CMS-10453 PPO Quarterly Template

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CMS Approved Part C Explanation of Benefits Template
PPO, Quarterly Summary 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 ad-hoc
communication, to request and review a sample of the materials to ensure compliance with our
requirements.
•

Organizations that choose to send per claim EOBs must also send this quarterly summary
document 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 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 quarterly EOB must be sent to members each quarter 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
•

Organizations that choose to send per claim EOBs may use their own format for those.

•

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.

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•

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.

•

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, 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 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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[Insert start month for reporting period]
through [Insert end month for reporting period]
[insert year]

Summary of Your
Out-of-Pocket Spending for
Medical and Hospital Claims
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 report shows the totals for claims we have
processed. It tells 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.)

[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.

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

Amount
providers
have billed
the plan

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]

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[Plans with no deductibles,
omit this section.]

YEARLY LIMIT – this limit gives you financial protection

[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.]

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].

For most covered services,
the plan pays its share of the
cost only after you have paid
your yearly plan deductible.

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.

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 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.]

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 ]

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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= 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
[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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