Explanation of Benefits Form (Back)
This is your Explanation of Benefits (EOB).
The front side of this document contains an explanation of how your
claim was processed.
Please examine it closely and compare it to your provider billing. Make certain that there are no duplicate or
incorrect charges. Report any possible discrepancies to EMI Health
customer service department. Please retain this copy for your
Explanation of Terms
Submitted - These figures represent the charges billed by your provider for the services you received.
Allowed - This is the amount established
by EMI Health as the allowable payment for those services (Table of
Allowances). The Table of Allowances is used for all providers,
regardless of their panel status. Participating providers have
agreed not to bill you for charges exceeding this amount. If you use
non-participating providers, you will be responsible for amounts
exceeding the Table of Allowances.
Adjustment - This column represents the
amount your physician has agreed to write off and not bill to you.
If you believe that you are being billed for amounts in the
adjustment column, please contact EMI Health customer service
Insured Pays - This is the amount you are
responsible to pay (e.g., copays, deductibles, non-covered
services), including any amounts you may have already paid. For
example, if you paid your copay at the time of service, that amount
will still be included in this total. Also, if you have other
insurance, the amounts they pay will be included in this
Plan Pays - This column shows the amount
EMI Health will pay for this claim.
Code/Benefit Determination - The codes on
your EOB and their corresponding explanations provide you with
additional information on how the benefits for this claim were
Answers to Your Questions
If you have any questions regarding your
benefits or payment of your claims, please refer to your member
handbook and summary of benefits chart, or contact our office:
Enrollment/Customer Service 801-262-7475 (local)
800-662-5851 (toll free)
Administrative 801-262-7476 (local)
800-662-5850 (toll free)
When you contact us with a claims question,
we will need the claim number, the subscriber's name and social
security number, the patient's name, the provider's name, and the
date of service. You will find all of the necessary information on
Claims Review Process
You may request a review of any adverse
claim decision by sending a written request to the EMI Health claims
review committee, within the timeframe printed on the front of this
statement. As part of this process, please review all pertinent
information regarding the claim and explain, in writing, your
reasons for believing the claim should have been granted. You should
also include any additional information that will aid the claims
review committee in reviewing the claim.
Membership Changes and Other Coverage
You may call the enrollment department or
submit a new enrollment application to notify EMI Health of a change
in address or telephone number. You must use the enrollment
application to make other changes, such as changes to your name or
marital status, as well as to add or delete family members to the
plan. EMI Health must be notified within thirty days of any
To facilitate accurate and efficient claims
processing, please keep EMI Health informed of any other insurance
coverage you or your covered family members may have. Failure to
notify EMI Health of other coverage may delay the payment of your
claims. Failure to notify EMI Health of primary insurance with
another carrier in a timely manner may result in overpayments, which
will have to be refunded to EMI Health.
Everyone must apply for Medicare Part A
(hospitalization) when they turn sixty-five. It is important that
you also apply for Medicare Part B. If you choose not to apply for
Part B, you must inform the Social Security office.
If you are age 65 and covered under an
EMI Health plan-and have been for at least six months-when you
retire, you may apply for the EMI Health Medigap Plan on an
individual basis. Contact the enrollment department for additional