The maximum amount allowed by the plan for payment

The coinsurance paid by the subscriber as specified in the plan provision

The copayment paid by the subscriber, as specified in the plan provision

The amount paid by the subscriber through the deductible arrangement of the plan

The discount amount applied to the service, based on plan pricing reductions

The Diagnosis Related Group (DRG) outlier amount, as reported on the facility claim

The amount paid by the subscriber outside of the flat copayment amount. Examples: (1) Additional copayment when selecting a brand name medication, instead of the generic alternative, or (2) Selecting a non-formulary medication, instead of the formulary option.

The ineligible amount or not covered amount that is associated with a reason code 1

The ineligible amount or not covered amount that is associated with a reason code 2

The ineligible amount or not covered amount that is associated with a reason code 3

Reason for the ineligible amount or not covered amount

For capitated services (encounter records), the fee-for-service equivalent amount for the service

Under a fully-insured arrangement, the actual check amount for the service. This represents the amount after applying all plan provisions and cost-sharing.

The amount applied towards the service, funded by the subscriber's Health Reimbursement Arrangement (HRA)

The amount applied towards the service, funded by the patient's Heathcare Savings Account (HSA)

The maximum amount allowed by Medicare for payment

The coinsurance amount determined by Medicare for the service

The deductible amount for the service, as determined by Medicare, that must be paid before Medicare pays

The amount paid by Medicare for the claim

The actual check amount for the service. This represents the amount after applying all plan provisions and cost-sharing.

The amount of the ITS access fee charged by the host plan for out-of-state patient use of its provider network

The amount of the ITS surcharge added to the ITS access fee by the host plan for out-of-state patient use of its provider network

The total amount of the service for which the subscriber is responsible. Generally, this includes, for example, copayments, coinsurance, and deductibles.

The penalty amount that reduces provider payments for the service. This is due to penalties that result from not meeting plan standards.

The submitted or billed charge amount, as reported by the provider for the service

Summary of the explanation of benefit

The state tax or another tax amount for the claim service record for medical and drug claims. Note that this is not the sales tax amount applied to the drug purchase.

The amount saved due to integration of third-party liability (Coordination of Benefits) by all third-party payers (including Medicare)

The amount of the net payment either retained or withheld from the servicing provider. This amount is placed in a risk-sharing pool, for future distribution.