Process Explanation of Benefits (EOB) Extractor — HIPAA Compliant

================================================================================
                    EXPLANATION OF BENEFITS
                  This is NOT a bill
================================================================================

BlueCross BlueShield of California
P.O. Box 629007
El Dorado Hills, CA 95762-9007

Customer Service: 1-800-333-0912
Member Portal: www.bluecrossca.com/member

================================================================================
                

{
  "document_type": "eob",
  "statement_date": "2024-11-15",
  "insurance_info": {
    "payer_name": "BlueCross BlueShield of California",
    "payer_address": "P.O. Box 629007, El Dorado Hills, CA 95762-9007",
    "payer_phone": "1-800-333-0912",
    "payer_website": "www.bluecrossca.com/member",
    "plan_name": "PPO Gold 1500"
  },
  "member_info": {
    "member_name": "Michael R. Thompson",
    "member_id": "XBC789456123",
    "group_number": "GRP-TECH2024",
    "patient_name": "Michael R. Thompson",
    "patient_relationship": "Self",
    "address": "1234 Sunset Boulevard, Apt 5B, Los Angeles, CA 90028"
  },
  "claim_info": {
    "claim_number": "CLM-2024-8847291",
    "date_received": "2024-10-28",
    "date_processed": "2024-11-12",
    "status": "Paid"
  },
  "provider_info": {
    "provider_name": "Westside Family Medicine",
    "provider_address": "5678 Wilshire Blvd, Suite 300, Los Angeles, CA 90036",
    "provider_npi": "1234567890",
    "provider_type": "Primary Care Physician",
    "network_status": "In-Network"
  },
  "service_info": {
    "date_of_service": "2024-10-22",
    "place_of_service": "Office",
    "type_of_service": "Preventive Care / Office Visit"
  },
  "claim_lines": [
    {
      "service_date": "2024-10-22",
      "procedure_code": "99395",
      "description": "Preventive visit, established patient, 18-39 years",
      "billed_amount": "$285.00",
      "allowed_amount": "$185.00",
      "plan_discount": "$100.00",
      "deductible_applied": "$0.00",
      "copay": "$0.00",
      "coinsurance": "$0.00",
      "not_covered": "$0.00",
      "plan_paid": "$185.00",
      "patient_responsibility": "$0.00",
      "remark_codes": [],
      "remark_messages": [
        "Preventive services covered at 100% when using in-network provider"
      ]
    },
    {
      "service_date": "2024-10-22",
      "procedure_code": "36415",
      "description": "Venipuncture (blood draw)",
      "billed_amount": "$35.00",
      "allowed_amount": "$22.00",
      "plan_discount": "$13.00",
      "deductible_applied": "$0.00",
      "copay": "$0.00",
      "coinsurance": "$0.00",
      "not_covered": "$0.00",
      "plan_paid": "$22.00",
      "patient_responsibility": "$0.00",
      "remark_codes": [],
      "remark_messages": [
        "Lab draw included with preventive visit"
      ]
    },
    {
      "service_date": "2024-10-22",
      "procedure_code": "80053",
      "description": "Comprehensive metabolic panel",
      "billed_amount": "$125.00",
      "allowed_amount": "$78.00",
      "plan_discount": "$47.00",
      "deductible_applied": "$0.00",
      "copay": "$0.00",
      "coinsurance": "$0.00",
      "not_covered": "$0.00",
      "plan_paid": "$78.00",
      "patient_responsibility": "$0.00",
      "remark_codes": [],
      "remark_messages": [
        "Preventive lab work covered at 100%"
      ]
    },
    {
      "service_date": "2024-10-22",
      "procedure_code": "80061",
      "description": "Lipid panel (cholesterol)",
      "billed_amount": "$95.00",
      "allowed_amount": "$62.00",
      "plan_discount": "$33.00",
      "deductible_applied": "$0.00",
      "copay": "$0.00",
      "coinsurance": "$0.00",
      "not_covered": "$0.00",
      "plan_paid": "$62.00",
      "patient_responsibility": "$0.00",
      "remark_codes": [],
      "remark_messages": [
        "Preventive lab work covered at 100%"
      ]
    }
  ],
  "summary_totals": {
    "total_billed": "$540.00",
    "total_allowed": "$347.00",
    "total_plan_discount": "$193.00",
    "total_deductible": "$0.00",
    "total_copay": "$0.00",
    "total_coinsurance": "$0.00",
    "total_not_covered": "$0.00",
    "total_plan_paid": "$347.00",
    "total_patient_responsibility": "$0.00"
  },
  "benefit_information": {
    "deductible_info": {
      "individual_deductible": "$1,500.00",
      "family_deductible": "$3,000.00",
      "deductible_met_ytd": "$1,247.50",
      "deductible_remaining": "$252.50"
    },
    "out_of_pocket_info": {
      "individual_oop_max": "$6,000.00",
      "family_oop_max": "$12,000.00",
      "oop_met_ytd": "$2,134.25",
      "oop_remaining": "$3,865.75"
    }
  },
  "adjustment_reasons": [],
  "denial_info": {
    "denied": false,
    "denial_reason_code": null,
    "denial_reason": null,
    "appeal_deadline": null,
    "appeal_instructions": null
  },
  "coordination_of_benefits": {
    "cob_applicable": false,
    "primary_payer": null,
    "primary_paid": null,
    "this_plan_is": "Primary"
  },
  "payment_info": {
    "payment_date": "2024-11-14",
    "payment_method": "EFT",
    "check_number": null,
    "paid_to": "Westside Family Medicine"
  },
  "messages": [
    {
      "code": "MSG-001",
      "message": "This Explanation of Benefits is not a bill. You may receive a separate bill from your provider for any amount you owe."
    },
    {
      "code": "MSG-002",
      "message": "Preventive care services are covered at 100% with no deductible when you use an in-network provider."
    },
    {
      "code": "MSG-003",
      "message": "Keep this statement for your records and for tax purposes."
    }
  ],
  "appeal_rights": {
    "appeal_available": true,
    "appeal_deadline": "2025-05-15",
    "appeal_address": "BlueCross BlueShield of California, Appeals Department, P.O. Box 629008, El Dorado Hills, CA 95762-9008",
    "appeal_phone": "1-800-333-0913",
    "external_review_available": true
  },
  "validation": {
    "amounts_balance": true,
    "all_lines_have_disposition": true,
    "dates_logical": true,
    "member_id_matches": true
  }
}