120.877 Full Transparency – Explanation of Benefits
MSSNY will advocate legislation and regulations that mandate that explanation of benefits, whether sent to the patient or the physician practice, include the actual CPT codes billed, DRG-codes, CPT descriptions, and optional consumer-friendly descriptions; and EOB must list the actual allowed amount, patient responsibilities (copay, deductible, coinsurance), non-covered and denied amounts with specific X12 reason codes in consumer-friendly explanations, what criteria is used for coverage and non-coverage, and includes detailed explanation on how to appeal, including contact information for plan administrator, applicable laws governing the plan benefits, and contact information to submit external complaints.
MSSNY advocates that AMA will advocate legislation and regulations that mandate that explanation of benefits, whether sent to the patient or the physician practice, including the actual CPT codes billed, DRG-codes, CPT descriptions, and optional consumer- friendly descriptions; and EOB must list the actual allowed amount, patient responsibilities (copay, deductible, coinsurance), non-covered and denied amounts with specific X12 reason codes in consumer-friendly explanations, what criteria is used for coverage and non-coverage, and includes detailed explanation on how to appeal, including contact information for plan administrator, applicable laws governing the plan benefits, and contact information to submit external complaints. (HOD 2024 – 266)
