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| Current Location: | Home > Interactive Demonstration > Employer Connection > Benefits & Eligibility > Sample EOB |
April 24, 2025
|
 | EXPLANATION OF BENEFITS |
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| HARVEY J SCHNEIDER 100 MAIN STREET STEVENS POINT WI 544810000 | Patient: | HARVEY J SCHNEIDER |
|---|---|---|
| Group No. | 93705-000-00000-00000 | |
| Claim No. | 0-6345-314-49 | |
| Check No. | 2603172 | |
| Payment Date: | 12/20/2006 | |
| DDS License No: | 333259162 USA 008 |
| TTH# | Date of Service | Proc. Code | Description | Submitted Amount | Approved Amount | Allowed Amount | % copay | * ** | COB | Patient Pay | Delta Pay | Ref code |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 18 | 12/06/06 | 02140 | FILLING | $107.00 | $85.00 | $85.00 | 80 | - | $.00 | $17.00 | $68.00 | - |
| $17.00 | $68.00 | |||||||||||
| THIS IS NOT A BILL | Total | Total | ||||||||||
| Check No: | 2603172 | Payment Date: | 12/20/2006 |
| Payee Name: | MIDWEST DENTAL CARE | ||
| Address: | PO BOX 90 ANYWHERE USA 555550000 | ||
Voucher Explanation
Submitted Amount: The amount billed/charged for the procedure.
Approved Amount: The amount approved for total patient/Delta payment.
Allowed Amount: The allowed fee for the covered procedure used to calculate Delta's payment.
* = Exceeds Maximum: Indicates the service exceeds patient/group benefit year maximum.
** = Deductible: Indicates patient/group must meet deductible for all or a portion of the service.