Ama Policy

Universal Explanation of Benefits Forms H-390.865

Fee Schedules, Prompt Payment Deadlines

Our AMA: (1) favors the use of a standardized, easy-to-understand explanation of Benefits form, whether in print or electronic form, for all third party payers, both public and private; and (2) encourages third party payers, including CMS, to use the standard EOMB forms. Our AMA will seek national implementation of a universally inclusive Explanation of Medical Benefits (EOMB) form that would conform, at a minimum, to the following requirements:

(a) The EOMB must be issued to the physician and to the patient when a reimbursement check is issued or payment is denied, and contain appropriate identifying information so the physician can relate a specific reimbursement or denial to the applicable claimant, the service (s) billed and the date of service.

(b) The carrier shall use the physician’s claim form’s listed CPT codes and descriptors to demonstrate how each charge has been reduced or disallowed.

(c) The EOMB shall specify what underlying managed care organization’s contractual fee schedule is used for determining reimbursement and/or applicable discounts.

(d) The EOMB shall clearly identify the insured’s remaining financial responsibility under the contract.

(e)The standardized form should clearly state information such as the patient’s name, the insured’s name, the patient’s date of birth, the date of service, the CPT code submitted, the amount charged, the amount allowed, the amount discounted, the amount of co-pay, the deductible amount, the withhold amount and the payment to the physician.

Policy Timeline

Res. 101, I-96 Appended by Sub. Res. 126, A-98 Reaffirmed and Appended: Sub. Res. 106, I-98 Reaffirmation A-05 Reaffirmed in lieu of Res. 710, A-06 Reaffirmation A-08 Reaffirmed: CMS Rep. 01, A-18