- Date EOB was generated
- Patient's name
- Patient's member number
- Subscriber/owner of policy (not necessarily patient)
- Employer's group number and policy name
- Claim reference number
- Provider of care
- Patient control number
- Date claim was received
- Check number
- Date of check
- Check issued to
- Dates of patient care
- Description of care
- Total charges
- Provider's responsibility
- Amount member owes + amount paid by HealthPartners
- Member's cost based on co-pay
- Member's cost based on deductible
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- Member's cost based on co-insurance
- Amount of services not covered by insurance
- Reference to notes (#33) on non-covered amounts
- Amount paid by HealthPartners
- Amount member owes
- *Individual out-of-network out-of-pocket balance
- Individual in-network out-of-pocket balance
- *Individual out-of-network deductible
- Amount paid by patient's other benefit plan
- Tax paid by provider
- Total plan covered amount payable to policyholder
- Total plan covered amount payable to provider
- Total member liability – what you owe
- Explanation of any non-covered amounts
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