the orthodontic treatment plan
O = Only; only or one -time payment for orthodontic treatment
Area of Oral Cavity — the area of the mouth that was treated, UL = Upper Left; LL = Lower Left; UR = Upper Right; LR = Lower Right or lower right quadrant).
Surface(s) — the surface (s) on which the procedure was performed;up to five surfaces can be selected per claim line.
Date of Service — the date the procedure was performed; a claim may contain claim lines with different service dates.
Procedure Code — the CDT procedure code number (e.g., 120 for a periodic oral evaluation).
Submitted Amount — the amount being charged per claim line.
Approved Amount — the portion of the submitted fee approved for the procedure performed.
Allowed Amount — The portion of the dentist’s submitted fee allowed for the procedure performed. This amount is used to calculate payment.
Ded — the portion of the covered expenses which the patient must pay before the program's benefits begin.
Office Visit — the amount the member is responsible for paying if an office visit fee applies to the service.
CoPay — The percentage , as stated in the group's contract, used to calculate the plan payment.
Patient Pmt — the dollar amount of a claim or claim line for which the patient is responsible to pay.
Plan Pmt — the dollar amount that the plan will actually pay.
Par Network — the network the provider participates in.
Product — a benefit plan between the plan and an employer group.. A product is closely tied to provider networks.
Claim Line Status — the current status (denied, disallowed, etc.) of the claim line
Payment Number — the number on your EFT payment
Pay To — indicates where payment was sent, custodial parent, subscriber, provider. .
Issue Date — date the Explanation of Benefit was issued.