Interactive CHAMPVA EOB Guide

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Interactive Sample EOB

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CHAMPVA EXPLANATION OF BENEFITS

Statement Date: 01/15/2026

PATIENT: SMITH, JOHN A. CHAMPVA ID: 123456789A
PROVIDER: DR. MARY JOHNSON, MD
123 MEDICAL CENTER DRIVE, ANYTOWN, ST 12345
Service Date Description Amount Billed Amount Allowed Amt Not Covered Remarks
01/03/2026 OFFICE VISIT LEVEL 3 $185.00 $150.00 $35.00 30, 252
TOTALS: Amount Billed: $185.00 | Amount Allowed: $150.00 | Your Responsibility: $50.00
REMARKS EXPLANATION:
Code 30: This amount is being applied to your annual deductible ($50 individual, $100 family for 2026). You need to pay this $50.
Code 252: Additional documentation is needed to process this claim. CHAMPVA needs more medical records before they can finish processing.

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