An example of an Explanation of Benefits is available at Aetna.com. Click on Doctors and Hospitals, then select Aetna Explanation of Benefits Samples to view a sample medical explanation of benefits or a sample dental explanation of benefits. An Aetna Explanation of Benefits for example, contains a PIN, which is the name and unique identification number that Aetna assigns to each provider. This explanation of benefits also contains the provider's mailing address and the provider's federal tax identification number.
An Aetna Explanation of Benefits also contains a check number and bank identification, or in some cases an EFT trace number, explains Aetna. The explanation also includes the amount of the check, as well as identification information for the patient including the patient's full name, the patient's account number and Social Security number as well as the patient's member identification number. The member's first and last name appears on the explanation, as does the relationship between the member and the patient.
The Explanation of Benefits also includes the sponsor's group name and number, the name of the member's insurance plan, the diagnosis code, the network name and number, and the claim identification number along with the date that the insurer received the claim, notes Aetna. Each explanation shows if Aetna categorizes the procedure as ambulatory or as part of the diagnostic related group, depending on if it is an inpatient or outpatient procedure.
The Explanation of Benefits includes details about the service the healthcare provider conducted including the name, place and date of the service, the service code and the number of services the provider conducted, according to Aetna. This statement also includes payment information including the deductible, the copay amount, the submitted charges, and the amount the patient is responsible for paying.