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How to Read Your TRICARE Explanation of Benefits (TEOB)?


You can watch the TEOB demo now or see the below clarifications of each section.

 TEOB_2008

 

1. PGBA, LLC PGBA processes all TRICARE claims for the region where you live.

 

2. Prime Contractor  The name and logo of the company that provides health services and support for the region where you live will appear here.

 

3. Date of Notice  PGBA prepared your TRICARE Explanation of Benefits (TEOB) on this date.

 

4. Sponsor SSN/Sponsor Name  We process your claim using the Social Security Number of the military service member (active duty, retired or deceased) who is your TRICARE sponsor.

 

5. Beneficiary Name  The patient who received medical care and for whom this claim was filed.

 

6. Mail To Name and Address  We mail the TRICARE Explanation of Benefits (TEOB) directly to the patient (or patient's parent or guardian) at the address given on the claim. (HINT: Be sure your doctor has updated your records with your current address.)

 

7. Benefits Were Payable To  This field will appear only if your doctor accepts assignment. This means the doctor accepts the TRICARE maximum allowable charge as payment in full for the services you received.

 

8. Claim Number  We assign each claim a unique number. This helps us keep track of the claim as it is processed. It also helps us find the claim quickly whenever you call or write us with questions or concerns.

 

9. Service Provided By/Date of Services  This section lists who provided your medical care, the number of services and the procedure codes, as well as the date you received the care.

 

10. Services Provided  This section describes the medical services you received and how many services are itemized on your claim. It also lists the specific procedure codes that doctors, hospitals and labs use to identify the specific medical services you received.

 

11. Amount Billed  Your doctor, hospital or lab charged this fee for the medical services you received.

 

12. TRICARE Approved  This is the amount TRICARE approves for the services you received.


13. APC#  Ambulatory Payment Classification (APC) program. Outpatient institutional claims will price similar to Medicare using an Ambulatory Payment Classification (APC) program. Payment is based on APC rate; each APC has a pre-established prospective payment associated with it. Multiple APCs can be assigned to an outpatient claim. Not all services on an outpatient claim will have an APC assigned. Some of the services will be packaged into the APC payment and others may pay the allowed amount while other services may be non-covered.

 

14. See Remarks  If you see a code or a number here, look at the Remarks section (17) for more information about your claim.

 

15. Claim Summary  Here we give you a detailed explanation of the action we took on your claim. You will find the following totals: amount billed, amount approved by TRICARE, non-covered amount, amount (if any) that you have already paid to the provider, amount your primary health insurance paid (if TRICARE is your secondary insurance), benefits we have paid to the provider, benefits we have paid to the beneficiary. A Check Number will appear here only if a check accompanies your TEOB.

 

16. Beneficiary Liability Summary  You may be responsible for a portion of the fee your doctor has charged. If so, you'll see that amount itemized here. It will include any charges that we have applied to your annual deductible and any cost-share or copayment you must pay.

 

17. Patient Responsibility  This is the amount you owe the provider.

 

18. Benefit Period Summary  This section shows how much of the individual and family annual deductible and maximum out-of-pocket expense you have met to date. Whether you are a TRICARE Prime, Standard or Extra beneficiary, we calculate your annual deductible and maximum out-of-pocket expense by fiscal year. See the fiscal year beginning date in this section for the first date of the fiscal year.

 

19. Remarks  Explanations of the codes or numbers listed in See Remarks will appear here.

 

20. Toll-Free Telephone Number  Questions about your TRICARE Explanation of Benefits? Please call PGBA at this toll-free number. Our professional customer service representatives will gladly assist you.


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