How to Read Your Explanation of Benefits Chart

Detail Information

Detail Information Provides details on each medical service provided.

1. Member Name: The person insured by WPS (policyholder).
2. Member Number: Number associated with each member, shown on your WPS ID card.
3. Group Name: Employer Name (if covered under a group plan) or Individual Plan Name (if covered under an individual plan).
4. Group-Division Number: Unique code identifying your health plan in our claims system.
5. Process Date: The date WPS processed this claim.
6. Claim Number: Unique code identifying the claim submitted.
7. Patient Name: Lists the person(s) who received health care services.
8. Patient Account: Unique health care provider code identifying the patient treated.
9. Services Provided By: The provider that performed the procedure, plus the code and general category of the procedure performed.
10. Service Dates: The start and end date during which the listed procedure was performed.
11. Total Billed: The total cost of the procedure, as billed by the provider.
12. Provider Discount: The discount WPS negotiated with your provider, which will be subtracted from the total cost. Usually based on contractual agreements between WPS and providers in your WPS network.
13. Amount Not Covered: The portion of the total cost not covered under your health plan. This portion is your responsibility. See Remarks codes in the last column and the Remarks box for explanation.
14. Your Copay: The portion of the total cost you are responsible to pay before any deductible or coinsurance is applied for certain covered services (e.g., office visits).
15. Your Deductible: The portion of total cost applied to your deductible. (Your deductible is the amount of covered charges you must pay each calendar year before WPS pays benefits).
16. Your Coinsurance: The balance of total cost after subtracting provider discount, ineligible amount, copay, and deductible.
17. Paid at %: The percentage of the coinsurance amount paid by WPS.
18. WPS Paid: The portion of the coinsurance WPS paid.
19. Other Insurance: The portion of the coinsurance paid by another insurance plan (e.g., auto insurance).
20. See Remarks: The procedure performed may have triggered additional comments that do not fit in the chart. Match the Remarks code to those in the Remarks box under the chart to view the specific comment.

Statement Totals

Statement Totals A summary of total charges billed by health care providers, negotiated provider discounts, WPS' financial responsibility and yours. What you owe is the portion of coinsurance you are responsible to pay. Includes copay, deductible, coinsurance, and any amount not covered. Paid directly to your provider, who will send you a bill.

Remarks

Remarks Includes explanations of any Remarks codes listed in the See Remarks column.

What I Need To Know For My Next Claim

What I Need To Know For My Next Claim Lists your plan's deductible, out-of-pocket maximum, and individual lifetime benefit; shows the amount of each you've met year-to-date; and the amount remaining.