ADAM FRANKIE EVERYMAN. 1234567890. ID. BlueCross BlueShield of North Carolina. Payer ID #### www.bcbsnc.com. BLUE BUTTON
BLUE BUTTON EXPLANATION OF BENEFITS
#23 of 25 as of NOV 15, 2012
ADAM FRANKIE EVERYMAN
BlueCross BlueShield of North Carolina
Payer ID ####
ID 1234567890
www.bcbsnc.com
EXPLANATION OF BENEFITS PROVIDERS
Providers on current EOB. Shaded areas represent lifetime billing.
All Childrens Holpital ID##### allkids.org
$2,081.21
Sunshine Radiology ID##### sunshineradiology.org
BILLED
Total billed by providers this EOB.
Total
$3,021.48 Year-to-date $25,022.92
$80.32
PLAN
PAID
Plan overview.
Blue Options HSA Plan ID##### providerwebsite.com
Claims approved and paid by your plan.
$2,497.48
Total paid
$32,104.22
Year-to-date $18,022.92
Benefit period starting Jan 1, 2012
$502.56
Total rejected
Year-to-date $1,329.33
PARTICIPANTS
OWED
Bold participants are patients in current EOB. Shaded areas represent quotas.
AMY
$2,500 $3,000
in $1,602 out $0 in $250 out $87
$2,500 $3,000 $2,500 $3,000
$35 $320 met met
ADAM MORGAN
Oct 2012 Sep 2012
Deductible
Out-of-pocket
$502.56
Total owed
Network met in $2,402 met out $0
Expect a bill from your yrovider for this amount.
OFFICE VISIT Sep 29, 2012 / Provider / CLAIM##
Total owed: $34.03
OFFICE VISIT Oct 12, 2012 / Provider / CLAIM## MEDICAL Sep 22, 2012 / Provider / CLAIM##
Total owed: $100.21 Total owed: $204.21
PROCEDURE PROCEDURE
BILLING BILLED
Name of service Chest x-ray Procedure code description. Lorem CODE### ipsum dolor without sit amet.contrast. Chest x-ray 7125 Code type
CTP PRE-NATAL EXAM
RESULTS VITALS RESULTS
Billed Plan paid
Weight
BMI
5’5” 165cm 177lb 58.5kg Diagnosis name Pneumonia RESULTS Ultrasound Diagnosis code description. Lorem CODE### ipsum dolordue sit amet. Pneumonia to respiratory syncitial 480.1 Code type virus. Normal Result ICD-9 CODE### Code type
Negotiated $100.00
Nov 1, 2012 / Bowdoin Associates / Thomas Plan paid Lampard, MD
Height
Diagnosis name
$204.21
29.5
Five-year BMI Trend
Reason ####
Savings Savings
-$104.21 -$104.21
-$4.00
Allowed
$100.00
Blood Pressure Copay Five-year BP Trend$20.00 Rejection reason description. Lorem ipsum dolor sit amet. $0.00 Deductible
135 / 80
Coinsurance
$100.21
Other liability Copay
$0.00 $0.00
$204.21.00
Patient to pay
Single live intrauterine pregnancy.
$204.21 -$0.00
Total owed
Deductible
Complete Count Diagnosis codeBlood description. Lorem(CBC) ipsum dolor sit amet.
7 Normal Results
$100.21
Coinsurance
$204.21
Other liability
$0.00
Results were within normal ranges for Red Blood Cells (RBC), Hemoglobin, Hematocrit, Red Blood Cell Size (MCV), Hemoglobin per Cell (MCH), Hemoglobin Concentration per Cell (MCHC), and Platelet Count.
PROVIDER
White Blood Cells (WBC)
www.doctorswebsite.com www.doctorswebsite.com
13.5
K/uL
3.5
Blood Differential
Sep 1, 2012 / Bowdoin Associates / Thomas Lampard, MD
Total owed: $12.00
Aug
5 Normal Results
12.5
13.5
were within normal ranges for Neutrophil absolute Total owed: SHOW $302.32 Sunshine Radiology / Thomas Lampard, MDcount, Lymphocyte absolute count, Monocyte ABDOMEN Aug 1, 2012 / Results
Jul
PRE-NATAL EXAM
SHOW
Last Five Results
Result
Dotor DoctorName, Name,MD MDCODE## CODE##
$0.00
OFFICE VISIT
absolute count, Eosinophil absolute count, and Basophil absolute count.
Jul 1, 2012 / Bowdoin Associates / Thomas Lampard, MD
Total owed: $50.84
