A2- Explanation of Benefits_Redacted.pdf

This document is an Explanation of Benefits from the Government Employees Health Association (GEHA) located in Eagan, MN, detailing medical claims for a National Medical Center. The document covers medical procedures performed between 12-30-2024 and 12-30-2024, with multiple healthcare procedure codes including HC J7120, HC C7703, HC B1025, and others. The total billed amount is $58,086.75, with a patient responsibility of $3,465.89 and a total benefit amount of $19,646.86.

The document breaks down various medical procedures with their corresponding procedure codes, billed amounts, allowed amounts, and adjustments. Most procedures are coded as CO 45, which indicates charges that exceed the fee schedule or maximum allowable amount based on contracted or legislated fee arrangements. The payment was processed through an Automated Clearing House method, with a check/EFT number and a processing date of 05-28-2025. The document serves as a detailed medical claims statement showing the breakdown of healthcare services, costs, and insurance coverage.