Understanding Your Claim Summary

How to Read Your Claim Summary This sample statement will show you where to look for information when your claims are processed. You will receive a Claim Summary that includes all family members during the noted period. You can see your weekly claims activity on our website by logging into your benefits portal website account at pbaclaims.com. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 (630) 655-3755

1 PBA contact information 9 Reason Code: Reflects any 15 Paid At: The percentage of appears here. If you have comments about why a benefit paid by the plan. any questions regarding service may not have been your Claim Summary, please covered or any other have your user ID number im portant information. 16 Payment Amount: and claim number available Reflects the total benefit when you call. that was paid by the plan. 2 Your name and address 10 Discount Amount: The will appear here. savings amount applied to this claim will be reflected 17 Patient’s Responsibility: 3 here. The patient is not Any amount you may be Your group number, responsible for this amount. responsible for will appear group name, and check here (deductible, generation date will coinsurance, copayments or appear here. services that are not 11 Covered by Plan: The new covered). 4 For the Period: Shows the allowed amount of the claim period that claims were after the ineligible and incurred. discount amounts are 18 Reason Code Description: applied. 5 Date(s) of Service: The Reflects any comments abo date the services were ut why a service may not incurred. have been covered or any 12 Deductible Amount: This other important information. 6 Type of Service: The type reflects how much of the of service performed by claim will be applied to your your provider (office visit, deductible. 19 Payment Details: Reflects lab, x-ray, etc.). who received a benefit payment for this claim. 7 Total Charge: The total 13 Co-Pay Amount: This amount charged by the reflects the amount you will provider. be responsible for as 20 Plan Status: Reflects your defined by your plan. deductible, and out-of- 8 Ineligible Amount: Any pocket amounts remaining amount not covered by the as defined by your plan. plan. Ineligible Amount will 14 be further explained with a Balance Amount: The reason code description in amount after all deductions section 18 and may be (ineligible, discount, 21 You Should Know: Special included in the amount you deductible, and co-pay reminders and amounts) are applied. announcements a may owe. ppear here. (630) 655-3755