Which term describes the insurer's summary of how a claim was paid, including allowed amounts and patient responsibility?

Which term describes the insurer's summary of how a claim was paid, including allowed amounts and patient responsibility?

• A. Capitation
• B. Clean claim
• C. Explanation of Benefits
• D. Fraud

Answer: (C)

The concept here is the Explanation of Benefits. After a claim is processed, the insurer sends an Explanation of Benefits to outline how the payment was determined: it states the allowed amount for the service, how much the insurer paid, and what the patient is responsible for (such as deductible, coinsurance, and copays). It may also note any adjustments, denied services, or reasons codes. This document helps you understand the payment outcome and how the bill from the provider fits with what the insurer covered. It’s not a bill itself. Other terms don’t fit: capitation refers to a fixed per-patient payment arrangement, not a claim-by-claim summary; a clean claim means the submission has no errors, not the payment summary; fraud is illegal deception for financial gain.

The concept here is the Explanation of Benefits. After a claim is processed, the insurer sends an Explanation of Benefits to outline how the payment was determined: it states the allowed amount for the service, how much the insurer paid, and what the patient is responsible for (such as deductible, coinsurance, and copays). It may also note any adjustments, denied services, or reasons codes. This document helps you understand the payment outcome and how the bill from the provider fits with what the insurer covered. It’s not a bill itself.

Other terms don’t fit: capitation refers to a fixed per-patient payment arrangement, not a claim-by-claim summary; a clean claim means the submission has no errors, not the payment summary; fraud is illegal deception for financial gain.