CMS-10452 PFFS monthly EOB

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Model Part C Explanation of Benefits
PFFS, Monthly EOB Version
General Instructions
This is a model Part C Explanation of Benefits (EOB). The text in this document is considered model;
therefore any modifications, beyond those allowed or stated below, or as specified by CMS, will render
this EOB a non-model document. As such, the document would be subject to a 45-day review period.
1. Instructions for organizations that send monthly EOBs:


Organizations may choose to send EOBs to non-dual eligible members on either a per claim basis
or a monthly basis. Plans are not required to send an EOB to dual eligible members.
o Organizations that choose to send monthly EOBs should use this “Monthly EOB” model
developed by CMS. Organizations that choose to send monthly EOBs must send this
document to non-dual eligible members each month, even in months when there was no
claim processed during the reporting period.
o The claim information in the EOB must include the American Medical Association’s
HCPCS code descriptors and CPT consumer descriptors, followed by the HCPCS or CPT
billing code shown in parentheses.

2. Claims that must be included within the EOB:


Plans must include all Part C claims processed during the reporting period, including all claims
for Part A and Part B covered services, mandatory supplemental benefits, and optional
supplemental benefits. Any benefit information that cannot be included timely must be accounted
for in a following reporting period.

3. Instructions within the template:


Italicized blue text in square brackets is information for the plans. Do not include in the EOB.



Non-italicized blue text in square brackets is text that can be inserted or used as replacement text
in the EOB. Use it as applicable.



The first time the plan name is mentioned the plan type designation (i.e., HMO, PPO, etc.) must
be included.



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When instructions say “[insert month]”, use a format that spells out the full name of the month,
e.g., “January.”

4. Permissible document alternations:


Minor grammar or punctuation changes, as well as changes in font type or color, are permissible.



References to a specific plan name in brackets may be replaced with generic language such as
“our plan.”



References to Member Services can be changed to the appropriate name your plan uses.



References to the plan’s Optional Supplemental Benefits can be changed to the appropriate name
your plan uses. If desired, you may add a brief description of these services, e.g., “dental
services.”



References to “year” may be changed to “plan year.”



If your plan uses a reporting period that does not correspond exactly to a calendar month, you
may substitute the date range for your reporting period (e.g., “1/1/12 to 2/3/12” OR “January 1 –
February 3, 2013”) whenever instructions say to “[insert month] [insert year].”

5. Instructions for formatting:


With the exception of charts, which should generally be in landscape formation, either landscape
or portrait may be used.



With the exception of the chart that gives the details on claims, the remaining sections of the
document are to be formatted as two-column or three-column text (the main title of a section may
extend beyond the first column) to keep line lengths easy to read. Plans may adjust the width of
the columns in the template.



To help conserve paper, the document can be printed double-sided.



The document must have a header or footer that includes the page number. In addition, if desired,
plans may also include any of the following information in the header or footer: member
identifiers, month and year, title of the document.



Charts that continue from one page to the next should be marked with “continue” at the bottom on
the page that continues. In an actual EOB, rows of a chart should not break across the page. Note:
in the model language in this document, rows sometimes break across a page because of the
instructions and substitution text.

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6. Instructions related to member appeals:


Plans are responsible for ensuring that members receive the notification of appeal rights within
the timeframes specified by CMS. If notification with an EOB would hinder the plan’s ability to
provide timely notification, it must be delivered separately, within the required timeframes
specified in the MA program regulations.

7. Instructions for HPMS submission:


All plans should submit a Part C EOB through File & Use Certification using the HPMS code
2083.

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MONTHLY REPORT

Medical and Hospital Claims
Processed in [Insert month]
[Insert Year]
For [insert member name]
[If desired, plans name also insert a member ID number
and/or other member numbers typically used in
member communications.]

This is not a bill:
 This monthly report of claims we have processed tells
what care you have received, what the plan has paid, and
how much you have paid (or can expect to be billed).
 If you owe anything, your doctors and other health care
providers will send you a bill.
 This report covers medical and hospital care only. [MAonly plans omit the next sentence.] We send a separate
report on Part D prescription drugs.
 If you notice something suspicious that might be
dishonest billing, you can report it by calling 1-800MEDICARE (1-800-633-4227), 24 hours a day, 7 days a
week. (TTY users should call 1-877-486-2048.)

[Plans may include the member’s mailing address on this
cover page.]

[Insert plan name and/or logo]
[Insert Federal contracting statement]
[Plans may insert their Web site URL]

[Insert plan name] Member Services
If you have questions, call us: [Insert phone number]
We are here [insert days and hours of operation].
TTY / TDD only: [Insert TTY/TDD number]
[Plans may insert other Member Services numbers, e.g., a Spanish
customer service number]
-------------------------[Plans that meet the 5% threshold, insert: This information is available for
free in other languages. Please contact Member Services at the number
above.] Member Services [plans that meet the 5% threshold, insert: also]
has free language interpreter services available for non-English speakers.
[Plans that meet the 5% threshold, insert the disclaimer about the
availability of non-English translations in all applicable languages.]

The benefit information provided is a brief summary, not a complete
description of benefits. For more information, contact the plan. [Omit terms
in the following sentence that are not applicable to the plan:] Benefits,
formulary, pharmacy network, premium, copayments, and coinsurance may
change on January 1 of each year. [Plans that do not renew on January 1,
revise date as needed in previous sentence.]
[Insert material ID] Accepted

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[In the “totals” section, plans must insert the total amounts for all claims for Part A and Part B services and mandatory supplemental benefits.
Amounts for claims for optional supplemental benefits should be excluded from the totals section.]

TOTALS
for medical and hospital claims

Totals for this month (for claims
processed from [insert reporting period
start date] to [insert reporting period end
date])

Amount
providers
have billed
the plan
$[insert
total billed
amount for
the
reporting
period]

Total cost
(amount the plan
has approved)

Plan’s share

Your share

$[insert total
approved amount
for the reporting
period]

$[insert total
plan share
amount for
the reporting
period]

$[insert total
member liability
amount for the
reporting
period]

$[insert total
approved
amount for the
year]

$[insert total
plan share
amount for
the year]

$[insert total
member liability
amount for the
year]

[If no claims
were
processed,
insert:
(No claims
were
processed
this month.)]

Totals for [insert year] (all claims
processed through insert reporting period
end date])

$[insert
total billed
amount for
the year]
[If no claims
to date,
insert:
(No claims
have been
processed
this year.)]

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[Plans with no deductibles,
omit this section.]

DEDUCTIBLE:
[Plans with an overall
deductible insert the text
below. If the plan has both an
overall deductible and service
category deductible(s), insert
information about the overall
deductible only.]
For most covered services,
the plan pays its share of the
cost only after you have paid
your yearly plan deductible.
As of [insert reporting period
end date], you have paid
[insert as applicable: [insert
amount member has paid
toward deductible if less than
the full deductible amount]
toward OR the full amount of]
your [insert deductible
amount] yearly plan
deductible.
[Plans are permitted, but not
required, to include a graphic,
such as the one shown below, to
illustrate the member’s progress
toward the deductible:

$0

$250
= your yearly

YEARLY LIMIT – this limit gives you financial protection
This limit tells the most you will have to pay in
[insert year] in “out-of-pocket” costs ([Delete
references to deductibles, copayments, or
coinsurance if not applicable for the plan:]
copays, coinsurance, and your deductible) for
[insert as applicable: medical and hospital
services covered by the plan OR covered Part A
and Part B services].
This yearly limit is called your “out-of-pocket
maximum.” It puts a limit on how much you
have to pay, but it does not put a limit on how
much care you can get. This means:
 Once you have reached your limit in outof-pocket costs, you stop paying.
 You keep getting your [insert as
applicable: covered medical and hospital
services OR covered Part A and Part B
services] as usual, and the plan will pay
the full cost for the rest of the year.

As of [insert reporting period end date], you have
had [insert amount paid toward MOOP as of
reporting period end date] in out-of-pocket costs
that count toward your [insert MOOP amount]
out-of-pocket maximum for covered services.
[Plans are permitted, but not required, to include a
graphic, such as the one shown below to illustrate
the member’s progress toward the MOOP:

$0

$3,400 ]

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plan deductible]
[Plans with no overall
deductible, but with service
category deductibles, replace
the text above with the text
below. If the plan has more
than one service category
deductible, Include
information about each.
The plan pays its share of the
cost for [insert service
category] only after you have
paid a deductible.
As of [insert reporting period
end date], you have paid
[insert as applicable: [insert
amount member has paid
toward deductible if less than
the full deductible amount]
toward OR the full amount of]
your [insert deductible
amount] deductible for [insert
service category].
[Plans are permitted, but not
required, to include a graphic,
such as the one shown below, to
illustrate the member’s progress
toward the deductible:

$0

$250
= your
deductible for

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[insert service
category]]

NOTE: To describe the services you received, this report uses billing codes and descriptions that were developed
and copyrighted by the American Medical Association (all rights reserved).

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[If there are no claims processed during the reporting period, omit the remainder of the document.]

Details for claims processed in [insert month] [insert year]
Look over the information about your
claims – does it seem correct?
 If you have questions or think there
might be a mistake, start by calling the
doctor’s office or other service provider.
Ask them to explain the claim.
 If you still have questions, call us at
Member Services (phone numbers are in
a box on page 1).

You have the right to make an appeal or complaint
 Making an appeal is a formal way of asking us to
change our decision about your coverage. You can
make an appeal if we deny a claim. You can also
make an appeal if we approve a claim but you
disagree with how much you are paying for the
item or services. For information about making an
appeal, call us at Member Services (phone
numbers are in a box on page 1).

Remember, this report is NOT A BILL:
 If you have not already paid the
amount shown for “your share,”
wait until you get a bill from the
provider.
 If you get a bill that is higher than
the amount shown for “your share,”
call us at Member Services (phone
numbers are in a box on page 1).

[Plans may insert the first claim (or part of the claim) on this page or begin claims on the following page. Claims that continue from one page to
the next should be marked with “continue” at the bottom of the page that continues. However, an individual row of a claim should not break
across the page. Note: in the model language in this document, rows sometimes break across a page because of the instructions and
substitution text.]
[Plans must insert information for all Part C claims processed during the reporting period, including all claims for Part A and Part B covered
services, mandatory supplemental benefits, and optional supplemental benefits.]

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[Insert name of provider]
Claim Number: [Insert claim number]
([Partial and full network plans, insert as
applicable: In-network OR Out-ofnetwork] provider)
[Show each service or item on a claim in
a separate row.]
[Insert description of the service or item
that was provided, using the American
Medical Association (AMA)'s HCPCS code
descriptors and CPT consumer
descriptors, followed by the HCPCS or
CPT billing code shown in parentheses.
For example: “Air and bone conduction
assessment of hearing loss and speech
recognition (billing code 92557)”]
[As needed, insert explanatory notes,
preceded by “NOTE”]
[If the service or item on the row is
shown only to describe what was
provided and is not billed separately,
insert an explanatory note: NOTE: The
amounts are $0.00 because the cost for
this service or item is covered under
another part of this claim.]

Date of
service
[Insert
date of
service,
using
x/x/xx
format]

Amount the
provider billed
the plan
$[Insert
billed
amount for
this service
or item]

Total cost
(amount the
plan approved)
$[Insert
approved
amount for
this service or
item]
[Note: if
service or item
is approved,
use amount
approved by
the plan for
the total cost.
If service or
item is denied
use the
contracted
amount.]
[Insert if
applicable
below amount:
DENIED
(See below.)]

Plan’s share
$[Insert
plan share
amount for
this service or
item]

Your share
$[insert member
liability amount for
this service or item]
[Note: if service or item has been
denied, use either the maximum
potential liability or “$0.00” for
the member liability amount,
whichever is applicable.]
[If cost sharing is a coinsurance,
insert:
You pay [insert percentage]% of
the total amount for [insert brief
description of service, (e.g.,
“specialty care”)] [insert if
applicable: from an [insert as
applicable: in-network OR out-ofnetwork] provider]
[If cost sharing is a copayment,
insert:
You pay a $[insert copayment
amount] copayment for [insert
brief description of service (e.g.,
“specialty care”)] [insert if
applicable: from an [insert as
applicable: in-network OR out-ofnetwork] provider]

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[Insert name of provider]
Claim Number: [Insert claim number]
([Partial and full network plans, insert as
applicable: In-network OR Out-ofnetwork] provider)

Date of
service

Amount the
provider billed
the plan

Total cost
(amount the
plan approved)

Plan’s share

Your share
[If the service is a preventive
service that is covered at no cost
under Original Medicare, add the
following:
(This is one of the preventive
services that is covered at no cost
under Original Medicare, and the
plan covers this service at no cost
to you.)]
[If balance billing is explicitly
included in your contract with
providers or in your terms and
conditions of payment, add:
In addition to collecting your
[insert as applicable: copayment
OR coinsurance amount], this
health care provider is allowed to
bill you up to an additional [insert
balance billing amount of 15 or
less]% of the total plan payment
amount for the services you
received.]
[If the service or item shown on
this row has been denied, and the
amount in this column for “your
share” is not zero, insert:
Because the claim was denied,
you may be responsible for

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[Insert name of provider]
Claim Number: [Insert claim number]
([Partial and full network plans, insert as
applicable: In-network OR Out-ofnetwork] provider)

Date of
service

Amount the
provider billed
the plan

Total cost
(amount the
plan approved)

Plan’s share

Your share
paying this amount. Look below
for information about your
appeal rights.]

[Insert next item or service for the claim,
using language described above]
[Insert next item or service for the claim,
using language described above]
TOTALS:

$[Insert
total billed
amount for
this claim]

$[Insert total
approved
amount for
this claim]
[Insert if
applicable
below amount:
DENIED
(See below.)]

$[Insert total
plan share
amount for this
claim]

$[Insert total member
liability amount for this
claim]
[Note: if service or item has been
denied, use either the maximum
potential liability or “$0.00” for
the member liability amount,
whichever is applicable.]
[If all items in the claim are
subject to the same coinsurance
percentage or copayment
amount, plans may insert the
coinsurance/copayment text in
this total row rather than
repeating the identical text in
the rows for each item or
service.]
[If more than one service or item
is denied, plans may omit the

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[Insert name of provider]
Claim Number: [Insert claim number]
([Partial and full network plans, insert as
applicable: In-network OR Out-ofnetwork] provider)

Date of
service

Amount the
provider billed
the plan

Total cost
(amount the
plan approved)

Plan’s share

Your share
denial language in this column
from the claim item rows and
insert it in this total row
instead.]

[If a service or item has been denied and there is member liability, include approved NDP language with the EOB or insert the
following text below the denied claim:

Things to know about your denied claim:
 [Plans may insert a denial reason.]
 We have denied all or part of this claim and you have the
right to appeal. Making an appeal is a formal way of asking
us to change the decision we made to deny your claim. If we
agree to change our decision, it means we will approve the
claim rather than deny it, and we will pay our share.
 The provider can also make an appeal, and if this happens,
you may not have to pay. You may wish to contact the
provider to find out if they will ask us for an appeal. If the
provider properly asks for an appeal, you will not be
responsible for payment, except for the normal cost-sharing
amount, and you don’t need to make an appeal yourself.

 When we deny part or all of a
claim, we send you a letter
(“Notice of Denial of Payment”)
explaining why the service or item is
not covered. This letter also tells
what to do if you want to appeal
our decision and have us
reconsider.
 IMPORTANT: If you do not have this
letter, call us at Member Services
(phone numbers are in a box on
page 1).

 If you have questions or need
help with your appeal, you can
contact:
o Our Member Services (phone
numbers are in a box on
page 1)
o 1-800-MEDICARE (1-800-6334227), 24 hours a day, 7 days
a week. (TTY users should
call 1-877-486-2048.)]

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[Network plans: If a service or item has been denied and there is no member liability, insert the following text below the
denied claim:

Things to know about your denied claim:
 NOTE: We have denied all or part of this claim. However, you are
not responsible for paying the billed amount because you received
this service [insert as applicable: from a [insert plan name] provider
OR based on a referral from a [insert plan name] provider].]

 If you have questions, you can contact:
o Our Member Services (phone numbers are in a box on page 1)
o 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a
week. (TTY users should call 1-877-486-2048.)]

[If the service or item in this row was previously denied and has now been approved on appeal, insert the following text
below the claim:

Things to know about your claim:
 NOTE: We initially denied this [insert as applicable: item OR service] and
received a request to appeal our denial. [Insert as applicable: After reviewing the
appeal request, we overturned our denial and approved the [insert as
applicable: item OR service]. OR Our denial was overturned and this [insert as
applicable: item OR service] is now approved.] This means that the [insert as
applicable: item OR service] is covered and the plan [Insert as applicable: has
paid OR will pay] its share of the cost.

 If you have questions, you can contact:
o Our Member Services (phone numbers are in a
box on page 1)
o 1-800-MEDICARE (1-800-633-4227), 24 hours a
day, 7 days a week. (TTY users should call 1-877486-2048.)]

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[If there are no claims for optional supplemental benefits processed during the reporting period, delete the remainder of this document.]
[If a claim for optional supplemental benefits was processed during the reporting period, it must be included in the EOB. Claims for optional
supplemental benefits should appear after the claims for Part A and Part B services and mandatory supplemental benefits. Plans should include
the section header provided below before the first claim for optional supplemental benefits. The format for the claims chart is provided below.
Please note that the format is the same as for other Part C benefits, except for the additional text describing optional supplemental benefits
which appears in the first column header.]

Optional Supplemental Services: Details for claims processed in [insert month] [insert
year]
(Amounts for optional supplemental services are not included in the totals shown on page 2)

[Insert name of provider]
Claim Number: [Insert claim number]
([If applicable, insert: [Insert as
applicable: In-network OR Out-ofnetwork] provider [plans may add the
type of optional supplemental benefits,
e.g., “of dental services.”]) [Insert type of
optional supplemental benefits] are
“optional supplemental services.” These
are extra services for which you pay a
separate premium.
[Show each service or item on a claim in
a separate row.]
[Insert description of the service or item
that was provided, using the American
Medical Association (AMA)'s HCPCS code
descriptors and CPT consumer
descriptors, followed by the HCPCS or
CPT billing code shown in parentheses.
For example: “Air and bone conduction
assessment of hearing loss and speech

Date of
service
[Insert
date of
service,
using
x/x/xx
format]

Amount the
provider billed
the plan
$[Insert
billed
amount for
this service
or item]

Total cost
(amount the
plan approved)
$[Insert
approved
amount for
this service or
item]
[Note: if
service or item
is approved,
use amount
approved by

Plan’s share
$[Insert
plan share
amount for
this service or
item]

Your share
$[insert member
liability amount for
this service or item]
[Note: if service or item has been
denied, use either the maximum
potential liability or “$0.00” for
the member liability amount,
whichever is applicable.]
[If cost sharing is a coinsurance,

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[Insert name of provider]
Claim Number: [Insert claim number]
([If applicable, insert: [Insert as
applicable: In-network OR Out-ofnetwork] provider [plans may add the
type of optional supplemental benefits,
e.g., “of dental services.”]) [Insert type of
optional supplemental benefits] are
“optional supplemental services.” These
are extra services for which you pay a
separate premium.
recognition (billing code 92557)”]
[As needed, insert explanatory notes,
preceded by “NOTE”]
[If the service or item on the row is
shown only to describe what was
provided and is not billed separately,
insert an explanatory note: NOTE: The
amounts are $0.00 because the cost for
this service or item is covered under
another part of this claim.]

Date of
service

Amount the
provider billed
the plan

Total cost
(amount the
plan approved)
the plan for
the total
amount. If
service or item
is denied use
the contracted
amount.]
[Insert if
applicable
below amount:
DENIED
(See below.)]

Plan’s share

Your share
insert:
You pay [insert percentage]% of
the total amount for [insert brief
description of service, (e.g.,
“dental services”)] [insert if
applicable: from an [insert as
applicable: in-network OR out-ofnetwork] provider]
[If cost sharing is a copayment,
insert:
You pay a $[insert copayment
amount] copayment for [insert
brief description of service (e.g.,
“dental services”)] [insert if
applicable: from an [insert as
applicable: in-network OR out-ofnetwork] provider]
[If the service or item shown on
this row has been denied, and the
amount in this column for “your
share” is not zero, insert:
Because the claim was denied,
you may be responsible for

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[Insert name of provider]
Claim Number: [Insert claim number]
([If applicable, insert: [Insert as
applicable: In-network OR Out-ofnetwork] provider [plans may add the
type of optional supplemental benefits,
e.g., “of dental services.”]) [Insert type of
optional supplemental benefits] are
“optional supplemental services.” These
are extra services for which you pay a
separate premium.

Date of
service

Amount the
provider billed
the plan

Total cost
(amount the
plan approved)

Plan’s share

Your share
paying this amount. Look below
for information about your
appeal rights.]

[Insert next item or service for the claim,
using language described above]
[Insert next item or service for the claim,
using language described above]
TOTALS:

$[Insert
total billed
amount for
this claim]

$[Insert total
approved
amount for
this claim]
[Insert if
applicable
below amount:
DENIED
(See below.)]

$[Insert total
plan share
amount for this
claim]

$[Insert total member
liability amount for this
claim]
[Note: if service or item has been
denied, use either the maximum
potential liability or “$0.00” for
the member liability amount,
whichever is applicable.]
[If all items in the claim are
subject to the same coinsurance
percentage or copayment
amount, plans may insert the
coinsurance/copayment text in
this total row rather than
repeating the identical text in

15

[Insert name of provider]
Claim Number: [Insert claim number]
([If applicable, insert: [Insert as
applicable: In-network OR Out-ofnetwork] provider [plans may add the
type of optional supplemental benefits,
e.g., “of dental services.”]) [Insert type of
optional supplemental benefits] are
“optional supplemental services.” These
are extra services for which you pay a
separate premium.

Date of
service

Amount the
provider billed
the plan

Total cost
(amount the
plan approved)

Plan’s share

Your share
the rows for each item or
service.]
[If more than one service or item
is denied, plans may omit the
denial language in this column
from the claim item rows and
insert it in this total row
instead.]

[If a service or item has been denied and there is member liability, include approved NDP language with the EOB or insert the
following text below the denied claim:

Things to know about your denied claim:
 [Plans may insert a denial reason.]
 We have denied all or part of this claim and you have the
right to appeal. Making an appeal is a formal way of asking
us to change the decision we made to deny your claim. If we
agree to change our decision, it means we will approve the
claim rather than deny it, and we will pay our share.
 The provider can also make an appeal, and if this happens,
you may not have to pay. You may wish to contact the
provider to find out if they will ask us for an appeal. If the
provider properly asks for an appeal, you will not be

 When we deny part or all of a
claim, we send you a letter
(“Notice of Denial of Payment”)
explaining why the service or item is
not covered. This letter also tells
what to do if you want to appeal
our decision and have us
reconsider.
 IMPORTANT: If you do not have this
letter, call us at Member Services

 If you have questions or need
help with your appeal, you can
contact:
o Our Member Services (phone
numbers are in a box on
page 1)
o 1-800-MEDICARE (1-800-6334227), 24 hours a day, 7 days
a week. (TTY users should
call 1-877-486-2048.)]

16
responsible for payment, except for the normal cost-sharing
amount, and you don’t need to make an appeal yourself.

(phone numbers are in a box on
page 1).

[If a service or item has been denied and there is no member liability, insert the following text below the denied claim:

Things to know about your denied claim:
 NOTE: We have denied all or part of this claim. However, you are
not responsible for paying the billed amount because you received
this service [insert as applicable: from a [insert plan name] provider
OR based on a referral from a [insert plan name] provider].]

 If you have questions, you can contact:
o Our Member Services (phone numbers are in a box on page 1)
o 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a
week. (TTY users should call 1-877-486-2048.)]

[If the service or item in this row was previously denied and has now been approved on appeal, insert the following text
below the claim:

Things to know about your claim:
 NOTE: We initially denied this [insert as applicable: item OR service] and
received a request to appeal our denial. [Insert as applicable: After reviewing the
appeal request, we overturned our denial and approved the [insert as
applicable: item OR service]. OR Our denial was overturned and this [insert as
applicable: item OR service] is now approved.] This means that the [insert as
applicable: item OR service] is covered and the plan [Insert as applicable: has
paid OR will pay] its share of the cost.

 If you have questions, you can contact:
o Our Member Services (phone numbers are in a
box on page 1)
o 1-800-MEDICARE (1-800-633-4227), 24 hours a
day, 7 days a week. (TTY users should call 1-877486-2048.)]