EXPLANATION OF BENEFITS — DE-IDENTIFIED DEMO SAMPLE
====================================================
IMPORTANT: All patient and member identifiers have been removed.
This is a sample for training the EOB Decoder skill.

Payer:          BlueCross PPO (demo)
Plan Type:      PPO
Network:        In-Network
Date of Service: 03/15/2026
Provider:       [Practice name redacted]

─── Plan Year Info (as of date of service) ──────────────────────
Annual Maximum:         $1,500.00
Deductible (Individual): $100.00
Deductible Met (YTD):   $0.00
Deductible Remaining:   $100.00
Annual Max Used (YTD):  $0.00
Annual Max Remaining:   $1,500.00

─── Claim Lines ─────────────────────────────────────────────────

Line 1
  CDT Code:       D2750  (Porcelain fused to high noble metal crown)
  Tooth:          #19 (mandibular first molar, lower left)
  Billed Amount:  $1,350.00
  Allowed Amount: $850.00   ← plan downgraded; see note below
  Plan Paid:      $0.00     ← deductible applied first; then coverage
  Patient Amount: (see calculation)
  Remark Code:    D-DOWNGRADE
  Note:           Alternate benefit applied. Plan covers posterior crowns
                  at the resin crown (D2710) rate of $850. Porcelain fused
                  to metal covered at base metal rate per plan contract.

Line 2
  CDT Code:       D2140  (Amalgam filling — 1 surface)
  Tooth:          #3 (maxillary first molar, upper right)
  Billed Amount:  $215.00
  Allowed Amount: $175.00
  Plan Paid:      $0.00     ← deductible applied
  Patient Amount: (see calculation)
  Remark Code:    PR-2
  Note:           Amount applied to patient deductible.

─── Expected Math (for decoder verification) ──────────────────
Plan: 80% coverage after deductible. Deductible: $100 remaining.
Annual max: $1,500.

LINE 1 (D2750 — downgrade to $850 allowed):
  Step 1  Deductible: $100 applied → $750 remains
  Step 2  Coverage:   80% × $750 = $600 plan pays
  Step 3  Max check:  $600 < $1,500 remaining ✓
  Patient owes: $850 − $600 = $250
  Deductible remaining after: $0
  Annual max remaining after: $1,500 − $600 = $900

LINE 2 (D2140 — $175 allowed):
  Step 1  Deductible: $0 remaining (fully met on Line 1)
  Step 2  Coverage:   80% × $175 = $140 plan pays
  Step 3  Max check:  $140 < $900 remaining ✓
  Patient owes: $175 − $140 = $35
  Annual max remaining after: $900 − $140 = $760

TOTALS:
  Total patient portion:      $285.00  ($250 + $35)
  Total plan pays:            $740.00  ($600 + $140)
  Annual max remaining:       $760.00
  Deductible fully met:       Yes

─── Key Patient Talking Points ────────────────────────────────
1. "Your crown (tooth #19) was downgraded — the plan paid at the lower
   rate for a resin crown ($850 vs. your billed $1,350). This is common
   with many PPO plans for back-tooth crowns. If you'd like, we can
   submit an appeal with clinical photos and X-rays."

2. "Your $100 deductible was applied to the crown and is now fully met
   for this plan year. Any future work this year won't need to satisfy
   a deductible again."

3. "Your total due today is $285. You have $760 remaining in your
   annual benefit — enough to cover another cleaning and a filling
   at 80%."

─── Appeal Note ────────────────────────────────────────────────
The crown downgrade (D-DOWNGRADE) may be appealable if clinical
necessity for PFM over resin can be documented. Typical supporting
evidence: periapical X-ray showing occlusal loading or existing
adjacent PFM crowns, intraoral photo, dentist narrative.
Appeal window: check EOB for deadline (commonly 90–180 days).

─── DISCLAIMER ─────────────────────────────────────────────────
This is a de-identified demo sample for training purposes only.
No real patient data is present. All names, member IDs, claim
numbers, and identifying information have been removed.
Amounts shown are illustrative. Actual payer determination may differ.
Verify benefits with payer before treatment.
