Roll over each section of the form for more information

General Information
Contact Information
Benefits Service Dates Amount Submitted Amount Allowed Adjustment Insured Pays This Amount Plan Pays This Amount Code
Total Submitted Total Allowed Total Adjustment Total Paid by Insured Total Paid by Plan
Benefit Determination

Explanation of Benefits Form (Back)

General Information

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 records.

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 department.

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 total.

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 determined.

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)
Fax 801-269-9734

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 this EOB.

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 change.

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 information.

"I think I can speak on behalf of my team in saying we are very happy to partner with EMI Health in delivering the very best health insurance program possible for UVU employees. In a very short time here at UVU I have learned that EMI is a leader in providing a high quality of customer service to their clients. This is the hallmark of a great organization and I look forward to our work together in the future."

Ronnie J. Price, Sr.
Associate Vice President
Human Resources-Equity Officer
Utah Valley University