September 5, 2026
The insurer sent this to show what it paid on an office visit. It asks for no money.
This is an Explanation of Benefits for an office visit on May 12. It is headed THIS IS NOT A BILL. The provider charged $420.00. The plan and the provider had already agreed a price of $310.00 for this visit, and the plan paid $270.00 of it. The $40.00 left is the part the provider can bill, and any bill for it comes from the provider's office.
Example Health Plan: Explanation of Benefits
The insurer's record of what it did with a claim. · From: Example Health Plan
- Period covered
- Service date May 12
- Reference to quote
- Claim number 2201-88
The visit was on May 12 and the claim was processed on June 2. The provider charged $420.00. The plan and the provider have an agreed price of $310.00 for this visit, so $110.00 comes off the charge and nobody pays it. The plan paid $270.00 of the $310.00. The remaining $40.00 is listed as patient responsibility.
- Amount billed$420.00
- The provider's full charge for the visit.
- Allowed amount$310.00
- The price the plan and this provider have agreed for this visit. The other amounts are worked out from it.
- Plan paid$270.00
- The insurer's share of the agreed price, already paid to the provider.
- Patient responsibility$40.00
- What is left of the agreed price, which the provider can bill. The document names the possible reasons for it. A deductible is the amount paid each year before insurance starts paying. A co-pay is a fixed fee per visit. Coinsurance is a share of the cost, set as a percentage. It can also be a service the plan does not cover.
How to respond
What's in the fine print
- The $310.00 allowed amount comes from the plan's network agreement with this provider. That agreement is why the $110.00 is not billed.
- The document shows $40.00 as patient responsibility without saying which of the four reasons applies here.
- The 180-day appeal window runs from the June 2 processing date. The May 12 visit date does not start it.
Deep-dive questions for the billing office or your insurer
Claim 2201-88 shows $40.00 as patient responsibility. Which is it: a deductible, a co-pay, or coinsurance?
What this is asking: Which of the plan's own categories this $40.00 falls into.
A clear answer covers: The category named, and how the plan worked the amount out.
Why it matters: The document shows the figure and lists four possible reasons without saying which one applies.
The charge was $420.00 and the allowed amount $310.00. Does the network agreement stop the provider billing the $110.00 difference?
What this is asking: Whether the gap between the two figures can still turn into a bill.
A clear answer covers: Yes or no, with the network agreement as the reason.
Why it matters: The document names the agreement as the reason for the lower figure without saying what happens to the difference.
The appeal window is 180 days from the June 2 processing date. What has to be sent, and does the deadline count from posting or from arrival?
What this is asking: What filing an appeal involves, and when the deadline falls.
A clear answer covers: Where an appeal is sent, what it has to contain, and which of the two dates counts.
Why it matters: The document gives the window without the mechanics, and posting and arrival are different dates.
The visit was May 12 and the claim was processed June 2. Will a separate bill for the $40.00 arrive from the provider's office?
What this is asking: Whether a real bill follows this document.
A clear answer covers: Yes or no, and when the office sends its bills.
Why it matters: This document asks for no money, so any bill comes separately from the provider.
What Jargone did not do
- We did not check whether the claim was processed correctly, only what the document says about it.
- We did not tell you whether to appeal, and we gave no view on the coverage decision.
- We translated the billing language only, never the medical care itself.
Disclaimer
Jargone translates documents. It does not give advice. We explain billing paperwork, not medical care, and this translation was written by an AI model, not reviewed by a human professional. It explains what the bill or letter says, not whether the charge or decision is correct or what to do about it. For your own situation, speak to your insurer, provider, or a patient advocate.