How to Read My Explanation of Payment (EOP) Statement Delhaize America Employees Internal Reference: B000P-01 Claim Reference Box Date: 04/18/11 Employer: Delhaize Subscriber: John Doe Subscriber ID: W12345678901 Date Paid: 04/18/11 Check No: 123456 Total Paid to Provider: $79.15 Provider: NAME OF MEDICAL GROUP INC Contact Information: Phone Number: 1-888-709-7092 Fax Number: 1-877-733-3964 Email Address: fundservices@bcbsnc-fund.com HRA – PAY TO PROVIDER STATEMENT – SUBSCRIBER COPY 1 Claim No. BNC001234567890E00000001 Patient Name Service Date Service Type Submitted Paid Pended Denied John Doe 03/24/11 – 03/24/11 Medical $79.15 $79.15 $0.00 $0.00 $79.15 $79.15 $0.00 $0.00 Total Explanation of Amount Pended or Denied 1 3 2 Employer Contribution Amount of funds that Delhaize has committed to your HRA account, including rollover funds from prior year. These funds may be used to offset your liability under your medical plan. 4 Submitted The amount in the Submitted column will match the “Amount Your Provider May Bill You” / TOTAL amount in your Explanation of Benefits (EOB). 5 6 7 Submitted Paid Pended Denied Available Balance BCBSNC will forward your medical claim to the BCBSNC Fund Administrator to be processed through your HRA account. Amount BCBSNC paid from your HRA account. In most instances, HRA reimbursement will be sent to your provider. This column is only populated if you have an FSA account with BCBSNC. Amount of either: the HRA reimbursement request that exceeds the available funds in your HRA account, or an ineligible expense. Amount remaining in your HRA account. At the end of the medical plan year, you can roll over the available balance to next year, with a maximum roll-over amount of $5,000. Paid Pended Denied Available Balance HRA Cumulative Account Balance Employer Contribution $625.00 2 Submitted 3 $79.15 4 $79.15 5 $0.00 6 $0.00 7 NOTE: This document gives highlights of the Delhaize America benefit programs. It is not intended to be a Summary Plan Description (SPD). If there are differences between the document and the SPD or plan document, the terms of the SPD and plan document will control. ® Marks of the Blue Cross and Blue Shield Association. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association. 11/2011 $545.85