EOB (Explanation of Benefit) Importatnt fields

EOB Claim Page Field Descriptions

Most of the field descriptions for each of the claim type Adjusted, Paid, Denied, and In Process are the same. Each claim type/Status may have fewer of the fields and a few have fields specific to the claim type. For example, Dental contains tooth references, Drug contains NDC codes.

The following table lists the fields in all the claims sections. The table includes all fields that display on all claim types. The Adjustments pages contain a few more fields that are described in the next section.

Note: The fields listed in the following tables are based on information available at the time of publication. The information is subject to change based on further review.

Field Description
Name Displays the recipient's last name, and first name. Claims are displayed in alphabetical order by last name.

Pat Acct No. Displays the Patient Account Number assigned to the recipient by the provider.

ICN Displays the internal control number of the claim. Use this number when inquiring about the claim.

MRN Displays the Medical Record Number assigned to the recipient by the provider.

Rendering Provider Displays the National Provider Identifier (NPI) of the rendering provider.

Attending ID Displays the National Provider Identifier (NPI) of the attending physician, if applicable.

Recipient ID Displays the 12 digit recipient Medicaid ID number as submitted by the provider.

Admit Date Displays the admitting date submitted on the claim, if applicable.

Dispense Date Displays the dispense date submitted on the claim, if applicable.

Days Displays the number of days submitted on the claim, if applicable.

Dates Of Service First Date Of Service - Last Date Of Service, Displays the dates of service submitted on the claims in

MMDDYY format. This displays for each line item billed,if applicable.

Dist Plan (District Plan) Displays the District Plan Code for the inpatient claim, if applicable

Surf (Tooth Surface) Displays the tooth surface on the detail line, if applicable.

POS Or PL SERV (Place Of Service) Displays the place of service as submitted on the claim,
if applicable.

TN (Tooth Number) Displays the tooth number on the detail line, if applicable.

Procedure/Revenue/ NDC Code Displays these codes as they were submitted on the claim. This displays for each line item billed, if applicable.

Modifiers Displays the procedure code modifiers as they were submitted on the claim.

Desc Displays the first six characters of the NDC code description

Billed Amount Displays the amount billed on the claim. This displays for each line item billed, if applicable.

Non Allowed Displays the amount of the billed amount that Medicaid will not cover. This displays for each line item billed, if applicable.

Allowed Amount Displays the amount of the billed amount that Medicaid will cover. This displays for each line item billed, if applicable.

Patient Liability This displays the patient liability applied to the claim payment, if applicable.

TPL Amount Displays the amount paid by a third party insurance. This displays for each line item billed, if applicable.

Paid Amount Displays the amount Medicaid paid the provider for the claim. This displays for each line item billed, if applicable.

HEADER And DETAIL EOBS Displays an Explanation Of Benefit code about claim adjudication. This displays for each header and line item billed, if applicable.

Copay Amount This displays the copay applied to the claim payment, if applicable.

QTY Or UNITS Displays the quantity or units submitted.

Rx No. Displays the prescription number.

Total Billed Displays the total billed for all the claim.

Total Non Allowed Displays the total payment that Medicaid will not cover for all the claims.

Total Allowed Displays the total allowed amount for all the claims.

Total Patient Liability Displays the total patient liability for all the claims.

Total Copay Amount Displays the total copay for all the claims

Total TPL
Amount Displays the total TPL for all the claims.

Total Paid Amount Displays the total amount of Medicaid payment for the
claims

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