§ 127.209. Explanation of benefits paid.
(a) Insurers shall supply a written explanation of benefits (EOB) to the provider, describing the calculation of payment of medical bills submitted by the provider. If payment is based on changes to a provider’s codes, the EOB shall state the reasons for changing the original codes. If payment of a bill is denied entirely, insurers shall provide a written explanation for the denial.
(b) All EOBs shall contain the following notice: ‘‘Health care providers are prohibited from billing for, or otherwise attempting to recover from the employe, the difference between the provider’s charge and the amount paid on this bill.’’
Cross References This section cited in 34 Pa. Code § 127.207 (relating to downcoding by insurers); 34 Pa. Code § 127.255 (relating to premature applications for fee review); 34 Pa. Code § 127.302 (relating to resolution of self-referral disputes by Bureau).
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