Kyhealth Choices Cms1500 Crossover Eomb Form
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1KYHealth Choices CMS1500 CROSSOVER EOMB FORM
Members Name:_______________________ Member ID:____________
EOMB Date: _____________________
Line
Allowed/Deduct Amount
Coinsurance Amount
Provider Pay Amount
Line
Allowed/Deduct Amount
Coinsurance Amount
Provider Pay Amount
Line
Allowed/Deduct Amount
Coinsurance Amount
Provider Pay Amount
Line
Allowed/Deduct Amount
Coinsurance Amount
Provider Pay Amount
Line
Allowed/Deduct Amount
Coinsurance Amount
Provider Pay Amount
Line
Allowed/Deduct Amount
Coinsurance Amount
Provider Pay Amount
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Parent category: Medical