CMS-10453 PPO Monthly Template

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CMS Approved Part C Explanation of Benefits Template
PPO, Monthly EOB Version
General Instructions
This is a Centers for Medicare and Medicaid Services (CMS) approved Part C Explanation of
Benefits (EOB) template. CMS views Part C EOBs as ad-hoc information materials; therefore, they
are not subject to CMS review and approval. However, CMS reserves the right, as with other adhoc communication, to request and review a sample of the materials to ensure compliance with our
requirements.
•

This template is for organizations that choose to send monthly EOBs to non-dual eligible
members.

•

Plans are not required to send an EOB to dual eligible members.

•

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.

•

The monthly EOB must be sent to members each month there is claims activity, whether or
not there is member liability.

HPMS submission:
•

All plans may be required to submit a Part C EOB to HPMS. CMS will provide more
information when available.

Format Instructions
•

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

•

Text and numbers must be in font size 12 or larger.

•

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

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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.
•

The document may be printed double-sided and, in lieu of a paper mailing, may be sent
electronically to members who elect the paperless format.

•

The document must have a header or footer that includes the page number. In addition, plans
may 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 continuing page. In an actual EOB, rows of a chart should not break across the
page. Note: in the template language in this document, rows sometimes break across a page
because of the instructions and substitution text.

Content Instructions
•

CMS encourages MAOs to use the HCPCS code descriptors and American Medical
Association’s CPT code descriptors, followed by the HCPCS or CPT billing code shown in
parentheses. Other appropriate billing codes, such as ADA approved dental codes, Medicare
revenue codes for in-patient facility claims, and other widely recognized code descriptors
may also be used.

•

When providing claim information, plans may use date ranges to combine multiple
occurrences of a service or item into a single row.

•

All claim information provided in the EOB must be HIPAA compliant to protect member
health information.

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. If applicable, claims for optional supplemental benefits are to be
displayed separate from medical and hospital claims. Information for all claims includes:
billing codes and descriptors, amount providers have billed the plan, total cost (amount the
plan has approved), plan’s share, and member’s share (your share). Any benefit information
that cannot be included timely must be accounted for in a subsequent reporting period.

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Instructions within the template:
•

All black text is required information that must be included as shown in the attached EOB
template.

•

Italicized blue text in square brackets is instruction and guidance specifically for MA plans.
This information is not to be included in the beneficiary’s EOB.

•

Non-italicized blue text in square brackets is text to be inserted as applicable.

•

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

•

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

•

Plans should make every effort to use a reporting period that aligns with a complete calendar
month, however, 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].”

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MONTHLY REPORT

Medical and Hospital Claims
Processed in [Insert month]
[Insert Year]
For [insert member name]
[If desired, plans may 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 out of pocket (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, provider network, premium,
copayments, and coinsurance may change each year.

[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

Amount
providers
have billed
the plan

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

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

[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 both
deductibles.]

Total cost
(amount the plan
has approved)

Plan’s share

Your share

$[insert
total billed
amount for
the
reporting
period]

$[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 billed
amount for
the year]

$[insert total
approved
amount for the
year]

$[insert total
plan share
amount for
the year]

$[insert total
member
liability
amount for the
year]

YEARLY LIMIT – this limit gives you financial protection
This limit tells the most you will have to
pay 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].

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:

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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
plan deductible]

[Plans with service category
deductibles, include the text
below 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

This yearly limit is called your “out-ofpocket 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.
Your out-of-pocket spending for [insert
service] will not count toward your yearly
out-of-pocket maximum. This means:
• Once you have reached your limit
in out-of-pocket costs, you stop
paying out of pocket for all
services [insert, if applicable:
except [insert service].
• 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. [Insert if
applicable: Your out-of-pocket
spending for services that are not
covered by Medicare does not
count toward your out-of-pocket
maximum.]

$0

$3,400 ]

Combined (in-network + out-of-network) limit
In [insert year], $[insert combined MOOP amount] is the
most you will have to pay for covered services you get
from all providers (in-network providers + out-of
network providers combined).
As of [insert reporting period end date], you have had
[insert amount paid toward combined MOOP as of
reporting period end date] in out-of-pocket costs that
count toward your [insert combined MOOP amount]
combined 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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[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
[insert service
category]]

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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]
([Insert as applicable: In-network OR
Out-of-network] provider)
[Show each service or item on a claim in
a separate row. Although, date ranges
may be used to combine multiple
occurrences of a service or item into a
single row, e.g., for claims related to
inpatient services.
[Insert description of the service or item
that was provided and its billing code.
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,
insert
applicable
denied amount
and/or insert:
DENIED
(Look below
for information
about your
appeal rights.)]

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] [insert if
applicable: for services from an
[insert as applicable: in-network
OR out-of-network] provider]
[If cost sharing is a copayment,
insert:
You pay a $[insert copayment
amount] copayment [insert if
applicable: for services from an
[insert as applicable: in-network
OR out-of-network] provider]
[If the service is a preventive
service that is covered at no cost
under Original Medicare, add the
following:

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[Insert name of provider]
Claim Number: [Insert claim number]
([Insert as applicable: In-network OR
Out-of-network] provider)

Date of
service

Amount the
provider billed
the plan

Total cost
(amount the
plan approved)

Plan’s share

Your share
(This is one of the preventive
services that is covered at no cost
under Original Medicare, and the
plan covers this service innetwork at no cost to you.)]
[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:
This service was denied, but you
may be responsible for 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]

[If service or
item is denied,
insert
applicable

$[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

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[Insert name of provider]
Claim Number: [Insert claim number]
([Insert as applicable: In-network OR
Out-of-network] provider)

Date of
service

Amount the
provider billed
the plan

Total cost
(amount the
plan approved)

Plan’s share

denied amount
and/or insert:
DENIED
(Look below
for information
about your
appeal rights.)]

Your share
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
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.)]

9
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.)]

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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.
In this section, deductible amounts may be included in the “Your share” column. 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 and its billing code.
For example: “Air and bone conduction
assessment of hearing loss and speech
recognition (billing code 92557)”]
[As needed, insert explanatory notes,
preceded by “NOTE”]

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

Amount the
provider billed
the plan

Total cost
(amount the
plan approved)

Plan’s share

$[Insert
billed
amount for
this service
or item]

$[Insert
approved
amount for
this service or
item]

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

[Note: if
service or
item is
approved,
use amount

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.]

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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.
[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)
approved by
the plan for
the total
amount]
[If service or
item is denied,
insert
applicable
denied
amount
and/or insert:
DENIED
(Look below
for
information
about your
appeal
rights.)]

Plan’s share

Your share
[If cost sharing is a coinsurance,
insert:
You pay [insert percentage]% of
the total amount [insert if
applicable: for services from an
[insert as applicable: in-network
OR out-of-network] provider]
[If cost sharing is a copayment,
insert:
You pay a $[insert copayment
amount] copayment [insert if
applicable: for services from an
[insert as applicable: in-network
OR out-of-network] provider]
[If there is a deductible charged
for the service or item, insert:
You pay a $ [insert copayment
amount] deductible for this
service or item]
[If the service or item shown on
this row has been denied, and the
amount in this column for “your

12

[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
share” is not zero, insert:
This service was denied, but you
may be responsible for 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 period
claim]

$[Insert total
approved
amount for
this claim]
[If service or
item is denied,
insert
applicable
denied
amount
and/or insert:
DENIED

$[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

13

[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

(Look below
for
information
about your
appeal
rights.)]

Your share
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
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.

• 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

• 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)

• 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.

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).

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o 1-800-MEDICARE (1-800-6334227), 24 hours a day, 7 days
a week. (TTY users should
call 1-877-486-2048.)]

[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.)]