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PGBA, LLC—PGBA processes all TRICARE claims for the region where you live.
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Regional Contractor—The name “Humana Military” and the Humana Military logo will appear here.
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Date of Notice—PGBA prepared your TRICARE EOB on this date.
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Sponsor SSN/Sponsor Name—We process your claim using the Social Security number
(SSN) of the military service member (active duty, retired, or deceased) who is your TRICARE sponsor. For security reasons, only the last four digits of your sponsor’s SSN will appear on the EOB.
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Beneficiary Name—The patient who received medical care and for whom this claim was filed.
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Mail-to Name and Address—We mail the EOB directly to the patient (or patient’s parent or guardian) at the address given on the claim. (Note: Be sure your doctor has updated your records with your current address.)
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Benefits Were Payable To—This field will appear only if your doctor accepts assignment. This means the doctor accepts the TRICARE allowable charge as payment in full for the services you received.
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Claim Number—We assign each claim a unique number. This helps us keep track of the claim as it is processed. It also helps us find the claim quickly whenever you call or write us with questions or concerns.
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Service Provided By/Date of Services— This section lists who provided your medical care, the number of services, and the procedure codes, as well as the date you received the care.
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Services Provided—This section describes the medical services you received and how many services are itemized on your claim. It also lists the specific procedure codes that doctors, hospitals, and labs use to identify the specific medical services you received. Amount Billed—Your doctor, hospital, or lab charged this fee for the medical services you received.
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TRICARE Approved—This is the amount TRICARE approves for the services you received.
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See Remarks—If you see a code or a number here, look at the Remarks section (17) for more information about your claim.
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Claim Summary—Here we give you a detailed explanation of the action we took on your claim. You will find the following totals: amount billed, amount approved by TRICARE, non-covered amount, amount that you have already paid to the provider (if any), amount your primary health insurance paid (if TRICARE is your secondary insurance), benefits we have paid to the provider, and benefits we have paid to the beneficiary. A check number will appear here only if a check accompanies your EOB.
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Beneficiary Liability Summary—You may be responsible for a portion of the fee your doctor has charged. If so, you’ll see that amount itemized here. It will include any charges that we have applied to your annual deductible and any cost-share or copayment you must pay.
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Benefit Period Summary—This section shows how much of the individual and family annual deductible and maximum out-of-pocket expense you have met to date. We calculate your annual deductible and maximum out-of-pocket expense by fiscal year. See the Fiscal Year Beginning date in this section for the first date of the fiscal year.
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Remarks—Explanations of the codes or numbers listed in the “See Remarks” section will appear here.
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Toll-Free Telephone Number—If you have questions about your TRICARE explanation of benefits, please call PGBA at this toll-free number. Our professional customer service representatives will gladly assist you.
